Healthy Voices, Unhealthy Silence

Healthy Voices, Unhealthy Silence: Advocacy and Health Policy for the Poor

Colleen M. Grogan
Michael K. Gusmano
Copyright Date: 2007
Pages: 170
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  • Book Info
    Healthy Voices, Unhealthy Silence
    Book Description:

    Public silence in policymaking can be deafening. When advocates for a disadvantaged group decline to speak up, not only are their concerns not recorded or acted upon, but also the collective strength of the unspoken argument is lessened-a situation that undermines the workings of deliberative democracy by reflecting only the concerns of more powerful interests. But why do so many advocates remain silent on key issues they care about and how does that silence contribute to narrowly defined policies? What can individuals and organizations do to amplify their privately expressed concerns for policy change? In Healthy Voices, Unhealthy Silence, Colleen M. Grogan and Michael K. Gusmano address these questions through the lens of state-level health care advocacy for the poor. They examine how representatives for the poor participate in an advisory board process by tying together existing studies; extensive interviews with key players; and an in-depth, first-hand look at the Connecticut Medicaid advisory board's deliberations during the managed care debate. Drawing on the concepts of deliberative democracy, agenda setting, and nonprofit advocacy, Grogan and Gusmano reveal the reasons behind advocates' often unexpected silence on major issues, assess how capable nonprofits are at affecting policy debates, and provide prescriptive advice for creating a participatory process that adequately addresses the health care concerns of the poor and dispossessed. Though exploring specifically state-level health care advocacy for the poor, the lessons Grogan and Gusmano offer here are transferable across issue areas and levels of government. Public policy scholars, advocacy organizations, government workers, and students of government administration will be well-served by this significant study.

    eISBN: 978-1-58901-339-1
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Preface
    (pp. ix-x)
  4. Acknowledgments
    (pp. xi-xiv)
  5. Introduction
    • 1 The Problem and Puzzle of Public Silence
      (pp. 3-20)

      Although the United States has the most expensive health care system in the world and offers a plethora of advanced medical technologies—many of which are life saving—there are many reasons advocates fight for improved health care services for the poor. Compared with higher income Americans, the poor are much less likely to receive preventive health care services and more likely to be diagnosed at a later stage for chronic and terminal illnesses, making the course of their illness more difficult and the probability they will die from their disease more likely (Idler and Kasl 1995; Case and Paxson...

  6. Part I Explanations and Background
    • 2 Explanations for Public Silence: Inequality, Dependence, and Infeasibility
      (pp. 23-41)

      When suppression of the public voice occurs under an oppressive state or under very clear power inequities, the problem is deeply concerning but not analytically troubling. The suppression is so clearly due to fears about a retaliating state or some other powerful source that there is no puzzle. Indeed, upon reading in chapter 1 the story of Chris—an able representative with ample opportunity to give voice about an expressed concern who chose not to—some critics, especially those well versed in the literature on participatory democracy, might respond, “Of course, that is an obvious limitation of participatory processes.” Indeed,...

    • 3 Medicaid’s Persistent and Conflicting Goals: Equal Access, Quality Care, and Cost Control
      (pp. 42-66)

      Despite persistent hopes, the goal of providing the poor access to high-quality, mainstream medical care at reasonable costs has remained elusive for the last forty years, for reasons too large and complex to cover adequately in this chapter.¹ Our main intent is to show, despite Medicaid’s failings, how these goals have remained aspirations for the program over time. Interested groups, most notably Medicaid providers and advocates for the poor, often use these stated program goals to hold states, agency heads, and elected officials accountable for program promises left undelivered. Indeed, variations on these same goals were explicitly stated as important...

  7. Part II Arguments and Findings
    • 4 The Political and Policy Difficulties of Discussing Unequal Access
      (pp. 69-90)

      Starting in August 1995, AFDC-Medicaid recipients living in Connecticut’s two largest counties were given the option to enroll in a Medicaid managed care plan.¹ Recipients’ response to the new program was extraordinary: By the end of the month, nearly ten thousand Medicaid recipients had enrolled in eleven different Medicaid HMOs. The number of voluntary enrollments was far greater than anyone—even the agency responsible for administering the program (the Department of Social Services), Medicaid advocates, or the HMOs—had anticipated.

      Not surprisingly, especially given this level of unanticipated demand, a number of enrollment difficulties arose during the first few months...

    • 5 Medicaid’s Policy Network and the Ties that Bind: Nonprofit Advocacy and Social Interactions
      (pp. 91-118)

      Concerns about the state’s budget, a political climate that made it difficult to criticize the new program, a lack of data to measure mainstreaming, and specific solutions that diverted attention from larger issues all contributed to the public silence over mainstream Medicaid access in Connecticut. Yet as we concluded in the previous chapter, these factors were not enough to prevent advocates for the poor from discussing equally tricky issues such as the state’s capitation rate or quality assurance, so there must be other reasons for the striking absence of public debate. To fill in the missing pieces of the public...

  8. Conclusion
    • 6 Medicaid Reform and Advisory Boards: Who Will Advocate for Poor People’s Health?
      (pp. 121-130)

      The primary goals of this book are to highlight the problem of public silence in deliberations over public policy and to offer an explanation of why it occurs. Specifically, we are concerned with deliberations among members of state advisory boards. These boards are ubiquitous in American politics, but we know very little about the public conversations that might emerge from them. When they are used to inform health and social policy, these advisory boards are often composed of representatives from the vast network of nonprofit agencies that provide services to and/or advocate on behalf of the poor. Evaluating the substance...

  9. Notes
    (pp. 131-136)
  10. References
    (pp. 137-150)
  11. Index
    (pp. 151-156)