Cover

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Frontmatter

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Contents

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p. vii

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Preface

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pp. ix-x

This book deals with two enduring themes in most advanced democracies: the persistence of political inequality and the desire to shape “good” social welfare policy. Although these themes are ubiquitous in any public policy problem, we didn’t actually intend to address them. We started this project in the mid-1990s with an interest...

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Acknowledgments

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pp. xi-xiv

This project started when we were at Yale University, where Bradford Gray, director of the university’s Institute for Social and Policy Studies at the time, encouraged us to examine the implementation of Medicaid managed care in Connecticut. Members of the Robert Wood Johnson Foundation’s Scholars in Health Policy...

Introduction

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1 The Problem and Puzzle of Public Silence

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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...

Part I: Explanations and Background

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2 Explanations for Public Silence: Inequality, Dependence, and Infeasibility

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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...

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3 Medicaid’s Persistent and Conflicting Goals: Equal Access, Quality Care, and Cost Control

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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...

Part II: Arguments and Findings

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4 The Political and Policy Difficulties of Discussing Unequal Access

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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...

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5 Medicaid’s Policy Network and the Ties that Bind: Nonprofit Advocacy and Social Interactions

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pp. 91-117

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...

Conclusion

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6 Medicaid Reform and Advisory Boards: Who Will Advocate for Poor People’s Health?

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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...

Notes

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pp. 131-136

References

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pp. 137-149

Index

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pp. 151-156