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

Notes

124 CONCLUSION nonprofit advocacy organizations had long-held ties with state government agencies and elected officials. When they were excluded from the initial discussions with DSS representatives, they ramped up their political advocacy and accomplished some major wins: creation of an open, inclusive advisory board; creation of an oversight body with appropriated state resources; and creation of policies to protect Medicaid recipients’ access to specific Medicaid providers. These were not minor concessions on the part of the state but major wins that DSS and HMO representatives advised against. Indeed, DSS and HMO representatives resented the granting of protections to some providers and not others, and the extra time devoted to meeting the data collection demands of the oversight body. Most important, they interpreted these wins as signaling significant political power by Medicaid providers and advocates. Medicaid providers and advocates also discussed the importance of their political connections to secure these wins. Given the acknowledged strength of these representatives of the poor, the simple political inequality story doesn’t work very well as a key explanation for public silence. Indeed, when we analyzed the public discussions that did occur, we found Medicaid advocates and providers to be the able representatives that deliberative theorists call for. Because they had been part of the Medicaid policy network for a long time, most advocates and provider representatives had a very good grasp of Medicaid policy issues. Therefore, even though they did not have an alternative solution for controlling Medicaid costs when DSS discussed moving to a competitive bid process, they asked detailed questions and wanted to be involved in the decision-making process. Even on highly technical issues, such as Medicaid reimbursement formulas for HMOs and measuring health care outcomes to determine appropriate quality of care, advocates did not defer to experts but asked pointed questions and made challenging remarks. Again, the political inequality argument did not hold up to the discussion we observed. Yet another alternative explanation is that the institutional factors related to the topic of equal access—political feasibility, lack of data, and lack of solution—stymied public discussion. As described in chapter 4, we do find some support for this argument, but when we compare the influence of these factors to the topics that were discussed , their explanatory power comes up short. For example, it is likely that the political and budgetary climate dampened the hopes of many participants that significant progress could be made on attaining mainstream access for Medicaid recipients. But many were MEDICAID REFORM AND ADVISORY BOARDS 125 equally pessimistic that the quality of care provided could also be improved under reduced funding, and yet they continued—despite their privately expressed fears—to fight publicly for the importance of improving the quality of care provided to Medicaid recipients. Moreover, the lack of an alternative solution might have made it more difficult to discuss mainstream access, but why then were participants eager to keep a sustained conversation about costs on the public agenda when there were no easy solutions about how to increase funding or change the reimbursement methodology? Moreover , our private interviews revealed that most participants believed that reliance on HMOs through the Medicaid managed care reform was the best hope for expanding access to mainstream providers. So why didn’t participants fight for this to happen in the way they envisioned it would? Finally, although it is clear that the availability of cost data enabled participants to have a focused and sustained discussion about this topic, it is unclear why participants did not raise public discussion about the importance of collecting of data for the purpose of tracking access to mainstream providers. There were no data on health care outcomes for Medicaid recipients when the reform started. Yet in stark contrast to the mainstreaming goal, participants devoted countless hours to discussing the importance of data collection and what data were important to collect. Although the combination of all three factors contributed to a limited public discussion around the goal of improving access to mainstream medical care, we show in chapter 5 how understanding the Medicaid policy network, and how Medicaid managed care reform changed the interests and participants in that network, provides the key additional explanatory pieces to the public silence puzzle . On the one hand, our findings concur with studies by Chaves, Galaskiewicz, and Stephens (2004) and Berry and Arons (2003) suggesting that nonprofits with significant government funding have high levels of political activity. Yet by...