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.

Colleen M. Grogan is associate professor in the School of Social Service Administration at the University of Chicago.

Michael K. Gusmano is is assistant professor of health policy and management at the State University of New York, Downstate Medical Center. He is the codirector of the World Cities Project, a joint project of the International Longevity Center—USA, New York University, and the State University of New York.

PrefaceAcknowledgments

Introduction

1. The Problem and Puzzle of Public Silence

Part I: Explanations and Background

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

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

Part II: Arguments and Findings

4. The Political and Policy Difficulties of Discussing Unequal Access

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

Conclusion

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

NotesReferences Index