Healthy Voices, Unhealthy Silence

Advocacy and Health Policy for the Poor

Colleen M. Grogan and Michael K. Gusmano

"This book provides an interesting and lucid case example for scholars and practitioners on some key deficiencies of Third Way theory and practice."
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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.

Table of Contents



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


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



"This book provides an interesting and lucid case example for scholars and practitioners on some key deficiencies of Third Way theory and practice."—Political Science Quarterly

"Has much to offer people, who believe that the encouragement of public voice, especially about issues of concern, is necessary for a healthy democracy . . . this engaging book provides a heightened awareness that we must find a means to give voice to the powerless, and to learn to speak and listen to the language of the poor."—Health Progress

"In Healthy Voices, Unhealthy Silence, Colleen Grogan and Michael Gusmano offer a very timely, richly textured analysis of the complex politics of Medicaid. The book’s comprehensiveness and detail is truly impressive. Consequently, this book should be essential reading for scholars, policymakers, and advocates interested in the future of Medicaid and health care policy in the United States."—Steven Rathgeb Smith, associate dean, Daniel J. Evans School of Public Affairs and director, Nancy Bell Evans Center on Nonprofits and Philanthropy, University of Washington

"A fascinating social science mystery: Why don't talented activists speak up? In searching for the answer Grogan and Gusmano explore the real world of health care, poverty, local government, activism and the grass roots. What they discover are painful new limits to the power of voice. Carefully researched, beautifully written, thought-provoking, iconoclastic, and highly recommended."—James A. Morone, author of Hellfire Nation and coeditor of Healthy, Wealthy and Fair

"Citizen advocacy is alive and well in this provocative study of a state Medicaid advisory board, as the policy network shifts and managed care is implemented. An important topic with many policy implications."—Rosemary A. Stevens, DeWitt Wallace Distinguished Scholar, Weill Cornell Medical College


Supplemental Materials


About the Author

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.

170 pp., 5.5 x 8.5

Sep 2007

170 pp., 5.5 x 8.5

ISBN: 978-1-58901-182-3
Sep 2007

170 pp.

ISBN: 978-1-58901-339-1
Sep 2007

American Governance and Public Policy series
Gerard W. Boychuk, Karen Mossberger, and Mark C. Rom, Series Editors

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