Contested Capacity: Advocacy Groups in the Public-Private Welfare State

Abstract

Social policy is big businesses for a growing number of nonprofit and private firms in the United States. Publicly-supported housing, social services, and health care have long been funded by government but supplied by a mix of nonprofit and for-profit firms. Despite its pervasiveness, we know little about the political dynamics of the public-private welfare state. There is growing attention to the role of the private sector in providing social benefits but we have few accounts of how the divergent interests of private service providers and beneficiaries of social programs are fought out and resolved. This paper addresses this question by analyzing the development of advocate-labor alliances in state-level battles over health care in the United States from the 1970s to the present. Examining the cases of California and New York, we argue that advocacy organizations can play a key role in promoting democratic engagement into the often hidden decision making processes that characterize the public-private welfare state. We show that the dynamism of private sector competition creates opportunities for advocacy groups to forge a strategy of “regulation from below” that defends social benefits at the same time that it builds advocate capacity. Advocates have used periodic market disruptions in the health care sector to draw public attention to the need for regulation, to build new coalitions, garner new resources for advocacy and grassroots mobilization, and ultimately to make organizational and policy changes that institutionalize the power of advocates and health care consumers.