The Power of Coalitions

• Published date: 01 March 2015
• Date: 01 March 2015
• Author: Margaret Weir,Charlie Eaton
• DOI: 10.1177/0032329214558558
• Subject Matter: Articles

Politics & Society

2015, Vol. 43(1) 3 –32

© 2014 SAGE Publications

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DOI: 10.1177/0032329214558558

pas.sagepub.com

Article

The Power of Coalitions:

Advancing the Public in

California’s Public-Private

Welfare State

Charlie Eaton

Margaret Weir

University of California, Berkeley, USA

Abstract

Between 1980 and 2010 California’s health care policy field shifted from a business-

dominated, closed-door pattern of decision making to a more open political arena.

Through this process, a wide-ranging and diversely resourced coalition advocating

on behalf of beneficiaries became an accepted partner in policymaking. This article

examines this transformation, considering its broader implications for the political

dynamics of the public-private welfare state and the role of advocacy groups in

defending beneficiary interests. We argue that multifaceted coalitions exploit three

vulnerabilities of the public-private welfare state, which presents openings for

advancing public priorities: 1) diverse and shifting interests, which allow advocates

to build broad coalitions that include labor and some providers 2) service gaps that,

when publicized, can generate public outrage; and 3) the hybrid institutional form

of the public-private welfare state, which can connect service delivery organizations

with a broader pro-public coalition.

Keywords

coalitions, welfare states, social policy, health care, advocacy, organizations

Corresponding Author:

Charlie Eaton, Department of Sociology, University of California, Berkeley, 410 Barrows Hall, Berkeley,

CA 94720, USA.

Email: charlie.eaton@berkeley.edu

558558PASXXX10.1177/0032329214558558Politics & SocietyEaton and Weir

research-article2014

4 Politics & Society 43(1)

Since the 1960s, new US social programs have often been delivered by the states and

an array of nonprofit and for-profit organizations rather than directly by the federal

government. This pattern of social provision through “the delegated state” pervades

policies that entail anything more than a check in the mail.1 A growing body of work

documents the political obstacles that these arrangements create for building stable

support for social policy and for challenging retrenchment. Few accounts, however,

consider what it would take to overcome these obstacles.

The challenges are formidable. Devolution and public-private implementation

make it more difficult to mobilize political support among beneficiaries, who often do

not recognize the public role in “the submerged state.”2 Public-private arrangements

also give rise to “subterranean politics” that allow a small circle of powerful actors to

make key decisions shielded from public eyes.3 Moreover, the path-dependent nature

of much social policy suggests that in constructing this type of welfare state the United

States turned onto a road of eroding public capacity from which it cannot depart.

In this article, we argue that despite these obstacles, the public-private welfare state

possesses three distinctive vulnerabilities that pro-public coalitions can exploit to

build their own power and to champion broad social interests in policy. The first are

the possibilities for realigning the interests of consumers, labor, and providers.

Competition and divergent interests among private providers supply openings for

advocates to redraw coalitional lines, making possible strong alliances that unite con-

sumers, workers, and eventually some providers. Second, public-private provision

inevitably creates service gaps around which pro-public coalitions can mobilize.

Third, pro-public coalitions can use the institutional hybridity of the public-private

welfare state to their own advantage, reining in private interests and expanding the

forces pressing for a broader public role.

We draw on the case of California to demonstrate how a coalition with diverse

organizational capabilities emerged to transform the politics of health care access after

1980. During that time California’s health care policy field shifted from a business-

dominated, closed-door pattern of decision making to a more open political arena.

Through this process, a wide-ranging and diversely resourced coalition advocating on

behalf of beneficiaries became an accepted partner in policymaking.

The coalition achieved significant policy victories beginning with anti-patient

dumping legislation in 1986. It played a central role in ensuring that the proceeds from

converting nonprofit health care organizations to for-profit status would fund a foun-

dation with significant advocate control. The coalition was also instrumental in creat-

ing the Department of Managed Care in 1999 and through that agency was able to

promote policies that aimed to expand access to health care. These included transpar-

ency policies that provided advocates access to industry data, regulatory review that

required advocate input, and consumer assistance policies through which advocates

could mobilize consumers to enroll and access health care programs.

In a state with a large immigrant and uninsured population, whose legislature

required supermajorities to raise taxes and approve budgets, the pro-public coalition

fought an uphill battle to expand health care access.4 Despite significant obstacles,

California improved health care coverage rates from 1999 to 2012 in contrast to other

demographically diverse states that also featured deregulated insurance markets in the