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Studies in Postwar American Political Development
The Delegated Welfare State: Medicare, Markets, and the Governance of Social Policy
Why are so many American social programs delegated to private actors? And what are the consequences for efficiency, accountability, and the well-being of beneficiaries? The Delegated Welfare State examines the development of the American welfare state through the lens of how policymakers have avoided direct governmental provision of benefits and services, turning to non-state actors for the governance of social programs. Utilizing case studies of Medicare and the 2009-10 health care reform, Morgan and Campbell argue that the prevalence of delegated governance reflects the powerful role of interest groups in American politics, the dominance of Congress in social policymaking, and deep contradictions in American public opinion. Americans want both social programs and small government, leaving policy makers in a bind. Contracting out public programs to non-state actors masks the role of the state and enlists private allies who push for passage. Although delegated
governance has been politically expedient, enabling the growth of government programs in an anti-government political climate, it raises questions about fraud, abuse, administrative effectiveness, and accountability. In probing both the causes and consequences of delegated governance, The Delegated Welfare State offers a novel interpretation of both American social welfare politics and the nature of the American state.
governance has been politically expedient, enabling the growth of government programs in an anti-government political climate, it raises questions about fraud, abuse, administrative effectiveness, and accountability. In probing both the causes and consequences of delegated governance, The Delegated Welfare State offers a novel interpretation of both American social welfare politics and the nature of the American state.
- GenresPolitics
328 pages, Paperback
First published September 16, 2011
56 people want to read
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October 22, 2023
In The Delegated Welfare State, Kimberly Morgan and Andrea Louise Campbell, both professors of political science, examine the evolution of the federal safety net since the mid-twentieth century, fingering the passage of the 2003 law that added a prescription drug benefit to Medicare as the archetype of a recent form of policy intervention that involved non-state actors, selective contracting, and private dependences. This process of policy implementation through intermediaries (what the authors call “delegated governance”) was a relatively common instrument of policymaking that enabled the administration of welfare services, child support enforcement, Medicaid, school vouchers, private prisons, and, as the authors prominently highlight, Medicare. The authors liken the delegation of governance to a compromise between completely marketized services with no federal oversight and enterprises wholly owned and operated by the federal government. Where there are pressing popular demands for social services, lawmakers have responded by using third-party actors (in the example of Medicare Part D, for-profit drug plans) with oversight from the federal government to operationalize policy objectives without concomitantly expanding the size of the government.
Under the 2003 Medicare Modernization Act (MMA), Congress created a universal prescription drug benefit facilitated by risk-bearing private plans that were tasked with contracting with the government to administer the drug benefit, process claims, and negotiate with drug manufacturers to ensure beneficiary access to medications. The authors describe how social pressures for a prescription drug benefit in the late 1990s led to legislative momentum among both parties. However, Republicans, who enjoyed majorities in both chambers at the turn of the century, spearheaded the movement to contract out the responsibilities of administering the benefit to private insurance plans. As the authors note, diffusing responsibility across a complicated array of non-state actors creates complications that undermine the operational efficiency of the policy design. Under such a delegated regime, administrative coherence is weakened and the principal-agent problem is strengthened – both concerns that would be mitigated under a public system. While still scratching a social itch for additional public goods, delegated governance often creates unforeseen problems that ultimately leave the government holding the bag. As the authors describe with Medicare, the use of private plans has led to a complicated environment of hundreds of plans which seniors find hard to navigate, wasteful private spending, and a web of private dependencies such as issue advocacy groups and stakeholders that spend vast sums of money to ensure the continuation of those dependencies. Additionally, the federal agencies in charge of overseeing these programs are often understaffed, underfunded, and simply unable to guarantee accountability in the system.
The Delegated Welfare State is an illuminating case study of the limitations of policy provision by proxy. The authors demonstrate that social demands for policy intervention are often met by creative solutions that avoid overt expansion of federal bureaucracy and involve an ecosystem of private intermediaries. While this may enable political compromise, it often leaves programs with less administrative coherence and large dependencies of non-state actors each clamoring for their place in the system. The authors dispel the myth of a fully public U.S. welfare state, instead revealing a more byzantine series of public-private partnerships where responsibility and risk are diffused (and diminished, as the authors argue), and interest groups thrive.
Under the 2003 Medicare Modernization Act (MMA), Congress created a universal prescription drug benefit facilitated by risk-bearing private plans that were tasked with contracting with the government to administer the drug benefit, process claims, and negotiate with drug manufacturers to ensure beneficiary access to medications. The authors describe how social pressures for a prescription drug benefit in the late 1990s led to legislative momentum among both parties. However, Republicans, who enjoyed majorities in both chambers at the turn of the century, spearheaded the movement to contract out the responsibilities of administering the benefit to private insurance plans. As the authors note, diffusing responsibility across a complicated array of non-state actors creates complications that undermine the operational efficiency of the policy design. Under such a delegated regime, administrative coherence is weakened and the principal-agent problem is strengthened – both concerns that would be mitigated under a public system. While still scratching a social itch for additional public goods, delegated governance often creates unforeseen problems that ultimately leave the government holding the bag. As the authors describe with Medicare, the use of private plans has led to a complicated environment of hundreds of plans which seniors find hard to navigate, wasteful private spending, and a web of private dependencies such as issue advocacy groups and stakeholders that spend vast sums of money to ensure the continuation of those dependencies. Additionally, the federal agencies in charge of overseeing these programs are often understaffed, underfunded, and simply unable to guarantee accountability in the system.
The Delegated Welfare State is an illuminating case study of the limitations of policy provision by proxy. The authors demonstrate that social demands for policy intervention are often met by creative solutions that avoid overt expansion of federal bureaucracy and involve an ecosystem of private intermediaries. While this may enable political compromise, it often leaves programs with less administrative coherence and large dependencies of non-state actors each clamoring for their place in the system. The authors dispel the myth of a fully public U.S. welfare state, instead revealing a more byzantine series of public-private partnerships where responsibility and risk are diffused (and diminished, as the authors argue), and interest groups thrive.
January 2, 2018
For these authors, the public is made out of imbeciles. Mostly. And they need the enlightened guidance of some academic paper pushers. And just like the old lady with a crystal ball, you need to pay the leeches with grants and tenures in order to make a better guess.
May 18, 2020
Well researched and well written, The Delegated Welfare State is useful to anyone who wants to better understand social policy and government in the US.
Displaying 1 - 3 of 3 reviews