Book Club: Healthy Voices, Unhealthy Silence: Advocacy and Health Policy for the Poor

It was difficult to read Healthy Voices, Unhealthy Silence by Colleen Grogan and Michael Gusmano; thankfully it is short. It explores Connecticut’s adoption of managed care for Medicaid in 1996. The picture it paints is not flattering. Published in 2007, I’m embarrassed that I hadn’t seen this book before now.

The authors track the implementation of managed care in Connecticut Medicaid through publix meetings of the Medicaid Managed Care Council (now MPOC) and its subcommittees. I was staff to the Council during this period; I was very new to health policy and Connecticut politics. The authors spent many hours attending meetings, reading summaries, and privately interviewing key stakeholders over two years. My recollections and experience align well with their perceptions.

Managed care, especially commercial plans, upended traditional relationships and the financial interests of Medicaid providers and advocates for the poor. The new incentives imposed competition, where there used to be collaboration. Consequently, providers and monitors were silent in meetings about concerns  for members’ healthcare that they voiced in private interviews. Advocates, who were not dependent on state funding, were also silent, not wanting to upset what seemed inevitable and not to disagree with powerful Medicaid advocates and providers.

The book is a powerful reminder that independent, informed voices representing poor people’s healthcare are critical to avoiding massive mistakes that harm health and waste taxpayer funds. The book outlines the harm that happens when advocates and providers aren’t brave and don’t speak up, because it offends important people/old friends and might jeopardize the bottom line.

Thankfully, sixteen years later, Connecticut reversed that bad decision, fired the managed care companies, and moved to a care management-focused system. Since then, costs are well below other states and stable. Access and quality of care are far improved.