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 delegation: 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.

Kimberly J. Morgan is Associate Professor of Political Science at George Washington University.

Andrea Louise Campbell is Associate Professor of Political Science at Massachusetts Institute of Technology.

Chapter One. Introduction
The Concept of Delegated Governance
The Case Study of Medicare
The Methodology and Organization of This Book

Chapter Two. Exploring the Delegated Welfare State
Conceptualizing the Delegated Welfare State
What Does the Delegated Welfare State Look Like?
A Cross-National Perspective on Delegated Governance
Why Did the Delegated Welfare State Emerge in the US?
Does It Matter How Social Programs Are Administered?
Conclusion

Chapter Three. Medicare and the Delegated Welfare State in the Post-War Era
The Emergence of the Delegated Welfare State
Delegating the Governance of Medicare
Conclusion

Chapter Four. The Rise of the Market Reform Movement
The Complex Politics of Welfare State Privatization
The Free Market Movement in Health Care
The Politics of Marketization
Conclusion

Chapter Five. Crafting the Medicare Modernization Act of 2003
Delegated Governance in the MMA
The Political Context: Polarization, Electoral Competition, and Partisan Conflict
Program Design: The Turn to Delegated Governance
Passing the MMA in 2003
The Politics of Delegated Governance

Chapter Six. Administering the Delegated Welfare State The Cases of Medicare and the 2003 Medicare Modernization Act
Delegated Governance in Traditional Medicare: A Mixed Picture
Creating a Social Welfare Marketplace: The 2003 MMA
Conclusion

Chapter Seven. The Delegated Welfare State and Policy Feedbacks
The Feedbacks That Haven't Happened (Yet)
The Feedbacks that Did Happen: Public Demobilization and Issue Preemption
Conclusion

Chapter Eight. Citizens, Consumers, and the Market Model
Consumers and the Requirements of the Market Model
Senior Consumers and Part D Decisionmaking
Part D Effectiveness and Senior Welfare: Mixed Evidence
Vulnerable Populations and Redistribution Issues
Conclusion

Chapter Nine. Conclusion: Delegated Governance, Past, Present, and Future
Implications for Thinking about the American State
The 2009-2010 Health Care Debate: A Fight about Governance

Appendix A. Data Sources
Interviews
MMA Panel Survey
Wisconsin Advertising Project Data

Appendix B. Supplementary Tables