Partnering with the Strong but Blind State: How Civic Associations Co-Create Policy While Implementing the Affordable Care Act

Scholars identify the United States as emblematic of a delegated welfare state and argue that this political form privileges elite and typically conservative interests. Such treatments overstate undemocratic aspects of delegated governance by focusing narrowly on the passage of new laws over other types of policy innovation—notably implementation, which creates opportunities for various stakeholders to co-opt public policy. I illustrate this via an ethnographic investigation of one state’s implementation of Medicaid expansion under the Affordable Care Act, which introduces at least three layers of delegated authority: from the federal government to the state, from the state to Managed Care Organizations (MCOs), from MCOs to Accountable Care Organizations. State bureaucrats exercise great discretion over the process but are administratively hobbled by staffing shortages and outsourcing, rendering them relatively blind. They achieve legibility by working with advocacy and social service organizations to obtain extensive information about practices elsewhere, extensive information about in-state practices, and intensive information about processes that produce metrics. These public-private partnerships present civic associations with opportunities to shape policy from within the state.