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.