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Safety-net providers play a central role in the U.S. health care system because they provide the bulk of services to the poor and the uninsured. The health policy literature focuses a great deal on the capacity of these institutions to provide services and the forces that shape these institutions and the services they provide, yet little is made of safety-net providers' potential role as advocates for the poor and for disadvantaged groups. In this article, we draw on findings from a case study of Medicaid policy making in Connecticut to explore efforts by safety-net providers and other nonprofit organizations to advocate around health care policy for the poor. Our findings illustrate how the capacity of nonprofit advocates to represent the poor can be compromised when the rules of the game change and nonprofit providers are asked to compete with for-profit organizations. We find that under a change in the contracting regime--from collaboration to competition--nonprofit service providers may increase political activity to secure a favorable role under the new regime, but these efforts may compromise their ability to act as representatives of the poor.

While the economic reforms since 1978 have brought about substantial changes in the rural health care system, there have been many and far-reaching implications for the urban health insurance system as well. This paper describes the evolving urban economy and examines the implications of these changes for access to health care coverage. Provided first is a brief description of the Chinese urban health care system. Three major areas of urban economic reform since 1984 are outlined and the possible effects of these reforms on health care coverage are discussed. The analysis reveals, first, the emergence of insurance coverage inequities under employment-based health insurance as China moves toward a open market economy. Second, the process of focusing on health services in rural and urban areas as separate systems is unnecessary and even counter-productive in light of the emerging integration of China's urban and rural-economies. Finally, some reasons for why China continues to search for employment-based health financing approaches are offered.

Although ERISA is a barrier to state health care reform, its hurdle is not as formidable as the financial and political constraints that state governments face. As the states themselves confess, they cannot solve this problem alone (National Governors Association 1993); but if they must, they will focus on the incremental, "low-cost" reform options--insurance reforms and Medicaid managed care. Connecticut Representative Courtney perhaps summarized state sentiment best: "Maybe we shouldn't be using the word 'reform'; it raises expectations" (Spencer-Molloy 1994b). Indeed, states will proceed more cautiously now than just a year ago because the federal failure accentuated the political gamble of health care reform and made the future prospect of transferring federal funds to state governments appear very bleak. Unfortunately, such cautious reforms will not move us toward the goal of universal (or statewide) coverage, a goal that seemed within our grasp only two years ago.