Public silence in policymaking can be deafening. When advocates for a disadvantaged group decline to speak up, not only are their concerns not recorded or acted upon, but also the collective strength of the unspoken argument is lessened - a situation that undermines the workings of deliberative democracy by reflecting only the concerns of more powerful interests. But why do so many advocates remain silent on key issues they care about and how does that silence contribute to narrowly defined policies? What can individuals and organizations do to amplify their privately expressed concerns for policy change? In "Healthy Voices, Unhealthy Silence", Colleen M. Grogan and Michael K. Gusmano address these questions through the lens of state-level health care advocacy for the poor. They examine how representatives for the poor participate in an advisory board process by tying together existing studies; extensive interviews with key players; and, an in-depth, first-hand look at the Connecticut Medicaid advisory board's deliberations during the managed care debate. Drawing on the concepts of deliberative democracy, agenda setting, and nonprofit advocacy, Grogan and Gusmano reveal the reasons behind advocates' often unexpected silence on major issues, assess how capable nonprofits are at affecting policy debates, and provide prescriptive advice for creating a participatory process that adequately addresses the health care concerns of the poor and dispossessed. Though exploring specifically state-level health care advocacy for the poor, the lessons Grogan and Gusmano offer here are transferable across issue areas and levels of government. Public policy scholars, advocacy organizations, government workers, and students of government administration will be well-served by this significant study.

A sweeping history of the American health care state that reveals the public has been intentionally misled about the true role of government. The US government has always invested federal, state and local dollars in public health protection and prevention. Despite this public funding, however, Americans typically believe the current system is predominantly comprised of private actors with little government interference. In Grow & Hide, Colleen M. Grogan details the history of the American health care state and argues that the public has been intentionally misled about the true role of government. The US created a publicly financed system while framing it as the opposite in what Grogan terms the "grow-and-hide regime." Today, the state's role is larger than ever, yet it remains largely hidden because stakeholders-namely, private actors and their allies in government-have repeatedly, and successfully, presented the illusion of minimal government involvement. The consequences of this narrative are scarce accountability and a highly unequal distribution of benefits. In the wake of a pandemic that has killed over one million Americans—with the highest death rates among minorities and lower-income people—the time has come for an honest discussion about the health care system. As Grogan reveals, America has never had a system that resembles a competitive, free-market model. Given how much the government already invests in the health care system, means how these funds are distributed and administered are fundamental political questions for the American public, not questions that should be decided by the private sector. If we want to fix care in America, we need to reimagine the way it is organized, prioritized, funded, and, perhaps most importantly, discussed. Grow & Hide is an important contribution to this reimagining.

The existence of health inequities across racial, ethnic, gender, and class lines in the United States has been well documented. Less well understood have been the attempts of major institutions, health programs, and other public policy domains to eliminate these inequities. This issue, a collaboration with the Robert Wood Johnson Foundation Investigator Awards in Health Policy Research Program, brings together respected historians, political scientists, economists, sociologists, and legal scholars to focus on the politics and challenges of achieving health equity in the United States. Articles in this issue address the historical, legal, and political contexts of health equity in the United States. Contributors examine the role of the courts in shaping health equity; document the importance of political discourse in framing health equity and establishing agendas for action; look closely at particular policies to reveal current challenges and the potential to achieve health equity in the future; and examine policies in both health and nonhealth domains, including state Medicaid programs, the use of mobile technology, and education and immigration policies. The issue concludes with a commentary on the future of health equity under the Trump administration and an analysis of how an ACA repeal would impact health equity. Contributors. Alan B. Cohen, Keon L. Gilbert, Daniel Q. Gillion, Colleen M. Grogan, Mark A. Hall, Jedediah N. Horwitt, Tiffany D. Joseph, Alana M.W. LeBron, Julia F. Lynch, Jamila D. Michener, Vanessa Cruz Nichols, Francisco Pedraza, Isabel M. Perera, Rashawn Ray, Jennifer D. Roberts, Sara Rosenbaum, Sara Schmucker, Abigail A. Sewell, Deborah Stone, Keith Wailoo

The contributors to this issue investigate the complex ways that policies of the Affordable Care Act (ACA) have diffused through the states over seven years of implementation. When the ACA was passed in 2010, states were given the option to set up their own health care exchanges, expand their Medicaid programs, and reform both their local public health and their health care delivery systems. These reforms significantly impacted citizens' access to insurance. Contributors examine how local conditions account for variation in enrollment across states, analyze the evolution of Medicaid waivers in Republican-led states, show how early-adopting states affected later adopters, explore the role of public opinion in the diffusion of ACA policies, and argue for the importance of rhetorical framing when advocating in favor of the ACA. Contributors. Frederick J. Boehmke, Timothy Callaghan, Rena Conti, Bruce A. Desmarais, Colleen M. Grogan, Jeffrey J. Harden, Lawrence Jacobs, David K. Jones, Andrew Karch, Elizabeth Maltby, Julianna Pacheco, Aaron Rosenthal, Abigail A. Rury, Phillip McMinn Singer, Craig Volden