published_or_final_version / Social Work and Social Administration / Doctoral / Doctor of Philosophy

Does authoritarian regime provide social protection to its people? What is the purpose of social welfare provision in an authoritarian regime? How is social welfare policy designed and enforced in the authoritarian and multilevel governance setting? Who gets what, when and how from the social welfare provision in an authoritarian regime? My dissertation investigates these questions through a detailed study of Chinese social health insurance from 1998 to 2010. I argue and empirically show that the Chinese social health insurance system is characterized by a nationwide stratification pattern as well as systematic regional differences in generosity and coverage of welfare benefits. I argue that the distribution of Chinese social welfare benefits is a strategic choice of the central leadership who intends to maintain particularly privileged provisions for the elites whom are considered important for social stability while pursuing broad and modest social welfare provisions for the masses. Provisions of the welfare benefits are put in practice, however, through an interaction between the central leaders who care most about regime stability and the local leaders who confront distinct constraints in local circumstances such as fiscal stringency and social risk. The dynamics of central-local interactions stands at the core of the politics of social welfare provision, and helps explain the remarkable subnational variation in social welfare under China's authoritarian yet decentralized system. This dissertation attempts to contribute to the studies of authoritarianism, decentralization and social welfare in the following aspects. First, in specifying the rationale, conditions and policy results of the interaction between Chinese central and local leaders in social welfare provision, the dissertation sheds light on how political leaders in an authoritarian regime with multilevel governance structure respond to social needs. The analysis of subnational politicians' incentive structure and policy choices in social welfare provision, which are missing in most extant studies of authoritarianism and social welfare, demonstrates an "indirect accountability" built into the Chinese social welfare provision. This "indirect accountability", evidenced by local leaders' proactive accommodation of social and local needs through social policies, may partially account for the puzzling resilience and flexibility of Chinese authoritarian regime. Second, the dissertation demonstrates that social welfare expansion, in some cases, is not a result of democracy but of resilient authoritarianism. Social welfare is one tool employed by authoritarian leaders to maintain regime stability. The political motivation for social welfare provision is different in non-democracies--it is more directly from top-down pressure of maintaining order rather than from bottom-up demands as in democracies--but this does not mean that non-democracies provide less social welfare than democracies do. Furthermore, the dissertation highlights the multidimensionality of social welfare policy and the trade-offs that politicians face in distributing welfare benefits. It suggests that politicians, no matter in democracies or non-democracies, face similar policy trade-offs (e.g. coverage versus generosity) in social welfare provision and that they make policy choices on the different dimensions of social welfare -coverage, generosity and stratification- according to the specific institutional and socioeconomic constraints they encounter. It is the combination of these different choices that constitute the variation of social welfare provision observed cross countries and within countries.

“Strange Bedfellows” examines how the political economy of Medicaid and hospital provision shaped the social, political, and thus material response to the HIV/AIDS epidemic in the United States. By doing so, this study explores the consequences of a decade-plus shift that began in the late 1960s, wherein federal, state, and local policymakers deemphasized epidemic preparedness and acute care in favor of downsized hospitals, increased outpatient services, and more “personal responsibility.” Over the course of seven chapters, the study links the transformation of Medicaid into a welfare medicine program; federal health planning’s shift from the pursuit of equality to cost-cutting; the role that anti-inflation policy played in curtailing subsidies for hospitals and clinics, which reduced access to acute care; the diminution of civil rights protections for quality healthcare; and the effects these developments had on the response to HIV/AIDS. Challenging the notion that the HIV/AIDS epidemic was unforeseen and, thus, impossible to plan for, the study demonstrates how a series of purposeful decisions by presidential administrations, Congress, state legislatures, and city officials led to chronic underinvestment in public and voluntary hospitals that served poor people and people of color. A story of the neoliberal transformation of the Medicaid program and public and voluntary safety net hospitals, this dissertation illustrates how healthcare and welfare politics intertwined from the mid-1960s to the new millennium in ways that confounded the United States’ epidemic preparedness. A healthcare system focused on chronic disease by the 1960s and cost cutting in the 1970s could not cope with an emergent infectious disease like HIV/AIDS.

Divorce and the Politics of the American Social Welfare Regime, 1969-2001 asks how rising divorce rates shaped the laws governing the American social welfare regime between 1969, when California passed the nation’s first no-fault divorce law, and 2001. Scholars have shown that in the early 20th century the American social welfare regime developed to distribute economic resources, such as Social Security, to women through their husbands. Between 1967 and 1979, however, the United States’ divorce rate doubled. This dissertation investigates how this sudden challenge to the breadwinner-homemaker family structure affected the gendered welfare regime. Divorce and the Politics of the American Social Welfare Regime examines how women organized to gain access to lost economic resources after divorce and how policymakers responded to their demands. It reveals important and forgotten components of the histories of welfare state development, the feminist movement of the 1970s, and marriage law. It argues that, ironically, rising divorce rates led to a series of federal laws that actually strengthened the social welfare system’s use of marriage to determine eligiblity for benefits. These new laws specifically rewarded intact marriages by providing more robust benefits to women in longer marriages. In a political world increasingly concerned with the impermenance of marriage, Congress created a legal system that signaled that marriage was about length of commitment above all else.