Interorganizational Advocacy Among Nonprofit Organizations in Strategic Action Fields: Exogenous Shocks and Local Responses

Opportunities for Stasis and Change

Organizations’ everyday actions and clashes over positions affect their fields, fostering either stasis or change. As fields are linked together, actions from one field can propagate across fields. These create opportunities and crises that can elicit changes in relations and meaning-making. In particular, the state can alter connected fields through policies and resource allocation (Fligstein & McAdam, 2012). As nonprofit organizations depend upon the state for legitimacy and resources, including contracts that exchange funding for service provision (Frumkin, 2005; Smith & Lipsky, 1993), they are especially attuned to the state’s activities. However, “many ‘opportunities’ . . . die before they produce change” (Fligstein & McAdam, 2012, p. 107). As actors grapple to use these opportunities to enhance their respective positions, their fields reflect shifts toward or away from the prior order (Thelen, 2004).

Nascent and uncertain fields are especially susceptible to changes. When exogenous shocks destabilize fields, these present opportunities for actors to form new relations and advocate desired frames (Fligstein & McAdam, 2011, 2012). These can foster alterations or, more likely, intensify efforts to preserve the status quo as incumbents defend their positions. Through institutional entrepreneurship, people can recast their groups’ positions. Such efforts are evident in (a) the state, by introducing legislation regulations; (b) professions, by advocating particular practices; (c) challengers, by unleashing innovations that may enhance their positions; and (d) groups with organizational capacity that pursue interests in opposition to others (Strang & Sine, 2002). In new and unstable fields, institutional entrepreneurs can forge and propagate novel “systems of meaning” (Fligstein, 2001, p. 106). Such efforts can include framing, or mobilizing ideas that identify problems that require change and possible targets and alternatives (e.g., Benford & Snow, 2000). Although institutional entrepreneurs are often associated with the development of new fields, they also operate in stable fields, but their efforts are usually less successful (Fligstein & McAdam, 2011). To correct for the institutional entrepreneur literature’s overprivileging of people’s abilities to manifest change, scholars have urged focusing upon actors’ activities and interactions, such as how incumbents rebuff challengers’ efforts (Lounsbury & Crumley, 2007).

To move or preserve the status quo, actors—people representing themselves, groups, or organizations—must wield “social skill,” or the abilities to convince others to cooperate in collective action. Social skill involves forming affinities with others by (a) tapping extant rules and accepted ways of organizing, (b) mobilizing power relations among groups, and (c) using frames to understand available actions. By encouraging colleagues to recognize common ground, actors can form coalitions to take collective action that reinforces or transforms the social order (Fligstein, 2001). Advocacy groups that successfully promote new frames (cf. Scott, Deschenes, Hopkins, Newman, & McLaughlin, 2006) exemplify such social skill. However, insufficient resources can blunt the efficacy of social skill (Fligstein & McAdam, 2011, 2012).

Several of SAFs theory’s distinctive features deepen our understanding of how actors develop the social order. First, SAFs refocus the attention upon meaning-making and identity for orienting collective action (cf. Diani & Pilati, 2011). In addition, SAFs highlight the role of social skill in coordinating action, as well as how linkages among fields shape opportunities for action. Furthermore, SAFs show how actors occupy cooperative versus conflictual positions and how IGUs reinforce the status quo. More importantly, SAFs acknowledge how actors’ activities reproduce or alter the status quo. Finally, SAFs include the state as a field that affects linked fields (Fligstein & McAdam, 2012); this strength is evident in recent studies that apply SAFs to show how economic and political conditions affect newspaper coverage (Lei, 2016) and to explain how transnational identities form (Lune, 2015).

Criticisms of SAFs have targeted its focus on action, narrow conceptions of action, and seeming concessions to rational calculation (Goldstone & Useem, 2012) and question whether actors occupying different positions can truly share the meaning (Minkoff, 2014). Nonetheless, SAFs underscore how the search for meaning and connection encourages people to undertake collective action, including coordinating organizations. As social beings, we cooperate, even without direct benefits to ourselves (Fligstein & McAdam, 2012). Moreover, as Western rationalization cultivates the pursuit of equality and progress (Meyer, Boli, & Thomas, 1987; Meyer & Rowan, 1977), we direct action toward addressing “social problems” (Strang & Sine, 2002, p. 513). Ethnographic observations are well-suited for documenting emerging interorganizational activities that fuel such efforts.

By examining how organizations interact, we can gain insight into the activities of SAFs, including how actors develop rules of the field (Haug, 2013). Through their interactions, actors solidify positions (Paquin & Howard-Grenville, 2013); a few collectively may successfully launch new fields (van Bommel & Spicer, 2011). However, we also need insight into “non-cooperative” actions among actors (Hardy & Maguire, 2008, p. 213). Thus, examining SAFs in which organizations, particularly nonprofit ones, contest versus reproduce the status quo would be helpful for differentiating conditions of change versus stasis.

Selection of Observed Umbrella Organizations

In delineating field boundaries, I followed Fligstein and McAdam’s (2012) definition of “field membership” as “those groups who routinely take each other into account in their actions” (pp. 167-168). I selected IOCs for their monthly meetings and associated events; a particular SAF included those organizations whose representatives attended these get-togethers. I focused on these umbrella organizations because they were the most visible—almost all had websites and listservs—and established, with meetings that welcomed both the public and members. ⁶ I identified these groups via online searches and informants’ recommendations.

IOCs drew members whose organizations served older adults in a specific geographic area. All of the IOCs had active nonprofit organizations with elected leadership. ⁷ Each IOC’s board volunteered their time to email announcements to members, update their group’s website, and arrange space, speakers, and sponsors for meetings and events. Individual persons and organizations paid annual dues between US$15 and US$75; these funded an online or paper directory of members. According to informants, IOCs’ activities dated back to the late 1960s and 1970s, when boroughs funded gatherings that allowed organizational representatives to network and share information.

Although the IOCs’ meetings were advertised as “open to all,” observations of meetings’ self-introductions revealed that representatives of member organizations comprised the overwhelming majority of attendees; older adults who were not organizational representatives rarely attended these meetings. IOCs’ meetings attracted small business owners such as moving coordinators and pest control specialists, fledging organizations that trained volunteers to visit with the homebound elderly, established nonprofit organizations that provided social services under contract (i.e., senior centers), health care providers, and law firms specializing in elder care planning. Representatives from local community boards, unions, governmental agencies, and other organizations also attended. These IOCs reflected the diverse and dense ecology of for-profit, nonprofit, and voluntary organizations serving a particular geographic area. Such differences fueled comparisons of how the umbrella organizations conceived of issues.

In the borough of Manhattan, observations covered all active IOCs, which were Northwestern Manhattan (NWMIOC), Northeastern Manhattan (NEMIOC), Western Manhattan (WMIOC), Eastern Manhattan (EMIOC), Central Manhattan (CMIOC), and Lower Manhattan (LMIOC). ⁸ These IOCs also could send representatives to the Manhattan-borough-wide IOC to coordinate efforts. However, because of organizational restructuring and insufficient funding from the borough, this super-umbrella organization suspended its meetings. Thus, I could observe only one of its meetings in 2012.

Related Observations

To understand the studied SAFs’ connections to the state, my research team and I also observed relevant local government meetings between the fall of 2010 through the fall of 2012. These included city council meetings and hearings about issues affecting older adults, such as the NYC Department. for the Aging (DFTA) budget, which funds local organizations to provide human services such as meals, Manhattan community board committee meetings, and a series of participatory budgeting meetings about funding allocation to improve infrastructure.

Conduct of Observations

The meetings of six IOCs were observed between 13 and 21 times each, for a total of 110 observations (Table 1). Observations covered a time span of 3½ years between September 2010 and June 2013, with follow-up observations in the fall of 2013. This duration helped me discern whether activities were typical or unusual, as well as follow ongoing issues. Although the economic recession spanning 2007 and 2009 suggested unusual conditions, studies and media reports (i.e., Fitch, 1995) of prior decades revealed corollaries with previous periods of fiscal austerity.

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Table 1.

Interorganizational Coalitions Regularly Studied.

Name	Number of observations conducted
Northwestern Manhattan Interorganizational Coalition (NWMIOC)	21
Northeastern Manhattan IOC (NEMIOC)	13
Western Manhattan IOC (WMIOC)	18
Eastern Manhattan IOC (EMIOC)	21
Central Manhattan IOC (CMIOC)	16
Lower Manhattan IOC (LMIOC)	21
Total	110

Note. Names are pseudonyms. All had monthly meetings from September to June, except NEMIOC, which met bimonthly.

While in the field, I also talked with organizational representatives about their understanding of interorganizational activities. I asked questions prompted by on-going events and included their responses in my field notes. Below, the names of quoted individuals (marked by asterisks*) and their identifying information are disguised. However, when quoting testimony at a city council meeting, I use persons’ actual names as these are documented in a publicly available record.

Analysis of Observations

I analyzed the field notes of IOC meetings by identifying presentation topics and their associated organizations, questions raised by attendees, and discussions. This content was coded into categories such as education about organizational programs, education about policy, education about older adult well-being, and education about advocacy. I further coded content into thematic memos about issues raised and actions proposed, such as mobilizing seniors, contacting local officials, or forming or joining coalitions, community board subcommittees, and forming IOCs subcommittees devoted to these issues. I then compared activities across the IOCs.

Collective Sensemaking of State-Initiated Exogenous Shocks

From 2011 onwards, Medicaid cuts posed an exogenous shock for SAFs serving older adults with this safety net health insurance. In January 2011, citing fiscal austerity, New York Governor Andrew Cuomo recruited CEOs of health service providers and one advocate from Medicare Rights, a coalition organization, to serve on the “Medicaid Redesign Team (MRT).” ⁹ As experts noted, this uneven representation ensured that providers could mold policy toward protecting their interests. Meanwhile, the voices of citizens and smaller, community-based organizations were relegated to a few opportunities for public comment on suggested “cost savings” measures. ¹⁰ Not unsurprisingly, the MRT’s recommendations mirrored the interests protected by an IGU, a hospital trade association. At a NEMIOC meeting, a representative of the Greater New York Hospital Association (GNYHA) described the field’s IGU as informing the state’s agenda: “All the hospitals are members [of GNYHA]; we are a trade association. We do advocacy and policy. The feds and state rely upon us for experience . . . .” Stating “You can throw tomatoes at me, but we were very supportive of [the MRT’s] recommendations,” he claimed that without the hospitals’ input, the cuts could have been worse. When asked about community-based organizations’ role in enhancing health care, the speaker glossed over this potential partnership, extolling the virtues of managed care. ¹¹ Such comments suggested that MRT’s composition allowed hospitals to disregard other organizations’ perspectives.

Given their lack of representation within this policymaking committee, organizations’ representatives scrambled to understand implemented policy changes. Several of the IOCs’ meetings featured information on how the Medicaid changes’ affected clients’ well-being. At a WMIOC meeting in December 2011, one presenter, an advocate with a legal degree, depicted how these changes had obviated “thirty years of minimum standards” built through advocacy and “litigation.” She anticipated that now that providers could decide what coverage to offer, they would prioritize their finances over their clients’ welfare. To illustrate how reduced coverage underserved people, she described how a 50-year-old client undergoing “radiation treatments five times a week” for cancer “had 30 hours of home care . . . slashed to 15 hours.” As the audience expressed distress, the speaker noted that the widower, who lacked family help, was allotted fewer hours of home care because “that’s what the tool says.” ¹² By curtailing home services, this new procedure risked clients’ quality of life and threatened service providers’ sustainability. Underscoring this period’s uncertainty, the advocate stated, “We are in the Wild, Wild West, and we don’t know how it’s going to shake out.”

Substantiating this comment about ambiguity, IOCs’ members concentrated on sensemaking, gathering information to understand the policy changes’ impact. For instance, at a LMIOC board meeting in January 2012, board members and guests discussed what topics and speakers to feature at future meetings. Meredith Chiao*, the LMIOC co-president, suggested discussing anticipated “changes in the Managed Long Term Care program.” This would help professionals educate clients about Medicaid’s new requirement that recipients of 120 days or more of home care enroll in Managed Long Term Care (MLTC) programs; MLTCs work with a capitated or set amount irrespective of demand, rather than being reimbursed per treatment. Elise Moore*, a board member of the Upper East Side (UESIOC) who attended the LMIOC board meeting as a guest, noted, “We had [a legal expert] speak about this [at a UESIOC meeting].” With a puzzled expression, Moore noted because this policy was so new, the presenter did not yet have examples to help attendees understand the policy: “I couldn’t understand any of it. She didn’t have any cases that it would hinge upon.” Nora Madera* responded, “At another [IOC] meeting, she had cases.” Madera then described how affected organizations had adopted a wait-and-see approach to the unfolding policy changes: “Visiting Nurse Services (VNS) has been quiet because they don’t have the info. What has the state, federal [government] sent out? Everyone is not ready.” Chiao suggested revisiting this topic later, when they better understood these changes: “In May, we may have some info.” ¹³ Indeed, at the May LMIOC meeting, a guest speaker, an analyst who worked at a large medical provider, answered a flurry of questions about Medicaid redesign and its anticipated impact. ¹⁴ Such presentations continued to familiarize attendees with implemented policies.

Through their direct input into policymaking, incumbent organizations, or the biggest health care providers, created policies in their favor. This left other organizations to puzzle out the consequences of policy changes. These organizations constructed understandings of their field through IOC meetings, with the help of presenters who outlined the implications of policy changes for clients. Several of the IOCs’ members—namely, organizations whose services enabled older adults to recuperate at home—were challenger organizations competing over resources with other health care providers; shrinking resources and imbalanced relations favoring hospitals reinforced a hierarchically constructed field. Several conditions suggest that the challenger organizations could have considered collective action to demand resources from the state: via the IOCs, organizations had a connected group with boundaries, a sense of a shared mission, and time and space dedicated to dialogue. At this point, the challenger organizations did not mobilize beyond collective sensemaking of the state’s guidelines. However, several months after these presentations, some of the IOCs’ members—senior centers—pursued collective action as new entrants to their SAF emerged with the Medicaid policy changes. In this phase, incumbent organizations and elected officials explored how rules and regulations could hold challenger organizations accountable, protecting incumbent organizations’ positions.

Defending Against New Challenger Organizations

Observations of IOCs’ meetings and a city council hearing, as well as conversations with social workers and health care professionals, indicated that actors viewed the Medicaid policy changes as an exogenous shock that was reconfiguring their SAF. Now that Medicaid recipients had to enroll in the aforementioned MLTC plan, incumbents—senior centers funded by the city government—and challengers—health care providers and “pop-up” senior centers—raced to recruit older adults to their programs. At this point, incumbent organizations engaged in meaning-making, articulating concerns about fraud, cost-savings, and well-being. Using this frame, incumbent organizations took collective action to urge the government to regulate challenger organizations.

At IOC meetings, representatives of various organizations described the emergence of new challenger organizations and their competition with incumbent senior centers. Moreover, existing health care providers broached possible partnerships with incumbent senior centers. ¹⁵ At a LMIOC meeting, a guest speaker characterized the new MLTC policy as “siphoning people to those places . . . many [existing] senior centers are tempted into becoming those kind of centers.” ¹⁶ As one senior center director Renee Smith* recounted at a NWMIOC meeting, one health care provider

has approached a number of senior centers for their senior citizens . . . I don’t know anyone [from a senior center] who has signed a contract because of the red flags, because they felt that they weren’t going to benefit.

Querying her colleagues from other organizations, she asked, “How do we take back control?” ¹⁷

On the flip side, Arnold Lee,* a representative of the aforementioned health care provider program, described how incumbent organizations—senior centers—“dragged their foot” on deciding whether to partner with his organization. Due to their indecision, they now had to compete with the challenger organizations. He described the newcomer organizations as including Licensed Home Care Service Agencies (LHCSAs) in which a licensed home care aide started a MLTC and recruited Medicaid recipients away from senior centers. Lee speculated that if regulated, “90%” of these newcomers would close. ¹⁸

Incumbent organizations urged city council to regulate challenger organizations. In September 2012, the NYC city council committee on Aging and committee on Health jointly held a hearing on “Oversight: NYC’s social adult day services programs.” Before a panel of city council officials, representatives of nine incumbent organizations gathered to testify about the need to monitor and regulate competing programs. City council member Maria del Carmen Arroyo explained that this hearing intended to gather information about an “influx of . . . programs” spurred by Medicaid reform. She explained, “New York state does not require a license, certification or registration to operate . . . [these] programs. There is also no application process with the state . . . ” and that these programs are “only advised to follow . . . regulations” that other organizations must follow. She stated, “concerns . . . that new programs are popping up . . . [and] are potentially entirely unregulated, which raises concern that they would not provide the appropriate level of care . . . .” Commissioner of the NYC DFTA Lilliam Barrios-Paoli testified about how such programs recruited seniors who did not need services (deemed “walkie-talkies” for their good health and abilities to care for themselves) while underserving the frail and disabled. She declared, “ . . . a lot of people that are using the system are people who do not need that level of service at this point . . . in their life.” She explained that by moving care from the home to centralized programs, the intended cost-saving measure would cost more: “ . . . it’s a moneymaking machine at this point . . . ” She recounted asking a Senator to research this as “the state is the one that has the regulatory authority over this, and begin to look into this as a possible Medicaid abuse.”

Moreover, the committee members worried about the impact on the quality of services provided and the livelihoods of incumbent organizations. As senior centers received governmental funds based on numbers of persons served meals, losing clients to challenger organizations could result in senior centers’ closure. del Carmen Arroyo outlined concerns about the newcomer organizations’ inexperience and monetary motivation:

Many of the pop up centers are not promoted or created by our very knowledgeable providers . . . our senior centers . . . are going to be competing with programs that are not held to the same standards . . . popup centers are in this for the profit . . . I . . . am not willing to wait for a problem to emerge . . . to then draft legislation . . .

Both elected officials and organizational representatives described how new programs did not provide nutritious meals as the senior centers were required to do; instead, they served take-out or catered restaurant food. A service provider testified how she had approached a new program to explain her organization’s transportation services. Depicting the new program as “manned by two very . . . gang looking people,” her comment questioned the legitimacy of such challenger organizations by raising possible ties to organized crime.

Elected officials identified state and local governmental agencies that could oversee organizations’ operations but were unsure of their enforcement capacity. As del Carmen Arroyo explained, city agencies lacked regulatory teeth,

NYSOFA [New York State Office for the Aging] is a relatively small agency . . . I don’t think they have the ability to really come and monitor this . . . it could be the Department of Health in the City . . . we don’t have any statutory authority to do that.

A service provider explained how the challenger organizations evaded regulations: “They’re not calling themselves social adult day centers. They’re saying they’re a senior center, but not funded by the city. So that’s how they are cutting between . . . regulations.” ¹⁹

At a subsequent October 2012 meeting of LMIOC, a guest speaker representing a city council member suggested how incumbent organizations could take action. This presenter suggested where concerned organizations should focus their efforts: “The important thing is to advocate for good regulation. Another thing is to increase transparency and gather information about the industry at the city level.” A meeting attendee then described a state official’s plan “to have an online training so that adult day care would follow the standards.” Another meeting attendee outlined what could happen, using a corollary of residential complexes that offer support to clients but not on a 24-hr basis: “It sounds . . . like the assisted living residences when there were no regulations.” She noted that after regulations were introduced, the number of assisted living residences dropped.

About a year later, a member at one IOC publicized new regulations affecting challenger organizations. At an October 2013 NWMIOC meeting, a member urged people to report programs that served restaurant meals or enrolled healthy older adults:

Inform the DOH [Department of Health] . . . that you want a program investigated because they are serving lunch from a restaurant [or] people are walking in with no disability. We know it’s happening at [specific location] . . . They [enrolled seniors who] belong in a senior center and not a social adult day program; the MLTC is what the DOH will hold accountable and assess penalties upon when they [MLTC programs] are enrolling people for services they don’t need. ²⁰

Such conversations indicated that interorganizational activities had moved from sensemaking to tackling challenger organizations. No longer information-seeking about the impact of policy changes, organizations collaborated on framing issues. With local elected officials’ help, incumbent organizations explored regulations and enforcement to check newcomers. In doing so, they legitimized and empowered governance units and state agents’ prerogative to protect clients’ well-being; such efforts helped maintain their positions against encroachment.

Summary

As predicted by SAFs theory, organizations mobilized collective action toward defending incumbents’ interests, thereby stabilizing a field upended by policy changes. To justify applying new regulations toward defending their positions, the incumbent organizations used a threefold frame of advocacy. First, such regulations would protect the health and safety of vulnerable adults, in line with policy’s promotion of people’s well-being. Second, such regulations would enhance cost-savings and fraud prevention, consistent with the aims of policy reforms. Third, such regulations would differentiate among providers that hewed to such aims. Without such action, stakeholders feared that incumbent organizations might not survive competition with unregulated challenger organizations. Moreover, they anticipated that challenger organizations would eventually exhaust Medicaid funds and close, further decimating the field. Unlike earlier meetings about Medicaid cuts when IOCs did not take action to challenge the state, incumbent organizations investigated possibilities for defending their positions against challenger organizations. Both elected officials and incumbent organizations started framing future action through advocacy. By 2014, city council passed legislation that required senior day care centers to register, with fines for those that did not comply (Litvak, 2014). This outcome evidenced that these collective actions had successfully mobilized actors, including the state, under this frame. Such advocacy restored incumbents’ positions, until the next exogenous shock emerges.

Conditions Dampening Interorganizational Action

Two interrelated conditions concern professionalism and relations between the state and organizations. One condition poses a habitus argument about the cultivation of social skill. When asked about the prevalence of advocacy efforts, nurses who were in their 60s and older and worked in health advocacy worried that younger colleagues, particularly social workers, lacked advocacy training and were more burdened by student debt incurred from pursuing educational credentials now necessary to the profession. Observations revealed that members of the less active IOCs focused more on professional networking or trouble-shooting individual persons’ cases rather than substantive discussions of issues and possible actions.

Another condition concerns hierarchy and resource dependency. Observations indicated that working in hierarchical organizations that operate on governmental contracts can constrain advocacy-type efforts, as representatives must ask higher-ups for permission to take collective action (Chen, 2017). These dampen consideration of disruptive actions, solidifying a sense of the status quo as immutable among organizations. However, observations suggested that a few professionals believed that within their respective organizations, they were introducing incremental changes through their subversive, everyday efforts. However, these were not part of interorganizational efforts.

Another factor promoting inaction concerned what kinds of organizational members attended interorganizational meetings. One IOC member identified another barrier to coordinating action: Some organizations sent interns, such as social workers in training, instead of regular workers to IOCs’ meetings. The interns were expected to bring info back to their respective organizations. However, they lacked the decision-making authority to cooperate in a coalition or engage in advocacy efforts. ²¹ Such representation by interns is not uncommon, according to other studies (Mosley, 2014).

Moreover, the sheer variety of organizations composing the IOCs made it difficult for members to identify common needs and causes. Ostensibly, senior centers were already represented by an IGU, although observations revealed discontent about this IGU’s ability to represent constituent organizations’ interests. ²² Moreover, because their meal services allowed them to tap federal funding, senior centers had access to a more stable, albeit shrinking, stream of funding than organizations that depended upon donations, foundations, and other funding streams. Although organizations in the IOCs could argue that their services were complementary in sustaining aging in place and thus deserved mutual support, these organizations that were not represented by an IGU had to fend for themselves. Critics felt that the IGU had a conservatizing effect, with senior centers attempting to preserve the status quo despite changing demographics and “consumer” preferences. Such senior centers could only serve a small fraction of the growing senior population, suggesting that other kinds of organizations are needed.

More tellingly, the most powerful actors—those currently at the top of the hierarchy of these SAFs, namely, hospitals and health care providers—had their own IGU. ²³ Although they sent representatives to IOCS, they did not collaborate with smaller organizations to represent the latter’s struggles. Although smaller organizations may be willing to partner with these actors, the state will have to encourage such collaborations via policy changes. ²⁴ Together, these conditions stymied exercising social skill to coordinate organizations.

Finally, no discussion of collective action is complete without considering the state. In particular, the decentralized distribution of funding by the city, as well as the complexity of operating with federal, state, and city levels of governance, make coordinating interorganizational activities more difficult. NYC operates on a decentralized version of machine politics, with city councilpersons distributing discretionary funds and assistance in exchange for votes (cf. Hyra, 2008; Marwell, 2004, 2007). This system sustains small, community-based organizations that can respond to local needs. However, it also diffuses interorganizational efforts that address issues on a more systemic basis, as some organizations have their short-term funding needs met by their local elected officials. If enacted, proposals to centralize discretionary funding under the control of mayoral agencies suggest a possible future natural experiment.

Conditions Promoting Interorganizational Action

The IOC that consistently undertook status-quo-disrupting activities had steady attendance by representatives who held decision-making power in their organizations. Moreover, attendees were often members of multiple organizations, including local community boards and professional associations, which allowed them to keep track of brewing issues; one member was a fiery, well-known disability advocate. With their multiple affiliations, these attendees were the most educated about policies affecting their organizations; their members were steps ahead of other IOCs where attendees struggled to understand latest developments. In addition, during their meetings, the most active IOCs constantly reviewed mechanisms for influencing policy in their organizations’ favor. They regularly invited elected officials and their aides to describe how to participate in the political process, such as letter-writing strategies. These organizations thus readied themselves for action beyond reacting to policy changes with dismay.

Organizations’ most potent tool involves pressuring the state to address issues. As demonstrated by the hospital trade association’s influence in Medicaid Redesign efforts, the hospitals protected their positions by shaping the tenor of cuts. However, given the popularity of social insurance programs even among constituents who believe in small government (Skocpol & Williamson, 2013), other health and social service–providing organizations can amplify existing frames to serve both their interests in survival and their clients’ well-being. As demonstrated by efforts to regulate “pop-up” social adult day centers, meaning-making around joint concerns can animate and legitimate collective action.

Vertical Versus Horizontal Relations

When considering the impact of policy changes, some umbrella organizations did not articulate collective action possibilities, including challenging the state. Like fish in the water, organizations did not think about the SAFs in which they swam. However, these meetings allowed constituent members to start organizing lateral actions against competitors. At the same time, these actors overlooked vertical relations with the state; they focused on ousting newcomer organizations rather than coordinating to demand more resources for all.

Although these organizations had linkages with advocacy-oriented groups and thus are aware of how individual constituents can target the state, the IOC members have not yet honed their social skill in coordinating interorganizational relations toward collective action. This may be due to perceived constraints. For example, the IRS can revoke an organization’s 501(c)3 nonprofit status if it engages in “too much” lobbying when “attempting to influence legislation” (IRS, 2017); thus, some organizations may avoid permitted advocacy activities (Berry & Arons, 2003). ²⁵ Moreover, when organizations combine advocacy and service provision, they encounter more constraints and threats to their survival (Minkoff, 2002). However, new entrants to their SAF who are interested in cooperating could provide the impetus—along with the social skill—to coordinate collective action. Studies have already shown that advocacy efforts are positively correlated with interorganizational collaboration, whether these involve coordinating services, making referrals, or forming joint ventures (Mosley, 2010; Staggenborg, 1988). When dependent upon federal funding, organizations are likely to advocate regarding policy changes that would affect such funding (e.g., Child & Grønbjerg, 2007).