Abstract 692 Health Services Research: Organization & Policy Platform, Monday, 5/3

In 1997, the State Child Health Insurance Program (CHIP)was passed as part of the Balanced Budget Act. The program provides $24 billion over 5 years for states to provide health coverage for uninsured children. A goal of this study was to identify factors that led to the passage of the bill, from the perspectives of both legislators and child health advocates. Twenty-six key congressional and White House staff members who specialized in health care in 1997, and representatives from six child health advocacy groups, were interviewed about factors leading to the bill's passage. Congressional staff was chosen from offices of members of Congress who introduced child health legislation in 1997 and congressional committee with jurisdiction over health care legislation. Advocates represented groups cited as most important by legislative staff. Interviews consisted of 8 open-ended questions, and ranged in length from 20 minutes to 2 hours. The average interview lasted about an hour. Interviews were tape recorded and transcribed. Key themes were identified from transcripts and interview notes.

Factors that contributed to getting child health insurance on the legislative agenda included: 1) it was a logical step in incremental health care reform; and 2) the president included funding for children's health coverage in his budget in early 1997. Factors that contributed to the bill's passage included: 1) it had bipartisan support, including that of Sens. Kennedy, D-Mass., and Hatch, R-Utah, who introduced joint legislation; 2) it was created in the context of a balanced budget; 3) there were means to finance the program, both through the general treasury and through a tobacco tax; 4) states had flexibility in designing the program; and 5) no one wants to be seen voting against children. The main controversy surrounding the program was whether it should be a Medicaid expansion or a block grant. The block grant approach prevailed, for reasons including: 1) Republican opposition to Medicaid expansion; 2) governors' opposition to Medicaid expansion; 3) support of a block grant by certain child advocacy groups, most notably the Children's Defense Fund; and 4) weak support for Medicaid expansion by administration.

Legislators and advocates differed in their perceptions of the role of advocacy groups in CHIP's development. Legislative staff saw child health advocates as moderately influential in the legislative process. Pediatricians were not seen as a strong force. Advocacy groups saw themselves as more influential. Additionally, legislators placed greater importance on the division in advocacy groups over the issue of Medicaid expansion versus block granting than did the advocacy groups themselves.

New health care initiatives are possible in the current legislative environment. They are, however, subject to political constraints. The role of advocacy groups needs to be examined further.