3
The Use of Information and Misinformation in a State Health Reform Initiative

Robert G. Frank and Coleen Kivlahan

Over the last 60 years, comprehensive reform of the U.S. health care system has been discussed every 10 to 15 years (Frank and VandenBos, 1994). In 1993 and 1994, health reform was discussed in the U.S. Congress and most statehouses. The course of these reform discussions differed, but the discussions were universally accompanied by intense debate in which advocates and proponents predicted radically different impacts of proposed legislation. In some states, such as Washington and Minnesota, major reforms were implemented (Crittenden, 1993; Leichter, 1993). Like the congressional debate, most states struggled with complex health reform issues, only to fail to enact any legislation. Despite the failures, health reform discussions have continued in most states. This paper explores significant factors involved in the failure of Missouri's health reform debate in 1993 and 1994, focusing on the use of information and misinformation in policy decision-making and legislative action.

STATE LEGISLATION

In most states, including Missouri, the legislative process and the systems supporting the development of legislation differ from



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3 The Use of Information and Misinformation in a State Health Reform Initiative Robert G. Frank and Coleen Kivlahan Over the last 60 years, comprehensive reform of the U.S. health care system has been discussed every 10 to 15 years (Frank and VandenBos, 1994). In 1993 and 1994, health reform was discussed in the U.S. Congress and most statehouses. The course of these reform discussions differed, but the discussions were universally accompanied by intense debate in which advocates and proponents predicted radically different impacts of proposed legislation. In some states, such as Washington and Minnesota, major reforms were implemented (Crittenden, 1993; Leichter, 1993). Like the congressional debate, most states struggled with complex health reform issues, only to fail to enact any legislation. Despite the failures, health reform discussions have continued in most states. This paper explores significant factors involved in the failure of Missouri's health reform debate in 1993 and 1994, focusing on the use of information and misinformation in policy decision-making and legislative action. STATE LEGISLATION In most states, including Missouri, the legislative process and the systems supporting the development of legislation differ from

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those in the U.S. Congress. State legislative sessions tend to be very short compared with those of the U.S. Congress. For an issue to gain salience in the frenetic and brief state legislative session, it must address a clearly perceived problem, contain a clear solution, and be politically viable (Kingdon, 1984). For an issue to emerge as a piece of legislation that is fully debated, it must be clear, and timing is critical. Despite reports by state legislators and their staff members indicating a significant need for advanced analysis of technical information, most state legislatures have limited access to members of the academic community or think tanks (Guston et al., 1996). Because access to experts is often limited, members of the legislature can gain credence as an ''expert" with even limited knowledge about a topic. In Missouri, for example, insurance agents are often seen as more knowledgeable about issues relating to health insurance and coverage for the uninsured than state officials and other traditional experts. WHY MISSOURI? Missouri is an excellent laboratory that can be used to obtain an understanding of the development and implications of state health reform initiatives. Located in the center of the nation, Missouri has 5.4 million residents, two large cities (St. Louis and Kansas City), several midsize metropolitan areas, and large rural regions. St. Louis is home to 33 of the nation's largest companies, including Anheuser-Busch, Monsanto, Ralston Purina, and McDonnell Douglas, a fact that heavily influences the regional economy. In addition, the presence of these national and international firms, with strong interests in the role of employers as purchasers of health care services, has a strong influence on the state's approach to health system reform. The health status indicators of Missouri's citizens, are virtually identical to those for the nation as a whole. Fourteen percent of Missouri's citizens are uninsured, and 63 of the 114 counties are areas federally designated to be experiencing shortages of health professionals. Health care is a $15 billion industry in Missouri. As in other states, Missouri's health care costs have increased over the last two decades. In 1994, both Houses of Missouri's General As-

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sembly were controlled by Democrats, and Mel Carnahan, a Democrat, had just been elected governor. Governor Carnahan's election reversed a 12-year trend during which Republicans held the governor's office. Governor Carnahan had a long history of government service. He had previously served as lieutenant governor, as Missouri state treasurer, and in the General Assembly. Like many states, Missouri remained mostly untouched by changes in the health services market until 1991. Changes in hospital and purchasing sectors in the St. Louis market heralded transformation for all of Missouri. From 1989 to 1993 the average length of stay dropped from 7.5 to 6.5 days. During the same period, the operating margins and profits of St. Louis hospitals dropped steadily (Katz, 1996). However, from 1991 to the present, urban and rural health care markets have evolved rapidly. In the metropolitan areas, hospitals began the practice of merging with other hospitals. In both St. Louis and Kansas City, three major hospital networks were developing. The merger of Barnes, Jewish, and Christian hospitals in 1993 in St. Louis to form the BJC Health System signaled the rapid onset of significant change in the relationship of hospitals with doctors, rural and community hospitals, and health maintenance organizations (HMOs). Hospital mergers during this period led to the appearance of first generation organized delivery systems: horizontally and vertically integrated health care providers preparing for a capitated financing system. Other evolutionary features included the formation of large metropolitan health coalitions of businesses committed to driving down health care prices by more prudent purchasing of health care for their employees. For example, the St. Louis Business Health Coalition was established in 1982 by the large companies that were members of St. Louis's Civic Progress. The St. Louis Business Health Coalition was one of the first civic coalitions in the United States to address spiraling health care costs (Katz, 1996). As early as 1987, the St. Louis Business Health Coalition had assembled a report on local hospital performance using data from Medicare cost reports (Katz, 1996). The St. Louis Business Health Coalition developed into a powerful political tool backed by St. Louis's Civic Progress that included the most powerful corporations in St. Louis, indeed in the United States. Because

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of the corporate powerhouses in St. Louis, the St. Louis Business Health Coalition had access to most elected officials and business leaders. Other important developments included the growth of the Missouri Consolidated Health Care Plan that promoted movement of public employees into managed care plans, with public employee enrollment in managed care plans growing from less than 10 percent to 75 percent in just a few years. Public employees are located throughout the state, forcing managed care into rural communities at a fast pace. Missouri Medicaid, a $2.5 billion program, recently initiated a capitated managed care system in counties stretching from St. Louis to Kansas City. During the health care reform debates, the Missouri Medicaid program submitted a waiver application under Section 1115 of the Medicaid law to the Health Care Financing Administration to promote policies that would result in a reduction of Missouri's uninsured population. Before 1990, few legislative initiatives changed Missouri's health care systems (Katz, 1996). In the early 1990s, growth in Medicaid costs became significant. An arrangement with the state's hospitals dramatically increased the disproportionate share funds available to hospitals serving a large number of people who were poor and uninsured. From 1990 to 1993, a series of incremental health reform initiatives were passed. In 1991, a high-risk insurance pool was formed to care for those individuals with devastating preexisting conditions. In 1992, legislation yielding minor changes in small group insurance practices was implemented. During that legislative session, a small group of vocal advocates paired with a very effective legislator to draw much attention to single-payer models. In 1993, a voluntary medical savings account provision was created. Also in 1993, the Speaker of the Missouri House of Representatives led the effort for the passage of House Bill (H.B.) 564, a broadly constructed piece of health legislation that increased Medicaid eligibility for pregnant women and children to 185 percent of the poverty level, allowed nurse practitioners to work under a collaborative practice agreement with physicians, and provided for enhanced school-based health services statewide. H.B. 564 also included a provision establishing a commission to examine financing

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of health care through a single payer, market-driven, or other market reform model. The compromise creating this commission reflected the success of single-payer advocates in focusing attention upon needed reform of the health care system. Despite these evolutionary events, in 1994, nearly 600,000 Missouri citizens remained uninsured, an ever-growing Medicaid program accounted for 25 percent of the state's budget, and health care costs continued to grow. THE SHOWME HEALTH REFORM INITIATIVE Governor Carnahan was inaugurated in January 1993. The legislative session began shortly after he was inaugurated. Governor Carnahan led successful education reform and joined the Speaker in the effort to pass H.B. 564. During this period, increasing national attention was directed to health reform in response to President Clinton's Health Reform Task Force. As federal health care reform proposals put forth by the Clinton Administration gained momentum, it became apparent that the state of Missouri was unprepared to evaluate the implications of federal reform proposals. Not only did the state lack a coherent mechanism to evaluate proposed reforms but Missouri also lacked definitive data on the health status of its citizens. In an effort to evaluate the status of health care delivery in Missouri and to design programs that were specific to Missouri's needs, the ShowMe Health Reform Initiative was created. The ShowMe Health Reform Initiative was designed to assess Missouri's health care needs and to design legislation that would allow for the implemention of reforms that complemented Missouri's needs while creating an interface for anticipated federal solutions to health care problems. To systematically address the problems of Missouri's health care system, a task force of 48 people was created in the summer of 1993. The task force was divided into three work groups. The three work groups addressed issues in health care delivery systems, finance and cost controls, and quality and information systems. During the summer and fall of 1993, the work groups met and reviewed the state of the art in each field. In the fall of 1993, the work groups

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submitted recommendations for major legislative reform, as well as incremental reform within each area. The composition of the work groups was carefully planned to reflect the spectrum of political and policy interests usually involved in health care reform issues. The individuals chosen to participate in the various work groups of the ShowMe Health Reform Task Force represented key stakeholders in Missouri's health care industry, health professions, and health care consumer advocates. The composition of the group offered a true cross section of the health care sector. Included on the Task Force were many individuals who had championed opposing views during previous legislative sessions. These individuals were then assigned to work groups without regard to their areas of interest. It was hoped that these collaborative interactions would create a working relationship that facilitated the reform debate. A series of commissioned papers was developed for each work group to provide the members with current technical information. The acceptance of this role and the development of plans by individuals representing groups that otherwise might have been antagonistic to health care reform were deemed as evidence of substantial progress in an effort to create effective coalitions that would later support the actual legislation. Within the constraints of the short period allowed for this task, there was ample evidence that new relationships developed and a spirit of collaboration ensued. Each work group was able to produce a complex series of recommendations at the appointed time. The recommendations spanned the entire continuum of political ideology, and no effort was made to form a consensus on one solution. Instead, the eventual bill was a compilation of proposals put forth by the work groups. Despite the lack of effort to orchestrate recommendations, the groups produced a number of similar recommendations focusing on critical issues, such as health care workforce, costs, and the quality of health care services. The recommendations of the work groups were based on materials that were specifically requested for the ShowMe Health Reform Initiative, the existing literature, and most importantly, the knowledge of the members of the working groups. In general, the members of the work groups were extremely knowledgeable and

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generously contributed their understanding of health care systems issues to the work group. The Insurance Commission created by H.B. 564 began work several months after the ShowMe Health Reform Initiative had begun. The Insurance Commission included some members of the ShowMe Health Reform Initiative. The Insurance Commission reviewed the documents prepared by the ShowMe Health Reform Initiative. There was frequent conversation between staff and members of the two groups. The Insurance Commission concluded its legislatively chartered agenda in about 8 weeks. Both commissions presented their recommendations to the governor, and a package of systemic reforms was developed. During the summer of 1993, Governor Carnahan had two health reform commissions operating. One was led by the director of the Department of Health and one was led by the director of the Department of Insurance. These two health reform efforts occurred amid daily news reports on impending federal health reform. The speaker of Missouri's House of Representatives supported additional health reform legislation. Governor Carnahan met routinely with staff of the two health reform initiatives and the directors of the Departments of Health and Insurance. These meetings provided opportunities to review fundamental health reform issues and to discuss legislative priorities. H.B. 1622 In January 1994, the speaker of the Missouri House of Representatives introduced H.B. 1622. The bill was designed to restructure Missouri's health care delivery and financing system to provide greater access to services and to improve the quality of health care available in Missouri. A comprehensive bill, H.B. 1622, combined a variety of legislative initiatives designed to control costs, provide mechanisms of controlling the growth of health care systems, create standardized indicators of outcomes, enhance consumer information, and enhance accountability for health outcomes measures. H.B. 1622 initiated a gradual transition to community rating by the year 1999. The legislation created three standard benefits

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plans, with the minimum benefit plan defined as the services available in federally qualified HMOs. Insurers were prohibited from excluding individuals on the basis of preexisting conditions and were not allowed to act as third-party administrators. In addition, the bill created integrated service networks (ISNs), risk-bearing entities licensed as insurance companies that compete on the basis of price and quality. ISNs could be formed by hospitals, physicians, insurers, HMOs, or other entities qualified under state insurance laws. ISNs could not discriminate against any class of medical professionals and were required to use 3 percent of their gross revenues to improve access to health care and public health services. H.B. 1622 also implemented a number of administrative reforms: creating a Missouri Healthcare Insurance Board responsible for licensing ISNs, establishing the standards for benefits packages, enforcing market rules, determining how to measure quality, and approving technology plans for ISNs. The bill also established the Health Guarantee Corporation, a private corporation established to allow providers and insurers to coordinate their efforts to develop plans to improve community health status, accomplish public health objectives, and develop risk adjustment mechanisms for the ISN premiums and ways to address universal coverage. INFORMATION AND EDUCATION Multiple steps were taken to educate Missourians about H.B. 1622 and to ensure that Missourians were involved in the debate. A "health care university" was held for state House and Senate members reviewing complex problems in the health care system and models for health care reform. These symposia were well attended and offered legislators a common understanding of the state's health care system. In addition, the health care university helped develop 10 to 15 leaders on health care issues in the House and Senate. Governor Carnahan held public meetings around the state to describe the health reform bill and to receive public input regarding its contents. Regular press releases and strong interest among the media led to numerous articles and editorials in newspapers throughout the state. Frequent radio and television appearances were made

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by advocates for H.B. 1622. The two health care commissions, the ShowMe Health Reform Initiative and the Insurance Commission, involved approximately 75 people who worked throughout the summer and fall of 1993 creating principles and specific recommendations. The two commissions' meetings and hearings were attended by hundreds of additional citizens and advocates. The legislature began holding hearings prior to the formal legislative session. Targeted fact sheets regarding the comprehensive legislation were prepared and distributed to all affected individuals, including physicians, hospitals, nurses, other health care providers, employers, and citizens. The ShowMe Health Reform Initiative commissioned a study by Lewin-VHI (Lewin-VHI, Inc., 1993) that assessed both the number of uninsured citizens in Missouri and potential financing methods to improve access for this group. The results of the study were distributed to the press and to the legislature. The directors of the Departments of Health and Insurance testified for many hours during the legislative session. A bipartisan committee, composed of members of the House and Senate, was formed to further evaluate health reform proposals. The speaker of the House was a strong proponent of universal access and effective health reform. The president pro tem of the Senate was also supportive. MOVEMENT OF HEALTH CARE REFORM BILLS THROUGH THE GENERAL ASSEMBLY Prior to the 1994 session, the General Assembly had rarely debated comprehensive health care reform legislation. In 1993, the General Assembly briefly considered several single-payer bills. These were debated rapidly and defeated. In 1993, the General Assembly debated a series of incremental reform bills, passing H.B. 564, which contained a number of independent provisions. The Missouri legislature, like most state legislatures, is composed of part-time legislators who serve only part of the year. In Missouri, for example, the General Assembly convenes in early January and adjourns in mid-May. As part-time legislators, members of the General Assembly frequently combine their roles as

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legislators with many other activities. Because the legislators are part-time, they rarely have the ability to develop expertise in an area unless it is related to their occupation. Several key members of the Missouri legislature in the 1994 session were insurance agents. A few other legislators were knowledgeable about health care reform issues, but most had little experience in the area. Thus, within the membership of the General Assembly, there was limited experience with health policy legislation. State legislatures also typically operate with few staff. Consequently, lobbyists often serve two critical roles: as advocates and as information suppliers. Effective lobbyists, whether advocating or providing information, are viewed by legislators with only a slightly jaundiced eye. Educating State Legislators At the beginning of the legislative session, the bill managers were faced with the need to educate 197 members of the legislature, to address the issues needed for passage of the bill, and to manage any misinformation created by opponents of the bill. The General Assembly's limited experience with comprehensive health care reform bills was an important issue. Because of this limited experience, public support was deemed critical in persuading the members of the General Assembly to support the legislation. Public Opinion To assess public support, eight focus groups were conducted in critical markets throughout Missouri. In the fall of 1993, focus groups revealed that there was consensus among Missourians that a crisis in health care existed. Most Missourians blamed the crisis on cost shifting, malpractice claims, the high cost of advanced technology and competition among hospitals, and greed among health care providers. Among Missourians there was no consensus on how to reduce these escalating costs. There was consensus that all Americans should have access to health care, but not on how to pay for these services. People were evenly divided about whether they

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would be willing to pay more taxes to fund universal coverage, and there was little support for passing legislation requiring individuals to carry health insurance. There was general support for insurance reform. Although consensus was not apparent in the focus groups, several common themes emerged; these themes reflected the competing models championed at the federal level. Potential solutions offered during the focus groups included the following: implementation of cost controls, increased use of nurses and physician assistants, enactment of tort reform, easing of restrictions on equity-sharing and risk-sharing ventures between hospitals and physicians, and reductions in costs created by unnecessary, "hassle" factors, such as the use of duplicate forms. Problems Encountered After Introduction of H.B. 1622 From the time that H.B. 1622 was introduced, through hearings and floor debates in the House, a variety of problems were encountered. Despite efforts to educate members of the General Assembly, only a few members had extensive knowledge of health reform issues. Although there was public awareness of problems with the health care system, no clear consensus for reform existed. With little clear public support and a bill that offered virtually every opposition group something to dislike, the legislative debate regarding H.B. 1622 was characterized by competing groups who supported or opposed portions of the legislation. In a series of successive reductions, the scope of the bill was cut in an effort to find solid conceptual ground that would engender more support. Eventually, some support was found by narrowing the bill to a series of insurance reforms (an end to banning coverage for preexisting conditions, portability, and modified community ratings) combined with some public health initiatives. Unfortunately, the effort to find common ground took too long, and the legislative session expired. Opposition Strategies Opponents of the bill used a number of strategies to limit the development of support for the bill. Two groups, insurance agents

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and physicians, were highly organized, well financed, and highly effective in opposing the legislation. Their reasons for opposing the bill were largely related to the perceived impact of the bill on their areas of operation. A third group opposed to the bill was the insurance industry, which rejected any effort by the state to further regulate the control of health care insurance. As in many states with large rural areas, insurance agents are highly effective in the political arena in Missouri. Virtually every small town has an insurance agent and these individuals are often prominent local citizens. Consequently, they often have direct access to local legislators. Knowing this, the insurance industry has created a highly effective political action program to inform insurance agents about issues that threaten them. Provisions in H.B. 1622 reduced the role of insurance agents in selling and marketing health insurance products. The insurance industry used the threatened loss of income to activate agents, but they did not attack the provisions affecting their potential loss of income. Instead, they attacked the community rating provisions. The insurance industry overstated the potential consequences of community rating to mobilize the industry. Using a recently released study of the effects of community rating in New York State, the insurance industry emphasized the worst possible outcome of community rating. This approach proved highly effective, even though the study and threat had little relevance to Missouri markets. The media management plan anticipated this type of problem. A series of responses and information packets were developed to address this issue and the concerns about uninsured individuals. Limited state resources made it extremely difficult to respond when the insurance industry activated its highly effective fax network. With links to virtually every town in Missouri, the industry's ability to simultaneously paint a single, albeit distorted, picture of the consequences of the bill created an information management crisis that could not be overcome with the limited information resources available to the handlers of H.B. 1622. At the same time, concerns among physicians culminated in a visit by many physicians to their representatives in the state capitol.

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The physicians arrived at the capitol wearing buttons proclaiming ''Patient Advocates." The visit by physicians occurred despite efforts to work with the leaders of the various state medical groups. Overall, physicians were fragmented into many small groups, each focusing on different aspects of reform. In general, physicians were poorly informed about the effects of the bill, in part because of the complexity and the rapidity with which the process developed and in part because of their lack of information regarding health care reform. Physicians reflexively opposed the bill, despite many provisions such as the increased access provision that would have enhanced their standing. Like insurers, most small towns have physicians who are also prominent local citizens. Their opposition to the bill, in conjunction with the insurance agents, spelled doom for health care reform in Missouri. Despite efforts to create an information base that clearly articulated the problems and several proposed solutions, the effort to pass H.B. 1622 failed in the last week in the legislative session. Although the failure of the national health reform effort has been detailed, a specific evaluation regarding the role of information and the success or failure of state health reform has not been described. The obvious causes of failure include the size of the legislative proposal and the enormity of the proposed change. The legislation would alter the flow of money and would control system resources. As occurred at the federal level, a significant amount of money promoting the status quo, combined with the simultaneous failure of national health care reform, killed reform in Missouri. Reasons for Success of Special Interest Groups The success of special interest groups was determined by the factors that differentiate legislative activity at the state level from that at the federal level. Included among these factors are legislators who are actively involved in another career (including officials involved in the insurance industry), limited resources for legislative staff, limited access to policy institutes and think tanks, limited availability to academic expertise, readily available national data

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but scarce state-level data applicable to policy analyses, limited executive branch expertise and even more limited policy analysis capacity, lobbyists' prominence and centrality to the evolution of the debate, especially given the lack of other expert resources, and limited ability to assess the impact of other state and national reform experiments on the local environment. The next section examines key aspects of the debate with reference to these points. CASE EXAMPLES The Uninsured In the debate surrounding universal coverage for Missouri's uninsured citizens, questions about the cost of extending coverage to the uninsured and the accuracy of the data concerning this group overtook the dialogue. Despite data demonstrating the advantages to all Missourians of extending health insurance coverage, many concerns remained. The primary data source for the uninsured came from a 1993 commissioned report from Lewin-VHI. The report was heavily quoted during the debate. A key issue in the discussion of coverage for the uninsured was the source of funding for such an effort. Misinformation and Lack of Information As the issue of shifting costs to pay for the uninsured unfolded, more attention was directed to the demographics of the uninsured. During this phase of the debate, misinformation and the lack of information from Missouri were critical. Like most states (Gold et al., 1995), few data were available for Missouri citizens to guide them through the health reform debate. The Lewin-VHI report used national data sources including the Missouri subsample of the Current Population Summary (CPS). The use of the Missouri subsample of the CPS was not appreciated by most Missouri audiences. Indeed, Missouri legislators were not content to make decisions based on national data and were suspect of extrapolated census data. The

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staff of the ShowMe Health Reform Initiative received numerous requests to better describe how many of the uninsured could pay, how many had preexisting conditions, and a myriad of variations on these themes. Because these questions could not be answered precisely, misinformation was often substituted. As in the national debate, attributions regarding the causes of being uninsured were often invented. The lack of information about the uninsured reflected the lack of a national system to provide a comprehensive picture (Schroeder, 1996). Common examples of misinformation (see Schroeder [1996] for an excellent description of the same issues in the national debate) included allegations that a significant number of the uninsured voluntarily withdrew from the market, despite being able to participate; that most uninsured lacked coverage for only a brief period; that the uninsured received coverage anyway; and that universal coverage was too expensive. During Missouri's health care reform debate, the small complement of legislative research staff, the absence of major academic policy consultation, and the limited availability of Missouri think tanks led to a heavy reliance on departmental (Department of Health, Department of Insurance, etc.) staff and lobbyists for professional associations. The relatively small staff of the ShowMe Health Reform Initiative was drawn from employees borrowed from the departments of Health and Insurance and the University of Missouri School of Medicine. This group was supplemented by the staff of the speaker of the House of Representatives. This small group focused on managing the process, developing legislation, and responding to input from key stakeholders. The breadth of need for education and the complexity of the issues overwhelmed the education efforts. Responding to questions from legislators during the legislative session was deemed critical, but proved difficult because of the small staff. Moreover, many of the questions required data that were not available for Missouri. Serious questions regarding the number and characteristics of the uninsured derailed the debate (Schroeder, 1996). Because of the lack of data specific to Missouri, a campaign of misinformation from those with the greatest investment in the structure of the cur-

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rent health care system led to a perception that the uninsured were primarily members of a minority group, lazy, nonworking, or young and chose to be uninsured. The inability of reform advocates to carefully describe the age, sex, race, employment, and social demographics of the uninsured reduced the intensity and passion for change that this issue could have engendered. Despite public hearings that clearly documented the plight of many working Missourians, it proved as difficult in the debate at the state level as it had been in the debate at the federal level to put faces on the uninsured. Opposition from big business (Katz, 1996), especially in St. Louis, combined with opposition to other parts of the bill, overwhelmed the empathy created by the issue. In the end, the case for covering the uninsured could not be made because of the short legislative session, the relative invisibility of the uninsured to elected officials and to the middle class, and the perception that no Missouri model existed to either count or provide health benefits for the uninsured. In addition, there was the perception that legislation expanding Medicaid passed in the previous session was sufficient to address the problem of the uninsured. When combined with the highly effective marginalization of advocates who worked for universal coverage, the debate on universal coverage was effectively halted. Community Rating Health insurance reform was debated throughout the legislative session and was one of the final pieces of legislation to be defeated. The final draft of H.B. 1622 included provisions for portability, guaranteed issue (requirement that health plans offer coverage to all businesses during the same period each year), and preexisting condition exclusions. Community rating was debated as a strategy to increase coverage and moderate premium increases. Community rating quickly became a battleground of misinformation. The technical elements and impacts of community rating reform could be understood by only a few people. Lobbyists became authoritative sources and the legislative leaders who were also insurance agents became the experts.

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There were no neutral sources of information on this issue. Even the experience of other states became subject to interpretation. New York State's experience was persuasively described as alternately a success and a miserable failure. Insurers were said to be leaving the state in droves, and young healthy people were dropping insurance because of the soaring rates. Other states' experiences were seen as irrelevant, given the perceived uniqueness of Missouri. The complexity of the topic at both the state and national levels severely limited the ability to engage a wide audience in the debate. Integrated Service Networks Consolidation of hospitals into vertically integrated systems was an emerging trend during the health reform debate. Hospitals, group practices and other ambulatory services were beginning to integrate horizontally as well. These ISNs* had begun carving up the urban markets and exploring partnerships with insurance companies and seeking HMO licenses. H.B. 1622 mandated that all providers become part of an ISN in order to equitably cover the uninsured and to reduce excess system capacity, thereby driving down costs. The market, especially in St. Louis and Kansas City, already was driving providers into networks. Throughout the rest of the state, there was remarkably little penetration by managed care. To the highly anxious physicians, the ISNs became either a form of "socialized medicine" or the "devil incarnate of managed care." The fact that few physicians in Missouri had actually been affected by changes brought about because of implementation of ISNs led to much misinformation about the potential advantages of ISNs. A proposal in the bill to create a tax on each ISN to pay for medical services for the uninsured and for public health/community health programs was ignored. This provision, if passed, would have created a significant windfall profit for physicians. *   At the time that H.B. 1622 was drafted, a number of names were used to describe the organization of health care systems. These systems would now be called "organized delivery systems."

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In retrospect, the ISN concept was an issue that was proposed before its time: it was too complex and it was too little understood by critical groups. Although the ISN concept has subsequently proven to be the most significant market-driven reform, at the time that it was proposed it was considered a mandate from state government. Too little information on the impact on Missouri providers was made available and the issue was problematic for the remainder of the debate. Opponents saw this move as the clearest example of government-regulated health care and worried about a progression to a single-payer system. ADDITIONAL OBSERVATIONS Advocates of Single-Payer System Advocates of a single-payer system found themselves in a difficult role during the debate. Having advocated for reform for years, they anticipated a bill that they would be able to support without reservation. The managed competition aspects of the bill and the lack of a single-payer mechanism created ambivalence among these advocates. They attended all of the public and legislative hearings and were actively promoting comprehensive reform. Although their "extreme" views about altering the health care system could have produced a movement toward a moderate reform package, their efforts actually undermined reform. Opponents of H.B. 1622 characterized the sweeping reforms in the bill as preliminary steps to a single-payer system. This elicited the opposition of moderates. Advocates of a single-payer system continued to push for more comprehensive reform, but this position eventually limited their voice in the debate. This ultimately robbed the bill of the support that the single-payer advocates could have provided. Concerns of the Middle Class Throughout the debate, inadequate attention was given to the

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concerns of the middle class. In focus groups, letters to the editor, and public testimony, most middle-class citizens believed that some health care reform needed to occur, and they were easily frightened by misinformation campaigns about their own insurance rates (the community rating debate) and the security of their insurance coverage. The debate about universal coverage, as described above, quickly became focused on the poor and those not working. This focus reduced the interest of middle-class Missourians in supporting efforts to promote enhanced health care coverage. The components of the bill—including ISNs, medical malpractice reform, health care quality and information system reforms, and public health changes—meant little to most middle-class working people. Health Reform Efforts of Other States Other states' efforts were interpreted by advocates in a variety of ways. As stated previously, although community rating was seriously considered during the health reform debate, the experience of New York State was used alternately to promote the advantages of community rating and simultaneously to describe the outrageous rate increases and reductions in coverage likely with community rating reforms. Although significant efforts were under way in Minnesota, Washington, and Oregon, to comprehensively alter the health care system, these states were seen as, at the least, not comparable to Missouri and at the worst, "Communist reforms." There was little debate regarding governments' role in health system reform. Because of the strong leadership role of government officials in this debate, it was tempting to describe all health care reforms as government takeovers of the health care system. Interest Groups Many of the key interest groups (physicians, nurses, and consumers) were led by volunteers with limited knowledge of the highly technical areas of the health system and insurance reform. Often, these key interest group leaders relied on lobbyists for education on

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these technical issues. In this manner, lobbyists quickly occupied critical roles in the debate. Because lobbyists were known to key stakeholders prior to the inauguration of the health reform debate, the lobbyists had gained the trust of leaders in critical organizations. As is common in state legislatures, several prominent lobbyists worked with more than one group, which further enhanced their centrality to the debate. Thus, several lobbyists became central to the debate, often simultaneously serving several "masters." A consequence of this process was the creation of informal alliances aligned by the activities of the lobbyists. Most often, these alliances were difficult to discern, and often they were apparent only in retrospect. Efforts After the Debate Since the 1994 legislative session, the Missouri Department of Health has formed a new Bureau of Health Services Research, which has successfully obtained a grant from the Robert Wood Johnson State Health Reform Initiatives Program, and has continued the public-private dialogue regarding the state's health care system. Five health-related agencies at the state cabinet level have formed an interagency health policy group focusing on the development of health care quality indicators, consistent patient satisfaction measures, and the development of consistent public purchasing policies. CONCLUSION Missouri's ShowMe Health Reform Initiative demonstrated the complexity involved in changing from an incremental legislative model to a comprehensive health reform agenda in too short a time. When legislators serve on a part-time basis and have limited knowledge of health reform issues, the intricacies of comprehensive legislation offer many opportunities for the dissemination of misinformation that controls the legislative debate. In Missouri, a cadre of legislative leaders and leading state officials were well informed about health reform, but the many opponents created by compre-

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hensive reform legislation, combined with the short legislative session, created numerous opportunities for the dispersion of misinformation and biased information that distorted the process. The highly technical nature of health care reform legislation severely taxed the resources of the state government. This was exacerbated by the rapid move from incremental to comprehensive legislation that demanded more expert resources than most legislation. Although there were some connections to a university or medical school and its expert resources, the network was not adequate for the breadth of the legislative agenda. States that have succeeded in comprehensive reform efforts have spent years in education and constituency building. States committed to reform have learned that it is critical to have strong partnerships with multiple constituents, adequate resources with expertise in providing real-time health policy analysis, and extensive public education efforts and that it is important to recognize the long-term nature of the health policy debate. ACKNOWLEDGMENT The authors gratefully acknowledge the input and ideas of Pamela R. Walker. REFERENCES Crittenden, R.A. 1993. Managed competition and premium caps in Washington State. Health Affairs 12:82-89. Frank, R.G., and G.R. VandenBos. 1994. HealthCare Reform: The 1993-1994 Evolution. American Psychologist 49:851-854. Gold, M., L. Burnbuaer, and K. Chu. 1995. How adequate are state data to support health reform or monitor health system change? Inquiry 32:468475. Guston, D.M., M. Jones, and L.M. Branscomb. 1996. Academe's place in the Legislatures. Chronicle of Higher Education, p. A44, May 31. Katz, A. 1996. St. Louis, Missouri: Site Visit Report. In P.B. Ginsburg and N.J. Fasciano, Eds. The Community Snapshots Project: Capturing Health System Change. Princeton, N.J.: The Robert Wood Johnson Foundation.

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