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.


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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