Federal influence on state health policy.

Journal of Health Politics, Policy and Law

Federal Influence on State Health Policy C . Gregory Buntz, Theodore F . Macaluso and Jay Allen Azarow, University of Arizona

Abstract. This paper reports on research that was intended to demonstrate the impact of federal programs on state health policy goals. The sample included four Public Health Service programs (Health Planning and Resources Development, Nurse Training, Cooperative Health Statistics and the Community Mental Health Centers program) in six states (Colorado, Maryland, Michigan, Oregon, South Carolina, and Texas). The authors conclude that, in general, states’ political environments tailor program implementation to suit state preferences.

Introduction

It has been suggested that states are indecisive, antiquated, timid, ineffective, unwilling to face their problems in health and other policy areas and, indeed, obsolete. In recent years state officials and students of American federalism have been moved to defend state governments against these charges,’ and the analysis presented in this paper lends credence to those defenses. In fact, we will argue that states are active partners in the national health policy enterprise. This paper reports the findings of a study sponsored by the U.S. Department of Health, Education, and Welfare whose purpose was to shed light on issues surrounding federal-state relationships in the health policy arena. The analysis was undertaken within a framework of intergovernmental relations which holds that the states and the federal government are active partners in the system. Furthermore, we took the view that states can and frequently do influence national health policy. Our interest was in determining whether the priorities of selected Public Health Service programs agreed with the health concerns and interests of state governments. This view is consistent with the cooperative or “marble cake” This paper is based upon a report prepared by Miller and Byrne, Inc., for the Health Resources Administration, U.S. Department of Health, Education, and Welfare under contract number HRA-230-7A-1064. The authors wish to thank Daniel Zwick, Robert Walkington, Anabel Crane, and Bruce Roucheleau of the Health Resources Administration, for their comments on earlier versions of this paper. They also wish to thank Gary Byrne of Miller and Byrne, and Louise Scott of JRB Associates for their valuable contributions to the project.

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Published by Duke University Press


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notion of federalism-the antithesis of the traditional notion of dual or “layer cake” federalism which holds that certain activities are the exclusive province of one of the levels (federal, state, or local) of government. :3 The recent empirical work of James Sundquist and of the Urban Coalition support the cooperative federalism notion. In his study of coordination in the Model Cities program, Sundquist found that mayors and local Model Cities officials relied heavily upon governors and state legislatures to help carry out the Model Cities ~ r o g r a mSimilarly, .~ in their analysis of housing and urban development programs, the Urban Coalition reported that when the abilities and legal authority of state governments are withheld from national programs, the federal government faces difficulty in program implementation. Given the cooperative federalism perspective and the relative lack of information on the ways in which the federal-state partnership is exercised in the health arena, we set out to gather data on the influence of federal health programs upon state health goals and priorities. Previous work. such as Derthick’s study of public assistance grants, has shown that the federal government, in altering the environment within which key state actors function, becomes an actor in state politics.6 Derthick argued that federal influence operates by “enhancing the role that the agency (receiving federal funds) plays in the state political system . . . (and it) increases the disposition of the state to respond to federal action and to undertake, independently, actions consistent with federal preferences.”7 Derthick implied that federal programs can force a shift in state goals. This implication was made even more explicit in an evaluation of the impact of federal aid within the city of Oakland, California. City officials reported that “federal programs often fail to meet . . . needs” and that “categorical aid programs sometimes skew city priorities.”8 The data regarding the extent of federal influence on state and local priorities, however, is mixed. In fact, in their analysis of federal impacts on state health policies in Connecticut and Vermont, Altenstetter and Bjorkman concluded that “continuity rather than change appears to be the most lasting impact of federal initiatives in the health care ~ y s t e m . ” ~ They went on to argue that change occurs only when the political environment of the state is receptive to change.’O Our findings support this argument. The Health Resources Administration (in DHEW) sponsored this analysis in recognition of the rapidly accelerating federal role in the health arena and because of the lack of comprehensive information concerning the impact of this increased federal role on the states. The primary purpose of the study on which this paper is based was to provide this information, and to gather and analyze data with regard to: (1) how



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supportive a federal program is of each state's health goals (is it forcing states to go in directions they oppose or is it helping states do what they want to do?); and (2) how states use federal program assistance in moving toward their goals (what are states doing with the federal support?). l 1 Our analysis covered six states and four Public Health Service programs. The states (Colorado, Maryland, Michigan, Oregon, South Carolina, and Texas) were chosen because they provided variation on urbanhral and large-statehmall-state factors, and because they presented a reasonable geographic cross-section of the country. The programs included in the study were Health Planning and Resources Development, Nurse Training, Cooperative Health Statistics System (CHSS), and the Community Mental Health Centers program (CMHC). Health Planning was chosen because of its importance as a major national program, because it has engendered some controversy within states, and because it was due for legislative reauthorization in 1977. The CHSS program, by contrast, is relatively noncontroversial and states choose to participate or not. Nurse Training was selected because it is a program to which states commit significant funds, and because manpower is an important subset of health policy. As the only non-Health Resources Administration program in the study, CMHC was included because of its importance in terms of national health goals and because operating funds flow directly from the federal government to community centers, thus formally bypassing states. It was felt that this latter characteristic might produce varied and interesting patterns within states. The findings of the study are based upon data collected from examination of relevant documents including budgets, legislation (federal and state), regulations or plans, and from conversations held with key personnel in the health arena at the federal and state levels.12Discussions were held with a total of 193 people distributed as follows: State Advocacy Group Officials

HEW Regional Office Officials

Total

Political Officials"

State Administrative Oficials

Colorado Maryland Michigan Oregon S. Carolina Texas

5 5 10 4 2 2

11 19 20 15 17 18

3 6 8 3 5 3

6 5 5 6 7 8

25 35 43 28 31 31

Total

28

100

28

37

193

State

State legislators, legislative aides, and gubernatorial liaisons.



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The nature of state health goals

Identifying and understanding the basic nature of state health goals is a necessary prerequisite to an understanding of federal impact. In general, we found that goals could be: (1) reactive; (2) active; (3) consistent; (4) adaptive; (5) multiple; or (6) conflicting.13For the most part, the states in our sample tend to have reactive goals-they wait for the formulation of a national goal and then they react to it. There are economic as well as political reasons for this posture. As an official in the wealthiest state we visited explained, “By the time (a state has) funded employee salaries and pensions, police, highways, and basic education, there is so little money left that we have to follow the federal bucks.” As for the politics of the situation, pressure from various health related advocacy groups also forces reaction. Labor unions and large employers, provider groups and professional associations, patient rights groups, and insurance carriers all exert influence on state health goals as they do on national goals and programs. In our sample states, the influence exerted was usually in favor of some categorical federal program, encouraging state officials who respond to such pressures to react to federal programs. Thus, the interest groups that support the enactment of health programs in Washington, tend to organize their affiliates at the state level so they in turn influence the local implementation of the national efforts. States respond to pressures, but we found that they also react because they are stimulated by the opportunities presented by a federal program. In health statistics, for example, certain states have responded to the federal initiative by assigning high priority to meeting in-state data needs. Many (including Maryland, Michigan and Oregon in our study) had well developed data collection activities prior to the emergence of the Cooperative Health Statistics System. Others, however, have decided to strengthen their efforts to serve in-state data users-particularly health planners-as a result of their participation in CHSS. A few states could be described as active in the sense that they have formulated goals or programs that predate federal activity. We found, for example, that four of the states in our sample were committed to the goal of community-based mental health care prior to the inception of the federal program. l 4 In these cases, the federal program seems to crystallize the state goals. State goals can also be consistent with federal goals, and for the most part we found this to be the case. In addition, states can resist national goals and adupt federal programs to suit their own orientations; we found significant examples of this in the health planning program. We will deal with the adaptive nature of state health goals in detail below.



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We also found that multiple and sometimes competing goals may arise in a state. In health planning, for example, a single state could support both the goals of cost containment and increased access to health care. These goals are not necessarily logical opposites, but it is usually the case that increasing access leads to higher costs. Colorado, Maryland and South Carolina exhibited a mixed orientation to these goals both of which are explicit in the national health planning legislation (P.L. 93-641). Clearly, federal health policies and programs can and do support positions on multiple sides of an issue. Within the six primary categories are numerous specific health goals. We turn now to the prime concern of the research: do federal programs facilitate or impede the efforts of states to attain those goals? Health Planning

Influence upon goals. A key finding of this project is the suggestion that Public Health Service programs may have their greatest impact through the placing of an item on a state’s active policy agenda. That is, because offederal activity issues are raised and debated that might otherwise have been ignored or stifled. This sort of impact is most evident with regard to the health planning program in states where it generates significant political opposition. Two such states are Texas and South Carolina. Key actors in the Texas health policy arena have long opposed health planning in general, and federal health planning legislation in particular, as constituting unnecessary restriction. Texas participated in the Comprehensive Health Planning program (which preceded P.L. 93-641) but did not enact certificate of need legislation until 1975. The state has also been ambivalent regarding the federal program intended to inhibit unnecessary capital expenditures for health care facilities (Section 1122 of the Social Security amendments of 1972). In 1973 the governor declined to participate in the 1122 program. Later, the state did decide to participate but withdrew after ten months. In addition, the Texas Medical Association adopted a “fight to the end-no surrender” stance15regarding the federal Professional Standards Review Organization program. The primary “health planning goal” in Texas, then, is to define the threats to the operation of free market forces in the area of health care which are perceived to be inherent in P.L. 93-641. In South Carolina the opposition to the program is not as strong nor as focused as it is in Texas. Some key actors are opposed on ideological grounds (regulation is unnecessary); some are opposed on political grounds (health concerns other than planning have a higher priority); and still others are opposed on administrative grounds (there has been considerable debate over the organizational locus of the state planning



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agency). The majority of those with whom we spoke do favor the free market approach to health resources development. They feel that planning is a luxury which the state cannot afford given the relatively underdeveloped nature of its health resources. The pro-planning forces, on the other hand, see P.L. 93-641 as an opportunity to rationally develop health resources. And the debate goes on. Given the environments in Texas and South Carolina, the federal influence is restricted to keeping the concept of health planning on the states’ active policy agendas. A Texas planner remarked that P.L. 93-641 is giving planners “a chance to do what we started out to do in 1969. Without [it] the health planning concept would have died [in T e x a s h i t was a new lease on life.” Significantly, our discussants indicated that any federal attempt to exert pressure in the direction of national goals would be met by increased resistance to, and thus delay in, the implementation of the planning program. We also found that goals are not likely to shift as a result of the federal presence in states where planning is an acceptable idea. States choose a planning-related goal on the basis of variables unique to their situations. In Michigan, for example, cost containment has been paramount, at least since the days of Comprehensive Health Planning. This emphasis is in large part due to the fact that firms in the auto industry and the United Auto Workers are keenly aware that rising medical costs represent both real and opportunity costs to their organizations. As a result, they have exerted significant political pressure on state officials. Another of our findings regarding the planning program supports this notion of the secondary role of federal influence. Public Law 93-641 is highly supportive of states that wish to move toward cost containment and/or regulatory planning modes-but only when the state is able both to supplement the authority of the state health planning agency (the SHPDA) and to subordinate it to gubernatorial authority. Michigan, for example, is using P.L. 93-641 assistance effectively in no small part because its SHPDA is in the governor’s oftice and has budget-making authority for the health department. Similarly. Colorado’s SHPDA is the management arm of the health department (it is in the same office with licensing and certification), and its executives are “governor’s people.” In both Oregon and Maryland the relationships between the SHPDA and the governor’s office are indirect, and, therefore, the authority of the SHPDAs has not been supplemented. States like South Carolina and Texas that have strong reservations about the acceptability of regulatory planning have three or more of the following characteristics: their SHPDAs are subordinate units within health departments, administrative reorganizations are relatively common, SHPDA coordination with certificate of need functions is relatively weak, andlor their SHPDAs are relatively isolated from gubernatorial contact.



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These examples suggest that when a state seriously wishes to engage in planning, it will delegate signlficant power to its planners-power that is, nonetheless, politically accountable to the state. When on the other hand, a state is hesitant about planning qua planning, it weakens and isolates its planners. The federal program-even though it is effectively mandatoryprimarily provides an opportunity that states can seize with a firm or weak hand as internal political realities dictate. Influence upon behavior. Health planning goals, and, thus, goaldirected behavior in the sample states, tend to revolve around four prime issues: (1) the relationship between cost containment and access to quality care; (2) the need for regulation of providers; (3) the relative policy authority of elected vs. administrative officials; and (4) the need for coordination of health planning agencies within a state.

The first two issues are substantive-they relate to the purposes of planning. The second two are procedural-they concern the methods of planning. Our investigation in the six sample states suggests that two conditions are necessary before a state can use federal assistance to move toward a state goal. First, the state should adopt a definite substantive goal; second, its procedural goals should support its substantive goal. Public Law 93-641 explicitly supports both the cost containment and increased access goals. While it is theoretically possible to seek and achieve both concurrently, a state usually must give priority to one before any progress occurs.16 In addition, a state must choose active or benign provider regulation before a program can be formulated. And, if a state is to make effective use of its health planning program, it must resolve the key procedural issues because the federal statute gives little guidance in this area-the relationships among state and substate planning groups, for example. Michigan, Colorado, and Texas seemed to be effectively using the health planning program to move toward their planning-related goals. The three states have different goals and are using the planning program in disparate ways. In Michigan, where the primary planning goal is cost containment, the concept of health planning and regulation is well accepted and P.L. 93-641 supports the regulatory behavior of Michigan health officials. We found a slightly different situation in Colorado. The primary interest of health planners there is the protection of health care consumer interests through strong regulation. Interestingly, the state is actively pursuing



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both increased access and cost containment goals, considering them to be elements of the same system, i.e., pursuit of one affects the other. In implementing P.L. 93-641, Colorado has consolidated regulatory power in the state health department (and, as we mentioned above, the Act is being used as a tool to manage the department). In fact, the state health planning agency does not have a distinct identity within the department. Rather the Ofice of Medical Care Regulation and Development is the SHPDA. State health officials see this arrangement as giving them tighter control over licensing and certification. In Colorado, then, P.L. 93-641 underpins health officials’ efforts at consumer protection. Because of a “free market” committment in Texas, however, officials there have implemented P.L. 93-641 in such a way as to subvert its intent. The state has a certificate of need law, but it is being applied by an agency independent of the SHPDA, thus weakening its clout. Furthermore, the state act contains a liberal “grandfather clause,” which, according to planning advocates in the state will result in gross overbedding rather than in restraint. Texas planning advocates also contend that regulatory functions have been captured by providers, and therefore that regulation is unlikely. As we pointed out above, the notions of planning and regulation are alive in Texas, but according to one view they are not well. Public Law 93-64 1. then, supports active regulatory behavior in Michigan and Colorado and free market oriented behavior in Texas. The contrast between the two approaches is striking. This leads us to the conclusion that states are capable of modifying federal programs during the process of application in order to adapt them to their own aspirations and conditions. The other states in our sample. Oregon, South Carolina, and Maryland, have not found the health planning program to be entirely supportive of their goals. In Oregon, this is due in part to the fact that the procedures have not yet been established. Highest priority is given to cost containment and Oregon health officials favor the idea of centralized regulatory planning. At the time of our discussions in the state, however, most of the planning efforts were directed toward organizing for the implementation of the health planning program. There are two other important constraints in the case of Oregon. The first of these is economic-the state feels that federal funds are inadequate to support required planning efforts, and that many of the Act’s provisions put an undue strain on an already overburdened state treasury. The second factor is political, and relates to the state’s attitude toward federal assistance in general. One might characterize Oregon as being pro-government. i.e., most people in the state believe in the use of government to bring about social change. But they prefer the state government level. As a result of this ideological position and the belief of




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key state officials that P.L. 93-641 makes planners accountable to the Secretary of HEW rather than to the governor, the state remains largely negative about the health planning act. Neither South Carolina nor Maryland have clearly formulated either substantive or procedural planning goals. In fact, health officials in both states appear divided over the purposes of health planning and the activities which planners should pursue. So although program implementation is progressing in both states, given the lack of goal focus and the embryonic nature of the planning activities (particularly in South Carolina), it is not possible to determine the degree to which P.L. 93-641 is being used for goal-attainment.

Health statistics Influence upon goals. Unlike health planning, the Cooperative Health Statistics System (CHSS) program is relatively free of controversy and there is little disagreement within and among states regarding goals. Generally, the six states we studied are attempting to: (1) upgrade and expand the scope and quality of data collection; (2) fulfill their roles as data collection points for the national system; and (3) meet the needs of in-state data users , especially health planners. Our research revealed that the health statistics program has been only marginally successful in these areas. None of the six states seriously disputes either the value of collecting high quality, uniform national data or of developing sophisticated data technologies. The question is whether national needs should be the primary focus of the program. Maryland and Michigan do not think so and CHSS has neither convinced them otherwise nor provided them with sufficient resources to meet their higher priority goal of assisting state data users through analysis, publication, and collection of locally relevant data. Oregon and South Carolina also have strong user orientations (and CHSS has not changed relative priorities), but state officials believe that CHSS data will be relevant to state user needs. A crucial difference here is that actual contact and coordination between CHSS personnel and state health planners is significantly greater in both Oregon and South Carolina than in either Maryland or Michigan. In Colorado and Texas there is relatively little in-state demand for user-oriented services. The goal of collecting high quality, uniform national data, therefore, retains highest priority. Influence upon behavior. The impact of CHSS on state activities ranges from virtually zero in a state like Maryland (where past data activities were sophisticated and there is now high in-state demand for useroriented services) to substantially beneficial in a state like Texas (where the scope and quality of past data activities were minimal according to



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state discussants and where there is low in-state demand for user-oriented services). I n all six states CHSS had some positive effects: it either improved the actual quality of state data collection and data processing or, at a minimum, increased state officials’ awareness of data related problems. In each state the program has increased communication among state agencies with health data collection functions, but discussants did not always believe that this led either to a corresponding increase in coordination or to a reduction in duplication of effort. It is significant to note that the three states which are attempting to expand their data collection and analysis capabilities to meet the needs of in-state users (Maryland, Michigan and Oregon) find the CHSS program to be only marginally helpful in those efforts. These states use the federal program to collect basic data, but then must go beyond what the program requires in order to make that data useful to planners and analysts within their states. The states making effective use of the CHSS program are those that are satisfied with supplying data for the national health statistics reporting system. Nurse training

The nurse training program is the least controversial of the four programs studied and, with the exception of the statistics program, is the least visible to state officials. As a result there were no serious political conflicts Over use of the program funds in our sample states and all of the officials contacted tended to view the program favorably. Influence upon goals. The six states have several goals in common with respect to nursing and nursing education. They are: (1) assuring the professional competence of practicing nurses; (2) maintaining minimum educational standards in the states’ nursing schools; (3) upgrading the quality of nursing care; (4) making use of public health nurses in the delivery of public health services; (5) improving the distribution of nurses within the states; and (6) assuring that the state’s system of nursing education produces an appropriate supply of nurses in the state. Discussants in each state indicated that the nurse training program supported these goals. Furthermore we found no evidence to indicate that the program had produced significant changes in goals in the six states studied. Federal funds are used extensively to support the development and maintenance of quality nursing education, and, in that sense, the program has a reinforcing impact on state goals. Influence upon behavior. In spite of the generally positive assessments by our respondents, the program could be having some negative effects. A majority of nursing officials in each state but Maryland expressed the




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view that the capitation component is encouraging new and expanded nurse training programs at a time when nurses may be in ample supply. The nurse training program, then, might be promoting too high an activity level (it could also be that the nursing officials to whom we spoke are sensitive to the labor market effects of any increase in supply). Graduate education for nurses is clearly affected by the program. Each nursing educator to whom we talked indicated that graduate programs would not have been developed, nor could they be maintained, without federal funding.

Community Mental Health The Community Mental Health Center (CMHC) program is unique among the programs in our study. Federal funds are distributed to local mental health centers rather than to state mental health agencies, although there is a mandated relationship between the local grantees and the state mental health authority. In addition, federal support is provided on a declining basis over an eight-year period, with the result that grantees increasingly turn to state agencies for much of their support. These factors produce some rather interesting intergovernmental relationships in mental health. Indeed, in the strictest sense, it is not states which “use” the resources that CMHC provides. The role of state mental health agencies is crucial, however, if a network of community-based care is to be established. For this reason, the federal CMHC program can have a significant impact upon state governments. Influence upon goals. All of the sample states were in favor (in varying degrees) of setting up a system of community-based mental health care. Thus they share the goal of the federal program. Deinstitutionalization is seen by some as a process which is related to that goal. In some of the states, however, deinstitutionalization is the primary goal. They are reacting to the pressures of overcrowding in state mental institutions and the resulting fiscal and quality-of-care problems which overcrowding produces. The CMHC program has affected state mental health goals in a variety of ways. The program either has exerted negligible influence or it has: (1) provided reinforcement for state goals; (2) modified goals; or (3) it has placed certain issues on state agendas. In South Carolina and Colorado, the impact on goals has been largely reinforcement. Mental health officials in both states actively encouraged local sponsors to apply for federal grants when funds became available, and they worked to design community-based systems in line with the objectives of the federal program. The development of community-based services was also an early policy



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goal in Michigan and Oregon. In Michigan, the federal program was reinforcing. In Oregon, the influence of the federal program has been marginal. The state mental health agency, in keeping with a skeptical, state-wide attitude toward federal assistance in any policy area, consciously discouraged the use of federal grants in developing its community programs. This, coupled with an almost total absence of local initiative, accounts for the lack of federal impact. In Maryland and Texas we found evidence to suggest that the CMHC program helped to place the issue of deinstitutionalization on the state’s policy agenda. In both states (although to a somewhat lesser degree in Maryland) the community-services goal emerged as a result of localrather than state-level initiatives and was, in effect, placed on the states’ policy agendas by the activities of federal grantees. Our discussants indicated that the CMHC program provided support for the adoption of a community-based services model in these two states. This is not to say that the influence of this federal program has been to force a radical shift in state goals. The shift that has taken place in Maryland and Texas has been very slight, and indeed the primary effect of CMHC has been to afford the pro-community-care forces an opportunity tc make a case and they have had some success. Influence upon behavior. In terms of mental health activities the program has either: (1) significantly assisted state agencies in their efforts to develop community-based services; (2) assisted in the development of an ad hoc system of community services; or (3) only marginally assisted in the development of community services. Use of the program varies a great deal in the states. Oregon, as we indicated. has had a long commitment to community-based care, but at present. has only one federally supported CMHC. The state has speclfically rejected the widespread use of the federal program because it (Oregon) relies heavily upon counties to provide community services and because it did not wish to fall into a “fiscal trap,” i.e., having to significantly increase state expenditures as federal support declined. Only two community mental health centers in Oregon have ever received construction or staffing grants, and one of these, privately sponsored, is about to close. The development of the other federallyfunded center was encouraged by the Division of Mental Health, and serves a huge area in the sparsely populated eastern portion of the state. This example is the proverbial “exception that proves the rule,” however, for our discussants indicated that a federal grant was sought only with the greatest reluctance. and only because the counties in the area were unable to support mental health services. An entirely different result occurred in Maryland and Texas. Substan-



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tively, despite the lack of direction or initiative provided by the respective mental health agencies in the early and mid-l960s, the federal program materially assisted in the development of an ad hoc system of community services. In Maryland we found cross pressures produced by strong political opposition to deinstitutionalization and the widespread desire to seek fiscal relief through reducing the population of the state institutions. The institutional forces have prevailed to this point, but the advocates of community service have been able to use the CMHC program as a lever to keep their program on the state’s agenda. Local private or governmental groups in both Texas and Maryland seized the federal initiative. These efforts at the local level were pursued in each state despite the absence of active state agency encouragement, for in each state there is little evidence that development of community programs was a high priority policy goal in the early or mid-1960s. In these states, then, the federal influence consists of support for community-based care, resulting in behavior designed to further this goal. The state of Michigan has long been committed to the concept of community-based mental health service delivery and, like Oregon, has relied on its counties to provide the services with state assistance. Unlike Oregon, however, Michigan has encouraged local grantees to seek CMHC funds. Despite this, the actual influence of the federal program is probably minimal since CMHC grants currently make up less than five percent of the Michigan community mental health budget. The states of Colorado and South Carolina are in somewhat different positions. Like Michigan and Oregon, their mental health agencies are committed to community-based care, the concept is accepted politically, and Colorado and South Carolina are using the assistance provided by the federal program in order to establish and maintain a community services network. Officials in both states, however, indicated that their community systems would not be in place without the federal grants. The CMHC program thus has materially assisted both of these states in developing their systems. Summary and conclusions

In conducting the research reported in this paper we set out to determine whether selected Public Health Service programs facilitate or interfere with state defined health goals and priorities. Given this was a pilot study encompassing only six states our findings are suggestive. They strongly suggest that federal programs facilitate rather than inhibit the attainment of state health goals. We found federal influence upon goals to be secondary to the influence



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of the states’ political environment. A federal program may elevate an issue to a state’s active policy agenda, but this does not lead to the formulation of a state policy or goal unless political interests within the state are receptive. The health planning program places national issues on state agendas. The CHSS program is in the main supportive of state goals, although some officials feel it does not go far enough. The nurse training program is helpful in terms of what states want to do in this area. The CMHC program has been both supportive (in the sense of providing reinforcement for state defined goals) and influential. It has influenced state policy agendas and therefore policy development in a positive manner according to most state mental health officials. We also found federal influence on goal directed behavior to be largely supportive and in very interesting ways. State officials are using the health planning program, for example, to maintain a range of activities from cost containment to increased access, and from active to benign regulation of providers. Activities in each range are in large measure on opposite poles, yet the federal program can be used to support behavior on each pole. State health officials, then, seem to have a considerable degree of policy space ’* vis-a-vis these selected federal health programs. On the basis of these findings, it is apparent to us that the political environment of the state is the most significant determinant of federal influence-both in terms of goals and behavior. This notion is consistent with the findings of similar research regarding health policy.19 Political environments, of course, vary from state to state but we found that they also vary within states. Two factors seem to be most responsible. First, if key state elected and administrative officials perceive that a given program bypasses them, the program will engender serious opposition. This seems to be true particularly with the health planning and CMHC programs. Second, we found that a major determinant of a state’s level of satisfaction with a federal health program is the degree to which the state accepts the program’s basic goals. In our view the dissatisfaction with the health planning program expressed by state officials has emerged largely because of the lack of a nationwide consensus in favor of the notion of health planning and regulation. The other three programs which we studied are being implemented in political environments which feature broader consensus-certainly not in the sense that conflict over goals is absent, but in the sense that key actors agree with the basic premise of each program. This suggests that feelings regarding national programs may go through a “life cycle” that ranges from strong and vocal opposition to virtual




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acceptance. Such is the case with the Medicare program. Physicians nationally were strongly opposed to Medicare at the policy development stage but, as Colombotos has shown, their attitudes have moderated over time.20Colombotos suggests that the legislation itself has established a new norm and that physicians have become “re-educated” in terms of that norm.21 If health planning is at the low end of its acceptance cycle (as it apparently is in Texas) the finding of little or no influence is predictable. If the state’s health policy environment shifts we may also predict that P.L. 93-641 will exert a stronger influence on that state’s health goals and activities. In short, federal influence on state health policy is both state- and program-specific, at least with regard to the programs studied here. From the federal point of view, this suggests the desirability of a flexible approach to program implementation. According to our findings, it is a mistake to attempt to implement all health programs in the same fashion. We have come to three additional conclusions regarding federal-state relationships. First, the federal government cannot force states to shift goals in any fundamental way. States may be forced to engage in certain activities, e.g., develop health planning organizations and pass certificate of need laws, but if the states do not wish those actions to lead to a rationalization of the health care financing and delivery system they tend to become largely empty exercises. Second, we found that federal intervention through these four programs can reinforce changes supported at the state level and it can alter state goals at the margin. Federal programs have this effect through placing an issue on a state’s active policy agenda, and through supporting the forces for change within the state. This changes state goals, however, only when the political environment of the state is receptive to change. Third, we found that the four programs support the individual goals of states to the extent that state officials actively undertake to make this happen and these state goals need not be entirely consistent with those embodied in federal policy. This study lends support to those who argue that the political environment of a given state is the key to an understanding of the ways in which federal aid influences state health goals and programs. It has also suggested that in terms of goals and activities states are not withering under the weight of the federal yoke, rather they are active partners in the national health policy development and implementation process.

Notes 1. See, for example, Terry Sanford, Storm Over the States (New York: McGraw-Hill, 1%7), and Ira Sharkansky, Policy Making in Government Agencies (Chicago: Markham

Publishing Co., 1972).



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2 . U . S . Department of Health, Education and Welfare, Public Health Service, Health Resources Administration, Evaluation of the Impact of PHS Programs on State Health Goals and Activities (Rockville. Md.: Health Resources Administration, 1977). 3. See. for example, Morton Grodzins. The American System a New. View of Government in the United States. ed: Daniel J. Elazar (Chicago: Rand McNally. 1966); Daniel J . Elazar. The American Partnership (Chicago: University of Chicago Press, 1962); and James L. Sundquist. Making Federalism Work (Washington. D.C.: The Brookings Institution. 1969). 4. James L. Sundquist, Federalism. 5 . Urban Coalition Task Force on Housing Reconstruction and Investment, Agenda f o r Positive Action: State Programs in Housing and Community Development (Washington, D.C.: The Coalition. 1968). 6. Martha Derthick, The Influence of Federal Grant5 (Cambridge: Harvard University Press, 1970). 7. Ibid., p. 207. 8. An Analysis of Federal Decision Making and Impact: The Federal Government in Oakland (San Francisco: Oakland Task Force, San Francisco Federal Executive Board, i%8). p. 5 . 9. Christa Altenstetter and James Bjorkman, Federal Impacts on State Health Policy: Lessons from Connecticut and Vermont (New Haven. Connecticut: Yale Health Policy Project, 1975). p. 61. 10. Ibid.. p. 58. 1 1 . We wish to reemphasize that we approached this research from the point of view that states are not merely passive and/or neutral implementors of federal policy. At the outset we held the view that states and the federal government jointly develop national health policy and that each has a significant role to play in the implementation of health policies and programs. Indeed our approach to the study is consistent with President Carter’s view (enunciated in a February 25, 1977, memo) that priorities developed at the national level should work in conjunction with and not at cross purposes to, priorities at the state and local level. 12. For a complete discussion of the methodology and a list of the discussants see State Health Coals, pp. 102-145. 13. These categories are not intended to be mutually exclusive. 14. It is significant to note that three states (Massachusetts, New York. and California) were catalysts in the development of the first federal Community Mental Health Act. 15. Jonathan P. West, Professional Standurds Review Organizations. Southwest Center for Urban Research Series on Comprehensive Health Planning, No. 1 (Houston: Southwest Center for Urban Research, 1974), p. 90.Also see Jonathan P. West and Michael D. Stevens, “Comparative Analysis of Community Health Planning: Transition from CHPs to HSAs,” Journal of Health Politics. Policy and Lan. 1 (Summer. 1976): 173-195. Of course this choice may be temporary and goal preferences may change over time. 17. A second phase of the study which will seek additional “hard data” in order to analyze program impact in ten additional states is currently under way. 18. For a full discussion of the notion of policy space see Sidney L. Gardner, “Policy Space: A Tool for Local Decision Making?” paper presented at an International City Management Association Conference on Human Services in Local Government: Approaches to More Effective Management, Annapolis, Md., April 13-15, 1977. 19. See the series of reports produced by the Yale Health Policy Project during 1972-76 under grant number 5-ROI -HS-00900 from the National Center for Health Services Research. Among these, Federal Impacts on State Health Policy: Lessons from Connecticut und Vcrmont, Politics and Social Policy: Failures in Child Health Services, and Federul-State Relations: Tensions, Conflicts, and Opportunities f o r American Child Health Policy, are particularly instructive. 20. John Colombotos, “Physicians and Medicare: A Before-After Study of the Effects of Legislation o n Attitudes.” American Sociological Reviei:. 34 (June 1%9): 3 18-334. 21. Ibid.. p. 318.


Nurses influence state, federal legislation.

The formulation of Federal health care policy.

Health Policy to Promote Colorectal Cancer Screening: Improving Access and Aligning Federal and State Incentives.

An Economist's Influence on Health Policy.

ethnic variation in immediate postmastectomy breast reconstruction.

The role of federal waivers in the health policy process.

Children and U.S. federal policy on health and health care: seen but not heard.

state partnership for health system reform.

The health needs of poor children: federal and state approaches.

The influence of the mass media on health policy.

Grading the federal government on health care.

Bill C-37 signals federal hands off policy in health care delivery.

Bridging the Policy-Implementation Gap in Federal Health Systems: Lessons from the Nigerian Experience.

Federal and state pesticide regulations and legislation.

A Corporate Veto on Health Policy? Global Constitutionalism and Investor-State Dispute Settlement.

Health education: a federal overview.

Federal Trade Commission policy paper promotes unrestricted practice.

Reducing childhood obesity through U.S. federal policy: a microsimulation analysis.

The inequity of the Swiss Health Care system financing from a federal state perspective.

State variation in health care spending and the politics of state Medicaid policy.

The effects of inflation on federal health spending.

Perspectives on Federal Funding for State Health Care-Associated Infection Programs: Achievements, Barriers, and Implications for Sustainability.

[Memorandum on sustainable reinforcement of prevention and health promotion: challenges at the federal, state and local level].

Job Satisfaction and Expected Turnover Among Federal, State, and Local Public Health Practitioners.