Pediatric Annals

Influencing the Political Process Through Coalitions: The Michigan Council for Maternal and Child Health

Robert S Holm, MD; Paul N Shaheen

Abstract

The following are some recent maternal and child health events in Michigan:

* In 1986, prenatal care was guaranteed to all pregnant women in the state.

* In 1987, the adolescent health center program was expanded.

* In 1992, legislative cuts to prevention programs were reversed.

* In 1993, Medicaid was expanded to 80 000 new children under 16 and up to 150% of poverty, the governor announced a universal vaccine program, and the Children With Special Health Care Needs Program was fully funded.

* In 1994, family planning became a right and the largest cigarette tax in the nation was passed with 6% dedicated to prevention programs.

Advances such as these have become common in Michigan over the last decade because advocates for children have gotten organized and are working together. What follows is the story of the largest coalition, the Michigan Council for Maternal and Child Health, (the Council), a key player in (if not the chief instigator) many of the efforts that warranted successes such as those above.

Pediatricians and others who provide medical care for individual children perform valuable and necessary services. However, our profession has long recognized that issues such as initiatives to reduce infant mortality, child abuse laws and their enforcement, clean water, sewage disposal, handling of toxic waste, and health education are not amenable to one-on-one encounters in the doctor's office. As hard as it may be to face, these issues are addressed through "POLITICS" (that dirty word).

Politics, however, is not a dirty word. Politics is the art of getting things done in a group where there are conflicting goals, objectives, levels of knowledge, and levels of concern. It is the art of compromise. Failure to be involved means that your goals will not be achieved. The American political system can be used by health professionals (without getting dirty) to improve the health of children and their families. Forming or entering coalitions is one effective and efficient way of accomplishing our professional mandate to take care of children. Forming coalitions takes advantage of the interest that many other individuals and groups have in the health and welfare of children and their families.

The stimulus for the formation of the Council was the Reagan plan to reduce block grants to states for Maternal and Child Health programs by 25% in the early 1980s. The officers of the Michigan Chapter of the American Academy of Pediatrics (MCAAP) requested a meeting with the governor over this new policy and its implications for children. The governor instructed the director of the Michigan Department of Public Health to meet with MCAAP to discuss this. It was gratifying to see these state officials expressing the same concerns that MCAAP had and also to see the efforts they were making to assure continuation of services to children. That would have been the full story had not some of the health department people told us of their need to have support and advocacy from nongovernmental sources in order to advance some child health initiatives that had low-level priorities in the legislative arena, and of other groups that had expressed an interest in these issues. They suggested that the time was ripe for MCAAP to take a leadership role in organizing these groups into an effective force for maternal and child health.

Contacts were made with the president of the University of Michigan's Women's and Children's Hospital, a member of the board of directors of the Children's Hospital of Michigan (in Detroit), and the president of MCAAP. In a series of meetings, this steering group developed ground rules for the fledgling…

The following are some recent maternal and child health events in Michigan:

* In 1986, prenatal care was guaranteed to all pregnant women in the state.

* In 1987, the adolescent health center program was expanded.

* In 1992, legislative cuts to prevention programs were reversed.

* In 1993, Medicaid was expanded to 80 000 new children under 16 and up to 150% of poverty, the governor announced a universal vaccine program, and the Children With Special Health Care Needs Program was fully funded.

* In 1994, family planning became a right and the largest cigarette tax in the nation was passed with 6% dedicated to prevention programs.

Advances such as these have become common in Michigan over the last decade because advocates for children have gotten organized and are working together. What follows is the story of the largest coalition, the Michigan Council for Maternal and Child Health, (the Council), a key player in (if not the chief instigator) many of the efforts that warranted successes such as those above.

Pediatricians and others who provide medical care for individual children perform valuable and necessary services. However, our profession has long recognized that issues such as initiatives to reduce infant mortality, child abuse laws and their enforcement, clean water, sewage disposal, handling of toxic waste, and health education are not amenable to one-on-one encounters in the doctor's office. As hard as it may be to face, these issues are addressed through "POLITICS" (that dirty word).

Politics, however, is not a dirty word. Politics is the art of getting things done in a group where there are conflicting goals, objectives, levels of knowledge, and levels of concern. It is the art of compromise. Failure to be involved means that your goals will not be achieved. The American political system can be used by health professionals (without getting dirty) to improve the health of children and their families. Forming or entering coalitions is one effective and efficient way of accomplishing our professional mandate to take care of children. Forming coalitions takes advantage of the interest that many other individuals and groups have in the health and welfare of children and their families.

The stimulus for the formation of the Council was the Reagan plan to reduce block grants to states for Maternal and Child Health programs by 25% in the early 1980s. The officers of the Michigan Chapter of the American Academy of Pediatrics (MCAAP) requested a meeting with the governor over this new policy and its implications for children. The governor instructed the director of the Michigan Department of Public Health to meet with MCAAP to discuss this. It was gratifying to see these state officials expressing the same concerns that MCAAP had and also to see the efforts they were making to assure continuation of services to children. That would have been the full story had not some of the health department people told us of their need to have support and advocacy from nongovernmental sources in order to advance some child health initiatives that had low-level priorities in the legislative arena, and of other groups that had expressed an interest in these issues. They suggested that the time was ripe for MCAAP to take a leadership role in organizing these groups into an effective force for maternal and child health.

Contacts were made with the president of the University of Michigan's Women's and Children's Hospital, a member of the board of directors of the Children's Hospital of Michigan (in Detroit), and the president of MCAAP. In a series of meetings, this steering group developed ground rules for the fledgling organization and identified other groups that seemed to be likely prospective partners. Articles of incorporation were written and filed with the state, and bylaws were developed. A financial commitment from the founders was made to cover start-up costs. Ads were placed in the newspaper in the state capital looking for an executive director. Because the ads were placed shortly after an election, legislators who had lost the election and their staff expressed interest in the job. From many acceptable possibilities, one stood out and was retained. The Council was ready to begin its work on behalf of children's and women's health.

One of the main reasons for the Council's successes and survival was the philosophical basis for its existence as expressed in its bylaws. From the beginning, the only organizations admitted to full membership would be those whose "constituted purpose and function was maternal and child health." This was done to avoid having the agenda driven by groups that had interests more important to them than maternal and child health. Over the first decade, this policy has held fast, with only groups with predominate interests in maternal and child health as full members although new classes of membership were later developed for other groups who wished to support the Council's activities. These groups participate in the discussions during which policies are developed. Considering how little conflict has arisen with these groups, the original policy may have been overly cautious, but it has worked well for the council's first 12 years.

Another reason for survival and success was the understanding from the beginning that each member was to be equally powerful even though each brought different assets to the table. The large hospitals brought great respect in their field along with most of the money and large organizational capacity to influence issues and policy. The professional physician organizations brought considerable expertise, credibility (based on a long history both in Michigan and nationally of speaking for children's needs instead of doctors'), and a medium amount of money. The volunteer agencies that are primarily organized around specific health needs brought great credibility based on their long history of selfless service involving large numbers of volunteers (which politicians see as voters) although they could not contribute much money. In order to sit on the Board, each organization's representative must be able to commit his or her organization. Each group is represented by a regular and an alternate member, and in many cases both attend, thereby assuring high-level individuals serving on the Board and comprising a capable group for problem-solving and work-related tasks. In a further effort to maintain equality among the members, the offices are carefully rotated among the representatives of the member groups. The only caution is that the individuals holding those offices need to have been on the Council long enough to be well versed in how the council operates.

Council members agreed from the beginning that divisive issues such as abortion would not be on the Council's agenda. While each sustaining member has veto power over the Council's actions, no one has ever had to use it, probably because of the quiet understanding that such issues need to be avoided. Leaving those issues off the agenda still leaves more than enough to do.

In addition to the personal and organizational commitment of the members, the Council's strength is in the consultants who oversee the day-to-day operations. The Council began with one part-time consultant; the Council now has three permanentand one full-time temporary consultants. Each has a commitment to the goals of the organization and each is skilled and respected in the governmental community. The original executive director came with a solid background in lobbying, and the others have learned on the job under his direction.

This coalition enables its members to have something that no other maternal and child health special interest has: full-time resources in the state capital dedicated to advocacy. This allows the Council to track legislation from its conception, to educate legislators and their staffe, to work closely with administrative offices, to be available for questions at all times, and to follow through on its concerns. The system can't put us otí, waiting for us to go home. The Council is a constant presence at the capítol, well known and accessible.

There are many other groups in Michigan with interests in issues that matter to the Council. The Council's full-time presence in the state capital allows it to be the focal point for those issues through what might be termed ad hoc coalitions and informal associations. Our ability to coordinate these political activities multiplies the power that can be brought to bear on important maternal and child health issues. One example of these efforts is the annual "Children's Agenda," developed by the Michigan Coalition of Children and Families, a broad-based human services coalition. The Children's Agenda, endorsed by more than 180 organizations, is an influential document, often quoted by the media as well as studied by political staffe.

Increasing opportunities through such associations have been one of the strongest forces for expansion of the Council's staff in recent years. The most recent staffer added on a 2-year trial basis is a specialist in grassroots community organizations, now working to develop maternal and child health advocates in nine different communities in Michigan. Other examples of these cooperative efforts include work with the professional associations, the hospital association, the state medical society, antismoking coalitions, heart/ lung groups, liability reform coalitions, public health associations, Healthy Mothers-Healthy Babies, Generations United, welfare rights groups, Office of Services to the Aging, Kiwanis, and others as specific issues evolve. We are proud that we have, on specific issues such as Family Planning, abstinence, and child health issues, worked cooperatively with both Right to Life and Planned Parenthood.

Table

TABLEMichigan Council for Maternal and Child Health

TABLE

Michigan Council for Maternal and Child Health

A major ongoing effort by the Council is the development of political sophistication within its member organizations. The Council works with its network on how to build relationships and how appropriately to support candidates so that one may be able to catch the ear of the official on issues that matter to the person and their organization. This includes such things as contributions of money, holding small "meet the candidate" programs and fund-raisers, letters to the editor, contributions of time working on campaigns, and other public expressions of support. With this background, an elected official will be receptive to a person or group that wishes to be heard.

Maintaining the Council's credibility was recognized as crucial from the inception of the organization. The Council exercises extreme care to keep on its "white hat" and not to be seen as working toward improving the financial status of its members. The philosophy has been and continues to be that things that are good for mothers and children ultimately will be good for those who care for and about them. Awkward and uneasy feelings develop around this philosophy when funding of the Medicaid program is under consideration. The Council maintains that this is not a provider payment issue but rather one of making quality care available and accessible to women and children. The Council does not discuss financial problems of doctors or hospitals as reasons for improving the Medicaid program. Rather, the legislators are apprised of the impossibility of making care available when providers can't meet expenses. With Michigan's recent history of financial woes, it is noteworthy that women and children's health has received fewer cuts and overall better support and growth than other parts of the state's budget. Michigan's current commitment to prevention and public health is unparalleled in the nation.

The current composition of the Council includes 11 sustaining members, of which 4 are women's or children's hospitals, 3 are medical professional groups, and 4 are voluntary public agencies with interests in specific health conditions. In addition, there are 2 contributing members who support the activities with money, time and advice (Table). There are also more than 100 individuals and associations who are general members who are kept informed of and help support the Council's efforts. Every success breeds more respect and more support, and the Council has continued to grow in respect and influence.

The American Academy of Pediatrics reports a number of state maternal and child health coalitions,' some of which were founded using our advice and model, but so fer as we could find, their composition and activities are not described in the literature. The Academy's list includes state maternal and child health coalitions" in Arizona, Florida, Georgia, Illinois, Kansas, Louisiana, Mississippi, Missouri, Montana, New Jersey, New Mexico, Texas, Virginia, and, of course, Michigan.

SUMMARY

Building a coalition with others is an effective tool for increasing influence at the state level of the political process. It allows for the hiring of a staff who are able to maintain a constant presence in the ever-changing state political arena, which individual physicians and other caregivers simply cannot do. It allows for the development of increased sophistication among its members, which likewise increases the ability to affect the political process. It should be done with a philosophical set of standards that preserves its integrity and focuses on its goals, which must be carefully delineated from the inception. Coalitions are an effective way to deal with public issues of maternal and child health.

REFERENCES

1. Cohen-Dolins J, FWelski JG, Schiavo CN. State Maternal and Child Health Coalitions. The Government Affairs Handbook. Elk Grove Village, Ml: American Academy of Pediatrics; 1992.

TABLE

Michigan Council for Maternal and Child Health

10.3928/0090-4481-19950801-07

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