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The Littlest Lobbyists

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Some of the most effective lobbyists to appear before the Minnesota legislature last year never said a word. They tumbled, tottered, crawled, and cried.

Participants in the Diaper Derby for Healthier Babies were part of a broad grassroots effort that convinced the lawmakers to adopt a novel health-insurance program that guarantees all children access to preventive medical services.

The derby, coordinated by the Children's Defense Fund-Minnesota Project and the March of Dimes, was designed to show lawmakers the range of activities that healthy--and fully insured--toddlers are capable of performing.

The state-funded insurance program that it and other equally dramatic presentations helped produce is the first of its kind in the country--a program intended to provide comprehensive coverage for those who often fall through the cracks of the health-care system, the children of the so-called "working poor."

And the carefully crafted campaign that achieved its passage has been hailed as a classic example of how grassroots lobbying and strong coalition-building can bring about fundamental change.

"Children don't have any power," said Luanne Nyberg, director of the cdf's Minnesota office. "So we have to use other approaches to have their needs heard and met."

The Children's Health Plan, which went into effect on July 1, offers all poor children between the ages of 1 and 8 a cornucopia of preventive services for only $25 a year. It does not, however, provide for hospitalization.

Children are eligible to participate if their family's income exceeds Medicaid guidelines but is less than 185 percent of the federal poverty line, which amounts to $21,552 for a family of four.

As of last month, 4,100 children were enrolled in the plan, which requires no co-payments or deductibles and allows an unlimited number of visits to doctors that serve Medicaid patients. State health officials believe that close to 4,000 additional children will enroll in the program by next June.

The legislature last year dedicated one penny of a 15-cent tax hike on a pack of cigarettes to pay for the program, which is expected to cost the state $1.3 millon this year and $3.6 million next year.

"It is absolutely a unique program," said Sara Rosenbaum, director of the health division of the Washington-based cdf "On these sorts of issues, Minnesota is ahead."

The state's action sets a model in an area that groups ranging from the National Governors' Association to the Council of Chief State School Officers have cited as critical in dealing with the problems of children at risk of school failure.

Many Uninsured Families

But children's advocates say that a variety of circumstances--some unique to the state--aided the program's passage.

Minnesota, they note, has had a history of providing more services to its poorer residents. But more important in the current debate, they add, was a growing realization on the part of both policymakers and officials in the health-care industry that money spent on preventive care is cost-effective over the long run.

Both the governor and the legislature were also studying ways to revamp the state's welfare system when the health-care campaign took shape, observers note.

And the conclusion drawn by the politicians dovetailed nicely with the citizens' effort: To wean more parents off public assistance, better health-care options had to be provided for their children. Study groups had found that these parents frequently opted to stay on welfare rather than accept a low-paying job with no health benefits.

In 1985, the Children's Defense Fund opened a Minnesota office to work specifically on health-insurance issues. The state was chosen, officials said, because a large portion of its population receives medical care from health-maintenance organizations, which are designed to cut medical costs and provide options for families of more modest means.

Despite this competitive environment, however, many Minnesota families were left without insurance, the cdf found. Approximately 450,000 state residents--many of whom work full time for all or part of the year--were not covered. And approximately one-third of the uninsured were children.

"We have many, many families where the parents are struggling as hard as they know how and all it takes is one illness, two office visits, to put them over," said Betty Nowicki, president of the School Nurse Association of Minnesota. "A child who doesn't feel well won't make the full use of his school day."

To remedy this situation, the8cdf's Minnesota office created alliances with medical associations, citizens' groups, unions, foundations, and some members of the health-care industry to look more closely at the issue and to organize a series of public hearings around the state on children's health care.

On an 'Emotional Level'

They then released a report in 1986 that outlined their proposal and explained how preventive services could save money. For example, the study said, spending $20 for a doctor's office visit to treat a child with strep throat is far less expensive than the $3,500 that would be needed to hospitalize a child whose untreated strep throat develops into rheumatic fever.

After finding several legislators who were willing to sponsor their bill, the group developed strategies to keep it on the front burner.

Shortly before the start of the 1987 legislative session, for example, cdf officials organized an informational program for several hundred activists from around the state. Many agreed to 'adopt' a legislator, and to keep him or her apprised of the bill's progress.

Some strategies were also clearly designed to appeal to lawmakers' parental instincts. For 20 days in a row, each lawmaker received a new, one-page story detailing the struggles of an uninsured family to cope with a health crisis involving their children.

On another occasion, a key House panel was taken to a local hospital to view a room full of premature babies. Ms. Nyberg says that the lawmakers were reminded that many of the costly medical procedures needed by premature babies could be eliminated by proper prenatal care.

"It was making them understand on an emotional level what [insurance] meant to poor families and their children," she said.

Ms. Nyberg and other advocates said that their next goal was to have the legislature extend the program to all children up to the age of 18. She said that her group would press for the introduction of such a bill during the next legislative session.

"Minnesota is a little bit different," observed Ann Wynia, the House Majority leader and one of two state lawmakers who introduced the original bill creating the program. "When we see a problem, we know we have to solve it."

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