Chapter 3: Leading Through Influence to Achieve Change
You have power, even if buried in the bureaucracy with decimal dust for a budget!
My years of experience in state government have shown me that sometimes people in the highest positions do not see themselves as having power and influence while 'true leaders' at lower levels of the hierarchy assume the leadership role and end up moving mountains. It's up to you! - Joan Wightkin, Director, MCH Program, Louisiana
MCH leaders vary in the degree of power they have by virtue of their positions within state bureaucracies and the magnitude of their budgets and programs. This chapter discusses tools that are available to you, including sources of potential power, statutory leverage, vision, partnerships, advocacy and marketing. Certainly Title V leaders do not have the same kind of power and influence that comes with leading a large state agency or directing a budget as large as Medicaid. But managers responsible for Title V programs have both formal and personal sources of power and influence. The greatest power comes from recognizing potential sources you have and using them strategically and judiciously.
As a Title V leader, you have a number of sources of potential power and influence, including:
- A rich legacy of MCH leadership
- Your knowledge, skills, expertise and passion
- Your staff's knowledge, skills, expertise and passion
- Stature, visibility and direct means of control related to your position
- Budget resources, including the ability to fund agencies and organizations that may be supporters or detractors
- Legislative and regulatory requirements governing your programs that can be used strategically to back up your course of action or requests of others
- Control or influence over contracts, regulations or other legal requirements
- Ability to develop voluntary standards and guidelines, backed by the power of your office and the influence of the stakeholders involved in development
- Data, information and reports needed by others or which can influence others
- Access to other state leaders and managers in your agency, other agencies, the governor's office and the state legislature
- Individuals, organizations and agencies with direct, vested interests in your programs, and those with more indirect investments in your mission, at both state and national levels
- A network of colleagues in other states, accessible via AMCHP
What Kind of Leverage Does Title V Provide?
While statutory requirements for Title V are fairly limited, there are some important tools to exert influence and lead change.
Within Title V
- Needs assessment and performance data can draw public and policy attention to unmet needs and insufficient progress. You can use this data to compare your state to the nation, other states or across political jurisdictions within the state.
- Legal requirements to address identified needs can help protect against changing political priorities.
- So called "30/30 earmarks" designate minimum funding for preventive and primary services for children and youth. These earmarks can help assure continued attention to children's needs and counteract mistaken assumptions that Medicaid and SCHIP can or will meet all needs.
- Requirements that Title V services be provided free of charge to those below the poverty line, and using a sliding scale for those above, can help assure that financial barriers are not erected to block access to services.
- Requirements for interagency coordination can be used internally and externally to place priority on interagency efforts and to help gain a "seat at the table." Requirements for Medicaid coordination are the most detailed and support roles in policy development for EPSDT, outreach and information, including toll-free phone lines.
Language referencing Title V in other programs' statutes
- The Medicaid statute was amended in 1967 to require that states provide for agreements with Title V agencies to deliver Medicaid services. This language has been interpreted to place Title V in the position of payor of last resort, after Medicaid. The language also assures that Title V services can be billed to Medicaid for Medicaid-eligible children and offered free of charge to others. This provision, which is contrary to general Medicaid policy requiring payment for all services, has been used in Title-V-supported, school-based health programs. Finally, some have used the language to argue that Title V programs should receive cost-based Medicaid reimbursement. Federal Medicaid regulations provide additional requirements for Medicaid agreements with Title V.
- Amendments to Medicaid to address managed care made special provisions for children with special health care needs, citing Title V as one category in defining special needs children exempt from mandatory enrollment.
- The federal State Children's Health Insurance Program legislation requires states to coordinate with maternal and child health programs. Although Title V is not specifically cited, this was the intent behind the language.
- In the Supplemental Security Income (SSI) for disabled children program, reference to Title V has provided the basis for state CSHCN programs to receive lists of all children enrolled in SSI. These lists have facilitated Title V outreach and follow-up to assure these children are linked with needed services. This policy also helped support a Title V role in outreach and recertification efforts following changes in federal eligibility rules in the 1990s.
- The authorization for the federal Healthy Start program requires grantees to coordinate their services and activities with state Title V agencies.
Congress enacted most of these provisions in response to recommendations from MCH leaders through AMCHP and its partner organizations. AMCHP continues to seek opportunities to strengthen the statutory basis for effective program coordination.
Use the "vision thing"!
Communicate your vision frequently. Be able to articulate it in 30-second sound bites that your audie