Judson Force, MD, MPH
MCH Director of Maryland in 1981

Responses to Questions regarding OBRA 1981
Personal Communication with Laura Kavanagh via email, February 14, 2007


  1. Discuss the context for this change in policy.  Who were the major players that initiated this change and what was the rationale presented for makingthis change?

    The context was that the economy was not doing well. Inflation was at 10 to12 percent. Money was tight and interest rates were in the 15 to 20 percent range. The new Republican administration came into office with a design to improve the economy through supply side economics by reducing federal taxes. Much of the offset in reduction of federal revenues was to be met by decreases in federal spending on discretionary programs. Unlike Title XVIII and XIX, Title V was one of well over 100 discretionary funded programs that were targeted for possible budget reduction or elimination.

    The Association of MCH Directors was advised in early Spring of 1981 at the annual MCH Directors meeting in San Diego that TitleV was likely to be defunded. The meeting was being conducted jointly with the Association of Teachers of MCH who were then and continued to be extremely important in providing assistance with efforts to preserve Title V. At this time there was no mention by the Administration or our Associations of creating a block grant. Our priority and focus at this time was on preserving Title V, as then enacted.

  2. Describe how the Title V directors prepared for this change. What were your priorities to discuss with the MCH state level leadership? What “game plan” did you devise?

    The game plan was to first of all get organized to meet the challenge. The Association up to then was a very loosely organized collegial group of physician directors. The group met annually for educational purposes and to learn from the federal MCH Bureau what the national priorities would be for the next year. It became clear that if Title V had a chance of surviving much help would be needed from Congress and the Title V oversight committees - Ways and Means in the House and Finance in the Senate.

    The major player in the Association to get us underway was John McQueen, who directed the Title V Crippled Children’s Program (CSHCN) in Iowa. The program in that state is administered through the University of Iowa. Through John’s effort we were introduced to Josie Gittler, a faculty member at the University’s Law School, who had recently worked in Washington as a staffer on the Hill and was a   real advocate for MCH. These two persons were instrumental in establishing the first national office for the Association that became the locus of our legislative   operational activities. Building a national Title V MCH consortium was also a needed undertaking in preparing for the change.

    A major issue for the Association was funding to support operational needs. Income for the Association consisted of annual membership dues paid by each director. A first order of business was to develop and implement a revised dues structure that could generate the income needed for defending and promoting Title V.  Increased funds became available through establishing State Title V memberships with higher dues to replace the individual membership structure.

  3. Why was a block grant chosen as afunding mechanism by policymakers? What were the benefits and potential concerns about a blockgrant? 

    The creation of block grants was a compromise position acceptable to Congress and the Administration’s Office of Management and Budget (OMB) Director David Stockman, the President’s budget expert, during conferencing on the 1982 budget bills. Initially, OMB had targeted a large number of programs for elimination. Title V MCH and most of the programs that eventually became part of the MCH Block Grant were on that list.

    Block grants were seen by Congress, to some extent, as the means to preserve programs serving national needs. OMB may have accepted block grants as a more expedient method to eventually zero out funding and thereby achieve projected expenditure savings in the out years. Block grants were also appreciated by many state officials as they would allow the state much greater flexibility in the use of grant funds.

    Prior to the OMB decision to drop the effort to eliminate individual programs from the President’s 1982 budget, considerable time and effort was expended by State Title V Directors in meeting with their Congressional members. Much work on their part was required in providing up-to-date information to these members on the importance of MCH activities in their states and the impact on direct service losses to their vulnerable constituencies with the elimination of Title V and MCH funds. Major work on the Hill with committee staff was undertaken by Peter Edelman, a colleague of Josie Gittler, who was extremely helpful in promoting the national importance of Title V activities. Also the efforts of Herb Cohen and University Affiliated Facilities (UAF’s), Don Cornely and Association of Teachers of Maternal and Child Health (ATMCH), and Jackie Noyes and the American Academy of Pediatrics (AAP) Washington office were critical to our success. These efforts were coordinated by the newly established national Association office and a revamped MCH Directors Executive (Political) Action Committee.

    The agreement by the Executive Committee to accept changes in the Title V law and become a Block Grant was seen as a positive for the most part. It would assure continuation of state Title V support, the continued presence of the federal MCH Bureau, and preserve those categorical programs that would become part of the Block Grant. The most significant negative, and not fully appreciated at the time, was the loss of federal regulations and an efficacious working relationship that had been established between states and the federal office.

  4. What was the legacy of that moment intime for today?

    Perhaps the greatest outcome for Title V and its constituency was the creation of  a Washington based organization, the Association of MCH Programs (AMCHP) to succeed the association of state Title V directors. Certainly, this development did much to broaden the network and base for involvement with many others serving the Title V target populations. The crisis faced by the Title V community also led to a greater recognition of the importance of quantifiable, results oriented information about Title V mission accomplishments. Subsequently, much help has been provided to states by the MCH Bureau and development of an enhanced data collection system. In Maryland, and most likely in some other states, we now have state regulations that were needed to replace federal authorizing regulations.