HCFA and the states: politics and intergovernmental leverage

In this article, we seek to explain variations in the Health Care Financing Administration's (HCFA) relationship to state governments. After reviewing several alternative models of the policy-making process, we argue that the utility of each model depends on certain issue characteristics, especially salience and conflict. We further argue that HCFA's choice of intergovernmental tools, rooted in a political setting, depends on the same issue characteristics. We illustrate our arguments by examining HCFA's behavior during the Clinton administration and by focusing on four cases: HMO performance measurement, nursing home regulation, lead screening for children, and the Children's Health Insurance Program (CHIP).