As mentioned in this column a few months ago, changes in state Medicaid rules and policies are as big a threat to many providers as the issues coming out of Washington and Baltimore. State Medicaid programs are imitating and adopting "cost savings and anti-fraud" initiatives of the Medicare program.

Several states have already promulgated rules to launch their own competitive bidding programs. Others are adopting draconian rules that will make it difficult for consumers to receive appropriate products and services. A few states are getting innovative and proposing ideas such as wheelchair recycling programs.

By and large, state government is much more agile, and the process for change is much quicker. At the same time, agencies and policy shops are generally smaller and cabinet officers interact with the Governor on a more regular basis. Major policy changes are usually based on a gubernatorial initiative. However, the majority of new rules originate in the bureaucracy as it struggles to meet goals set by the Governor or interpret obtuse legislative language. In most states, a rule can become final with little or no legislative or executive oversight.

Smaller Medicaid bureaucracies are able to move from draft rules to implementation much faster than the Medicare program. An idea floated in a speech can, in some cases, become a final rule in as little as 60 days.

So the question looms, how does the industry respond to proposed changes in Medicaid payment policy and coverage guidelines? The first answer is that all providers must become active members in their state or regional associations. These groups monitor changes in Medicaid rules. They have also worked hard to develop relationships with Medicaid staff and state legislators. You abdicate your right to complain if you are not a member of your state association. To change proposals or block state-level legislation, you must be able to energize and empower the grassroots.

The grassroots is a large and diverse constituency that includes employees, customers, and their extended network of family and friends. It is a broad group encompassing senior citizens, parents of young children with disabilities, and everything in between. Add to the mix clinicians and referral sources, and most "disease organizations" through their state and local chapters (National Multiple Sclerosis Society, the American Cancer Association, ALS groups, Easter Seals, and the American Lung Association).

These groups all maintain extensive e-mail lists to which they can send alerts. Many of these organizations hold regular meetings. Sponsor a speaker, a meeting, or a special event so you can be seen as more than just a vendor of supplies and equipment. Most of these groups have sophisticated government relations committees who are used to writing letters and meeting with officials.

To overturn or modify legislation or a proposed rule, consumers, advocacy organizations, and service providers need to be educated—not on how it affects HME providers—but how it infringes on the ability of citizens to fully integrate into community life.

The leaders of the consumer/disability community are experienced political operatives. They are not "Jerry's Kids"—objects of pity who don't spend enough time talking about the issues. Frankly, the industry has done a poor job of enlisting consumer advocates for the long haul. Five or six visibly disabled individuals showing up for a photo-op just does not cut it. Sustained consumer advocacy must be led by experienced insiders from organizations that can reach out to activist consumers. There is a large component of "quid pro quo" at work. This means that support for the industry's position depends on the industry understanding, endorsing, and advocating for the consumer agenda.

The HME/rehab industry must invest the time and resources to recruit and educate consumer advocates. A 1-hour briefing before sending them to legislators' offices with a prewritten position paper just won't do. Respect their intelligence and abilities by providing information about how the proposed changes in Medicaid rules and policy will adversely affect consumers.

Emphasize the impact on consumers and not your business. Let them know who to write and give them addresses. Encourage them to use their own words and use personal stories when writing to policy makers.

Ten letters from real constituents is enough to make any state legislator take notice. Fifty letters from constituents to the Governor of even the largest state will cause them to look into the matter. State legislative districts are smaller, and consumer advocates will get time on the busiest legislator's schedule.

Cara C. Bachenheimer, JD, is VP of government relations for Invacare Corp. David T. Williams is a political and legislative strategy consultant.