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Legislative Skills for Future
Generalists
The American health system is changing remarkably. Market forces, as
well as state and federal legislative proposals, have shaken the system's
foundation and given birth to radically different mechanisms of
health-care finance and delivery. At the core of this revolution is an
immense drive toward cost-containment, coupled with a resurgent interest
in primary care, health promotion and disease prevention. As future
physicians, medical students must understand the foundations of health and
the health-care system as functions of larger political and socio-economic
forces. Maximal patient health must then stem from properly adapted
political, social and economic factors, and not merely the scientific
interplay of biochemical reactions.
- Why is it important for
medical students to be involved in legislative issues?
- What legislative issues
impact primary care?
- What is the best way for
me to convey my opinions to congressional representatives?
- How can my voice be
heard?
As the health-care system evolves, it is essential for medical students
to become more knowledgeable about both the policies affecting the
health-care system and the legislative process that creates those
policies. Medical students, properly trained and effectively mobilized,
can be a potent political force advocating for the public health. As
physicians, and especially as primary care providers, you will be the
quarterbacks of the health-care delivery system.1 The
speed at which the health-care system is changing also provides both a
great opportunity and substantial responsibility to plot its course.
This GPIT Project-in-a-Box aims to empower medical students with the
fundamentals of political activism. By carefully considering its contents,
you can significantly affect the political process, advocate for sound
health policies, and in turn become a better doctor by helping more than
just your own patients. The challenge is yours--read on.
STUDENT ORGANIZERS
GUIDE
This Project-in-a-Box contains a glossary of
legislative language, suggestions for taking action, a description of the
legislative process, letter writing tips and much more. Everything you
need to take political action and become an advocate is contained in this
box. Enjoy!
Activity Suggestions
- Organize a brown bag lunch or afternoon discussion group to
talk about the information contained in this module. This could also be
done after class or over dinner.
- Invite a speaker: Possibilities include a generalist
physician who is active in legislative affairs, a local congressional
representative or staff member, or someone who works for a local agency
that's involved in health-care policy. You could invite multiple
individuals and create a panel discussion. Any of these activities would
enhance the material contained herein.
- Discuss the issues and create a plan for action: Conduct a
voter-registration drive, an education project, or anything else you
think will be beneficial to your school and community with respect to
political activism. Ideas and knowledge are useless without action.
Legislative Language
Appropriations bill - Proposed legislation that approves
government spending for a particular federal program for the upcoming
fiscal year. Appropriations are considered only for programs that have
been authorized.
Authorizing legislation - Basic legislation to establish or
continue a federal program or agency, either indefinitely or for an
established period of time; generally a prerequisite for subsequent
appropriations.
Ballot initiative - A ballot item by which legislation may be
introduced or enacted by a direct vote of the people.
Calendar - The agenda or schedule of business awaiting action by
the full House or Senate.
Cloture - Process to end a filibuster other than by unanimous
consent in the Senate.
Committee report - Recommendations of a committee on a
particular bill.
Conference committee - Members of the House and Senate assigned
to resolve the differences between two versions of the same legislation
passed by the House and Senate.
Continuing resolution - Provides continued budget authority for
federal programs and agencies to continue operations until regular
appropriations bills are signed into law.
Entitlement programs - Federal programs such as Medicaid or
Medicare that guarantee certain benefits to individuals or entities who
meet requirements set by law.
Filibuster - A stalling tactic used in the Senate to delay or
prevent a vote. A filibuster can only be stopped by cloture or unanimous
consent.
Hearings - Committee sessions at which witnesses testify to
provide information relating to a bill.
Lobbying - Influencing the opinions of senators and
representatives through meetings, letters and phone calls.
Mark up - Committees may modify, or "markup," a bill by
amending, deleting or revising sections of the legislation.
Rescission - An appropriations bill item that cancels budget
authority previously appropriated but unspent.
Rider - An amendment to a bill not germane to the content of the
bill.
Testimony - Opinions provided to committees or subcommittees
with regard to a particular bill.
Veto - Rejection of a congressional bill by the President.
Congress can override a veto by a two-thirds majority in each chamber.
Taking Action: Things You Can
Do
- Hold a voter-registration drive for your school. Most medical
students spend at least four years in a community and should be
registered there.
- Invite a congressional or state legislator to speak at your school.
- Set up a bulletin board at your school where you can post literature
on current issues and encourage students to periodically post
information such as newspaper articles.
- Educate your students (and faculty) for upcoming elections. Collect
pamphlets on as many candidates and issues as possible, and set up an
information table in the weeks before the election.
- Invite a congressional representative to visit health centers in
your district. As an elected representative, he or she should be greatly
interested in these centers. Use this time to educate your legislator
about your health center and district's needs.
- Set up a phone (or e-mail) tree to notify interested students (and
faculty) about issues that need to be addressed through letter writing
or phone calls to legislators.
- Set up a state lobby day for students. Contact AMSA's Legislative
Affairs Director for a guide to setting up a local lobby day (call
703.620.6600, ext. 211, or e-mail lad@www.amsa.org).
Nuts and Bolts of the Legislative
Process
The federal government is organized into three
branches: executive, judicial and congressional. The executive branch
includes the president, vice president and various federal agencies (e.g.,
the FDA) that are charged with carrying out federal laws. The judicial
branch includes the Supreme Court, which interprets the Constitution and
other federal laws. The legislative branch includes Congress, which makes
federal laws. The U.S. Congress is composed of two chambers, the House of
Representatives (435 representatives distributed by population) and the
Senate (two senators per state). Each chamber possesses some specific
powers but must rely on the other chamber and approval from the President
to pass a bill into law. Senators are elected for six-year terms and
Representatives for two. Each session of Congress is two years long and is
numbered consecutively. For example, the 1995-96 session was the 104th
Congress.
The path of legislation begins with bills and resolutions. Bills are
the most common form of legislation and can be introduced by either
chamber. When introduced, each bill is given a number and prefixed with
"H.R." in the House of Representatives and "S." in the Senate. The bill's
number is usually based on the order in which it was introduced during
each session. However, there are exceptions to this rule; for example, a
bill that involves access to telephone emergency numbers could be called
H.R. 911.
Joint resolutions are very similar to bills and can be used to propose
amendments to the Constitution. Concurrent resolutions (approved by both
chambers) and simple resolutions (approved by only one chamber) express
opinions or positions, but they do not have the force of law, nor do they
require approval by the executive branch.
A bill can be introduced in either side of Congress (although all
funding bills must originate in the House), and is referred to an
appropriate committee. Both the House and Senate have numerous committees
and sub-committees with jurisdiction over particular programs. The vast
majority of bills die in committee. Thus, committee consideration is
crucial in determining the future of a bill. Considerable support must
exist if the bill is to advance any further, including strong support from
the sponsors, the committee members and the committee chair.
Public hearings on proposed legislation take place during this phase.
It is therefore extremely helpful to know which committees have
jurisdiction over issues of interest to you, and who is on those
committees. When public hearings are arranged, an organization may write
to the clerk of the committee and request to have a representative speak
at the hearings. This process is referred to as testifying and can prove
extremely valuable in promoting or discouraging legislation.
If a bill is approved in committee it goes to the floor of that chamber
for debate and a vote. If passed, it then goes through the entire process
in the opposite chamber. Once the two processes are complete and the bill
has been successfully passed out of both chambers, it can proceed in one
of two directions. If the House and Senate versions are different, the
bill will go to conference, where members of each chamber will attempt to
resolve the differences. If the bill passes both chambers in identical
form, it then goes directly to the executive branch for presidential
approval. With the president's signature, the bill becomes law. With a
presidential veto, the bill is sent back to Congress, where a subsequent
two-thirds majority in each chamber is required to override the veto.
Many political activists start their efforts by attempting to introduce
bills into the legislative process. By writing proposed legislation and
securing the sponsorship of a member of Congress, they have the
opportunity to parlay legislative concerns into public policy. After a
bill's introduction, numerous opportunities to influence the course of the
legislation exist through testimony and lobbying.
Lobbying involves influencing the opinions of congresspersons through
personal meetings with them or their staff, letter writing or phone calls.
It can consist of simply voicing an opinion about a bill or particular
parts of the bill, or it can mean advising the member on how to improve
the bill through alterations. Lobbying can be effective at any stage of
the legislative process from a bill's introduction to committee
consideration to floor debate to vote. The President may even be lobbied
to sign or veto a bill.
How Do I Get Bill
Information?
You can get information on bills through
various organizations, news media or the Internet. For copies of bills,
call the Congressional Document Room at (202) 225-3456. For the status of
bills in committee, call the committees or subcommittees themselves at the
numbers listed on the previous page.
Political activists have up to eight
opportunities to support or oppose legislation
- Introduction of a bill in the House of Representatives
- Introduction of a bill in the Senate
- Committee consideration in the House
- Committee consideration in the Senate
- General consideration in the House
- General consideration in the Senate
- Conference committee between the two chambers
- Presidential approval or veto
Six Most Important Committees Affecting
Health Care
House: The House Ways and Means Committee (202-225-3625) and its
Health Subcommittee (202-225-1025) oversee Medicare in the House and were
responsible for launching most of the health financing legislation that
was passed in the 1960s and early 1970s.
The House Commerce Committee (202-225-2927) and its Health and
Environment Subcommittee (202-225-2927) have jurisdiction over the Public
Health Service (PHS) and Medicaid programs, and share jurisdiction with
the House Ways and Means Committee over Medicare. Funding of family
medicine residencies may be debated here.
The House Appropriations Committee (202-225-2771) and its Subcommittee
on Labor, Health and Human Services, and Education (202-225-3508)
appropriate funds for individual health programs, such as the Ryan White
AIDS programs and rural health research.
Senate: The Senate Finance Committee (202-224-4515) has
jurisdiction over Medicare and Medicaid in the Senate.
The Senate Labor and Human Resources Committee (202-224-5375) has
jurisdiction over Public Health Service programs. Funding of primary care
research would be considered here.
The Senate Appropriations Committee (202-224-3471) and its Subcommittee
on Labor, Health, and Human Services and Education (202-224-7230)
appropriate funds for individual health programs, e.g., rural outreach
grants.
Engaging Your Elected Officials: Tools of
the Trade
Many legislators lack a background in health care
and rely on health-care leaders among their constituents to provide them
with information and direction. Legislators are most responsive to voters
in their own districts or states. Letters, phone calls and personal visits
can all be valuable means of communicating with and influencing your
legislators. Be assured that letters receive more than just a passing
glance
Each is read, documented and given a response. Phone calls, while
considered less effective, are similarly recorded and receive a response.
Personal visits from constituents to politicians and their staff are very
important and can be an excellent opportunity to make your concerns heard.
Whichever method you choose, remember that legislators are elected to
represent and work for you, their constituent. To do their job
effectively, they need to hear from you as frequently as is appropriate
and necessary.
Any legislative office can be reached by
calling the U.S. Capitol switchboard at (202) 224-3121. Simply ask for a
member of Congress and you will be transferred to that office.
Letter Writing
The optimal
time to write to a legislator is while the bill you are interested in is
in committee. Your letter will be especially influential if one of the
committee members represents your district. If the bill has already been
voted on, your letter will have very little impact.
Identify yourself as a medical student. This lends credibility,
especially with legislation pertaining to health care. It is important to
state whether or not you are a constituent. If you are representing a
particular organization, be sure to say so.
Immediately identify the issue or legislation you are writing about.
Identify the bill by name and number (e.g., S.1028) if possible. State
your support for, or opposition to, the bill and the reasons for your
position. Clearly outline the facts, and precisely state what you want the
legislator to do.
Try to personalize the issue by stating how it will affect you or the
organization you are representing. Offer to follow-up with additional
information by letter, telephone or in person. Legislators rely on
accurate and timely information from constituents to assist them in the
consideration of legislation.
DOs and DON'Ts of Letter Writing:
- DO be respectful.
- DO address the legislator properly:
Senator:
The Honorable ______(use correct spelling)
United States Senate
(office building address, may be obtained by calling
202-224-3121)
Washington, DC 20510
(begin letter with: Dear Senator Smith,)
Representative:
The Honorable ______( use correct spelling)
U.S. House of Representatives
(office building address, may be obtained by calling
202-224-3121)
Washington, DC 20515
(begin letter with: Dear Representative
Smith,)
- DO include any pertinent bill number or the popular name of the
pending legislation.
- DO be specific and try to keep your letter to one page.
- DO ask the legislator for his or her support, as well as his or her
position on the issue.
- DO send a personal letter, either typed or neatly hand-written and
always personally signed.
- DO be sure to write a follow-up letter to thank your legislator for
consideration of your position.
- DO be timely; it is important to contact your representative while
action can still be taken.
- DON'T promise items, such as specific information, which you cannot
deliver.
- DON'T send form letters or petitions.
- DON'T mix requests. Focus on one topic and one request.
Telephone Calls
Phone calls
should be limited to situations in which a letter would not reach the
legislator in a timely manner. Be respectful and polite, and have
available the specific bill number and its status. Be prepared to speak
with a staff person and give a brief and concise overview of your
position. In some instances, the staff person may suggest a time for you
to call back and speak with the legislator personally. Be sure to leave
your name and number. Remember, it is often just as effective to speak
with a staff member as the legislator. Regardless of with whom you speak,
always follow the telephone call with a letter, in which you briefly
restate your position and thank the legislator or staff person for his or
her time.
Personal Visits
A personal
visit, when performed properly, is perhaps the most influential form of
lobbying that exists. The challenge is to know your issue well, be
organized, and communicate clearly. You should try to bring written
materials (journal articles, examples of community programs, etc.) that
contain the information you wish to discuss. These can be left with the
legislator or appropriate staff person.
You should make an appointment with the appointments secretary at least
two weeks prior to your scheduled visit. If you desire a specific staff
person to be present (e.g., the legislative assistant for health policy),
you should communicate that wish at the time of scheduling. Explain your
purpose and identify yourself as a medical student. Make sure to identify
yourself as a constituent, if you are. Keep in mind that legislators are
very busy, so be flexible if asked to reschedule.
Be on time for your appointment. Once the meeting begins, state your
issue and position as quickly as possible. If there are several members of
your group, you should appoint a spokesperson to lead the discussion. Try
to avoid medical jargon and confusing statistics. Give information;
misrepresenting the facts will only cause the legislator to mistrust you.
If you do not know the answer to a question, don't make something up
--simply tell the legislator you will get back to him or her or the staff
person. This will give you the opportunity to set up another meeting in
the future.
Specifically state what it is that you would like the legislator to do
for you. Explain the relevance of this request to the interests of the
legislator's constituency. Obtain the name of the staff person with whom
you should follow- up, and be sure to leave your name, address and
telephone number. Always send a follow-up letter to the legislator to
thank him or her for the meeting and to reiterate your position. Any
additional material that you have promised should also be included.
DOs and DON'Ts of Personal Visits:
- DO make appointments at least two weeks in advance. Be flexible if
asked to reschedule.
- DO be polite and respectful.
- DO be willing to meet with a staff member if the legislator is not
available.
- DO be prepared. Use facts to support your position, and illustrate
with personal experiences.
- DO ask your legislator to do something specific; for example, to
vote for or against particular legislation.
- DON'T be rude or argumentative.
- DON'T give answers you are unsure of.
- DON'T sacrifice future gains for short-term solutions.
E-mail
Some legislators
have e-mail accounts established to communicate with constituents. Call
and ask if this is an available option with your legislator. If you have
access to the World Wide Web, you may be able to e-mail your legislator by
using The Electronic Activist (http://www.berkshire.net/~ifas/activist/).
Tips on Staying
Informed
Bills and reports are accessible to the public, and
legislators are usually cooperative in providing copies; you can also call
(202) 225-3456 to obtain this information. When legislators are supportive
of a cause, they often will offer advice on how to rally congressional
support.
Ask to be added to the e-mail list of AMSA's Legislative Affairs
Director (lad@www.amsa.org). As a
member of this list, you'll receive Straight From the Hill, a weekly
electronic newsletter on important legislative and political issues. Make
sure you are receiving AMSA's Health Policy Forum, a new publication of
the Legislative Affairs Committee. Post a copy of this and any other
pertinent information on a designated bulletin board at school for
students and faculty to read.
Utilize Online and Internet
Sources
There are numerous sites on the World Wide Web that
provide legislative information. Below is a sample of excellent sites:
- Intergovernmental Health Policy Project (IHPP)
- http://www.gwu.edu/~ihpp
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- CNN
- http://allpolitics.com/
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- The White House
- http://www.whitehouse.gov/
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- Department of Health and Human Services
- http://www.os.dhhs.gov/
Various excellent political and election web pages:
- Thomas: legislative language on the Internet
- http://thomas.loc.gov/
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- Vote Smart Web: one-stop shopping center for political information
- http://www.vote-smart.org/
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- Politics Now: complete coverage of politics, election, government,
etc.
- http://www.politicsnow.com/
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- The Democratic Party On-Line
- http://www.democrats.org/
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- Republican Main Street
- http://www.rnc.org/
Additional Resources
- Almanac of American Politics (most public libraries)
- Congressional Staff Directory (most public libraries)
- League of Women Voters (locate phone number in local directory)
- Congressional Quarterly (a weekly publication, available at most
libraries)
- AMA Congressional Directory (pocket-sized directory of members of
congress and names of health staffers. For a copy, write to Kate Cox,
AMA, 1101 Vermont Ave, NW, Washington, DC 20005)
- American Public Health Association [maintains voting records of
members of Congress on public health issues, updated semi-annually. Call
(202)789.5600 for a copy]
References
- Mullan F., Politzer, R.M. Building primary care: the
beat goes on. Primary Care Quarterly, 1995; (3) 4:2.
- Wolpe, B. Lobbying congress: how the system works.
Washington, DC: Congressional Quarterly Inc, 1990.
- Graduate medical education reform. Position statement
from the Organizations of Academic Family Medicine. Washington, DC:
1995.
- Midtling, J. Family practice training programs and
research. Testimony before the Subcommittee on Labor/HHS, Education and
Related Agencies, House Committee on Appropriations. Organizations of
Academic Family Medicine, January 31 1995.
- Senate report 102-426 accompanying PL 102-410.
Washington, DC: United States Senate, 1992.
- Tschida, M. Corps or less. The New Physician 1995;
(44) 8: 12-16.
Case Studies
Political Activism and Primary Care: Policy Issues
Now that
we've covered the basics of legislative action and activism in general,
what can you do to affect primary care in particular? Below are some
examples of how public policy affects primary care. As you read through
these issues, try to think of political strategies that would improve
primary care health policy.
Case 1
The Federal government historically has supported
graduate medical education (GME) through several mechanisms, including
Medicare and the Public Health Service Act. Support for GME through titles
VII and VIII of the Public Health Service Act are especially important for
primary care residencies. Despite the need for more generalist physicians,
the federal government's current proposals threaten to decrease GME
funding. Primary care residency programs will be hit especially hard if
the title VII and VIII support is lost.3 Authorization and appropriation
of funding for GME is a complicated process that occurs in the House and
Senate Appropriations Committees, the House Commerce and Ways and Means
Committees, and the Senate Labor and Human Resources and Finance
Committees.
Questions
- Are your legislators on any of these Committees?
- How could you advocate for or against GME funding based on the
information contained in this Project-in-a-Box?
Case 2
In testimony before the Subcommittee on Labor/HHS,
Education and Related Agencies (House Committee on Appropriations), the
Organizations of Academic Family Medicine made the following statement:
"Eighty percent of family practice residency programs are located in
community hospitals, half of which have no other specialty residency. This
is a key reason family medicine produces physicians who practice in all
areas of the country, but also one of the reasons there is not a great
deal of outside funding available to these programs. This is especially
true because Medicare does not reimburse hospitals for graduate medical
education (GME) training that occurs in the ambulatory setting--the
hallmark of family medicine residency training." 4 Despite the public
demand to move residency education away from the hospital and toward
outpatient and community-based care, federal public policy makes it
punitive to train residents anywhere other than within the hospital
setting.
Questions
- What organizations in your communities would have an interest in
this issue (e.g., community health centers, public health agencies, your
academic health center)?
- How could medical students form action-oriented partnerships with
these groups to advocate for this change in public policy?
- What specific actions would such a coalition of groups take?
Case 3
In the past, very little federal funding has been
available to support primary care research. The agency for Health Care
Policy and Research (AHCPR) is the only entity of the federal government
that provides this funding. The 1992 Senate report reauthorizing AHCPR
states that the Agency should strengthen its commitment to family practice
and primary care research.5 "The committee believes
that inadequate attention has been given to conditions that affect the
vast majority of Americans--that is, the undifferentiated problems
individuals present to their generalist physicians. A focus on family
practice/primary care research is essential if we are to redirect the U.S.
health-care system that is currently skewed toward high-technology
medicine for catastrophic diseases."
Questions
- What House and Senate committees would make decisions on funding of
AHCPR?
- Who are the members of those committees, and how could you contact
them in support of primary care research?
Case 4
The National Health Service Corps (NHSC) was designed
to place health-care providers in underserved areas. Today more than 1,900
NHSC primary care providers are at work in both rural and urban areas
across the country, serving 3.8 million people.6 It
is estimated that an additional 12,000 primary care providers are needed
in shortage areas. Republicans have been proposing significant cuts to the
NHSC. Despite this information, some recent proposals called for a 50%
reduction of NHSC funding.
Questions
- Does your state have NHSC providers caring for the underserved?
- Does your state have special populations who could benefit from
NHSC-supported providers?
- How could this information be used to educate policymakers about
NHSC funding?
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