Advocate Summary

Issue:  Optometric clinical education training
Advocate:  American Optometric Association – David S. Danielson
Date of Interview: 6/4/02

Basic Background
I and others, I personally – let me stop here and back up a little bit.  I am one of the lobbyists here, senior lobbyist, that I work on smaller issues, not mega issues. We have a number of lobbyists here.  My focus is representing educational interests and federal employed optometrists and other things that I'm pulled into doing. You will have interviewed other health professions, this is one that we all work on.  This is a big issue because it's a money issue.  Any time you have a popular issue with your membership, that's a big issue.  That's one.  
Beyond that is another mega issue that will cut across lines and has kind of gone into hibernation is this patients bill of rights.  This is important for non-physician providers.  It gets complicated.  We're physicians for the purposes of reimbursement under Medicare but we're not an M.D. physician.  For the patient bill of rights, insurance companies can circumvent state law and only deal with ophthalmologists.  We're optometrists.  Do you know what an optometrist is?
Okay.  We're the fellows who do windows too.  Ophthalmology is a surgical subspecialty of medicine, they do it all because they're not limited licensed practitioner.  An optometrist is a limited licensed practitioner, similar to a dentist or a podiatrist.  We don't do surgery.  In some states we do.  The practice is defined by the status.  Any non-physician provider will have different rules.  An optometrist is a limited licensed practitioner. Just like podiatry, dentistry.  I'm using those two because the curriculum is somewhat similar.  For the patients bill of rights, it would allow non-physician providers to not be included.   Those are mega issues.  
You asked what in particular I'm doing.  Right now I'm doing an administrative – I do legislative things, but I'm working on an administrative initiative.  You say also that these things are…is this going to be advertised?  Because I don't want the world know what we're doing on regulatory issues.
[No, definitely not.  But if that's what you're most currently working on –]
This is the most current thing, it's where I was this weekend working on it.  The issue is this.  It's a Medicare issue, it's a clinical education issue.  It's a reimbursement issue.  It's a graduate medical education issue.  Physicians, dentists, podiatrists, have residency training, that's training after their doctoral for specialty areas.  Optometry has no specialty defined areas.  So while we have residency training in areas of advanced competence, if you will, there are no licensing requirements for residency to get board certification in an area.  We're not there yet.  
I bring this up because allopathic and osteopathic medicine, dentistry and podiatry have specialty.  Medicine has some twenty-six specialties, dentistry has seven, I believe, podiatry has two and I think they're going into a third surgical subspecialty.  When you get these areas, traditionally you have a residency training for this and it results in a certification process.  In this case, a board professional, specialty board certification.  Those boards are recognized and they're recognized in law.  
The Medicare has a policy of paying for the education of specialty areas, it's a set policy.  That gets you into direct and indirect payment of Medicare residency training.  Again, we don't have that.  We would have to change the law.  First the profession would have to get into specialty areas.  We're not there yet.  Then in order to get training money for residents, independent and dependent training money, you would have to change the law.  We're not there.  
There's another way around that I found.  The Secretary of HHS has the administrative authority to release funding or approve funding for training programs.  In fact, in regulation  Allied Health, by Allied Health I mean, There is medical records management, inhalation technician, occupational therapy, physical therapy, those kinds of things are essentially hospital based occupations.  They have training elements to them Medicare under the rubric of GME releases training certain clinical training.  Again, we are neither fish nor foul it’s an odd set up.  I can't go after residency GME only because we would have to change the law and there’s no rational there.  
So what I'm doing right now is get into the administrative end of things and approach the Secretary of HHS and try to get clinical education training for optometry.  They won't do it of their own accord.  They meaning HHS, so I, in the last month, put together a legislative push, we don't need legislation but I need legislative language to know – much of my work is done my legislative language.  For example, in appropriations bills.  
I'll give you another example.  I’m going to digress here. I represent federally employed optometrists.  I give you an example right now, I get payments for the military in the United States, USPHS the Commission Corps for the United States public health services.  I have bonus payments for optometrists.  You have to change the law and I do that I go in and change the law.  You have to go through the authorization process and get it into law.  The agencies don't always want to do this, because there's no requirement to do it.  So you have to go through appropriations to get that kind of stuff itemized.
Appropriations language, while it doesn't have the force of law, the appropriator of the House and Senate, the chairmen of the committees writes the Secretary in charge, they can't ignore them too many times because that's where they get their money.  So much of what I do when I write legislative language, I write these things and get language attached to appropriations bills, to say we urge you to implement X, Y and Z.  
That's where we are on this - what I’m calling graduate medical education training.  It's not really GME but it's under that rubric of GME.  That's where we are now, in the process of getting our advocates lined up on the Senate Finance, the House Ways and Means and in Commerce.

That's what I'm working on.  That's a big project right now.  It's a regulatory matter, not a legislative.  However, I'm using Congress to encourage, if you will, them to take a look at it.  HHS will never take a look at a blind letter saying give us money.  We know that won't work.  But administrators can’t ignore Congress, because that's where they get their money.  It's been my experience that when you have letters of interest on any a number of things, they can ignore an issue once or twice.  Once maybe.  Twice, that's not good because the Congress will come back.  
This is a fair amount of money.  We will have to have a special rule written for us.  It's a pretty big deal.

Everything will be done with the cooperation of our association of schools and colleges of optometry.  I make it a point never to lie, never, never, never.  You do that one time, you're dead.  We have a model now, a cost model, what it costs to educate.  I could probably pull that one out.  I think the only thing that would make sense to you, it's a $100 charge patient encounter.  That's a very expensive thing for a school to go through.  My encounters with the VA, the VA has full-time optometrists, we have a very robust resident program in optometry.  We train students, 500-600 students a year.  Those patient encounters under that regime is about $3 versus $100.  
That's a huge thing that the private schools are getting into.  We're just not all that.  We're not as sophisticated as medicine yet, nor should we be, we only have 17 schools.  Medicine found out the cost of a clinical education episodes a long time ago and that's why they have all this other overhead.  Optometry has had to run their own boat.  So we've got to address this problem if we want to stay in the game.  Again, it's a “me-to” argument.  Other disciplines have gotten training money.  Optometry has a rightful place in health care.  It's our turn; to do it, we have to come up with costs to score it and a rationale.  
What I'm giving you is not much, after looking at this other thing – I have the exact thing - I'm not prepared to share that with anybody right now.  But I will see that the clinical education costs for  private schools, of which half the optometry schools are private schools, is high.  That figure is a little high.  It usually less than $40 an episode, it's right around $100 in this instance.  That's terrible for a tuition-driven system where you don't have any medical help.  
If you bring down the cost of clinical training, one of the happy results of bringing this down would be to reduce tuition, reduce debt level, better your choice.  That's all parochial within the system.  But outside, you're giving training to the elderly and those who need it, because the schools are making these clinical care decisions based upon funding.  They're going to have to reduce some of their training for the elderly because they don't have the money.
It's not legislation.  Regulatory, it's not legislation.  A very important distinction.  The change in regulation would permit optometry to get graduate medical education funding from Medicare.  That's part of that. Through a provider, the schools wouldn't get it directly by the way.  This is very complicated and I don't even know the ins and outs of it.  But the hospitals and the community health service where the teaching physicians, teaching optometrists are would get that funding.  It's called pass-through funding.  But the overage, the cost of a supervised teaching position and the associated overhead of equipment would be partly defrayed by this education money from Medicare.  
It's precisely what Medicare does for graduate medical education.  They have indirect and direct funding for GME, for the residents and the teaching positions.  This is the same principle dropped down to only the clinical training now of optometrists.  This only applies if you're seeing Medicare patients.  It has nothing to do if you're seeing Medicaid patients or any other patients.  This only kicks in because Medicare has a policy of supporting education for Medicare recipients. The schools, the private schools and city schools, have a huge Medicare population and Medicaid population as well.  It's only right that they should have their fair share.  Other disciplines are getting it, clinical training money.  Again, would that we had a requirement for residency training, if we had specialties, I wouldn't be going through this at all, I'd be going for a change in law, not a change in regulation.

How does the funding pay out the provider level?  Again, a provider, you have to get into the lexicon of the law.  A provider is a hospital, a community health center, a mental health center, these multidiscipline health centers and outpatient clinics of the hospitals.  A provider isn't an individual practitioner, a provider is this.  The money goes to the provider in any sense, in Part A funding of Medicare, all the direct and indirect training monies go to the provider.  There's all these arcane formulas.  They then determine in consultation with VMS, they have policy on how the money is doled out.  I don't know what it is.  
It's very loosely written for allied health, what the dollars would be.  It's called "reasonable costs," whatever they are, to help defray – they can establish whatever – to help defray these clinical training costs.  Those clinical training costs are the partial salary of the teaching physician, in this case the teacher supervising optometrist for any residency help you have.  And some overhead for the equipment.  There's a lot of equipment in optometry, a lot of dials and stuff.  That's what these education monies go for.  I don't think they're for bricks and mortar issues at all, it's just clinical training.  
It's called pass-through, a provider passes it through.  So somehow the teaching physician, in this case optometrist, has to be affiliated with that provider, that outpatient clinic, or else it doesn't work.  There's no money in everybody's pocket, it just goes back from the provider to the school for clinical care.

Prior Activity on the Issue 
None mentioned. 

Advocacy Activities Undertaken
HHS is required to write their own rules.  My job, what I intend by the end of this summer is to have put together a model.  I'm working with staffers and principals, the senators I'm working with turned it over to their staff.  What I'm doing right now is to produce a model, a rationale – you asked me, what are your item points?  I'm developing those.  I've given you an outline of what I'm going to do.  I will flesh out a model and I'll give them a cost, I'll give them a rationale.

That's where we are now, in the process of getting our advocates lined up on the Senate Finance, the House Ways and Means and in Commerce.

I targeted ten people.  I've dealt with about four of them thus far.  I targeted, I sent our volunteer structure – let me digress on another point here. When you're in the business I am, we're not glorified salesmen.  What do we have to bring to bear ?  We can advocate for our discipline.  But what really do we bring?  There's the ugly thing of PAC funding.  AOA has a robust PAC.  That's the crass end of it.  But it allows you to get in and at least get an audience with people.
But the part of that that we're most proud of, and I think that among the health professions we're among the best, believe it or not, at grassroots structure.  We call ours the key people program.  It's where optometrists have been identified in a congressional district Congressmen or Senators or whatever.  Optometry has always been very good at reacting and representing themselves, I think, in twenty-seven years, I grew up with this outfit, and if I were to lay credit to the strength of this profession in Washington, it is at the grassroots level, state level is enormously strong.  These folks are out in the hinterlands, they're politically active.  In the twenty-seven years I've been working for the AOA, we've had three optometrists in the Congress.  They're politically astute as a discipline at the state level and the national level.  
Just recently in April, annually we bring a group of optometrists in, some 160 of them.  We don't cover every member of Congress but we attempt to.  We're always honing and refining our whole apparatus.  In April we brought for our annual legislative conference and these are the fact sheets I told you about.  We bring them in for a day and half, talk over the issues very thoroughly, bring in outside speakers.

I've had my guys talk to him, said I'll give you the staff I’m working with, Lisa German of Senator Jack Reed of Rhode Island. That's the one I'm working with right now.  But I will shift, I identified him because we had a strong personal contact with a his staff.  The subject is germane to his responsibilities on his committee.  He's a Democrat.  I have Republicans in the House as well and Democrats.  We try to work bipartisan.  Again, we've gotten unfocused support.  The focused support is coming from Jack Reed, to which I must report back to him with my product.  If I stand their muster and their inspection, the next step will be to go to Finance.  
Here's the tactics.  This is what's going on, it could happen very quickly.  We have, if you've been reading any of the health press, there's this prescription drug thing that's been going out there.  And I’ll tell you the politics of that – that’s on the path to certain death ok. A large number of Republicans wrote that.  We have this big thing that's attached to it right now, I've just been working on that bill.  That's been rolled into, in the House, whatever markup they come up on the Medicare package.  The bill has low-vision coverage under Medicare.  That's a big thing, I worked with Steve Foyer on this two weeks ago.  That's going to get rolled into the House package.  The Republicans are putting together a prescription drug package.  That’s going to crash and burn.  
However, there's a sunset provision on the hospital giveback of a couple of years ago – 1997 budget bill and tax package.  The hospitals were raped, they say.  They really clipped them went too far so they had what’s called a giveback package later this year.  If there is, they've got to do something about that I predict there will be a second package later this year. They’ve got to do something about that. I want to put this thing in there.  This is a separate bill, but we rolled provisions of that bill into the package and then it becomes an amendment, it's a discrete thing.  That one's been taken care of in principle.
This thing, this administrative thing, I've got a one-two punch thing.  That thing going and now I have this administrative language I want the conference committee.  You know there's two different bills that come together in a conference committee and then there's legislative language that attaches to that.  Doesn't have the force of the law, but you can't ignore it either.  That's my stock in trade, by the way, legislative language.  From that standpoint, all I have to do is get one or two sentences in the conference committee report that the committee urges the secretary of HHS to add optometrists to clinical training under Medicare GME, or words to that effect.  
When you get that into – it's got to be a germane package we're hooking onto.  Then the clock starts ticking on implementation.  They'll just thumb their nose and it we’ll just keep coming back to them and back to them.  The ball will be set in their court.  We will assemble the package, that will be our rationale.  Jack Reed will have done all this stuff.  We will need the people in Finance Committee to really, to work on this thing.  I haven't talked to a soul in Finance.  I haven't sold Jack Reed yet, he's still waiting on the package.  

Future Advocacy Activities Planned
So the game plan is later this summer.  Everything will be put together and we'll have a package.  Hopefully I'll find a warrior or some advocate in Finance who will pick up our sentence.  I work, again, it's all done at the staff level.  We bring in our key people, our key docs, we physically bring them in, pay for them and bring them in.  Have meetings with the principals, in this case the Finance Committee members, to talk them into adding the sentence.  It's amazing how much comes down to one sentence legislative language is very powerful.  In this case it could mean up to 30 million dollars a year.  That's ultimately what we could be looking at.

Key Congressional Contact(s)/Champions
Senator Jack Reed (D-RI)

Targets of Direct Lobbying
That's where we are now, in the process of getting our advocates lined up on the Senate Finance, the House Ways and Means and in Commerce.

[Are there specific individuals in Congress that you would be working  with?]
 A bunch of them.  I'll give you this, this is what we give them and gives you an idea.  Because we're health, our key committees on the Senate would be Finance, the HELP Committee.  Because of health issues.  Of course appropriations cuts across every year.  But the key ones are Finance, because they do so much here.  The Senate Finance Committee, the Health, Education, Labor, Pensions Committee has jurisdiction over health issues and major Medicare issues.  That's where we go.  
For me, I deal in the Veterans Affairs and the Defense Department, Armed Services committees, because I work with the military.  I do a lot for the VA committees, we have a very robust VA program which we built by legislation.  So that's a big part of what I do.  Indian Affairs is a big thing for us too, we have public health service optometrists, in fact all of them, work for the Indian Health Service.  They provide services to Indians.  That's a big deal.  So that's a big committee too.  So we cut across all kinds of lines.  If you're health, what are you doing in Defense Department?  We have military practitioners.  What are you doing in VA?  We have a huge program of optometry in VA.  In fact, we have our own service in VA.
In the House, of course always appropriations, defense appropriations, health.  We do Energy and Commerce, most of our stuff is Energy and Commerce, and Ways and Means, because they have a health care component.  They split jurisdiction, Energy and Commerce and Ways and Means for jurisdiction on Medicare issues.
[And your targets on this issue specifically -]
Where we are on this GME thing right now, I'm not there yet.  In April I just came up with this brain fart if you will, I came up with this Idea, because actually I have a very close friend up on the Senate staff up there.  He's a psychologist and they have some success in this.  I thought, why not me too?  What I'm doing thus far is gauging interest.  It's unfocused at this juncture, on House and Senate some members want to go forward and write a letter to the secretary of HHS and say why don't you include optometrists in your clinical component.  That's where we are now.  But in so doing, you don't want unfocused letters.  There has to be a rationale, there has to be a model.  We did series about this.  They have to do what's called scoring, it's got to be a modest thing.  

Targets of Grassroots Lobbying
I targeted ten people.  I've dealt with about four of them thus far.  I targeted, I sent our volunteer structure.

Coalition Partners: Names/Participants
[Will you be working with any other groups on that?]
Mine, no.  I don't want anybody to know about this.  Again, it's a zero-sum game.
There is an association of schools and colleges of optometry, I represent them.   They don't do lobbying, they're a 501(c)(3) organization.  We're a (c)(6) for the purpose of taxes.  We do lobbying, they're educational.  They don't do that kind of stuff.

Other Participants in the Issue Debate
None mentioned.

Ubiquitous Argument(s) and Evidence
It's a zero-sum game that we're dealing with, because Medicare is squeezing the dollar on Medicare.  This is yet another unfunded mandate you're putting on them.  We're correct in doing it.  Medicare has…the way I’m reading it and the way I’m dealing with it is, Medicare has a stated policy to try to educate those who are practicing and delivering services under Medicare, and we're a provider under Medicare, we're a physician under Medicare.
[Will that be your main argument?]	
That is part of it.  That's part of it, but you've got to get the community need in it.  Why would you want to educate optometrists?  Don't we have enough optometrists?  Lord knows, we have enough optometrists, don't we?  Why are we doing this?  Well, the optometrists, there is a record that optometry is a hinterland, if you will.  That's why the Indian Health Service optometry department is so strong.  Ophthalmologists, because there's no sense in them doing optometry if you're trained for ophthalmology, they want to be around surgery, do retinal surgery, all kinds of surgery.  They need hospitals.  But they're putting closer in the cities and understandably there are fewer ophthalmologists out in Iowa or Oklahoma than there are optometrist, understandably.  
If you were to coin a term we're primary eye care providers, we're first contact providers.  People go to the optometrist because they're available, around.  Optometrists in many more communities than are ophthalmologists, understandably.  So that is a part of our rationale.  There is a need for urban health shortage areas that ophthalmology won't go into and optometry does.  Our schools have clinics affiliated with Medicaid, where there's a dearth of providers.  In urban and many of our city schools, in Chicago there's a school of optometry in New York City.  So there's an urban health shortage as well as a rural health shortage.  So optometry can fill that need.  You're not going to get ophthalmologists – you'll get residency coverage, but not full-time ophthalmologists, understandably.

Secondary Argument(s) and Evidence
So that's part of the rationale.  The rationale is “me too”.  But it's a stated policy of Medicare.  We're a provider under Medicare.  We provide services under Medicare.  There's a need.  There's some thirteen or fourteen other allied health groups getting this training.  
This is why I don't want to go in too much, because I don't want this to go outside too much.  This is unprecedented what I'm going after, because there could be a time when we get specialty training, and there would be a specialty board, and then we would go ahead and change the law and get that.  That would be residency funding, we’re not going for residency funding. 
I'm going for clinical training money in the third or fourth year.  Optometry school, the didactic training is the first two years, it needs to be all through four years.  More and more the schools are moving toward a total clinical training component in their fourth year and they're going to a twelve-month training period so it’s like a whole year they're training.  The cost to the school, state and private schools – I don't know how to break down the state, but I know what the private school cost of training when they have teaching physicians.  You have to have all these students supervised of course.  The cost of an episode of coming in and getting an eye exam, is almost $100 an episode, so very high.  If we can do something to bring that cost down, that will help the schools and hopefully bring tuition back to the students, very high tuition.  
You’ll run into, as you talk about other health professions, what are the students facing?  Huge student debts, six-figure debts, no difference for vet med, dentistry is actually less than ours, podiatry is higher than ours.  Medicine is somewhere in between because they get so much help that the other non-physician providers don't get so much help.  Student debt, it curtails your career choices.  This is the thing I'm doing, I'm trying to ameliorate that a little bit.  It's not a panacea, it's little dribs and drabs.  We've worked with other groups to get the student interest loan deductions, tax deductible, and had some success over the years.

Targeted Arguments, Targets, and Evidence
None mentioned.

Nature of the Opposition
Oh yeah, one after another after another.  I haven't even – it's easy for a senator or congressman to say oh yeah, and some back slapping, we'll look into this stuff.  When it comes down to it, I have to deal with both committee staff and their individual member staff.  You’re not going to blow anything by them.  You better have your act together.  I'm not very – they're still giving me that kind of stuff, I can show your bona fide, that sort of thing.  I think I can.  It's not enough to show a case, it better be compelling to make them believe, even your friends won’t believe.  It's a cost issue and everybody's sensitive to that.  Even things that don't cost a dime are sensitive.  It's not that easy to do these things and to move the status quo.  It's not easy at all.
So again, what I'm doing is working at the staff level.  I've got to get them on my side.  They're malleable right now.  This is a parochial issue you won’t hear anything about it, in other interviews you won't hear anything about it, I'd appreciate if you didn't say anything about it.  This is something that I like to call run at periscope depth.  I don't like others to come after me.  

Ubiquitous Argument(s) and Evidence Articulated by the Opposition 
There is competition for the eyes such as you wouldn’t believe, the dentists have it easy, there is only one, they don’t have to fight anybody.  We have to fight ophthalmology.  Ophthalmology very much opposes anything that optometry does, just as psychiatry opposes psychology, orthopedic surgery opposes podiatry.  In this case, you have sometimes vicious competition for these two square inches of eye. We’re not physicians but we are getting provisions that would allow us to start doing minor procedures.  Optometrists can now manage and treat, they do glaucoma.  Ophthalmology can't stand it, because once that’s in the medical bowl, they have that part of turf.  All of the physician groups are sensitive.  Psychologists now, the state of New Mexico just passed a bill to allow them the use of drugs, psychotropic drug use mind altering drug use.  Psychiatrists are fit to be tied over that.  So they're following optometry, these non-physician providers to break the water level the specialist physicians react and they react negatively because it part of their issues.  
This thing will help train optometrists, the bane of ophthalmology.  Because in fact, the eye is such a healthy organ that fewer than 5 percent of the population have any medical eye problems.  Many of the ophthalmologists are doing optometry.  You don't really need, it's primary care kind of eye care, it's not surgical eye care.  Laser treatment, laser correction that’s been the greatest thing for ophthalmologists.  So they've been going off on that.  We have a tradition of saving  vision, ophthalmology wants to get into that now too.  
Back to your thing, Will there be any opposition to this?  You better believe there's opposition.  We're taking some money away.  Again, Medicare is not an open pit.  It's an entitlement, but under the 1997 budget act they put some caps on things.  We're asking another unfunded mandate.  They have the find the money.  It's such a small component though.  When you look at the funding for GME it’s 8 billion bucks or something like that.  For the training of allied health, I don't what it is, maybe $500-600 million, I'm not sure.  But we're asking for a comparatively small amount of money, but it's money itemized nonetheless.  It's got to come out of somebody's pot.  Again, it's another unfunded mandate that you have to deal with.  Certainly HHS will not do this on their own initiative.  That's where Congress comes in.

Secondary Argument(s) and Evidence Articulated by the Opposition
None mentioned.

Targeted Argument(s) and Evidence Articulated by the Opposition (and Targets)
None mentioned.

Described as a Partisan Issue
No.

Venue(s) of Activity
Senate Finance, the House Ways and Means and in Commerce.
HHS

Action Pending or Taken by Relevant Decision Makers
No action pending. 

Policy Objective(s) and Support for/Opposition to the Status Quo
Working to change the status quo, to get clinical education training funding for optometrists. 

Advocate’s Experience: Tenure in Current Job/Previous Experience
My degrees are in economics and political science.  I do a lot of lab work, believe it or not, in chemistry and biology.  I was working and my then girlfriend was in the Washington, D.C. area, it's a cottage industry.  And she said why don’t you look into that, I did.  I had spent a little bit of time in the government and I interviewed with this outfit and they had an erstwhile program for federal employees but they weren’t even talking to the association.  Simply because I happened to be a federal employee at one time, they said you know how to deal with this.  It wasn't considered a sexy thing at all.  So I got a bag of lemons is what it was, and I though oh I could probably fix this up.  I brought the groups together and I was doing strategic planning before it was cool to call it strategic planning.  I got everybody together and said what’s your beef.  We had these long-term goals and we met every one. That's how it started.  Then like any business, it grows.

Reliance on Research: In-House/External (Code for Organizational Advocates Only)
We do research 100 percent in-house.  Yes, I can say that.  But for certain things we have outside counsel.  For example, because Medicare is arcane, it's convoluted.  We have retained for the last fifteen years a group called Health Policy Alternatives.  The principals of that were the ones who staff that developed Medicare so they set up their own lobbying firm.  We still use them, because they continue to get government officials going through and they know what they're doing.  So we use them all the time.  They're retained to help with the research and these arcane.  
For my issues, 100 percent me you’re looking at him, vertically organized.  I do it all myself I don’t go outside.  We do have on bigger issues, the Medicare issues and Medicaid issues, we will engage the Rand Corporation or other groups and I don't know how many others, for certain projects.
No PR though.  If we do have it, I'm not aware of it, that's all headquarters.  I should know, but I don't.  We have a general counsel that happens to be in Washington, we engage them.  Like FTC trade regulation rules those kind of things we need outside counsel for that, but they take forever. They just take forever.  So we have outside counsel, inside counsel.  But for me, for purposes of development of regulatory matters like this one, 100 percent inside.  We use our volunteer structure.  
We have a volunteer structure composed of maybe forty committees that covers a lot of ground.  But the focus of this, we have a federal relations committee composed of private practitioners nationwide.  We have military members we have a department of veteran’s affairs we'll have public service members.  These are the folks who, in what they're interested in.  They gauge what's of interest of them, because they get it from the states.  
We're a federation of states.  Many professional societies are.  Things happen at the state level.  These folks bring perspective nationwide at the state and local level.  The AOA has a house of delegates, that's how you change your direction, the house of delegates and federation of states.  It's convened once a year.  This year it's going to be later this month in New Orleans all the fifty states, the associations come together and pass resolutions which generally steer the organization.  I don't think we're any different than any other individual membership society.  All the power of the association is held in the house of delegates or the state socities.  We elect a board of trustees and officers.  They all have one-year seats and they all move around and have their own goals.  
So the power is vested in the house of delegates.  Issues that become important to them come up in board meetings and they're held four or five times a year.  The states also have direct access to the federal relations committee through our volunteer structure, our board of trustees travels all over the nation to get a pulse attend all the annual state conventions and get a pulse of what's going on.   that's how we react to things.  We Jeff and I don't do policy.  It's up to the board to decide the policy and the members decide which direction they want to go in.  We're the executive branch, if you will, we're the ones that get told what to do.  
You’ll find some associations having a lot more Washington staff. We find it works well if we don't have too many people, too many moving parts.  I dabble in everything, the others do to, we're not totally compartmentalized so it works well.  We're very nimble that way, bounce around.  Again, if I had to do a model for you we're the executive component.  We are dead without our volunteer structure, we are dead.  You won't find that in medicine so much.  Medicine, the individual members don’t like to roll up their sleeves, they expect staff to do that. That only goes so far. I think our strength absolutely is at the grassroots level.  I could no more go into Jack Reed’s office with this thing, without the help of the volunteer structure.  We use them to a great extent.
Give you an example Trent Lott, we had an optometrist in  Mississippi, a decorated war veteran.  This doc established  Republican Party down there in Meridian.  He and Trent Lott were like that forever. And we need somebody in Medicare a couple years ago.  So doc Morgen went down there to see Trent, and he put in on the table and he goes, done. Next. So we could never have done that - so our guys deliver.  Every individual member society has contacts.  We have a strong membership.  For being a relatively small society but we are strong.  We work all the time. Mureen’s our PAC manager, she does the key person program as well, That's a full-time job.  Always going back to states, who's doing what to whom, how we can. Who are people who have connections to legislators, it sometimes starts in the state.  It's a long-term you have to be almost Chinese in your philosophy it takes decades sometimes to get guys to stay key guys.  
But we do a good job of that, I'm very proud of the job we do of that.  We put a lot of resources into that too.  But it's paid off.  Again we’re dead without legislation, because we are defined by legislation. All limited licensed practitioners are limited at that level of limitation we try to raise we’re not like unlimited physician, they have it all.  So we're nothing without legislation.  Our Washington office started in about 1969 or 1970.  So comparatively speaking, the optometrists at the national level – there was no presence before 1970 so you need that. Medicaid was passed in 1966, of course optometry was not included.  So it was a fifteen-year battle to get optometry included in Medicare.  That's job one forever and it remains the centerpiece .

Number of Individuals Involved in Advocacy (Code for Organizational Advocates Only)
Four

Units in Organization Involved in Public Affairs/Policy (Code for Organizational Advocates Only)
	We're down to four, Washington director, me, Al, Kelly and we have a PAC director.
This is the Washington office, we do legislative and regulatory matters only.  The St. Louis headquarters office does membership activities.  But they have a large component of state legislative activity that goes out of there.  Again, optometry has so many non-physician providers.  This is a legislative profession.  They can't expand their professional responsibilities their scope of practice without a change in the state law and state practice acts.  So that's a big component, that's done in St. Louis.
We are organized for federal and regulatory matters here.  We have a Washington office director and a bunch of lobbyists.  Some do nothing but administrative, some do administrative, I do everything.   We cross over everything.  Again, if I were to say the focus of all this is Medicare, because optometry was not eligible to be reimbursed for Medicare until 1987.  That ends up being, that's the centerpiece of federal funding for optometry, it's about $167-170 million a year, 30,000 optometrists, it's a big part of their practice.  Were not eligible until 1987.  
When you get into that, it's one problem after another.  You have the same problems over and over again, because you're not a physician, we're not physician in law, it's only for the purposes of reimbursement.  It can only change the reimbursement mechanism that I don't understand any of that we have a specialist right next store, Kelly does that.  That's the centerpiece of Medicare regulatory matters.

Advocate’s Outstanding Skills/Assets (Code for Organizational Advocates Only)
None mentioned.

Type of Membership: None, Institutions, Individuals, Both (Code for Organizational Advocates Only)
Individuals

Membership Size (Code for Organizational Advocates Only)
30,000

Organizational Age (Code for Organizational Advocates Only)

Miscellaneous