The U.S. Congress and Health Policy

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The U.S. Congress and Health Policy

• Sheila Burke, RN, MPA
• Deputy Secretary and
• Chief Operating Officer
• Smithsonian Institution
• April 2006

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Congress and Health
Figure 1

• Congress plays a major role in development of
  health policy
• Health policy is a bi-partisan priority
• Authority spread across several committees
• Involvement includes regulatory, programmatic,
  financing, and oversight

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Health Care Priorities for Policymakers
Figure 2
Percent saying each of the following should be a
top priority for the President and Congress in
2005
Lowering cost of health care and insurance
63
Increasing number of Americans with insurance
57
Improving nations ability to respond to
bioterrorism
50
Improving the Medicare Rx drug law
38
Allowing Rx drugs to be imported from Canada
31
Reducing jury awards in malpractice lawsuits
26
Increasing funding for stem cell research
21
Source KFF/Harvard School of Public Health,
Health Care Agenda for the New Congress,
(conducted November 4-28, 2004).
4
Examples of Congressional Legislation in Health
Policy
Figure 3

• Enactment of Medicare and Medicaid (1965)
• Employee Retirement Income Security Act (1974)
• Americans with Disabilities Act (1990)
• Family Medical Leave Act (1993)
• Temporary Assistance for Needy Families (1996)
• Health Insurance Portability and Accountability
  Act (1996)
• State Childrens Health Insurance Program (1997)
• Medicare Modernization Act (2003)

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Congressional Basics
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Figure 4
U.S. Senate 109th Congress
55 Republicans 44 Democrats 1 Independent
LEADERSHIP
Majority Leader Bill Frist (R-TN) Minority
Leader Harry Reid (D-NV) Majority Whip Mitch
McConnell (R-KY) Minority Whip Richard Durbin
(D-IL)
KEY COMMITTEES
Finance Health, Education, Labor,
Pension Chairman Chuck Grassley
(R-IA) Chairman Michael Enzi (R-WY) Ranking
Max Baucus (D-MT) Ranking Edward Kennedy
(D-MS) Budget Appropriations Chairman Judd
Gregg (R-NH) Chairman Thad Cochran
(R-MS) Ranking Kent Conrad (D-ND) Ranking
Robert Byrd (D-WV)
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Figure 5

• U.S. House 109th Congress
• 232 Republicans
• 202 Democrats
• 1 Independent

LEADERSHIP
Speaker Dennis Hastert (R-IL) Majority
Leader John Boehner (R-OH) Minority Leader
Nancy Pelosi (D-CA) Majority Whip Roy Blunt
(R-MO) Minority Whip Steny Hoyer (D-MD)
KEY COMMITTES
Energy Commerce Ways Means Chairman Joe
Barton (R-TX) Chairman Bill Thomas
(R-CA) Ranking John Dingell (D-MI) Ranking
Charles Rangel (D-NY) Budget Appropriations
Chairman Jim Nussle (R-IA) Chairman Jerry
Lewis (R-CA) Ranking John Spratt
(D-SC) Ranking David Obey (D-WI)
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Critical Differences between House and Senate
Figure 6

• House is more than four times size of the Senate
• Senators represent a broader constituency than
  House members
• Senators serve longer terms (6 yrs) while House
  members run every two years
• Floor debate in House has more limits and is more
  expeditious than Senate.
• Senate filibuster can block action on legislation
• Power less evenly distributed in the House
• Majority more powerful force in the House.

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Majority vs. Minority Party
Figure 7

• Majority controls Committee chairs, number of
  committee members and votes
• Staff and funding allocations to committees
• Majority has more control over agenda, floor
  debate, and committees
• Can call for hearings and investigations
• Use of procedural tools (i.e. veto override,
  filibuster, Constitutional amendment)

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Key Congressional Committees
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Senate Health, Education, Labor and Pension
(HELP) Committee
Figure 8

• Chief Health Responsibilities
• Aging policy
• Biomedical research and development
• Domestic activities of the American National Red
  Cross
• Individuals with disabilities
• Occupational safety and health, including the
  welfare of miners
• Public Health

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House Committee on Energy and Commerce
Figure 9

• Chief health responsibilities
• Medicaid
• Medicare
• Public health programs
• Food and drug safety
• Hospital construction mental health and
  research biomedical programs and health
  protection in general

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House Committee on Ways and Means
Figure 10

• Chief Health Responsibilities
• Government payments for programs in Social
  Security Act
• Medicare
• Welfare (TANF)
• SSI
• Social Services (Title XX)
• Tax credits and related matters in tax code
  dealing with health insurance premiums

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Senate Committee on Finance
Figure 11

• Chief Health Responsibilities
• Health programs under the Social Security Act and
  health programs financed by a specific tax or
  trust fund, including
• Medicare
• Medicaid
• SCHIP
• Welfare (TANF)
• Maternal and Child Health block grant
• SSI
• ERISA (w/HELP Committee)
• Revenue measures generally, except as provided in
  the Congressional Budget Act of 1974

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Senate and House Committees on Budget
Figure 12

• Review and evaluate Presidents budget proposal
• Formulate budget resolution establishing
  Congressional spending and revenue levels
• Submit resolution to full chambers for vote and
  negotiations in conference
• Monitoring budget reconciliation process
• Oversight of Congressional Budget Office (CBO)

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Senate and House Committees on Appropriations
Figure 13

• Allocates funding to federal agencies,
  departments, and programs
• Sub-committees prepares funding allocations for
  programs within jurisdiction
• Subject to spending levels established in budget
  resolution
• Mid-year supplemental spending bills for
  emergency funding

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Federal Budget Timeline Wishful thinking
Figure 14
February 2005 Presidents budget
released Congress holds hearings on Presidents
budget request
March 2005 CBO baseline and re-estimate of
Presidents budget released House and Senate
develop a Budget Resolution
April 2005 Budget Resolution completed
May-Dec 2005 Reconciliation bill to make
changes in tax policy or entitlements if required
in budget resolution Action on Appropriations
bills
October 1, 2005 Beginning of Fiscal Year 2006
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Federal Budget Process
Figure 15

• Presidents Budget Submitted to Congress
• First Monday in February

Congressional Budget Resolution
OR
Discretionary spending allocated to the
Appropriations committees

• Budget Reconciliation
• - Senate Finance, House Commerce, House Ways
  Means, and other committees report changes to
  House/Senate budget committees
• - Changes compiled into one bill
• - Bill considered by House/Senate and negotiated
  in conference
• - Bill signed by the President

• Annual Appropriations
• - House and Senate Appropriations committees
  sub-allocate spending to their subcommittees
• - Bills considered by House/Senate and negotiated
  in conference
• - Bills signed by the President

Fiscal Year begins October 1
SOURCES Congressional Budget Act of 1974, as
amended Oleszek, Congressional Procedures and
the Policy Process, 2001
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Legislative Process
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Legislative Timing
Figure 16

• Idea Phase
• Drafting of Bill
• Hearings
• Committee Mark-up
• Floor Action
• Amendments
• Conference
• Implementation

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Influencing the Process
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RULES OF THE ROAD Working with Members
Figure 17

• Legislation should be last resort
• Be aware of legislation bearing gifts, anecdotes
  good politics - poor policy
• Compromise
• There is little that is black or white Lots in
  the middle.
• Can you gain by taking step forward?
• Be a resource
• Members cant do exhaustive search on every
  issue.
• Know facts never mislead,
• Admit what you dont know

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RULES OF THE ROAD - Communication
Figure 18

• Know the staff
• Put a human face on the issue
• Provide expert testimony at Congressional
  hearings
• Avoid jargon and acronyms
• Make it easy, - Action statements, pros and cons

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RULES OF THE ROAD - Partnerships
Figure 19

• Work collectively when possible
• Find common ground with unlikely bedfellows
• Never burn bridges - an enemy today is a friend
  tomorrow
• Know your opposition never leave an ally
  unprepared or unprotected

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Conclusions
Figure 20

• Congress plays an integral role in the
  development, financing and oversight of public
  and private sector health policies
• Congressional health policy agenda driven by
  range of forces, including Presidents budget,
  political agenda, lobbying and advocacy.
• Developing relationships early with staff and
  members provides opportunity to be a resource and
  equip them with information.