The Legislative Process #415

After studying Module 3: Lecture Materials & Resources, discuss the following:

**Describe the legislative process of a health policy you are familiar with. What were the major steps and challenges in its development?

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Policy Analysis and Design

CHAPTER 4

Stages of the Policy Process (1 of 4)

Federal Government’s Involvement in Social Issues

Rapid expansion in the 20th and 21st centuries

Creation of Medicare and Medicaid

Passage of the Patient Protection and Affordable Care Act (ACA) in 2010

Current considerations

Quadruple aim initiative

Availability of funding

How to incorporate policy design into all phases of the policy process

The Policy Process

Policies that address social problems are usually formulated by many groups.

The proliferation of participants in policy formation makes it difficult to achieve systemic program design.

Decision making is often conducted hastily.

Lack of information

Constituency impatience

Lack of expertise

Much policy that regulates nursing practice is determined at the state level.

Research Informing the Policy Process

Health services research

Examines a multitude of factors, systems, and processes in the delivery of health care

Informs policy in a number of ways

Public Opinion Informing the Policy Process

Four groups of society

Advantaged—politically influential; public views positively (scientists, veterans)

Dependent—politically weak but viewed positively (children, mothers, those with disabilities)

Contenders—politically strong but perceived negatively (the rich, big unions)

Deviants—politically weak and perceived negatively (criminals, drug addicts)

Effects of policies favoring the advantaged and punishing deviants

The Design Issue

Unclear mandates often result in a mismatch between legislative intent and bureaucratic behavior.

Unintended consequences

Policy failure

By shifting the focus of study to policy design, a more reliable answer regarding policy success can be found.

Requires understanding of policy tools or instruments chosen for policy design

Requires understanding underlying assumptions of policymakers during the design process

Policy Instruments (Government Tools)

Schneider and Ingram’s (1990) analysis uses government or instruments and underlying behavioral assumptions as variables that guide policy decisions and choices.

They argue that the tools approach moves policy beyond considering the standard analysis and improved frameworks.

To understand which tools are the most productive, emphasis should be on using them in conjunction with a particular policy design.

Authority Tools

Most frequently used by governments to guide agents and officials at lower levels

Are statements backed by legitimate power of government that grant permission and prohibit or require action under designated circumstances

Incentive Tools

Assume individuals will not be motivated to take action without encouragement or coercion

Rely on tangible payoffs as motivating factors

Positive or negative

Assume individuals have the “opportunity to make choices, recognize the opportunity, and have adequate information and decision-making skills” to choose the best option

Capacity-Building Tools

Provide information, training, education, and resources to enable individuals, groups, or agencies to make decisions or carry out activities

Assume populations will be motivated adequately without incentives

Require that populations be aware of the risk factors associated with the tools and how these tools can help

Symbolic or Hortatory Tools

Assume people are motivated from within and decide whether to take policy-related actions based on their beliefs and values

Examples of hortatory tools

Use of lower-number legislative bills reserved by congressional leadership

Federal request for proposals to research a particular topic

Examples of symbolic tools

Presidential executive orders

Learning Tools

Used when the basis upon which target populations might be moved to take problem-solving action is unknown or uncertain

Often used with policies that are open-ended in purpose and have broad goals and objectives

May require a needs assessment to be completed

Behavioral Dimensions

APRNs must understand behavioral assumptions and the political context in which tools exist.

The political climate in which social problems are addressed often prescribes the choice of tools to be implemented.

Case Study: COVID-19, Disparities, and the CARES Act

Race-related health disparities in both COVID-19 cases and deaths

Social contributors to health disparities

Income

Education

Structural racism

CARES Act beneficiaries

Authority tools at play during the pandemic

Conclusion

Active participation in the policy process is essential.

RNs and APRNs must understand:

How the process works

Points where the greatest impact can be made

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Policy Enactment: Legislation and Politics

CHAPTER 5

Introduction

Structure of governments

Engagement of nurses in politics at all levels

Expectations of the public

Structure of the Federal Government

Constitutional republic

Democratically elected leaders

Separation of powers between the federal and state governments

Three branches

Executive

Legislative

Judicial

The Executive Branch

Consists of:

President

Vice president

Executive Office of the President

Presidential cabinet members

Powers of the president

Oversees military

Signs legislation into law

Can create executive orders

Can veto bills from Congress

This branch has shared responsibility for federal agencies with legislative branch.

The Legislative Branch

Consists of Congress

House of Representatives

Senate

Congressional committees

Nurses can monitor committees for significant federal legislation and work with professional organizations to influence policymakers on the issues.

The Judicial Branch

Consists of:

Supreme Court

Courts of Appeals

District Courts

Bankruptcy Courts

Article I Courts

Resolves disputes about the U.S. Constitution and other federal laws

Structure of State and Local Governments

Three branches

Executive

Legislative

Judicial

Similar to federal branches but structures may not be identical

Legislation

Nurses can present issues or ideas to solve a problem to legislators.

Legislators then draft a bill and introduce it to Congress.

After the bill is introduced, the following take place:

Debate and review

Amendment

Vote by both chambers

Committees

Congress members are voted into leadership positions by their peers.

The majority party leadership selects committee chairs for the session.

The minority party selects leaders called ranking members.

Committees vote to accept or reject bills after reviewing them.

If accepted, the bill goes to the floor of the House or Senate and is voted on again.

If the bill passes both chambers of Congress, it is sent to the chief executive.

Federal: president

State: governor

The chief executive either signs or vetoes the bill.

Funding Legislation: Winning a Seat at the Table

Raising campaign funds

Individuals

Special interest groups: 527 organizations and Political Action Committees (PACs)

Campaign finance law

Citizens United v. Federal Election Commission

Influences That Affect Decisions in the Policy Arena

The People: Legislators and Legislative Staff

Legislators (lawmakers)

Chief of staff

Administrative assistants

Legislative directors—responsible for day-to-day legislative activities

Press secretary—responsible for press releases and public relations

Legislative assistants/aides (LAs)—multiple areas of responsibility

Committee staff—support work of congressional committees

The People: Constituents

Engaging constituents/voters to support an issue is an important way to gain momentum.

Nursing groups have succeeded in advancing legislation by creating coalitions that include stakeholders from various perspectives and voting blocks.

The People: Special Interest Groups

Lobbyists

Often hired by special interest groups

Must follow established guidelines if professional lobbyists

Special interest groups

Stakeholders attempting to gain influence on an issue

Types of special interest groups

Political action committees (PACs)

527 organizations

Registered nurses constitute a special interest group

Political Strategy

Success in influencing health policy requires knowledge of:

Political environment

Political players

Political climate

Strategy includes knowing:

When to strike

Which stakeholders will have the most impact

Who can and will work together

What the opposition’s strengths and weaknesses are

Funding of efforts to get legislation passed

Approaches for nurses

Communicating directly with legislators

Working with political advisers

Nurses Engaged in Legislative Policy Change

Federal level

Common areas of focus

Nursing Workforce Development programs of Title VIII of the Public Health Service Act and its amendments in the Nursing Reauthorization Act

State level

Common areas of focus

Scope of practice issues

Conclusion

Build relationships with legislators, legislative staff, policy experts, and key stakeholders.

Understand that change is often incremental and takes time.

Look for common ground and measures that will appeal to both sides of the aisle.

Think politically, use strategy to develop a plan, and play the political game.

The Legislative Process #415

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