MHSA 8635 Health Policy Seminar The Public Policymaking Process

MHSA 8635 Health Policy Seminar The Public Policymaking Process I. Policymaking Process Characteristics ** Continuous and cyclical process ** Significant external influences on process (open system) ** Interactive/interdependent process steps: (1) Policy Formulation: setting policy agenda and drafting legislation; primarily legislative activity. (2) Policy Implementation: rulemaking to guide policy/legislation enactment; primarily executive activity. (3) Policy Modification: changing/amending of existing laws, policies, legislation; primarily legislative activity. II. The Policy Formulation Stage of Public Policymaking ** Agenda setting ** Legislation development ** Agenda Setting: establishment of a specific issue as a public policy priority. Given the innumerable public policy areas that often simultaneously compete for legislative/policy attention at any given time, this step may be the most critical of the entire policymaking process. ** May be conceptualized as representing the confluence of three critical factors in the public policymaking process: policy problems, possible solutions, and the political circumstances/environment surrounding the consideration of the policy. Theoretically, all three factors must be present at the correct time (legislatively) for most policy issues to successfully proceed beyond this stage. ** Policy Problems: only problems considered to be important/high priority (by policymakers) tend to make it onto the public policy agenda. Such problems tend to involve any/all of the following: ** Problem represents unacceptable trend in certain factors (#AIDS cases, # of uninsured, etc.) important to the policymaker. ** Problem brought to light by specific, high-profile event(s) (drive-through deliveries) ** Problem has wide applicability to large # of persons

** Problem affects a small # of persons, but those persons a part of a politically powerful/influential interest group (elderly, AMA) ** Piggybacking of proposed policy onto legislation already on the policy agenda (Patient Bill of Rights legislation attached to Defense Appropriations Bill). ** Possible Solutions: Typically must coincide/coexist with policy problem to advance onto policy agenda. Problems, regardless of how significant, that lack identifiable solutions will never make it onto the policy agenda at any level. ** Most typically, any policy issue/problem will be associated with more than one identified possible solution from which policymakers will choose a preferred alternative. ** Legislative research plays a substantial role in this stage of the policymaking process in assisting policymakers by providing an empirical knowledge base upon which policymakers may make more informed legislative decisions. Most common types of research in this domain are biomedical and health services research. ** Both types of research assist with the documentation/ quantification of health-related problems as well as through structured analysis of possible solutions (policy analysis). ** Political Environment: aka political will, this describes the general political circumstances that are most favorable in terms of moving a policy problem/possible solution onto the policy agenda. ** In a completely apolitical environment, choice among possible policy problem/possible solution(s) sets (in terms of advancing onto the policy agenda) would proceed using explicit, objective criteria such as: which problem(s) are most substantial, which solutions are most likely to address the problem adequately, which solutions are preferable in terms of costs and benefits of each, etc. ** In the realm of public policy, however, nothing is ever accomplished of substance without prior consideration of the politics of a given policy environment and how that environment will likely affect that proposed policy as it goes through the policymaking process.

** Examples of such circumstances include: public attitudes, concerns, opinions regarding the policy issue; preferences and power/influence of various special interest groups with a stake in the proposed policy; positions/views held by key policymakers in executive and legislative branches. ** Roles of Special Interest Groups In Agenda Setting ** As mentioned before, special interest groups are far more successful in terms of influencing the policymaking process than individuals, due to advantages in terms of resources, commitment, and singularity of purpose/goals. ** Such groups commonly influence the public policymaking process prospectively, in terms of assisting with agenda setting and policy formulation tasks, as well as retrospectively in terms of performing tasks to block any proposed changes to existing policy that benefits group membership. ** Activities of special interest groups that are especially effective as part of the agenda setting stage of policy formulation include: ** Lobbying: communication with policymakers to attempt to influence policy decisions to favor group membership. Provide policymakers with important technical information they would otherwise lack. ** Electioneering: organized efforts to elect/re-elect policymakers who are sympathetic to group policy views. Most common mechanism is through The formation of PAC s to channel Funds to election campaigns of these policymakers. (50% of all funds) ** Litigation: attempt to influence public policymaking process through litigation to change existing policies, laws, stimulate new policies/laws, etc.

** Shaping Public Opinion: interest groups activities aimed at shaping public opinion to reflect the group s policy preferences, so as to indirectly influence policymakers on key policy issues. (e.g. Harry and Louise) ** The most successful special interest groups, in terms of influencing the policymaking process, tend to be very effective at marshalling adequate resources (see text) to support various combinations of the above mentioned activities to collectively influence public policymaking. ** Additionally, interest group size can actually become a hindrance to effective group influence in the public policymaking process, especially when such groups become too large and diverse. At such a point, these groups tend to lose their singularity of voice/purpose and become more ineffective due to the free rider phenomenon. ** Executive Role in Agenda Setting ** President, governor, mayor ** Can be especially powerful/influential in terms of establishing the policy agenda if popular with the general electorate. ** In certain circumstances, a popular chief executive may have sufficient power/influence in the public policymaking process to rival/surpass that held by various special interest groups. ** Policy Agenda for Health ** Given the presence of multiple, often conflicting/contradictory views of health policy issues, coupled with a desire on behalf of policymakers to accommodate as many divergent views as possible during the agenda setting process, it is not surprising that many health policy domains consist of individual laws/policies/rules and regulations that seemingly contradict one another. (e.g. medical technology (public) policy in the U.S.)

** Legislation Development Stage: movement of policy proposal(s) from the agenda setting stage of policy formulation towards the actual development of written legislation that may be formally deliberated upon by one or more legislative bodies. The end result of this stage of the process (if it proceeds that far) is either (1) new public laws, or (2) amendment(s) to existing public laws. ** Only a small percentage of all legislative proposals ever make it to the point in the policy formulation process where these laws become formally enacted. The majority of legislative proposals die in a given legislative session (2-year congressional term), as the constitution requires that any legislative proposals not acted upon in a given session be re-introduced in a future session (as a separate bill) in order to be re-considered. ** Legislative Development Process: ** Legislative Proposal Development: conversion of policy proposal related to a specific problem/solution set(s) into concrete written legislative proposal(s) called bills. May sometimes be referred to as resolutions instead. ** Sources of Policy Proposals/Bills: ** Legislators representatives, senators ** Individual citizens rare ** Special interest groups primarily derived from the lobbying process described previously. ** Executive communications official correspondence between executive branch (president, governor, mayor) and legislature (e.g. state of union, state of state speeches) involving the communication of specific policy proposals to legislators. ** Drafting Legislative Proposals: translation of informal policy proposal(s) into formal, written legislation (using appropriate legislative language and format) that may then be formally considered during the legislative process. ** All potential sources of policy proposals make significant use of individual expertise in drafting written legislation by using legislative staff, Legislative Counsel s Office, as well as legislative staff located within the executive branch of gov t.

** Regardless of the source of legislation, one or more legislators within the appropriate legislative body must formally introduce the proposed legislation within the legislature, acting as the sponsor/co-sponsor of the proposed legislation. (constitutional requirement). ** Upon formal introduction by one or more legislators in the appropriate legislative body, the proposed legislation is assigned a number based on the order of introduction by the presiding officer (House H.R. 1, 2,.; Senate S. 1, 2 ) ** Legislative bills are then assigned to the committee(s) of that legislative body that have jurisdictional responsibilities over that particular area of policy. ** Currently, there are 19 House and 16 Senate standing committees that may receive a bill for purposes of deliberation. Committee membership is based on majority party status (in terms of numbers of members of each party who serve) and seniority status (in terms of what members are assigned to leadership positions on those committees). Committee chairpersons are appointed by the majority party leadership, and committee chairs are responsible for selecting committee members when committee seats become vacant. Lastly, each committee has its own legislative staff to assist with the administrative tasks of legislative deliberations. ** Health-related Congressional Committees: ** Senate: ** Finance Committee (Healthcare Subcommittee) jurisdiction over all health programs authorized by the Social Security Act (Medicare, Medicaid), as well as all other health programs financed by a specific tax or trust fund distribution. ** Labor/Human Resources Committee (Subcommittees on Aging, Children/Families, Public Health/Safety) Jurisdiction over bills related to health personnel policies, Public Health and Safety Act, Food, Drug, and Cosmetic Act, etc. ** Appropriations Committee (Subcommittees on Labor, Health, and Human Services, VA/HUD) jurisdiction over all appropriations (spending) bills for DHHS and the VA.

** House of Representatives: ** Ways and Means Committee (Subcommittee on Health) jurisdiction over bills requiring federal taxes to fund such as health services, health systems, and research. (Medicare, Medicaid, tax code changes) ** Commerce Committee (Health and Environment Subcommittee) jurisdiction over Medicaid, Medicare Part B, public health bills, etc. ** Appropriations Committee similar jurisdiction and responsibilities as senate version, additional jurisdiction over appropriations for FDA. ** Legislative Committee Proceedings: ** Committees usually commence their activities with respect to deliberations on specific proposed legislation by holding public hearings (CSPAN) on the proposed legislation, both opinions in favor of as well as opposed to the legislation typically. ** Subsequent to these hearings, the proposed legislation is marked up, a process that involves making line-by-line changes in the original bill in terms of language and/or intent/scope. This process is necessary to prepare the bill for final deliberations by the full committee. ** If the committee/subcommittee votes favorably to move a bill out for further consideration by the full committee or the full legislative body, the committee (vis-à-vis its legislative staff members) drafts a committee report, which fully describes the purpose/scope of the proposed legislation, the presumed justification for its passage, and an executive summary of the committee s deliberations on the bill. ** The proposed legislation (along with the committee report) is then presented to the full legislative body for its consideration/deliberation/debate. These deliberations may involve the additions of amendments by one or more floor members to the proposed legislation.

** Subsequent to deliberative process, the bill (in its original or otherwise amended form) is voted on by the full legislature. If a majority votes favorably, the bill then goes to the other legislative body (if bicameral) for formal consideration/deliberation, where the process is essentially repeated. ** If approved by both legislative bodies, and the approved bills between the two bodies is identical in all respects, the bill goes to the executive branch for action. If the approved bills between the two bodies are different in one or more respects, the two versions must be reconciled in conference committee proceedings before submission to the executive branch for action. ** Many legislative bills have died in conference, due to the length of time involved in the conference process and the difficult nature of negotiating different bills, which typically symbolize distinct policy preferences among the two bodies. ** Executive Branch Action: ** Legislation approval and passage vis-à-vis the affixation of the official signature of the Chief Executive to the bill. ** Legislation rejection vis-à-vis executive veto power and remanding of legislation to one or both houses. (subject to 2/3 over-ride provisions) ** Legislation passage vis-à-vis taking no action (positively or negatively) on the bill, allowing the bill to become law in 10 days as required in the constitution. ** Legislation rejection vis-à-vis pocket veto, whereby the chief executive pockets the legislation and allows the legislative term to expire, effectively killing the bill. ** Legislative Development The Federal Budget ** As the annual federal budget approved by the government drives much of the public policy debate and deliberation with respect to virtually all areas (including health policy), a basic understanding of this legislative process is warranted.

** (See Figure 4.2) The federal budgetary process is a highly prescribed process per the Congressional Budget and Impoundment Act of 1974 and its subsequent amendments. This law (P.L. 93-344) requires a number of formal steps to be followed in the process of developing the budget of the federal government. ** A substantial amount of health policy and law, as well as changes to existing health policies and laws, have occurred during the budget reconciliation phase of this process. The final product of the budget reconciliation phase of the budgeting process is the passage of Omnibus Budget Reconciliation Acts (OBRA) and Consolidated Budget Reconciliation Acts (COBRA) during a given FY. Examples of health policies/laws that were enacted as part of OBRA/COBRA are innumerable. (pp.113-117) ** The reconciliation process of the budgeting process requires lawmakers in both houses, acting through the various standing committees of those bodies, to reconcile current federal law to conform to the budgetary constraints imposed during the concurrent resolution phase of the process, specific to their areas of jurisdiction. ** For example, if the concurrent resolution passed by the two bodies (and reconciled in committee) stipulates that federal spending on vaccine research will not change in a given FY, those committees with oversight in this area (Senate Labor and H.R. committee, Appropriations, House Appropriations, etc.) would have to amend existing policies/laws that apply to this area to conform to the budgetary constraint.