2. The Legislative Branch Role in Health Policy Presentation to: Geiger Gibson Capstone Program in Community Health Policy & Leadership George Washington University – School of Public Health & Health Services Presented by: Dan Hawkins, Senior VP for Public Policy & Research National Association of Community Health Centers March 31, 2015

3. Learning Objectives  What are the major committees in Congress with relevance to health policy?  What are the jurisdictions of the major health authorizing committees?  How does the budget process generally work?  How a bill becomes a law: theory and practice.  How to understand Congress in an era of dysfunction.  The importance of policy advocacy and your role

4. How It Is Supposed to Work: The Committee System

5. A Structure for Legislating Generally a Seniority-Based System System where committee assignments are given to those with the longest time in Congress Committee chairperson is usually a committee member in the majority party with the most time in Congress (although not always) Senior member of the minority party is usually called the ranking minority member or vice chair Legislation-Generation, Consideration, and Oversight Bills referred, and the select few “marked-up” Oversight takes many forms

6. Key Health-Related Committees House and Senate Budget Committees House and Senate Appropriations Committees Authorizing Committees –Energy & Commerce (House) –Ways & Means (House) –Finance (Senate) –Health, Education, Labor, and Pensions aka HELP (Senate)

7. House and Senate Budget Committees Hearings on fiscal year (FY) federal budget – department heads and OMB Director (President’s Administration) testify on funding levels for federal programs contained in the President’s Budget. Budget Resolution – Not sent to President –What does “budget” mean in Congressional parlance? –Broad outline – lays out priorities for public policy –Draft and mark-up House Budget Resolution – Chairman’s “mark”, alternative view from the President (sometimes...) –Chairman manages budget resolution on House/Senate floor Budget ≠ Appropriations in Congress-speak

8. House and Senate Appropriations Committees Responsibility for deciding annual fiscal year (FY) allocations for each individual discretionary program in government Broad authority, within overall discretionary limits -historically flows from Budget Resolution or “deeming resolution” - now Budget Control Act (BCA) caps as well Health-related Subcommittees –Labor HHS –Public Health, including funding for 330 grants and other HHS discretionary programs

9. House Energy & Commerce Committee Public Health Service Act (CDC, NIH, HRSA, SAMHSA,) Section 330 grants, including Health Center mandatory funding from ACA, and Teaching Health Center GME program Medicaid and Child Health Insurance Program – general eligibility and benefits, FQHC payments Medicare –FQHC Payments –Part B (physician and outpatient hospital, home health, etc.) –Part C (Medicare Advantage – private insurers offering all Medicare benefits) –Part D (private insurers offering prescription drug coverage) Affordable Care Act (ACA) – Essential Community Provider, private insurance matters and Exchange operations.

10. House Ways & Means Committee Internal Revenue Code (All taxing issues, including insurance deductibility, exclusion and tax credits) Medicare (shares and splits jurisdiction with Energy and Commerce) –Part A (hospitals and other inpatient providers) –Parts of Part B (outpatient hospital, home health, not physicians) –Part C (Medicare Advantage – private insurers offering all Medicare benefits) –Part D (Private insurers offering prescription drug coverage)

11. Senate Finance Committee Tax Code (all revenue issues, deductibility and tax credits) Medicaid and Child Health Insurance Program – incl. FQHC payments Medicare (parts A, B, C and D) – incl. FQHC payments, Medicare GME

12. Senate Health, Education, Labor & Pensions (HELP) Committee Public Health Service Act (Section 330 grants, Health Center mandatory ACA funding, NHSC, Teaching Health Center GME) Food and Drug Administration Affordable Care Act (ACA) – Essential Community Provider, private insurance matters and Exchange operations.

13. How a Bill Becomes a Law

14. The Schoolhouse Rock Version aka the Exception to the Rule Problem/Goal Member drafts bill (House or Senate) Committee consideration Committee mark-up Committee vote To the floor- Yea or Nay Other chamber passes their version Conference committee Conference Report Final Passage on the Floor of each chamber. To the President for Signature

15. How It Really Works: Congress in an Era of Dysfunction Legislating crisis to crisis Last minute, big packages, no committee consideration. Few people “in the room” diminishes democratic (small “d”) process Signs of hope last year (and perhaps this)...

16. 16 Health Centers: A Policy (and Political) History Unique Public-Private Partnership: Resources Directly to Community-Owned Organizations O.E.O./War On Poverty: A Way Around Entrenched Political/Medical Powers to Address Needs Of Poor/Minorities Health Centers: Two-Fold Purpose - –Be Agents of Care in Communities With Too Little of the Same –Be Agents of Change, Giving Communities Control of their Health Care System

17. 17 Health Centers: A Policy (and Political) History (Cont’d) How Health Centers Succeeded Where Others Had Failed –Founded Outside of ‘Mainstream’ Health Policy and Politics –Focused on Forgotten People and Places (Poor, Uninsured, Farmworkers, Homeless, Rural) –Accepted Slow Growth, Low Visibility to Stay in Realm of Distributive Politics Today, those characteristics are no longer true

18. 18 Policy Analysis and Policy Advocacy All Public Policy flows from Policy Analysis –Analysis can be Good or Bad, but almost all Good Policy requires Good Analysis Analysis Can Stand Alone, but Effective Advocacy Requires Good Policy Analysis Advocacy is Analysis PLUS Strategy (Game Plan) and Tactics (Players & Plays) Advocacy is a Form of Lobbying, but Advocacy is Different Advocacy is an Active, not a Passive Process

19. 19 Keys to Successful Advocacy Know What You Want (Be Specific) Know Who Can Give It To You (Which People Have the Real Power) Know What They Want (Positive Press, Public Recognition, Votes) Know What You Can and Cannot Offer Them (Recognition vs Contributions) Know Who Will Be Your Allies and Your Opponents Know What It Will Take to WIN

20. 20 YOGI BERRA’S RULES FOR SUCCESS When You Come to a Fork in the Road, Take It (choose objectives wisely, don’t over/under-shoot) You’ve Got to be Careful if You Don’t Know Where You’re Going, Because You Might Not Get There (know the system & players – what it will take to win) It Ain’t Like Football -- You Can’t Make Up No Trick Plays (find a shepherd, get firm commitment, build support among players, mobilize effective grass-roots) You Can Observe a Lot by Just Watching (anticipate and counter your opposition & their points) It Ain’t Over ‘til It’s Over (never let up, learn to win & lose gracefully, thank supporters regardless of outcome)

21. 21 WHY SHOULD YOU BE AN ADVOCATE? You can make a difference People can change laws (think: Child labor, public education, clean air or water, etc.) It helps find real solutions (but only when people with ‘front-line’ knowledge & experience are involved) It’s easy (especially when many are involved together) It helps people (group vs individual intervention) It advances your work and builds public trust It’s a democratic tradition (at heart of system, helps people feel connected and avid alienation)

22. Acknowledgments Content of certain slides adapted from the work of Katherine Hayes, J.D., Faculty, Department of Health Policy, GWU School of Public Health & Health Services

23. Thank You! Questions?