The U.S. Congress and Health Policy Sheila Burke, RN, MPA Deputy Secretary and Chief Operating Officer Smithsonian Institution April 2006

Congress and Health 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 Figure 1

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

Examples of Congressional Legislation in Health Policy 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 Children’s Health Insurance Program (1997) Medicare Modernization Act (2003) Figure 3

Congressional Basics

U.S. Senate: 109th Congress 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) BudgetAppropriations Chairman: Judd Gregg (R-NH)Chairman: Thad Cochran (R-MS) Ranking: Kent Conrad (D-ND)Ranking: Robert Byrd (D-WV) 55 Republicans 44 Democrats 1 Independent Figure 4

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 & CommerceWays & Means Chairman: Joe Barton (R-TX)Chairman: Bill Thomas (R-CA) Ranking: John Dingell (D-MI)Ranking: Charles Rangel (D-NY) BudgetAppropriations Chairman: Jim Nussle (R-IA)Chairman: Jerry Lewis (R-CA) Ranking: John Spratt (D-SC)Ranking: David Obey (D-WI) Figure 5

Critical Differences between House and Senate 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. Figure 6

Majority vs. Minority Party 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) Figure 7

Key Congressional Committees

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

House Committee on Energy and Commerce 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 Figure 9

House Committee on Ways and Means 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 Figure 10

Senate Committee on Finance 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 Figure 11

Senate and House Committees on Budget Review and evaluate President’s 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) Figure 12

Senate and House Committees on Appropriations 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 Figure 13

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

Federal Budget Process SOURCES: Congressional Budget Act of 1974, as amended; Oleszek, Congressional Procedures and the Policy Process, 2001 Congressional Budget Resolution Discretionary spending allocated to the Appropriations committees 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 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 Figure 15 OR President’s Budget Submitted to Congress First Monday in February Fiscal Year begins October 1

Legislative Process

Legislative Timing Idea Phase Drafting of Bill Hearings Committee Mark-up Floor Action –Amendments Conference Implementation Figure 16

Influencing the Process

RULES OF THE ROAD – Working with Members 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 can’t do exhaustive search on every issue. –Know facts – never mislead, –Admit what you don’t know Figure 17

RULES OF THE ROAD - Communication 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 Figure 18

RULES OF THE ROAD - Partnerships 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 Figure 19

Conclusions 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 President’s budget, political agenda, lobbying and advocacy. Developing relationships early with staff and members provides opportunity to be a resource and equip them with information. Figure 20