Download HSCC 3120 – Health Policy and Law

MHSA 8635 – Health Policy Seminar
The Public Policymaking Process
I.
Policymaking Process Characteristics
**
**
**
II.
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.
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.