QUESTION 1 : Why am I writing this article?
After 25 years of working within our health-care system, I took a year-long sabbatical to work on changing that system. The laws that govern our institutions and our practices often have their origins in Congress. Therefore, going to Washington to work as an insider seemed to be a reasonable way to try to understand, if not change, the laws relating to health care. The vehicle for my passage from outsider to insider was the Robert Wood Johnson Health Policy Fellowship. This 20-year-old program, based at the Institute of Medicine, has enabled a half-dozen people each year, mostly physicians with academic medicine as their home base, to experience Washington in a unique way. We were not merely visiting inside the Beltway, but were living inside the hallways of the Senate and House of Representatives as staff members of the offices and committees that write the laws by which we must live and work.
Shortly after President Clinton presented his plan for the Health Security Act to Congress, I joined the professional staff of the Senate Finance Committee, chaired at that time by Senator Daniel Patrick Moynihan. For 9 months I worked, usually 7 days a week, on each stage of the health-care reform debate. I met with more than 100 lobbying groups, helped put together some of the 40 hearings held during the second session of the 103rd Congress by the Committee, wrote sections of the Finance Committee bill that was ultimately passed by that committee (but not the full Senate), and worked on other proposals, versions, and amendments that were debated on the floor of the Senate during the summer of 1994.
While 1993-1994 was certainly the "Year of the Great Health-Care Reform Debate," it was not the year of passage of the great health-care reform act, nor passage of any health-care reform bill, as it turned out. Nonetheless, it was a momentous year for the country, as terms such as "small market insurance reform," "benefits packages," and "integrated delivery networks" became the buzz words of the debate. ??t me, it was a life-transforming experience. I entered with a great amount of curiosity and ignorance about the role of the federal government in health care. I emerged as a card-carrying health policy person, ready to turn in my white coat for a white horse, to devote my professional energies to health and science policy on a full-time basis. After an exhausting, but pivotal year, I have decided to stay in Washington, not working within the government, but rather as part of a unique institution that advises the government and others in matters related to health and science policy. I have just assumed the responsibilities of Executive Officer at the Institute of Medicine, part of the National Academy of Sciences. The Institute of Medicine was established in 1970 and is the newest part of the Academy complex. The Academy was created by a Congressional charter written in 1863, establishing it as an independent agency. Through its membership and its convening and analytic activities, the Institute brings the worlds of research and policy together to advance understanding of health and science and to improve the health of all people.
QUESTION 2: Why should we worry about the federal role in health care now?
There are basically three reasons why you should know about or become involved in the federal role in health care. First, since comprehensive health-care reform legislation did not pass last year, it is likely that a series of smaller reforms will be introduced this year and over the next few years. As one piece of our complex system is altered, it will undoubtedly affect other parts of the system. For better or for worse, these little changes in the law could have big effects on your practice.
Second, the programs created by laws written by Congress, such as Medicaid, Medicare, Aid to Families With Dependent Children, Women, Infants, & Children (WIC), and Social Security, will continue to be in effect, unless repealed, modified, or replaced by new ones. Since your professional life and your patients' lives are greatly affected by these laws, it will be helpful for lawmakers to have your input about their impact. There are a handful of physicians who are currently Congressmen (no women at the moment). Another handful of physicians are congressional staff members. An additional few have nursing, dentistry, social work, or teaching backgrounds. All are potential patients, but only a few have chosen to speak about their experiences as a patient as a basis for changing the system. All have excellent health benefits through the Federal Employees Health Benefits Program. They have formed opinions and viewpoints based on input from others. Therefore, laws are often crafted by people with technical expertise, but little direct experience with the programs being created, planned, or dismantled.
Third, as the spotlight shifts in the health-care debate from the federal government to the marketplace, some choices will have to be made about which pieces appropriately belong at the federal, state, or local levels. As the drama plays out in the marketplace, the role of the federal government in tracking the changes in access to services, in measuring and assuring quality of care, and in balancing costs will have to be clarified. Decisions about the federal government's role in defining a standard benefits package, reforming malpractice laws, or providing incentives for work force changes (eg, more or less federal dollars to support medical residencies, the National Health Service Corps members, continued support for urban and rural health professional shortage areas, or capital support for hospitals in rural areas) are likely to be made within the next few congressional sessions, so now is an important time to be connected to the process.
QUESTION 3: Exactly what is meant by "federal" role?
Three quite distinct components of the federal government currently exert great influence over health care: 1 ) the President, his advisors, and cabinet officers, 2) federal agencies, and 3) Congress. Each has its distinct set of players, priorities, viewpoints, and tensions. Understanding "Washington* means understanding the different role of each component. The President chose the First Lady and a set of ad hoc advisers specifically to work on health-care reform. The process of having temporary task forces to help architect the managed competition plan put forth by the Administration turned out to be a controversial strategy. The task forces were not part of the permanent advisory structure within the Executive Branch, which usually refers to the Office of Science and Technology Policy (OSTP), and relevant cabinet members, particularly the Secretary of the Department of Health and Human Services. In addition, there are domestic policy advisers for specific areas, such as illicit drugs or human immunodeficiency virus/acquired immunodeficiency syndrome (HlV/ AIDS), sometimes referred to by the colloquial term, "czars,* who serve on the Domestic Policy Council and may have additional roles in federal agencies. Although these advisers are not directly responsible for programs, they help articulate the President's priorities and try to coordinate activities with other parts of the government.
Figure 1. Organizational chart for the US Department of Human Services, Public Health Service.
The agencies most responsible for health care reside within the Department of Health and Human Services (Figures 1 and 2). The Office of the Assistant Secretary for Health is the central office of the Public Health Service (PHS). It houses the Office of the Surgeon General and contains groups focusing on policy planning and agency coordination, such as the Office of Population Affairs. Within the PHS are agencies such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Health Resources and Services Administration (HRSA), the Agency for Health Care Policy and Research (AHCPR), the Indian Health Service, the Substance Abuse and Mental Health Services Administration (SAMSHA), the Agency for Toxic Substances and Disease Registry (ATSDR), and the National Institutes of Health (NIH), which administer most of the programs in health services, financing, and research.
In addition to the PHS, other agencies with an impact on health care include the Health Care Financing Agency (HCFA) and the Agency for Children and Families. During the 103rd Congress, a bill was passed that moved the Social Security Administration (SSA) out of the Department of Health and Human Services and established it as an independent agency. That transition will occur during 1995. Programs created under Social Security legisla' tion and administered by SSA include many aspects of Medicare, Medicaid, Aid to Families With Dependent Children, and Social Security Disability Income (SSDI).
Within Congress, the elected members have to balance the responsibilities of their individual offices with those of the specific committees on which they sit. Several committees in each part of Congress have major jurisdiction over health-care legislation. In the House of Representatives, the newly reorganized Committee on Ways and Means (with its subcommittees on health, social security, and human resources), the Committee on Energy and Commerce (with its subcommittees on health and the environment, science, oversight, and investigation), and the Education and Labor Committee are the major loci for health legislation and program monitoring. In the Senate, the two major committees are the Labor and Human Resources Committee and the Finance Committee. There are also appropriations committees in both the House and Senate.
Generally speaking, committee staffs have specific expertise in the areas covered by the laws written in their committees. The individual offices of a senator or representative may have one or more "health LAs" (legislative assistants) who look after a range of health-related activities, depending on the particular interests or committee membership of the individual member of Congress. The average age of a "Hill Staffer" is 24 years, and the average tenure is 2 years. Therefore, outside expertise is a valued commodity. Many Congressional support services such as the Congressional Research Service (CRS), the Office of Technology Assessment (OTA), and advisory groups have been established over the past two decades to deal with the increasingly complex issues faced by Congress. Given the sentiment that the size of the federal government should shrink, the fate and funding levels of these support services is a major topic of debate.
QUESTION 4: Who and what are health lobbyists?
Health lobbyists come in many different sizes and shapes. Many of the large professional health organizations have headquarters in or near Washington and staff represent their special interests or constituencies and educate the Hill staff and members of Congress. Examples of groups with a special interest in children and youth include the American Academy of Pediatrics, the Maternal and Child Health Coalition, and the National Association of Children's Hospitals and Related Institutions.
If an organization is licensed as a not-for-profit 501 (c)3 organization, it can have an educational role but cannot "lobby" in the sense of trying to influence legislation. There can be separately funded and licensed entities for this purpose. Often, coalitions are composed of several groups with a common interest. Examples include The Alliance for the Mentally III and the National Network of Runaway and Homeless Youth Programs. During the health reform debate, many new groups were formed, including one focusing on "children with special health-care needs." Sometimes groups represent a very narrow, specific interest, for example, those of the manufacturers and people concerned about nutrients used to treat phenylketonuria, or a broad coalition, such as one alliance consisting of more than 100 organizations of people with various chronic illnesses.
When "lobbying on the Hill," one or more individuals from these organizations meet with key staff members from committees or individual member's offices to provide a specific point of view about pending legislation, to give background about the importance of a specific problem or to offer their expertise in reviewing drafts of laws or amendments. Sometimes lobbyists will sponsor a symposium or seminar to review topic areas to help educate Hill members and staff. They also may help identify witnesses who can testify at hearings to provide professional or personal experiences. The current debate about lobbyists centers around restricting certain types of lobbying practices involving gifts and financial support and their role in contributing to elections of members of Congress through political action committees (PACS), but their basic educational role is not in dispute.
QUESTION 5: What can you do as an individual physician or health-care worker?
There are three options for action. They are not mutually exclusive.
* Vote and elect those people who represent your views . Less than half of the registered American voters cast ballots in the November 1994 election. Thus, major shifts in power in both the House and Senate, as well as in the state governorships and legislatures, were accomplished by a minority of eligible voters. Did you vote? Do your elected representatives represent your views? Some people decide not to vote as a measure of protest, thereby leaving those who do vote to decide who will be in office.
* Visit, call, or write your representatives in Congress, both in the House and Senate. All of your opinions are recorded in a tally form. Some individual letters are actually read by members of Congress, but all are read, tallied, and usually answered by staff. It does make a difference if you are writing or calling from the jurisdiction that elected the member to Congress, particularly if that person is interested in running again. Make an appointment to visit the local office of your senator or representative when they are in your area. By identifying yourself as an expert and a concerned citizen, you may be called on in the future in addition to expressing your views on current topics. Bring along a professional business card, a one-page summary outlining your concerns and suggestions, and copies of reports, articles, or other literature to provide background information. \our meeting will most likely be with staff members, not the elected official, but key health staff are the ones with direct responsibility for drafting legislative proposals, amendments, and background pieces for the members.
* Identify and join organizations or coalitions that best represent your viewpoint, interests, and concerns. The professional staff of these organizations are often best equipped to know how to multiply the impact of your single voice. Through your membership and participation, they can extend your effect directly or indirectly through their mailings, meetings, symposia, visits to the HiU, and campaigns.
QUESTION 6: Can or should a physician or healthcare worker be a politician or policy person?
The answer is "Yes, but. . . * A background in health care is a most appropriate background for contributing to changes in the health-care system. However, to be an effective change agent means embarking on a new course of study and discipline, just as a political scientist or lawyer who wants to practice medicine would first have to study medicine. Currently, there are physicians at many high levels of government including the governors of Vermont, Oregon, and Puerto Rico; senators from Tennessee and Georgia; a representative from Washington; and many heads of federal agencies including OASH, FDA, and HRSA. In other countries, there is a long and strong tradition of physicians as politicians. Here and abroad, physicians and other health-care workers have held key posts in agencies directly related to health such as health ministries, the World Health Organization, and the United Nations Children's Fund (UNICEF) as well as legislative bodies. Skills as a listener, negotiator, and consensus builder make an effective health care worker and family member as well as politician or policy person. The major question is how to apportion your time. If the world of federal policy or politics seems too fer away, complex, or unknown, imagine how the political or policy maker feels trying to change the health-care system without the skills and knowledge you possess.
The author thanks Marion Ein Lewin for reviewing the manuscript, Michael Edington for editing the manuscript, and Sue Barron for preparing the manuscript.
Arnold RD. The Logic of Congressional Action. New Haven, Conn: Yale University Press; 1990.
Bisnow M. In the Shadow of the Dome: Chronica of a Capítol Hill Aide. New York. NY: William Morrow and Co Inc; 1990.
Davidson RH, Olestek WJ. Congress and Ia Members. 3rd ed. Wellington. DC: Congressional Quarterly Ine; 1990.
Field M, Lohr K, Yordy K, eds. Institute of Medicine's Commitut on Assessing Health Care Reform Proposals: Assessing Health Care Reform. Washington, DC: National Academy Press; 1993.
Mayhew DR. Congress: The Electoral Connection. New Haven, Conn: Yale University Press; 1974.
National Health Council. Congress and Health: An introduction to the Legislative Process and Its Key Participants. 10th ed. Washington. DC: National Health Council Government Relations Handbook Series; 1993.
Smith H. The Power Game: How Washington Works. New York, NY: Ballantine Books 1993.
Thurber JA. Divided Democracy: Cooperation and Conflict Between the President and Congress. Washington DC: Congressional Quarterly Inc; 1991.