Health Policy to Legislation

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Health Policy to Legislation

• Robert G. Frank
• Lecture 2
• Health Services, Research, Management and Policy
• 6152

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Who is this man?
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Who is this lady?
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Who is this man?
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Sonny Hoyer Majority Leader of the House of
Representatives

• Congressman Steny H. Hoyer of Maryland's Fifth
  Congressional District was elected in November
  2006 to serve as House Majority Leader in the
  110th Congress by his colleagues in the
  Democratic Caucus, after serving as the
  Democratic Whip in the previous two Congresses.
• As the Majority Leader, Congressman Hoyer is
  charged with scheduling legislation for
  consideration on the House Floor, as well as
  building unity among House Democrats and
  delivering the Democratic Party's message.
• Now serving his 14th term in Congress, he also is
  the longest-serving Member of the U.S. House of
  Representatives from Southern Maryland in
  history.
• Prior to serving as the Whip in the 108th and
  109th Congresses, he served as Chair of the
  Democratic Caucus B the fourth-ranking position
  among House Democrats B from 1989 to 1995.  He is
  the former Co-Chair (and a current member) of the
  Democratic Steering Committee, and served as the
  chief candidate recruiter for House Democrats
  from 1995 to 2000.  He also served as Deputy
  Majority Whip from 1987 to 1989.

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Congress and Health Reform
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Weve Got Goldwater to Thank for This

• 165 more Democrats than Republicans
• Lyndon Johnson
• Medicare
• Medicaid
• Maternal and Child Health Program
• Health Planning
• Regional Medical Programs
• Physician Training Programs

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1964 Landslide Brought 42 New Northern Democrats
to the House

• Ways and Means Committee transformed allowing
  development of payroll tax to finance Medicare

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1981 Presidential Landslide

• Republican Senate
• Party leaders now controlled powerful chairman
• Post Watergate reforms enacted

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1993 Bill Clinton - 43 Majority

• Largest first year class since 1949 in House
• Many experienced in State legislatures
• Whip weekly meetings to enhance common agenda
• Speaker Foley refused to strip dissident chairs

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U.S. Operated under Articles of Confederation for
13 Years

• Strong States
• Weak federal government
• Convention to modify Articles of Confederation
  became the Constitutional Convention

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Constitutional Convention

• Popularly elected House
• Elitist Senate elected by State legislatures
• Strong executive with veto power

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David Broder

• Majority of Senators come from states that elect
  20 of the House
• 1995
• the two Senators from Oregon, which is the
  population of greater Atlanta
• chaired Appropriations and Finance
• Senate Majority Leader from Kansas
• Minority Leader from South Dakota

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(No Transcript)
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U.S. Senate

• 6 year terms
• Statewide elections
• 2 from each state

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Composition of the US Senate 110th Congress
(2007-2009)

• Majority Party Democrat (49 seats)
• Minority Party  Republican (49 seats)
• Other Parties 1Independent 1 Independent
  Democrat
• Total Seats 100
• Note Senator Joseph Lieberman of Vermont was
  reelected in 2006 as an Independent Democrat.
  Senator Bernard Sanders of Vermont was elected as
  an Independent.

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Senate Oath

• OATH REQUIRED BY THE CONSTITUTION AND BY LAW TO
  BE TAKEN BY SENATORS"I, A__ B__, do solemnly
  swear (or affirm) that I will support and defend
  the Constitution of the United States against all
  enemies, foreign and domestic that I will bear
  true faith and allegiance to the same that I
  take this obligation freely, without any mental
  reservation or purpose of evasion and that I
  will well and faithfully discharge the duties of
  the office on which I am about to enter So help
  me God." (5 U.S.C. 3331.)

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Standing Rules Standing Rules of The Senate RULE
XXIIIPRIVILEGE OF THE FLOOR

• Other than the Vice President and Senators, no
  person shall be admitted to the floor of the
  Senate while in session, except as follows The
  President of the United States and his private
  secretary. The President elect and Vice
  President elect of the United States.
  ExPresidents and exVice Presidents of the United
  States. Judges of the Supreme Court. ExSenators
  and Senators elect. The officers and employees
  of the Senate in the discharge of their official
  duties. ExSecretaries and exSergeants at Arms of
  the Senate. Members of the House of
  Representatives and Members elect. ExSpeakers of
  the House of Representatives. The Sergeant at
  Arms of the House and his chief deputy and the
  Clerk of the House and his deputy. Heads of the
  Executive Departments. Ambassadors and Ministers
  of the United States. Governors of States and
  Territories. Members of the Joint Chiefs of
  Staff. The General Commanding the Army. The
  Senior Admiral of the Navy on the active list.
  Members of National Legislatures of foreign
  countries and Members of the European Parliament.
  Judges of the Court of Claims. The Mayor of the
  District of Columbia. The Librarian of Congress
  and the Assistant Librarian in charge of the Law
  Library. The Architect of the Capitol. The
  Chaplain of the House of Representatives. The
  Secretary of the Smithsonian Institution. The
  Parliamentarian Emeritus of the Senate. Members
  of the staffs of committees of the Senate and
  joint committees of the Congress when in the
  discharge of their official duties and employees
  in the office of a Senator when inthe discharge
  of their official duties (but in each case
  subject to such rules or regulations as may be
  prescribed by the Committee on Rules and
  Administration). Senate committee staff members
  and employees in the office of a Senator must be
  on the payroll of the Senate and members of joint
  committee staffs must be on the payroll of the
  Senate or the House of Representatives.f the
  Senate

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U.S. House

• 2 year terms
• District elections
• 435 members
• Reallocated every 10 years

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Composition U.S. House of Representatives110th
Congress

• Membership
• 435 Members
• 4 Delegates
• 1 Resident Commissioner
• Party Divisions
• 233 Democrats
• 202 Republicans
• 0 Independent
• 0 Vacancies

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Senate

• Fewer procedure rules
• Amendments do not have to be germane to the topic
  of the bill
• 1 Senator can filibuster
• filibuster used 22 times per year since 1990 vs.
  12 times per year 1968 - 1989

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Leadership

• Leadership
• Both houses organized by parties
• Majority party selects leader
• Schedules
• Committee memberships
• Bill referral
• Conference committees
• Party strength inversely correlated with chairman
  power

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Legislative Calendar

• A legislative day
• begins when a house of Congress meets and ends
  when it adjourns.
• The House almost always adjourns at the end of a
  daily session, so its calendar day and
  legislative day coincide.
• The Senate often does not adjourn at the end of a
  daily session, but instead "recesses," so when
  the Senate next meets, it continues in the same
  legislative day. As a result, a legislative day
  in the Senate may extend over days, weeks, or
  even months.

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Legislative Calendar

• Day certain or a day not yet determined (as
  in a unanimous consent request)
• Refers to calendar date

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Legislative Day

• Period of time following an adjournment of Senate
  until another adjournment
• No senator may speak twice upon one issue on the
  same legislative day

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Legislative Calendar

• Senators refer to bill or nominations on the
  calendarthese are on the legislative calendar

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Morning Hours

• Through unanimous consent, majority leader
  provides a brief period (about 10 minutes each)
  two leaders
• Provide direct observations current events or
  pending legislation
• Also receive reports, communications, messages
  from the House

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Senate Procedure

• Senate rules promote comprehensive debates
• A simple majority may end debate
• Filibuster can be ended by invoking cloture
• Usually by a 3/5 vote
• Even with cloture, debate can continue for 30
  hours

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Filibuster

• Encourages consensus in Senate
• Unanimous consent agreements limit time available
  for debate

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Not Germane Amendments

• Except when debating appropriations, budget, and
  certain other measures
• Senators may propose amendments not related to
  the topic, that have not been reviewed by
  committees.
• Senators can also place business directly on the
  Calendar of Business without committee referral
• makes Senate schedule less predictable.

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Senate Majority Leader

• Proposes proposes bills or resolutions for the
  Senate to consider.

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Committees

• Woodrow Wilson (1885)
• Congress in its committee rooms is Congress at
  work
• Roughly 20 standing committees in each house
• Conference committees are temporary to reconcile
  differences between the houses

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Standing Committees

• 35 standing committees
• 19 in House, 16 in Senate
• 8,000 bills introduced in a 2-year session_at_80
  Pass
• Committee that drafts legislation also handles on
  floor
• every health bill moved by the Senate Labor
  Committee passed in 99th Congress

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Committees

• Extends beyond Congress
• affects bureaucracy, agencies and commissions
• Cabinet offices spend 1/3 of their time on
  Capitol Hill

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Appropriating vs. Authorizing Committees

• Appropriating
• House Ways and Means
• Senate Finance
• Appropriations
• Budget

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Forms of Legislative Business

• Bill
• Public --- most common
• Private designed to affect or benefit specific
  individuals or group

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Bills

• Senate numbers bills in sequence
• Starting with 1
• Designation S
• Joint resolutions --same effect as a bill unless
  amendment to the Constitution
• S Con. Res.___
• For Senate concurrent resolution --- express
  sense of Congress to President or others.

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House Bills

• H.R. ___
• H.R. Res.____ for House joint resolutions
• H.R. Con. Res. ___ for House Concurrent
  resolutions

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Bills and Joint Resolutions

• Identical bills and joint resolutions, passed by
  both Houses and approved by President become law
• Public laws affect the Nation
• Private laws affect only a class or group of
  individuals

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Constitutional Amendment

• Requires 2/3 vote with a quorum present
• Not sent to President
• Instead sent to GSA who transmits to the various
  states
• Must be ratified by ¾ of states

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Concurrent Resolutions

• Must be approved in identical form by both Houses
• Do not become law not sent to President
• Attested by Secretary of Senate and Clerk of
  House
• Transmitted to Administrator of GSA for
  publication in Statutes at Large

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House vs. Senate

• Senate order of business simpler than House
• Procedure for both bodies founded on Jeffersons
  Manual of Parliamentary Practice
• Primary differences in method of calling up
  business

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House vs. Senate

• Senate business is not divided into classes nor
  are calendar days set aside for specific business
• Senate is a continuing body (2/3 of Senate
  returns after each election)
• House readopts old rules inception of each
  Congress
• Senate has not reaffirmed rules since 1789
  rules adopted since first Congress remain in force

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Bill Introduction

• Any member may introduce a bill
• Blank forms are kept at Clerk (House)
• Introducing member is the sponsor
• Must sign the bill

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Bills

• Co-sponsors do not have to sign the bill
• Co-sponsors may not be added after the bill has
  been reported from the last committee
• In no event shall the Speaker entertain a
  request to drop the sponsor

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Bills in the Senate

• Senator may have Presiding Officer place the bill
  in the record or be recognized to give comments
• Senators frequently obtain consent to have the
  bill printed in the Congressional Record
• If a Senator objects to the introduction of a
  bill, it is delayed one day.
• If there is no objection, the bill is read and
  placed in the Congressional Record

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Bills in the House of Representatives

• In the House, bills are not read.
• Printed in the Journal and Congressional Record.
• Bills referred according to the Rules of the
  House.
• Bill Number and committee referral appear in the
  Congressional Record

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Senate

• Maintain decorum
• No senator may refer offensively to any State of
  the Union

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Standing Committees

• 19 Standing Committees in the House
• 16 Standing Committees in the Senate
• Several Select Committees
• Four Standing Joint Committee which oversight,
  but no legislative jurisdiction
• House may create select committees or task forces
  through formal resolution or informal agreement
  among members

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Committee Referral

• Rules of House and Rules of Senate have 200
  classification for bills
• Prior to 1975, Speaker could refer to only one
  bill
• Now Speaker may make multiple referrals must
  designate a primary committee

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Health Committees Senate

• Senate Finance Committee
• Subcommittee on Medicaid and Health-Care for Low
  Income Families
• Subcommittee on Medicare, Long-Term Care and
  Health Insurance
• Senate Health, Education, Labor and Pensions
• Senate Appropriations Committee
• Senate Budget Committee

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Key Health Committees in the House

• House Ways and Means
• Subcommittee on Health
• House Appropriations Committee
• Subcommittee on Labor, HHS, and Education
• House Commerce Committee
• Subcommittee on Health and Environment
• House Budget Committee

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Committees Movement of Bills to the Floor

• House Committees pass bills to House Rules
  Committee ? determines rules of debate including
  whether amendments allowed
• Senate Committees pass bills to floor

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Subcommittees

• 1979 Henry Waxman challenged for chair of House
  Commerce Health and Environment Subcommittee
• shared campaign money with supporters
• House Subcommittees heavily involved legislation
  development, hearings, mark-ups
• Still variability between committees on
  importance
• House full committees mark-ups - hearings rare

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Senate

• HELP Committee
• jurisdiction over 26 major health programs
• subcommittee under Ted Kennedy in 1970s
• eliminated by Orin Hatch in 1987
• 1987 Democrats regain Senate
• still no subcommittee

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House

• Healthcare policy - Commerce Health and
  Environment Subcommittee
• Under Dems - subcommittee establish its own
  agenda - picked legislative battles - won most
• lost Clinton bill
• Neither subcommittee and full able to agree

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Bill Movement

• House
• 85 measures on House floor first referred to
  subcommittee
• Senate
• 42 measures referred first to subcommittees
• 80 measures brought to House floor referred by
  subcommittees
• 46 in Senate

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Turf

• Committee chairs guard
• 1993 House Judiciary chairs would not allow
  medical malpractice to go to Ways and Means
• 1971 Paul Rogers changed subcommittee name to
  Public Health and Environment Subcommittee
• argued subcommittee should have jurisdiction over
  Medicaid, then under Ways and Means
• 4 years later, subcommittee gained Medicaid

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Subcommittee Jurisdiction Changed with Times

• 1970s - energy committees increased
• 1993 - 15 committees claimed health jurisdiction
• previously only 8 subcommittees claimed
  jurisdiction

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Referral Assignment

• Clinton bill
• Senate Finance Chair
• Moynihan claimed jurisdiction over entire bill
  (though he was known for welfare reform)
• Senator Kennedy - chair of Labor and Human
  Resources
• the traditional authorizing committee claimed
  jurisdiction over non-tax issues, including
  employer mandate, premiums, insurance-buying
  cooperatives on insurance reform

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Conference Committees

• Penultimate power
• Decisions final
• Voted up or down
• May differ on representation
• 1989 conference savings and loan
• 8 Senate, 94 House

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Conference Committees

• Powerful
• 1974 inserted state preemption clause in ERISA
• state insurance plans prohibited
• added 10 days before final passage without
  knowledge most insurers, Department of Labor or
  state government associations
• has not been altered despite almost 30 years of
  efforts

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Entitlements

• Combination of authorization and appropriation
• Funded automatically - do not require
  appropriations
• Spending for entitlements difficult to control

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Entitlements

• Social Security, Medicare, Medicaid, Food Stamps,
  AFDC
• Avoids routine Congressional scrutiny
• Often indexed for COLA

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Entitlements

• FY 64
• 24 Federal spending
• grown 12 per year since 1964
• Social Security alone now 20 of Federal spending
• Between 1980 and 1990 Medicare grew 200

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Entitlements

• Social Security grows slower than health
  entitlements - Medicare, Medicaid
• popular programs - difficult to cut
• the political third rail

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Budgeting

• Authorizations
• establish or continue a program or agency
• Appropriations
• provides funding
• Process designed to separate policy from fiscal
  decisions
• Process typically sequential

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Budget Process

• First 150 years budget surplus
• federal spending was quite low
• 1930s Federal spending grew
• 1939 Bureau of Budget made part of Executive
  Branch
• 1970 became Office of Management and Budget (OMB)

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Budget Process

• Early 1970s presidential budget control peaked
• Richard Nixon refused to spend funds appropriated
  by Congress for programs he did not support
• Congress passed Congressional Budget Impoundment
  Control Act of 1974
• established Senate and House Budget Committees
  and CBO
• mandated concurrent budget resolution

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Budgeting

• Balanced Budget and Emergency Deficit Control Act
  of 1985
• known as Gramm-Rudman-Hollings Act
• forced Congress to reduce deficit
• 36 billion/year reduction
• sequestration- across board cuts if Congress
  fails to make cuts
• many entitlements - Social Security, medicaid,
  AFDC exempted

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Administrative Budgeting

• CBO Produces Annual Report to House and Senate
  Committees on budget
• Provides a broad range of options
• Released in February

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The Congressional Budget Calendar

• Date Action
• Between first Monday in January President
  transmits the budget, including a sequester
  preview report
• and first Monday in February
• Six weeks later Congressional committees report
  budget estimates to budget committees
• April 15 Action to be completed on
  congressional budget resolution
• May 15 House consideration of annual
  appropriations bills may begin
• June 15 Action to be completed on
  reconciliation
• June 30 Action on appropriations to be
  completed by House
• July 15 President transmits midsession review
  of budget
• August 20 OMB updates the sequester preview
• October 1 Fiscal year begins

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Budget Process

• President must submit budget by first Monday in
  February
• Budget establishes priorities for program funding
  and funding level
• In election years, the budget is a broad overview

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Budget Process

• Congress develops a budget resolution
• Defines parameters all budget related activities
• Defines size of budget, levels of funding, and
  revenues
• Must consider revenues for the forthcoming year
  and next 10 fiscal years

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Budget Process

• Budget Resolution is not law
• Concurrent resolution of both Houses

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Budget Process

• Levels established in the budget resolution are
  supported by procedural mechanisms followed in
  both Houses

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Budget Process

• Budget resolution is an outline for the budget
• Legislation must be passed to implement
• Appropriation Act
• Changes in tax law
• Entitlement programs

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Budget Process

• Discretionary spending allocated to Appropriation
  Committees
• House and Senate Appropriation committees
  sub-allocate spending to 13 subcommittee
• Develop 13 appropriation bills
• Each bill must move through the legislative
  process and be signed by the president

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Budget Process

• In years the Budget Resolution calls for changes
  in taxes or entitlements
• Budget Committee direct relevant committees to
  enact legislation to reconcile changes

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Reconciliation

• Budget process has weakened the authorizing
  committees
• Increase leadership rule
• Authorizing Committees rarely launch new programs
  - protect older programs from cuts

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Appropriation Committees

• Increased power
• Spending caps require tough decisions
• Important to special interests

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Reconciliation Bill

• Important to health policy
• Implements the concurrent budget resolution
• Little attention to specifics - no hearings
• In 1980s every major health legislation in
  reconciliation bill
• Health block grants
• Physician payment reform

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Reconciliation

• Henry Waxman used to expand Medicaid
• Many argued reconciliation made legislation more
  secret, increased budget and staffing needs
• delayed impact of changes
• increased power of smart chairs and members