Influencing Policy: Tools

Advocating for policies to support health information exchange at the community, regional, state and national levels requires savvy organization, leadership and follow through, and perhaps most importantly, developing a strategy to assure success in achieving one’s public policy objectives. Former US House of Representatives Speaker Tip O’Neill maintained that “all politics are local.”  Nothing could be more true. Indeed, communities are the locus for the patient and for healthcare delivery. Home is not only where the heart is, it’s also the base from which real political power can be galvanized. What you say to your Representatives, US Senators and elected State officials and the real-world experience you can offer to national and state policymakers can have a strong impact on the proper shaping and forward momentum of health information exchange policy development.

Telling one’s own story about local needs, successes and situations - both good and vexing - is an effective way to communicate to state legislators and US Senators and Representatives about regulatory barriers to health information exchange and to deliver important requests for seed funding and similar messages. Below are several paragraphs to help you begin the process of communicating with your elected representatives.  They explain the fundamental building blocks of successful advocacy for your cause.

Grassroots Advocacy. Grassroots advocacy is the act of an individual constituent communicating ideas and opinions to government officials (Senators, Representatives and Administrative Agency personnel). This communication is made even more effective when numerous individuals and representatives from multiple stakeholder groups, part of a community health information exchange, for example, email, and write letters to State legislators and Members of Congress to express an opinion on a particular topic.

Building Relationships. Establishing relationships with your Members of Congress, their staffs and with State officials may seem daunting, but is one of the most important steps to getting your voice heard. Be confident in knowing your political representatives are very eager to hear from you. While your immediate goal may be to request a regulatory change or suggest enabling legislation, remember that one of the best ways to cement relationships with influencers on Capitol Hill or in State Capitols is to be an on-going information resource for your legislators and their staff, particularly on the topic of health information exchange.

You can learn about elected representatives through your legislator's internet homepages and other resources as noted on these websites for Members of Congress. These websites are searchable by state and name of the representative. Most States also maintain websites for State elected officials, which can be found by visiting State websites. Websites with federal legislator resources include:

http://www.senate.gov/

http://www.house.gov/

http://www.c-span.org/

http://www.congress.org/congressorg/home/

Communicating with Your Legislator.  Legislators maintain regular correspondence systems to track mail from constituents. Multiple requests for a legislative change are especially noted. Thus, several constituents writing about one topic may move the representative to adopt a certain political position. Letters, phone calls and emails are effective. With respect to the latter, caution is in order to customize your correspondence and assure that representatives are not “Spammed” on a particular issue.  Addresses for legislators can be found on their Internet home pages.

Letters to Elected Representatives. Some general rules for letters include the following:

 Visits with Legislators.  Meeting with Senators and Representatives and State elected officials is an effective way to start or maintain a relationship. Staffers, who are principal advisors and draft much of the legislation, are likely to be present in such meetings.  They are a very important part of the relationship. To arrange a meeting, a phone call, a letter, fax or email is often needed. Meeting with federal elected representatives may also take place in the District office in your community as opposed to Washington. Further, as means to educate your elected representatives on health information exchange, arrange a tour of your facility during recess and other non-legislative periods.  This will provide an opportunity to explain in-person how a health information exchange works, the value of your efforts and the impact on patient care. 

How a Bill Becomes Law. At the federal level, the legislative process is as follows:

1. Bill Introduction in House or Senate - The legislative process often begins when a Representative or Senator introduces a bill or resolution. The bill is numbered - "H.R." signifies a House bill (e.g., H.R. 2590) and "S." a Senate bill (e.g., S. 1325).
2. Referral to Committee/Subcommittee - After introduction, a bill is referred to a specific committee(s) with jurisdiction over the proposed legislation. The bill may then be further assigned to an even more specialized subcommittee. Given the high volume of legislation, most of the deliberation and decision-making is done by subcommittees.
3. Committee/Subcommittee Hearings - Committees and subcommittees may hold hearings on a bill. Hearings provide the opportunity to gather information about a topic or proposal and put on record the views of the Executive branch, experts, other public officials, and interest groups. Testimony can be given in person or submitted as a written statement.
4. Mark-up Session - When hearings are completed, the subcommittee typically will meet to "mark-up" the bill. During "mark-up" legislators will debate and vote on amendments and literally mark up the bill. The subcommittee will then vote whether or not to report the bill to the full committee, where the process is largely repeated.
5. Bill goes to House or Senate for a Vote - If the bill is approved by the committee, it then goes to the floor of the House or Senate for debate and a vote. After the debate and approval of any amendments, the bill is passed or defeated by the members voting. If the bill is approved by one body, it will be forwarded to the other legislative chamber where the process begins all over again.
6. Conference Committee - If the House version and the Senate version of a bill are not identical, then a conference committee, consisting of Representatives and Senators from both parties, is convened. The conference committee works out the differences between the bills. Once a consensus is reached on the legislation, it is sent back to the House and Senate chambers for a final vote.
7. President’s Role - After Congress has approved a bill, it is sent to the White House for the President's signature. The President may sign the bill, making it law, or veto the bill, in which case it is sent back to the Congress where both chambers may attempt to override the veto by two-thirds vote, or allow the bill to die. If the President does not act on the bill within ten working days of receiving it, and Congress is in session, the bill automatically becomes law. If the President does not act within ten working days, and Congress is not in session, the bill is subject to a "pocket veto" and dies.

See the Library of Congress at http://thomas.loc.gov/  for a user-friendly website called "THOMAS" that catalogues legislation. This website is a useful resource to obtain bill text and track legislation.

The Regulatory Process.  Following passage of legislation, Federal agencies are charged with implementation. Numerous agencies concerned with HIT include the Department of Health and Human Services (HHS), Centers for Disease Control (CDC), Food and Drug Administration (FDA), Veterans Administration (VA) and the Department of Defense (DOD). The focal points within HHS are the Office of the National Coordinator for Health Information Technology (ONCHIT), Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).

 HHS and CMS issue hundreds of regulations annually that impact the delivery of health care. Before any regulation is finalized and implemented, the issuing agency must give the public the opportunity to comment. The agency must then respond to comments. If the agency chooses to disregard comments on a particular point, it must explain its reasons for doing so. Because of these rules federal agencies are often persuaded by comments, particularly when bombarded by a large number of comments.

The eHealth Initiative submits comments on proposed rules that impact the HIT community. In preparation for comments, eHI members are invited to provide input through working groups. The proposed comments are then posted on the eHI website for members and the public. 

• Public Policy and Advocacy-Index of Lessons Learned and other Resources from the Funded CCBH Communities