Influencing Health Care in the Legislative Arena

Sheila Abood, PhD, RN


Online J Issues Nurs. 2007;12(1) 

In This Article

Strategies for Effective Action in the Legislative Arena

As nurses get ready to take their issues into the legislative arena and to use their legislative power and political clout, it is essential to determine which strategies will be timely and most effective. This section briefly addresses the five following strategies: entering the legislative arena, understanding steps in the process, understanding the power players, understanding committees, and communicating with legislators.

The legislative arena is where most advocates concentrate their efforts to make their point of view on a particular issue known. It is where citizens go to meet their legislators and meet with people who are staff for the legislators and the various committees, and where they testify at hearings and briefings.Entering the legislative arena is the first step in bringing about policy change. When Maggie Flanagan (n.d.) found herself with a musculoskeletal injury after years of bedside nursing, she spoke up in the legislative arena in her state to educate policy makers about the need for Safe Patient Handling legislation. When Karen Daley (n.d.) suffered a needle stick injury at work, she courageously carried her own experience into the legislative arena to advocate for Safe Needle Protection policy. When Patti Moss and Iva Hall, nurse researchers from Texas, identified the need for legislation to develop a comprehensive disaster preparedness plan that included home bound medically fragile patient populations, they went to the legislative arena to get needed legislation enacted (Hall & Moss, 2000).

In addition to entering the legislative arena, all the nurses described above learned first hand how to effectively play a part in the legislative arena by influencing policy designed to have a positive impact on patients and their profession. This section will describe the legislative process since knowing these steps is fundamental to the movement from a problem to a viable program. It is the process that enacts laws, creates and funds health programs, and balances health policy with other policy domains. Once an issue takes its place on the public agenda, a bill must be introduced, delegated to a committee, hearings held, and committee action taken on the bill before the legislation is taken to the floor for a final vote. (For a review of how a bill becomes a law and other nuts and bolts of political action go to The Legislative Process). Each state has a similar legislative process to authoritatively make policy decisions.

Patti Moss and Iva Hall learned first hand lessons of how to use the legislative process effectively for patients and the profession. When the results of their research revealed the need for a change in the Texas law, they went to work. Working with a consultant, they developed a bill that would make the changes needed to remove barriers to a comprehensive disaster plan. Once the bill was drafted, they had to identify a legislator willing to introduce and sponsor the bill. They used posters, slide presentations, and verbal explanations to present the highlights of their research and the bill they were proposing to local legislators and their staff. Newly elected state Representative Joe Deshotel agreed to introduce the bill and shepherd it through the process. A companion bill was introduced in the state Senate by Senator David Bernsen. Making many trips to Austin for visits to the offices of key legislators, these nurse advocates learned to present their issue in a concise two-minute speech. They also made a point of actively listening to the legislators in an effort to help support the legislators' causes as the legislators supported theirs. By the end of the legislative session, the efforts of these two nurses were rewarded with the enactment of their legislation paving the way to the establishment of an improved state disaster plan for individuals with special disaster needs (Hall & Moss, 2000).

In the legislative arena there are always key players who have the ability to impact the outcome of proposed legislation. Final voting decisions are influenced by many factors other than the merits of the issue. These factors include party politics, personal preferences, district voters' preferences, and the pressure of organized interest groups. Shaping the final outcome and content of the proposed policy change depends on identifying the supporters as well as the non-supporters among legislators, contacting the chairperson and the members of relevant committees, and most importantly contacting one's own legislator.

As constituents, nurses have considerable power to influence legislation especially when nursing has a firm, cohesive preference on an issue. When potential voters are divided or don't care, a legislator is less likely to take their preferences into consideration when voting. Legislators ask themselves many questions before they vote to support or oppose a bill. Some of their considerations will likely include: Does this measure affect my district and if so, how? What do people in my district think? Have they communicated with me? Does my political party support or oppose this bill? Who are the individuals or groups supporting/opposing this bill and what kind of relationship do I have with them? Building credibility with one's legislators and their staff should start before one needs their support. Don't overlook the importance of finding out which staff person advises one's legislator on health care issues and scheduling a meeting with that person early in the legislative session to get to know the staff persons by name and share your expertise with them.

The immediate impact of nurses speaking out and being visible at the Capitol cannot be overstated. Following a recent lobby day, when nurse advocates made visits to a hundred Congressional offices, a significant number of legislators signed on to support increased funding for nursing programs.

Committees are the centers of policy making and public education at both the federal and state levels. Proposed legislation is given the most intensive consideration at the committee stage. This is when conflicting points of view are discussed and where legislation is hammered out. The committee chairperson controls the work of the committee; and by negotiating with committee members, establishes the agenda for the consideration of a given bill. Committee procedures perform a gate keeping function by selecting from the hundreds of measures introduced in each session those that merit floor debate and ignoring the rest. Committees conduct hearings to educate committee members and the public about a particular bill under consideration. Hearings provide an opportunity for various views to be discussed. Nurses can influence the process at this point by requesting an opportunity to testify. However, invitations to testify are usually offered to larger, organized groups which have developed a position on the issue, rather than to individuals. Even though you may not be invited to testify in person at a committee hearing, there are still opportunities to communicate your position to committee members and or their staff and to explore who supports the bill and who opposes it. Thus it is important to know which committee or committees will address your area of concern.

The nursing profession is fortunate to have Representative Lois Capps, RN, one of the three nurses currently in Congress, serving on the powerful Committee on Energy and Commerce and its Subcommittees on Health, Energy and Air Quality, and Environment and Hazardous Materials. From these posts, Capps has focused on Medicare reform, the nursing shortage, cancer, mental health, energy policy, the environment, and telecommunications issues. She also serves on the influential House Budget Committee where she takes an active role in promoting fiscally responsible spending priorities for the annual federal budget. Representative Capps is also the founder and co-chair of the Congressional Nursing Caucus, a non-partisan forum for the discussion of issues that impact the nursing profession. The Nursing Caucus allows members of Congress an open forum to address issues affecting the nursing community.

Each year, legislators at both the state and federal levels must wade through hundreds of bills that cover a broad range of issues. It is impossible for them to be knowledgeable about all issues and to completely understand each bill. This is where advocates can wield a lot of power by helping their own legislators to evaluate an issue and determine how they will ultimately vote on that issue. The effective advocate will work to develop communication skills in order to convince others to listen and gain the perceptions of others. Repeated contacts with legislators and their staffs made in a straightforward manner greatly increase the likelihood that the information one provides will be heard and understood, and perhaps influence their decisions.

When dealing directly with policy makers, advocates must be informed, be concise, and be clear about what they want. Writing a well crafted letter, sending emails, leaving a written summary of your issue with staff, sending thank-you notes, and inviting the legislator to visit your workplace are all ways to get one's legislators to consider one as an expert on health care and nursing issues and to make contact when they need information related to nursing and health care. One state legislator stated, "The nurses in my home district made me aware of the impact this legislation would have on patients." By utilizing the nurse's information the nurse provided, the legislator was able to reconsider her position on several pieces of pending legislation and supported bills relevant to nursing practice. To review some techniques for working with policy makers go to Hill Basics: Visiting Capitol Hill and Making Your Voice Heard in Congress .

The legislative arena is a highly competitive environment where there are no guarantees of success for even the most reasonable proposal. At times decision makers have an invested interest in maintaining the status quo. Political advocacy can at times be discouraging when facts or research are discredited or agendas are challenged. It is wise to anticipate these types of setbacks and to be prepared with an appropriate response.


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