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The U.S. Congress and Health Policy

Sheila Burke, RN, MPA, FAANHarvard Kennedy School of Government

June 2011

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Health Care Priorities for Policymakers

Series1 56%

61%

61%

64%

66%

66%

73%

84%

87%

Source: Pew Research Center for the People & the Press, January 2011 Political Survey

Percent saying each of the following should be a top priority for the President and Congress in 2011:

Figure 1

Taking steps to make Medicare system financially sound

Reducing healthcare costs

Revising the health care legislation passed last year

Dealing with the problems of poor and needy people

Reducing the budget deficit

Improving the educational system

Strengthening the nation’s economy

Improving the job situation

Taking steps to make Social Security system financially sound

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Congress and Health

• Congress plays a major role in development of health policy• Medicare• Medicaid• Veterans Affairs• National Institutes of Health• Health care reform

• Health policy is a bi-partisan priority

• Authority spread across several committees

• Involvement includes regulatory, programmatic, financing, and oversight

Figure 2

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Temporary Assistance for Needy Families (1996)

Examples of Congressional Legislation in Health Policy

Figure 3

Enactment of Medicare and Medicaid (1965)

Patient Protection and Affordable Care Act (2010)

Medicare Modernization Act (2003)

Children’s Health Insurance Program (1997)

Family Medical Leave Act (1993)

Americans with Disabilities Act (1990)

Employee Retirement Income Security Act (1974)

1960 1970 1980 1990 2000 2010

Health Insurance Portability and Accountability Act (1996)

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U.S. Senate: 112th Congress

LEADERSHIPMajority Leader: Harry Reid (D-NV) Minority Leader: Mitch McConnell (R-KY)Majority Whip: Richard Durbin (D-IL) Minority Whip: Jon Kyl (R-AZ)

KEY COMMITTEES

Chairman: Max Baucus (D-MT) Chairman: Tom Harkin (D-IA)Ranking: Chuck Grassley (R-IA) Ranking: Michael Enzi (R-WY)

Chairman: Kent Conrad (D-ND) Chairman: Daniel Inouye (D-HI)Ranking: Jeff Sessions (R-AL) Ranking: Thad Cochran (R-MS)

51 Democrats47 Republicans2 Independents

Figure 4

Finance

Budget

Health, Education, Labor, Pension

Appropriations

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U.S. House: 112th Congress

241 Republicans

192 Democrats

2 vacancies

LEADERSHIPSpeaker: John Boehner (R-OH) Majority Leader: Eric Cantor (R-VA) Minority Leader: Nancy Pelosi (D-CA)Majority Whip: Kevin McCarthy (R-CA) Minority Whip: Steny Hoyer (D-MD)

KEY COMMITTEES

Chairman: Fred Upton(R-MI) Chairman: Dave Camp (R-MI)Ranking: Henry Waxman (D-CA) Ranking: Sander Levin (D-MI)

Chairman: Paul Ryan (R-WI) Chairman: Harold Rogers (R-KY)Ranking: Chris Van Hollen(D-MD) Ranking: Norman Dicks (D-WA)

Figure 5

Energy & Commerce Ways & Means

Budget Appropriations

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Critical Differences between House and Senate

Figure 6

HOUSE SENATEHouse is more than four times size of the Senate

Senators represent a broader constituency than House member

Floor debate in House has more limits and is more expeditious than Senate

Senators serve longer terms (6 yrs) while House members run every two years

Power less evenly distributed in the House, but Majority more powerful force in the House

Senate filibuster can block action on legislation with only 41 votes

House disproportionate share of majority seats on Committees

Senate more equity in distribution of staff funds

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Majority vs. Minority Party

• Majority has more control over agenda, floor debate, and committees

• Majority controls committee chairs, number of committee members and votes

• Greater staff and funding allocations to Majority

• Use of procedural tools (i.e. veto override, right of first recognition)

• Can call for hearings and investigations

Figure 7

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Key Congressional Committees

Figure 8

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House Committee on Ways and Means

Chief Health Responsibilities:• Government payments for programs in Social Security Act:

– Medicare (Part A, Parts B, D joint with E&C)

– Welfare, Temporary Assistance for Needy Families (TANF)

– Supplemental Security Income (SSI)

– Social Services (Title XX)

• Tax credits and related matters in tax code dealing with health insurance premiums

Figure 9

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House Committee on Energy and Commerce

Chief health responsibilities:• Medicaid and Children’s Health Insurance Program

• Medicare (Part B, Parts C and D shared with Ways & Means)

• Centers for Medicare and Medicaid Services (CMS), including the Center for Consumer Information and Insurance Oversight

• Aging policy, individuals with disabilities

• National Institutes of Health (NIH)

• Domestic activities of the American National Red Cross

• Occupational safety and health, including the welfare of miners

• Public Health

Figure 10

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Senate Health, Education, Labor and Pension (HELP) Committee

Chief Health Responsibilities:– Public Health

– Employee Retirement Income Security Act (ERISA), (shared with Finance Committee)

– Individuals with disabilities

– Occupational safety and health

– Biomedical research and development

– Aging

Figure 11

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Senate Committee on Finance

Chief Health Responsibilities: – Health programs under the Social Security Act

and including: • Medicaid- including ACA expansions, Center for

Consumer Information, and Insurance Oversight• Medicare • CHIP• Welfare (TANF)• Maternal and Child Health block grant• Supplemental Security Income (SSI)• ERISA (w/HELP Committee)

– Revenue measures

Figure 12

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Senate and House Committees on Budget

• Review and evaluate President’s budget proposal

• Formulate budget resolution establishing Congressional spending and revenue levels

• Submit resolution to full chambers for vote and negotiations in conference

• Monitoring budget “reconciliation” process

• Oversight of Congressional Budget Office (CBO)

Figure 13

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Senate and House Committees on Appropriations

• Allocates discretionary funding to federal agencies, departments, and programs

• Sub-committees prepares funding allocations for programs within jurisdiction

• Subject to spending levels established in budget resolution

• Major authority over discretionary, non-entitlement programs

Figure 14

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Federal Budget Process

SOURCES: Congressional Budget Act of 1974, as amended; Oleszek, Congressional Procedures and the Policy Process, 2001

Figure 15

February - President’s budget released

- Congress holds hearings on President’s budget request

March - CBO baseline and re-estimate of President’s budget released

- House and Senate develop a Budget Resolution

May-Dec - “Reconciliation bill” to make changes in tax policy or

entitlements if required in budget resolution- Action on Appropriations bills- Bill signed by President

April Budget Resolution completed

October 1 Beginning of new fiscal year

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Legislative Timing

Figure 16

Idea Phase Drafting of Bill

Hearings Committee Mark-Up

Floor Action- Amendments

House/Senate Conference

President signs bill

Implementation by Administration 0

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Working With Congress

Figure 17

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Lobbyists and Interest Groups

• To conduct activities aimed at influencing public officials and government at all levels.

• A group of persons working on behalf of or strongly supporting a cause, such as an item of legislation.

Figure 18

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Communication

• Know the staff• Put a human face on the issue

• Provide expert testimony at congressional hearings

• Avoid jargon and acronyms

• Use action statements, pros and cons

Figure 19

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Partnerships

• Work collectively when possible

• Find common ground with unlikely bedfellows

• Never burn bridges – an enemy today is a friend tomorrow

• Know your opposition – never leave an ally unprepared or unprotected

Figure 20

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Conclusions

• Congress plays an integral role in the development, financing and oversight of public and private sector health policies

• Work with Congress members to identify issues and strategies

Figure 21

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Additional Resources

• U.S. Senate Committee Websites– Budget Committee (www.budget.senate.gov)– Finance Committee (www.finance.senate.gov) – Health, Education, Labor and Pensions Committee (www.help.senate.gov)– Appropriations Committee (www.appropriations.senate.gov)

• U.S. House of Representatives Committee Websites– Energy and Commerce Committee (www.energycommerce.house.gov)– Ways and Means Committee (www.waysandmeans.house.gov)– Budget Committee (www.budget.house.gov)– Appropriations Committee (www.appropriations.house.gov)

• KaiserEDU.org Tutorial: Health Policy and the Federal Budget• KaiserEDU.org Tutorial: The Process of Health Reform

• KaiserEDU.org Issue Module: The Role of States in Health Policy

Figure 22