Health Policy to Legislation
Robert G. Frank
Lecture 2
Health Services, Research,
Management and Policy
6152
Who is this man?
Who is this lady?
Who is this man?
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 longestserving 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 fourthranking 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.
Congress and Health Reform
We’ve 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
1964 Landslide Brought 42 New
Northern Democrats to the House

Ways and Means Committee transformed
allowing development of payroll tax to
finance Medicare
1981 Presidential Landslide



Republican Senate
Party leaders now controlled powerful
chairman
Post Watergate reforms enacted
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
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
Constitutional Convention



Popularly elected House
Elitist Senate elected by State legislatures
Strong executive with veto power
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
U.S. Senate



6 year terms
Statewide elections
2 from each state
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.
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.)

Standing Rules Standing Rules of The Senate
RULE XXIII
PRIVILEGE 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
U.S. House




2 year terms
District elections
435 members
Reallocated every 10 years
Composition U.S. House of
Representatives
110th Congress









Membership
435 Members
4 Delegates
1 Resident
Commissioner
Party Divisions
233 Democrats
202 Republicans
0 Independent
0 Vacancies
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
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
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.
Legislative Calendar


“Day certain” or “a day not yet
determined” (as in a unanimous consent
request)
Refers to calendar date
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
Legislative Calendar

Senators refer to bill or nominations “on
the calendar”…these are on the legislative
calendar
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
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

Filibuster

Encourages consensus in Senate

Unanimous consent agreements limit time
available for debate
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.
Senate Majority Leader

Proposes proposes bills or resolutions for
the Senate to consider.
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
Standing Committees




35 standing committees
19 in House, 16 in Senate
8,000 bills introduced in a 2-year
session@80 Pass
Committee that drafts legislation also
handles on floor

every health bill moved by the Senate Labor
Committee passed in 99th Congress
Committees

Extends beyond Congress


affects bureaucracy, agencies and
commissions
Cabinet offices spend 1/3 of their time on
Capitol Hill
Appropriating vs. Authorizing
Committees

Appropriating




House Ways and Means
Senate Finance
Appropriations
Budget
Forms of Legislative Business

Bill


Public --- most common
Private – designed to affect or benefit specific
individuals or group
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.
House Bills



H.R. ___
H.R. Res.____ for House joint resolutions
H.R. Con. Res. ___ for House Concurrent
resolutions
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
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
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
House vs. Senate



Senate order of business simpler than
House
Procedure for both bodies founded on
Jefferson’s Manual of Parliamentary
Practice
Primary differences in method of calling
up business
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
Bill Introduction




Any member may introduce a bill
Blank forms are kept at Clerk (House)
Introducing member is the sponsor
Must sign the bill
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”
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”
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”
Senate


Maintain decorum
No senator may refer “offensively to any
State of the Union”
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

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
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
Key Health Committees in the
House

House Ways and Means


House Appropriations Committee


Subcommittee on Labor, HHS, and Education
House Commerce Committee


Subcommittee on Health
Subcommittee on Health and Environment
House Budget Committee
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
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, markups
Still variability between committees on
importance

House full committees mark-ups - hearings
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
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

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

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
Subcommittee Jurisdiction
Changed with Times


1970s - energy committees increased
1993 - 15 committees claimed health
jurisdiction

previously only 8 subcommittees claimed
jurisdiction
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

Conference Committees




Penultimate power
Decisions final
Voted up or down
May differ on representation


1989 conference savings and loan
8 Senate, 94 House
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

Entitlements



Combination of authorization and
appropriation
Funded automatically - do not require
appropriations
Spending for entitlements difficult to
control
Entitlements



Social Security, Medicare, Medicaid, Food
Stamps, AFDC
Avoids routine Congressional scrutiny
Often indexed for COLA
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%
Entitlements

Social Security grows slower than health
entitlements - Medicare, Medicaid


popular programs - difficult to cut
the political third rail
Budgeting

Authorizations


Appropriations



establish or continue a program or agency
provides funding
Process designed to separate policy from
fiscal decisions
Process typically sequential
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)
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
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
Administrative Budgeting



CBO Produces Annual Report to House
and Senate Committees on budget
Provides a broad range of options
Released in February
The Congressional Budget Calendar
Date
Action
Between first Monday in January
and first Monday in February
President transmits the budget, including a sequester preview report
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
15 days after the end of a session
OMB issues final sequester report, and the president issues a sequester of Congress
order, if necessary
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
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
Budget Process


Budget Resolution is not law
Concurrent resolution of both Houses
Budget Process

Levels established in the budget resolution
are supported by procedural mechanisms
followed in both Houses
Budget Process

Budget resolution is an outline for the
budget

Legislation must be passed to implement
Appropriation Act
 Changes in tax law
 Entitlement programs

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
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
Reconciliation



Budget process has weakened the
authorizing committees
Increase leadership rule
Authorizing Committees rarely launch new
programs - protect older programs from
cuts
Appropriation Committees



Increased power
Spending caps require tough decisions
Important to special interests
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

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