It is essential that surgeons be politically active and serve as advocates for their patients and their profession. This article provides an overview of the legislative and political process and describes the role of the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) and the actions it takes to represent surgeons and surgical patients in Washington, DC.
How a bill becomes a law
Any senator or representative may introduce a bill by filing it with the Clerk of the Senate or the House of Representatives. Once a bill is submitted, the Clerk assigns it a bill number and sends it to the committee(s) of jurisdiction. Most health care authorization legislation falls within the purview of four committees: House Energy and Commerce; House Ways and Means; Senate Finance; and Senate Health, Education, Labor, and Pensions (HELP). After a bill is referred to a committee, it is subject to hearings and markups. A hearing involves invited guests and industry experts who testify on the potential effects of the legislation. The markup process allows for legislators to amend the legislation before voting on it. The vote after markup will determine whether a bill is voted out of committee, fails, or is returned to the committee for further development.
If a bill is successfully voted out of committee, it will either be referred to another committee of jurisdiction or advance to the full chamber for a vote if the House or Senate leadership decides to move the bill forward. Once a bill passes in the full chamber, it will advance to the other chamber, where the entire process is repeated. Assuming the same version passes the second chamber (versions can vary due to markups and amendments), the bill will continue to the president, who may either sign or veto the legislation. If the president vetoes the bill, Congress can override the veto with a two-thirds majority in both chambers.
If the House and Senate pass different versions of a bill, a conference committee is formed with members of the House and Senate to iron out the differences and create compromise language. This compromise language will then be subject to a vote by the full House and Senate.
Branches of government
The three branches of government are the executive branch (the president and his or her administration), the judicial branch (the U.S. Supreme Court and lower-level federal district courts), and the legislative branch (Congress). The responsibilities and authority of each are described as follows.
The president plays a significant role in setting the tone for a national legislative agenda but is limited as to what he or she can do without congressional approval. The president may issue executive orders, which are policy directives deemed to carry the full force of the law, and may sign or veto legislation.
The president also appoints individuals to key federal agencies, which are part of the U.S. Department of Health and Human Services (HHS). These agencies include the following:
- Centers for Medicare & Medicaid Services (CMS)
- U.S. Food and Drug Administration (FDA)
- Health Resources and Services Administration (HRSA)
- National Institutes of Health (NIH)
- Centers for Disease Control and Prevention (CDC)
The judicial branch plays a critical role in sustaining or overturning legislation that can significantly affect day-to-day clinical practice. For example, the judiciary has ruled against physician data protections pertaining to Medicare claims data, and in February struck down a Florida law that restricted what physicians can say to patients regarding firearm ownership. In addition, the Supreme Court played a role in shaping and reaffirming the legality of parts of the Affordable Care Act.
As the nation’s legislative body, Congress has the most direct effect on health policy. As mentioned earlier, several congressional committees have jurisdiction over health policy. These committees and their purview are as follows:
- House Energy and Commerce: The Energy and Commerce Health Subcommittee considers bills and resolutions pertaining to public health and quarantine; hospital construction; mental health; biomedical research and development; health information technology, privacy, and cybersecurity; public (Medicare, Medicaid) and private health insurance; medical professional liability; the regulation of food, drugs, and cosmetics; and drug abuse.1
- House Ways and Means: The jurisdiction of the Ways and Means Committee includes bills and matters related to payment (from any source) for health care, health delivery systems, or health research; health care programs of the Social Security Act; and, concurrent with the full committee, tax credit and deduction provisions of the Internal Revenue Code dealing with health insurance premiums and health care costs.2
- Senate Finance: The Senate Finance Committee reviews bills and resolutions pertaining to health care programs under the Social Security Act, including Medicare, Medicaid, the Children’s Health Insurance Program, and Temporary Assistance to Needy Families, as well as other health and human services programs financed by a specific tax or trust fund.3
- Senate HELP: The HELP Committee has jurisdiction over bills and matters related to health care, education, and employment and retirement policies, including measures relating to education and training, labor, health, and public welfare.4
- House and Senate Appropriations Committees: The House and Senate Appropriations Committees hold considerable sway over health policy in that they set the expenditures of the U.S. budget. Both have Labor and Health and Human Services subcommittees that focus more directly on health care appropriations, choosing the funding amounts for programs authorized by the aforementioned health authorization committees.
The role of congressional staff
Capitol Hill staff also play a crucial role in the legislative process. These legislative aides and advisors keep the congressional offices and committees running. Because members of Congress and congressional committee leaders cannot be subject matter experts in all areas, they rely on staff to keep track of the details about individual topics. As a result, the congressional staffer frequently makes policy decisions for the office. As the gatekeepers to the members, who often have less time for meetings, it is common to find a meeting with staff to be more productive and substantive.
ACS government relations
The ACS DAHP is dedicated to ensuring surgeons’ voices are heard in Washington, DC, and throughout federal agencies, as well as statehouses. To this end, the DAHP comprises a pool of federal lobbyists, each responsible for tracking activity in a key legislative committee, building relationships with congressional offices, and serving as a trusted resource on surgeon-specific health care topics.
To enhance the College’s presence on Capitol Hill, the ACS also participates in several coalitions that bring together similar-minded health care organizations to pool their resources and to speak with a unified voice. For example, the Health Coalition on Liability and Access is a national advocacy coalition working to enact medical liability reform at the federal level.5 In addition, the Surgical Coalition comprises 30 surgical organizations that meet several times a year to map out a pro-surgery strategy and legislative action plan. This Surgical Coalition has successfully sought repeal of the sustainable growth rate (SGR) formerly used to calculate Medicare physician payments and to limit the impact of a flawed CMS policy on global surgery codes.
The ACS works with specialty coalitions to advocate on issues related to cancer, trauma, pediatrics, and rural surgery.
Participation in coalitions has many benefits inside the beltway, but it’s the College’s grassroots action from surgeon-advocates that makes the biggest difference. When the ACS advocacy team can point to the number of surgeons in a legislator’s district who have taken action on an issue, it can be a legislative game changer.
SurgeonsVoice is the nationwide, interactive advocacy program of the American College of Surgeons Professional Association (ACSPA). This program provides surgeons with tools to become effective advocates in every U.S. congressional district and to establish professional and personal relationships with decision makers, both on and off Capitol Hill, as well as at the state and regional level. Fellows may seek assistance and coordinate advocacy efforts through the DAHP, but SurgeonsVoice is a self-service tool kit that allows ACS members to carry out advocacy activities anytime, anywhere in the nation without having to set foot in Washington, DC.
The ACSPA’s political action committee, ACSPA-SurgeonsPAC, was established in 2002 to enable members of the ACS to help elect, and reelect, U.S. House and Senate candidates for Congress who are willing to promote issues of importance to surgery and the surgical patient at the federal level. SurgeonsPAC plays a critical role in ensuring that the College, particularly surgeon-advocates and the federal legislative team, are able to establish and maintain relationships with legislators and advance the College’s health policy priorities.
When the SurgeonsPAC Board and staff make the determination to support a candidate, surgeon-advocates have the opportunity to participate in an in-district check delivery or attend a local event in Washington, DC. To learn more about delivering a SurgeonsPAC check at home or in Washington, DC, contact ACSPA-SurgeonsPAC and Grassroots Manager, Katie Oehmen, at firstname.lastname@example.org.
Get involved and stay involved
The involvement of surgeon-advocates is paramount to establishing an active relationship with federal and state legislators. The key to successful advocacy is an engaged membership, and you can help support this work by engaging in the following activities:
- Attend the Leadership & Advocacy Summit 2018, May 19–22 in Washington, DC
- Host a tour of your institution or practice for your federal/state legislators
- Meet with your member of Congress in your home district or in Washington, DC
With respect to meeting with your legislators, it is important to bear in mind that Congress follows a set calendar of legislative days in Washington, DC, interspersed with in-district work periods (recess). A common misconception about a congressional recess is that it is a vacation for the members of Congress. Lawmakers typically will have numerous in-district events and meetings to make the most of their limited time at home. These periods away from Capitol Hill present a great opportunity for surgeon-advocates to meet in-district with their legislators and engage them on health care issues. Two ways to conduct these meetings are to schedule a meeting in the district office or to invite them to join you on a tour of your institution or practice.
The ACS DAHP staff is available to help with these efforts and can assist with preparations for a congressional meeting or facility tour. For more information on advocacy or ACS policy priorities, contact DAHP staff at email@example.com or 202-337-2701.
Glossary of legislative terms
At times, it may seem as though the political sector uses a language all its own. Following are a few key terms that surgeon-advocates are likely to encounter:
*American College of Surgeons. Surgeons As Advocates: A SurgeonsVoice Handbook for Advocacy. February 20, 2017. Available at: facs.org/~/media/files/advocacy/state/surgeons%20as%20advocates%20handbook.ashx. Accessed on February 20, 2017.
- U.S. House of Representatives. The Energy and Commerce Committee. Health. Available at: https://archives-energycommerce.house.gov/subcommittees/health-115th-congress. Accessed February 20, 2017.
- U.S. House of Representatives. Committee on Ways and Means. Health Subcommittee. Available at: https://waysandmeans.house.gov/subcommittee/health/. Accessed February 20, 2017.
- U.S. Senate. Committee on Finance. Jurisdiction. Available at: www.finance.senate.gov/about/jurisdiction. Accessed February 20, 2017.
- U.S. Senate. Committee on Health Education Labor and Pensions. About. Available at: www.help.senate.gov/about. Accessed February 20, 2017.
- Health Coalition on Liability and Access. About the HCLA. Available at: https://protectpatientsnow.org/about-hcla/. Accessed July 20, 2017.