Posted: April 24th, 2025

The Legislative Process #415

After studying

Module 3: Lecture Materials & Resources

, discuss the following:

**Describe the legislative process of a health policy you are familiar with. What were the major steps and challenges in its development?

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Policy Analysis and Design

CHAPTER 4

Stages of the Policy Process (1 of 4)

Federal Government’s Involvement in Social Issues
Rapid expansion in the 20th and 21st centuries
Creation of Medicare and Medicaid
Passage of the Patient Protection and Affordable Care Act (ACA) in 2010
Current considerations
Quadruple aim initiative
Availability of funding
How to incorporate policy design into all phases of the policy process

The Policy Process
Policies that address social problems are usually formulated by many groups.
The proliferation of participants in policy formation makes it difficult to achieve systemic program design.
Decision making is often conducted hastily.
Lack of information
Constituency impatience
Lack of expertise
Much policy that regulates nursing practice is determined at the state level.

Research Informing the Policy Process
Health services research
Examines a multitude of factors, systems, and processes in the delivery of health care
Informs policy in a number of ways

Public Opinion Informing the Policy Process
Four groups of society
Advantaged—politically influential; public views positively (scientists, veterans)
Dependent—politically weak but viewed positively (children, mothers, those with disabilities)
Contenders—politically strong but perceived negatively (the rich, big unions)
Deviants—politically weak and perceived negatively (criminals, drug addicts)
Effects of policies favoring the advantaged and punishing deviants

The Design Issue
Unclear mandates often result in a mismatch between legislative intent and bureaucratic behavior.
Unintended consequences
Policy failure
By shifting the focus of study to policy design, a more reliable answer regarding policy success can be found.
Requires understanding of policy tools or instruments chosen for policy design
Requires understanding underlying assumptions of policymakers during the design process

Policy Instruments (Government Tools)
Schneider and Ingram’s (1990) analysis uses government or instruments and underlying behavioral assumptions as variables that guide policy decisions and choices.
They argue that the tools approach moves policy beyond considering the standard analysis and improved frameworks.
To understand which tools are the most productive, emphasis should be on using them in conjunction with a particular policy design.

Authority Tools
Most frequently used by governments to guide agents and officials at lower levels
Are statements backed by legitimate power of government that grant permission and prohibit or require action under designated circumstances

Incentive Tools
Assume individuals will not be motivated to take action without encouragement or coercion
Rely on tangible payoffs as motivating factors
Positive or negative
Assume individuals have the “opportunity to make choices, recognize the opportunity, and have adequate information and decision-making skills” to choose the best option

Capacity-Building Tools
Provide information, training, education, and resources to enable individuals, groups, or agencies to make decisions or carry out activities
Assume populations will be motivated adequately without incentives
Require that populations be aware of the risk factors associated with the tools and how these tools can help

Symbolic or Hortatory Tools
Assume people are motivated from within and decide whether to take policy-related actions based on their beliefs and values
Examples of hortatory tools
Use of lower-number legislative bills reserved by congressional leadership
Federal request for proposals to research a particular topic
Examples of symbolic tools
Presidential executive orders

Learning Tools
Used when the basis upon which target populations might be moved to take problem-solving action is unknown or uncertain
Often used with policies that are open-ended in purpose and have broad goals and objectives
May require a needs assessment to be completed

Behavioral Dimensions
APRNs must understand behavioral assumptions and the political context in which tools exist.
The political climate in which social problems are addressed often prescribes the choice of tools to be implemented.

Case Study: COVID-19, Disparities, and the CARES Act
Race-related health disparities in both COVID-19 cases and deaths
Social contributors to health disparities
Income
Education
Structural racism
CARES Act beneficiaries
Authority tools at play during the pandemic

Conclusion
Active participation in the policy process is essential.
RNs and APRNs must understand:
How the process works
Points where the greatest impact can be made

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Policy Enactment: Legislation and Politics

CHAPTER 5

Introduction
Structure of governments
Engagement of nurses in politics at all levels
Expectations of the public

Structure of the Federal Government
Constitutional republic
Democratically elected leaders
Separation of powers between the federal and state governments
Three branches
Executive
Legislative
Judicial

The Executive Branch
Consists of:
President
Vice president
Executive Office of the President
Presidential cabinet members
Powers of the president
Oversees military
Signs legislation into law
Can create executive orders
Can veto bills from Congress
This branch has shared responsibility for federal agencies with legislative branch.

The Legislative Branch
Consists of Congress
House of Representatives
Senate
Congressional committees
Nurses can monitor committees for significant federal legislation and work with professional organizations to influence policymakers on the issues.

The Judicial Branch
Consists of:
Supreme Court
Courts of Appeals
District Courts
Bankruptcy Courts
Article I Courts
Resolves disputes about the U.S. Constitution and other federal laws

Structure of State and Local Governments
Three branches
Executive
Legislative
Judicial
Similar to federal branches but structures may not be identical

Legislation
Nurses can present issues or ideas to solve a problem to legislators.
Legislators then draft a bill and introduce it to Congress.
After the bill is introduced, the following take place:
Debate and review
Amendment
Vote by both chambers

Committees
Congress members are voted into leadership positions by their peers.
The majority party leadership selects committee chairs for the session.
The minority party selects leaders called ranking members.
Committees vote to accept or reject bills after reviewing them.
If accepted, the bill goes to the floor of the House or Senate and is voted on again.
If the bill passes both chambers of Congress, it is sent to the chief executive.
Federal: president
State: governor
The chief executive either signs or vetoes the bill.

Funding Legislation: Winning a Seat at the Table
Raising campaign funds
Individuals
Special interest groups: 527 organizations and Political Action Committees (PACs)
Campaign finance law
Citizens United v. Federal Election Commission

Influences That Affect Decisions in the Policy Arena

The People: Legislators and Legislative Staff
Legislators (lawmakers)
Chief of staff
Administrative assistants
Legislative directors—responsible for day-to-day legislative activities
Press secretary—responsible for press releases and public relations
Legislative assistants/aides (LAs)—multiple areas of responsibility
Committee staff—support work of congressional committees

The People: Constituents
Engaging constituents/voters to support an issue is an important way to gain momentum.
Nursing groups have succeeded in advancing legislation by creating coalitions that include stakeholders from various perspectives and voting blocks.

The People: Special Interest Groups
Lobbyists
Often hired by special interest groups
Must follow established guidelines if professional lobbyists
Special interest groups
Stakeholders attempting to gain influence on an issue
Types of special interest groups
Political action committees (PACs)
527 organizations
Registered nurses constitute a special interest group

Political Strategy
Success in influencing health policy requires knowledge of:
Political environment
Political players
Political climate
Strategy includes knowing:
When to strike
Which stakeholders will have the most impact
Who can and will work together
What the opposition’s strengths and weaknesses are
Funding of efforts to get legislation passed
Approaches for nurses
Communicating directly with legislators
Working with political advisers

Nurses Engaged in Legislative Policy Change
Federal level
Common areas of focus
Nursing Workforce Development programs of Title VIII of the Public Health Service Act and its amendments in the Nursing Reauthorization Act
State level
Common areas of focus
Scope of practice issues

Conclusion
Build relationships with legislators, legislative staff, policy experts, and key stakeholders.
Understand that change is often incremental and takes time.
Look for common ground and measures that will appeal to both sides of the aisle.
Think politically, use strategy to develop a plan, and play the political game.

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