Karrie Cummings Hendrickson, Christine Ceccarelli and Sally S. Cohen “What government is the best? That which teaches us to govern ourselves.” —Wolfgang von Goethe Nurses need to know how government works so that they can convince public officials to create policies that improve access to quality and affordable health care for all. This chapter provides an overview of the federal, state, and local levels of government, how each level works, and the relationships among them in a federalist system. Such information is essential to effect policy and bring nurses’ unique perspective to those who make the final decisions—legislators, regulators, and staff who support them. Because budget policies underlie all health policy issues, this chapter also reviews the federal budget process and related state and local processes. All health programs require funding, and the budget process is the means by which the executive and legislative branches reconcile competing priorities and make budgetary decisions. In this chapter, we identify key access points for influencing policy at different levels and branches of government and throughout the federal budget process. We have used the issue of long-term care to demonstrate why nurses need to know how government works. The United States government is a federalist system. Simply stated, this means that the government consists of multiple levels, including both a centralized, national tier and at least one decentralized, subnational tier, and that power is shared among them. In the case of the United States, tiers include the federal, state, and local levels of government. Unlike a unitary state, a federalist system constitutionally divides sovereignty among the different governmental levels so that the policymakers at each level have final authority in some areas and can act efficiently and independently of each other. The U.S. Constitution divides governmental authority by prescribing the duties and responsibilities of the federal government and withholding both specified and unspecified powers for the states. The Tenth Amendment to the Constitution (also known as the State’s Rights Amendment), ratified in 1791, helps to clarify how this authority is divided among the levels of government. It states, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” This means that states have jurisdiction over issues that the Constitution does not explicitly grant to the federal government. This is a fundamental aspect of the Constitution; state policymakers often interpret their constitutional states’ rights quite liberally. Because the U.S. government is one of divided powers, citizens are accountable to three levels of authority. In a federalist system, the allocation of authority among the levels may vary over time, and successful state initiatives may eventually become national policy as part of the “marble cake federalism” of the U.S. (Nathan, 2006). Alternately, the federal government may participate in and influence local policy through government grants, sanctions, and federal mandates (federal requirements for state, local, or tribal governments to expend their own resources to achieve certain goals) (Hanson, 2004). Finally, many powers, such as taxation and law formation and enforcement, are shared equally among the levels of government and may be exercised in conjunction or independently. For more information on federalism and associated court cases, see the Rockefeller Institute website provided with the Web Resources on this book’s Evolve website. Because governmental powers and responsibilities laid out in the Constitution are imprecise and subject to interpretation, some controversy and conflict has occurred among all the levels of government, most particularly between federal and state authorities (Hanson, 2004). The U.S. Supreme Court, however, works to interpret the Constitution and maintain the balance of power among the levels of government (Hanson, 2004). It is important to understand the court’s stand on federalism and states’ rights when designing a federally administered program and planning its implementation. Court decisions may affect when, how, and by whom your program is implemented (see Chapter 7). The U.S. federal government is centered in Washington, D.C., and has 10 regional offices. These regional offices are instrumental in policy implementation and enhance access to federal officials for issues concerning health and well-being. Like the three levels of government, the three branches of the federal government represent a separation of powers and work as a series of checks and balances on one another. These branches require policymakers to work together to formulate policy that is acceptable to as many people as possible, and they are designed to prevent any individual or small group from making sweeping changes. For more information on the roles and powers of the federal government, see the U.S. Government’s Official Web Portal website listed in Web Resources. The role of the executive branch of the federal government is to implement laws and oversee their enforcement. The executive branch is made up of the Executive Office of the President (EOP); the Executive Cabinet; and many independent agencies, boards, committees, and commissions, the staffs of which both advise the president and help to oversee the programs. Both the EOP and the Cabinet will be discussed here. The EOP consists of the president, the vice president, and related White House offices and agencies (Box 64-1) that develop and implement the policy and programs of the president. Of these offices, the Office of Management and Budget (OMB) is one of the most relevant to nursing. This office prepares the president’s budget for presentation to Congress on the first Monday of every February. The budget reflects the president’s national agenda and provides those seeking to influence policy a realistic picture of the likelihood of their project receiving funding. It also serves as a potential access point for policy change. The president is the highest ranking elected federal official and serves as the head of the executive branch. The president also serves as the commander in chief of all U.S. military forces, and with the approval of the Senate, grants pardons, makes treaties, and appoints high-ranking officials such as Supreme Court justices and cabinet secretaries. One of the president’s most notable domestic powers, however, is the veto, which effectively stops (or at least delays) a newly passed piece of legislation from becoming a law. This power is not to be taken lightly because, if the president invokes the veto, it can only be overridden by a two-thirds majority vote in both houses of Congress. Of key importance to those hoping to influence policy are the powers of the president not defined in the Constitution, including the power to set the national agenda. This is sometimes referred to as “the power of the pulpit.” Newly elected presidents bring their priority issues to the forefront of the American political agenda. Even though this may not result in policy change, it does open the door for discussion and debate of some issues and closes the door on others. For example, at the beginning of his presidency, President George W. Bush’s proposals regarding Social Security, Medicare prescription drug coverage, and homeland security were high on the public and policy agendas. But the election of President Barack Obama in 2008 shifted emphasis away from those issues and onto discussions of revitalizing the domestic and worldwide economies, ending the war in Iraq, and providing universal health care. A savvy activist must be aware of policymakers’ priorities and anticipate how changes in the political climate following an election may affect the politics of health policymaking. White House staff are influential in setting national agendas and disseminating the president’s priorities. These individuals are appointed by the president, but are not confirmed by Congress. Thus, they usually hold views similar to those of the president and are instrumental in White House decision-making. One can determine White House staff perspectives on health policy through newspaper and other media reports. For more information on the federal executive branch, see the U.S. Executive Branch websites listed in Web Resources. The Executive Cabinet is made up of the heads of 15 departments (see the President’s Cabinet websites listed in Web Resources). After confirmation by Congress, cabinet members work with the president and oversee the enforcement and administration of federal law through regulation and the appropriation of funds. Although all cabinet departments may have jurisdiction over areas of interest to nurses, the ones most relevant to nursing practice are discussed next. According to their website (www.hhs.gov), the HHS is “the United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.” To accomplish this mission, HHS incorporates the Office of the Secretary as well as 11 agencies (Box 64-2) that oversee more than 300 programs such as Head Start, Vaccines for Children, Medicare, and Medicaid. HHS is responsible for the distribution of the second largest portion of federal budget. New programs or changes to existing programs advocated by health professionals will likely be overseen by HHS. Therefore, it is vital to understand its structure and functions. For more information on HHS, see the websites listed in Web Resources. Economic security for most retired workers age 65 or older in the U.S. is guaranteed through Social Security, funded through payroll contributions. The SSA also provides monthly benefits to permanently disabled workers who have contributed to the program, as well as Supplemental Security Income (SSI) payments to needy elderly, blind, and disabled individuals. Participation in the program also enables elderly and disabled individuals to qualify for Medicare health coverage, currently administered by CMS (see Chapter 37). For more information about the SSA and its benefits, see the website listed in Web Resources. U.S. military spending makes up the largest portion of the federal budget, and a large part of that money goes to health care. The DOD provides care to all active duty military personnel, retirees, National Guard and Reserve members, and their families, approximately 9.4 million people stationed throughout the world (DOD, 2009). The military employs over 35,000 nurses, runs 63 military hospitals, oversees 413 medical and dental clinics, and provides funding for nursing research. For more information on the DOD and TRICARE, its health maintenance organization, see the DOD website in Web Resources. (See also Chapter 19.) Through the Veterans Health Administration, the Department of Veterans Affairs oversees programs to provide health care and other services to U.S. military veterans and their families. In 2008, approximately 5.5 million people received care at a VA facility (U.S. Department of Veterans Affairs, 2008). The Veteran’s Administration also manages the largest medical, nursing, and health professions training program in the U.S. Over 90,000 health professionals receive training in VA medical centers annually (U.S. Department of Veterans Affairs, 2009). (See also Chapter 20.) The Department of Education, along with the Health Resources and Services Administration of the Department of Health and Human Services, provides billions of dollars in grants and loans for students to attend college and professional schools, including schools of nursing. This is highly relevant to nurses, particularly in times of nursing shortage, because the department works with hospitals and other government agencies to provide incentives such as loan repayment programs, which attract nurses to the most underserved areas (U.S. Health Resources and Services Administration [HRSA], 2009). In February 2009, President Barack Obama signed the American Recovery and Reinvestment Act, part of which expanded federal funds available for the loan repayment for nurses (HRSA, 2009). The executive branch of the federal government is responsible for implementing laws enacted by Congress. This task falls to staff of the relevant departments and agencies, often with input from the agencies under the EOP. Once a law is enacted, the federal agency staff develops regulations for implementation of the relevant program, which specify definitions, authority, eligibility, benefits, and standards. This step is necessary because while the laws passed by Congress express the legislators’ intentions, they do not spell out the details of the new program (Smith, Greenblatt, Buntin, & Clark, 2005). The regulations (or rules) are published in the Federal Register, giving interested individuals and organizations a limited opportunity to review and comment. This is an important access point for nurses interested in shaping health policy. Agency staff reviews all of the comments and then issues final regulations in the Federal Register. These regulations govern how agencies and individuals in states and localities are to implement the law. For more information on regulatory functions of the federal government and the Federal Register, see the Federal Register website in Web Resources. The legislative branch of the federal government consists of the Congress, which is divided into two chambers—the Senate and the House of Representatives. Members of Congress are elected by their constituents. The Senate, with two members from each state, has 100 seats. The House of Representatives has 435 voting seats and 6 non-voting seats, with each state’s number of representatives based on its population size. The number of members in each state’s delegation may change every 10 years based on the results of the national decennial census. Members of the Senate and House are elected for 6-year terms and 2-year terms, respectively. The primary role of the legislative branch is the formulation of laws for recommendation to the president. The process of creating such laws can be long and arduous, and is thoroughly discussed in Chapter 65. It is key to note, however, that once a new topic or bill is introduced into a congressional chamber, it is often assigned to one of the committees or subcommittees for further discussion and hearings. In 2009, the Senate had 16 standing committees and 4 select committees, while the House of Representatives had 20 standing committees and 2 select committees. Select committees do not have the legislative jurisdiction of standing committees, but facilitate agenda setting by focusing on specific issue areas. Between them, the House and Senate share four joint committees. The committee stage is a critical step for the nurse activist to recognize because it provides one of the primary points of entry into the policy arena. The assignment of a bill to a committee signals to those who care about the issue that it is time to act. Although this point of entry is not without roadblocks, measures can be taken to help keep the issue salient. Successful entry requires that the policy advocate be knowledgeable about the committee with jurisdiction, its members, and their priorities. It also requires that they be prepared with both a primary and backup policy plan, be willing and able to educate committee members and their staff, and be capable of providing persuasive testimony before committee members. For a complete list of committees and their health-related jurisdictions, see Tables 64-1 and 64-2. A complete listing and other information is also available on the department websites listed in Web Resources. By following the link to each committee, one can obtain information about committee and subcommittee membership, complete jurisdiction, hearings, recent bills, and other timely health policy information. The status of all federal bills can be obtained at one of the most important websites for congressional information: http://thomas.loc.gov/. Finally, it is also important to recognize that the members of congressional staffs are accessible via phone and the Internet. Nurses should be familiar with not only representatives from their home state but also other legislators who either support their issue or sit on a committee with jurisdiction over it. TABLE 64-1 Standing Committees of the U.S. Senate with Jurisdiction over Health Policy Issues
How Government Works
What You Need to Know to Influence the Process
Federalism: Multiple Levels of Responsibility
The Federal Government
The Executive Branch
Executive Office of the President (EOP).
The Cabinet.
The Department of Health and Human Services (HHS).
The Social Security Administration (SSA).
The Department of Defense (DOD).
The Department of Veterans Affairs.
The U.S. Department of Education.
Regulatory Functions of the Executive Branch of Government.
The Legislative Branch
Committee
Jurisdiction
Agriculture, Nutrition, and Forestry
http://agriculture.senate.gov
Agricultural economics and research
Food Stamp programs
Human nutrition
School nutrition programs
Appropriations
http://appropriations.senate.gov
Appropriation of revenue
Armed Services
http://armed-services.senate.gov
Issues relating to national (common) defense
Banking, Housing, and Urban Development
http://banking.senate.gov/public
Construction of Nursing Homes
Public and Private Housing
Budget
http://budget.senate.gov
Congress’s annual budget plan
Commerce, Science, and Transportation
http://commerce.senate.gov/public
Science, engineering, and technology research and development and policy
Energy and Natural Resources
http://energy.senate.gov/public
Emergency preparedness
Nuclear waste policy
Environment and Public Works
http://epw.senate.gov/public
Air pollution and environmental policy
Solid waste disposal and recycling
Finance
http://finance.senate.gov
Public moneys and customs
Health programs under Social Security Act
Health programs financed by a specific tax or trust fund
Government Affairs
www.whitehouse.gov/omb/mgmt-gpra_gprptm
Census and collection of statistics
Studying the efficiency of government departments
Evaluating the effects of enacted laws
National security
Health, Education, Labor, and Pensions
http://help.senate.gov
Aging
Biomedical research and development
Domestic activities of the Red Cross
Individuals with disabilities
Public health
Student loans
Wages and hours of labor
Indian Affairs
http://indian.senate.gov/public
Indian Health Service
Veteran’s Affairs
http://veterans.senate.gov
Life insurance for members of the armed forces
Veteran’s hospitals and medical care
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