This chapter begins with an overview of the structure and function of the three branches of the U.S. government as created by the constitution. In the legislative branch, elected officials create and enact laws, rules, and regulations. The chapter continues with definitions of legislative politics, policy, political action, and lobbying; examinations of the intersection of policy, political action, lobbying, and the provision and quality of mental health services; and a discussion of the impact of nurses’ roles in the political arena. The active involvement of psychiatric nurses in protecting the rights of those facing mental illness and homelessness, with or without additional substance abuse challenges, is encouraged; furthermore, the chapter highlights the importance of political activism to promote uniform advanced practice across the country. The chapter considers means of achieving policy changes through grassroots, community-based initiatives, as well as through the support of or direct involvement in the legislative process. Interdisciplinary collaboration is encouraged, given the increased role and power of psychiatric nurses, advanced practice registered nurses (APRNs), patients, and families involved in psychiatric care and treatment. The chapter concludes with a review of the “call to action” by the Institute of Medicine (IOM) and an educational and professional roadmap for baccalaureate-prepared psychiatric nurses, including entry to practice and advanced practice educational issues.

AN OVERVIEW OF THE STRUCTURE OF THE U.S. GOVERNMENT

The Constitution

The Constitution of the United States of America is the “law of the land.” There is no higher law in the country. All federal and state laws, rules, and regulations must be in compliance with Constitutional rights and responsibilities. Based on the structure of checks and balances set forth in the Constitution, the U.S. government is divided into three branches: the executive branch (the Office of the President), the judicial branch (the Supreme Court), and the legislative branch (Congress, composed of the Senate and House of Representatives). Each branch has been granted powers to ensure that no one branch takes action without the cooperation and agreement of the other branches. For example, if Congress passes a bill that the president does not want to support, the president has the right to veto that bill. Furthermore, if Congress delays action on a bill proposed by the president, the president may issue an executive action on the matter. For example, President Barack Obama issued an executive order implementing the national HIV/AIDS strategy for the United States for 2015 to 2020 (HIV/AIDS, 2015, July 30, retrieved January 27, 2015, https://www.whitehouse.gov/the-press-office/2015/07/30/executive-order-implementing-national-hivaids-strategy-united-states. If there is opposition to an executive order that provides rights to a particular group, the Supreme Court may be asked to review the executive order and can nullify it, if the court determines it to be in violation of the U.S. Constitution.

Congress (The Legislative Branch)

Congress is composed of the 100-member Senate and the 435-member House of Representatives. Senators serve 6-year terms; Representatives serve 2-year terms. Congress appropriates funds, approves the federal budget, and authorizes military action, among other powers. For the purposes of this chapter, the most important power of Congress is to “make all laws which shall be necessary and proper for the carrying into execution the foregoing powers, and all other powers vested by this Constitution in the government of the United States” (Article I, Section 8, Clause 18). The legislative process also provides for a variety of checks and balances.

The Office of the President of the United States (The Executive Branch)

The president is the commander-in-chief of the armed forces and chief executive of the United States. The president may exercise his legislative power in conjunction with Congress. The president has the power to veto legislation passed by Congress, first by the House of Representatives and then by the Senate.

The Supreme Court (The Judiciary)

The Supreme Court provides oversight of Congress and the president through review of laws, determining whether or not statutes, laws, rules, and regulations are consistent with the requirements of the Constitution. The president nominates candidates when any one of the nine seats on the Supreme Court fall vacant; however, Congress must approve nominations to the Court. As the nine justices determine the constitutionality of laws that have an impact on the rights and privileges of those involved in the mental health system, the appointment and confirmation of judges knowledgeable in the area of health, and mental health in particular, is an important issue.

THE LEGISLATIVE PROCESS: HOW A BILL BECOMES A LAW

The legislative process (see Figure 29-1, https://www.congress.gov/content/legprocess/legislative-process-poster.pdf) on federal and state levels is a multistep process in which interested parties are provided with opportunities to influence the passage of legislation. Both the House of Representatives and the Senate (the chambers of Congress) must agree on the terms of a bill before it is sent to the president for signing into law. Bills or joint resolutions can become laws. There is little difference between a bill and a joint resolution, however, the Constitution may only be amended through use of a joint resolution. “A joint resolution is a legislative proposal that requires the approval of both the House and Senate and the signature of the President … to have the force of law” (About Joint Resolutions, retrieved from http://www.lexisnexis.com/help/CU/Serial_Set/About_Bills.htm#joi).

Figure 29-1 Legislative process.

Assisted by staff, Representatives and Senators draft bills; attorneys in each chamber’s Legislative Council advise staff on the correct language for policy proposals. However, as we discuss later in this chapter, lobbyists may also influence the wording of a bill. A sponsor of a bill may circulate the proposed bill to obtain cosponsors, thereby demonstrating support for the bill during the legislative process.

Bills are given a designated number and letters that indicate where they were submitted for consideration. Those beginning in the House are given the letters H.R. or H.J. Res. (bills or Joint Resolutions); those in the Senate are given the letters S. or S.J. Res.

The Speaker of the House refers bills to committees that may have jurisdiction on sections of the bill. However, in the Senate, it is usual to refer a bill to the committee that has jurisdiction over the largest number of issues in a bill. Some bills might be placed directly on the Senate’s Calendar of Business, instead of going through a committee. The Senate Majority leader exercises this fast-tracking option.

Committee Actions

The committee chair identifies any issues in a bill that require further attention. A committee may hold a hearing about a bill so that members and the public can hear about the bill’s strengths and weaknesses; such hearings put the issues under a spotlight. Witnesses called to the hearings will testify about a bill’s pros and cons, and may submit their own versions to the committee.

Mark-Up

After the hearings, the committee will mark-up a bill with suggestions for changes to the language, if needed. The committee “mark-up” is finished when the committee reports the bill to the House or Senate; alternately, a bill may be sent to a subcommittee for further discussion about policy, if necessary.

Calendar

A bill that has been reported is placed on one of the individual chamber’s calendars. Some bills will never proceed to the floor of the chamber because it did not survive referral to committee.

Consideration of a Bill

The majority party leadership decides which bills the House will consider and in what order. In the Senate, after a motion to proceed with respect to a bill is made by a Senator (normally the majority leader), there is a debate on whether to proceed with the bill. If the motion passes by a majority, the Senate can consider the bill.

When members of the House of Representatives are considering a bill, they first decide on the rules for consideration of each bill, after which the bill itself is considered. After any amendments to a bill are considered and passed, the “Committee of the Whole” will report to the full House any recommended amendments for approval. There will be a brief debate and vote on a motion to recommit. In the House of Representatives, most votes are recorded electronically.

During the full Senate debate on the bill, amendments may be offered for consideration. As Senate rules do not impose a time limit on debates, moving to a final vote can be very difficult. Through an extended debate or filibuster, Senators may thwart holding a vote. The CLOTURE rule permits a supermajority of the Senate (three fifths of the Senate or 60 Senators) to limit debate on bills, amendments, or motions. Although a simple majority can pass a bill in the Senate, a supermajority is required to first end debate; thus, in actuality, three fifths of the Senate must favor a bill before it can be passed. Reaching a final vote on a bill can take a week of Senate floor time. The Senate votes by roll call, as it does not have an electronic voting system. The voting records of members of Congress can be found at the Senate’s home website at the U.S. Senate, retrieved from www.senate.gov/index.htm.

Both chambers must agree on a bill in the same form before it is sent to the president. Once passed in a chamber, a bill is engrossed (prepared in official form) and sent to the other chamber. If the second chamber agrees to the exact text as passed by the first, Congress has completed its job with respect to the bill. If, however, amendments have been proposed, the bill may be sent back and forth between chambers for discussion until there is an agreement. A conference committee can be formed to negotiate a proposal to which both chambers can agree.

Presentation of a Bill to the President of the United States

After the bill passes in both chambers of Congress, it is enrolled (prepared in its final official form) and presented to the president. The president has 10 days, excluding Sundays, to sign or veto a bill. Bills that are signed within those 10 days become law. If the president neither signs nor vetoes the bill, then it becomes law without his signature. If the president vetoes the bill, it is returned to its original chamber where the veto could be overridden by a two thirds majority vote. If the vote is successful, the other chamber can consider an override vote as well.

Publication of a Law

Bills that are enacted into law are delivered to the Office of the Federal Register at the National Archives. After the public law number has been assigned, the law is included in the next edition of the “United States Statutes at Large” with all other laws enacted during that session of Congress.

THE DIFFERENCES BETWEEN A LAW, A RULE, AND A REGULATION

Bills become laws after they are agreed on by Congress and signed into law by the president of the United States. Laws provide guidance to regulatory agencies; regulations are made by federal agencies to apply the laws. The agencies have subdivisions (such as offices) to handle the actions necessary to enforce the regulations that have been developed to implement the laws. These offices have rules that establish procedures to which individuals and business entities must adhere. All federal agency regulations are contained in the paper Code of Federal Regulations (CFR). An unofficial version of the CFR as an e-version is also available (Electronic CFR, 2016, January 26, retrieved January 27, 2015, http://www.ecfr.gov/cgi-bin/ECFR?page=browse).

An example of a state law that addresses the requirements to become a nurse may be found in the New York State Education Law, Title VIII, Article 139, Section 6900–6910 (2010, June 18, http://www.op.nysed.gov/prof/nurse/article139.htm.). These sections define diagnosing, treating, and human responses, as well as a definition of the practice of nursing, a description of the composition of the State Board for Nursing, requirements for licensure as a registered professional nurse, and definitions of who may be considered a registered nurse, a licensed practical nurse, a nurse practitioner, and a clinical nurse specialist, among other consideration. The Regulations of the Commissioner of Health apply the laws passed by the New York State Legislature; they are contained in Sections 6900–6910 and can be found in Part 64 of the Commissioner’s Regulations (2006, August 17, www.op.nysed.gov/prof/nurse/part64.htm). Part 64 provides minute, detailed requirements concerning the actual detailed practice of nursing, scope of practice for nurse practitioners, and a review of the duties of clinical nurse specialists. The rules of the Office of Professional Discipline, which manage misconduct hearings for nurses whose conduct fails to meet the regulations, are in Sections 6900–6910 and can be found in Part 29 of the Rules of the Board of Regents, the body that hears and rules on professional misconduct matters (2011, October 5, http://www.op.nysed.gov/title8/part29.htm). Part 29 describes in detail individual instances of professional misconduct. In sum, laws provide the overall substance that must be obeyed. The regulations are provisions by which the law is enforced. The rules are established to assist in the implementation of the regulations.

OTHER SENATE EXECUTIVE BUSINESS

The Senate conducts such other executive business as confirmations of presidential nominees to the federal judiciary and certain executive branches, as well as approving treaties. Confirmation of presidential nominees is a critical function, as the judiciary ultimately decides on the constitutionality of bills passed by Congress and signed into law by the president. Decisions of the Supreme Court can be influenced by the judges’ conservative or liberal viewpoints with regard to the application of Constitutional law.

The proposal of and contents of bills, and the timing of their submission to Congress or to the legislatures of individual states, can be influenced by political action and lobbying with regard to numerous issues.

POLICY, POLITICS, POLITICAL ACTION, AND LOBBYING SHAPE THE PROVISION OF MENTAL HEALTH SERVICES

Birkland (2014) defines policy as “a statement by government—at whatever level-of what it intends to do about a public problem. Such statements can be found in the Constitution, statutes, regulation, case law (that is, court decisions), agency or leadership decisions, or even in changes in the behavior of government officials at all levels.” Examples of policies shaped by government are those regulations that provide for consumer safety, that provide consequences for driving while intoxicated, or that provide subsidies for use of electronic health records. “Social policy, in particular, provides the means to ensure the provision of basic necessities such as food, shelter, healthcare, and education” (Nickitas, Middaugh, & Aries, 2011, p. 7). Health policy is found within the realm of social policy. Health policy provides guidelines as to how access to health care is to be distributed. Health policy details the quality of health care to be provided to a population and can define quality and access by the haves and have-nots based on economic success of a particular group of people.

POLITICS has been defined as “activities that relate to influencing the actions and policies of a government or getting and keeping power in a government.” The term politics has also been described as “the art or science of government” (Merriam Webster, 2015). We are familiar with politics insofar as we participate as citizens in the electoral process, or in voting for various referendums concerning budget or other items.

Political Action

Political action has been defined as an “action designed to attain a purpose by the use of political power or by activity in political channels” (Merriam Webster, online dictionary, n.d.).

POLITICAL ACTION COMMITTEES or PACs provide a mechanism for the collection of funds that may be necessary to push and publicize the need for political change. The Federal Election Committee defines two types of PACs: “SEPARATE SEGREGATED FUNDS (SSFs) and nonconnected committees.” SSFs are political committees established and administered by corporations, labor unions, membership organizations, or trade associations. An SSF “can only solicit contributions from individuals associated with, connected or sponsoring organizations.” NONCONNECTED COMMITTEES are not sponsored or connected to any of the previously mentioned entities. These committees are free to solicit contributions from the general public (SSFs and Nonconnected PACS, May 2008, www.fec.gov/pages/brochures/ssfvnonconnected.shtml).

For example the American Nurses Association (ANA) PAC was established to “promote the improvement of the health care system in the United States by raising funds from C/SNAs (Constituent/State Nursing Associations) members and contributing to support worthy candidates for federal office who have demonstrated their belief in the legislative and regulatory agenda of the American Nurses Association” (ANA, 2015). A recent call to change nursing education policy was issued to New York Nurses by Karen Ballard, president of ANA-NY, urging nurses to contact Senators on the committee considering the BS in Ten bill to vote for the bill, thus supporting the BSN as the entry to practice for nurses and requiring nurses without a BSN to obtain the same within 10 years of the passage of the legislation: An act to amend the education law, in relation to the educational preparation for practice of professional nursing Senate Bill 02145 (2011). The bill did not make it out of the Senate education committee in the 2015 session.

Lobbying

The National Conference of State Legislatures provides information as to how each state defines lobbying; there are more than 50 versions of lobbying laws. The basic definition throughout each is that LOBBYING is an attempt to influence government action and it includes written and oral communications. States have defined a lobbyist as someone who receives any amount of compensation or reimbursement to lobby (How states define lobbying and lobbyist, March 4, 2015, http://www.ncsl.org/research/ethics/50-state-chart-lobby-definitions.aspx). In their definition of lobbying, Delaware, Kansas, and Texas include providing entertainment, recreational events, and/or food and beverages to legislators. Not generally included in the definition of lobbying are such actions as testifying at committee hearings, meetings, writing letters, and having casual conversations with lawmakers (National Conference of State Legislatures, 2014). Numerous specific rules and regulations pertain to lobbying activities and address conflicts of interest, financial disclosures, restrictions on gifts, regulation of lobbyists, and ethical considerations.

The National Conference of State Legislatures brings representatives from the Democratic and Republican parties together to monitor legislation and matters of general public interest and welfare, for example, an itemized description of each state’s legislation concerning prescription drugs and biological medicines (2015 Prescription Drug Legislation Database, April 2015, National Conference of State Legislatures, www.ncsl.org/research/health/pharmaceuticals-fact-policies-and-ncsl-resources.aspx). Legislation addressing mental health issues that may arise in the foster care system is also being monitored by the National Conference of State Legislators (Mental Health and Foster Care, May 20, 2015, www.ncsl.org/research/human-servcies/mental-health-and-foster-care.aspx).

Policy and politics on global, national, and local levels affect the provision of and type of mental health services provided to those affected by mental illness and their families.

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