Former U.S. Congressman Barber Conable once remarked “exhaustion and exasperation are frequently the handmaidens of legislative decision.”1 By the end of any busy legislative session, many medical board directors, staff and members would agree. Most have their share of war stories about meetings that ran until 2 a.m., AWOL bill sponsors and eleventh-hour ambushes. Yet as undeniably frustrating as the legislative process can be, it is also absolutely essential. Indeed, legislation lies at the heart of everything that boards do, so it pays to gain a deeper understanding of the process and learn some proven strategies for influencing it.
The degree to which medical boards can interact with their legislature varies from state to state. Some boards have relatively direct access. “Others are actually subdivisions of the state Department of Health, and, in that case, the department would be the entity interacting with the legislature,” says Jeanne Hoferer, manager of Legislative Services at the Federation of State Medical Boards (Federation). Obviously, then, any general strategies for dealing with legislative issues would have to be adapted to a board’s specific circumstances. Whether access is direct or indirect, though, boards can play an important role in shaping the laws that determine what they do, what funds they receive and how well the public is protected. Below, some savvy folks who have learned to navigate the legislative waters share their insights about what works — and what doesn’t.
BUILDING RELATIONSHIPS
If the first rule of real estate is location, location, location, then it might be said that the first rule of lobbying is relation, relation, relation. “Lobbying is all about relationships and connections,” says Lyle Kelsey, executive director of the Oklahoma State Board of Medical Licensure and Supervision and previously a lobbyist for the Oklahoma State Medical Association. The other experts contacted for this article all agreed that relationship building is a core skill for anyone hoping to have an impact on legislative decisions.
The first step is to identify the key players. Try to anticipate who the next session’s movers and shakers — and especially the members of relevant committees — are likely to be. “In every legislature, there are people who have specialized in certain areas. Here in Alabama, I’m considered to be someone who is very interested in and knowledgeable about the health care field,” says Larry Dixon, who is currently not only a state senator, but also executive director of the Alabama State Board of Medical Examiners. While the health care leaders in your state may not be quite so obvious, it is usually fairly easy to figure out who they are.
Once you have identified these key legislators, make it a point to establish and nurture relationships with them during the interim. That way, you will already be a familiar and trusted resource once the next session begins. “The first few times we make contact, we don’t ask for anything,” says Tina Steinman, executive director of the Missouri State Board of Registration for the Healing Arts. “We just go over to their office to introduce ourselves and let them know we’re here.”
Your initial goal should be simply to acquaint legislators with who you are, what the medical board does and how to reach you. “Let them get to know the board,” says Dixon. “Have them meet some of your board members, and invite them to the public portion of board meetings.” Dixon has even taken legislators to Federation meetings when funds allowed in the past. However, “unlike what the media would have you believe, you don’t have to buy legislators dinner to get their attention.” It is far better to make an impression with your sterling professionalism.
Don’t forget the legislator’s staff, either. They are often your first point of contact — and sometimes your only point, when legislators are tied up with other business. In addition to serving as middlemen for information, staff members may also be intimately involved in the nitty-gritty of policymaking. “If they know you as someone who is honest and reliable, they’re more likely to turn to you when they need information fast,” says Jane McFarland, special projects manager at the Texas State Board of Medical Examiners. This is an excellent way to establish the board as a resource for objective data on such issues as how many physicians are practicing in a state, how many complaints there are and whether a state is really losing doctors.
CREATING ALLIES
While you may focus a lot of attention on a few key players, don’t ignore the rest. Nancy Achin Audesse, executive director of the Massachusetts Board of Registration in Medicine and a former state senator, suggests dropping off brochures on how to file a complaint in every legislator’s office. Let the staff know that, if any constituents call about a problem with a physician, they can send out a brochure and direct the caller to the medical board. “It seems like a small thing, but constituent service is a big part of any legislator’s day,” says Audesse. “To the degree that you can make it easier, you’re being helpful and showing professionalism. But the legislators also become your education and outreach arm in dealing with their constituents.”
In Massachusetts, medical board staff members sometimes travel around the state giving presentations about their physician profiling program, the first of its kind in the nation. “If we’re going out to a senior citizen group or public library, we always inform the appropriate legislators that we’ll be going into their district and invite them to attend,” says Audesse. “It seems hostile to legislators if you don’t.” On the other hand, by keeping them informed, you not only make allies, but also get another chance to educate those legislators about the services your board provides.
“The number one thing that legislators hate is losing an election,” says Audesse. “However, the number two thing is being surprised by something in the press.” Once again, a friendly heads-up is often both appropriate and appreciated. For example, consider the worst-case scenario in which there are numerous victims from one area in a sexual misconduct case. “Once the public action has been taken, there’s no harm in calling the legislator and saying, ‘I just wanted you to know that there’s going to be a lot of press in your district about an action the board took.’” This gives you an opportunity to tell the legislator about the action, and it gives the legislator time to collect his or her thoughts before the calls from reporters start rolling in.
Keeping in touch is good, as is making sure that legislators know about the board’s vigilance and diligence. However, wearing out your welcome is definitely counterproductive. “You don’t have to be at their doorstep every day,” says Dixon. At the start of a busy legislative session, often all that is needed is a courteous letter reiterating that you are ready and willing to answer any questions the legislator may have, either in person or by phone, whichever is more convenient.
In all your contacts, keep your message as focused as possible. Never lose sight of your mission as an ambassador for the medical board. “I’m a single-interest person,” says Trey Delap, deputy executive director of the Nevada State Board of Osteopathic Medicine. “I don’t try to be their guru of health care . But I do try to be their guru of professional medical regulation for osteopathic physicians.
Your value as a resource will be greatly enhanced if you stay on top of pertinent legislation. Within your own state, make frequent use of online bill-tracking services as well as your personal contacts. For information about what is happening elsewhere, the Federation’s Legislative Services Department can be very helpful. “We monitor state and federal legislation that has the potential to affect state medical boards, medical regulation or any of the issues that the Federation has a position on,” says Hoferer. The Federation provides other kinds of assistance as well, such as identifying national trends, providing sample legislative language from other states, writing letters to legislative leadership, assisting in drafting testimony and sometimes presenting testimony to support member board initiatives or reinforce opposition to particular issues.
FINDING SPONSORS
At times, you will need to approach a legislator about authoring a bill or championing it in the legislature. If you have been conscientious about relationship building, the groundwork should already be laid, and you should know enough about the individual interests and strengths of various legislators to find the best match for your bill. “When it’s going to be a difficult bill, you want a very strong person who’s well respected and probably in the majority party,” says Linda Whitney, chief of legislation for the Medical Board of California. “When it’s a bill that crosses party lines, sometimes it’s helpful to get a member from both sides to serve as coauthors. And when it’s a bill that has to do with a lot of licensure and technical kinds of things, you want to make sure you have somebody from the original policy committee carrying it, because they’re the ones who really understand the technical issues.”
Whitney’s skill as a matchmaker is seen in her success at finding the right author for Assembly Bill 948, a board-backed bill that was signed into law in 2003.2 This bill gives the board authority to approve fellowship programs for nonlicensed physicians who, under the supervision of a licensed physician, would provide primary care in clinics located in underserved areas. These fellowship programs are still in the discussion stage. However, this was a necessary first step in the development process, since California law requires the board to approve any such programs.
Whitney says the board would ordinarily approach a member of the Business and Professions Committee about authoring this type of bill. In this case, however, she approached Assemblyman Fabian Núñez, who is a relative newcomer and not a member of the professions committee. Nevertheless, Núñez does sit on the Future of California’s Health Committee, and he is known to have a deep interest in bringing quality medical care to underserved areas, including those in his district. He turned out to be an effective champion for this particular legislation.
Once you find the right author or sponsor, your job has only begun. First, you need to make sure that the sponsor is fully informed about what the bill involves, why it is important and who the opposition, if any, is likely to be. “Then, each time the bill comes up for a hearing, we make sure we meet with the sponsor that day to go over the issues one more time,” says Steinman. “We put together bullet points for them to use when they make their presentation.” These points should briefly highlight the main ideas of the bill in easy-to-communicate terms.
“You don’t ever want to embarrass your sponsor,” adds Steinman. “You don’t want them up there looking like they’re sponsoring something just because they were asked to. Instead, you want it to be clear they’re sponsoring the bill because they understand it and believe in it.” The time invested in educating sponsors and providing a quick pre-hearing refresher is time well spent.
OVERCOMING OPPOSITION
Legislators aren’t the only folks who can make or break a bill, of course. Interested parties, such as the state medical society, can certainly sink a bill by lobbying against it. As a result, medical board staff often put considerable time and energy into lining up support from these parties — or, at least, trying to head off active opposition. In Missouri, for example, the board is under the Division of Professional Registration, which is under the Department of Economic Development, whose director reports to the governor. If the board wants to pursue legislation, it must first obtain approval from the division director, department director and governor’s office. “But before we even start up that flagpole, we usually run any legislation past our state medical association and state osteopathic association to get their reaction,” says Steinman.
A negative reaction doesn’t necessarily mean that a bill will be dropped, but it does mean that a concerted effort will be made to find a mutually acceptable compromise. “There are going to be times when you just have to agree to disagree and go against each other, but that should only happen rarely,” says Steinman. It benefits everyone if the medical board and medical society have a good working relationship based on mutual trust and two-way communication. On a pragmatic level, having the medical society’s stamp of approval improves the odds that a bill will make it all the way to the top of the flagpole.
The need for compromise is even more vital when conflict arises with another governmental agency. In Montana, the medical board is one of several licensing boards under the Department of Labor and Industry. Here, too, the department and governor’s office must approve any legislation sought by the board. “If it’s too controversial — let’s say, if it’s an issue between medical and nursing — the governor may decide not to take one side or the other, so the legislation never makes it through the executive branch,” says Jeannie Worsech, executive director of the Montana Board of Medical Examiners. In such cases, the board might then approach the state medical association and ask them to carry the ball. However, a better solution is to avoid getting into this position in the first place, by ironing out differences with other boards before a bill ever lands on the governor’s desk.
A cooperative approach can also come in handy when a medical board opposes a bill backed by other parties. A good example of this occurred in New Mexico, where the board found itself at odds with a bill that granted limited prescribing authority to specially trained psychologists. When the psychologist prescribing bill was first introduced, “we opposed it, because it was so badly written,” says medical board member Grant La Farge, M.D. “Psychotropic drugs are very complex medications, so it’s important to know what the heck you’re doing if you will be prescribing them.” La Farge and many other physicians felt that the bill in its original form called for neither sufficient training nor adequate medical supervision for new prescribing psychologists. Nevertheless, the medical board understood the bill’s grassroots appeal. “It’s intended to create more access for patients,” says La Farge. “There are twice as many psychologists as psychiatrists outside the major cities in New Mexico.”
The version of the bill that ultimately passed in 2002 was revised to address many of the medical board’s concerns.3 In pushing successfully for these changes, the board emphasized objective, scientific evidence. The law now mandates joint decision-making by the New Mexico Medical Board and Board of Psychologist Examiners on many critical matters, including approval of an educational program and certification exam. There are still unresolved implementation issues, which a joint committee of the two boards is currently trying to hash out. In general, though, the final version of the bill offers much better protection to the public than the original, thanks to skillful collaboration and negotiation by the medical board.
GIVING TESTIMONY
Once a bill finally makes it to the legislature, you still have your work cut out for you. Often, this includes testifying — one of those tasks that looks deceptively easy to do, but is actually quite difficult to do well. “I’ll usually call over to the committee staff and try to understand what kind of witness they want,” says McFarland. “Do they want the executive director there with his recognition and authority? Or do they need a detail person who can rattle off statistics about our licensing process?”
Of course, the goal is to send the best person to answer the legislators’ questions. When that person is you, “make sure your remarks are clear and concise,” says Whitney. “If there are any fiscal considerations, be sure to mention those. If you don’t know the answer to a question, say, ‘I don’t know, but I can get back to you on that.’” Try to avoid this, however, by arriving well prepared. If you have strong opposition, Whitney suggests that you proactively address the main points you believe your opponents will raise, since you generally will speak before they do.
Occasionally, you may be called upon to make a very formal public statement — especially “when there is a great deal of media interest, and they are looking for clips for the evening news,” says Audesse. In most cases, however, it isn’t a good idea to simply hand legislators your written testimony and read it to them. “It is usually far more effective to send your technical briefing about the bill to members of the committee before the hearing,” Audesse says. “Then, at the hearing, you can say something like, ‘Members of the Healthcare Committee, we have previously given you our concerns. Let me briefly recount those for you.’” Quickly reiterate the high points to refresh their memory, and offer to answer any questions.
At times, you may be waylaid by comments that seem staggeringly irrelevant or even hostile. “Sometimes, legislators simply want to make a public statement about their problems with some doctor somewhere, and they just happen to pick that time to perform,” says Donald Patrick, M.D., J.D., executive director of the Texas board. “I’ve been picked on a little bit! But I realize it’s not personal, so I don’t take offense. I just smile rather grimly and say, ‘Well, we’re doing our best to work on that. I appreciate you bringing it to my attention, and we’ll work harder on it.’”
Indeed, keeping your cool at all times with legislators can be one of the more challenging parts of a medical board job. “But if you get mad or upset, you can really hurt yourself in the long run,” says Kelsey. Next week, you may need that legislator again as an ally. Of course, not everyone is blessed with an even-tempered personality. “You need to size yourself up honestly and ask, ‘Am I really the person who ought to be doing this?’” Kelsey says. “You may realize that you need to send in somebody who’s a little less passionate, from the standpoint of not getting upset or not taking it personally if a legislator says that he or she can’t support your bill.’”
SURVIVING SETBACKS
Even with the best-laid plans, however, you may sometimes run into unforeseen snags. That’s what happened to the Iowa Board of Medical Examiners in 2003, when they first pursued legislation that would authorize criminal background checks on applicants for new or reinstated licenses as well as licensees who are placed on probation. 4 The board certainly tried to follow all the right steps. They worked not only with a bill writer, but also with the state Division of Criminal Investigation, attorney general’s office, and the Federal Bureau of Investigation (FBI) to ensure that the language was crafted appropriately. “I also worked with a variety of professions who wanted to be included in this,” says Ann Mowery, Ph.D., executive director of the Iowa board. “The bill that we came up with basically included all of the professional licensing boards in the state” — covering everyone from physicians and dentists to insurance agents and cosmetologists.
The bill passed the Iowa Senate unanimously. However, “when it went to the House, it ended up in committee with a person who is absolutely and totally opposed to the bill, and won’t give any reason why,” says Mowery. As a result, the bill got stuck in committee. One possible explanation, Mowery reasoned, was the inclusion of so many professions, most of which had a much less compelling need for criminal background checks than medicine. In an effort to resolve the impasse, “I offered to take out every single profession but medicine, but that didn’t fix the problem.” Mowery also sought advice from the governor’s staff and House leadership, but she has yet to find a way to move this seemingly immovable legislator. Currently, she is looking for someone other than the board to sponsor the bill — possibly a legislator with a background in law enforcement — so that it won’t be assigned back to the same committee in 2004.
This highlights another trait that can be invaluable when dealing with legislative issues: patience. Beyond that, you need persistence, an even temper, and — perhaps most importantly — a reputation for integrity and sound judgment. “We don’t have any lobbying resources here other than our staff and our credibility,” says Tom Dilling, J.D., executive director of the State Medical Board of Ohio. “We wouldn’t get anywhere near as much accomplished if we didn’t have a solid record of making prudent decisions.”
LEARN MORE ABOUT THE LEGISLATIVE PROCESS
Navigating the intricacies of the legislative process will be on the agenda at the Federation of State Medical Boards’ 92nd Annual Meeting, April 29 – May 1 at the Crystal Gateway Marriott in Arlington, Va. “The Legislative Process, Building Relationships” will feature U.S. Rep. Mike Rogers, whose leadership experience and legislative record created new and unique opportunities usually not open to a relatively new member of Congress. Attendees will explore how state medical boards can be a valuable resource to policymakers, the importance of establishing effective relationships with legislators and strategies for capitalizing on collaborative opportunities to positively affect public protection.
To register or for more information, contact Carol Lucas at the Federation at (817) 868-4007 or at [email protected].
References
- 1.↵ConableBBJr. Time. Oct. 22, 1984. Cited by: Donadio S, Smith J, Mesner S, Davison R, eds. The New York Public Library Book of 20th-Century American Quotations. New York: Warner Books; 1992.
- 2.↵California Assembly Bill 948. Approved Sept. 20, 2003. Available at: ftp://www.leginfo.ca.gov/pub/bill/asm/ab_0901-0950/ab_948_bill_20030922_chaptered.html. Accessed Dec. 15, 2003.
- 3.↵New Mexico House Bill 170. Effective July 1, 2002. Available at: http://legis.state.nm.us/session02.asp?chamber=H&type=++&number=170&Submit=Search. Accessed Dec. 15, 2003.
- 4.↵Iowa Senate File 235. Passed Senate March 17, 2003. Available at: http://www.legis.state.ia.us/cgi-bin/Legislation/Bill.pl. Accessed Dec. 15, 2003.
