Primary Care Advocacy Tool Kit

Policy Skills

Christie L. Hager, J.D., M.P.H.
John E. McDonough, D.P.H.
Schneider Institute for Health Policy
Heller Graduate School
Brandeis University
Waltham, MA

Contents

Introduction
Example
Setting Off to Influence Policy
Identify a Policy Problem
Seek Your Allies and Join Together
Persuade Policymakers
Some examples of issues of interest to policymakers
References

Introduction

Primary care providers can be especially key stakeholders in policy development. Policymakers, including legislators and regulators, are a target audience for a constituency group seeking policy change. Primary care providers have participated in the policymaking process on behalf of their patients as well as on their own behalf. Their specialized knowledge of the delivery of health care and the importance of the primary care model, in particular, is helpful to legislators, regulators, and other policy makers.

Primary care providers can become engaged in the policymaking process by building upon a record of advocating for issues that affect not only their patients but also their own ability to practice quality medicine. This can be done at the federal or state levels, but the “New Federalism” in health policy has presented states with an increasing number of opportunities to develop legislation and regulation, tailored to needs of their own residents, to improve the health care delivery. As local practitioners, primary care providers can approach policymakers with a knowledge of the needs of their patients, their own needs related to delivering appropriate care, and a familiarity with local resources that enables them to identify issues that can be addressed through policy change.

One example of translating a practice experience into policy change:

State Children's Health Insurance Program (SCHIP)

The lack of health insurance for so many patients persists as a critical issue in health care, and policy makers are dedicated to preserving and expanding insurance coverage and, in turn, access to health care. Several years ago in Massachusetts, Dr. Barry Zuckerman, chief of pediatrics at Boston Medical Center, joined up with the Success by Six® program, an initiative of the United Way of Massachusetts Bay, whose mission is to ensure that every child is healthy and ready to succeed by age 6. It represents a collaboration between corporate and business leaders, health providers, legislators and advocates that serves the common goal of achieving improvements in the overall health and well being of children. In that role, he brought corporate and labor leaders to Boston Medical Center to develop a sense of urgency among them to expand health insurance coverage for uninsured kids in Massachusetts. This message was brought to the State House, to legislators who were seeking to increase access to health care for all residents of the Commonwealth. This action contributed to the ultimate enactment of “Chapter 203 of the Acts of 1996” in Massachusetts, a major expansion of health insurance coverage and access. He later played the same role on the federal level, advising his U.S. Senator, Edward Kennedy, about these issues to create what is now called the State Children’s Health Insurance Program (SCHIP), enacted by Congress in 1997.

This is an example of policy in action. As a primary care physician, you are at “Ground Zero” of many of the health care issues that interest policymakers. Your ability to advocate meaningfully on behalf of your patients and to serve them effectively can be enhanced by considering some tried and true approaches to the public policy arena.

Setting Off to Influence Policy

The following tips come from Real Clout, a book published by and for community advocates seeking to expand health insurance; it is a valuable resource for anyone interested in influencing public policy at the grassroots level.

1. Identify a policy problem
2. Seek your allies and join together
3. Persuade policymakers

Identify a Policy Problem

Policy problems or issues are common avenues through which to become introduced to policymakers and the policymaking process. Identifying a problem that can be solved appropriately through the policymaking process involving legislators, regulators, and other stakeholders, is the initial step toward entering that process.

Once you have identified a specific issue that requires a policy change, which may or may not include a legislative solution, there are some important skills that will help you to participate effectively in the policymaking process.

Seek Your Allies and Join Together

Relationship building is an essential ingredient in effective participation in the policymaking process. Your position will be strengthened by showing that you have identified individuals and organizations with common concerns, and that you can work with them toward your common goals. Just as important, however, is to identify the sources of your likely opposition and prepare a strategy to overcome them.

Persuade Policymakers

Policymakers and political agendas must be receptive to change and ideas for change in order for your input to really make a difference. The metaphor of the “open window” is particularly apt in the sphere of opportunities to change public policy. In his book, Agendas, Alternatives, and Public Policies, Professor John Kingdon describes three streams which together constitute the “Open Window” model of policy change: The Problem Stream, the Policy Stream, and the Political Stream.

• The Problem Stream refers to a widespread public recognition that there is a problem that needs to be solved
• The Policy Stream consists of proposed solutions or alternatives that have been identified as viable and that become elevated to a critical visibility.
• The Political Stream is the change in politics (i.e., public opinion, key elected officials, or momentum within your own interest group and among your allies) that renders particular solutions or alternatives desirable.

When these three streams flow together, the window opens, and the potential for public policy change is great. Getting policymakers to see that there is a problem with viable public policy solutions that are supported by politics—of public opinion, elected officials or your own interest group—sets you on the road to influencing public policy.

Remember: Legislators and other policymakers are patients, too. Their own experiences as patients will shape their attitudes and perceptions toward primary care and the medical profession. This may have implications for how you choose to frame a particular issue or policy problem that you would like to communicate. It may also determine how you approach a policymaker.

In general, be clear about what your ideas are, and how they can actually be put into practice. Who does your idea benefit, and why is it important? Be prepared to defend your ideas and proposals. Policymakers are going to hear from your opposition, too. Be respectful of legislators, other policymakers, and their staff. They do their homework and will be interested to know how your issue is of concern to their constituents and how your ideas can be translated into policy changes.

Some examples of issues of interest to policymakers

Managed care is, and has been for the several years, a significant health policy issue, on both the federal and state levels. As Congress has failed to pass a so-called “Patient Bill of Rights,” the majority of states have enacted some form of managed care reform over the past six years or so. The role of primary care and primary care physicians in a health care delivery system that works in the best interest of patients is important to convey to policymakers.

The ways in which primary care is responsive to the needs of patients can be of great interest to policymakers. Primary care physicians can offer their patients accountability, coordination and continuity of care. It is no coincidence that these elements mirror those found in major recent managed care reform legislation and regulation. It is important for policymakers to know the extent to which primary care makes these available for patients. (“Consumers and Primary Care” by Cary et al., unpublished)

The training of primary care physicians is an area that is of great interest to policymakers. Patients need accessible medical care that is responsive to various cultural beliefs and attitudes. A culturally competent workforce is a major focus and the nation looks to eliminate racial and ethnic health disparities on both the national and state levels. Physicians who are close to the community in which they practice can be valuable sources of information regarding health status and outcomes of the patients in their area. Primary care physicians thus can be effective patient advocates as an important link between their patients and the support services, medical and otherwise, that will improve their health. (“Primary Health Care in the U.S.: Outcomes and Future” by Qaseem et al., unpublished)

References

Both of the following publications offer tips on how to become active in changing public policy through involvement in coalitions and contact with legislators, regulators and other policymakers. Both are available free of charge at www.accessproject.org.

• Healthcare Policy: The Basics by John E. McDonough. The Access Project: Boston (1999).
• Real Clout (A how-to manual for community activists trying to expand healthcare access by changing public policy) by Judith C. Meredith and Catherine M. Dunham. The Access Project: Boston (1999).

The following public policy textbook is an excellent resource for anyone interested in influencing public policy, and describes in detail the policymaking process .

• Agenda, Alternatives, and Public Policies by John W. Kingdon. Addison Wesley Co.; 1995.

For Web sites linking to policy skill development, click here.