Colorado Technical University Matt Zimmer, DHA (FACHE) Adjunct Faculty Week 4 objectives Understand the policy formulation phase of policymaking more thoroughly; List and describe the steps in the choreography of legislation development; Discuss the legislative process in state governments; Discuss the drafting of legislative proposals, including the forms they can take; Discuss the legislative committee and subcommittee structure of Congress; Describe the responsibilities of the executive, legislative, and judicial branches of government in policy implementation; Explain why the Centers for Medicare & Medicaid Services (CMS) is an important policy-implementing organization; Describe the legislative history of CMS s formation and evolution; Describe the organizational structure of CMS; Discuss the functions of CMS; Discuss the management aspects of policy implementation. Policy Making Process Formulation Phase- 1) agenda setting. 2) policy development. Agenda setting- describes the ways in which particular combinations of problems, possible solutions, and political circumstances emerge and advance to the next stage. Policy development- problems, potential solutions to them, and political circumstances converge to stimulate legislation development as a window of opportunity. Only small number make it to law. Formulation of Law Enacted laws are first printed in pamphlet form called slip law. Later, laws are published in the US Statutes at Large and eventually incorporated into the US Code. The Statutes at Large, published annually, contains the laws enacted during each session of Congress. In effect, it is a compilation of all laws enacted in a particular year. The US Code is a complete compilation of all the nation s laws. Legislative Development Legislation development begins with the origination of ideas for legislation and extends through the enactment of some of those ideas into law or the amendment of existing laws. The path through which legislation is developed begins with ideas for proposed legislation or bills in the agenda-setting stage, extends through formal drafting of legislative proposals and then several other steps, and culminates in the enactment of laws derived from some of the proposals. Once a health policy problem or issue achieves an actionable place on the policy agenda and moves to the next stage of policy formulation development of legislation those with concerns and preferences often continue to seek to exert influence. Forms of Legislative Proposals Congress selects between using bills or joint resolutions to introduce legislative proposals using conventions that have developed over time for the subject matter involved. A good example of a routinely used joint resolution is one to make continuing appropriations beyond the end of a fiscal year when the regular appropriations bills for the next year have not been completed. (Continuing Resolution) Simple resolutions (passed in either the House of Representatives or the Senate) and concurrent resolutions (passed in both the House of Representatives and the Senate) are not presented to the president because they do not become law. Origins or Ideas for Policy Members of the House of Representatives and the Senate. Individual citizens, health-related organizations, and interest groups representing many individuals or organizations may petition the government a right guaranteed by the First Amendment and propose ideas for the development of policy in the form of laws or amendments. Executive communication from members of the executive branch to members of the legislative branch. Many of the executive communications to Congress follow up on ideas first aired in annual presidential State of the Union addresses to Congress. The most important regular executive communication is the proposed budget the president transmits annually to Congress. Drafting Legislative Proposals Legislators Executive Branch Public-Private Partnership Clinton Healthcare Plan- failed The Affordable Care Act- Successful Introducing Legislation to Committees Members of the Senate and the House of Representatives who have chosen to sponsor or cosponsor legislation introduce their proposals in the form of bills The proposal is then sent to the appropriate committee for further consideration Legislative Committees and Subcommittees Committee and subcommittee deliberations provide the settings for intensive and thorough consideration of legislative proposals and issues. Each standing committee has jurisdiction over a certain area of legislation, and all bills that pertain to a particular area are referred to its committee. Committees are divided into subcommittees to facilitate work. For example, the Ways and Means Committee of the House of Representatives has six subcommittees: Health, Human Resources, Oversight, Select Revenue Measures, Social Security, and Trade. Sometimes the content of a bill calls for assignment to more than one committee. Committees with Health Policy Jurisdiction Most general health bills are referred to the House Committee on Energy and Commerce and the Senate HELP Committee. However, any bills involving taxes and revenues must be referred to the House Committee on Ways and Means and the Senate Committee on Finance. These two committees have substantial health policy jurisdiction because so much health policy involves taxes as a source of funding. See page 180 and 181 for details on the specific committees Committee and Subcommittee Operations Depending on whether the chairperson of a committee has assigned a bill to a subcommittee, either the full committee or the subcommittee can, if it chooses, hold hearings on the bill. Members of the executive branch, representatives of health-related organizations and interest groups, and other individuals can present their views and recommendations on the legislation under consideration. Members of committees or subcommittees mark up the bills they are considering. In cases of subcommittee involvement, when the subcommittee has completed its markup and voted to approve the bill, it reports out the bill to the full committee with jurisdiction. When no subcommittee is involved, or when a full committee has reviewed the work of a subcommittee and voted to approve the bill, the full committee reports out the bill for a vote, this time to the floor of the Senate or House. House or Senate Floor Action Bills can be further amended in debate on the House or Senate floor. However, because great reliance is placed on the committee process in both chambers of Congress, amendments to bills proposed from the floor require considerable support. Once a bill passes in either the House or the Senate, it is sent to the other chamber. The step of referral to a committee with jurisdiction, and perhaps then to a subcommittee, is repeated, and another round of hearings, markup, and eventual action may or may not take place. If it is passed in the second chamber, any differences in the House and Senate versions of a bill must be resolved before the bill is sent to the White House for action by the president Conference Committee Actions To resolve differences in a bill that both chambers of Congress have passed, a conference committee may be established. If the conferees cannot reach agreement, or if either chamber does not accept the report, the bill dies. If both chambers accept the conference report, the bill is sent to the president for action. Presidential Action on Proposed Legislation The president can sign the bill, in which case it immediately becomes law. The president can veto the bill, in which case it must be returned to Congress along with an explanation for the rejection. A two-thirds vote in both chambers of Congress can override a presidential veto. The president s third option is neither to veto the bill nor to sign it. In this case, the bill becomes law in ten days, but the president has made a political statement of disfavor regarding the legislation. A fourth option may apply when the president receives proposed legislation near the close of a congressional session; the bill can be pocket vetoed if the president does nothing about it until the Congress is adjourned. Policy Implementation Implementing organizations, primarily the departments and agencies in the executive branches of governments, are established and maintained, and the people within them employed, to carry out the intent of public laws and amendments as enacted by the legislative branch. DHS, CMS, etc. The implementation phase of public policymaking involves managing human, financial, and other resources in ways that facilitate achievement of the goals and objectives embodied in enacted legislation. Responsibility for Policy Implementation Responsibility for policymaking shifts from the legislative branch to the executive branch, although implementation is a shared responsibility among the branches of government. The executive branch bears much of the responsibility for implementation and plays a central role in policy implementation, the legislative branch oversees implementation, and the judicial branch also plays a role, largely refereeing implementation. Executive Branch Responsibility Department of Health and Human Services (HHS) and the Department of Justice (DOJ), and subdivisions of those departments; independent federal agencies such as the Environmental Protection Agency (EPA), the Consumer Product Safety Commission, and the Food and Drug Administration (FDA); and many other executive branch organizations exist primarily to implement the laws formulated by the legislative branch. Administration of Health Care Law The Department of Health and Human Services (DHHS) is the cabinet-level agency that is responsible for the national health and human service policy. The agency is also responsible for the regulation of the health care industry. The agency contains smaller agencies, which include the following: Social Security Administration (SSA) Centers for Medicaid and Medicare Services (CMS) Office of Human Development Services Public Health Service Family Support Administration Center for Medicare and Medicaid (CMS) CMS now has major responsibilities for implementing the ACA, which requires that CMS coordinate with states to establish health insurance marketplaces, expand Medicaid, and regulate private health insurance plans, among other things. Legislative Branch Oversight Ensure that implementing organizations adhere to congressional intent. Improve the efficiency, effectiveness, and economy of government s operations. Assess the ability of implementing organizations and individuals to manage and accomplish implementation, including investigation of alleged instances of inadequate management, waste, fraud, dishonesty, or arbitrary action. Ensure that implementation of policies reflects the public interest. Means of Legislative Oversight Funding appropriations that Congress must make to continue implementation of many of the policies it enacts. Although Medicare is an entitlement, others require annual funding through appropriations acts. NIH, VA, US Public Health Service. Direct contact between members of Congress and their staffs and executive branch personnel who are involved in implementing policies and the use of implementation oversight agencies, including the Congressional Budget Office and the Government Accountability Office. Judicial Branch Involvement Conduct hearings and render decisions in proceedings regarding laws after implementation Preside over enforcement and permit proceedings under the Administrative Procedure Act, and they conduct other proceedings involving alleged violations of laws. Implementing Agencies (CMS) CMS is the largest purchaser of healthcare in the United States, currently paying for almost one-third of the nation s health expenditures. With implementation of the ACA, CMS will provide benefits to millions of additional people. CMS functions Serves as CMS s focal point for the formulation, coordination, integration, implementation, and evaluation of national Medicare program policies and operations. Identifies and proposes modifications to Medicare programs and policies to reflect changes or trends in the healthcare industry, program objectives, and the needs of Medicare beneficiaries. Coordinates with the Office of Legislation on the development and advancement of new legislative initiatives and improvements. CMS functions, cont Serves as CMS s lead for management, oversight, budget, and performance issues relating to Medicare Advantage and prescription drug plans, and Medicare fee-for-service providers and contractors Oversees all CMS interactions and collaboration with key stakeholders relating to Medicare (i.e., plans, providers, other government entities, advocacy groups, Consortia) and communication and dissemination of policies, guidance, and materials to the same to understand their perspectives and to drive best practices in the healthcare industry Develops and implements a comprehensive strategic plan, objectives, and measures to carry out CMS s Medicare program mission and goals and position the organization to meet future challenges with the Medicare program and its beneficiaries Coordinates with the Center for Program Integrity on the identification of program vulnerabilities and implementation of strategies to eliminate fraud, waste, and abuse. Policy Implementation as Management Implementing organizations must manage the implementation of policies, and to do so is these organizations reason for being. In addition to managing policy implementation, the managers of these organizations must also oversee their own organizations. CMS Must Manage Itself Analyze variables in CMS s external environment, assessing their importance and relevance, and responding to them appropriately; Determine CMS s mission and objectives; Assemble the resources necessary to achieve the mission and objectives; Determine the processes necessary to accomplish the mission and objectives and ensure that the processes are carried out effectively and efficiently; and Lead others in contributing to the accomplishment of CMS s mission and objectives. Implementation Phase Summary The implementation phase of public policymaking involves managing human, financial, and other resources in ways that facilitate achievement of the objectives embodied in enacted legislation. In this sense, policy implementation is primarily a management undertaking. The essence of policy implementation is described as the use of resources to pursue the objectives inherent in legislatively enacted policies. Implementing organizations, primarily the departments and agencies in the executive branches of governments, are established and maintained and the people within them employed to carry out the intent of public policies enacted by legislative branches. The relationship between those who formulate policies and those who implement them is symbiotic. Questions?
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