Physicians and Scientists in Gastroenterology as Legislative Advocates: Practical Tips and Resources

Abstract

Broadly defined, physician advocacy is intended to promote changes that ameliorate human well-being (adapted from the definition by the American Medical Association’s Declaration of Professional Responsibility1American Medical AssociationDeclaration of Professional Responsibility.www.cms.org/uploads/Declaration-of-Professional-ResponsibilityDate accessed: September 10, 2018Google Scholar). Physicians frequently advocate on behalf of their patients; however, engagement beyond the individual patient is less common, especially when it comes to legislative advocacy aimed to influence local and federal legislation. Among scientists, participation in legislative advocacy is likewise low. Reluctance to engage in legislative advocacy is likely due to a number of factors, such as lack of advocacy training or experience, limited time, and a culture in medicine and research that avoids political discourse.2Earnest M.A. Wong S.L. Federico S.G. Perspective: physician advocacy: what is it and how do we do it?.Acad Med. 2010; 85: 63-67Crossref PubMed Scopus (174) Google Scholar Yet, physicians and scientists are among the best equipped to advocate for changes that impact the practice and science of gastroenterology and medicine given their unique position “in the trenches” of patient care, research, and/or practice management. This form of advocacy transcends politics by focusing on issues that affect human health in general and individuals suffering with digestive diseases specifically. Indeed, advocacy by physicians and scientists has undoubtedly contributed to recent increases in funding for the National Institutes of Health, progress in understanding the treatment of chronic diseases as well as improvements in delivery of high-quality care.3Grace N.D. Dennis L.B. Advocacy: what is a nice scientist like you doing in Washington, DC?.Hepatology. 2007; 45: 1337-1339Crossref PubMed Scopus (2) Google Scholar Of course, plenty of work still needs to be done, and more physicians and scientists are required to amplify the collective voice. Although a discussion of current advocacy priorities is beyond the scope of this commentary, a recent commentary summarizes these priorities4Jain R. An insider view: AGA advocacy priorities.Gastroenterology. 2018; 155: 572-573Abstract Full Text Full Text PDF Google Scholar and readers are encouraged to visit the American Gastroenterological Association (AGA) website for updates. The objective of this commentary is to describe ways, both large and small, in which a physician or scientist can engage in legislative advocacy with a brief review of the legislative process in the United States, practical advocacy tips, advocacy resources, and an introduction to the new AGA Congressional Advocates program. Because legislative advocacy aims to influence law making, it is helpful to have a general understanding of the legislative process. Although a detailed review of these procedures is outside the scope of this commentary, a short overview is provided with an emphasis on how an advocate can influence each step in the process. The focus here is on federal legislation because procedures on the state level can vary, although the general processes are similar. Laws are drafted by the 2 chambers of Congress, the Senate and the House of Representatives. The Senate is composed of 100 members, 2 senators from each state and the House is composed of 435 representatives who represent districts defined by population numbers in their state. Members of Congress (MOC) begin the legislative process by introducing a bill. Co-sponsors may be sought through a “Dear colleague” letter to express widespread support for a bill. The bill is given a number beginning with “S.” in the Senate and “H.R.” in the House of Representatives. In the 115th Congress (2017–2018), there have been 10,083 bills introduced, of which 212 have become law.5Congressional Activity.Congress.govDate accessed: September 10, 2018Google Scholar MOC work closely with members of their staff who are often responsible for specific legislative areas, such as health care. Advocates can play an important role in this step by influencing bill content and language, as well as advocating for a proposed bill. In addition, advocates can help to obtain co-sponsors. During visits on Capitol Hill, advocates will often meet with staff members and not necessarily their MOC; however, staffers play key roles in informing and educating the MOC and their position on a specific issue. During in-district or in-state meetings and events, an advocate is more likely to directly interact with their MOC. Once a bill is introduced, it is referred to a committee of jurisdiction, where it is developed and assessed, sometimes through review on a specific subcommittee. Bills selected for consideration by the committee chair are subject to hearings in which experts and interested parties provide testimony and answer questions from committee and subcommittee members. The key committees for health care-related legislation in the Senate include Health, Education, Labor and Pensions, Budget, Appropriations, and Finance. In the House, key committees include Ways and Means, Energy and Commerce, Budget, and Appropriations. A bill is “marked up” with amendments, voted on, and then reported out in an official version to the chamber. On the floor of each chamber, there is debate and proposal of amendments until there is a vote on the final bill. The bill is then sent to the second chamber for review and returned back to the original chamber for re-review. This process can go back and forth until compromise is achieved. The final piece of legislation is then sent to the president and action must be taken within 10 days for the bill to become law. Advocates can play an important role in these steps of the process by supporting hearings on a bill, informing other MOC about the bill, and continuing public acknowledgement in support or opposition of a bill. Legislative advocacy depends on building relationships with legislators such as MOCs to affect change. Personal visits, letters, phone calls, and attending town halls or political fundraisers are all effective ways to reach representatives. Legislators are often sincerely grateful to have a constituent’s expert views on issues relating to gastroenterology and medicine. When communicating with representatives, health care providers should offer input as a trustworthy and knowledgeable resource. Regardless of political party affiliation, legislators are responsible for representing all constituents and value input particularly on health care-related topics. If there is an issue to bring to a legislator’s attention, a phone call or email to his or her office to express one’s views can work well. Staffers keep track of all incoming requests and will send back information on the representative’s stances in that area. Although waiting on hold or drafting an email can seem tedious, it is a very personal approach to reaching representatives. A faster and easier way to communicate on major legislative issues is through the AGA’s online automated system (https://gastro.org/advocacy-and-policy/advocacy-resources). For each active issue, there is an overview, and a form to enter contact information, which generates an editable templated email to send to legislators. This system uses the entered zip code to determine which representatives to send emails to, with a simple click of a button. It takes <5 minutes, and is an efficient method to express views on important topics during busy work days. In-person meetings are the best way to connect personally with legislators. The logistics of planning a legislative visit are described in Figure 1. If there is flexibility in scheduling a visit in-district during a Congressional recess or traveling to Capitol Hill for a meeting, there is a greater opportunity to meet directly with the MOC. Aside from group visits, other opportunities to meet with representatives include their local town halls, or political fundraisers. Another option is to host an event at a GI practice, hospital, or academic institution. This strategy allows for an opportunity to conduct a facility tour, which can give representatives a much better sense of the patient experience as well as new health care innovation arising in his or her district. It will also allow for the legislator to meet with a larger group and for potential media coverage. As clinical experts and legislative advocates, physicians and scientists have the unique opportunity to share their perspectives with colleagues and patients. Outlets for speaking and writing to the general public include town hall meetings, rallies, opinion editorials, letters to the editor, online community forums, and blog posts. When crafting a message, the aim should be to write at an eighth- or ninth-grade reading level to stay aligned with local newspapers and magazines. In this context, patient stories and narratives can be powerful avenues to describe more complex situations of coverage denial or barriers in access to care. Prior studies highlight the importance of storytelling in effective advocacy.6Anderson H.A. Changing fashions in advocacy: 100 years of brief-writing advice.Journal of Appellate Practice and Process. 2010; 11Google Scholar, 7Baesler E.J. Persuasive effects of story and statistical evidence.Argumentation and Advocacy. 1997; 33: 170-175Crossref Scopus (22) Google Scholar Include and cite statistics supporting the issue, and end with a compelling argument in the form of a question or tie back into a patient story. Concise, powerful, and relatable messages in this form can motivate patients and colleagues to support a legislative cause, and place pressure on representatives to take action more quickly. The AGA has a robust Government Affairs group (Figure 2) that actively advocates for its members on important legislative and regulatory issues. Issues of importance can be brought to the attention of the AGA staff either through their own initiatives or AGA member or Congressional staff involvement. Each year, issues are prioritized by several AGA groups, including the public policy staff, practice management committee and other AGA members. As additional advocacy issues might arise throughout the year, the AGA staff prioritizes these and acts accordingly. The Political Action Committee (PAC) of the AGA is a 501(c)(6), which the IRS defines as an organization that may engage in political activity or lobbying.8American Gastroenterological AssociationAGA-PAC.www.gastro.org/advocacy-and-policy/aga-pacDate accessed: September 10, 2018Google Scholar The PAC is a voluntary, nonpartisan political organization affiliated with and supported by the AGA and the only PAC supported by a national gastroenterology society. Its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. Among professional medical organizations, there is considerable variation in PAC spending; for example, in 2018, the AGA donated $160,000 compared with $1.6 million donated by the American College of Radiology.9Center for Responsible PoliticsHealth professionals PAC contributions to federal candidates.www.opensecrets.org/pacs/industry.php?txt=H01&cycle=2018Date accessed: September 10, 2018Google Scholar The AGA-Institute is a 501(c)(3), which can only engage in political activity up to a certain point. Therefore, it is important to note that monies contributed to the AGA Institute cannot be used for lobbying MOC or other political activities. The AGA has active partnerships with several coalitions who share similar advocacy priorities. These include patient groups such as the Crohn’s and Colitis Foundation and other GI/medical groups. The AGA is part of the Deadliest Cancers Coalition, which was established in 2008 by patient advocacy groups to advocate for policy issues important to patients who have cancers which have a 5-year survival rate of <50%. The AGA is also a member of the Friends of the National Institute of Diabetes and Digestive and Kidney Diseases, a coalition of professional organizations supporting the institute’s mission, funding, and research. In 2018, the AGA launched a new program to promote and facilitate grassroots legislative advocacy. The AGA Congressional Advocates Program is an avenue to engage in legislative advocacy by promoting legislation that will enhance the practice and science of gastroenterology and the delivery of care to patients. The goal of the program is to bring together gastroenterologists and scientists throughout the country to maintain long-term connections with legislative offices as experts in the field and as constituents. The Congressional Advocates Program not only offers a community of support, along with technical resources from AGA staff, but also training opportunities to learn how to lobby and write policy pieces. The program of activities and opportunities is summarized in Figure 3. Applications can be submitted to [email protected] and are reviewed on a rolling basis. Involvement by physicians and scientists in legislative advocacy is much needed to continue ongoing efforts to educate and influence legislators on critical issues related to the practice and science of gastroenterology. There are several ways, both big and small, to get involved in advocacy. This commentary provides a number of practical tips and resources to help individuals engage in legislative advocacy. An excellent program to consider joining is the AGA Congressional Advocates program because it provides multiple opportunities to advocate on the federal level and serves to establish a community of grassroots GI advocates. To quote the wise Dr Seuss, “Unless someone like you cares a whole awful lot, Nothing is going to get better. It’s not.” (The Lorax).