Spending Bill Research Articles

Try, Try Again: Repeat Veto Threats in Presidential-Congressional Bargaining

Presidents use veto threats to bargain over legislation with Congress. While presidents may fail if Congress passes legislation over their veto threat, they also lose some power if they must repeatedly “go public” in bargaining over one bill. This article examines “repeat” veto threats: multiple veto threats issued to the same bill. Using data on all veto threats issued from 1985 through 2022, I find that presidents issue fewer repeat veto threats during unified government and when majority control of the two congressional chambers is divided. Presidents with higher approval ratings also tend to issue more repeat veto threats. Presidents avoid repeatedly “going public” when they can but more popular presidents do so if they must. I also find evidence of more repeat veto threats on spending bills, which suggests that presidential bargaining and “going public” operate differently across the authorization and appropriations processes.

Hawks versus Doves: Who Leads American Foreign Policy in the US Congress?

Abstract The combination of partisan polarization and controversial military engagements has produced contentious debates over US foreign policy in Congress. Who has been winning these debates and exerting greater influence over the development of security and defense bills, hawkish or dovish legislators? The literature offers competing answers—on the one hand, arguing that hawks enjoy policy advantages because of Congress’s commitment to US hegemony and, on the other, claiming that doves gain policy openings because of shifting partisan and security conditions. To determine the influence of hawkish versus dovish legislators, we examine congressional actions on all defense spending bills from 1971 to 2016. Specifically, we track roll call votes to see which legislators enjoy the greatest support for their measures. We find that hawks have disproportionate influence over the content of defense bills, whether Republicans or Democrats are in control, and whether the United States is at war or enjoying relative peace.

Just How Unorthodox? Assessing Lawmaking on Omnibus Spending Bills

Abstract Scholars commonly observe that lawmaking in Congress has transitioned from the textbook system of “regular order” in which power was decentralized in committees and lawmaking followed a formal process to one of “unorthodox lawmaking” characterized by the centralization of power in party leaders and a lack of formal process. It is debated whether this change marks a decline in Congress’s lawmaking capacity, or is a procedural adaptation that has allowed Congress to remain productive despite high levels of partisanship. In this article, we maintain that lawmaking in Congress varies along two dimensions: formality of process and centralization of power. We analyze non-spending bills added to omnibus appropriations packages to demonstrate that lawmaking on these bills is informal and decentralized. Rank-and-file members retain a capacity to place matters on the legislative agenda and authorizing committees retain gatekeeping and policymaking authority. The process through which add-ons are approved is also bipartisan. Our findings demonstrate that this style of lawmaking is a procedural adaptation used by members to pass legislation important to their districts and in which committees continue to play an important deliberative role.

Health Care Provisions in the 2022 Omnibus Appropriations Bill.

The US Constitution requires that federal money may not be spent unless appropriated by Congress. Under regular order, this is achieved by Congress passing twelve individual bills that, together, fund all the activities of the federal government. These bills must be approved by the President. The last time Congress passed all the individual bills was in 1996. Since then, the practice has been to fund the government through a series of continuing resolutions, which serve as temporary spending authorization, normally at levels from the previous fiscal year. Congress is not required to pass twelve individual appropriations bills. It may also pass a single bill to cover all spending for the fiscal year. This is generally referred to as an "omnibus spending bill". That is what was passed in December 2022. There were health policy provisions in the bill, and this article discusses some of the more relevant areas for pharmacists.

It’s 10 O’clock: Do You Know Where Your State Legislature Is?

It’s 10 O’clock: Do You Know Where Your State Legislature Is?

Buprenorphine opens up for easier access, but what about adolescents?

Late last year when President Biden signed the “omnibus” spending bill eliminating the X‐waiver and the patient caps for buprenorphine, prescribers were thrilled. The American Society of Addiction Medicine (ASAM), which had fought hard for the changes, claimed that the X‐waiver, formerly required by the Drug Enforcement Administration (DEA), was a barrier to prescribing.

Buprenorphine opens up for easier access, creating hope for all patients

Late last year when President Biden signed the “omnibus” spending bill eliminating the X‐waiver and the patient caps for buprenorphine prescribers were thrilled. The American Society of Addiction Medicine (ASAM), which had fought hard for the changes, claimed that the X‐waiver, formerly required by the Drug Enforcement Administration, was a barrier to prescribing.

Biden Urges Bipartisan Effort on Mental Health

Back to table of contents Previous article Next article Government & LegalFull AccessBiden Urges Bipartisan Effort on Mental HealthKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:9 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.68AbstractPresident Joe Biden outlined numerous priorities related to mental health and substance use disorder care during his State of the Union address. He emphasized the importance of working across the aisle to support patients in need.iStock/drnadigIn his State of the Union address, President Joe Biden pointed to numerous health policies, including improving mental health and addressing the opioid epidemic, that represent opportunities for members of both parties to work together.APA applauded the inclusion of mental health in Biden’s address in a news release. “While the nation faces the opioid epidemic, an ongoing crisis in youth mental health, and barriers to access, mental health is truly an issue where bipartisan progress can and must be made,” APA’s statement reads.During his address, Biden spoke about his four-part Unity Agenda, which focuses on tackling the mental health crisis, especially among youth; addressing the epidemic of opioid and other drug overdoses; ending cancer; and supporting veterans.“Despite the division within American politics today, leaders on both sides of the aisle can agree that many of our citizens are struggling with mental health challenges, often without support,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Congress’s recent spending bill represented a huge victory for psychiatry and the patients we serve. We must continue that momentum and provide much-needed support, especially to our youth, those with substance use disorders, and our health care workforce.” Biden outlined specific actions his administration will take in his Unity Agenda, including the following:Supporting the health care workforce: This year, the Centers for Disease Control and Prevention (CDC) will launch a new campaign to provide mental health and resiliency resources for health care organizations on how to support their workforces. In his Unity Agenda, Biden acknowledged that health workers experienced high levels of burnout, anxiety, and depression even before the onset of the COVID-19 pandemic. “Studies have shown that burnout [has] reached crisis levels, affecting up to 54 percent of nurses and physicians,” Biden’s Unity Agenda Fact Sheet states. Strengthening parity enforcement: Though the Mental Health Parity and Addiction Equity Act was passed in 2008, many health plans are still not in compliance with the federal law. The administration will propose new rules this spring to ensure insurers are not imposing inequitable barriers to care and that mental health professionals are being paid on par with other health professionals.Investing in crisis services and 988: The 988 Lifeline launched in the summer of 2022, and while it has increased access to crisis counseling for all Americans, experts emphasize that more work is needed to improve the country’s mental health crisis system. In the coming year, the Department of Health and Human Services (HHS) will improve the Lifeline’s capacity by investing in the crisis care workforce, scaling mobile crisis services, and developing guidance on best practices in crisis response.Expanding access to telehealth services: According to the Unity Agenda, HHS will triple resources dedicated to promoting interstate license reciprocity for delivering mental health services across state lines. The Department of Defense (DOD) will also expand the BRAVE program, a virtual behavioral health center providing services 24/7 to service members and their families located on federal installations across the globe.Recruiting a more diverse mental health workforce: HHS will increase funding to expand the Minority Fellowship Program and recruit mental health professionals from Historically Black Colleges and Universities.Fighting the opioid epidemic: The administration will expand access to proven treatments, including buprenorphine, for opioid use disorder; launch a national campaign to educate young people on the dangers of fentanyl and how naloxone saves lives; and ensure every jail and prison across the country can provide treatment for substance use disorders.Supporting veterans and their families and reducing veteran suicide: The Department of Veterans Affairs (VA) will create new resources to improve suicide risk identification and increase counseling on the safe storage of firearms and lethal medications. ■ResourcesThe APA statement on the State of the Union addressFACT SHEET: In State of the Union, President Biden to Outline Vision to Advance Progress on Unity Agenda in Year AheadRemarks of President Joe Biden – State of the Union Address as Prepared for DeliveryCongress Passes Spending Bill With Several APA PrioritiesAfter 988’s Launch, Experts Emphasize More Work Needed ISSUES NewArchived

Senator Joe Manchin's Useful, but Stalled, Interstate Energy Permitting Reform

West Virginia Senator Joe Manchin spent much of 2022 pursuing an energy siting and permitting reform bill—“Building America's Energy Security Act of 2022”—that aimed to accelerate permitting of all types of American energy infrastructure to promote energy security and climate objectives, without bypassing environmental laws or state and local input. At the same time, 2022 saw actions by the Federal Energy Regulatory Commission (FERC), in the form of Notices of Proposed Rulemaking (NOPRs), that muddied permitting for both useful natural gas pipelines and electricity transmission projects in different ways, as I previously wrote about in this column in July and September, 2022. Manchin was not successful in inserting his permitting reform bill into President Biden's $1.7 trillion federal spending bill signed on December 29, 2022. But as Chairman of the Senate Energy and Natural Resources Committee, he expressed his displeasure with FERC—effectively sacking then FERC Chair Richard Glick by failing to hold a hearing on his nomination by President Biden for a second term.

Animal Alternatives for Drug Development

Animal Alternatives for Drug Development

Policy Gains and Ongoing Collaboration in the House of Medicine

Back to table of contents Previous article Next article From the PresidentFull AccessPolicy Gains and Ongoing Collaboration in the House of MedicineRebecca Brendel, M.D., J.D.Rebecca BrendelSearch for more papers by this author, M.D., J.D.Published Online:25 Jan 2023https://doi.org/10.1176/appi.pn.2023.02.2.17As I write this column in the first month of 2023, the year is already turning out to be as busy and auspicious for mental health as in 2022! We began the new year against the backdrop of the latest findings of the APA Healthy Minds Poll, which showed that more Americans rated their mental health as fair or poor in 2022 than in 2021 (37% versus 31%) and that a significant number of Americans were making New Year’s resolutions about their mental health in anticipation of more stress ahead in 2023. As mental health remains front and center in our private lives, Congress ended 2022 with bipartisan legislation that funded key policy measures to improve access to mental health care (“Congress Passes Spending Bill With Several APA Priorities”). These policy gains addressed key issues and priorities for psychiatry and APA, including legislation proposed and championed by our policy and government relations teams and on which APA members testified in the House and the Senate over the past year, myself included.These are among the highlights of gains made during the final days of the 117th Congress: the addition of 200 graduate medical education slots, including 100 dedicated specifically to psychiatry and its subspecialties; extension of pandemic-era telehealth flexibilities under Medicare; and new grants to support implementation of the Collaborative Care Model in primary care practices. While these are important wins for advancing psychiatry and mental health, they are nonetheless just a start in what is needed to address the current and ongoing mental health needs of Americans post-pandemic. We have our work cut out for us in 2023, including continued advocacy for measures to bolster the effectiveness of the 988 mental health crisis hotline with community resources and investments; addressing ongoing workforce shortages; achieving mental health parity in practice; leveraging telehealth and other innovative technology to advance access to high-quality, evidence-based mental health care; and championing patient safety.While we continue to advance our policy initiatives in Washington, we cannot do this work alone. Collaboration with other medical organizations and professional societies is a key element of boosting our effectiveness in advancing health, including mental health, and gaining momentum and support for key legislation on the state and federal levels. One critical partnership is with the AMA—our psychiatry delegation to the policymaking House of Delegates is growing in influence and size with participation of psychiatry’s subspecialty organizations. Recent contributions of our psychiatry delegation include championing 988 to obtain critical AMA support, advocating for the end of discriminatory medical licensing questions related to mental health that are more restrictive and probing than questions about physical health, and recognizing the need for additional investments in the physician workforce.As we go to press, members of the AMA delegation and APA government relations staff have just returned from the annual AMA State Advocacy Summit, which met in person for the first time since 2019. Summit participants addressed challenges facing medicine at the state level—where the majority of medical practice and private insurance is regulated—and opportunities for action and change. Many of the featured topics had key relevance to APA and our members, including addressing physician wellness through the creation of confidential resources for physicians to address well-being and burnout, eliminating discriminatory medical licensing questions about mental health, and collaboration with state medical boards. Another central issue for both APA and the AMA is patient safety related to prescriptive authority and nonphysician practice parameters; one of the topics discussed at the meeting was the emerging evidence about gaps in quality and higher spending when nonphysician professionals serve in independent roles in primary care and emergency settings. Other important areas on the advocacy agenda included insurance priorities, discriminatory prior authorization requests, continued focus on effective measures to combat the opioid epidemic, and considerations in delivering comprehensive reproductive health care following the U.S. Supreme Court 2022 Dobbs decision.Our collaboration with the AMA is continuing at this year’s AMA National Advocacy Conference in Washington, D.C., to provide a critical assessment and call to action on federal law and policy influencing health and the practice of medicine.There is no question that in 2023 state and federal advocacy for health and mental health will continue to be front and center in APA’s work on behalf of our profession, members, and those whom we serve. You can follow my efforts in real time on Twitter @Pres_APA, and, as always, I look forward to hearing from you, especially about your advocacy adventures and successes! ■ ISSUES NewArchived

Congress Passes Spending Bill With Several APA Priorities

Back to table of contents Previous article Next article Government & LegalFull AccessCongress Passes Spending Bill With Several APA PrioritiesKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:20 Jan 2023https://doi.org/10.1176/appi.pn.2023.02.2.43AbstractThe $1.7 trillion omnibus package includes many provisions for which APA heavily advocated, including new investments in the psychiatric workforce, collaborative care, and mental health parity.dkfieldingIn December, Congress passed the Consolidated Appropriations Act of 2023 (HR 2617), a massive spending bill that will keep the U.S. government funded through September.The package, which President Joe Biden signed on December 29, includes numerous APA priorities for which it has advocated heavily. They include APA initiatives focused on encouraging implementation of the evidence-based Collaborative Care Model (CoCM), enforcing mental health parity, and bolstering the psychiatric workforce.“These accomplishments as well as many others in the legislation are a great victory for psychiatry and the patients we serve and could not have been achieved without the active engagement of APA members and the dedication of APA staff,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.Some of the APA priorities in the package include the following:Collaborative care: The package includes grants and technical assistance to implement the CoCM in primary care settings for the prevention of mental and substance use disorders (SUD) and early intervention for treatment.Mental health parity: Grants for state insurance agencies were included in the package to enforce the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and ensure that insurers are complying with the federal parity law. The spending package also eliminates the parity opt-out for non-federal governmental health plans.Workforce: The package made significant investments in the medical workforce with the creation of 200 new graduate medical education (GME) residency slots, half of which are designated specifically for psychiatry or psychiatric subspecialties.Telehealth: The package extends the current Medicare telehealth flexibilities instituted due to the ongoing public health emergency. It delays the implementation of the in-person requirement for telehealth services for mental health until December 31, 2024.APA’s members and staff have initiated many of these provisions and actively advocated for them. In May 2022, in her role at the time as incoming APA President, Rebecca Brendel, M.D., J.D., provided expert testimony to the Subcommittee on Health of the House Committee on Energy and Commerce. She spoke about numerous bills that would bolster the nation’s mental health system, explaining that many insurers are not in compliance with MHPAEA and that Congressional action is needed. She also emphasized the importance of integrating mental and physical health care to enhance access and the need of primary care offices for support so they can implement the CoCM (“Incoming APA President Testifies Before House Subcommittee”).In addition, APA members and staff engaged congressional offices and deployed a strong grassroots push to encourage congressional action addressing the psychiatry workforce shortage, resulting in the 100 new GME slots reserved for psychiatry. Congress has increased the number of GME slots only twice over the last 25 years.Other APA-supported provisions within the spending package include investments in health equity. The package increased the authorizations and funding for programs to improve maternal health and for the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Minority Fellowship Program, a program in which APA participates.Additionally, the package increases funding for critical mental health and SUD programs under SAMHSA; the Centers for Disease Control and Prevention; and the National Institutes of Health, including the National Institute on Minority Health and Health Disparities.In a statement applauding the package’s passage, APA also emphasized the need for continued work. Congress did not entirely eliminate a cut in Medicare payments for physicians imposed by the Centers for Medicare and Medicaid Services. The cut, which went into effect January 1, was originally slated to be 4.5%, but Congress adjusted it down to 2%. “This runs counter to the need to improve access to care for patients, and we urge Congress to revisit this continuing challenge as soon as possible in the new year,” APA’s statement reads.“Improving mental health care is critically important for families across the country,” said Sen. Ron Wyden (D-Ore.). “I was proud to fight for measures that will bring more mental health providers into the workforce and boost access through innovations like telehealth. There’s still more work to do, but the accomplishments in this legislation are a promising start for Americans that need mental health care.” ■APA Statement on Mental Health Provisions in Federal End-of-Year Spending Package ISSUES NewArchived

Spending bill for 2023 includes major benefits for treatment of mental illness

At the end of 2022, Congress approved (and President Biden signed it, just in time to avert a government shutdown) a spending bill that includes measures to reauthorize vital mental health and substance use programs.

Recent Developments in U.S. Climate Law: Judicial Retrenchment and Congressional Action

Abstract The United States signed the United Nations Framework Convention on Climate Change in June of 1992. For nearly 30 years thereafter, Congress remained gridlocked and unable to pass significant climate change legislation. During that time, the executive branch was the main forum for the development of federal climate policy, forcing the Environmental Protection Agency (EPA) to creatively reinterpret 1970s legislation to deal with climate change. The situation changed in two crucial ways in 2022: The Supreme Court’s decision in West Virginia v. EPA reined in EPA’s authority, and Congress finally enacted major climate legislation in the form of a multi-billion dollar tax and spending bill. These two events will shape the future of US climate efforts.

Research Gets Funding Boost for FY 2023.

The federal spending bill enacted by the U.S. Congress in December for fiscal year 2023 totals $1.7 trillion, a sum that includes increases ranging from 5.6% to 6.5% for the NCI, NIH, and FDA. The increase for the NCI is positive news overall, but cancer research advocates say greater increases are needed to meet NCI's goal of raising the payline to the 15th percentile by 2025.

Perils of eliminating the x‐waiver: Comments from former CSAT official

A highly unusual meeting took place in 2014—a group of experts, including federal officials, and top legislators – namely, former senators Carl Levin (D‐Michigan) and Orrin Hatch (R‐Utah) met in June of that year to discuss changing the Drug Addiction Treatment Act of 2000 (DATA 2000), which regulated buprenorphine prescribing up until it was eviscerated in the spending bill last month (see https://onlinelibrary.wiley.com/doi/epdf/10.1002/adaw.20431). The lawmakers wanted to raise the maximum number of patients one physician could have (at the time, it was 30 under DATA 2000, and 100 under the 2006 amendment; since then it has been raised further).

More on the funding additions for SUD treatment and prevention

The “omnibus” spending bill, passed by Congress and signed by President Biden last month (see https://onlinelibrary.wiley.com/doi/10.1002/adaw.33651), has too many important additions for substance use disorder (SUD) prevention and treatment to occupy even a few issues, so we will be shedding more light on what the law contains in coming weeks. The Substance Abuse and Mental Health Services Administration (SAMHSA) will be undergoing bigger changes than it has in more than two decades.

Spending bill includes X‐waiver elimination, more

To avert a government shutdown and get key provisions into the spending bill before a new Congress is seated this month, Congress and President Biden passed and signed a spending bill for fiscal year (FY) 2023 on Dec. 23. The $1.7 trillion proposed appropriations bill, referred to as an “omnibus,” includes proposed spending for the National Association of State Alcohol and Drug Abuse Directors’ (NASADAD) priority programs within the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention, the Health Resources and Services Administration (HRSA) and other federal agencies.

Year in review 2022: Big changes proposed for field

The end of 2022 saw a culmination of many reforms addiction treatment providers have long fought for, mainly, proposals by the Substance Abuse and Mental Health Services Administration (SAMHSA) to reform methadone treatment by keeping opioid treatment programs (OTPs) in control but making it easier for patients to get take‐homes; and a vast spending bill signed into law by President Biden at the very end of the year that allows buprenorphine to be prescribed without a waiver, and much more (see page 3).

The macroeconomic effects of funding U.S. infrastructure

This paper quantitatively assesses the macroeconomic effects of the recently agreed U.S. bipartisan infrastructure spending bill in a general equilibrium model with a mix of neoclassical and new-Keynesian features. We add to the relevant literature by allowing for a more detailed tax structure, different types of infrastructure spending and linkages between the final and intermediate goods sectors. We find long-run output multipliers above unity if the rising public debt, triggered by the increase in infrastructure spending, is stabilised by rises in consumption, dividend and labour income taxes and less than unity for corporate taxes. We also find that self-financing rates associated with infrastructure spending are not generally above 50% despite underprovided private and particularly public capital. Finally, a sensitivity analysis reveals that intersectoral linkages and zero-interest rate policy are critical determinants of multiplier size.