Emergency Medicine Advocacy Handbook

Ch. 18. All Politics Is Local

Kira Gressman, MD; Nikkole J. Turgeon, MD; Nicholas P. Cozzi, MD, MBA; Puneet Gupta, MD, FACEP

Chapter 18. All Politics Is Local

Recorded by Sabrina Bawa, MD | University of Connecticut

Emergency physicians are uniquely positioned to be powerful voices in health policy. But to be effective advocates, we must understand health policy history and appreciate the various state and local structures where policy lives and grows. This will equip the next generation of emergency physician leaders with applicable and time-tested strategies to generate patient-centric policy changes.

Taking that first step into the world of health politics can feel daunting. Look first in your own backyard. Health policy changes made at a local level can have the strongest impact.

Why It Matters to EM and ME

Because EM serves as a social safety net, emergency physicians are often the first to see downstream effects of policy. Seeing policy’s direct impact on our patients is exactly why emergency physicians make powerful local voices. Bearing witness to harmful effects of policy can inspire action through advocacy and health policy.¹ Policies that constrain physicians’ ability to act in accord with their individual and professional ethical values can result in moral distress and lead to burnout.² Being active in policy can empower emergency physicians to stand up not only for the welfare of our patients but also for ourselves.

Medicine, especially EM, is inextricably linked with politics that affect the health of our patients, ourselves, and our ability to practice. In 2001, the AMA adopted the Declaration of Professional Responsibility - an oath by which 21st century physicians reaffirm and uphold medicine’s social contract with humanity. This oath included the commitment of all physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”³ Advocacy through policy is a core tenant of our jobs and a skillset worth investing in at all levels.

How We Got to This Point

Medical care in our society does not occur in a vacuum and, unfortunately, has never been apolitical. The American Medical Association (AMA) was founded to regulate medical education and licensure in order to raise professional standards. By 1901, the AMA had grown to become a confederation of local and state medical societies that represented the majority of delegates at the national AMA conference.⁴ The AMA House of Delegates serve as liaisons between the AMA and grassroots physicians. The delegates are a key source of information on programs and policies of the AMA.⁵ The formation of the state medical societies resulted in an explosive period of growth for the AMA, and its members accumulated political power and financial clout.⁴ Paul Starr writes in his book “The Social Transformation of American Medicine,” that physicians “had a lot of cultural authority” and were not shy about using their community contacts to shift public opinion.⁶

Over the next several decades, scientific discovery and academic advancements spurred the formation of new specialties and the creation of corresponding specialty medical societies. The role of specialty societies is to advocate for policies specifically related to patients within that specialty. As these societies grew, the historic majority of state delegate representation dwindled to approximately half of the delegates to the AMA.

In 1968 the American College of Emergency Physicians was founded as physicians worked to attain specialty board recognition. Four years later, the AMA recognized emergency medicine as a specialty,⁷ and in 1979 the American Board of Medical Specialties approved the American Board of Emergency Medicine to be the certifying agency for the new specialty. Unlike most other specialties, EM arose out of a progressive social demand for services linked to the moral and ethical aspects of providing care for poor and uninsured people.⁸ In1986, the egalitarian mentality of EM, “take anyone, with anything, anytime,” became more than a philosophy with the passage of the Emergency Medical Treatment and Labor Act (EMTALA) signed into law - in essence creating a federal right to emergency care for all people in the U.S.⁸

Today, EMRA and ACEP are allotted delegates who represent EM as a specialty to the AMA. This relationship seeks to be an avenue where the greater emergency medicine specialty as a whole is advocated amongst the house of medicine. To better understand this interplay, let us use the ACEP workforce study report as an example.⁹ At the AMA, advocacy efforts to expand residency positions are taking place. Emergency medicine is undergoing a transformation with workforce supply and demand economics taking center stage. Delegates at the AMA were able to explain the needs of EM and advocated for targeted expansion of residency positions. Being able to represent the needs of the specialty is invaluable and imperative.¹⁰

You might be wondering why is it important to understand this history to participate in advocacy or policy now? One reason is because these organizations are still operating in the political arena and are often the main ways for someone to get involved in health policy and advocacy. For example, the AMA is among the top five lobbying groups in the U.S.¹¹ Understanding the historical context and power dynamics of health policy organizations will help you be a better advocate.

Current State of the Issue

Let us consider how organized medicine functions within state and federal policy more broadly.

Comparing State versus Federal Policy

It is first important to compare state versus federal policy and how they interact. One of the most glaring distinctions is their constitutional scope. State level policy is more granular whereas federal is broader.¹ Many topics have a state and a federal component and the lines may become blurred. Consider Medicaid, where funding is set at federal level but decisions on expansion occur at the state level.¹⁰ If federal and state laws are incongruent, the federal law overrides. A state cannot create a law adding restrictions to an existing federal policy, but states can write laws for additional freedoms. If an issue does not have a corresponding federal law, policy automatically defaults to the state level. One timely example is the Supreme Court overturning Roe v. Wade (410, U.S. 113), effectively deflecting abortion legislation to states. If a state policy exists, this becomes the active law at the state level. This remains true even if it is an old law, since state laws are not typically removed.¹¹

Justice Louis Brandeis inspired the common phrase, “States are the laboratories of democracy.”¹² Policies are often trialed at the state level before implementing a model on a federal scale. For instance, the Affordable Care Act was modeled on policy first established in Massachusetts.¹³ In a crisis, an issue may need to quickly jump to the federal level - take PPE access during the COVID-19 pandemic, for example.¹⁴ Other times, a particular issue might get stuck at an impasse federally or there is a concern that a federal approach will infringe on states’ rights. In these cases, policymaking falls back to the states. One example is tort reform that would involve enacting legislation to limit the impact of medical malpractice litigation on physicians. For years, federal legislators have resisted efforts to enact medical tort reform, preferring to leave those decisions to the states. Advocacy efforts have likewise evolved, and resources have shifted from federal tort reform advocacy to state tort reform advocacy. When switching between levels of policy or geography, it is important to revisit the “ask” and evaluate how your approach should change.¹

The timelines of state vs federal policy also differ. State-level changes may occur more quickly, sometimes on the order of months to a year (of course, not every issue sees rapid change).¹⁴ Each state’s legislature has a unique schedule. The majority of states pass new bills over designated months each year, most frequently from January to June, while others have a year-round legislative schedule.¹⁵ You should be aware of your respective state’s policymaking schedule and utilize your specific issue’s network to know when there is legislative activity.¹⁴ Quick policymaking can be an advantage if the legislation addresses your community’s needs; it can also be negative if harmful legislation is passed rapidly.¹⁴ Federal policy, on the other hand, can take much longer, on the order of years. Consider the question of universal health care - this has been revisited by multiple presidential offices since the AMA campaigned against Truman’s proposal in 1950.^1,16 There is a significant amount of federal red tape; once something is implemented nationally, it becomes very challenging to remove or amend it.¹⁴

Equity in health policy is also different at each level. At a local or state level, a policy can specifically address a community’s unique needs. In rural states, a few voices may actually have a larger impact. While a federal level can be used to protect rights broadly, making a policy equitable becomes much more challenging when trying to take into account the variability across such a large population and geography.¹⁴

Relationship Building

Building relationships is a key piece of policy work, at all levels. However, it is much easier to do so at a local or state level where you can readily schedule meetings with legislators and provide insight about the unique needs of your patients, who are also their constituents. It is more difficult to build deep relationships at a federal level.^1,13 The majority of health policy issues are regulated at a state level.¹⁹ While Washington, D.C., gets more press and can seem more glamorous, we can make the biggest impact locally.^13,17 This is where personal narratives shine, where we have meaningful relationships and networks, and most closely see the impact of policy changes.¹⁸ Any advocacy that you can keep local, do so.¹⁰

Relationship building is not limited to just the legislators but an extensive group of individuals including constituent groups, lobbyists, staff, legislators, regulators, and more. At the local and state level, ACEP state chapters work with groups like state medical societies, departments of health, local community organizations, and constituents. Additionally, approximately 60% of ACEP state chapters have lobbyists.¹⁴ While not essential, lobbyists are effective because they are policy experts and understand how to navigate the system. Lobbyists can facilitate networking, set up meetings, and provide topic resources. ACEP is aware of the chapters without lobbyists and provides them with additional support.^13,14

It is often useful to join forces with the state medical society because they will also have resources available. When state ACEP chapters have similar issues, they can also communicate with the ACEP Director of State Chapter and State Relations who works to ensure ACEP state interests are represented, connect state chapters on similar issues, and provide resources such as assistance with writing testimonies.¹⁴

How to Be Effective in Health Policy Advocacy

We have established that emergency medicine policy advocates can be most effective at a local level. Below are strategies gathered from emergency physicians involved in policy on how to do it well.

Be informed. Know the basics and know your limits. “Describing policy perspectives to legislators is like explaining medical issues to a patient.” Balance helping them understand the issue without being condescending or overly simplistic.¹⁸ Recognize that you may not be a topic expert; find someone who is and advocate alongside them.¹³

Share stories and anecdotes. You are advocating for your patients; ensure that your narrative reflects that and be prepared to explain how your policy position represents what is best for your patients.^10,19 Keep a list of anecdotes that can be used for testimonies later.

Find your networks and be hyper-aware of your community. Who else is already involved in your issue? Who else will be impacted? What has already been done? Identifying existing efforts and networks to join is easier than reinventing the wheel. Talk with community members and organizations to understand their perspective and whether they believe a proposed policy will have a desired impact. Different partners may have varying ways to approach the issue.¹⁸

Define your boundaries and play the long game. Understand at what point you are prepared to draw a line and lose completely. Also, as stated by Dr. Arvind Venkat, “recognize when it is important to compromise to give the opposing side a win that also functions as a win for yourself.”¹³ Do not let perfection be the enemy of the good.

Strategic timing is crucial. What other factors are playing a role in the timing of a bill or issue? “It is a skill to recognize when something should be delayed,” or when it is the right time to revisit an issue.¹

Tailor your points to your audience. A proposed policy change may look the same in different states, but the arguments underlying them might be different. Understand the goals and priorities of your legislators to better frame your arguments, anecdotes, and approach.¹⁷

Look for opportunities to bridge ideas together into a larger product. Is there a way to add one issue into a larger, broader bill? Take advantage of these opportunities because they can increase the chance of advancing your issue.¹

Be prepared to work across the aisle. While it is fine to have personal opinions and political affiliations, you can be most effective in policy if people know you are willing to listen and engage with people who might think differently than you.¹⁴ Many health policy issues are an opportunity to garner bipartisan support and this is often what is needed for it to pass. If you are working on a wedge issue, understand the opposing side’s thinking and decide how best to center the narrative around what is best for the patient.

Build and cultivate relationships – before there is a crisis. “A lot of times, having the relationship will trump partisanship.”¹ Relationships with your community networks and state legislators do not happen overnight - it takes time and patience. You want to develop longitudinal relationships with people so that when bad legislation or a policy emergency arises, they will be more likely to listen to you.¹⁴

Moving Forward

The Code of Ethics for Emergency Physicians in EMRA’s Policy Compendium states, “Support societal efforts to improve public health and safety, reduce the effects of injury and illness, and increase access to emergency and other basic health care for all.”²⁰ Being health policy advocates is one of the most impactful ways we can do that.

Of course, there are many challenges. Sub-optimal bills become law. We can lose advocacy battles. When this happens, it is imperative to maintain relationships with legislators; you may want them to revisit the issue later or continue working with them as an advocate for other important issues. Start collecting data and stories of how you and your patients are impacted. After time has passed with that legislation in place, come back with new information and make your case.¹⁴ Other times, no legislation is passed when it needs to be. Consider mental health access. In the state of Washington, there was a set of legal and legislative victories almost a decade ago that seemed primed to improve emergency mental health resources. Years later, nothing new has passed and the state ranks very low for mental health care resources compared to other states.¹⁸ When these obstacles occur, we must be persistent and continue moving forward - “Not doing anything is worse.”¹⁸

The path to being an emergency medicine advocate will be different for everyone. Regardless of where you start, the journey is worth the challenge. If you are looking for a group to join, EMRA, ACEP, state ACEP chapters, and the AMA all have active advocacy activities and interested groups. As you consider a group, look for the mentors and opportunities to learn from them. Take the opportunity to share your passion or work as well. Join those groups and become an advocate on an issue by visiting with legislators. If your passion is there for federal advocacy, consider participating in ACEP’s annual Leadership and Advocacy Conference in Washington, D.C., and help represent your state with other emergency physicians. Regardless of the avenue, educate yourself on the issues that are important to you and your patients.

Taking that first step into the world of health politics can feel daunting. Maybe you feel overwhelmed not knowing where to start. Never let concerns about your age or level of experience prevent you from getting involved. Legislators want to hear from us! No matter your level of training, you have something to bring to the table.¹⁰

• Health policy advocacy is a core tenet of EM’s history and ethics.
• Emergency physicians can and should play a key role in mitigating health disparities through health policy advocacy.
• Understanding the processes and actors for local and federal health policy, as well as the history of organized medicine, is helpful to be a strong health policy advocate.
• Health policy changes made at a local level can have the strongest impact.
• Effective health policy advocacy is grounded in powerful storytelling and cultivating relationships with local legislators.

References

1. Terry A, Turgeon N. Health Policy & Advocacy Interview. May 2022.
2. Dzeng E, Wachter RM. Ethics in Conflict: Moral Distress as a Root Cause of Burnout. J Gen Intern Med. 2020;35(2):409-411.
3. American Medical Association. AMA Declaration of Professional Responsibility. https://www.ama-assn.org/delivering-care/public-health/ama-declaration-professional-responsibility. Published December 2001. Accessed May 18, 2022.
4. Marks C. Inside the American Medical Association’s Fight Over Single-Payer Health Care. The New Yorker. February 22, 2022.
5. American Medical Association. Delegates & Federation Societies. American Medical Association - HOD Organization. https://www.ama-assn.org/house-delegates/hod-organization/delegates-federation-societies. Accessed May 18, 2022.
6. Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. Basic Books; 2017.
7. Suter RE. Emergency medicine in the United States: A systemic review. World J Emerg Med. 2012;3(1):5.
8. Zink B. Social Justice, egalitarianism, and the history of emergency medicine. Virtual Mentor. 2010;12(6):492-494.
9. American College of Emergency Physicians. Workforce Progress. EM Physician Workforce of the Future. https://www.acep.org/life-as-a-physician/workforce/workforce-progress---june-21-2021/. Published August 5, 2021. Accessed June 5, 2022.
10. Spadafore S, Gressman K, Turgeon N. Health Policy & Advocacy Interview. May 2022.
11. Open Secrets. Top Spenders in Lobbying. April 2022. https://www.opensecrets.org/federal-lobbying/top-spenders. Accessed May 18, 2022.
12. Greve MS. Laboratories of Democracy. American Enterprise Institute. March 31, 2001.
13. Venkat A, Gressman K, Turgeon N. Health Policy & Advocacy Interview. April 2022.
14. Monroe H, Gressman K, Turgeon N. Health Policy & Advocacy Interview. April 2022.
15. Saucedo S. 2022 State Legislative Session Calendar. National Conference of State Legislatures. https://www.ncsl.org/research/about-state-legislatures/2022-state-legislative-session-calendar.aspx. Updated June 1, 2022. Accessed June 5, 2022.
16. Eldred SM. When Harry Truman Pushed for Universal Health Care. History. Published Nov. 12, 2019; updated Nov. 20, 2019.
17. Khoury R, Gressman K, Turgeon N. Health Policy & Advocacy Interview. May 2022
18. Kang C, Gressman K, Turgeon N. Health Policy & Advocacy Interview. April 2022.
19. Shoemaker J, Gressman K, Turgeon N. Health Policy & Advocacy Interview. May 2022.
20. Wiler JL, Bowen J. EMRA Policy Compendium: Section II – Emergency Medicine Workforce; Item III – Code of Ethics for Emergency Physicians. Emergency Medicine Residents’ Association. 2005.