Creating an Agenda and Developing Legislation

Health policy rules, regulations, and legislation are the results of a policy process involving legislators, executive branch leaders, influential stakeholders and the general public. Although the development of health policy can take place at all levels of government, the discussion in this section focuses on legislation at the federal level. The process is similar at each government level, although the strength of the stakeholders may vary somewhat depending on the policy and the government level.

Before policy evolves through the legislative process, it must develop from a policy stream through agenda setting.


For an issue to become important enough to be addressed in legislation, the emergence of a major issue usually proceeds action.

The policymaking process is initiated through the emergence of some subsequent movement. As mentioned in the previous session, the Clinton health policy action was based on a recognized concern among the American public about the escalating costs of healthcare. And Clinton only jumped on the political bandwagon. Harris Wofford won a special senatorial election in 1991 after the death of the sitting Senator, Republican John Heinz. Harris Wofford, a Democrat, won the special election on the single issue of healthcare. Clinton found the buzzword appealing to the electorate and used the issue as a major campaign strategy in 1992. Interestingly, Harris Wofford was defeated in the mid-term elections of 1994, when Republicans swept into power in both the Senate and House of Representatives, in part because of the failure of Clinton's healthcare bill.

The AIDS epidemic that presented itself in the 1980s took longer to develop, primarily because of the constituents that were being affected. Most Americans cared little about the plight of homosexuals, but once the disease began to infect across heterosexual lines - particularly as children became infected with the disease - did government include the fight against AIDS as an issue worthy of an Agenda. President Ronald Reagan did not even mention the word AIDS, until 1985 - nearly four years after the onset of the epidemic - and only until Ryan White, an adolescent hemophiliac became infected.

President George W. Bush's Homeland Security Legislation provides a perfect example of the emergence of an issue that all side could rally around and take into action quickly. In this case, most of the problems will have to be worked out as the new Department of Homeland Security gains experience in the agenda initiating process.

There are a number of problems that merit consideration for policy. Even within health policy, as we discussed previously, there are a myriad of issues that require attention. The amount of "noise" surrounding that particular issue will help determine the level to which the issue may make its way onto an agenda. Beforehand, there are a number of events that will impact whether an issue sees the agenda light of day. The way problems emerge are critical in determining whether they will be put on agenda. The development of legislation is a complex process that angles all of the interest groups into coalitions to support or defeat proposed legislation. Even if the issue moves from the agenda process to the legislation process, there is no assurance that passage of the legislation will be forthcoming (think Clinton's Healthcare Security Act of 1994). Only a small number of from the universe of potential problems ever emerge from the agenda setting process to the legislative action. Policy makers submit specific legislative proposals - one can think of these as potential solution in the chart above. The path can be a very long and winding road indeed.

Kingdon refers to agenda setting as a process of a "confluence of 'streams' if activities": problems, possible solutions, and political circumstances. The policy is the result of the process coming together during a favorable setting or "window of opportunity". Problems alone won't justify legislation, there must also be agreeable solutions.

Not every problem can be addressed by policy development. Usually, a problem must be urgent or important.

Possible Solutions
Alternative solutions vary in size and scope and the results can slow policy making as the merits of all possible solutions are considered.
Each choice has its own proponents and opponents. This can lead to "analysis paralysis" and inaction. Each of these decisions can thus make the process chaotic.
An example is viewed by examining several of the options given to controlling health care costs. Health care research provides policy makers with alternative solutions. Research helps to develop facts about the problems and identify solutions to address those problems. Research informs and thus influences the policy decision process.

The Rational Model of Decision Making Provides a backdrop for the decision making process. But implementing the model at the policy making level is much different from the private sector. Thus, the criteria for evaluating alternatives can be different. That is because the decisions that are made have much more wide sweeping consequences than they do at the private level. Their scope of impact is much broader.

While costs and benefits are often employed at the public and private policy making levels, the decisions made in the public sector are required to reflect greater political sensitivity to the public at large as well as the preferences for individual constituencies and interest groups.

Political Circumstances
The political circumstances regarding each problem and potential solution is important because getting policy makers to take action can be one of the most complex and difficult processes in the window of opportunity.
Competing interests can determine the direction of the policy making process. In addition, one policy and the support for that policy may be overshadowed by other political events or policy decisions that are deemed to be more appropriate.

When a nation is involved in serious threats to its national security or its civil order, or when a state is in the midst of sustained recession, health policy wil be treated differently than when policy makers are less preoccupied with other, perhaps more urgent concerns. The factors that impact the window of opportunity include public attitudes, concerns, and opinioins surrounding the combiation, the preferences and relative ability to influence poliitical decisions of various groups that have an interest in the problem or in the way in which it is addressed; and the positions and views of key involved policymakers in the executive and legislative branches of government.


Only a fraction of all proposed legislation actually becomes law. Congress meets annually to consider legislation. Any proposal not enacted by the end of the congressional session dies in the legislative process and must be re-introduced in a new session if it is to become a new law.

Ideas that emerge from agenda setting are called bills.  Proposed legislation can also take the form of a resolution. Practically, there is no difference between the two.

Origins for a Bill
Bills are proposed by mebers from the House of Representatives or the Senate. In the House, bills are typically referred to as House Bills while in the Senate they are referred to as Acts.

Although most bills are proposed by legislators, the origins of their ideas can come from a variety of sources including constituents, interest groups, and the president. Increasingly, legislation has been proposed through "executive communication". However, no matter who proposes the legislation, only members of congress can actually introduce legislation.

Drafting Legislation
It is usually the staff of the bill's sponsor that drafts the legislation. The executive branch may also draft legislation, though it must have a sponsor in the Congress. Because only Congressional members can actually sponsor proposed legislation, they are ultimately responsible for the language in the bill.

Introducing Legislation and Referring to Committees
On occasion, identical bills are introduced in both the Senate and the House of Representatives. Numbers for the legislation are assigned sequentially. They are then referred to the appropriate standing committee or committees - those committees that have jurisdiction in the area of the bill..The Speaker of the House (Dennis Hastert) is the highest official in the House of Representatives and is elected by members. The speaker is always selected by the majority party in the House. In the Senate, the Vice-President is officially the presiding officer of the Senate, but the power belongs to the Senate Majority Leader (Thomas Daschle). There are minority leaders in both the House (Richard Gephardt) and the Senate (Trent Lott).

Legislative Committees
Both the Senate and the House of Representatives are organized into committees and subcommittees. The Chairmen of the committees and subcommittees are also from the majority parties. There are currently 19 standing committees in the House and 16 in the Senate. At times, a bill may be assigned to more than one committee either jointly, or more commonly sequentially. The Health Security Plan was an example of this process. It was referred to ten House committees and two Senate committees. Each committee has a professional staff to assest with administrative details of the hearings. It is while a bill is in committee that the public and interest groups have the opportunity to testify in support or against a bill.

Committees with Health Policy Jurisdiction
Most general health bills are referred to the House Committee on Commerce and to the Senate Committee on Labor and Human Resources. However, any bills involving taxes must also be routed through the House Ways and Means Committee and the Senate Finance Committee.

Committe on Finance and Subcommittee on Health Care. Senate committee with jurisdition over all bills that relate to health programs under the social security Act and to health programs financed by a specific tax or trust fund (includes oversight on Medicare and Medicaid).

Committee on Labor and Human Resources (includes subcommittee on Agin, Subcommitte on Children and Families, and Subcommittee on Public Health and Safety. (Bills related to health personnel, Public Health Service Act, the Federal Food, Drug and Cosmetic Act, and Developmental Disabilities Assistance and Bill of rights Act.

Committee on Appropriations (Subcommittee on Labor, Health and Human Services, and Education, Subcommittee on Veterans Affairs, Housing and Urban Development, and Independent Agencies.

Committee on Ways and Means - (Subcommittee on Health) House committee with jurisdiction over bills that pertain to providing payments from any source for health services.

Committee on Commerce - Subcommittee on Health and Environment - oversees all bills related to Medicaid, Medicare Part B, public health, health personnel, mental health and research, biomedical research and development programs; HMOs, food and drugs, drug abuse.

Committe on Appropriations (subcommittee on Labor, Health and Human Services, Housing and Urban Development, Independent Agencies, Subcommittee on Agriculture, rural Development, food and drug administration. Jurisdiction over appropriations for HHS, FDA, and VA.

Reporting out of Committee/Subcommittee
Following a committee hearing, members of the committee "mark up" the bill. This means going though line by line and making changes or amending a bill. If there are similar bills being considered, they may be combined at this time. If a bill is reported out of committee favorably, a member of the committee staff in the name of the committee member writes the committee report. This report describes the purposes and scope of the bill and the reasons why the committee recommends it approval by the House or Senate. Any bill that does not come out of committee generally "dies" in committee and may be re-introduced at a later session.

Action on the Floor
The House or Senate receives the bill being considered out of committee and places it on the legislative calendar for floor action. Further debate on the House or Senate floor can take place at this time. Amendments to the bill can also be considerred from the floor. If a bill passes through the House or Senate, it is then referred to the other chamber where referral to a committee or subcommittee once again takes place to consider the bill. At this point, the bill goes through another set of hearings, markup, and eventual action. Any bills that are approved by the other chamber but have revisions to the previous bill is then sent to conference committee for action.

Conference Committee Actions on Legislation
Differences in bills that pass both Chambers of Congress are worked out in conference committee. Conferees are usually the ranking members of the committees that reported out the bills. If they reach agreement, a conference report is written and is then voted on by both Chambers. If they cannot reach agreement or if either chamber does not accept the conference committee report, the bill dies. If both chambers approve the bill, it is sent to the president for action.

Presidential Action on Proposed Legislation
The President has several options regarding proposed legislation. He can sign it and the bill becomes law immediately. He can veto the bill which rejects the bill.  A two-thirds majority of both chambers is needed to over-ride a veto. Or the President can decide not to sign or veto the bill. If that happens, the bill becomes law in ten days, but it is clear that the president does not support the bill.