By Alexander J. Gajewski and Isabel A. Draper
Political engagement is neither a grandiose pursuit available only to the wealthy nor a technical venture best left to policy professionals. I worked in local advocacy, the Texas Senate and the U.S. Senate, often on mental health policy, and saw how an individual can be an effective advocate at each level. An advocate only needs professional or lived experience, a steadfast commitment to their cause and a bit of political know-how.
Here is what I have learned about the basic political knowledge needed to generate public policy at the local, state and federal level.
The first step in advocacy is to concisely organize your thoughts. Write down relevant anecdotes, practice presenting them and collect data whenever possible. This process should force you to be specific when articulating what policy reforms are needed. Specificity is key to moving policy experts to action.
The second step to advocacy is active involvement in local health councils to develop relationships with people who have had similar experiences. If five professionals or advocates unite, for example, to voice a complaint with a local Health Maintenance Organization, the collective perspective is more powerful than a single person’s argument.
This strategy is particularly important when it comes to mental health parity enforcement. Parity laws require insurers to cover mental health services without any greater restrictions than those imposed on physical health services. A compelling complaint regarding an insurance company’s failure to comply with parity standards would describe differences between the coverage of a mental health service and a comparable physical or surgical service. So, to make an effective argument, advocates need data from both a mental health practice and, say, a primary care provider.
If you suspect a patient’s parity rights are being violated, ask your local pediatrician how the insurance company handles reimbursement for annual check-ups. With data in hand, file a complaint with your state’s parity ombudsman or insurance regulator, and consider bringing your case before local councils, city or county agencies or the state legislature.
Mental health care is a pressing issue across the country and lawmakers want to learn from your lived experience. That said, it is important to know the right and wrong times to engage with your state representatives. Most states have annual legislative sessions. If you bring a new idea to a legislator during session, the lawmaker and their staff will be too busy to do more than smile and thank you for your time. In contrast, if you come in four to six months before the session, the legislative staff can work with you to develop a bill.
What you bring to your representative matters. For a bill to be written, someone has to describe a problem, propose a solution, determine how the solution can be enacted through a change to state law, vet the specific proposal with those likely to be impacted and address concerns or modify the proposal accordingly. Although you do not need to know how to write a bill, you should do your best to suggest changes to specific laws, and if you are comfortable doing so, vet the policy with stakeholder interest groups. The more legwork you do upfront for legislative staffers, the more likely your policy proposal will become a bill.
The most important factor in whether a bill moves or stalls is its cost. Ideally, your policy would be free for the state government. Imagine you are proposing an insurance coverage mandate for a new substance use disorder treatment. You might consider excluding state-run health insurance plans (e.g. the Teacher Retirement Service) to avoid incurring a cost to the state budget. If you anticipate your bill will have a price tag, start several months earlier and pursue the support of the committee chairs in charge of the relevant portion of the state budget.
Once your bill is filed, talk to the relevant committee chair’s staff and ask them to consider the bill in a committee hearing. If the bill gets out of committee, you need enough votes for the entire assembly to pass it. Local advocacy organizations and your chosen representative can help you educate the rest of the chamber. Depending on the bill, the distribution of a one-page brief may be enough. Rinse and repeat in the other chamber.
Much of the state-level advice applies to advocacy at the federal level as well. Prepare thoroughly and talk to your representatives when Congress is in recess. As you draft your policy, keep in mind that a bill stands a better chance of passing if it has a small but nonzero price tag. Items that affect the budget can be passed in a reconciliation bill that requires the support of just 50 Senators, whereas traditional legislation needs 60.
Begin your process by speaking with your representatives and ask for an official draft of the bill. Once you have this “legislative text,” pursue an official Congressional Budget Office (CBO) cost estimate. Cost estimates are difficult to obtain without the support of a powerful office in the House or Senate; so, you might ask staffers of the Ways and Means, Energy and Commerce, Appropriations, Budget, or Finance committees for assistance. Once you have bill text and a CBO estimate, urge both the bill’s author and any committee staffers you have briefed to include your bill in every legislative package that comes under consideration.
Mental health is a hot topic on the Hill and will be for the foreseeable future. There are multiple major bipartisan mental-health-related packages in development. Now is as good a time as any to bring forward your ideas.
If any of the steps do not go in your favor, you should try again at the next local council meeting, during the next legislative session or when the next big legislative package is being written. While much in this process will be outside of your control, you should pursue policy change at every level of government and remember that slow and steady wins the race.
Alex Gajewski is a medical student at the University of Texas Southwestern Medical Center. Previously, he served as an intern in the Texas State Senate and as a fellow with the U.S. Senate Finance Committee. In the latter role, he co-led preliminary work on comprehensive mental health care access reform.
Isabel Draper is a third-year medical student at Baylor College of Medicine in Houston, Texas.
She is interested in the intersection of psychiatry and social determinants of health. In her free time, she enjoys reading, biking, and playing with her 14-year-old rescue chihuahua, Kermit.
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