A Community of Exceptional Nurses
Thousands of bills are introduced as proposed new laws during every session of Congress.
The federal legislative process is complicated and Congress often considers proposed
bills for months or years before a bill becomes law. Anyone may draft a bill; however,
before it can be introduced in the U.S. House of Representatives or Senate a member
of Congress must sponsor it. State legislative processes are very similar to the
federal process, although fewer bills are introduced and can often be enacted in
a period of days.
Many sources draft legislative proposals. They include members of Congress, individuals
or groups of constituents, coalitions, lobbyists and congressional committees. The
president is the main source of legislative proposals through "executive communications
originating from the executive branch." Identifying the source of a proposal can
reveal a lot about it and its chances of passage.
There are four basic forms of congressional action: bills, joint resolutions, concurrent
resolutions, and simple resolutions. An amendment is a rider to any of the actions
and if passed is incorporated into the original measure.
The official legislative process begins when a bill or resolution is numbered, -
H.R. signifies a House bill and S. a Senate bill - referred to a committee and printed
by the Government Printing Office. Frequently, a senator and a representative sponsor
identical or "companion" bills in their respective legislative bodies.
With few exceptions, bills are referred to standing committees having proper jurisdiction
in the House or Senate according to carefully delineated rules of procedure. Committee
chairs have great discretionary power and can delay, block or expedite action on
measures with few restrictions.
A senator or a congressman who is a member of the Committee has a much greater opportunity
to influence a particular piece of legislation. The Committee staff is a key resource.
Committee staff are frequently experts in their field. Their duties include drafting
the legislation (per the member's instruction), advising and counseling Committee
Members and writing the Committee Report to the legislature.
When a bill reaches a committee it is placed on the committee's calendar. A bill
can be referred to a subcommittee or considered by the committee as a whole. Committees
carry out the central functions of Congress. They process bills that have been introduced,
investigate the need for new legislation and oversee the Executive Branch within
their areas of jurisdiction. Committees and subcommittees are where the decisions
about the content and language of the bill are made.
Committee actions include:
Often, bills are referred to a subcommittee for study and hearings. Hearings provide
the opportunity to put on the record the views of the executive branch, experts,
other public officials, supporters and opponents of the legislation. Testimony can
be given in person or submitted as a written statement.
When the hearings are completed, the subcommittee may meet to examine or "mark up"
the bill, usually section by section, to make changes and amendments prior to recommending
the bill to the full committee. A subcommittee may elect to report the bill out
favorably or unfavorably to the full committee, or it may decide to "table" the
bill and take no further action.
After receiving a subcommittee's report on a bill, the full committee can conduct
further study and hearings and may repeat the entire process of the subcommittee.
The full committee then votes on its recommendation before voting to report the
bill out to the full House or Senate. They may report it as it was introduced, with
amendments, or as a "clean" bill - a new bill incorporating all the amendments made.
This procedure is called "ordering a bill reported." If the committee fails to report
the bill, the measure is dead and with few exceptions cannot proceed. This is the
stage where most bills die.
After a committee votes to have a bill reported, the committee chairman instructs
staff to prepare a written report on the bill. This report describes the intent
and scope of the legislation, impact on existing laws and programs, position of
the executive branch, and views of dissenting members of the committee.
After a bill is reported back to the chamber where it originated, it is placed in
chronological order on the calendar. In the House there are several different legislative
calendars, and the speaker and majority leader largely determine if, when, and in
what order bills come up. In the Senate there is only one legislative calendar.
In the House, the bill normally must clear the powerful Rules Committee, which directs
bills to the floor for debate. The Rules Committee can specify a "closed rule,"
which means amendments can only be offered on the floor by members of the committee
that handled the bill. An "open rule" may be granted by the Rules Committee, which
means that any House member can offer an amendment. The Rules Committee can also
delay or kill a bill by majority vote refusing to grant a rule. The Senate's Rules
and Administration Committee is responsible for general administration in the Senate
and does not exercise any of the power of the House Rules Committee.
When a bill reaches the floor of the House or Senate, there are rules or procedures
governing the debate on legislation. These rules determine the conditions and amount
of time allocated for general debate. In the House, debate may be limited to the
subject at hand. There is no limit on debate in the Senate, except when the Senate
decides to create one. The "filibuster" is a delaying strategy where senators make
prolonged speeches to put off legislation. A process called "cloture" can end the
filibuster and requires 16 senators to file a petition to limit debate and a three-fifths
majority vote to approve the petition.
After the debate and the approval of any amendments, the bill is passed or defeated
by the members voting. A simple majority will pass the bill in most cases. Some
actions require a larger percentage. A two-thirds vote is required to amend the
constitution, to override a presidential veto, or to suspend the rules of the chamber.
The House or the Senate can return a bill to committee for further study by a simple
When the House or the Senate passes a bill it is referred to the presiding officer
of the other chamber - the speaker of the House or the president of the Senate -
where it usually follows the same route through committee and floor action. This
chamber may approve the bill as received, revise it, reject it, or fail to take
action on it.
Both houses of Congress must approve identical language before it can be sent to
the president. If the other chamber only makes minor changes to a bill, it is common
for the legislation to go back to the first chamber for concurrence. However, when
the actions of the other chamber significantly alter the bill, a conference committee,
composed of members of both chambers, is formed to reconcile the differences between
the House and Senate versions.
The speaker of the House and the presiding officer of the Senate select conferees.
There are generally three recommendations that can be made in attempting to reconcile
the two versions of a bill: 1) that the other chamber withdraw its provisions; 2)
that their own chamber withdraw its provisions and accept those of the other chamber
or 3) that both chambers compromise by withdrawing some provisions in exchange for
keeping others. The conferees are not supposed to insert any provision that was
not part of one bill or the other.
If the conferees are unable to reach agreement, the legislation dies. If agreement
is reached, a conference report is prepared describing the committee members' recommendations
for changes. Both the House and the Senate must approve the conference report.
After a bill is revised in conference, both the Senate and the House must pass the
amended bill again. If both chambers vote to accept the final language, the bill
is put in its final form, signed by the speaker of the House and president pro tempore
of the Senate, and sent to the president for his signature.
If the president approves of the legislation he signs it and it becomes law. The
president can take no action for ten days, while Congress is in session, and it
automatically becomes law. However, if the president opposes the bill he can veto it; or, if he takes no action after the Congress has adjourned its second session,
it is a "pocket veto" and the legislation dies.
If the president vetoes a bill, Congress still has an opportunity to enact the law
with an override vote in which both houses decide whether to honor the president's
veto or to enact the law without his signature. An override requires a two-thirds
roll call vote of the members who are present in sufficient numbers for a quorum
in each chamber. No debate is allowed before the vote on a veto. If both houses
override the veto, the bill becomes a public law, having the same effect and power
as if approved by the president.
The Budget Committees prepare a Budget Resolution that outlines revenue and spending
estimates for the upcoming fiscal year. Congress must pass a Budget Resolution every
year. Committee hearings usually begin in February and a Budget Resolution is typically
not agreed upon by both Houses until late spring or early summer. The Budget Resolution
does not require the president's signature; therefore, it is non-binding and does
not have the statutory force of law. However, the recommendations contained in the
Budget Resolution are used as a guide for the Appropriations Committees, which ultimately
determine what level of funding each program receives.
Despite the dissatisfaction Congress typically expresses over the president's request,
the president's budget is the blueprint for the appropriations process. What changes
from the request to the final appropriation are the spending priorities. For example,
Congress might appropriate less money for the Space Station than the president requests,
and more money for biomedical research.
In recent years, Congress has come to rely increasingly on the Reconciliation process.
Reconciliation is a method of bringing existing tax and spending laws into conformity
with the Budget Resolution (which was necessary since the Budget Resolution is non-binding).
The authorizing Committees have flexibility in how they will attain the budget savings.
Each Authorizing Committee reports its bill back to the Budget Committee, which
then consolidates each bill into an Omnibus Reconciliation Bill. The Budget Committee
may not amend this bill and must either approve or reject the entire passage. The
Omnibus Reconciliation Bill must then be approved by the House and the Senate (it
is amendable on the House and Senate floor, subject to certain guidelines). The
Reconciliation Bill requires the president's signature.
In addition to using the Reconciliation process to achieve budget savings, Congress
has used it as a method of passing authorizing legislation, since it is considered
a "must pass" bill and is an excellent opportunity to add amendments and other legislation.
Authorizing legislation establishes either discretionary programs, which are subject
to annual funding levels set in the Appropriations bill (appropriations are at or
below the authorized amount); or mandatory (entitlement) programs, which are funded
at a set level by law. A funding change in a mandatory program is possible only
if the authorizing law is amended. Authorizing bills can be introduced in either
the House or the Senate. For example, the NIH Reauthorization Bill may originate
in either the House or the Senate. The two chambers may act on their respective
versions simultaneously, or the Body may decide to wait until the other chamber
has passed a bill before considering a version of its own. A reauthorization of
expiring law can be one in which the authority for the program is extended under
the same essential provisions, or it can include major changes to the program.
The Appropriations Committees must pass a bill every year to establish funding levels
for specific programs, unlike authorizations, which typically cover three to five
years. The United States Constitution requires that all revenue (tax) bills and
all appropriation bills originate in the House. For example, the Labor, Health and
Human Services, and Education Appropriations Bill must originate in the House. The
Senate Appropriations Committee usually conducts its hearings simultaneously with
its House counterpart, but does not actually write its bill until the House has
passed its version.
In theory, a program must be authorized before it can receive appropriations. While
this is almost always the practice for new programs (i.e., spending for a program
that has not previously received funding), it is not always the case for ongoing
programs that simply need to be reauthorized. Often, action on a program's reauthorization
may face a delay, but the Appropriations Committee will go ahead and provide funds,
knowing that the reauthorization legislation is pending.
Influencing the making of the law is only part of the process. After Congress enacts
legislation, the Executive Branch Departments and Agencies must implement it. The
law provides only the outline of a program, and it is the responsibility of the
Executive Branch, through the regulatory process, to translate the law into policy.
This is a crucial part of the process for a grassroots organization, to assure that
the implementation of the law is conducted in accordance with your intentions.
The law is usually broad by design, and the Executive Branch establishes specific
policies and procedures to implement the law. Regulations are very specific. They
may specify a program's operating procedures; determine how funds may and may not
be spent; determine qualifications for participation in a program; etc. The regulatory
process provides an opportunity for interested parties to comment on and influence
proposed regulations. The process begins with the publication of the proposed regulation,
and the public has an opportunity to issue comments within a specified period of
- Medicare is a federal program that provides health insurance for the elderly.
Medicare is one of the largest purchasers of healthcare services. The coverage and
reimbursement decisions made by the Medicare program affect the ways providers operate
and have an impact on the health services industry as a whole. Often Medicare coverage
and reimbursement decisions are adopted by the private sector.
- The Medicaid program is run jointly by the federal and state government to provide
health insurance for individuals categorically eligible -- predominantly the poor
and disabled. Medicaid is undergoing substantial change as Congress is considering
turning over all authority and responsibility to the states. These changes in the
structure of Medicaid will affect you and your patients.
- The federal government supports training programs for health professionals through
the Health Services and Resources Administration. Congress is currently restructuring
the way in which these programs operate, which will affect the educational and training
programs for healthcare professionals.
The federal government is one of the largest funders of biomedical research and
health services research. The National Institutes of Health (NIH) supports research
at 2,000 colleges, universities and other scientific institutions, including the
efforts of more than 50,000 researchers and their staffs throughout the country.
The Agency for Health Care Policy and Research (AHCPR) funds health services research,
including outcomes research and clinical guideline development.
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