It has become particularly clear in recent years that federal law can have profound influence on the daily practice of medicine, including otolaryngology-head and neck surgery. Consequently, otolaryngologists and other physicians have become more active in supporting legislators and legislation that advance efficient, high-quality medical care and patient safety. As we recognize the importance of advocacy in order to have an effective impact on future legislation, it is useful for otolaryngologists to understand the processes involved in establishing laws in the United States Congress.
Each year, approximately 6,000 bills are introduced in Congress, although only about 500 (8%) are passed and become law.1 In Congress, a bill gets started by being written by a member of Congress, usually with the assistance of congressional staff. At any time during the congressional session, the written bill is placed in a box on the rostrum in the Senate or the Speaker's desk in the House. The box is known colloquially as the hopper. A bill number is assigned, beginning with “S” for a Senate bill and “HR” for a bill in the House.
Once a number has been assigned, the bill is referred to the appropriate committee or committees. There are 19 standing committees in the House and 16 in the Senate. At this point, the influence and expertise of the sponsor (the bill's primary author) are of particular importance. A sponsor who cares about the bill generally makes efforts to enlist cosponsors from both parties, and to communicate with members of the relevant committees. Such efforts are critical, since most bills are tabled in committee. Hence, they are never addressed and “die” in committee.
Considerable political effort is required even to have the bill debated in committee rather than ignored. In the House, the Speaker may set a time limit after which a committee is required to report back on a given bill, but this prerogative is not exercised for most bills. The entire House can also rescue a bill from committee and have it debated on the House floor through the filing of a “discharge petition.” To be successful, a discharge petition requires a majority vote of 218 members of the House.
If a sponsor is successful in getting a bill heard before the relevant committee, the bill often will be referred to subcommittees for more intensive analysis. The subcommittee may make changes in the bill. When the subcommittee is satisfied with the wording, a vote is held. If the bill is passed in subcommittee, it is referred back to the full committee. If it does not pass in subcommittee or committee, it is likely to go no further and die. If it is passed in committee, the House or Senate has the opportunity to debate the bill and vote on it.
The process for debate and voting is different in the House than in the Senate. In the House, the House Rules Committee determines when a bill will be considered by the full House of Representatives, how long the debate will last, and how many amendments may be considered. Importantly, in the House, debate and amendments must be relevant to the topic at hand. Hence, some action usually occurs.
The process differs in the Senate. The decision on if/when a law will be considered rests with the Senate Majority Leader. Perhaps most importantly, Senate debate does not have to be relevant (germane). Hence, open-ended debates may result in filibuster, which can prevent a bill from ever coming to a vote. Ending a filibuster requires a vote for cloture, and 60 votes are needed. In addition, the quantity and subjects of amendments are unlimited in the Senate.
Passage of laws usually is required in both the House and Senate. Sometimes identical bills are passed in both chambers. However, often there are differences that need to be resolved by a conference committee with members from the House and Senate. Once the conference committee has agreed upon modified wording, the House and Senate must approve the final bill.
Once a bill is approved by the House and Senate, it requires the signature of the President to become law. The President can sign a bill within the required 10 days (excluding Sundays), making it law. Alternatively, the President may veto the bill. In order to become law, a vetoed bill has to be passed by a two-thirds majority of the House and Senate.
The President's third option is called a pocket veto. A pocket veto can be accomplished if Congress is no longer in session and the President does not sign the bill within the 10-day time limit. In this case, the bill dies.
It is helpful for otolaryngologists to understand the political process and to be available to our legislators to assist when important bills are introduced. A sponsor from one district commonly requires support from committee members and subcommittee members of various districts and parties. In some cases, communication to those committee members from their own voting constituents (us) can be a powerful factor in saving a bill from being tabled and dying in committee. It is important for us to understand and exercise our abilities to assist in the legislative process.
The various states have somewhat similar processes. Otolaryngologists are encouraged to learn about them. Baker and Morse prepared a useful summary of both federal and state processes.1 That article was the primary source for this editorial. Readers who have found this information of interest are encouraged to consult the original article to find similar information about state legislatures, in which approximately 80,000 bills are introduced annually with approximately 23,000 (28.8%) becoming law.1 It is essential that our voices be heard by our legislators and that we remain sufficiently knowledgeable to be able to help well-meaning legislators articulate sensible bills and guide them to becoming law.