Stroke Addendum

Chapter Two:  Working on Stroke Legislation

This chapter supplement addresses how a bill becomes law and describes how pending federal legislation on stroke could affect state legislation and the state legislative process in regard to stroke-specific bills. Chapter 2 of the Communication Guide offers a discussion of the differences between advocacy and lobbying and offers some guidelines about how state staff can work with legislatures. Generally, states can provide information to the legislative branch to foster implementation of public health interventions but cannot work to influence a specific piece of legislation. The information in this section complies with Regulation AR–12, which prohibits using federal funds for lobbying activities.

This section provides:

• A step–by–step look at how a federal bill becomes law;
• An overview and legislative history of the federal STOP Stroke bill;
• A mock timeline for stroke legislation with suggestions for how state staff can participate at different milestones;
• Case studies of two states' implementation of stroke legislation or regulations; and
• Resources on state stroke legislation.

Review of the Federal Legislative Process: How a Bill Becomes Law

1. Bill is introduced. A bill designated "H.R." is in the House of Representatives. A bill designated "S" is in the Senate.
2. Bill is referred to a specific committee(s) with jurisdiction over the proposed legislation. The bill may then be assigned to a more specialized subcommittee. Most deliberation is done by subcommittees.
3. Committee (or subcommittee) may hold hearings on the bill; this allows various groups to put their views on record.
4. A mark–up session occurs when hearings are completed. Legislators meet to debate and vote on amendments and thus "mark" the bill. If this occurs in a subcommittee, there is then a vote whether to refer the bill to the full committee. The committee votes on whether to recommend the bill to the House or Senate.
5. If bill is recommended by a committee, it goes before the Senate or House for a vote. There may be debate and amendments. Bill is approved or defeated. If approved by House or Senate, it then goes to the other legislative chamber where the process begins again.
6. If both chambers pass the bill, there may be differences between the two versions. A conference committee made up of Representatives and Senators from both parties is then convened. This group works out the differences between the two bills. Once consensus is reached, the bill goes back to both chambers for a final vote.
7. If both chambers pass an agreed–upon version of the bill, it then goes to the White House for the President's signature. The President may sign or veto the bill. If it is vetoed, the bill goes back to both chambers. A veto may be overridden by a two–thirds vote of the legislative chamber. Both chambers must pass the bill with a two–thirds vote for the bill to become law.
8. If the President does not sign a bill within 10 working days and Congress is in session, the bill automatically becomes law.
9. If the President does not sign a bill within 10 working days and Congress is not in session, the bill is subject to a "pocket veto" and dies.

Overview of the Federal Stroke Treatment and Ongoing Prevention Act (STOP Stroke Act)

The STOP Stroke Act was introduced in the U.S. Senate in late 2001. Though it had many cosponsors, the bill did not pass the 107th Congress and was reintroduced during the 108th Congress. A revised version of the bill had passed the House of Representatives but was not expected to pass the Senate in 2004. It is unclear whether it might be reintroduced in the 109th Congress.

In its current draft, the STOP Stroke Act would have:

• Amended the Public Health Service Act to authorize the Secretary of the Department of Health and Human Services (HHS) to engage in activities designed to increase knowledge and awareness of stroke prevention and treatment.
   
• Required the HHS Secretary to conduct educational campaigns, maintain a national registry, and establish an information clearinghouse for the disease. The legislation would authorize $5 million per year for fiscal years 2005 through 2009 for these activities.
   
• Authorized the HHS Secretary to make grants to states and other public and private entities to develop medical professional training programs and telehealth networks that would seek to coordinate stroke care and improve patient outcomes. The bill would authorize $14 million in 2005 and $70 million for 2005 through 2009 for the programs and for a study to evaluate the telehealth grant program.

The STOP Stroke Act would have required states to use the grants to:

1. Identify entities with expertise in the delivery of high–quality stroke treatment;
2. Work with those entities to establish or improve telehealth networks to provide stroke treatment assistance and resources;
3. Inform emergency medical systems of the location of entities to facilitate the transport of individuals with stroke symptoms;
4. Establish networks to coordinate collaborative activities for stroke treatment;
5. Improve access to high–quality stroke care, especially for populations with a shortage of stroke care specialists or with a high incidence of stroke; and
6. Conduct performance and quality evaluations to identify activities that improve clinical outcomes for stroke patients.

States would have also been required to establish a consortium of public and private entities, including universities and academic medical centers, to carry out these activities. The bill prohibits a grant to a state or a consortium within a state with an existing telehealth network for improving stroke treatment unless the state or consortium agrees to use the existing telehealth network to achieve the purpose of the grant. The bill gives priority to any applicant that submits a plan demonstrating how the applicant will use the grant to improve access to high–quality stroke care for target populations.

Timeline of the STOP Stroke Act 107^th and 108^th Congress of the United States

* STOP Stroke Coalition (American College of Radiology, American Academy of Neurological Surgeons, American College of Preventive Medicine, American Academy of Neurology, American Heart Association/American Stroke Association, American Physical Therapy Association, American Society of Interventional & Therapeutic Neuroradiology, American Society of Neuroradiology, Association of American Medical Colleges, Boston Scientific, Congress of Neurological Surgeons, Emergency Nurses Association, Johnson & Johnson, National Stroke Association, Society of Interventional Radiology, Stroke Belt Consortium).

Mock Timeline for Legislation Process with Suggested Communication Interventions for States

Failed and pending federal legislation often becomes the model for state legislation. Below is a mock timeline for a state stroke bill that would provide state funding to establish stroke centers and patient care protocols. For many of the milestones for legislation, there are potential communication interventions that can be offered to contribute to the legislature's debate and decision making. All these proposed action items comply with the AR–12 restrictions on lobbying.

Almost all states require that communication activities be coordinated through the health department commissioner's public information office. Before engaging in any of the activities outlined below, staff should be sure to work with the public information/legislative office to receive proper clearances.

Case Study of How State Staff Participated in Stroke Legislation in Their States

Case Study: Primary Stroke Services Regulations in Massachusetts
To help influence policy and environmental change concerning stroke care in Massachusetts, the state program staff developed the Massachusetts Department of Public Health (MDPH) hospital licensure regulations authorizing the Department's Division of Health Care Quality to designate hospitals with primary stroke services. This example provides a model for other state programs to improve quality of care through regulations. The MDPH, nonprofit organizations, providers, and hospitals collaborated to develop these regulations.

The Coordinator of Stroke Initiatives in the Division of Community Health Promotion in the MDPH was the lead cardiovascular health staff person involved with drafting the regulations. Communications with different MDPH internal and external partners was integral to the success of regulation development. The Massachusetts approach to this policy intervention focuses on communication strategies.

Case Study: Florida Stroke Act
Florida offers an excellent example for states that may have pending legislation to improve stroke–related policy and regulation. In 2004, Florida passed the Florida Stroke Act (S.B. 1590), which created the nation's first statewide emergency stroke system. The legislation will help ensure that EMS transports stroke victims to a hospital that is capable of providing the latest stroke treatments. In addition, the bill requires the development of criteria for primary and comprehensive stroke centers. The American Heart Association/American Stroke Association (AHA/ASA) helped lead the coalition of groups and organizations that advocated for the successful passage of the act.

Although the Florida Department of Health did not spearhead the creation of S.B. 1590, it was and continues to be critically important to the success of the overall effort. The following summary of an interview with the Florida–Puerto Rico Affiliate of AHA offers some guidance for how states can understand and help advance stroke legislation in their states.

Date last reviewed: 05/12/2006
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion