Advocacy Makes an Impact in the Process of a Bill Becoming Law

Ms. Sax is a freelance writer based in Chevy Chase, Maryland.

Much of the fate of the pharmacy profession's future rests on the decisions elected officials make. That is why it is so important for pharmacists to support legislators who understand pharmacy issues. Individual pharmacists and pharmacy students can help by lending their support to those professional and trade organizations that remain at the forefront of legislative decisions that will impact the profession.

"It is important for pharmacists to be advocates for their profession, because nobody else will do it," said Paul Kelly, vice president of government affairs for the National Association of Chain Drug Stores (NACDS). "There is a saying in Washington that goes 'If you are not at the table, you are not on the menu.' There is a lot of competition for the time and attention of members of Congress, so to break through the noise, we have to beorganized, forceful, and persistent." NACDS is aggressively involved in the legislative issues that mean the most to pharmacy operators, pharmacists, and the patients they serve.

Kelly said that when it comes to reimbursement issues for programs like Medicare and Medicaid, a limited amount of money exists to go around. "Pharmacists will not betreated fairly unless they go up to the Hill and explain the impact on pharmacy of cutting these programs," he said. "It is important that pharmacists get recognizedfor their professional abilities, and one key way to do that is to be recognized by government programs like Medicare and Medicaid."

That is why Kelly urges pharmacy students to get on the phone, write letters, and arrange meetings with their elected officials and join forces with their professional and trade organizations to learn and support the specific messages that the profession is supporting.

It also is important that pharmacists help educate their elected officials. "Legislators are not health care experts. They have to be generalists, because they represent such a diverse group and such large numbers of people. So when it comes to health care issues, the old joke is that they think a terminal illness is something you get at the airport. Their knowledge is usually limited to what the general public knows."

Paul Kelly

Most people, said Kelly, do not really see pharmacists and pharmacies as "absolutely essential health care providers," so they do not really worry about making cuts when it comes to how pharmacists are reimbursed. "One example is the draconian Average Manufacturer Price [AMP] cuts, which would have a devastating effect on how pharmacists dispense generic drugs," he said.

At NACDS, part of Kelly's role is to explain to legislators that the current definition of AMP is not correct. In 2005, Congress passed a law that would change the Medicaid reimbursement rate for generic drugs to a formula based on AMP. The AMP reimbursement amount was scheduled for reduction in 2008. "Using this formula, pharmacies would lose money on each Medicaid transaction," said Kelly. "It was all in an effort by Congress to try to save money."

NACDS has worked hard in support f legislation that would delay Medicaid AMP reimbursement cuts. The first step, which is usually the first step in any legislation, was to convince a member of Congress to introduce a bill supporting its position. Two key members of Congress, who are responsible for dealing with Medicaid, sponsored the bill, known as the Fair Medicaid Drug Payment Act. The bill is assigned a number in both the House (HR 3700) and the Senate (S 1951).

Under normal circumstances, committee action is the next step. The bill is assigned to the appropriate House or Senate committee(s) for review and potential approval. Hearings can be held to discuss the pros and cons of the bill. "In this part of the process, you may want to convince other committee members to cosign the bill, sending a clear signal that the legislation is widely supported," said Kelly. During the committee action phase, the bill can also go to a "markup session" during which revisions or additions can be made.

The bill then moves on to the floor action phase, where it is placed on the calendar and is open to debate from members of the House or the Senate, and then members vote on the bill. In the case of the Fair Medicaid Drug Payment Act (HR 3700 and S 1951), the bill has not garnered enough support from both Democrats and Republicans to move forward, especially because the Bush administration is opposing the bill. This has made it difficult to get enough Republican support for the measure this year.

Recognizing that cuts to generic drug payment levels could be devastating to pharmacies, pharmacists, and the Medicaid patients they serve, however, lawmakers added a provision that would delay the cuts through September 2009 to a larger bill (HR 6331) that the industry supports. The Medicare Improvements for Patients and Providers Act (HR 6331) also includes language that would ensure prompt payment for Medicare claims, encourage electronic prescribing in Medicare, and postpone competitive bidding fordurable medical equipment.

In an unusual display of congressional procedure, the House voted on HR 6331 in late June and overwhelmingly passed the bill with bipartisan support?355 to 59, with 129 Republicans voting for the bill. Although the Senate failed to advance this legislation by a single vote, a second vote provided the two-thirds veto-proof majority (69-30) to not only pass the vote, but help ensure, if vetoed by President Bush, the Senate could override a potential veto and enact the bill.

A week later, the president vetoed the bill, but on the same day both the House and the Senate overrode the veto with strong bipartisan support, thus enacting the legislation, which provided a huge victory for pharmacy with 4 key priorities includedin the bill.

While an override of a presidential veto is not commonplace, it does illustrate the system of checks and balances in our 3-branch system of government, and how advocacy is critical to help ensure that all branches understand an industry's priorities.

"You really need to be organized and keep on top of the process," Kelly said. With persistence, and a cooperative effort by NACDS and other professional organizations, bills unfavorable to the profession will be defeated, and bills advancing the profession will be nurtured through the legislative process until they become law."