Chapter1
   
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  Chapter3
   
  Chapter4
   
  Chapter5
   
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  Chapter9
   
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Chapter 9. Advocacy, Legislation and Regulatory Changes

Chapter Description

This chapter describes ways to advocate for broader changes that will improve oral health when individual efforts are not enough. The focus is on changes in systems, laws and policies. It briefly reviews how laws and regulations are made, and includes advocacy strategies and tips. Numerous links to examples and resources are included.

Chapter Overview

Advocacy at the local level is usually the fastest and most effective way to initiate changes that benefit local programs. This occurs through a number of activities, ranging from those that individuals can do privately to those accomplished through various public forums. Sometimes, however, changes must be made in systems at the state or federal level to solve an oral health access problem that affects numerous towns or counties. This is often the case with Medicaid policies, procedures or regulations; state dental practice acts, rules and regulations; or fluoridation of water systems. Oral health policy development is a challenging and often confusing process, but can be immensely rewarding when efforts are successful.

Self-Assessment: Personal Advocacy Experience

How active and effective are you in advocating for improvements in oral health? Have you ever testified at a city council meeting or a public hearing on water fluoridation? Have you ever written to your state senator when oral health programs or adult dental Medicaid benefits (including those for pregnant women) are threatened for elimination in the budget? Do you know where to go to look for resources on how to be an effective advocate or what other states or counties are doing to promote oral health? Complete the Advocacy Self-Assessment Worksheet to reflect on your advocacy experiences and to plan how you can increase your knowledge and skills in the advocacy arena.

Concepts of Oral Health Policy Development and Implementation

Policy development often is a mystery to people, especially when government rules and regulations suddenly appear that affect our daily lives and our health care. The terminology and concepts can be confusing, so organizations such as the California Center for Health Improvement (CCHI) have created helpful tools to educate the public. Since this Rural Smiles Resource Guide is not a Government 101 course, readers are referred to CCHI's online Health Policy Guide (http://www.healthpolicycoach.org-- click on tips and tools.) Some of the concepts will be reviewed in this chapter as a framework for the discussion on oral health policy. An extensive glossary as well as tips and tools are included on the website.

"A policy is a plan or course of action designed to define issues, influence decision-making and promote broad community actions beyond those made by individuals. Policy developmentis the process by which society makes decisions, selects goals and the best means for reaching them, handles conflicting views about what should be done and allocates resources to address needs." Policies can be developed in the private sector to address how a business or organization is run, or in the public sector to put forth the set of rules by which a society is governed."

CCHI. Health Policy Guide.



Public policies might address which populations are deemed eligible to receive oral health services and what types of health providers can deliver these services. State and local legislative, administrative and regulatory processes often parallel those in federal agencies.

Public policy development can be viewed as a three-part process. Phase I includes developing the scientific foundation (evidence) for recommending services or programs, e.g., use of dental sealants. Phase II involves translating that science into policies that will improve oral health, e.g., convincing public financing programs to include sealants as a covered service. Phase III is implementing the policies and documenting if, in fact, they create a positive change, e.g., if sealants reduce dental treatment costs by preventing dental caries (Taylor SE.1989, pg 4-5-see references.) Individuals and communities can impact all three phases.

What are some examples of issues that have oral health policy implications? A few are listed in the box.

Examples Of Issues With Oral Health Policy Implications

  • Medi-Cal reform
  • Mandatory oral exams for school entrance
  • Dental coverage for pregnant women
  • Supervision levels for dental auxiliaries
  • Providing services to children with special health needs
  • Age at first dental visit
  • Use of Rural Urban County Areas (RUCAs) vs. Medical Service Study Areas (MSSAs) for designating underserved rural areas
  • Vending machines in schools
  • Healthy snacks in preschools
  • Provision of fluoride varnishes in medical offices
  • Licensure by credentials rather than re-examination
  • HIPAA and OSHA regulations

A good way to learn about oral health issues where policy changes are needed is to read policy briefs that are developed by organizations or coalitions. Examples of recent oral health policy briefs or position papers are listed in the References and Resources section.

How a Bill Becomes a Law

This also is a mysterious process to many people. To see a diagram of the process, go to http://www.leginfo.ca.gov/bil2lawd.html. The best way to remember the process is to actually follow a bill through the state legislature or through the US Congress until it becomes a law. Most people do this through the news media, but it can be accomplished by viewing http://www.leginfo.ca.gov for California bills and through http://www.congress.gov , http://Thomas.loc.gov or through the Congressional record at your local library for federal bills. The websites allow you to search bills by their number [senate bill (SB) or assembly bill (AB) in California, or the senate or house versions for federal bills], view committee reports, and link to other webpages that address the issues. Congressional records are day-to-day accounts of what happened, and give the speech and bill text. You can also watch the process live on TV on C-SPAN or on the California Channel. Once a bill becomes a law, it is assigned a different number, e.g., PL 104-42-the 42nd law passed by the 104th Congress or state assembly.

In California, county boards of supervisors or city councils pass or amend county or city laws for local activities that address the basic infrastructure of services. These also may be referred to as ordinances. In other states, local ordinances are passed by residents on citizen councils or boards of selectmen, or during town meetings. In California and some other states (most notably Oregon, North Dakota, and Colorado) citizens can bypass the legislature to amend a law through a referendum or initiative petition. Statutory and constitutional initiatives allow citizens to propose new laws through a petition process. Through a referendum, voters can approve or reject a measure adopted by the legislature. Both involve collecting a specified number of signatures from registered voters within a limited timeframe to have the issue put on the ballot. Voting is then by the electorate at large. Special interest groups often use this strategy to advance their issues.

Regulatory Changes

Some laws require that regulations be written by employees in the agencies that will administer and enforce them, (e.g., Dept. of Health Services). Regulations are guidelines for how laws are interpreted and enforced. This sometimes entails a long process that is subject to public comment and hearings. Notices of public hearings are posted in local newspapers and in public places. View an example of regulations for licensure of dental professionals.

Executive orders are another way to create a public policy or program, and can be issued by the president, governor or chief executive officer of a county or municipality. View an example of an executive order. Public policies can also be made through the court system if a judge rules on disputes about how a law should be interpreted, e.g., what constitutes a public building for purposes of enforcing no-smoking laws. This is referred to as case law.

Advocacy Strategies and Tips

The genesis of most laws and policies comes from individuals and communities, even though they may be enacted at the federal level. There are definite "windows of opportunity" to accomplish policy goals. Windows open and windows close. The past two or three years have represented significant windows of opportunity for oral health policy development in many areas, including fluoridation of water supplies, expanded responsibilities and relaxed supervision for dental hygienists, and access to/coverage of dental services.

"Influencing policy is largely a matter of communication and credibility."

CCHI. Health Policy Guide.


What constitutes a good public policy? Consider these questions (J Kumar, National Oral Health Conference, 2004):

1. Is it cost-effective?
2. Is it feasible?
3. Is it politically acceptable?
4. Is it socially acceptable?
5. Is it administratively simple?

These questions are particularly important during difficult economic times and budget deficits, and when there is an emotionally charged social and political climate. Policies that once were considered good may now be obsolete or socially unacceptable. In many cases, timing is everything. Changes in public policies or clinical policies may take years and numerous revisions and setbacks to implement. Patience, persistence and flexibility are requisite characteristics for anyone involved in advocating for policy changes.

When trying to answer the questions about the value of a potential policy, consider two techniques for analyzing the situation:

  • SWOT analysis--see Chapter 1
  • Force-field analysis-"a method for listing, discussing and evaluating forces for and against a proposed changeBy knowing the pros and cons, you can develop strategies to reduce the impact of the opposing forces and strengthen the supporting forces." See a tutorial at http://www.extension.iastate.edu/communities/tools/forcefield.html.

    How do you develop support for a particular policy? Develop an action plan. The action plan should answer these questions:

  • Who can best influence individual policymakers?
  • What are the key messages?
  • How and what are the best formats for educating them?
  • Where are you going to channel your efforts?
  • When is the best time to advocate and how often?

View a checklist for creating an advocacy action plan.

Public interest lawyers can be helpful in a number of ways: participate in alliances for oral health; educate consumers and providers on laws, resources and self-advocacy; serve as a liaison to track legislation and link to opportunities for public input; help enforce laws through various types of advocacy and systemic litigation (Jamey Bell, National Oral Health Conference, April 2003).

How can you communicate with/influence policymakers? Term limits in some states, including California, make it difficult to form long-term, consistent relationships with legislators. Changes in political parties and administrations affect all levels of government, making re-education of policymakers a constant activity for advocates and governmental managers and staff.

Find out what other interests your legislators are championing-actively support some of them and show how oral health may coincide with their concerns. You will ultimately need to find a specific champion for your oral health issues to have a bill introduced. When communicating with legislators and other policymakers, optimize your credibility by initiating direct regular contact as an issue expert, and provide clear and consistent messages. Try to reach the point where they recognize your name and face. Your goal in any communication is for the legislator or policymaker to see an issue from your perspective-this requires diplomacy and negotiation, not arguments and adversarial positions. You can also comment on budget issues, preferably early in the process. Although hearings of the budget conference committee are open to the public, no public testimony is heard at that time.

Ways to communicate:

A few cautions about lobbying-attempting to influence legislation on a specific issue. Lobbying and related rules are included in the Internal Revenue Code and Treasury Regulations. These rules are complex, particularly as they apply to non-profit agencies and use of government monies. Many of you may be members or employees of non-profit organizations or employed by government agencies. It is important to remember that citizens are permitted to communicate their views as individual citizens, but may be considered to be lobbying if appearing to represent a non-profit or governmental agency when expressing views. This can jeopardize non-profit status or employment. See the resources at the end of the chapter to learn more about advocacy and lobbying.

Once a bill has been introduced, you have the opportunity to attend committee hearings, submit written testimony or offer oral testimony (contact the author of the bill to do the latter.) Read the analysis of the bill and contact your legislator or committee secretary to see when the committee hearing is scheduled. Exact timing, however, may vary, so plan to have a flexible schedule if you want to testify.

Creating Effective Advocacy Messages

Here are four steps to getting your message across (Libby Mullin, National Oral Health Conference, 4/27/02)

Step 1: Present the problem. Go back to Chapter 1 and review the problem statement that you developed. Be concise and clear, using understandable "lay terminology". Discuss any oral health disparities in certain population subgroups and why those disparities exist. Discuss the consequences of not addressing the oral health problem, relating it to financial consequences, readiness to learn, self-esteem, or overall health issues. Photos comparing children who are "orally healthy" with children who have untreated dental disease help to put a face on the problem. Personal stories also are valuable. Shock value in pictures is not sufficient to create action, however.

Step 2: Present the facts. Use both quantitative data (answer the questions "who, what, when, where") and qualitative information (answer the questions "how and why"). How large are the disparities? Who doesn't have dental insurance coverage? How many have coverage but don't use it? How many providers won't participate in Denti-Cal, and why? Keep your statement short and simple. Don't overwhelm people with facts or your key messages will be buried and you will lose their attention.

"You need to convince policymakers that too many children have too much disease that is consequential but overwhelmingly preventable
(and it is getting worse.)"

Libby Mullin, op cit.

Step 3: Promote awareness: What can be done to reduce barriers to care and to improve oral health? How you interpret and report data will determine its relevance to policymakers. How does it fit into their overall legislative health strategy? What can government agencies do? What can communities do? What can they specifically do as individual policymakers? What other resources are available? Fact sheets often are used in advocacy efforts. Fact sheets provide a brief summary of the issue and what can be done. View a variety of facts sheets on oral health at http://www.mchoralhealth.org. It may be necessary to create more than one version of a fact sheet to be effective with different audiences.

Step 4: Provide the salience: Engage policymakers and organizations that do not solely represent dental professionals or oral health concerns, e.g., those involved with child care, pregnant women, primary care, rural health, Head Start, children with special health needs. Compare oral health problems with other health problems, but emphasize that oral health is part of general health.

An Advocate's Lessons to Live By

  • Meet policymakers' needs, not yours
  • Value and support coalitions
  • Have the facts ready
  • Respond quickly and authoritatively
  • Accept risk, disagreements, disappointments
  • Be clever, sharing, caring, determined
  • Take what you can get. Go back for more.

Libby Mullin, op cit.

Implementing Policies in the Community

"Implementing a policy is all about joining forces in support of positive change. It entails tailoring a solution to address the unique health problems and resources in your community"

CCHI. Health Policy Guide.

Go back to Chapter 2 and review all the potential partnerships you brainstormed. Which ones would be most effective for promoting and implementing policy changes? A number of examples of policy development related to state and community programs can be accessed via the ASTDD Best Practices website at http://www.astdd.org/index.php?template=sp_home.php&shell=state.

Summary

This chapter asked you to assess your own advocacy experiences and how you could increase your advocacy efforts. General information was covered on the process of policy development and implementation. Examples of oral health policy issues and policy papers were provided, as were advocacy strategies and tips for creating effective advocacy messages. The goal of this chapter was to increase your knowledge, skills and participation in oral health advocacy efforts.

References and Resources

Policy briefs or position papers

Center for Policy Alternatives. Policy Brief. State of the States: Overview of 2002 Oral Health State Legislation. http://www.stateaction.org/issues/healthcare/dental/2002.pdf
This review examined policies related to 1) increasing access to oral health care through additional funding, expanding treatment for special populations, use of volunteers, additional dental benefits through public programs, 2) provider incentives such as educational loans/scholarships, increased Medicaid reimbursement, lower taxes or fees for dentists, 3) assuring patient rights and quality of care by strengthening quality oversight, guaranteeing patient choice, oral health warning labels on products, 4) expanding licensure and scope of practice through flexible licensure requirements and altering regulation of allied dental health professionals.

Ryan, Jennifer. Improving Oral Health: Promise and Prospects. National Health Policy Forum Background Paper, George Washington Univ. 2003. http://www.nhpf.org/pdfs_bp/BP_OralHealth_6-03.pdf.

Oral Health. Strategies to Prevent Dental Caries: Fluoridation. Center for Health Improvement. Health Policy Guide. http://www.healthpolicycoach.org/doc.asp?id=6495 .

Sanchez, OM. and Childers, NK. Anticipatory Guidance in Infant Oral Health: Rationale and Recommendations. American Family Physician. Jan 1, 2000. http://www.aafp.org/afp/20000101/115.html.

Michigan Primary Care Association. Oral Health Priority Paper. http://www.mpca.net/healthpolicy/lp_oralhealth.htm.

Gehshan S and Straw T. Access to Oral Health Services for Low-Income People:
Policy Barriers and Opportunities for Intervention for The Robert Wood Johnson Foundation
. NCSL. October 2002. http://www.ncsl.org/programs/health/forum/rwjoral.htm.

National Rural Health Association. Policy Brief. Oral Health in Rural America. http://www.nrharural.org/dc/policybriefs/oralhealthbrief.pdf.

Health Policy Brief. Access to Oral Health Care in Iowa. University of Iowa. Public Policy Center. February, 2004. http://ppc.uiowa.edu/policybriefs/pdf/oralhealth.pdf.

Warren, RC. Oral Health For All: Policy for Available, Accessible, and Acceptable Care. Community Voices.1999. http://www.wkkf.org/pubs/Health/CommunityVoices/Pub678.pdf.

Other Resources

Children's Dental Health Project. http://www.cdhp.org. The website contains a number of resources.
o State Surveys of Oral Health Needs and Dental Care Access for Children. Provides a summary of 15 state reports and also has the reports by state (California is one of the states; reports are based on the 1993-94 oral health needs assessment.)
o Congressional testimony, hearings and briefings
o Federal legislative accomplishments
o Congress/Public policy links
o Publications on dental access and coverage and oral health policy

Government resources and contact information-national and by state: http://www.vote-smart.org/mystate_government_resources.php.

National Health Law Program: legal resources related to health care for underserved populations; there is a section related to oral health. http://www.healthlaw.org.

The Health Consumer Alliance (http://www.healthconsumer.org/advocatelinks.html), a California group, has a variety of valuable information on its website related to children's health, Medi-Cal, etc.

American Dental Education Association's website has a number of advocacy tools and links. They provide a good overview of the federal legislative process http://www.adea.org/CPPA_Materials/AdvocacyTools/2002LegislativeProcess.pdf.

Center for Health Improvement.Bringing Policy Change to Your Community. Health Policy Guide. http://www.healthpolicycoach.org/advocacy.asp?id=23 .

School Health Policies and Programs Study 2000. Fact Sheet. Dental and Oral Health. NCCDPHP. Centers for Disease Control and Prevention. http://www.cdc.gov/HealthyYouth/shpps/factsheets/fs01_dental_health.htm.

Crall JJ and Edelstein BL. Primer on Oral Health Policy. Appendix to Elements Of Effective Action To Improve Oral Health & Access To Dental Care For Connecticut's Children and Families. A report commissioned by Connecticut Health Foundation, Children's Fund of Connecticut, 2001. http://www.cthealth.org. Look under publications.

Smucker B. The Nonprofit Lobbying Guide.2nd ed. Washington, DC: Independent Sector, 2004. Chapters can be viewed online at http://www.independentsector.org/programs/gr/lobbyguide.html.

The Legislative Process and The Budget Process: A Citizen's Guide to Participation. Available from California Senate Publications. 1020 N Street, B-53, Sacramento, CA 95814, 916-327-2155. Easy to read booklets, also available in Spanish, which contain good glossaries. They show a sample bill, a bill analysis, and the path of a bill and how it becomes a law, as well as a list of standing committees and how to access a variety of information. The budget booklet is a good overview of the budget process and the various documents that are generated.

Taylor SE. Congress and public health policy. Congressional Research Services Review.1989.

Evaluation

What did you learn or accomplish as a result of reading this chapter? Did it help you to organize your thoughts about how to advocate for policy changes? Were the resources and examples helpful? Complete the feedback form for Chapter 9 and tell us what was useful and not useful for you.