Chapter 9. Advocacy, Legislation and Regulatory Changes
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.
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
- 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
- Vending machines in schools
- Healthy snacks in preschools
- Provision of fluoride varnishes in
- Licensure by credentials rather than
- 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
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.
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
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
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
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
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
- 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
Libby Mullin, op cit.
Implementing Policies in the Community
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
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.
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
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.
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.
Warren, RC. Oral Health For All: Policy for Available,
Accessible, and Acceptable Care. Community Voices.1999.
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
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.
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