James MacIntyre, M.D.
From AACAP News March/April 1997

Over years too numerous to count, in the AACAP Assembly of Regional Organizations or at our own local council meetings I have heard child and adolescent psychiatrists say, "we need to do something about that policy issue. ..or piece of legislation". Unfortunately, however, no specific plan is developed and nothing is done -the opportunity is lost! I believe that frequently this inaction stems from a lack of knowledge and understanding about how to get involved and influence both legislators and the legislative process at the state level.

In March 1996, my understanding of state legislators and the legislative process was dramatically changed and shaped through my participation in the 3rd State Legislative and Public Affairs Joint Institute organized by the American Psychiatric Association (APA). I attended this Institute in my role as AACAP's Liaison to the APA's Joint Commission on Public Affairs. The Joint Institute's three-day program was designed specifically to enhance a psychiatrist's ability to get involved and influence the process at the state level. The program included selected legislators from various states, professional lobbyists, and other speakers. Because I found the Institute so informative and helpful, I decided to summarize some of the highlights and share them with the AACAP membership through this newsletter.

The importance of understanding the state legislative arena and making the commitment to get involved cannot be over-emphasized to child and adolescent psychiatrists. It is particularly important at this time of such massive change (and chaos) in our healthcare system. While the AACAP has hard-working and talented staff in its Government Affairs Department, they can't possibly monitor and deal with every state legislature on all critical child and adolescent mental health issues. Instead, it is critical that both individual child and adolescent psychiatrists and local councils be involved.

The APA's Joint Institute clearly highlighted that dealing with state legislators and legislation is a very different arena for psychiatrists. In order to be effective (and not over-whelmed or intimidated), child and adolescent psychiatrists need to learn about the process and develop a different "head set" when getting involved in this arena. For example, the several speakers emphasized that crafting legislation is mostly a reactive process, not proactive like we were taught in our earlier schooling and education. In addition, child and adolescent psychiatrists may have misinformation about state legislators and view them with some stereotypes and/or bias. Some of this may be the result of not really knowing or having contact with any legislators.

As child and adolescent psychiatrists begin to work at the state level, in order to be effective they must develop a deeper understanding of their state legislators and the legislative process. The following information was presented by several speakers at the Institute to increase psychiatrists understanding of state legislators:

State Legislators are...

• elected by their constituents to carry out a mandate
• interested in local issues and local impact
• often interested in re-election
• lay persons with regard to health and mental health
• honest and well intentioned people
• sensitive to political process
• facing difficult choices and decisions (e.g. budget cuts)

State legislators are not...

• experts in mental health
• versed in all details and minutiae of most issues
• able to process different levels of complex issues

State legislators need...

• clear, organized information
• compromise options/solutions when making difficult choices or decisions
• numbers and statistics
• win/win compromises
• positive outcomes for their local constituents
• delay as a way to get the "pulse" of local constituents before making a tough decision

The APA Joint Institute also examined how legislators make decisions. Clearly, state legislators' decisions are affected by many different factors. Also, different issues will involve different factors and each legislator may be affected differently by the same factor. Lobbyists try to determine (predict) which factors are affecting a particular legislator on a given issue. In order to be effective, child and adolescent psychiatrists need to approach legislators in a similar manner. The following summary was presented at the Institute:

Factors which influence the thinking, position and voting of a legislator:

• Communications from voters/constituents in their district (i.e. who have they heard from? What are the positions/sentiments?)
• Personal interest or experience of the legislator or someone in their family
• Facts on an issue that capture their interest
• Persuasive arguments from their staff or hearing testimony
• Intensity of an issue or controversy
• Leadership within the legislature
• Money
• Media coverage of the issue
• Campaign promises
• "Horse-trading" process (political chits)
• Coalitions (means larger numbers of voters involved)
• Career/future plans of legislator (aspirations within government, plans to leave, etc.)
• Personal bad press
• Federal legislation
• Time available to devote to an issue (legislators can't possibly deal with every bill or issue)
• Legislator's staff (legislators frequently use their staff to get information and compensate for their own lack of expertise)
• Lobbyist credibility (legislators will run things by them, ask for help in finding compromises, etc.)
• Legislative committee recommendations
• Legislator colleagues (often along partisan lines)
• Partisanship (caucus, conference leadership, etc.)
• Race and gender
• Legislator's own family (personal views/experiences)
• Constitutionality and other legal impacts/issues
• Experience in other states (effects level of certainty versus risk)

This is a "wild and crazy" time in healthcare policy in the United States. State legislators are increasingly being asked to make important decisions which will have far reaching impact on mental health care for children, adolescents and families. Both regional councils and individual child and adolescent psychiatrists need to be heard at the state level as these critical issues, decisions or pieces of legislation are being considered. Child and adolescent psychiatrists need to be aware that there are many others (mental health professionals, business groups, lobbyists, etc.) who do speak on these issues and work to shape the thinking and decisions of state legislators. In conclusion, the following guidelines are offered for child and adolescent psychiatrists:

Guidelines for working effectively with state legislators:

• Planning - start early and take a long-term view
• Stick to the facts - develop and use "fact sheets" with key information on issues (use AACAP and APA products)
• K.I.S.S. - keep it short and simple (one-page rule)
• Gather support - use coalitions, strategic partnerships and get organized.
• Claim the "high ground" - avoid professional turf issues, talk about the impact/effect on local "citizens" (not "patients") and the community.
• Mobilize and include parents - they're voters and they're seen as more objective and less self-serving.
• Get involved - contact legislators, send letters, make yourself available if asked, cultivate relationships, etc.
• Stop complaining, whining and being negative - remember, "If you're not part of the solution, then you're part of the problem".
• Remember - legislation is mostly a reactive process, it is not typically proactive.
• Remember - "all politics is (ultimately) local".