The Legislative Process and the Kidney Care Quality and Improvement Act of 2005

Kathleen Kuchta, BSN, RN, is Advisor of ANNA’s ESRD Education Week. She is a member of the Windy City Chapter of ANNA.

Anita Gilbreath, RN, CNN, is Clinical Science Liaison, Sigma Tau Pharmaceuticals, Inc., Jacksonville, FL. She is a member of the First Coast Chapter of ANNA.

Cyrena M. Gilman, MN, RN, CNN, is Manager, Kidney MSA/Pediatric Dialysis, Riley Hospital for Children, Indianapolis, IN. She is a member of the Hoosier Hills Chapter of ANNA.

Angeline Wieler, BN, RN, CNN, is Quality Improvement Coordinator, End Stage Renal Disease Network of Texas, Inc., Dallas, TX. She is a member of the Dallas Chapter of ANNA.

Acknowledgments: The authors gratefully acknowledge the assistance of Nancy Sharp, MSN, RN, FAAN, and Kathleen Smith, BS, RN, CNN, in the preparation of this manuscript.

Laws impact every aspect of our lives, yet the legislative process seems unfamiliar and complex to most of us. Because of the importance of some laws to those who depend on the Medicare End Stage Renal Disease (ESRD) Program for their lives or their livelihood, the purpose of this article is to review the process in the context of the Kidney Care Quality and Improvement Act of 2005 that is currently pending action in the United States Congress (The U.S. Constitution Online).

The Legislative Process

All legislation begins as an idea presented to or conceived by a Member of Congress. He or she develops the idea, has it written in legislative language, and introduces it as a bill to consider in whichever Congressional chamber he or she sits: the House of Representatives or the Senate. Only a Member of Congress can introduce a bill. A member of the Congressional leadership from the President’s party introduces Presidential initiatives. Because the U.S. Congress is bicameral (two chambers), a bill must be passed by both the House of Representatives and the Senate before being forwarded to the President for signature and enactment into law (The U.S. Constitution Online).

The work of Congress is done in committees, each of which has jurisdiction over certain areas of law. All new bills are initially referred to one or more (depending on the chamber) specific committees and their subcommittees. If the chairpersons decide to take action on the bills referred to them, they will meet to review the bill, to determine whether or not, and how, to amend it, and then to vote on the bill. Passage by the subcommittee does not compel the full Committee to act on the bill, but Committee passage is usually required for a bill to be scheduled for a vote in the full chamber. Furthermore, passage by a Committee does not compel action by the full body. The leadership of the majority party makes these determinations (The U.S. Constitution Online).

House Procedure. Bills can be jointly referred to more than one Committee in the House. The House Energy and Commerce and/or the House Ways and Means committees share jurisdiction over Medicare; the former has sole jurisdiction over Medicaid. Therefore, issues related to the financing of health care for persons with ESRD through these federal entitlement programs are dealt with in these Committees. After approval by one or both of these committees, a bill is sent to the full House through a number of procedures for consideration, debate and voting, subject to handling orders determined by the House Rules Committee (The U.S. Constitution Online).

Senate Procedure. In the Senate, a bill can be referred to only one Committee. The Senate Finance Committee has jurisdiction over Medicare and Medicaid; hence it is the focus of attention for issues related to the ESRD Program. The Senate committee process mirrors that of the House. However, because the Senate is a much smaller chamber (100 members versus 435 in the House), most of the work is done in the full Committee rather than in subcommittees. As in the House, introduction or passage by a Committee does not necessarily propel the bill forward. The leadership of the majority party in that chamber determines each step of the process (The U.S. Constitution Online).

Conference Committees. In order to proceed to the President, a bill must be passed by both the House and the Senate. Sometimes identically worded bills are introduced in both houses, but often they are different at the outset. After passage in each chamber, they are rarely identical. Bills passed on a similar subject by the House and Senate are compared after passage and the differences are “reconciled” in a Conference Committee. These are ad hoc committees comprised of Members of both the House and Senate, usually from the committees of jurisdiction and the leadership in each body, to deal with the sections of the passed bills that are different. The Conference Committee will agree, disagree, or partially agree on reconciliation. Disagreement or partial agreement results in referral of the bill to another conference, or back to the committees of the House and Senate. Once a consensus is reached, the “conference report” or reconciled bill is sent back to both chambers for a vote. If it is altered in any way in one chamber, the other chamber has to vote again on the bill. Once a single version of the bill has passed both houses, the bill proceeds to the President (The U.S. Constitution Online).

The President. The President has 10 days to either sign the legislation, enacting it into law, or veto it. If the President intends to veto the legislation, that is usually done immediately. If Congress is in session and the President takes longer than ten days to act, the bill becomes law by default. The “pocket veto” is the one exception to the default process. If Congress adjourns during this ten-day period, the President can do nothing; this is known as a pocket veto as the lack of action serves as a veto. The vetoed bill is sent back to the House and the Senate with a message from the President explaining the reasons for the veto. Congress can override the veto with a two-thirds majority vote in both houses. This is one reason why the size of the majority in both houses is important. If not overridden, a vetoed bill dies (The U.S. Constitution Online).


Representative Government
Our forefathers designed a representative form of government for us that means every citizen can be part of the legislative process. Our votes cast for Members of Congress and the President is one form of participation. It is essential that the individuals we elect will represent our beliefs and support our values. As citizens, we are obligated to be aware of and involved in the process. As the League of Women Voters reminds us: Democracy is not a spectator sport (League of Woman Voters of Greater Youngstown)!

Renal Community Involvement in the Legislative Process
In 2003, ANNA joined others in the renal community to form the largest stakeholder organization in the history of the ESRD Program, Kidney Care Partners (KCP), to speak with one voice on legislative matters – initially and primarily, the need for an annual update to the Medicare dialysis payment. To date, two pieces of legislation have resulted from KCP’s efforts.

ESRD Modernization Act of 2004 (S 2614, HR 4927)
During the 108th Congress, on July 7, 2004, Senators Kent Conrad (D-ND) and Rick Santorum (R-PA) introduced the ESRD Modernization Act of 2004 (S2614) in the Senate, where it was referred to the Senate Finance Committee (ESRD Modernization Act, 2004a). On July 22, several Members of the House, led by Representatives Dave Camp (R-4th MI) and William Jefferson (D-2nd LA), introduced HR 4927, where it was referred to the House Ways and Means and the Energy and Commerce committees (ESRD Modernization Act, 2004b).

These identical bills advocated the following amendments to Title XVIII of the Social Security Act (Medicare law) to improve benefits under the Medicare Program for beneficiaries with kidney disease in the following ways:

• Establish an annual update framework for the composite rate;
• Support public and patient education initiatives for kidney disease;
• Establish Medicare reimbursement for kidney disease patient education;
• Support a blood flow monitoring demonstration project;
• Improve home dialysis Medicare benefits;
• Conduct an Institute of Medicine evaluation and report on home dialysis;
• Modify physician reimbursement for vascular access procedures (http://thomas.loc.gov/cgi-bin/query/F?c109:2:./temp/~c109kcDqlB:el340)

Largely due to the passage of the Medicare Modernization Act in late 2003 and the fact that it was an election year, there was no Medicare bill in 2004. As a result, this legislation died in December 2004 at the end of the 108th Congress; however, many Members of Congress were educated that year about the importance of these issues to their constituents due to the participation of many members of KCP organizations, including ANNA, in the legislative process as they urged their Members to become cosponsors (supporters) of the legislation.

Kidney Care Quality and Improvement Act of 2005 (S. 635, H.R. 1298)
Undaunted, the renal community immediately worked with its supportive Members of Congress to revise the previous bill. The Kidney Care Quality and Improvement Act (KCQIA) of 2005 was introduced in the 109th Congress in March (KCQIA, 2005a). The bipartisan team of Senators Santorum and Conrad were the original sponsors of the bill in the Senate (S.635). There are currently 20 co-sponsors in the Senate, 11 Democrats and 9 Republicans. The bill was introduced in the House of Representatives (H.R. 1298) by Representatives Camp and Jefferson, and currently has 130 cosponsors (KCQIA, 2005b). If passed, this legislation will positively impact the health of patients with chronic kidney disease now and in the future and will help to ensure the viability of the ESRD Program. The KCQIA includes several important provisions that are summarized in Table 1.

The KCQIA legislation is important for both patients with CKD and their caregivers, and is consistent with ANNA’s goals of advocacy. ANNA is in support of this legislation and ANNA members are working toward its passage. While it was not addressed in the first session of the 109th Congress, there is hope that it will gain more support from Members of Congress and that there will be a Medicare vehicle in 2006 that will include at least some of the provisions of the bill. The bill engendered education of Members of Congress and their staffs by ANNA members as well as others involved in KCP along with the local media about CKD and ESRD. Increased awareness of the needs of this patient population and subset of the Medicare program will inevitably lead to policy changes.

Conclusion
The Code of Ethics for registered nurses adopted by the International Council of Nurses (ICN) (2000) states that “the nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.”

It is clear that ANNA members have a responsibility to care for the population of patients with ESRD as a whole in addition to those they care for in their daily practice. The Association takes that responsibility seriously, incorporates it into its mission, goals and objectives, and encourages the reader to work toward passage of this and similar legislation now and in the future.


References
ESRD Modernization Act of 2004, S. 4927, 108th Congress. (2004a). Retrieved December 5, 2005, from http://thomas.loc.gov

ESRD Modernization Act of 2004, H.R. 2614, 108th Congress. (2004b). Retrieved December 5, 2005, from http://thomas.loc.gov

International Council of Nurses. (2000). The ICN code of ethics for nurses. Retrieved January 29, 2006, from http://www.icn.ch/icncode.pdf

Kidney Care Quality and Improvement Act (KCQIA) of 2005, S. 635, 109th Congress. (2005a). Retrieved January 2, 2006, from http://thomas.loc.gov

Kidney Care Quality and Improvement Act (KCQIA) of 2005, H.R. 1298, 109th Congress. (2005b). Retrieved January 2, 2006, from http://thomas.loc.gov

League of Women Voters of Greater Youngstown. (n.d.) Retrieved January 29, 2006, from http://www.cboss.com/lwv/
The U.S. Constitution Online. (n.d.). How a bill becomes a law. Retrieved December 19, 2005, from http://www.usconstitution.net/consttop_law.html

Additional Reading
California State Legislature. (n.d.). Overview of legislative process. Retrieved December 19, 2005, from http://www.leginfo.ca.gov/bil2lawx.html

Michigan Legislative Service Bureau. (n.d.). How a bill becomes a law. Retrieved December 19, 2005, from http://www.michiganlegislature.org

Project Vote Smart. (n.d.). Government 101: How a bill becomes law. Retrieved December 19, 2005, from http://www.vote-smart.org/resource_govt101_02.php

School House Rock. (n.d.). Lyrics from “I’m just a bill.” Retrieved December 19, 2005, from http://www.school-house-rock.com/bill.html