A nurse's head, heart, and hands are no longer sufficient tools to ensure quality care for our patients. Nurses must also use their voices to promote the health of our citizens (Smith, 2003).

To influence health care policy, we must start with a basic understanding of the legislative process. We shall begin with how a bill becomes law, identify the steps in the legislative process, and identify the points in the process at which we have the greatest opportunity to exert influence on our congressmen and women.

The United States Legislature is considered "bicameral," or having two chambers, namely the House of Representatives and the Senate. For a bill to become law, it has to pass both chambers. Bills start as ideas. The best bills are ones that are easy to explain and positively affect many people. (Source: www.yourcongress.com.) Anyone can draft a bill, however, only members of Congress can introduce legislation and by doing so become the bill's sponsor(s). (Source: www.nursingworld.org.)

Before introducing a bill, a member of Congress will do research to collect facts and send draft versions to different organizations for their input on how it will affect their members. This is the first opportunity for citizens to influence a bill. Members of nursing organizations, when called upon to provide feedback, should take advantage of the opportunity to influence a bill at this stage of development.

Introducing the Bill

  • Bills
  • Concurrent resolutions
  • Joint resolutions
  • Simple resolutions

Concurrent and joint resolutions are usually expressions of Congress' opinion. Simple resolutions address internal House or Senate matters (www.yourcongress.com).

From Bill to Law 

Step 1:

 A new bill is referred to a committee in the House or Senate depending on the chamber in which it originated. A bill can then be referred to a subcommittee or considered by the committee as a whole. There are three House and three Senate committees with jurisdiction over legislation affecting health care and health care professionals.

The House committees and their respective subcommittees are:

  • Appropriations Committee - subcommittees are Labor; Health and Human Services; and Education.
  • Energy and Commerce (Medicare Part B and Medicaid) - subcommittees are Health and Environment; and Hazardous Materials.
  • Ways and Means Committee (Medicare Part A) - subcommittee is Health.

The Senate committees overseeing health care are:

  • Appropriations Committee - subcommittees are Labor; Health and Human Services; and Education.
  • Finance (Medicare) - subcommittee is Health Care.
  • Health, Education, Labor, and Pensions Committee (H.E.L.P) - subcommittees are Aging; Children and Families; Employment Safety and Training; and Substance Abuse and Mental Health Services.

You can find listings and information on all congressional committees at www.senate.gov and www.house.gov.

It is important for nurses, grassroots organizations, and citizens to know which committee is handling a particular bill, as well as the chairperson and members of the committee. When organizations call for action, their efforts are much more effective when targeted to the appropriate congressmen or women. It is also helpful to keep your respective congressmen abreast of your sentiments and views about pending legislation even if they are not a member of the reviewing committee.

Step 2:

 Three things happen once a bill goes to a committee or is referred to a subcommittee: hearings, mark ups, and votes. Hearings are held to record the views of the supporters of the bill. "Mark up" is the process of making changes and amendments to the bill following the hearings and prior to recommending the bill to the full committee. Next the committee votes on its recommendation to the House or Senate. The hearings and "mark up" offer another opportunity for citizens and organizations to have input into the progress of a bill.

Step 3:

 When the bill is recommended to the House or Senate, a written report is prepared. This report describes the intent, scope, and impact of the legislation and includes the views of dissenting members of the committee.

Step 4:

 The bill is reported back to the originating chamber and is scheduled for floor action, which includes debate, approval of any amendments, and voting. At this point a bill is passed or defeated. When a bill is passed by the House or Senate, it is then referred to the other chamber where it usually follows the same process through committee and floor action. The second chamber can approve the bill as received, reject it, ignore it, or change it.

Step 5:

 If the second chamber makes significant changes to the bill, a conference committee is formed to reconcile the differences between the House and Senate versions. It is during this step that organizations and citizens have their last opportunity to influence the outcome by contacting the conference committee members. The House and Senate approved versions of the bill must be identical before they can be forwarded to the President.

Step 6:

 If the President approves the bill, he signs it and it becomes law. If he takes no action for 10 days while Congress is in session, the bill automatically becomes law. If the President vetoes the bill, Congress can override the veto with a two-thirds vote. Finally, if the President takes no action after Congress has adjourned its second session, it is a "pocket veto" and the legislation dies. (Source: N-STAT, 2003).


As you can see, the legislative process can be a daunting task with limited opportunities for input into the process. There is always the potential for a bill to die during each step for a variety of reasons. One reason is lack of support, which is why it is important for nurses to respond to calls for action when important health care legislation is pending.

The American Nurses Association (www.nursingworld.org) and the National Council of State Boards of Nursing (www.ncsbn.org) Websites are excellent sources of information on pending legislation affecting health care and health care professionals. AAACN's Website (www.aaacn.org) frequently highlights pending legislation that calls for nurses to take action and periodically sends broadcast e-mails urging members to contact their legislators to support measures important to ambulatory care nurses. AAACN was recently active in supporting the Nurse Reinvestment Act (HR 3487; S 1864), a bill sponsored by Congresswoman Lois Capps that addressed the nursing shortage. The billed was approved and signed into law on August 1, 2002 by President Bush.

Understanding the legislative process and knowing when to act helps nurses use their power and influence to affect a bill's outcome. Another crucial aspect of the process is lobbying; a topic that will be explored in the next installment of this series.

Regina C. Phillips, MSN, RN

Smith, K. (2003). Overview of developing legislation and implementing regulation: How to influence both. Presentation: Arlington, VA. Nurse in Washington Internship (NIWI) Program.

N-STAT. (2003). N-STAT, Politics in Action. Hill Basics: The Legislative Process. Retrieved July 24, 2003 from www.nursingworld.org/gova/federal/politic/hill/glegproc.htm.

Original Publication
Phillips, R. (2003). How a Bill Becomes a Law. Viewpoint, 25(4), 6-7.