Aging of the U.S. population raises numerous public policy issues about which gerontological researchers, policy experts, and practitioners have much to contribute. However, the means by which aging-related public policy is influenced are not always apparent. Drawing on experience working in the U.S. Senate and other settings as Health and Aging Policy Fellows, the authors outline the formal and informal processes by which public policy is shaped in the U.S. Congress. Many who seek to influence public policy do so by telling legislators what they want. A less obvious path to policy influence is for gerontologists to offer their expertise to legislators and their staff. The authors provide specific recommendations for how gerontologists can establish productive and ongoing relationships with key legislative players. The authors also emphasize the importance of collaboration with advocacy groups and with local and state stakeholders to advance aging-related public policy to improve the lives of older Americans.
Advocacy for older people is interwoven with the history of gerontology. Advocacy efforts have been driven by concerns about the health and social, emotional, and economic well-being of older adults that have guided the field of aging. Individuals from the many academic and professional disciplines that constitute the field of gerontology influenced public policy at the first White House Conference on Aging in 1961. This seminal event led to federal and state initiatives to improve the lives of older adults, notably the Older Americans Act of 1965, Medicaid, and Medicare (Brown, Liebig, & Sterns, 2004; National Retired Teachers Association, 1971). Establishment of the National Institute on Aging (NIA) in 1974 and an aging research portfolio in the National Institute of Mental Health were, in part, a result of advocacy by gerontologists and aging organizations (Freeman, 1980). However, congressional funding for the Older Americans Act, NIA, and other programs focused on older adults has fluctuated over the years and is very modest relative to funding for other categorical programs (Moses, Dorsey, Matheson, & Thier, 2005;,Alliance for Aging Research, 2009; Butler, 1999; Kerin, Estes, & Douglass, 1989). The reasons for this variable support are complex, may appear mysterious to gerontologists, and be attributed to “politics.”
Policy solutions for pressing social issues of the day have successfully advanced some measure of real change. Consider, for instance, the community mental health movement of the 1960s (Smucker, 2007) or the public health benefits accrued as a result of changes in tobacco and safety belt laws (Brownson, Hopkins, & Wakefield, 2002; Dinh-Zarr et al., 2001). There have been advances in elder care as well. Two examples include the creation of the Supplemental Security Income program and recent efforts to rebalance long-term care away from institutions and toward home- and community-based settings. So what now can the gerontological community do better to help members of Congress, their staff, and others understand aging issues and advance public policy in this area? In this article, we focus on the U.S. Senate where most of us have worked as part of the Health and Aging Policy Fellowship Program. After describing the fellowship program, we share insights yielded from our day-to-day work in the Senate about the structure and organization of Congress and the legislative and advocacy processes. We then contextualize these observations by integrating them with insights deriving from the policy process literature. Finally, we put forth specific strategies for advancing aging public policy drawn from political theory as well as from our experiential learning as Fellows.
The Health and Aging Policy Fellowship
The Health and Aging Policy Fellowship supported by the Atlantic Philanthropies and administered through the Research Foundation for Mental Hygiene at Columbia University offers gerontological professionals at various career Stages 9- to 12-month opportunities to participate directly in the policy-making process (http://www.healthandagingpolicy.org/). The Fellowship includes a residential and nonresidential track. Residential fellows serve as legislative assistants in federal or state legislative bodies or staff in executive agencies or in external policy organizations. Nonresidential fellows remain at their home institutions and work on a project relevant to aging public policy and may engage in brief governmental off-site placements during the fellowship year. Extensive orientation to policy, mentorship by policy leaders in aging, and other activities are part of the fellowship in partnership with the American Political Science Association Congressional Fellowship Program. The first cohort of five residential and three nonresidential fellows was launched in 2008 with placements in offices of individual U.S. senators, the Senate Finance Committee, and the U.S. Department of Veterans Affairs. Nonresidential fellows worked on individual aging policy projects and on projects with Senate offices. Fellows worked on a wide range of aging-relevant policy issues, including health care reform, long-term care, end of life, mental health, Medicaid, the geriatric workforce, and community-based services. (See recent issue of the Public Policy and Aging Report [Hudson & O’Neill, 2010] for a fuller description of the Fellowship and activities of fellows.)
U.S. Senate Personal Office
Individual Senate member offices (referred to as “personal offices” in distinction from Senate committees or other organizational structures that support Senate functions) vary in size and complexity. The general structure of a Senate personal office includes the chief of staff who oversees the office, the legislative director who is responsible for legislative activities, legislative assistants who handle different portfolios (e.g., health, aging, environment, foreign relations), legislative correspondents who handle day-to-day constituent issues and related activities, and a press officer. Senators who are chairs of Senate committees or are ranking minority members of committees also have separate committee staff. The work of the U.S. Congress (Senate and House of Representatives) often takes place within committees or subcommittees that have jurisdiction over legislative issues (Koempel & Schneider, 2007). Despite the common organizational structure of personal offices, each office has its own unique culture and dynamics reflecting the interests and personality of the individual Senator. The U.S. House of Representatives has a similar organization, although House offices are much smaller than Senate offices.
Although each Senate office handles a broad array of issues, staff energy is often focused on issues most important to the Senator, which are usually based on state and regional interests. For example, Senators from rural states are more likely to have interest in agricultural issues and have membership on relevant committees. Hall (1996) has noted the “intensity” of attention given by members of Congress to state or district issues of importance to their constituents. He further observes that some members of Congress play a central role in promoting non–state-specific issues (e.g., mental health) that reflect either their personal interests or initiatives on the part of the President of the member’s same party (Hall).
Senate offices are very busy places, and staff handle a multitude of issues. Because most offices experience frequent staff turnover (Weissert & Weissert, 2002), staff are constantly in learning mode. Staff need to quickly master a new content area, get up to date on existing issues, and then provide advice and guidance to the Senator who must take stands on policy issues affecting state and regional interests while also balancing personal interests and political concerns.
Legislative activity on issues may emerge unexpectedly, and staff need to get factual and reliable information very quickly. Although some types of legislative action are more predictable (e.g., those related to expiring authorizations or budget year deadlines), other items rise suddenly on the agenda because of a crisis or “hot button” issue that is in the public view and therefore has gathered political clout. Ultimately, party and committee leadership are responsible for setting and adjusting the legislative calendar as needed.
An important resource for congressional staff is the nonpartisan Congressional Research Service (CRS). CRS has a large staff, which specialize in acquiring and synthesizing information in areas of concern to the Congress. The Government Accountability Office also does research and reports for Congress frequently based, in part, on large-scale field investigations. The Congressional Budget Office does so as well, focusing on budgetary costs and benefits of particular bills. A large number of policy institutes and advocacy organizations produce policy briefs that inform members of Congress and their staff. Most staff have a trusted group of key informants to whom they turn for advice and information on emerging issues and for help sorting through the political implications of supporting (or opposing) specific proposals. Senate committee staff are another source of information for their colleagues working in members’ personal offices (Weissert & Weissert, 2002).
Other Policy Players
Integral to the work of staff in Senate personal offices are meetings with constituents, advocacy groups, and lobbyists. Those relevant to the public policy and aging world include professional organizations (e.g., American Geriatrics Society, American Medical Association, American Psychological Association, National Association of Social Workers, the Gerontological Society of America [GSA]), for-profit businesses (e.g., those concerned about Medicare payment rates for the products they manufacture or distribute), free-standing (e.g., The Brookings Institution) and university-based policy institutes (e.g., The Georgetown Public Policy Institute; Van Tassel & Meyer, 1992), and advocacy groups (e.g., AARP, Medicare Rights Center, National Council on Aging, National Committee to Preserve Social Security). Often congressional staff have regular contact with representatives of these groups and may rely on these organizations for information, input, and guidance (Weissert & Weissert, 2002). When legislation is being developed, congressional offices try to garner organizational support for a bill. The endorsement of aging-relevant advocacy groups may be critical to a bill’s success, and it is not uncommon that legislation will be drafted or revised with the concerns of these organizations in mind.
Reliance of members of Congress on lobbyists and interest groups has been well documented in the political science literature (Hall, 1996; Hall & Deardorff, 2006; Weissert & Weissert, 2002). Indeed, outside interests and experts play an important role in how the policy agenda unfolds. Before legislative decisions are made, agendas are set and alternatives specified. Political agendas are typically established when problems are recognized, and there is growing consensus that some action should be taken. According to Kingdon (2003), agenda setting is the usual domain of “visible participants” in the policy process, a group that includes among others, the President, high-level appointees, and prominent members of Congress. “Hidden participants”—a group typically composed of academic researchers, consultants, career bureaucrats, congressional staffers, and others—are instrumental in crafting the policy alternatives or solutions designed to respond to these identified problems. Kingdon further explains that specific policy issues are most likely to find a place on the agenda when three otherwise independently flowing political “streams” intersect: public problems, policy alternatives, and political opportunities. While bringing these three streams together is challenging, Kingdon observes that there are some individuals who are dedicated to finding productive connections between politics and policy making. These “policy entrepreneurs” may reside inside or outside of government and may inhabit different roles and locations in the policy process, yet all have a common interest in advancing policy change. They search for “windows of opportunity” that offer the chance to promote their proposals for change.
Passage of the Community Living Assistance Services and Supports Act (i.e., the CLASS Act) as part of health care reform provides one recent example of seizing a window of opportunity. As the general public has become more aware of the need for affordable long-term care (i.e., the public problem), the CLASS Act creates a new national insurance program to help individuals pay for home and institutional long-term care. Furthermore, this policy option was given the seal of approval by the Congressional Budget Office, which indicated that the program is fiscally sustainable and will actually reduce the national deficit over 10 years (i.e., the policy alternative). The bill enjoyed the support of more than 260 national organizations and is considered part of the legacy of the late Senator Edward Kennedy who introduced it. Inclusion of the CLASS Act in the comprehensive health care reform bill was particularly fortuitous because the health care reform bill was championed by the President who expended a considerable amount of political capital to ensure its passage (i.e., political opportunity).
The professional community of gerontological researchers, academics, and practitioners represents “hidden participants” in the policy process and have an enormous amount to offer members of Congress and their staff. Some may even adopt the role of policy entrepreneur promoting favored solutions to widely perceived problems (Kingdon, 2003). In lieu of assuming this more intensive role, however, there are many ways in which gerontologists can influence policy making. One fundamental contribution is to introduce an aging perspective into a wide array of policy issues and within a diverse range of policy and practice settings. Most of us were struck by how little discussion there is about aging by legislators and legislative staff. For instance, despite the fact that the lion’s share of health care is consumed by older adults, rarely was the health care reform debate framed from an aging perspective.
Like others in American society, members of Congress and their staff may hold stereotypical attitudes toward older adults (Bodner, 2009). Because aging public policy issues under debate are often framed around the problems of aging, it may not occur to these decision makers that aging is more than problems. Staff, in particular, may be unfamiliar with the many strengths of older adulthood and the numerous contributions made by older members of our society. That is, in part, due to the fact that most staff are younger people who are less likely than middle-age or older individuals to have had direct experience with aging issues for themselves or their family members. Congressional staff have been portrayed as the “gatekeepers and opinion shapers of many public health issues” (Brownson, Royer, Ewing, & McBride, 2006). Enlightening them about the relevance of aging issues in public policy should be seized as an opportunity to bring such issues to the forefront.
Advancing the Aging Policy Agenda
We know from past policy debates that aging-related issues can be framed in ways that pit the needs of older adults against younger adults (Binstock, 1983; Polivka & Estes, 2009). However, these issues can be reframed in a way that older age cohorts also are seen as groups in American society whose concerns are vitally interwoven with those of all generations (Kingson, Cornman, & Hirshorn, 1986). Helping congressional members and their staff to think about how aging is integral to broader policy concerns may subtly, yet powerfully, shift the ways in which they view those issues. It has been noted elsewhere that changes to conventional wisdom take time and may be the long-term product of many years of research (Kemper, 2003). Making the connections between aging and other social issues more explicit is one way to ensure that age-relevant public policy will begin to get the attention it needs.
To that end, we present some specific considerations and strategies that anticipate the propitious intersection of Kingdon’s (2003) three political streams—public problems, policy alternatives, and political opportunities—which can be used by members of the gerontological community to identify and support aging-related public policy change.
Bring Aging Friendly Legislators Out of the Shadows
Does aging map on to the legislative priorities and agenda of the member of Congress? Usually, aging matters to those members who are on committees relevant to health and aging. Beyond the bright lights of Senate and House committee hearings, other members of Congress evidence interest or potential interest in aging through introduction of aging-relevant legislation. A review of the last 2–3 years of legislative activity in the Library of Congress’s “Thomas” website may reveal aging friendly legislators or political champions (Brownson et al., 2006) who are in the shadow of the roughly 10,000 bills that are introduced during each session of Congress. “Thomas” (as in Thomas Jefferson) is a compendium of the status of legislation, which may be found on www.thomas.gov.
These members will most likely dedicate time, staff resources, and political capital to aging-related legislative issues. These are the members of Congress for whom information, counsel, and recommendations from aging experts will be most valued. This does not mean that those who are uncommitted to aging issues should be ignored. However, influencing those not already attuned to aging policy issues will likely require more persistence and a longer term outlook (Kemper, 2003).
Listen and You Are More Likely to be Heard
Washington is filled with people who like to talk—about politics, policy, and public perception. When establishing relationships that potentially yield political influence, it is also important to really hear what others have to say. The advice of a seasoned Washington political communications specialist was simple: In a town where everyone wants to talk about themselves, be a good listener. We believe that in the legislative process where the conversation is often about “the ask” (for a politician’s time, attention, and vote) and “who gets what” (money, influence, and power) giving staff your attention and providing credible, reliable information can be very powerful. In our work in the Senate, we encountered people whose opinion is sought by congressional staff and sometimes we consulted with them ourselves. Some have well-known names, others do not. They have the ear of congressional staff because they are knowledgeable, trustworthy, confidential, easily available, and, most importantly, helpful. When they themselves have a policy issue or concern to communicate, it is much more likely that they will garner staff and member attention than others.
Emphasize Local Issues and Access Local Avenues for Policy Advocacy
As former Speaker of the House Tip O’Neil is often quoted, “All politics is local.” Being a resident of a state or congressional district of a member with an interest in aging is important. Gerontology professionals—especially those who are constituents—can serve as available resources to congressional staff on a variety of issues without a specific advocacy agenda. We know staff and their respective senators who rely heavily on the advice of aging experts from their state. Local experts can not only offer broad guidance on public policy but are more likely to be knowledgeable of and sensitive to state or congressional aging issues or concerns. Connection with an aging expert from one’s state or district likely enhances the member’s reputation among voters and state interest groups.
Lack of attention to aging-related policy issues at the federal level also is evident at the state and local levels. Given this, gerontology experts may also choose to direct their knowledge and advocacy efforts toward local and state legislators. State policy making can happen much faster than at the federal level, and states often have flexibility to try new program and policy approaches. This multilevel approach to policy advocacy will further extend the scope of influence that members of the gerontological community can ultimately wield.
Build Relationships to Influence Public Policy
There are multiple pathways to building relationships with legislative offices (Jones, Kreuter, Pritchett, Matulionis, & Haan, 2006).
(1) Establish connections with local, state, or Washington, DC, legislative offices. Make an appointment in advance and ask to meet with the staff member who handles aging or related matters. Introduce yourself, explain what you do, and talk about the relevance of aging to people in the legislator’s state or district. Offer to be of help when aging issues arise.
(2) Learn about the legislator and his/her priorities. Visit the legislator’s website, find out on which committees the legislator sits, and be familiar with legislation that he/she has introduced, cosponsored, or supported. If there is pending legislation that has aging relevance, become familiar with it by reviewing “Thomas,” the Library of Congress website mentioned earlier, or the website of your local or state legislature.
(3) Make yourself useful and memorable. Prepare a 1–2 page brief on aging issues that are germane to your legislator and try to make a case why aging issues are or could be relevant to his/her agenda. Offer to be of assistance to the legislator’s staff when aging-related issues emerge. If you have previously visited one of the legislator’s offices, mention the name of the person with whom you spoke. Be friendly, sincere, enthusiastic, and knowledgeable. Tell a compelling story relevant to aging issues in the legislator’s state or district.
(4) Utilize other avenues for influencing policy. Professional organizations and advocacy groups often organize a day during which they arrange meetings between their members and their respective representatives. Participating in your organization’s national or local chapter might include taking part in state or national “ lobby days,” which provide yet another entrée into the policy arena.
Congressional committee staff and state legislative analysts often dig more deeply into specific policy issues than is typical for personal office staff (Weissert & Weissert, 2002). They may be especially interested in gaining information and ideas from gerontologists with expertise relevant to their immediate interests. If you have a relationship with staff in the office of a member of Congress, the office may be able to make an entrée to the committee staff for you, especially if the member is on the committee. Or, you may call the committee office directly and arrange to speak with a staff member who handles the issue for which you possess expertise. At the local level, you may find ways to communicate and exchange ideas with the legislative analysts who work more directly on relevant policy issues.
Follow Up With Staff
Whether you visit a local or Washington DC–based office, a personal or committee office, it is important to follow up with an E-mail thanking the staff member for the visit and reiterate your willingness to provide aging expertise. If aging-related policy issues arise, contact these staff members reminding them of your past visit and expressing your interest in being of help. If the staff member responsible for aging issues changes (which often happens), remind the new staff person of your past connections with the office.
Be Attuned to the Importance of Timing in Policy Making
The legislative agenda often moves quickly and staff need information right away. As illustrated by Kingdon (2003), the “windows of opportunity” to advance policy change often open and close abruptly and without warning. Policy alternatives need to be ready to go. If contacted by a congressional staff person, respond quickly (within a few hours, if possible). This may be your chance to help that person gather information, share your perspective, and offer the “local view” on an aging issue. If you are helpful, you are likely to be remembered and find a place in his or her electronic Rolodex. Committees and/or subcommittees often have hearings about legislative issues. Members of Congress are especially interested in having individuals from their state or district testify at hearings. If asked to testify, grab the opportunity. Issue-specific congressional caucuses offer less formal forums to make presentations.
Further Expanding Aging Advocacy Efforts
Despite the fact that aging is often regarded as a peripheral issue on the legislative agenda, the sheer size of the population of older adults should eventually prompt most legislators to realize that aging matters. Numerous scholars have forecast a series of public policy crises likely to result from a lack of long-term planning for an aging society. They portend, for instance, that Medicare will begin to run out of money, the Social Security Trust fund will operate at a deficit, Medicaid expenditures for long-term care will wreak havoc on state budgets, and demands for Administration on Aging funded community services will far exceed supply (American Academy of Actuaries, 2008; Burgess & Applebaum, 2009; Olshansky, Goldman, Zheng, & Rowe, 2009; Van de Water, 2008). If any of these predictions are realized, legislators will hear from aging constituents in ways that they cannot now imagine.
Although gerontologists may bemoan the fact that our society has not well planned for an aging America, we ourselves can prepare for the day when windows of opportunity for addressing aging-related issues open and gerontologists’ expertise can play a critical role in shaping public policy in this area. We believe that this invigorated effort should start now and build on the many activities that public policy and aging specialists, aging advocacy organizations, professional groups, and others have been doing for a long time.
In particular, Sabatier and Jenkins-Smith (1988, 1993) have articulated a policy-making theory that, among other assumptions, acknowledges the central role that scientific and technical information plays in policy processes. The Advocacy Coalition Framework (ACF) that they have developed recognizes that actors in the policy environment include a much broader range of players than may be apparent. Sabatier and Jenkins-Smith argue that explanations of the policy process need to better account for the influence wielded by officials from all levels of government, consultants, scientists, and members of the media. Within the ACF, coalitions form between diverse groups of actors because certain interests link to core beliefs or ideas. These connecting interests in turn make it possible to map a network of actors within a particular policy sector whose core beliefs or ideas become the causal driver for political behavior.
We present the following suggestions for expanding the influence of aging organizations and gerontologists on public policy based on the broader coalition of actors within which they might participate.
Find New Channels for Policy Advocacy
Think broadly to identify advocacy organizations and other actors that map on to your ideas and areas of aging expertise and interest. In a fashion parallel to building relationships with congressional staff, start a relationship with that organization or actor or move an existing relationship beyond a casual acquaintanceship to an enduring partnership. For example, researchers may find that their academic work clearly resonates with an advocacy group whose mission is to change policy. A researcher on end-of-life issues could reach out to one or more advocacy groups for whom this is a focus, sharing research knowledge and expertise. Better yet, explore avenues by which you can partner with the relevant organization to potentially make your work policy actionable or think about a future research stream that is policy actionable (Brownson et al., 2006; Gold, 2009). Because enduring relationships are mutual, explore ways in which the policy interests of the advocacy organization can guide and support your own research agenda.
The constraints of academia often inhibit or preclude dedication of time to policy action, especially for those in the early stages of their careers. However, many of us participating in the fellows program discovered that partnering with the right organization resulted in a complementary and productive relationship, one in which research and policy action were not experienced as distinct pursuits. This discovery suggests the potential for a shift to a reciprocal paradigm in which research drives policy and policy drives research.
Work With Local Groups
States and localities can be cauldrons of novel and creative ideas as is evident in some state initiatives to improve access to health care for their citizens (Jones et al., 2006). Wisconsin's Family Care Program provides one state-level example of a successful long-term care initiative that has improved quality of care while also reducing costs (http://dhs.wisconsin.gov/ltcare/Generalinfo/). The promise of consumer-directed home care is illustrated by the success of the Cash and Counseling Demonstration, initially implemented in 3 states and now being replicated in an additional 12 (www.cashandcounseling.org). These state/local level initiatives provide examples of fruitful collaborations between gerontological researchers, practitioners, and advocacy groups that have policy-actionable implications that may be readily translated to the national level.
Expand the Policy Reach of National Member Organizations Representing Aging Researchers and Practitioners
The GSA provides one such example. GSA’s “Expert Referral Service” opens the door to the offices of the nation’s aging leaders (http://www.geron.org/Resources/ExpertReferralService) and has been a substantive resource for media who, like congressional staffers, have short time frames through which they need to gather facts and tell a story related to aging. Other national organizations could emulate and enhance this feature, by tailoring such a list to specifically identify members who can be a resource for policy issues. Furthermore, member organization annual meetings and journals could feature “hot topics” that are policy actionable, thus making explicit the connection between research, practice, and policy in ways that may not be so readily apparent to its members, policy makers, or the public.
Use Current and Past Policy Fellows as a Resource
Those gerontologists who have worked at the intersection of aging and policy are a potential resource to guide the expansion of policy efforts. In addition to the newly established Health and Aging Policy Fellowship other programs include the Robert Wood Johnson Health Policy Fellows, the American Psychological Association Congressional Fellowship, the American Association for the Advancement of Science Congressional Fellowship, and the American Political Science Association Congressional Fellowship. Although the Health and Aging Policy Fellowship explicitly focuses on aging, fellows in other congressional programs work or have worked in Congress on aging-related issues.
This is a remarkable time to be in the field of gerontology with the rapidly aging population here and in other countries. The 2002 Madrid International Plan of Action on Ageing developed at the Second World Assembly on Ageing testifies to growing enthusiasm, interest, and concern about the challenges to and contributions of older adults throughout the world (Report of the Second World Assembly on Ageing, 2002). Aging policies formulated in one country can inform those of other nations. The United States has a large cadre of gerontologists who can substantively contribute to our own national aging policies and potentially those of other countries. The motto of the baby-boomer generation in their youth was “make the world a better place.” As that generation ages and again reshapes American society, the gerontological community can heed this earlier idealistic call and work with government policy makers to make the “aging” world a better place.
The Health and Aging Policy Fellows Program is funded by the Atlantic Philanthropies.
The authors thank Harold Alan Pincus, MD, and Phuong Trang Huynh, PhD, MPH, who are, respectively, the Director and Deputy Director of the Health and Aging Policy Fellows Program (HAPFP), for their support and guidance during the fellowship year. We also thank the American Political Science Association Congressional Fellowship Program with which HAPFP partners and the HAPFP National Advisory Board members. Finally, we want to express our appreciation to the two reviewers of this article who offered especially helpful comments.