Understanding State-Level Advocacy: A Guide for Hearing Healthcare Professionals

Abstract

Advocacy is a core component of moving the hearing healthcare environment forward to optimize patient care and allow providers to work to the full extent of their scope of practice. Despite its importance, advocacy, particularly at the level of state governments, can present to many as a daunting, sometimes futile, task. The purpose of this article is to describe advocating at the state level for hearing healthcare service providers. This article will discuss considerations for audiology practitioners interested in state-level advocacy, including variations in state government organization, benefits and barriers to state advocacy, and state-level issues that affect practitioners.

The role of a hearing healthcare provider extends well beyond the walls of the clinic or laboratory. According to the American Speech-Language-Hearing Association's scope of practice for audiologists, audiologists are responsible for “advocating at the local, state, and national levels for funding for services, education, and research” as well as “advocating for fair and equitable services, including accessibility for all individuals, especially the most vulnerable.” ¹ A core tenant of the role of any clinician is to educate and inform other stakeholders about the clinician's areas of specialty, as well as advocate for their patients. Educating the public may be done through teaching, community outreach, or advocating at the state or federal level. Advocating is not only a way to educate but an ethical and professional standard. To that end, advocating and engaging in politics on behalf of the profession is an obligation and a “fundamental tenant” ² of clinical professionalism.

For many, the idea of advocating governments, federal, state, or local, may seem to be a daunting process. Over the past 30 years, political polarization has increased exponentially both between ³ and within political parties. ⁴ However, governments require the input of professionals to guide legislation. State governments determine funding to institutions of research and education, healthcare coverage, licensure laws, scope of practice, and other critical aspects of clinical practice. Successful advocacy must occur at all levels of government, though many of the issues directly affecting clinical audiologists occur at the state level, which is often overlooked. Consider the following scenario:

You work in a hospital-based clinic in a rural area serving pediatric populations. You notice that despite being a birthing center, newborn hearing screenings are being completed inconsistently, and there is no reporting mechanism. Additionally, once a newborn is identified with a hearing loss, few are fitted with hearing aids, as pediatric hearing aids are not covered by Medicaid/CHIP in your state. You want to advocate for change but are not sure where to go.

This example highlights the interconnectivity between federal and state policies that affect the audiologist. Newborn hearing screening programs are generally funded by state governments, though these governments are supported by the federal agencies outlined in the Early Hearing Detection and Intervention (EHDI) Act of 2018 (PL 115-71). Medicaid and Children's Health Insurance Programs (CHIP), however, are regulated almost entirely by the state government. Additionally, screening procedures, follow-up outcomes, and all administrative functions related to newborn hearing screening are administered and monitored by individual states, rather than through a national database. By using the information in this example, the audiologist in this situation may find the most success by advocating for change at their state level. In advocating at the state level, audiologists will be able to bring expert opinion directly to the decision makers responsible for regulating and servicing the newborn hearing screening program in their state. The purpose of this article is to highlight the advantages of advocating at the state level and provide more insight into the workings of state government, as it applies to hearing healthcare professionals.

What is the Difference Between a State and Federal Government?

Like the federal government, most state governments consist of three branches: the executive, legislative, and judicial. Unlike the federal government, however, there is wide variability in the way many of the individual states organize their government, particularly the legislative branch. State legislatures can vary in their chamber composition (unicameral vs. bicameral), the size of the legislature, the time commitments for elected officials (full time vs. part time), and the frequency of a legislative session (annual vs. biennial). A state-level advocate must be knowledgeable about their state legislature when considering how and when to advocate for an issue.

Forty-nine of the 50 states have a state legislature that is bicameral, or a state legislature that consists of two chambers. States with bicameral legislatures have an upper and lower chamber, with the lower chamber usually called the House of Representatives and the upper chamber called the Senate. The name for the lower chamber can vary from state to state. For example, both Georgia and Wisconsin call the lower chamber the State Assembly and Nevada refers to the lower chamber simply as the Assembly . Regardless of their names, the function of these bicameral chambers is like that of the federal legislative branch.

The only state that does not have a bicameral system is Nebraska, which has only one chamber, or a unicameral chamber. In Nebraska, all members of the legislature are referred to as senators. Nebraska also differs from other states in that it does not officially recognize political party affiliation, though members often identify with political party. It is also the smallest state legislature, counting a total of 49 members.

States also differ from the federal legislature in that they do not have a set size requirement. The United States Constitution requires that two senators from each state are elected to the U.S. Senate, while the Permanent Apportionment Act of 1929 fixes the size of the U.S. House of Representatives to 435 representatives. This is not the case for state legislatures. Each state, however, can determine the size of their chamber, and often adjusts the size. This results in a nonuniform legislature from state to state. For example, New Hampshire has a total of 424 legislators (400 state representatives and 24 senators), while Alaska has 60 (40 state representatives and 20 senators). You may think that this is due to differences in population within the state, and that the size of the legislature reflects the population of the state, but this is not exactly true. In 2013, Texas had 150 legislative seats, suggesting a population ratio of 173,000 for each legislator. That same year, Maine had a total of 151 legislative seats, with a ratio of 8,800 people per legislator. ⁵

In addition to size, state legislatures differ from the federal legislature by the time requirement for elected officials. Understanding the time commitment and legislative timing of your state government is essential in planning an action on a policy relevant to the audiologists in your state. The National Conference of State Legislatures (NCSL) categorizes state legislature time commitments into three color-coded categories: Green Legislatures, Gray Legislatures, and Gold Legislatures. In addition to the time commitment, each color corresponds to the pay awarded to the legislator and the number of staff.

States deemed “Green Legislatures” are states that require a full-time commitment for legislators. Those elected are generally well-paid and are provided with a larger staff. States with Green Legislatures generally have larger legislative sessions, and therefore may devote more resources to addressing policy issues. Gray Legislatures, or “hybrid legislatures,” are legislatures that require elected legislators to work roughly two-thirds of a full-time workload. On the opposite end of the spectrum, the “Gold Legislatures” refer to states that require elected legislators to work roughly half of the time. Legislators in these states have a much lower compensation rate compared with those in the other categories and a much smaller staff. These legislators are often required to work multiple jobs to maintain a livable wage. Additionally, part-time legislatures tend to have shorter, or more compressed, legislative calendars, meaning that there is a shortened timeline from the start of a legislative session to the deadline for a bill's passage. Due to their limited time commitment, it requires advanced planning to pass a policy change in states deemed gray or gold states. That said, there are benefits to having a part-time or hybrid legislature, as state legislators in these areas are likely spending more time in their districts, making them more accessible to their constituents. As both clinicians and constituents, it is imperative that hearing healthcare providers understand the time commitment of their state legislators. The NCSL provides accessible and detailed information to help constituents find this information online at https://www.ncsl.org/research/about-state-legislatures/full-and-part-time-legislatures.aspx .

Why Lobby at the State Level?

Though federal policy efforts often receive more publicity from media outlets, a substantial number of policies that effect audiology are established at the state level. ⁶ Policy areas such as professional licensing, educational funding, and healthcare access are common areas of state government expenditure, and therefore allow state governments a high amount of control over these areas. Audiologists should familiarize themselves with legislation and policy efforts at the state level to ensure that they are optimally advocating to the correct institutions. State-controlled issues include higher education funding and student loan repayment management, professional licensure rules and regulations, and payment rules related to Medicaid and other state-run health insurance programs.

Another reason an audiologist may be interested in advocating at the state level is that there is a higher chance that the policy of interest is considered. In general, state legislatures are far more productive than the federal legislature. In an analysis of legislation introduced between January 1, 2016, and June 30, 2016, the public policy analysis software, Quorum, found that state legislatures introduced 23 times the number of bills that the federal legislature introduced. State legislatures also passed more bills, with 19.3% of bills passed through state Senates and 13.3% of bills passed through the state House, compared to 3.6 and 1.9% of the federal Senate and House, respectively. That year, the Arkansas state legislature passed 94% of bills that were introduced! The data from Quorum demonstrate that, in general, a piece of legislation has a much greater chance of becoming a law at the state level compared with the federal level. This is even more evident when the legislature is unified, meaning the house and senate are composed of the same political party. Unified legislatures approve up to four times as many laws compared with divided legislatures. ⁷

State Regulation and Professional Licensure

Licensure oversight is another policy regulated by state governments that directly impact audiology provision. Occupation regulation and licensing is a significant task for state governments, one which provides states a high degree of independence. States may develop individual systems for establishing licensing requirements for a specific occupation, authorizing oversight and compliance boards to maintain standards for licensure and reviewing standing licensure regulations. ⁸ As states have flexibility in establishing and maintaining licensure regulations, each state may have its own design in licensure oversight, differences in licensure board design, and requirements to practice within the state. Advocacy efforts related to licensure can be extremely broad and cover a wide range of topics. For example, in 2021, a grassroots effort at the state level led to the passage of the Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC) in 10 states. ⁹ The passage of this compact allows for audiologists and speech-language pathologists to practice across state lines in participating states without requiring licensure in each state. It is the duty of hearing healthcare providers to understand how licensure in the state(s) that they provide services operates, and actively monitor any state-level legislation that may affect their ongoing licensure.

State Funding and Higher Education

Higher education funding is critical for the profession of audiology. As of 2018, student loan debt is the second-highest commitment for consumers, preceded only to mortgage debt. ¹⁰ For audiologists, this may be a significant impact on the profession. Student loan burden can contribute to increased stress levels and significantly impact healthcare career aspirations among those considering a healthcare profession. ^{11 12} Understanding the funding mechanisms behind higher education can be beneficial for not only professionals currently experiencing student loan repayments but also for recruitment efforts to grow the profession.

Funding for higher education, including loan servicing, related to education accounts for roughly 2% of federal spending. ¹³ Federal legislation such as the Higher Education Act (HEA, P.L. 89–329) authorizes federal student aid programs and provides federal support to post-secondary programs. The HEA also provides funding to allow federal dollars to support institutions that serve a high degree of students who identify as a minority status, such as institutions that are predominately Black, Alaska Native/Native Hawaiian-Serving, or American Indian (identifiers quoted from the bill). ¹⁴ Additionally, the Federal Legislature, along with the Department of Education, is key in distributing and managing student loan payments. Student loan repayment programs are available through both federal and state-level governments.

Despite federal initiatives, state legislatures have historically provided substantially more assistance to institutions of higher education, though the difference between the two has decreased. In 1990, states spent nearly 140% more than the federal government on funding per student. By 2015, the difference in spending between state and federal governments has dropped to only 12%. ¹³ Despite this drop, higher education is still one of the largest areas of state funding, lagging behind only elementary and secondary education and Medicaid funding in 2017. ¹³ Knowledge of the role that state governments play in higher education is essential in developing an effective advocacy effort for hearing healthcare providers. Such advocacy efforts could include developing a state-run loan forgiveness program. Despite many states having loan forgiveness programs for primary care physicians, dentists, nurses, and mental healthcare providers, there are few state-level incentive programs for hearing healthcare services. Incentive programs such as these would attract more hearing healthcare providers to states with greater needs for services and could serve as an aid in college recruitment efforts for future clinicians.

State Funding and Health Insurance Provision

Medicaid allotment is another policy area that is largely regulated at the state level. Though the federal government provides criteria for populations that are mandatory for coverage, states can expand or deny coverage for other populations or services. The variability of service provision is particularly important to know as a practitioner of hearing healthcare. As of 2018, thirty-seven states provide Medicaid benefits for speech, hearing, and language disorders, with 21 states having some limit on services. ¹⁵ Ultimately, states have final say in the Medicaid services, so long as the state abides by the essential federal guidelines. Consider the following scenario:

Your state implemented a temporary policy regarding telemedicine expansion, allowing for audiologists to be reimbursed for services rendered remotely for Medicaid recipients, a service that is not usually reimbursed. This temporary policy expires at the end of the month. Federal guidelines recommend that audiologists continue to be reimbursed for services rendered to Medicaid recipients, though the state has not passed any formal update to the policy. Are the federal guidelines sufficient for you to continue rendering services remotely to Medicaid recipients?

The answer to the scenario above is no. Though the federal government can recommend ways to implement Medicaid at the state level, the state has authority over how Medicaid recipients can be reimbursed. Insurance and Medicaid regulation are two of the largest state-level policy areas that impact audiologists and make up a large percentage of a state's budget. Public welfare is the largest area of state resource allocation, largely to support public health insurance programs, such as Medicaid and CHIPs, with health and hospitals the fourth largest category of state spending. ¹⁶

For hearing healthcare providers, knowledge of Medicaid and CHIP is an essential part of clinical practice. States lack uniformity in their coverages, particularly when the coverage relates to hearing aids. As of 2021, eighteen states require that health benefits cover hearing aids for children and six states require at least partial coverage of hearing aids for both children and adults. The amount of coverage varies dramatically from state to state. Table 1 provides a list of state coverage for both children and adults.

Table 1. State Insurance Mandates Regarding Hearing Aid Coverage for Either Children or Adults and Children ^a .

Hearing aid coverage for children	Hearing aid coverage for children and adults
Colorado	Arkansas
Delaware	Connecticut
Georgia	Illinois
Kentucky	New Hampshire
Louisiana	Maine
Massachusetts	Rhode Island
Minnesota
Missouri
New Jersey
New Mexico
North Carolina
Oklahoma
Oregon
Tennessee
Texas
Wisconsin b

^aInformation obtained as of August 2021. Coverage subject to change with changing regulations.

^bWisconsin statue uniquely mandates pediatric coverage for both hearing aids and cochlear implants.

Addressing Barriers to Advocacy

At the individual level, advocating for policy changes can prove to be an intimidating task. Hearing healthcare professionals are often busy trying to balance providing quality clinical care with other aspects of a personal life, which leaves little time for advocacy. Additionally, providers may feel that there are other personal and professional barriers to advocating effectively. Heinowtiz et al ¹⁷ found that there are three components that serve as barriers to advocating: disinterest, uncertainty, and unawareness of issues. Though Heinowtiz et al studied advocacy efforts in clinical psychologists and psychology students, the findings from that study can be used to understand hesitation among hearing healthcare providers.

Disinterest in policies, as outlined in Heinowtiz et al, refers to not having an interest in advocating or not perceiving advocacy as a clinical priority. Advocacy is included as a part of an audiologist's scope of practice by ASHA and is therefore something that should be viewed as a task as useful and imperative as hearing loss detection and intervention. Additionally, evidence shows that as relationship with policy makers and other advocacy partners increases, strong feelings about advocacy increase. ¹⁸

Uncertainty in advocacy may refer to either the uncertainty that the advocacy efforts of the clinician will be effective or not feeling that a clinician is persuasive enough to enact change. Evidence suggests that uncertainty tends to abate with increased practice and advocacy experience. ¹⁹ Additionally, advocating not only influences lawmakers but empowers other members in the field. Rogers et al ²⁰ described advocating as a way of mentorship, which can empower new advocates to become more comfortable in identifying and presenting policy changes.

Knowledge and awareness of a policy matter is one of the most important aspects of an effective advocacy strategy. In a discussion regarding optimizing advocacy efforts, Moran ²¹ outlined an “advocacy pyramid” highlighting a model of advocacy from lowest effort on the individual or association to highest amount of effort. Knowledge and awareness serves as the base of this pyramidal model. The full model consists of the following steps:

• Knowledge of the issues and processes.

• Emailing/writing letters to representatives.

• Meeting representatives at their home office.

• Attending meetings at the capitol.

• Building relationships with legislators.

• Testifying at hearings.

Moran argued that the goal of any advocacy effort is to move clinicians and other healthcare professionals up the pyramid from knowledge of issues to testifying. Complete knowledge of any policy proposal is unlikely for any individual. For that reason, it is beneficial to partner with state and national professional organizations for aid in moving up this pyramid.

Professional advocacy groups, such as state audiology and/or speech and hearing organizations, at both the national and state level, can provide a substantial level of help to a clinician who desires to see policy change in their state. These organizations often provide detailed overviews of the policy issues at hand, as well as provide resources to discuss with local legislators. Organizations at the state level go by a variety of names and have different affiliations, but they all bring the benefit of a collective advocacy effort. Such organizations may include the following:

• State Academies of Audiology.

• State Audiology Coalitions.

• State Speech-Hearing Associations.

Bringing policies of interest to the attention of a state legislature is the first step in enacting legislative action. State-level organizations have the benefit of having multiple members and can establish a grassroots network to introduce the policy change to multiple legislators within a legislative session. These organizations often have the added benefit of working with a lobbyist, either full-time or part-time, who can assist healthcare providers in navigating through the legislature process and act as a prominent voice for the organization when communicating with lawmakers.

Conclusions

As workers on the front line of patient service delivery, it is an essential function of hearing healthcare workers to advocate for policy change. Both federal and state-level legislation will affect audiologic service provision; however, many critical policies that affect hearing healthcare and its service provision occur at the state level. Increased knowledge of the legislative and advocacy-related processes is a powerful tool for clinicians and service providers to yield when addressing these issues. Incorporating state and national organizations will allow for healthcare providers to serve as effective advocates for the profession. Knowledge of advocacy processes can be translated beyond the state level into regional and national levels, to affect change at all levels of government and to optimize hearing healthcare throughout the country.