The Audiologist's Role in Advocacy

Abstract

Healthcare policy decisions that affect the day-to-day work of an audiologist and his/her ability to best serve our patients occur every day. It is imperative that every professional participate in advocacy efforts; however, many audiologists are unfamiliar with current advocacy initiatives, how to participate, or how critical one phone call, email, or meeting could be in the legislative process.

Healthcare policy decisions are proposed and made legislatively every day. These decisions can have a critical impact on the profession of audiology and our ability to provide accessible, evidence-based, quality care to our patients. Healthcare policy decisions affect every aspect of audiologists' day-to-day work, including, but not limited to, access to quality care, cost of care to the patient, reimbursement, education of audiologists, licensing of audiologists, and scope of practice. As the experts in communication, hearing, and balance, audiologists must stay informed on policies that will affect patients and our ability to best serve them.

A commonly cited reason for an individual's hesitation to participate in advocacy efforts is the belief that their voice will not carry weight, the outcome will not change, or that it will not be worth the effort. It is often believed that someone else is better at advocating, has more experience, or more knowledge. Other allied health and medical professions' guidelines emphasize the critical role all healthcare providers and professional organizations have in participating in the legislative process in the healthcare space and specifically call out advocacy as a fundamental role of the healthcare provider. ^{1 2} For example, the American Society of Health System Pharmacists (ASHP) published the following statement on advocacy for pharmacists in 2018:

“ ASHP believes that all pharmacists have a professional obligation to advocate on behalf of patients and the profession. Pharmacists should stay informed of issues that affect medication-related outcomes and advocate on behalf of patients, the profession, and the public. These issues may include legal, regulatory, financial, and other health policy issues, and this obligation extends beyond the individual practice site to their broader communities… ASHP urges all pharmacists to accept this responsibility and to be advocates both within and outside the profession, in the community, and in society as a whole to strengthen the care of our patients ”. ³

This edition of Seminars in Hearing includes articles explaining the critical importance of advocacy efforts by healthcare professionals, the historical attempts at audiology advocacy efforts, and proposed future efforts. Given that audiology is a profession that prides itself on adhering to evidence-based practice, it seems this principle should hold true in the realm of advocacy as well. The objective of this article is to provide the reader with the basic understanding of the legislative process at the federal level, evidence that citizen-driven advocacy is effective and critical to accomplishing the profession's goals, and to utilize the limited evidence available to inform readers how to participate in advocacy efforts effectively. Now is a critical time in the profession of audiology; previous advocacy efforts have gained momentum and there is great potential to influence legislative and policy changes so that audiologists can continue to provide exceptional, evidence-based care.

Advocacy is the act of supporting, defending, or promoting a cause or an issue. Advocacy is a broad term and includes anything an individual or an organization may do to communicate or promote a specific cause. ⁴ Systems advocacy specifically aims to influence or change a system, such as legislation or policy. ⁴ This may include creating a new law, changing existing law, influencing the plan or priority item of an agency, or influencing rules on how a law or policy is implemented. Systems advocacy can be accomplished at the local, state, or federal level, by individuals or organizations. ⁴ Many organizations, such as our state and national audiology organizations, hire professional lobbyists whose job is to interact directly with politicians, elected officials, and their staff in attempt to influence legislation. These trained, experienced lobbyists are critical in advising and progressing our advocacy efforts forward; however, it is clear that advocacy efforts made by citizens and constituents are imperative in the advocacy process. The focus of this article is citizen-driven advocacy, or advocacy efforts that can and should involve the everyday audiologist.

Congress 101

Article I of the United States Constitution grants the power to create or enact laws to Congress, the House of Representatives (the House), and the Senate. ⁵ There are 435 members in the House of Representatives; each representative serves a 2-year term and the number of elected officials from each state in the House is based on the population of the state. Each state has two elected senators who serve a 6-year term, resulting in 100 total senators. The role, rules, and function of each chamber differ; any piece of legislation must be agreed upon by both chambers before being sent to the president to be signed into law. ⁵

In both the House and the Senate, long-standing, established committees exist in attempt to establish a smaller cohort of elected officials with expertise in specific areas (e.g., finance, healthcare, education, agriculture). The committees are led by a member of the majority party in the chamber and generally follow the make-up of majority to minority party members to mimic the ratio in the congressional chamber. ⁵ Once a bill is introduced in each chamber, it receives a bill number; for example, the joint audiology legislation Medicare Audiologist Access and Services Act of 2021 (MAASA) has been introduced in the House as HR 1587 and in the Senate as S 1731. ^{6 7} MAASA is currently being reviewed by the Energy and Commerce and the Ways and Means committees and the Health subcommittee in the House and in the Senate Finance committee. ^{6 7}

One of the first opportunities of many along the legislative pathway for any citizen to participate may be taking a concern to your local, state, or federal elected officials. Any senator or representative can draft or propose a bill. Many bills or laws originate because a private citizen, or a group or citizens, took a concern to their representative and garnered their attention and interest to the issue at hand. ⁶ The elected official(s) who introduced a bill or amendment is referred to as the sponsor of the bill. An example of a citizen concern leading to a piece of legislation is “Madeline's Law” or House Bill 198 (HB 198), which was first introduced in the Ohio General Assembly in 2019. ⁹ The sponsors of this bill have stated that this bill came to fruition after families in Ohio met with their state legislator to share their financial hardship purchasing hearing aids for their children because they are not covered by many private insurance companies in the state of Ohio. ¹⁰

Advocacy also may take the form of thanking a sponsor for introducing a piece of legislation that you agree with or conversely, contacting a sponsor to share your opposition to a piece of legislation. Furthermore, once a bill is introduced, a constituent could and should contact their elected official to encourage them to support or oppose the bill and explain why. Cosponsoring a bill is a mechanism for both senators and representatives to formally show their support for a bill. Adding cosponsors is a common way for a bill to gain traction and demonstrate support or popularity which is believed to increase its chances of being passed into law. ¹⁰ As an example, referring to Madeline's Law, 18 representatives in the Ohio House have currently “signed on” as cosponsors; however, there are 99 total representatives serving in the Ohio House. ¹² This leaves ample opportunity for audiologists and citizens in the state of Ohio to encourage their state representative to formally support HB 198. Similarly, at the time this article was written, there were 38 cosponsors of MAASA (HR 1587) of 435 in the House and six cosponsors in the Senate, of 100 possible. ^{6 7} Depending on the timing of this article being read, these two specific bills may or may not be relevant; however, there will always be advocacy efforts occurring within your state and national professional organizations. The author strongly encourages all readers to visit the websites of their state and national organizations and review current legislative efforts. A proposed action item to all readers is to determine if your elected official in the House and Senate is already listed as a cosponsor of the bill you are interested in supporting, or opposing, by typing the bill number into the search bar on Congress.gov. If they are not, this is a fantastic opportunity to reach out to your elected official by phone, email, or an in-person visit to ask them to support (or oppose) the legislation. Specific recommendations for this process will be provided later in the article.

Once a bill is introduced, the process for a proposed bill to become a law includes several steps. A hearing is a public forum in which “witnesses” provide oral and written testimony to the chamber committee in support (proponent testimony) or against (opponent testimony) the proposed piece of legislation. At this time, the committee also may ask the witnesses questions about the bill and the testimony they provided. ⁵ Often witnesses include professionals with expertise in a relevant area and constituents who have an impactful, memorable story in support or against the legislation. As experts in hearing and balance care, this is another opportunity to participate in advocacy efforts and the legislative process. It is common and critical that those who have expertise in areas relevant to the bill provide in-person or written testimony in these hearings. If one is motivated to provide testimony, the sponsors of the bill or the professional lobbyists coordinating these efforts are often willing to assist in preparation for the hearing. For Madeline's Law, proponent testimony included multiple pediatric audiologists, pediatric otolaryngologists, children who have hearing loss, educational audiologists, and parents of children who have hearing loss. ⁹

Committee markup is a critical step indicating a bill may advance in the legislative process for a vote. ⁵ This usually occurs after committee hearings and the review of oral and written testimony. In markup, the committee proposes modifications or amendments to the original text of the bill. Once the committee agrees on the final bill language by majority vote, the bill ideally will head to the chamber floor for a vote. However, in any year, there are so many bills eligible for vote that many will never end up making it to this step. The final step for a proposed bill to become law is the signature of the President. However, both the House and the Senate must first agree on the same bill language, in the same form, before it can move forward to the President. ⁵ It is a common occurrence that proposed legislation will volley back and forth between the House and Senate with alternative proposals of the bill language and amendments to land at a compromise.

Citizen-Engaged Advocacy

The Congressional Management Foundation (CMF) is a nonpartisan, nonprofit organization whose mission is to enhance the effectiveness of Congress and facilitate understanding and “meaningful democratic dialogue” between constituents and their representatives in Congress. ^{13 14} In the past decade, CMF has published a series of articles sharing the results of surveys conducted among congressional staff and elected congressional officials themselves. The purpose was to share a view of the democratic process from the eyes of those serving in Congress and provide recommendations on how to effectively be involved in the democratic process. ¹³ Outside of the work completed and published by CMF, there are little data on this topic. The majority of what we know about communication between the public and members of local, state, and federal agencies come from experience and from those who have spent their careers in politics. The results of these surveys and the recommendations of CMF will be reviewed with the goal of ensuring communication with representatives and constituents are as effective and meaningful as possible.

The persistent message in the numerous documents published by CMF is that personal communication from constituents is very influential among our elected officials, especially when a member of Congress is undecided on an issue. ^{14 17} Congressional representatives want to hear from their constituents and consider it vital in their ability to represent their communities. Members of Congress surveyed by CMF reported “staying in touch with constituents” as the most critical aspect to being an effective legislator; 95% of respondents in the survey ranked communication with constituents as “very important“. ^{14 15} Members of Congress who participated in the survey ranked “working with constituents” as the number one utilization of their time while in their home districts and as the number two use of their time while in their Washington DC office, second only to “legislative and policy work”. ^{14 15} These responses from our elected representatives in Congress demonstrate that communication with constituents is considered a critical aspect of public service. We must rid ourselves of the notion that one voice does not make a difference or that someone else is advocating on our behalf. Pause here and reflect how many audiologists live or work in your district? How many of those audiologists are taking the time to meet with, communicate, and form a relationship with your member of Congress or local government? If not you, then who will?

Communication Opportunities

One mechanism that has drastically changed communication between voters and their elected officials is the internet and social media. These tools have made it easy and accessible for constituents to email, message, like, share, and tweet, with their congressional representatives from the comfort of their couch and mobile devices. Congressional staff reported in 2011 that email and the internet had dramatically increased the number of constituents who attempted to communicate with their office. However, 65% of congressional staff felt that the quality of the messages had simultaneously decreased as a result of to electronic communication. ¹⁴ It is worth noting, in a more recent survey of legislative assistants, directors, and office communication directors (2015 vs. 2011), 78% reported that social media posts directed to a congressional office from “multiple constituents affiliated with a specific group or cause would have ‘some’ or ‘a lot’ of influence if their member was undecided on an issue.” ¹⁶ Implications and recommendations for communication via social media will be discussed further in a few short paragraphs.

Nearly all respondents reported in-person visits to Washington, District of Columbia, or local district offices as the most influential way to communicate with a member of Congress. ¹⁴ The next most effective strategies, ranked in order by congressional staff, were: individualized postal letters, emails, phone calls, and comments during a town hall. Ranked lower in impact potential included: comments on social media, post cards, identical form emails, letters, or faxes. ¹⁴ It is imperative to note that congressional staff reported that communication with constituents, in any form, is more influential than communication with news and media sources and hired lobbyists. Staff expressed distrust when advocacy efforts utilize an onslaught of identical form letters or are facilitated by lobbyists. ¹⁷ This continues to highlight the importance of every professional in our field, our patients, and our communities participating in advocacy efforts and not assuming the ownness is on our professional organizations to move our initiatives, and thus our profession and the needs of our patients, forward.

Communication Via Email: Make It Personal

There has been a substantial increase in communications to congressional offices in the past decade. This is due to the rise of communication through email and the commonly used tactic of pushing for the public to send identical form emails or sign petitions. Congressional staff reported that while grassroots campaigns with high volumes of identical form emails and mass petitions provide the office with a broad sense of the community and constituents' opinion on a matter, they lack a complete, personalized picture officials are looking for to inform their decisions. ¹⁷ Furthermore, congressional staff have developed a distrust and question whether these messages are sent with the constituent's knowledge. ¹⁷ An unequivocal finding in surveys conducted by CMF was that the content of a message sent to a member of Congress was more critical than the delivery mechanism of that message. Messages that are personalized and customized are far more influential than identical form messages. ¹⁷

Professional audiology organizations offer mechanisms for members to easily send form emails or letters by simply plugging in their contact information. When one is crunched for time or new to advocacy, this is better than nothing at all and encouraged. The more emails sent, the more contacts made, the more an office pays attention to a particular issue. Legislative aides often create a dashboard, or bird's eye view, of the number of contacts made about a particular issue as the legislator themselves do not have time to review every piece of contact made to their office. ¹⁷ The more times an office is contacted about a particular issue, in any form, the more likely that issue will garner the attention of both the legislative aide and the higher the likelihood that issue will be brought to the attention of the legislator. Many national audiology organizations have a legislative action center on their webpage to allow members to easily input their contact information and send a form letter to their representatives. An alternative option is to use this carefully crafted language as a foundation to be customized by copying the text put together by our professional organizations into your email and personalizing it. This way the writer is building from a solid foundation, rather than reinventing the wheel; however, the language is personal and relevant to each elected official, region, and provider. Suggestions for customizing the language include discussing how the bill impacts your patients, practice, or the district or state you live and work in and providing evidence-based reasons you are asking for support or opposition to the bill or issue. Including relevant personal or patient stories is memorable and imperative for congressional members to easily understand the real-life impact of the issue or bill in a relatable way. It cannot be stated strongly enough that the most persuasive mechanism to include in your communication is how a piece of legislation will affect you as a constituent in their district or the local community; this should be the focus of the message rather than self-serving language such as reimbursement rates. ¹

Additionally, CMF recommends that when citizens contact their member of Congress, one piece of communication should be sent via one medium (social media, email, or handwritten letter) one time. It is recommended that each communication is specific to only one issue or topic. If there are multiple topics at hand to discuss with your member of Congress and their staff, send multiple, separate communications. Finally, utilize the same contact information for every communication sent (home address, same email address). This allows the office to track communications and keep a record on how each constituent feels about relevant issues. ¹⁷

Effectively Using Social Media

It goes without saying social media has changed the game in terms of citizen engagement with their elected officials. Social media has given access to all individuals to communicate with, or at, their elected officials and legislative staff. As of 2020, nearly all United States Congress members utilized both Facebook and Twitter, with high percentages also posting to YouTube and Instagram. ¹⁸ CMF survey data suggests legislative staff generally agree that social media has allowed for more meaningful interactions with constituents and held elected officials more accountable to constituents. ¹⁶ Offices pay close attention to constituent reactions to their own posts to gauge what constituents think of legislators' statements and actions. Offices also report that comments are most likely to be viewed and considered when posted shortly after the original post and less likely to be viewed as time passes. ¹⁶

Based on the survey responses of legislative staff, the following recommendations are suggested to use social media platforms most effectively. Follow your legislators (local, state, and federal) on the social media platform of your choice and prioritize their posts so that you can see them first. Many social media platforms use algorithms to decide what you see and do not see; the more you interact with a page, or the more time you spend on a page, the more likely you are to see that page's posted content. Respond to posts that matter to you quickly and encourage friends and neighbors to do the same. The more posts on a specific topic, the more likely it is to catch the office's attention. For example, “ Thank you for supporting HR 1587! .” Posts on social media are publicly viewable and should be thought of as making a public statement. Interestingly, CMF also recommends that professional organizations prioritize educating their members on how to best respond or post on social media. This can ensure that posts are accurate, professional, and lead to more timely interactions. ¹⁶

In-Person Advocacy

Face-to-face meetings with your elected official and their staff are considered one of the most critical ways to influence policy and legislation and are desired by your elected officials. The recommendations of CMF suggest professional organizations expend more effort and resources to supporting their members to participate in advocacy efforts over lobbyists and email campaigns. ¹⁶ This investment will allow professional members, for example, constituent audiologists, to develop ongoing, integral relationships with their own members of Congress. Furthermore, the professional who is directly affected by a particular issue will be able to best articulate the impact of an issue, bill, or decision on their practice and their patients. This does not undervalue the essential role our professional organizations' hired lobbyists play in the advocacy process but emphasizes that constituent interaction carries heavy weight and should be prioritized in any organizations' advocacy efforts. ¹⁶

Members of Congress have offices both in Washington, District of Columbia, and in their home states and districts. Start by determining which location is feasible and contact the office, via phone, email, or submission form on the congressional member's website to schedule a visit. Virtual video visits have become more common in recent years and also may be an option, dramatically reducing barriers to “meet” with your elected officials. When contacting the office to schedule a visit, it is important to identify yourself as a constituent; often you will be asked the topic of the meeting when scheduling. Depending on your elected official's schedule, you may be scheduled with one of the office's legislative aides. While this may seem discouraging, legislative aides are critical in the legislative process; many offices have more than one legislative aide and they are often specialized in specific topic areas. For example, a legislative aide may specialize in Veteran's issues, healthcare, or education. The job of a legislative aide is to gather information, share constituent feedback, and propose responses to the elected official. ⁷ Building a relationship with the entire office, including the legislative aides, is an important step for effective advocacy. This takes time with repeated interactions through email, office visits, and regularly attending events hosted by the office. ¹⁶

There is no wrong time to schedule a meeting with your member of Congress; however, there are opportune occasions to make contact. Including when a newly elected official takes office, when new data are released, when a new issue is introduced, after the elected official takes a stance or makes a public statement, days leading up to a vote, at the start of a new Congress, or anytime your professional organization sends out an action alert asking members to engage in advocacy efforts. While not necessarily expected, it can be beneficial to research your legislator's stance on a particular issue. Topics of interest include the committees the elected official serves on, their priorities or interests, and previously expressed stance on an issue. This information can often be found on the legislator's website and social media pages. ¹⁹

Upon arrival, your introduction should include your name, where you live and work, and a brief, easy to understand explanation of your job. If possible, try to find common ground with the person you are meeting with; often you will have something in common—cheer for the same sports, teams, went to the same school, live in the same area of the state. While it can allow for a more personal, memorable meeting to find a connection, keep in mind that your time is likely limited and thus this conversation should be kept short and sweet. When planning your key message for any type of interaction (in person, video, phone, email), prepare your message with the following critical talking points ⁴ :

1. A Clear, concise message on what action you want your elected official to take.

2. Why you want them to take this stance.

3. What are the current and/or potential impacts locally.

4. Share a personal story or connection to this policy, particularly how it will affect your patients or your community. This will be the most memorable and the most impactful piece of your message.

The summary of your request and the reason behind it should be well-rehearsed and kept short; no more than 3 minutes. In this meeting, your best credential is exactly who you are—a constituent who lives and votes in their district and the expert in the room on hearing and balance. Make sure that any data or facts you provide are accurate. It is okay if you do not know the answer to a question. It is not expected that you enter these meetings knowing every single detail about a piece of legislation, remember you are there as a constituent. The best way to promote a trusting relationship is to be honest and open about a given policy's pros and cons and challenges and admit when you do not know the answer to a question. After completing the meeting, seek out additional resources to answer any questions you did not know and take the opportunity to follow up alongside a necessary thank you.

If possible, bring to your meeting printed materials that visually show the impact of an issue or bill such as maps, charts, infographics, or a handout summarizing your key points to leave behind. Some congressional staff also recommend sending these handouts in advance of your meeting to be reviewed prior to the meeting. ⁴ Both the American Academy of Audiology (AAA) and American Speech and Hearing Association (ASHA) have government relations staff and resources ready to aid you in this process. Consider reaching out to these organizations in advance of your meeting; staff will help prepare you and provide you with already developed handouts to leave behind, depending on the topic.

It is important to remember that most elected officials do not have much experience or expertise on many issues they are expected to vote on. To inform these voting decisions, offices lean on trusted constituents with whom they or their staff members have developed a relationship. Establishing this trust requires multiple interactions with a legislator or their staff by frequently scheduling meetings, attending local events, and communicating with the office in an ongoing and substantial way. ⁴

Advocating for our patients and our ability to serve them is the responsibility of every member in the field of audiology, hearing, and balance care. While the idea of advocacy is intimidating to many, there are small, meaningful steps every audiologist can take to participate in the forward progress of our profession. While most of this article discussed legislation at the federal level, most of these recommendations can be applied to every level of government. Every individual and every contact made helps. Our elected officials want and expect to hear from us, and these communications benefit our profession and our patients.