Washington Gridlock Still Threatens Stroke Legislation

When it comes to public health, the biggest strides are typically made when the government intercedes, be it through regulation or funding. But it's the citizens, reformers and activists that always initiate that momentum for change. When Upton Sinclair's The Jungle exposed an inferno of sickness, disease, and "Durham's Pure Leaf Lard," the public outcry led to the passage of the Meat Inspection Act and the Pure Food and Drug Act of 1906, which established the Food and Drug Administration. Today, recent public health wins include teen smoking programs and public smoking acts.

The idea of the STOP Stroke Act operates under similar thinking. The act, which would grant federal dollars to several stroke initiatives, was originally introduced in the US Senate in late 2001. Since then it has been kicked back and forth between the Senate and the House in various reincarnations. The bill has had several tombstones and its obituary reads like this:

110th Congress: S. 3297 – Died
110th Congress: H.R. 477 – Passed House
109th Congress: S. 1064 – Died
109th Congress: H.R. 898 – Died
108th Congress: S. 1909 – Died
108th Congress: H.R. 3658 – Passed House
107th Congress: S. 1274 – Passed Senate
107th Congress: H.R. 3431 – Died

The bill approved by the House in 2007 would have included $95 million to fund the project. Here, we take a look at what the bill would entail, what has stopped it from receiving a president's signature, and how advocates can place pressure to possibly revive the bill.

The Bill
As of April 16th, 2008—the last time any action was taken on the bill— it sought to amend the Public Health Service Act to authorize the Secretary of Health and Human Services to:

1. establish and evaluate a grant program to enable states or consortia of states to develop stroke care systems;
2. foster the development of systems of stroke care through total quality improvement of health systems providing primary stroke prevention and identification, treatment, and rehabilitation of individuals who experience a stroke;
3. provide a state, consortia of states, and local agencies technical assistance; and
4. collaborate with appropriate medical and health professional associations to disseminate evidence-based practices on stroke systems of care. Authorizes the Secretary to award matching grants to states or consortia of states to develop and implement stroke care systems that provide high-quality prevention, diagnosis, treatment, and rehabilitation.

The legislation sets forth requirements for each state or consortium, including requirements that they establish, enhance, or expand a statewide stroke care system to promote the total quality improvement of stroke care consistent with evidence-based practices. The bill also calls for them to establish, enhance, or expand stroke care centers and enhance, develop, and implement effective methods for training emergency medical services personnel in the identification, assessment, stabilization, and prehospital treatment of stroke patients. Lastly, this aspect of the bill seeks to establish, enhance, or improve a support network to provide assistance to facilities with smaller populations of stroke patients or less advanced on-site stroke treatment resources.

It allows each state or consortium to use grant funds for several reasons, including to:

1. improve existing stroke prevention programs;
2. conduct a stroke education and information campaign;
3. make grants to public and nonprofit private entities for medical professional development; and
4. develop and implement education programs for appropriate medical personnel and health professionals in the use of evidence-based diagnostic approaches, technologies, and therapies for the prevention and treatment of stroke.

It will prohibit the Secretary from making payments to a state or consortium unless the state or consortium agrees that the payments will not be expended:

1. to make cash payments to intended recipients of services;
2. to satisfy any federal matching requirements;
3. to provide financial assistance to any entity other than a public or nonprofit private entity; or
4. for construction, alteration, or improvement of any building or facility.

The Secretary will be authorized to give special consideration in awarding grants to any state or consortium:

1. geographic areas in which there is an elevated incidence or prevalence of stroke or disability resulting from stroke or in an area that is underserved by medical specialists;
2. that demonstrates a significant need for assistance in establishing a comprehensive stroke care system; or
3. that will enhance regional cooperation.

One Man Wrecking Crew or Budget Hawk?
The inability to pass a bill seemingly without even a hint of controversy is odd, but as the past few sessions of Congress have shown, the STOP Stroke Act is not without company. In our three-tiered system, the government is designed to keep too much power from falling into one person's hands. Yet a lot of legislation seems to be at the will of one man. And he doesn't even reside in the executive branch.

Sen. Tom Coburn, MD (R-OK), seated as the junior senator from the Sooner state first in 2004, is noted for his conservative stances and remarks calling the gay agenda the greatest threat to America's freedom.¹ But it is in the mundane and procedural where Coburn has left his mark recently, including on the STOP Act. Coburn has found power in using a special "hold" privilege to prevent several bills from coming to the Senate floor. The hold privilege, allowed by Rule VII of the Senate Standing Rules, is typically used to form consensus on questionable legislation and came under fire for its procedural secrecy.

The hold is a parliamentary procedure that allows one or more Senators to prevent a motion from reaching a vote on the Senate floor. A hold, in brief, is a request by a Senator to his or her party leader to delay floor action on a measure or matter. It is up to the majority leader to decide whether, or for how long, to honor a colleague's hold.² Current Senate rules allow the hold to be only temporarily anonymous.

Unless a group of trouble-making neurologists-to-be gave Sen. Coburn a hard time in medical school, where he specialized in family medicine, obstetrics and allergy treatment, there doesn't seem to be anything special or unique about the STOP Act, stroke care, or neurologists that is causing him to hold the legislation. By Coburn's own office's count, he at one point was holding as many as 95 different pieces of legislation for a variety of reasons; typically he is looking for earmarks and wasteful spending.³ "Every one of the bills I have had a hold on, I proudly hold those bills," he said on the floor of Congress. "I have notified everyone involved in the legislation on why I was holding those bills. The fact that we had no response to negotiate any sort of compromise whatsoever on those bills tells us there was no good intent in the first place to try to pass those bills."

He is not deterred at the prospect of coming across as cold-hearted by holding such bipartisan legislation: "I've held up tons of bills that I've gotten bad press on," he told Politico.com.³ Most recently, he used the pending financial crises as the reason to stop all new spending on public health programs, according to an AAN release.

Given the nature of legislation pending versus legislation passed that's typical of an election year and the extraordinary time and resources spent on financial bailouts in 2008, it's no surprise this version of the STOP Act went down without much of a real fight. The bill will have to be reintroduced in the 111th Congress, but even that will have the added difficulty that comes with a transition of presidential power.

Any transition creates significant voids in key leadership and decision-making positions through selection of political appointees. Essentially, until new policies are established by the Obama administration, all programs will operate in a status quo mode.⁴ By law, the president must submit his budget to Congress the first Monday in February of each year. But during presidential transition years, the budget that is submitted is usually a "place holder," sent to Congress to act in accordance with the Congressional Budget Act but not reflecting the incoming Administration's principles and priorities.⁴ Final numbers will not be known until the formal budget amendment is submitted—sometime in April, 2009. And once the Congressional budget and appropriations process will begin in earnest, the goal will be to send President Obama all appropriations bills by October 1.⁴ With all of these aspects running interferences, there's one thing tied to the STOP Act that won't be held—neurologists breath.

1. Schlesinger, R. Medicine man. Salon.com. Sep 13, 2004.
2. Oleszek, W. "Holds" in the Senate. Government and Finance Division. Updated May 19, 2008.
3. Grim, R. The bucks stop here. Politco.com. http://www.politico.com/news/stories/1207/7310.html. Accessed 1/5/09.
4. Missouri Emergency Medical Service Association. Latest EMS Legislative News. http://www.memsa.org/content/view/134/1/. Accessed 1/11/09.