It's politics, then process, then policy: friendly political advice for physician executives from a rehabilitated medical lobbyist.

Will Rogers once observed that watching the United States Congress in action gave him the same feeling as "watching a two-year-old pick up a hammer."

During my tenure as a state medical association lobbyist, I occasionally experienced a similar sense of dread when sending physicians to the state capital to talk to their legislators, which some would invariably call "congressman" just before they threatened to involuntarily remove an incumbent from high office, along with their favorite appendage, all without the benefit of anesthesia.

A surgical view of politics sounds righteous and fun from the hospital staff lounge, but potentially fatal once you've parachuted behind the lines inside state government, armed only with your opinions.

It is a world invented by Kafka for Bubbas, where one should never assign to coincidence what can be fully explained by conspiracy, and only one in perhaps 50 know that Estrogen is not a chapter in the Old Testament.

Yet, in a matter of weeks, if not hours, a determined or well-placed legislator with the humblest of origins or the IQ of a walnut can reject germ theory as matter of state law (look at some state immunization laws) or turn your medical training into a high school equivalency (look at the privileges bestowed by some states on non-physicians). It is the harmonic convergence of medical and political science, where anyone can play doctor.

Politics--taking the early train

Legislators, being elected public officials, are by definition politicians. At some time in their career they had to at least once campaign and pander among the unwashed masses to win their coveted post.

Organizations with the most consistent influence tend to be those that were there at the first, crucial, career-making election. This is not necessarily a bad or crass thing. As football coach Daryl Royal would say, "you always dance with those that brung ya.."

It follows then, that relationships at the grassroots--and the capacity to bring those relationships to bear with legislators--are paramount. There are three kinds of political grassroots that organizations or trade and professional groups attempt to mobilize:

1. Organic: A member or employee who has a naturally developed relationship--childhood or college friendships, family member, business relationships. These relationships are the most valuable and unassailable. They are also rare. I once prevailed with the governor's mother, through her beloved family physician, to persuade her son not to veto an important bill all his big donors were opposing.

2. Homegrown: A politically developed relationship as a consequence of an election effort--hands-on volunteering in a campaign, fund- raising, hosting a neighborhood rally, placing an endorsement ad, etc. This component represents the bulk of successful grassroots lobbying, since an organization can grow as many of these relationships as there are election contests. Over time, we grew literally hundreds and hundreds of key contacts by methodically placing physician volunteers and their spouses on the front lines of contested races.

3. Artificial turf: No previous relationships other than being a constituent who is typically called to react based on a phone bank, direct advertising or direct mail. Despite its proliferation, it is far less effective due to the impersonal, manufactured nature of the contacts. The volume can be impressive, but almost always a non-starter against informed, homegrown and organic grassroots. Imagine the confused voter calling the representative "senator" and reading a script about "endangered feces," while the representative has his personal physician and college roommate on the other line talking the other side.

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Every decision a politician makes, every vote they cast, is calculated along a continuum ranging from hard cold-blooded pragmatism to unadulterated ideology. Before a vote, they ask themselves rhetorically (and privately), will this vote get me a well-funded opponent, the loss of a committee assignment or to what degree do I care?

Health care issues readily lend themselves to this calculus. Because most legislators lack any formal medical training, they rely on personal beliefs and political relationships to vicariously determine on which side they will fall ideologically.

When both sides bring competing, well-honed arguments before the legislator, neutralizing the ideological battle over who is "right" and "wrong," the legislator is likely to default to the least political risk.

The most common excuse I heard from legislators voting against physicians and for, say, optometrists, was: "these guys really helped me get elected," followed in the same breath by, "besides, I'm backing you against the chiropractors and I'm on your side on tort reform."

Being told no, especially in disingenuous fashion, is enough to make most citizens grab a pitchfork. However, unless your organization sits at the right hand of the Almighty and can smite with one bold stroke those who defy you, I recommend the politics of forgive and remember.

A representative in a safe district that also includes, besides your residence, the state's largest chiropractic college or the corporate headquarters for a commercial managed care company, can be forgiven for straying from organized medicine's views occasionally when asked to choose between you and them.

The first principle of politics is to rise above principle and spread your votes around the district, not necessarily your conscience. There are many, many discretionary votes a legislator will cast in any given session that lead to the second principle: Never cuss the alligators before you cross the swamp. Provocation and threats while in their swamp simply increases the probability of being bit.

The third principle regarding anger management is borrowed from Machiavelli: If at long last you are compelled to take a swing at the incumbent, make sure he/she doesn't get up. Unseating an incumbent has long odds, hence the caveat to the third principle by author Damon Runyon: "The race does not always go to the strongest or the most swift, but that is the way to bet."

The legislative process

The last half of the election cycle is where they get to govern. Remember, politicians are still running for office even as they are serving. Here are five easy principles to persuade you to be ever so humble when entering their swamp:

1. The system is designed for type II error avoidance. Better no law pass than a bad law. There are countless procedural barriers and cross checks to minimize that eventuality. Killing a bill is much easier than passing one.

2. It's their game, not yours. They ran, they were elected and they make the rules.

3. Committee assignments, legislative referrals, order of public testimony, authors and co-sponsors of legislation--there are no random events. Politicians are like turtles on a fence post. Someone put them there.

4. Open market: Everything is trade-able, regardless of content. The amendment to save your profession is as likely as not to get hung up over the chair's personal rivalry with your sponsor who is holding up funding for his community college.

5. It's always an end game. Most legislative work is based on the religious doctrine that God did not make the world in seven days. He sandbagged the first six then pulled an all-nighter. Well over two-thirds of the major legislation in state legislatures is tied together at the 11th hour. This is simply a manifestation of political brinkmanship.

Once you cross over into their world, your most frequent contact--unless you're in the organic grass-roots category--will be with legislative staff. They vary in temperament, skill, intellect and integrity. Keep in mind that they self-selected for this job. They are gatekeepers, filters and interpreters of your opinions, so you don't have the luxury of rage, impatience or indignation.

These visits are short-attention-span theater. Your average legislator has several thousand pieces of legislation cross his/her desk during a session. It's like drinking from a fire hose and you will only have a 15- to 30-minute shot. So, here are five more easy bits of advice:

1. Avoid value-laden ideology. The legislation you oppose may indeed be a communist, un-American plot, but that in and of itself is not persuasive.

2. Avoid hyperbole. The sky usually doesn't fall and they've rarely seen widows and orphans in the streets. And avoid scatological references to your opposition's canine ancestry. Might be true, but, again, not persuasive. There are lots of those people in the statehouse.

3. Gauge the level of interest. If you're getting the deer-in-the-headlights-stare, slow down and reduce the number of syllables.

4. Tie your arguments to local relevancy. The senator may not care how it affects those outside the district.

5. Be specific, be human, and connect the dots between cause and effect. Don't talk about the working uninsured, talk about the County Hospital ER and the 18-hour wait, and the 15 kids to whom you gave antibiotics for otitis media and missed school, and their parents missed work, because a school health program went under-funded.

Policy options

Assuming your politics are in order and you are fully engaged in the process, you have to have a product the legislature will buy.

1. Perfect is the enemy of good. Your position should be grounded in realistic expectations and plausible compromises anticipated in those positions. You can't always get everything you want and incremental progress tends to be the most enduringly successful.

2. Triage from the field. Ideally, you and your advocates should have a clear set of limits on your position when you arrive, and the flexibility to respond to offers without waiting two weeks to hear from national headquarters.

3. Support from On High. Equally important, senior management should have a full understanding of the local political environment and the relative strengths and weaknesses. This is rare among corporations and national organizations engaged at the state level; I frequently could work out a reasonable compromise with their lobby, who otherwise had no exit, only to have the scions on high in their parallel universe invoke the perfect world dogma. Legislators usually responded to this kind of stonewalling by simply running over the objectors.

4. Stick to experts only. Those who prepared the positions should be involved in their presentations. I have seen many CEOs and general counsels self-destruct when it became evident to the legislator their technical knowledge of the subject was limited to a few talking points on index cards.

5. Obtain insider advice. Your policy positions should be crafted with ongoing advice from your lobbyists or government specialists who are on the ground and intimately familiar with the political environment. There should be an unfiltered, direct line between the trenches and the command post at all times. Overreaching, unrealistic "asks" and demands expose your lack of preparation, political sophistication and local sensitivities.

As long the state and federal governments pay for an increasing share of the health care dollar, and further their reach into public and commercial health care endeavors, political considerations will precede and outweigh other factors driving policy.

There is not a free market driving this train, especially in terms of health care services. Yet, I have not witnessed a discernible shift in commercial, trade and professional organization resources toward the fundamentals of policy development, which begins in a solid political foundation.

Those organizations that master the basics will more likely prosper than other well-intentioned groups that have great policy, great science and tepid or non-existent political strength. It's not rocket science. It's blocking and tackling.

IN THIS ARTICLE ...

If you're looking to influence politicians on health care laws or regulations, better take a few lessons in politics before you enter "their world."

Kimble (Kim) Ross served as vice president for public policy and director of public affairs for the Texas Medical Association (TMA) from 1986 to 2003, coordinating every aspect of state and federal legislative, regulatory and political advocacy for the association's 37,000 physician members. Today, be is a writer, speaker and public affairs consultant. He can be reached by phone at 512-750-8030 or by e-mail at [e-mail].