Rx for Survival — A Global Health Challenge

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Stage IVb: … while appropriations committees allocate discretionary spending

In the meantime, appropriations committees in both the House and Senate receive the discretionary spending portion of the budget resolution together with any new authorizing legislation created by the authorizing committees. Authorizing legislation remains in effect for three or more years, but appropriations to fund discretionary programs must be approved annually.

Each appropriations committee divides up among its relevant appropriations subcommittees the spending targets outlined in the budget resolution. In the House of Representatives, the Subcommittee on Labor, Health & Human Services and Education (L-HHS) controls domestic discretionary health spending. For international health spending, the Subcommittee on Foreign Operations and Export Financing is in charge.

Point of Influence Each of the House subcommittees has its counterpart in the Senate, and around the middle of May, the health-related appropriations subcommittees of both houses hold a series of hearings at which subcommittee members debate and comment on the portions of the budget assigned to them. The hearings are open to the public and include oral and written testimony from individual citizens, special interest advocates, professional lobbyists, representatives from trade associations, and academics, among others. In addition, all federal agency heads are required to appear and, as employees of the president, lend support to his budget proposal.

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Federal Agencies with Mandates for Health

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Which appropriations committees control which discretionary health programs?
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Point of Influence After the hearings, the subcommittee members and their staff meet for the "mark-up" process, during which they allocate specific funding amounts to individual programs, including foreign aid. Part of the foreign aid contribution takes the form of "assessed dues" paid to international membership organizations such as the World Health Organization (WHO) and various United Nations programs. The amounts of these dues are proportional to the size of the U.S. economy and are calculated according to formulas established under the bylaws of each organization. The remainder of U.S. foreign aid is channeled through federal agencies with international health mandates such as the Centers for Disease Control and Prevention (CDC), the U.S. Agency for International Development (USAID), and the Office of the Global AIDS Coordinator (OGAC). In the course of the mark-up process, which is effectively closed to the public, certain funds are "earmarked"; i.e., dedicated to a specific issue, group, industry, or geographic area.

Point of Influence At the end of the mark-up process, each House Appropriations Subcommittee sends its budget, now referred to as a bill, to the full House Appropriations Committee for it to amend and approve. The bills then travel back to the full House. Following a similar subcommittee process in the Senate, the bills also travel back to the full Senate, which, according to the Constitution, can vote on its version of a given appropriations bill only after it has been passed by the House.

The House and Senate must then resolve any differences between the two versions of each bill in order to produce a single one. Each body selects conferees, or negotiators, who work with their counterparts to agree on compromises. After both the House and Senate have voted on all the bills and approved all compromises, Congress sends the bills to the White House, along with committee reports describing how the funds are to be used and by which programs.

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Intro | Stage: 1 | 2 | 3 | 4a | 4b | 5 | Sources

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Earmarking and Pork-Barrel Politics
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