Making sausage

ACP has clear policy on what the organization stands for, which allows it to bring specific legislative recommendations to Congress.


This isn't a recipe column, in the literal sense of offering instructions on creating good-tasting sausages. It's about how ACP influences legislation, a process that has often been compared to the making of sausages.

A quote often attributed to Otto von Bismarck (although there is doubt about its true origin) says, “Laws are like sausages. It's better not to see them being made.” More recently, in the hit musical “Hamilton,” the character of Aaron Burr bemoans being left out of the “room where it happens” and not knowing “how the sausage gets made” (referring to a deal Alexander Hamilton makes with Thomas Jefferson and James Madison, in which Jefferson and Madison dropped their opposition to Hamilton's plans for a central banking system in return for Hamilton's support to move the nation's capital from New York to Virginia):

No one really knows how the game is played

The art of the trade

How the sausage gets made

We just assume that it happens

But no one else is in

The room where it happens.

The truth is “how the sausage gets made” isn't much of a mystery to organizations like ACP with decades of experience in the legislative process. While some legislative sausage-making is unseemly (like the influence of big-money contributors), much is about creating opportunities for citizens to bring their concerns directly to lawmakers and have them acted upon, the essence of good government.

What are the key ingredients for making good legislation? One is to be sure you know what you stand for before approaching lawmakers, and what you want them to do about it. In the same “Hamilton” scene, Burr is told that he wasn't invited into the “room where it happens” because no one knows what he stands for or wants:

What do you want, Burr?

What do you want, Burr?

If you stand for nothing

Burr, then what do you fall for?

In ACP's case, we have clear policy on what we stand for, such as lowering the price of prescription drugs, expanding access and coverage, reducing paperwork, and reducing gun violence, policies that allow us to bring specific legislative recommendations on what we want to Congress.

Another ingredient ACP adds to the sausage is the perspectives of rank-and-file internal medicine physicians. For sure, professional staff lobbyists—ACP has four of them—play an influential role in bringing the College's views to Congress, yet nothing beats the influence of internal medicine specialists telling their elected representatives how patient care is affected by problems that Congress can help solve, like the high costs of prescriptions.

ACP's legislative sausage-making skills were on display on May 14-15, when ACP hosted its 27th annual Leadership Day on Capitol Hill. trainees-take-charge-at-leadership-day-2019.htm Leadership Day brought nearly 400 internal medicine specialists from 48 states and the District of Columbia to Washington. They learned from Capitol Hill staff persons and me “how the sausage gets made” so that they could become effective advocates during meetings with their congressional representatives. The results of their Capitol Hill visits were commitments by hundreds of lawmakers to support, or consider lending support to, a variety of bills favored by ACP to make medications more affordable, reduce administrative burdens on physicians, and expand health care access and coverage.

A third ingredient is persistence. Our country's founding fathers, distrustful of government and the whims of the masses, created a system of checks and balances that makes it hard to get a bill, even one with majority support from the public and lawmakers themselves, over the finish line and signed into law by the president. (Recent trends, such as the intense polarization and partisanship in Congress and the country, stoking of division by traditional news and social media outlets, and the influence of big-money industry contributors, make it even harder.) This requires a commitment to be tenacious and to persevere, knowing that over time, determined advocacy can wear down Congress and overcome the institutional and political barriers to legislative solutions. This is why ACP emphasized to Leadership Day participants that one day of meetings with their lawmakers, important as it is, must lead to sustained efforts to engage regularly with their elected senators and representatives after they return home.

Knowing what we stand for, engaging our rank-and-file members in bringing their stories to Congress, and being tenacious and persistent. Such are the ingredients for successful legislative sausage-making, enabling ACP to be in the room where it happens.