The Politics of Public Health in Florida: Insights from Debates Over Medical Cannabis and Needle/Syringe Exchange Legislation

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THE POLITICS OF PUBLIC HEALTH IN FLORIDA: INSIGHTS FROM DEBATES OVER MEDICAL CANNABIS AND NEEDLE/SYRINGE EXCHANGE LEGISLATION

Tamara Y. Demko

A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Public Health in the Department of Health Policy and Management in the Gillings School of Global Public Health.

Chapel Hill 2020

Approved by:

Pam Silberman

Catherine McCann

Kathleen Kaney

Jonathan Oberlander

Tom Ricketts

ii ABSTRACT

Tamara Y. Demko: The Politics of Public Health in Florida: Insights from Debates Over Medical Cannabis and Needle/Syringe Exchange Legislation (Under the direction of Pam Silberman)

This study examined the question of why some health-related legislative bills in the state of Florida pass into law while others do not. Using a retrospective, sequential, mixed methods case study design that included in-depth, key informant interviews, I explored how sociopolitical factors and stakeholder actions influenced policymakers and the outcomes of two

Florida bills on medical cannabis and needle/syringe exchange.

Both bills were considered during the 2014 election year by a Republican majority legislature. The medical cannabis bill passed, and the needle exchange bill died in return messages at the end of the legislative session. Several sociopolitical and policy themes influenced the outcome of the bills: window of opportunity; persuasive health and/or economic arguments; effective grassroots mobilization with active, in-person citizen/constituent advocacy; influential legislative relationships (predominantly member-to-member and family members); and constituents and legislators acting as policy entrepreneurs and issue champions.

However, certain expected themes were less influential: professional lobbying, state health agency influence, and pre-passage support by the governor’s office. The medical cannabis bill had unique favorable factors that helped it pass compared to the needle/syringe exchange bill: the threat of a constitutional amendment that might increase Democratic voter turnout and further influence a gubernatorial election; a CNN documentary on medical cannabis; strong

iii majority party sponsorship; and a sympathetic focus on sick children, viewed as blameless relative to injectable drug users.

This work provides insights into Florida legislative processes and can be used as a roadmap for success for future public health legislation. An advocacy checklist for public health and health-related professionals and organizations provides recommendations on how to strategically invest their resources when pursuing health-related legislation.

iv To the One who makes all things possible To my beloved mother, who is in hospice To all my loved ones who have gone before & To Charlotte Figi, who passed away at the age of 13, just as this dissertation was being submitted

ACKNOWLEDGEMENTS

It is with the deepest appreciation that I thank my infinitely patient and talented dissertation committee. Tom Ricketts, Jonathan Oberlander, Kathleen Kaney, and Catherine Howard-McCann provided invaluable guidance over many years of work. As committee chair, Pam Silberman ensured my successful completion with just the right mix of feedback and encouragement. Thank you all for helping me to climb this mountain.

I am grateful for the constant love and support of my parents, Dr. Charles and Maria Yang.

Thank you to my beloved sons, Cole and Josh Demko, for giving me the inspiration to continuously learn and grow. A special thank you to my husband, Rob Siedlecki, Jr., for giving up many date nights so I could finish this dissertation. I would also like to thank Ed and Ronnie

Demko, Thomas Yang, Angela Yang, Karen Halperin Cyphers, Diosa Moran, and Alrica Goldstein for countless years of support and encouragement.

Thank you to the many wonderful teachers I have had in my life, to all study participants and advisors, to Virginia Gray, to my favorite cohort C7, and to everyone who has encouraged me to keep going on the unexpectedly obstacle-ridden paths of dissertation writing and life.

Perseverance, persistence, resilience.

TABLE OF CONTENTS

LIST OF TABLES ...... xii

LIST OF FIGURES ...... xiii

LIST OF ABBREVIATIONS...... xiv

CHAPTER 1: INTRODUCTION ...... 1

Overview of Dissertation ...... 1

Discussion: Loss of Health Ideas When Health-Related Legislation Fails to Pass ...... 3

Main Research Question & Contextual Scope of State Health Legislation...... 4

State Selection: The Fate of Health-Related Policy Ideas in Florida ...... 5

About Florida ...... 5

About Florida Health Legislative Processes ...... 6

Health-Related Legislation—Topic & Bill Selection ...... 10

SB 1030 (2014)—Cannabis (Low-THC Cannabis/Charlotte’s Web) ...... 12

Health Significance...... 12

Bill Purpose ...... 12

Recent Prior Legislative Attempts...... 13

Brief 2014 Bill History ...... 13

SB 408 (2014)—Infectious Disease Elimination Pilot Program ...... 14

Health Significance...... 15

Bill Purpose ...... 15

Recent Prior Legislative Attempts...... 16

vii

Brief 2014 Bill History ...... 16

CHAPTER 2: LITERATURE REVIEW ...... 18

Time Period Selection...... 18

Sources Used ...... 18

Selection Criteria: Inclusion and Exclusion ...... 19

Keywords and Search Strategy ...... 20

Search Process ...... 20

Emergent Themes & Focus in the Literature ...... 22

General Policy Themes ...... 23

Health Policy Distinction Themes ...... 25

The Legislative Stage in the Policymaking Spectrum ...... 25

Importance of Health Policy Focus at the State Level ...... 26

Discussion of the Literature ...... 27

Convergence of Political Policymaking Paradigms with Public Health Theories ...... 27

Emergent Overarching Themes in Health Legislation ...... 27

Additional Key Themes in the Case Studies ...... 34

Gaps in Research and Knowledge/Bridging the Gaps ...... 37

Search Strategy Limitations and Weaknesses ...... 37

Informing a Dissertation & Conclusion ...... 38

CHAPTER 3: METHODS ...... 39

Study Design ...... 39

Data Collection Procedures ...... 40

Online Qualtrics Survey (Quantitative Focus) ...... 41

Key Informant Interviews (Qualitative Focus) ...... 43

IRB Approval ...... 45

viii

Consent & Confidentiality ...... 45

Interview Recording Procedures ...... 47

Data Analysis Strategy ...... 47

Quantitative Analysis...... 47

Coding Guide ...... 47

Key Informant Interviews ...... 48

CHAPTER 4: RESULTS ...... 49

Summary of Qualtrics Survey Results ...... 49

Medical Cannabis ...... 49

Needle Exchange ...... 50

Summary of Key Informant Interview Results ...... 50

Medical Cannabis ...... 51

Needle and Syringe Exchange...... 75

Study Limitations ...... 87

CHAPTER 5: SUMMARY/INTERPRETIVE ANALYSIS ...... 91

Window of Opportunity ...... 91

Persuasive Arguments and Economic Considerations ...... 93

Grassroots Mobilization, Persistent Constituent Advocacy, and the Children ...... 96

Professional Lobbying ...... 97

Legislative Relationships ...... 98

Legislative Power and Perception ...... 100

Governor’s Office Impact and State Health Agency Influence ...... 101

Conclusion ...... 102

CHAPTER 6: RECOMMENDATIONS AND PLAN FOR CHANGE ...... 105

Recommendations ...... 105

1. Thoroughly Assess the Sociopolitical Environment ...... 105

2. Thoroughly Assess the Target Audience ...... 106

3. Strategically Select the Health Issue to Bring Forward as Legislation ...... 108

4. Carefully Craft the Message and Select the Messenger ...... 109

5. Locate a Legislative Champion or Legislative Champions ...... 111

6. Focus on Visibility, Influence, and Persistence in Advocacy Efforts ...... 111

7. Remain Vigilant in the Final Hours of the Legislative Session ...... 113

8. Evaluate and Plan for Continuous Strategic Advocacy Improvement ...... 114

Plan for Change ...... 114

Diffusion of Innovations Theory ...... 115

Dissemination of Recommendations ...... 117

Moving Toward Diffusion of Innovations: The Advocacy Checklist ...... 119

APPENDIX A: QUANTITATIVE SURVEY AND CONSENTS ...... 121

APPENDIX B: QUALITATIVE KEY INFORMANT INTERVIEW AND CONSENTS ...... 125

APPENDIX C: KEY TERMS DEFINED ...... 131

APPENDIX D: QUALTRICS SURVEY QUESTION CODING AND HOVER FUNCTION DESCRIPTIONS ...... 133

APPENDIX E: SELECT RESULTS FROM QUALTRICS SURVEY ...... 136

APPENDIX F: FACTORS OF INFLUENCE, DESCRIPTIONS, SOURCES OF CONCEPT, AND GENERAL INTERVIEW FINDINGS...... 141

APPENDIX G: CODING GUIDE FOR KEY INFORMANT INTERVIEWS ...... 148

APPENDIX H: POSTSCRIPT TO THE 2014 FLORIDA LEGISLATIVE SESSION: MEDICAL CANNABIS AND NEEDLE EXCHANGE EFFORTS ...... 153

APPENDIX I: SAMPLE OF SMALL TO MEDIUM HEALTH-RELATED ORGANIZATIONS ...... 157

APPENDIX J: DRAFT ADVOCACY CHECKLIST ...... 159

APPENDIX K: FLORIDA-SPECIFIC RESOURCES FOR ADVOCACY ...... 165

ENDNOTES ...... 169

REFERENCES ...... 194

LIST OF TABLES

Table 1. Florida demographics ...... 6

Table 2. Florida government overview ...... 8

Table 3. PubMed search strategy ...... 20

Table 4. Initial key informant interview goals...... 44

Table 5. Description of the categories of key informants interviewed for each bill ...... 45

Table 6. Comparison of key factors across the medical cannabis ...... 103

xii

LIST OF FIGURES

Figure 1. PubMed Search Results Based on Table 1 Search Terms ...... 22

Figure 2. Mixed Methods, Sequential Explanatory Design ...... 40

xiii

LIST OF ABBREVIATIONS

CS Committee substitute

D Democrat

HB House bill

IDEA Infectious Disease Elimination Act

R Republican

SB Senate bill

xiv

CHAPTER 1: INTRODUCTION

The topic of this dissertation is state public health legislation and how it is formally developed. Every year, important pieces of public health-related legislation are passed into law.

What sets these items apart from those that do not? What factors granted them favored status above all other health-related ideas? Was there a moment, action, actor, or event that changed their fate? Are there factors that helped them be successful? If so, can a working guide or roadmap of suggested actions be created for use by a public health advocate to improve chances of having the idea made into law or policy?

Overview of Dissertation

Health sector policy advocates often encounter significant problems in promoting desirable health legislation. Their efforts often fail or are passed over for other priorities. As such, critical population health needs may not be met. While no study can fully capture the totality of interpersonal and political transactional elements that shape the outcomes of particular bills, this dissertation seeks to add insight to the larger picture. Using two specific examples, one successful, one not, I hope to assist public health professionals, related professionals, and policy advocates in expediting the enactment of beneficial, but potentially controversial, health policy legislation. I also hope to add to the discussion of factors impacting health-related legislation.

The passage of state health-related legislation has been explored periodically in academic and general literature. These studies identified potential factors that influence passage of legislation and were grounded in established, but often limited and generalized political and

policymaking theories. Few studies, however, examine the breadth of potential influencing factors specifically impacting the health policy sector that confront state legislative processes.

This dissertation used a retrospective, sequential, mixed methods case study design to explore the factors influencing the outcome of health-related legislation in the state of Florida. It focused on two controversial health bills in the 2014 Florida legislative session, one that passed

(use of Charlotte’s Web/Low-Level Cannabis, SB 1030), and one that ultimately failed

(Infectious Disease Elimination Pilot Program, SB 408). The study used a Qualtrics-based online survey that combined categorical Likert-scale questions of factors that influenced specific legislation with open-ended survey fields for participants to write in additional factors. The

Qualtrics survey was sent to legislators and stakeholders of record. The survey results were used to inform key informant interviews of 20 selected stakeholders (“influencers”). These influencers included legislators, including primary bill sponsors, executive branch employees involved with the bills, lobbyists, and citizen stakeholders who both supported and opposed the legislation.

Data were coded, analyzed, and then triangulated by examining the legislative history and media reports of actions occurring during the legislative process.

The study explored more than 22 sociopolitical and interpersonal factors that have been posited to influence policy formation. They were derived from the literature review, Qualtrics survey write-ins, and my personal knowledge of Florida’s political mechanisms. These factors were thematically grouped for coding purposes into “General Factors” (e.g., window of opportunity), “Argument & Persuasion” (e.g., health benefit), “Constituencies” (e.g., legislative testimony), “Legislature” (e.g., sponsoring legislator’s power), “Lobbyists” (e.g., professional lobbyist work), and “Executive Branch” (e.g., governor’s office support).

To increase internal validity and reliability, a second coder was used to classify the responses. Given the specific legislative leadership and climate during 2014, potential researcher bias in factor and interviewee selection, and limitation to Florida, the results need to be viewed with caution. However, I believe that the results will be useful to the public health community through the sharing of study insights with public health associations and schools. Research-based suggestions for the effective deployment of monetary and manpower efforts will help to improve chances of legislative success.

Discussion: Loss of Health Ideas When Health-Related Legislation Fails to Pass

Important ideas that would advance the public’s health are often lost when higher priority topics supersede them, when reports gather dust on shelves, when administrations change, or when public health champions lose energy on the long, tedious paths to legislation and policymaking. A practical paradigm for any health professional or interest group to change health-related ideas into accepted health policies/laws in the fastest, most effective way possible could enable those groups to move issues “up the agenda” and maximize their impact on public health.

For example, prevention, early detection, and early treatment for cancer, obesity, and diabetes are challenging political “sells” that can have high costs attached. Yet prevention and evidence-based interventions can, over time, increase the chances for improved quality of life and health, reduced long-term health care expenditures, and a stronger workforce. As another example, the concept of newborn screening has gained support in state legislation to varying degrees over the years. While the Health Resources and Services Administration (HRSA) recommends screening for 35 core disorders and 26 secondary conditions, state newborn screening programs vary in which conditions are screened.1 Enacting state legislation that covers

screening for more conditions can improve long-term prognoses or functionality in many cases and allow families to make informed decisions for health care earlier, saving money for families and the state.

In the limited number of studies of factors influencing state health legislation, analysis has primarily focused on specific aspects of influence, rather than on integrating factors into a larger picture or schema. In large part, either quantitative or qualitative investigations describe certain behaviors, attributes, or actions, without providing an understanding of the meaning behind such actions or an observation of the degree to which the factors weighed or interacted to provide the desired legislative success. While quantitative results can indicate that a factor of influence was or was not present, or even provide a scale of how influential a factor was subjectively thought to be, by themselves they fail to provide a complete picture that could lead to greater effectiveness in future legislative efforts. However, reviewing quantitative results with the additional qualitative narrative provided by key informant interviews can add situational context and better guide future legislative efforts. For example, interviews can provide behind- the-scenes political context about why there was sponsorship by the majority party, not merely that there was or wasn’t support as indicated through a survey instrument. For this reason, I used a retrospective, sequential, mixed methods case study design to illuminate case studies of state health legislation. Because of its large population and political influence, and because of my experience in health policy in the state, I chose to study Florida.

Main Research Question & Contextual Scope of State Health Legislation

This study sought to address the question: What factors most influence the passage or defeat of health-related legislation at the state level in Florida? As discussed in the literature review (see Chapter 2), while a study of health policymaking can encompass policy

implementation inclusive of rulemaking and subsequent programming, this research study was exclusively focused on a policy formulation step involving the passage of health legislation. This is an important preliminary step in broader policy adoption and change—but also a culmination of policy work. Specifically, the research issues had already reached a level of salience to be introduced as legislative bills, and this study explored what factors influenced whether these bills successfully passed legislative scrutiny.

State Selection: The Fate of Health-Related Policy Ideas in Florida

I selected Florida for ease of access to research and participants. It is my state of residence, which reduces transportation costs and improves the accessibility in scheduling interviews as part of the qualitative component of this mixed methods study. In addition, my knowledge of Florida’s legislative and governmental processes provides additional context for data interpretation. Further, public health legislation has historically met resistance in Florida, with public health professionals and advocates rarely achieving desired legislative ends despite some knowledge of the legislative process.

About Florida

Florida was ranked fourth largest in population with 18.8 million reported in the 2010

U.S. Census2 but eclipsed New York in December 2014 to become the third most populous state in the nation.3 Florida ranks near the bottom of all states for the number of people without health insurance, and about two-thirds of all states have better overall health than Florida.4 With an increase in population (especially in persons 65 or older) and impending physician and nursing shortages,5 the health of Florida’s residents needs greater attention.

Florida’s demographics are described in Table 1. The demography of a state jurisdiction is often closely aligned with its politics.6 The higher percentage of Hispanic, Black, and older

adults (65 or older) in Florida than in the United States may increase the influence of certain stakeholders or change the “window of opportunity” for particular health topics to reach the legislative policy agenda. Florida is older and more Hispanic than the rest of the United States.

Table 1. Florida demographics7

HISIPANIC

< >

FEMALE REGION 2014 <

BLACK

WHITE

ASIAN

18 65

MALE

OLD OLD OLD U.S. CENSUS

YEARS YEARS

ESTIMATED YEARS YEARS

POPULATION

Florida 19,893,297 48.9% 51.1% 17.4% 7.0% 24.1% 3.3% 5.4% 20.4% 19.1% United 318,857,056 49.2% 50.8% 13.9% 75.9% 17.3% 6.2% 6.2% 23.1% 14.5% States

About Florida Health Legislative Processes8

Health care programs comprise approximately one-third of Florida’s state budget, making health care an important topic du jour. At times, Florida has been at the vanguard of health policy issues, and the state has been known previously as a health policy “innovator.”9 However, in 2014, when the medical marijuana and needle/syringe exchange program bills reviewed in this dissertation were introduced, Florida ranked 35th among the states in public health funding, allocating $58 per person.10 In contrast, as the top-ranking states in public health funding in

2014, Alaska allocated $219 per person, Hawaii allocated $213 per person, and New York allocated $149 per person.11 Florida ranked 31st in health determinants and 36th in health outcomes among the states in 2014.12

Politically, Florida was at the time of this study, led by a Republican governor. The bicameral legislature consists of the Florida House of Representatives (120 representatives) and the Florida Senate (40 senators). Republicans held the majority in both the chambers. Each chamber has at least one substantive health committee and one appropriations subcommittee

focused on health issues. In 2014, despite having both a Republican legislature and governor,

Florida ranked 32nd in the nation in percentage of adults identifying as Republican or

Republican leaning at 37%. Texas, Virginia, North Carolina, and Georgia were among the 31 states with greater Republican-leaning tendencies. Florida ranked 15th highest nationally for adults identifying as being neutral (19% showed no lean) and 22nd nationally for Democrat or

Democrat-leaning at 44%.13 The explanation for the apparent mismatch between the population and the politics of Florida is hard to explain easily, and this analysis partly speaks to the paradox.

In the executive branch, several separate agencies comprise the “health” grouping:

Department of Health, Agency for Health Care Administration, Agency for Persons with

Disabilities, Department of Elder Affairs, Department of Children and Families, and Department of Veterans’ Affairs. The agency heads report to a deputy chief of staff in the Executive Office of the Governor.

The Florida Legislature meets in session every year for 60 consecutive days. A regular session of the legislature shall convene on the first Tuesday after the first Monday in March of each odd-numbered year, and on the second Tuesday after the first Monday in January of each even-numbered year. See Table 2.

Table 2. Florida government overview

STATE LEGISLATIVE LEGISLATIVE DOMINANT HOUSE SENATE GOVERNOR RECENT BRANCHES MAJORITY PARTY DURING MEMBER MEMBER TERM GOVERNORS PARTY STUDY PERIOD TERM TERM ELECTION HISTORY FOR SESSION INFO ELECTION ELECTION INFO STUDY INFO INFO PERIOD Florida Florida Republican Republican 2 years, 4 years 4 years; 1999-2007– Legislature- 4 consecutive generally; 2 consecutive Jeb Bush (R) Bicameral— ********** term limits 2 years (first terms; then 1 House (120) Regular sessions election of term break; 2007-2011– and Senate are held every decade), no lifetime Charlie Crist (40) year for 60 2 4-year term limit (R at time; consecutive days: limit now D) beginning the Staggered

8 first Tuesday ********* terms 2011-2019 –

after the first ********** Rick Scott (R) Monday in March Last Election: ********** (odd-numbered Nov.6, 2018 Last Election: 2019-Present years) and the Next Election: Last Election: 2018 – Ron second Tuesday Nov. 3, 2020 Nov. 6, 2018 DeSantis (R) after the first Next Election: Next Monday in Nov. 3, 2020 Election: January (even- 2022 numbered years

In simplified form, a typical progression of a Florida bill involves referral to committees following its introduction by a member of one of the houses (first reading is accomplished by publication). If the bill is voted favorably out of all committees, it is placed on the chamber calendar for second reading (consideration of questions and amendments) and then for third reading (consideration of questions and amendments only by two-thirds vote, debate on the bill, and the sponsor’s closing statement) before being voted on the chamber floor. If passed by a chamber, the bill will be sent in “messages” for approval to the other chamber. If both legislative chambers pass the bill, it is ordered enrolled and sent to the governor’s desk for approval or veto.

Several situations can occur in the progression of a bill. For example, a bill can be voted favorably off the floor in one chamber and then referred to the other chamber’s committees. A bill can be voted favorably by each chamber but amended so heavily that there is no final agreement. At any of these points, a bill may die. In other instances, a bill may die in one chamber, but its similar companion bill14 in the other chamber may pass, in original or highly amended forms. Successful bill language in one chamber is sent to the other chamber for review

(the bill is said to be “in messages”), at which point the second chamber may refer it to additional committees of references in that chamber.15 This study focused on the legislative progression to the point of legislative passage and, therefore, did not explore factors in the governor’s approval process.

A five-year average of Florida legislative bill data surrounding the time of the bill, 2012-

2016, indicated that, of the bills that died, 87% of bills died in committee, 8% died on a chamber calendar waiting to be voted on the floor, and 4% died in messages.16 In the 2014 Florida legislative session, 1,540 general bills were filed by the House and Senate, with 332 passing one chamber, and 229 passing both chambers.17 Of the 2,014 bills that died, 74 bills died on calendar,

and 53 bills died in messages.18 This study examined two bills, both of which survived all committees of reference and were voted favorably off both chamber floors. However, one of the bills was ordered enrolled into law, while the other bill died in return messages before final legislative passage.

Florida is known for having an unusually large pool of lobbyists and lobbying interests.19

In 2007, Florida had 411 interest groups registered to lobby on health issues, more than any other state. By comparison, New York had the second highest number of health lobby groups registered at 368.20 In addition, Florida had more interest groups registered to lobby (across all sectors) than any other state, at an average of 2,305 interest groups from 1980 to 2007.21 In 2014,

Florida remained one of the top states for lobbying with more than 3,500 registered lobbyists.22

In comparison, New York had more than 5,800, and California had more than 2,100 registered lobbyists that year.23

Health-Related Legislation—Topic & Bill Selection

To limit the scope of the study, this research retrospectively analyzed two instances of controversial, health-related legislation in Florida’s 2014 regular legislative session, each with a different legislative outcome. A single legislative session was selected to remove confounders attendant to changes in political actors and political climates. The 2014 legislative session saw both a Republican House and Senate majority, and a Republican governor, Rick Scott. It was an election year and, therefore, both House and Senate leadership were well-established—and were, perhaps, more sensitive to the public’s perception of the intent of legislation.

Bills were selected by reviewing House and Senate bills presented during the recent 2013 through 2016 legislative sessions. To be considered, any bill submitted by any member had to be referred to the highest substantive health committee in its chamber of origination to ensure that

legislative leaders believed the bill topic to be substantive to health: Health and Human Services

Committee in the House, and Health Policy in the Senate. From 2013-2016, 447 bills were referred to the House Health and Human Services Committee,24 and 379 bills were referred to the Senate Health Policy Committee.25 These bills were reviewed for passage or defeat and, if defeated, for how far the bills had progressed when they died. In addition, to reduce source confusion and narrow the basis for passage or defeat, omnibus or “train” bills (bills that start as single issue or single topic, but by the end of the legislative session have additional issues tacked on in the hope of resurrecting dead issues on still-viable bills), and bills that originated with appropriations language were not included. Substantive, single-issue bills were selected.

The year 2014 bills specifically selected for this study were SB 1030 on the use of medical cannabis, and SB 408 on an Infectious Disease Elimination Pilot Program. Each selected bill, described briefly below and detailed in Chapter 4, addressed a relevant, present-day, health- related concern that raised some degree of ethical or social controversy: the compassionate use of cannabis for certain medical conditions, and an infectious disease pilot program for clean needle and syringe exchange. Although the cannabis bill was referred to appropriations, bill selection was focused on substantive policy significance, and bill referrals to appropriations committees were not used in selection criteria. Therefore, any attached funding or appropriation related to the selected bills was not specifically examined as part of this study.

In addition, these health topics were based on a combination of considerations, such as the support of public health groups (e.g., the American Public Health Association has supported medical cannabis since 1995), continued public and media attention, potential long-term impact on improving the public’s health and well-being, and investigator-known state/stakeholder interest. The topics selected were intentionally controversial in some respects to provide deeper

insights into how public health issues are managed as well as the strategies used by those who seek to implement substantive public health policy.

SB 1030 (2014)—Cannabis (Low-THC Cannabis/Charlotte’s Web)26

Health Significance

The use of medical marijuana or medical cannabis in the treatment of a variety of health conditions has been a topic of much attention and controversy for decades, with extensive anecdotal experience and some research supporting beneficial claims.27 With varying degrees of evidentiary support, medical cannabis use has been explored in the treatment of cancer,28 epilepsy,29 amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease),30 chronic pain,31 and other health conditions.32 Florida was expected to have more than 114,000 new cancer cases and

43,000 cancer deaths in 2015, higher than any state except California.33 At the time of the bill, more than 1,500 individuals in Florida had ALS,34 and an estimated 375,000 individuals

(125,000 children) in Florida had epilepsy.35

Bill Purpose

CS/CS/SB 1030,36 also known as the “Compassionate Medical Cannabis Act of 2014,” permitted certain physicians to order low-THC cannabis for patients with medical conditions such as cancer and epilepsy. The legislation required the Florida Department of Health to create a compassionate use registry and establish an Office of Compassionate Use. The bill also authorized certain medical centers to conduct research on cannabidiol and low-THC cannabis, provided for physician education, and created criteria for authorized dispensing organizations.

Low-THC cannabis was often referred to as “Charlotte’s Web” throughout the legislative debate, in honor of a five-year-old girl with epilepsy who benefited from the cannabis.

Recent Prior Legislative Attempts37

Medical cannabis legislation was previously introduced in both the 2012 and 2013

Florida legislative sessions. In 2012, Senator Dwight Bullard (D-Parts of Miami-Dade and other counties) and Representative Jeff Clemens (D-Palm Beach) introduced joint resolutions (HJR

353 and SJR 1028) that would create Section 28 of Article X and Section 32 of Article XII of the

State Constitution to allow the medical use of cannabis. The resolutions died unheard in their respective first committees of reference. In 2013, Representative Katie Edwards (D-Broward) and Senator Jeff Clemens (D-Palm Beach) introduced more extensive bills (HB 1139 and SB

1250) authorizing medical cannabis with corresponding rulemaking authority. Despite additional legislator cosponsors, both bills died before being heard in their respective first committees of reference.

Brief 2014 Bill History

CS/CS/SB 1030 developed from a series of committee substitutes in language put forward by the Senate Appropriations and Health Policy Committees, and the original sponsors

Senators Rob Bradley (R-Baker County and Parts of 11 others), Aaron Bean (R- Nassau County and part of Duval County), and Jeff Brandes (R-Pinellas County). When the Senate bill went forward, six senators (which included Senate leadership) had appended their names to the sponsorship list as cosponsors. Groups supporting the bill included the Florida Democratic Party, and specialty health nonprofits (e.g., American Cancer Society, Florida chapter). Groups originally opposing the bill included the Florida Medical Association and pharmaceutical companies. The Florida Republican Party and Governor Rick Scott supported a non/low- euphoria-inducing version of medical cannabis for use in certain conditions, in part, to improve the quality of life for Florida’s children with debilitating illnesses.38 This bill was voted

favorably out of the Senate Health Policy, Criminal Justice, and Appropriations committees of reference with minor objection and several changes to bill language via committee substitutes. At least nine legislators offered amendments at various points close to the end of the voting period.

Over the course of the bill’s progression, 17 amendments were offered. It was voted favorably by the full Senate (36-3), favorably by the full House with amendment (111-7), sent via return messages back to the Senate and then favorably by the Senate with amendment (30-9). The bill underwent final passage and was ordered engrossed then enrolled on May 2, 2014, the last day of the legislative session.39

SB 1030’s substantively similar companion bill in the House CS/CS/HB 843, was sponsored by Representatives Matt Gaetz (R-Okaloosa), who is now a US representative, and

Katie Edwards (D-Broward), the Judiciary Committee, and the Criminal Justice Subcommittee, and later cosponsored by 35 additional state representatives. Originally filed by Gaetz, HB 843 was referred to the Criminal Justice Subcommittee, where it passed favorably with committee substitute (12-1). HB 843 was then voted favorably out of the Appropriations Committee (24-0).

In the Judiciary Committee, the bill’s last committee of reference, HB 843 was voted favorably with committee substitute (15-3). It was laid on the table and underwent first reading on April

22, 2014, but no additional action was taken, and it died pending review of the committee substitute.

SB 408 (2014)—Infectious Disease Elimination Pilot Program

The Infectious Disease Elimination Pilot Program (SB 408) provided for a clean needle and syringe exchange pilot program in Miami-Dade. It also originated in the Senate, passed successfully out of all committees of reference, was voted successfully out of both chambers

once, but died in returning messages from the House when final consensus could not be reached following last-minute amendments.

Health Significance

As of 2011, Florida ranked third nationally for the number of newly diagnosed HIV infections and second nationally for the number of pediatric AIDS cases.40 As of January 31,

2014, more than 104,000 people were living with HIV/AIDS in Florida,41 with Miami-Dade ranking first in the state, and Broward County ranking second in the state for the number of new cases.42 By 2014, the number of people living with HIV/AIDS in Miami-Dade County had increased by 23% since 2004.43 The availability of clean, unused needles and syringes may help to prevent or reduce the transmission of blood-borne diseases such as HIV, hepatitis, and AIDS among IV drug users and their intimate partners and offspring.44

Bill Purpose

SB 408 and similar companion bill HB 491 created the “Miami-Dade Infectious Disease

Elimination Act (IDEA).” The bill required the Florida Department of Health (DOH) to establish and administer a five-year pilot program in Miami-Dade County for sterile needle and syringe exchange toward the prevention of HIV/AIDS and blood-borne infectious diseases. Funding would be outside of state dollars through private donations and grants. In 2014, Florida law prohibited the supplying of syringes to known drug users, and therefore the IDEA ensured that the distribution of needles and syringes under the pilot program did not violate the Florida

Comprehensive Drug Abuse Prevention & Control Act or other laws. It further required the

Office of Program Policy Analysis and Government Accountability (OPPAGA) to report on the pilot program and to recommend whether it should be continued.

Recent Prior Legislative Attempts45

Legislation to create a Needle and Syringe Exchange Pilot Program for Miami-Dade

County was previously attempted in the 2013 Florida legislative session. Representative Mark

Pafford (D-Palm Beach) introduced a “similar” bill in the House (HB 735), which was subsequently voted favorably, adopted, and additionally sponsored by the House Health Quality

Committee, its first committee of reference. However, the bill died waiting to be heard in its second committee of reference. In the Senate, Senator Gwen Margolis (D-Miami-Dade), who previously served as that body’s first woman president, introduced the bill (SB 808), which was subsequently voted favorably, adopted, and additionally sponsored by the Senate Health Policy

Committee, its first committee of reference. SB 808 also passed its second and final committee of reference but died on calendar for a third reading.

Brief 2014 Bill History

CS/SB 408 was sponsored by Senator Oscar Braynon (D-Parts of Broward and Miami-

Dade Counties) and the Health Policy Committee, and co-introduced by Senators Eleanor Sobel,

Dwight Bullard, Audrey Gibson, Anitere Flores, and Rene Garcia. Originally, SB 408 was filed by Senator Braynon and referred to the Senate Health Policy Committee, the Criminal Justice

Committee, the Appropriations Subcommittee on Health and Human Services, and the

Appropriations Committee. It was voted favorably with committee substitute out of Health

Policy (9-0) and redirected to the Criminal Justice and Rules Committees as the bill had no appropriations at the time. It was voted favorably out of the Criminal Justice Committee (6-0) and introduced and read on the Senate floor. It then passed favorably out of the Rules Committee

(9-1) and was placed on the calendar for second reading. At that time, an amendment was adopted, and the bill was ordered engrossed and placed on third reading. Over the course of the

bill’s progression, four amendments were offered. Upon third reading, it was passed by the full

Senate as amended (30-10). CS/SB 408 was then sent to the House in messages. On May 2,

2014, the last day of the 2014 legislative session, it was read a second time and a strike-all amendment (sponsored by Representative Mark Pafford, see below) was adopted. (A strike-all bill is when the bill title and enacting clause are kept but all substantive portions are deleted and replaced.) The House-amended version was read a third time and passed the House with the vote of 109-8. It was then sent back to the Senate in returning messages, where it died.

SB 408’s substantially similar companion bill in the House was HB 491. CS/HB 491 was sponsored by the Health Quality Subcommittee and Representatives Mark Pafford and Julio

Gonzalez (R-Part of Sarasota). Ten additional cosponsors were listed in the final stage. The bill was voted favorably with committee substitute out of the Health Quality Subcommittee (13-0) and then voted favorably (10-0) out of the Government Operations Subcommittee. The bill then was voted favorably out of the Judiciary Committee (14-0) and also passed favorably (17-0) out of the Health & Human Services Committee, its fourth and final committee of reference. It was added to the House second reading calendar on April 10, where it remained and died without being put to a vote on the floor, and without an additional proposed amendment being adopted.

CHAPTER 2: LITERATURE REVIEW

I performed a literature review to investigate the question, “What determining factors most influence the outcome of state health legislation?” and focused on the period since 1990. I focused on studies of factors that determine legislative success. The results of the literature review contributed to the selection of factors of influence used in the disseration study design.

Time Period Selection

The literature review examined scholarly work that investigated state health legislation published from 1990 through 2016. The earlier date was chosen to include recent, relevant research on state health policymaking processes and was extended through 2016 to include recent studies.

Sources Used

I obtained contextual background through a review of classic political science and policy books and research of additional references through the university library system. I systematically searched for publications on state health legislation determinants primarily using

PubMed, which accesses MEDLINE, and the Google Scholar database. Medical subject headings

(MeSH) terms (see Table 3) were utilized in PubMed to home in on the research topic. To fill any gaps in the list generated using the selected key words, I reviewed a handful of known, industry-standard, legal, public policy and health policy journals, and recommended articles

(PRISMA review, see Figure 1). Initial review of relevant books and instructive literature covered the 26-year period (1990-2016) with the intention of gauging and describing the historical context of an advocacy/legislation framework and providing a solid foundation for

subsequent identification of relevant sources by first examining well-referenced sources. A snowball technique found additional references identified by these “core” sources. Only articles and reports for which a full-text version could be obtained were included in the review. For additional context and direction, I explored organizational websites, such as the National

Conference of State Legislatures (NCSL), the National Governors Association (NGA), the

American Legislative Exchange Council (ALEC), the National Academy for State Health Policy

(NASHP), and the American Public Health Association (APHA).

Selection Criteria: Inclusion and Exclusion

Two basic inclusion criteria focused on determining which factors of health-related policy and legislation are widely considered influential: 1) The article or report must be published in English and refer to humans; 2) The health care legislation or policy discussed by the article must have passed between January 20, 1985, and July 1, 2016.

Articles and reports that addressed health policy implementation in general rather than the passage of health-related legislation were excluded. In addition, descriptive studies that broadly discussed successful legislation without consideration or analysis of influential factors and those that, while meeting basic inclusion criteria, had no direct relevance to the study objectives (judged on a case-by-case basis) were excluded.

Keywords and Search Strategy

Table 3. PubMed search strategy

ALL Searches were limited to Publication date of 1990–2016: Concept Key Words, Search Terms Legislation (“legislation”) as topic OR (“health/legislation and jurisprudence”) OR (“health policy/legislation and jurisprudence”) OR (“health planning/legislation and jurisprudence”) OR (“public policy/legislation and jurisprudence”) OR (“politics/legislation and jurisprudence”) AND Health “health” AND State “federal” OR “state” Other search terms may include Concept Key Words, Search Terms Factor “factor” OR “determinant” Influence “influence”

Search Process

I used PubMed initially with the search strategy detailed in Table 3. All searches were limited to a publication date of 1990 through 2016. A search of “Legislation” concept terms in

Table 3 yielded 113,260 articles, which was narrowed to 83,796 articles when the term “health” was added. From that point, the search explored both “state” and “federal” term paths, with

15,248 articles and 5,896 articles returned, respectively. To further refine state path results, I added the terms “factor” (186 articles), “determinant” (27 articles), and “influence” (423 articles). I then refined federal path results in the same manner, adding the terms “factor” (69 articles), “determinant” (seven articles), and “influence” (140 articles). The refined state and federal paths yielded a combined total of 852 articles. I then used article titles to determine that

96 of those articles were potentially relevant and confirmed by scanning abstracts. PubMed search results based on Table 3 search terms are depicted in Figure 1. From full-text review of each of the 90 unique articles, I identified 34 for inclusion in this dissertation, reduced to 27 after

the elimination of duplicates. Twelve additional articles were found using a snowball method of cross-referencing works cited in the articles selected and included. Furthermore, health policy scholars recommended a handful of articles for inclusion, leading to more than 39 articles ultimately included for reference. I read these articles until themes and results began to repeat and saturation was presumed.

The systematic search and initial review of content resulted in the inclusion of 27 primary relevant articles detailing researched factors that influenced the outcome of health care legislation and policy across a variety of health-related topics. These articles were reviewed individually and in conjunction with political science and public policy theory source materials.

Figure 1. PubMed Search Results Based on Table 1 Search Terms46

After full-text review, 34 articles remained instructive and 27 were ultimately included after duplicates were removed. Search results reflect a previous limitation by date criteria.

Records identified through database searching Records excluded through (n = 113,260) narrowing by search terms (n = 112,408)

Records screened Records excluded by title (n = 852) (n = 756)

Full-text articles assessed for eligibility Full-text articles excluded (n = 96) by abstract (n = 62)

Studies included in qualitative synthesis Duplicates removed (n = 34) (n = 7)

Studies included in quantitative synthesis Additional studies identified (meta-analysis) through other sources (n = 27) (n = 12)

Studies included in quantitative synthesis (meta-analysis) (n = 39)

Emergent Themes & Focus in the Literature

Policy themes in the literature were reviewed and resulted in a question of whether they were applicable to health policy. The literature suggested that health policymaking and politics were similar but distinct from general policymaking (as described in more detail below). While

policymaking includes a spectrum of activities from problem identification through policy implementation, I focused on those policies rising to the level of legislation, and research discussing other previous and post-enactment activities were culled out. In addition to the articles, I reviewed policymaking themes to provide context and to ensure that larger political and policy theories were not overlooked in the creation of research scope and methodology.

General Policy Themes

Across various resources and instructive policymaking academic books, several agenda- setting and policy paradigms emerged. Some of these models are not exclusive to health policy but, rather, encompass scholarly theories well-cited over time as applicable to health policy development.

Widely acclaimed and referenced, John Kingdon’s “three-streams” model of agenda- setting, 47 originally developed as a description of the policymaking in the federal government, posits “largely independent” major process streams.48 This involves actors’ recognition of problems, or the “problem stream”; development of proposals to alter public policy, or the

“policy stream”; and political action to influence change, or the “political stream.” Kingdon keeps these process streams mostly separate, with stream “coupling” and convergence at times when change is most feasible. These critical times present opportunities for action within one or multiple streams known as “policy windows,” “open windows,” or “windows of opportunity.”

Within this model, Kingdon recognizes multiple actors can work across streams and identifies particular “specialists” in the streams.49 For example, specialists in the policy stream may include researchers, academics, and bureaucrats. “Policy entrepreneurs” can exist throughout the system at any point, as can “specialists” who generate solutions but remain “relatively hidden.”

These actors may include researchers, bureaucrats, and consultants. In addition, Kingdon’s research found special interest groups such as the media to be important in policymaking.

The streams model went beyond other previously considered models such as Lindblom’s

(1952) incrementalism,50 Cohen, March, and Olsen’s (1972) “garbage can” mix of the conditions in a given time leading to outcomes;51 or even a potentially unrealistic concept of comprehensive, “rational decision making.”52

Deborah Stone’s body of work53 argues that policymaking does not exist in a clean, logical vacuum devoid of politics. As such, it does not fit neatly into the concept of “rational decision making” and is necessarily messy as points of view will contradict, seem illogical, or appear to be in paradox. The larger political community, or “Polis,” has underlying paradoxical needs, thoughts, and ethics. A tension exists across goals, problems, and solutions. “Reasoned analysis is necessarily political … [p]olicy analysis is political argument, and vice versa.”54

Other scholars analyze public policy by asking who, what, when, where, why, and how of policy issues to “tell a story.”55 In considering “who,” subsets include elites who run things, professionals, bureaucrats, scientists/academics, media, the public or “The People,” policy entrepreneurs, and “great people” who may act as role models.56 Institutional actors such as legislators and governors may also play large roles.57 The role of lobbyists or government relations specialists, interest groups, and the impact of health science research58 (and therefore researchers59) have been studied for their impact on policymaking. Effective advocacy across these special interests is critical to policymaking success,60 along with the ability to use resources so as to influence others.61 For the question of “when,” subsets includes windows of opportunity, election and funding cycles, agendas and schedules, and history. The question of “how” looks at

subsets of lawmaking, intergovernmental processes, the policy “market,” politics, and making deals. Questions of “why” might include justice, for example.

Health Policy Distinction Themes

Although these paradigms are widely applied across political and policy topics, some political scientists consider health politics and health policymaking to be distinct from general policymaking. Carpenter (2012) finds that health politics is set apart from other policy areas along various lines such as organizational identity (e.g., groups nontraditionally aligned but unified under a disease banner), deference to professionals/experts in areas such as science and medicine, and governmental treatment of health access and inequities different from other social inequalities and injustices.62 In addition, the more involved role of the state and its regulatory agencies also differentiates health policy. For these and other reasons, health politics may not easily conform to more generalized political science and policymaking theories of analysis.

Some scholars note a seemingly inherent conflict between population health and politics, with the “public health community seldom acknowledge[ing] that its work is pervasively political,” and find that few studies are devoted to the politics of public health within health policymaking.63 Furthermore, the complex politics of health care, the varied effectiveness of

“organized interests” across issues,64 and the intricate dance of various private actors65 set a distinct political health stage.

The Legislative Stage in the Policymaking Spectrum

The policymaking process is frequently portrayed as multiphase or multistage, with a minimum of three phases to include agenda setting, policy formulation, and program implementation.66 “The politics of agenda setting, policy formulation, and implementation are complex and, in many respects, uncertain in both their causes and consequences.”67 Within

policy formulation, certain policy agendas rise to legislative review and are passed into law.68

Because the research is aimed at determinants that predict the legislative voting outcome of state health legislation, the literature review excluded later-stage implementation and preliminary- stage agenda setting. Issues introduced as bills are assumed to have been deemed sufficiently salient to invest legislator effort. How the issue was introduced, however, may have implications for later passage and is noted whenever applicable.

Importance of Health Policy Focus at the State Level

Federalism and history suggest that state and federal health policymaking may involve both different health issues and different processes. While the federal government holds certain enumerated, implied, and plenary powers, those powers that are not delegated to the federal government nor prohibited to the states are reserved to the states by the Tenth Amendment to the

Constitution. Traditionally, federalism has allowed concurrent governing of public health at the federal and state levels, with states often holding the role of innovator, public health regulator, and executor of core public health functions. This status remains unless or until a multistate or national health issue creates a need for congressional preemption or triggering of the Supremacy

Clause.69 “Delivering public health services requires local knowledge, civic engagement, and direct political accountability. States and localities are also often the preferable unit of government … a ‘laboratory of the states’ enables local officials to seek innovative solutions.”70

In the case of natural disasters and epidemics, federal action is frequently seen; however, states are fertile ground for novel public health policies.

State health policy decisions have ripple effects for policy diffusion across levels of stakeholders. While federal health policy can impact state health policy in a vertical, top-down manner,71 state health policy can also help to shape federal health policy to varying degrees,72 as

has been seen historically and in more recent health reform efforts.73, 74 In addition, the adoption of health policy in one state can have a horizontal impact on the adoption of similar health policy in a neighboring state.75 States have also worked together through collaborative associations such as the National Conference of State Legislatures (NCSL), the National Governors Association

(NGA), and the American Legislative Exchange Council (ALEC), to put checks and balances on federal decision-making,76 and provide analyses that impact state legislatures and federal initiatives.77

Discussion of the Literature

Convergence of Political Policymaking Paradigms with Public Health Theories

Among renowned policy scholars, several policymaking and agenda-setting paradigms are widely consulted for political and policy analysis.78 While health policymaking can certainly be analyzed using these time-tested models, the models are not exclusively tailored to public health and health-related issues. Political scientists believe that the politics of health is different from other politics.79 Discussions by health policy experts appear to find classical paradigms instructive but requiring of additional health context.80

Emergent Overarching Themes in Health Legislation

The primary relevant articles appear to revolve around the following five overarching themes that are in keeping with, or expand upon, the political science literature on policymaking:

1) general factors long-discussed as impacting legislative outcomes, or that are unattributable to traditional actors, are discussed herein as the “Influence of General Factors,” such as having a

“window of opportunity”; 2) the influence of legislators and legislative staff are discussed herein as the “Influence of the Legislature”; 3) tactics used directly by constituents and special interest groups to impact legislation are discussed herein as the “Influence of Constituences”; 4) the

ability of paid professional lobbyists to influence votes is discussed herein as the “Influence of

Professional Lobbyists”; and 5) the influence of government officials in the legislative and executive branches at the highest position levels is discussed herein as the “Influence of Highest

Government Leadership.”

Influence of General Factors

Various factors that do not clearly correspond to a traditional actor (e.g., legislator, lobbyist) or are not easily categorized can influence the outcome of health-related legislation. For example, such “General Factors” may include celebrity attention, research, strength of argument, or bill timing, as in a “window of opportunity” opening.

“Time-tested general factors” were explored in a seven-state, health care reform legislation study by Paul-Shaheen (1998).81 She categorized her research results into three lessons that reinforced a current understanding of state health reform (crisis as a catalyst for action, the role of new special interests in game-changing opportunities, and expanded bureaucratic influence in health care reform) and six additional lessons that extended an understanding of state health reform (timing, the continuum of many smaller steps leading up to a larger product, policy entrepreneurship, media and public opinion, Democratic introduction of the bill, and single-payer option). While factors such as “single-payer option” may be limited in applicability, Paul-Shaheen’s study supports the general influence of both non-categorical factors such as persistent action and “window of opportunity,” and actor-attributable influence, as in the case of policy entrepreneurship.

In addition to Paul-Shaheen’s work, other studies have explored persistence, or the impact of prior attempts at similar legislation, with or without incremental success as an influential factor in current legislative outcome.82, 83 Media attention is another general factor that may influence legislation.84, 85, 86

Furthermore, studies have reviewed the influence of evidence-based reports or research on legislative outcomes,87, 88, 89, 90 with some legislatures forming partnerships with universities for research purposes.91 Persuasive arguments on the health benefits92, 93, 94, 95, 96 and economic benefits97, 98, 99 of health-related legislation also influence legislative outcomes. Whether a bill is viewed as being fiscally legitimate and consistent with state need and resources also plays a role.100

In recent political times, celebrity advocacy and endorsement have had a growing impact on policy focus and legislation.101, 102 Notably for this dissertation, famous personalities have visited Florida legislators to discuss current legislative bills.103

Finally, the strategic exchange of political support and/or opposition across bills and positions may occur across a variety of actors such as interest groups, lobbyists, and legislators.

“It is difficult to conceive of a legislature without internal horse-trading, and recent work suggests that logrolling [prior agreement between legislators to vote for each other’s bills] is widespread among legislators and more frequent than commonly thought.”104 This practice of

“horse-trading” may affect legislative decisions.105, 106

The Influence of the Legislature

“General Factors” do not touch upon the complex powers and factors within the legislature and legislative process. The willingness of a particular legislator to champion a bill and the political power or capital of a bill-sponsoring legislator can play significant roles in legislative outcomes, 107, 108, 109 as can committee sponsorship.110 Whether a legislator believes a bill has significant constituent backing,111, 112 covers an important topic,113 or will be of great benefit to the state, 114, 115, 116, 117 also impacts a bill’s fate.

In studying the influence of think tanks, media, and foundations on Minnesota legislators,

Gray and Lowery (2000) noted that legislators determine how important a particular source of information is for legislative voting purposes.118

Some studies distinguish supportive legislators based on topic and timing. From Carol

Weissert’s (1991) study of the North Carolina Legislature,119 policy entrepreneur legislators who have subject-matter knowledge and persistence are great influencers of successful legislation and are perceived to be highly effective (e.g., legislators known for health expertise become more effective when health issues are salient). Second to policy entrepreneurs, policy opportunist legislators, who identify and become associated with a topic during a window of opportunity, also become influential in the passage of bills. Opportunists did not necessarily have committee ties and generally lacked the substantive knowledge of entrepreneurs. Both policy opportunists and policy entrepreneurs varied from year to year. Legislative turnover could not explain a finding that legislative policy entrepreneurship was highly transient in nature. Thirty legislative entrepreneurs were identified over three legislative sessions, but only one legislator was named twice, and he was successful on a similar issue in a subsequent legislative session. Weissert concluded that any legislator could seize a window of opportunity and increase substantive knowledge to gain effectiveness.

Other studies explored how the personal attributes of legislators may be significant factors in whether legislation passed. In Ellickson’s 1992 study of the Missouri House of

Representatives,120 personal (e.g., occupation, age, race, gender, education), environmental (e.g., urban/rural dimension district competition), and institutional (e.g., seniority, political party) attributes were identified.121 Institutional and personal characteristics impacted legislative success more than environmental factors. Seniority and political party (institutional attributes)

were noted as particularly important as they impacted the level of influence the legislator had in formal office. In addition, Ainsworth (1997) found that legislators influence lawmaking by

“selective associations” with professional lobbyists, interest groups, and other legislators, often in “lobbying enterprises” that vary distinctly across policy areas.122

General attitudes and norms appear to be important in predicting the voting intentions of legislators. A three-state, tobacco control legislation study by Flynn et al. (1998)123 found that the perception of the 444 legislators interviewed regarding whether the bill would have a beneficial outcome to stakeholders was a strong, influential factor. Also, legislators’ perceptions of constituent pressure, perceptions of potential bill impact on various economic and social sectors, political party affiliation, and location (state) played roles in influencing voting intentions.

Legislative staff members such as legislative aides, committee staff, and staff directors may also play an important role in whether legislation passes.124, 125 Health policy staff functions involve intelligence, information gathering, agenda setting, and proposal shaping. Weissert and

Weissert (2000)126 found a significant correlation between trust of staff and influence in studying health policy legislative staff across five states, including Florida. They reviewed public documents and interviewed “forty-six legislative staff, former staff, governor’s advisors, agency liaison, lobbyists, and legislators.” Fiscal staff had a higher correlation for influence than trust.

The role of legislative staff is paramount to state health policy in that staff members serve as the institutional memory of what is typically a highly transient state legislature.

The Influence of Constituencies

The ability to influence the successful passage of legislation may also be found at the grassroots or organizational level.127, 128, 129, 130, 131, 132, 133 This may include a variety of tactics such as using patient case studies,134 coalition building, 135 and unifying health care elites.136

Constituencies may also present testimony or have direct discussions with legislators and relevant government agencies.137. 138, 139, 140 For example, nurse practitioners have become active advocates in recent years for scope of practice expansion, directly engaging with legislators.141

In 2001, Zakocs, Earp, and Runyan142 explored 35 advocacy tactics regarding gun control policies to prevent related injury and found that legislative lobbying, media, and education were commonly used while litigation and electioneering (actions to influence voting during campaign and election seasons) were least used. Tactics also included administrative lobbying. Tactics to mobilize public support included public education, working with mass media, and protest events.

Surprisingly, no association was found between an organization’s financial resources and the use of various advocacy tactics. The most effective group employed a wide range of tactics at various stages of the policymaking process.

The Influence of Professional Lobbyists

Increasing expenditures in legislative lobbying efforts in all states demonstrate the important role of lobbying as a factor in legislative success. In-house government relations personnel representing a single constituent may not have the same bargaining power as higher- paid professional lobbyists representing multiple interests, who have better ability to trade off client interest to obtain desired results (e.g., the “unprincipled agent hypothesis” posed by

Lowery, 2013143).

Ahrens, Jones, Pfister, and Remington (2001)144 studied legislative lobbying of tobacco control legislation in Wisconsin and found that the numbers of hours spent lobbying (time invested) correlated more strongly to successful bill outcomes than did the amount of money paid for lobbying. Despite pro-tobacco groups spending three to seven times more than anti- tobacco groups, anti-tobacco groups invested 117% to more than 150% more lobbying hours and could achieve substantial portions of their agenda. Even so, Landers and Sehgal (2004) found

that federal health care-lobbying expenditures in 2000 were larger than the lobbying expenditures of any other sector, with 1,192 organizations involved in health care lobbying.145

“There are sizeable disparities in the health care-lobbying expenditures of various groups. Health advocacy groups may need to consider the relative distribution of these expenditures as they formulate legislative strategies.”146

When studying the Georgia General Assembly, Bullock and Padgett (2007)147 observed that lobbyists had to change strategies at the time as the state legislature moved from a single- party to a two-party political system. Old lobbying methods of offering perks to legislators (e.g., golf outings) and single-legislator connections have become less effective than newer methods of lobbying committee members individually and reaching “across the aisle” to gain support for positions. Lobbyists must work harder to stay on top of their bills through the entire legislative process, to expand their contacts to be successful, and to become subject-matter experts to educate legislators and influence outcomes. In addition, negative lobbying strategies (lobbying against an issue) may be even more effective than positive lobbying strategies.148

Lobbying efforts may be hidden/“behind the scenes” (informal) or visible (formal), with a combination of both styles potentially yielding the greatest policy changes.149 Lobbyists further influence the outcome of legislation through financial contributions to legislators either directly, or indirectly through donations to political parties or political action committees in their name or their clients’ names.150, 151, 152 Campaign contributions have been correlated with influential changes in state legislative policymaking behavior, such as in the case of tobacco control.153

The Influence of Highest Government Leadership

Support of legislation by officials at the highest level of government leadership plays a significant role in the outcome of legislation. The support of the leading state agency with subject-matter expertise can influence outcomes,154, 155, 156, 157, 158 as can the active support of the

governor’s office.159, 160, 161, 162, 163 Florida governors who use a verbal style that conveys realism, action, and passion are more successful in achieving legislative objectives than those who do not.164 Legislative leadership support is critically important to legislative bill outcomes.165, 166, 167,

168 In studying state health care reforms, Oliver and Paul-Shaheen (1997) found that “[b]y attracting the support of highly placed elected officials, advocates of reform … were able to bring public opinion into greater prominence, secure the support and resources of many interest groups …” and fight off opposition.169

Additional Key Themes in the Case Studies

Although not included in the original literature review, two critical themes arose in these drug-related health policy case studies that necessitated additional selective literature review and discussion: “framing” and “deservingness.”

The “prudent choice of frames, and the ability to effectively contest the opposition’s frames, lie at the heart of successful policy advocacy.”170 “Frames” are based on internalized concepts or values that create meaning for people. They function as “existing constructs that allow us to interpret developing events” that can be impacted by “various elements, such as language choices and different messengers or images.”171 According to Ostrom (2007), frameworks “organize diagnostic and prescriptive inquiry” and “provide a metatheoretical language that can be used to compare theories.”172

Sabatier and Weible (2007) described policy participants as holding three levels of beliefs that impact advocacy: deep core beliefs, policy core beliefs, and secondary beliefs.173 Competing internalized frames can be influenced by selective communication that “resonates with people’s deeply held values and worldview” and “appeal[s] to higher-level values.”174 By appealing to

“big ideas” such as justice and responsibility, rather than general or specific issues such as the

environment or tropical rainforests, advocates can frame an issue to drive community and policymaker action.175

Negating a frame both activates and strengthens it; therefore, successful argument introduces different frames while avoiding an opponent’s frames.176 Metaphors play a key role in framing issues, are used by people to reason and frame, and can be used to redirect reasoning.177

According to Lakoff (2014), reframing is “social change” and “new language is required for new frames.”178 “Sustained public discussion” may prepare an issue for effective reframing, or “the changing of millions of brains to be prepared to recognize a reality.”179

Framing influences all steps in the policymaking process, including policy formulation and adoption, the subject of this case study.180 Framing may be particularly salient in the context of drug-related policy, because in telling the political story, “the narrative is more powerful than the numbers, the meaning more memorable than the mean.”181 For example, needle exchange may seem a logical policy choice toward HIV prevention. However, policy options become limited when the issue is framed using the image of “illegal drug use” rather than using the “big picture” concept of preventing HIV and helping children and families. Framing the issue in a way that conflicts with the values of major groups in the country (e.g., the religious right) restricts alternatives.182

The perceived disparities in drug policy may be better understood through the lens used by Ryan (1976), who contends that people are likely to use the ideological framing of “blaming the victim,” which unintentionally distorts reality.183 In this framework, perspectives of social problems range from “exceptionalism,” focused on correcting what is “unusual,” “different,” or

“internal” about an individual, to “universalism,” which recognizes “similarity” across people and a need for a “collective” or “external” focus on the larger society for change.184 The

universalistic perspective frames social problems as issues of society and system that are

“predictable and … preventable through public action,”185 while exceptionalism leads to classifications and change efforts focused on an individual’s differences such as culture, race, and socioeconomic class, and further sub-labeling of “the worthy poor” (the deserving) versus

“the unworthy poor” (the undeserving).186

According to Morone (1997), “drug policy remains enmeshed in racial politics and biases.”187 While “crude racialist rhetoric is far less prevalent,”188 Netherland and Hansen (2016) observed that, historically, the “U.S. ‘War on Drugs’ has had a profound role in reinforcing racial hierarchies.”189 For example, history has shown legal action to coincide with “widespread” public fears of violence and deviance related to the use of opium (associated with Chinese immigrants), of cocaine (associated with African Americans), of recreational marijuana

(associated with Mexicans) and, more recently, of crack cocaine (associated with African

Americans).190 Use of powdered cocaine and opioids (associated with Caucasians) carried reduced criminal penalties in comparison and were framed more from a perspective of treatable illness (deserving) rather than deviant (undeserving).191

Recent research suggests that medical marijuana use is more common in high-income whites (similar to opioids) because of reduced drug enforcement.192 In addition, “minorities have been largely absent from the push for medical cannabis across the South,” and advocates have needed to specifically push for medical cannabis laws to cover conditions disparately impacting

African Americans, such as sickle cell disease.193 The racial underpinnings and politics of drug policies may cause universal harm as Hansen and Netherland assert that “racially disparate drug policies and health care practices ultimately hurt White patients.”194

Gaps in Research and Knowledge/Bridging the Gaps

The articles reviewed were often specific to one health topic and may not be applicable across other health topics. Studies appear to favor the controversial topics of state health care reform and tobacco legislation, big-ticket items that may not be viewed in the state legislative process the same way as chronic disease prevention, for example.

Most of the articles in this literature review acknowledge that the determinants studied are not the only factors influencing legislation. Factors that influence the success or failure of legislation may not always be observable. For example, Lowery (2013) observed “many null findings in influence research” and synthesized divergent research into 12 null hypotheses on types of influence, while noting that “the dark matter of influence that is vitally important to the distribution of power in a society … [may be] … influence that cannot be readily observed.”195

A study based on factors gathered in this literature review, augmented with investigator- preferred factors from anecdotal experience, will improve understanding of how state health- related legislation is passed. Using mixed methods in qualitative and quantitative research design may allow for a more thorough exploration and understanding of the determinants identified.

Search Strategy Limitations and Weaknesses

Search strategies used for this literature review have limitations. The search terms were specific to health and state legislation, but a significant number of articles initially retrieved were not limited to state legislation and did not address state legislation specifically. Narrowing the search to include the terms “factors” and “influence” resulted in a few key articles but may have unintentionally excluded important articles. However, given the time gaps in relevant articles reviewed, it appears that much of the cross-referenced literature, even by newer articles, predates the expanded exclusionary date criterion of 1990 to present. Furthermore, each of the articles

identified as relevant and reviewed explores different potential factors of successful legislation rather than merely supports prior theories. Expanding the date criterion further may have included significant primary articles that could have led to other newer articles through a snowball method.

Informing a Dissertation & Conclusion

This literature review served as the cornerstone to this dissertation to explore the development of a comprehensive assessment of the key determinants of successful health legislation. Specifically, the literature review identified factors that are associated with the successful passage of health policies at the state legislative level. The convergence of general policymaking theories with research supporting specific determinants of state health legislation formed a basis from which to develop a survey instrument to test the extent to which each of the selected determinant impacted specific legislation. Further, the literature review supported a research design involving a triangulation of resources to include legislation, public records, key informant interviews, and surveys. Certain studies provided ideas for selection of interviewees, questions, and scope. The literature review also highlighted differences across articles showing variations in validity, reliability, and quality. Additionally, the literature review aided in narrowing what turned out to be a very broad topic into a more manageable endeavor. To help fill in gaps of knowledge in the literature and address concerns found in the literature, key informant interviews captured additional factors not reflected in previous research studies. In addition, the dissertation will add to the discussion of influential factors that, while not conclusive or definitive, may provide valuable suggestions to health-related professionals seeking a path to successful health legislation and may offer new factors for future studies.

CHAPTER 3: METHODS

Study Design196

This dissertation presented a retrospective, sequential, mixed methods case study design that seeks to gather information on what factors influence the passage or failure of health-related legislation in Florida. The research aimed to create a roadmap for stakeholders to follow for potentially increased efficacy in the pursuit of health-related legislative and policy changes.

However, prospective policy analysis inherently brings many challenges.197 The mixed methods design allowed the testing of legislative factors, compiled using the literature review and researcher-selected factors, through an online survey and key informant interviews.

The online survey contained quantitative elements that were descriptive in nature. The structured key informant interview questions contained qualitative elements derived from previous case studies found in the literature review and from the results of the online survey.

Both open-ended and closed-ended questions were included. The blended mixed methods approach identified factors and their levels of influence on the outcome (successful legislation).

The study design is outlined in Figure 2.

Figure 2. Mixed Methods, Sequential Explanatory Design198

Quantitative Qualitative Data Collection Connecting Data collection Cross-sectional, Integration of the Quantitative and Key informant interviews Quantitative and web-based survey Qualitative Phases with 20 stakeholders, in- Qualitative person, videoconference, ●Purposefully or on phone Results selecting participants Comparative from each group interpretation and (n=20) explanation of the ●Derive additional quantitative and Quantitative Data Analysis interview questions qualitative results, *Data screening, analysis, based on survey discussion, frequencies, descriptive statistics results implications Qualitative Data ●Analysis by Analysis Influential Stakeholder group (5): ●Coding and thematic 1) Legislative Branch, grouping analysis, within- 2) Executive Branch, 3) case (bill) and across-case Lobbyists, 4) Constituencies, theme development, cross 5) Other thematic analysis, MAXQDA software ●Analysis by Influential Factor group (6): 1) General Factors, ●Analysis by Influential 2) Constituencies, 3) Legislature, Stakeholder group 4) Professional Lobbyists, ●Analysis by Influential 5) Highest Government Factor group Leadership, 6) Other ●Review of Respondent ●Analysis by Respondent Role Role and Political and Political Affiliation Affiliation

Data Collection Procedures [See Appendix C for Key Terms Defined.]

Data for this study were derived from two sources: an online survey of key stakeholders

(quantitative) and 20 key informant interviews (qualitative).

Multiple information sources were examined and cross-referenced to: 1. identify bill proponents and opponents, including lobbyists and constituencies, 2. to add specific context to tested factors, 3. to better understand bill language changes that impacted bill support, 4. to observe the interactions of relevant parties, and 5. to inform additional guiding prompts for key informant interviews. These background data sources included relevant documents for each of the two bills such as bill versions, legislative history, committee testimony, and other archival

records that are accessible as public records online or through special order via the Florida

Legislature and The Florida Channel.

Online Qualtrics Survey (Quantitative Focus) [See Appendix A for Online Survey and Consent Forms.]

An online, self-administered survey entitled “Why Did That Bill Pass?”199 comprised the main quantitative survey research component. The survey was distributed via email through

Qualtrics. Using a Likert scale, stakeholders were asked to weigh the level of influence of different factors on the success or failure of the specific piece of legislation. Prior to distribution, the survey was tested on three individuals who each had been involved in Florida government for at least 10 years at the time of testing.

These individuals were asked for general feedback on items such as wording, the sensibility of the survey questions, and the amount of time needed for survey completion.

The survey consisted of five sections. The first section listed 22 factors derived primarily from the literature review and then augmented by factors from my knowledge of Florida politics.

The survey taker was asked to respond to each factor’s level of influence in passing a particular bill on a scale of one (1) through five (5), with “1” being “Less Influential,” and “5” being “More

Influential.” “I don’t know” was also an option. The respondent was able “hover” over each factor for additional description of the factor. (See Appendix D for more information on the

Qualtrics Survey Question Coding and Hover Function Descriptions.) The survey allowed respondents the ability to type up to three unlisted subjective factors and provided respondents the opportunity to type additional thoughts into an open field.

The second part asked respondents to rank the influence of 14 stakeholder groups (with the possible addition of up to three write-ins) from “1” (less influential) to “5” (more influential).

The Qualtrics hover function was employed to provide the respondent with additional description

of each stakeholder group. The third part asked the respondent to generally identify their occupational position/role at the time of the bill passage by clicking on one of 12 categories, such as “Professional Lobbyist.” The Qualtrics hover function was also employed in this section and provided detailed descriptions for the occupations listed. The fourth part asked the participant to select their political affiliation as listed on their 2014 voter registration card. The fifth part, which was optional, asked the survey taker to type into an open field any additional comments or thoughts on what they felt was influential but not previously listed.

For each of the two selected bills, all legislative members on committees of reference, all registered health-related lobbyists of record for the bills (lobbyists representing organizations with interests in the bills derived from state lobbyist registrations in combination with legislative committee records and videos), executive branch agents, and testifying stakeholders, were invited to participate if contact information was available. Contact information was derived from the legislative lobbyist directory, government webpages, and public records. This totaled 215 unique individuals.

Surveys were sent electronically with an email introduction to 187 cannabis bill stakeholders and 188 needle exchange stakeholders, which included an overlap of 160 legislators

(120 House member and 40 Senate members). Eighteen messages to cannabis stakeholders and

24 messages to needle exchange stakeholders were returned as undeliverable, for a net total of

169 cannabis stakeholders and 164 needle exchange stakeholders presumably reached. Up to five reminder emails were sent to potential respondents over a three-month period. Participants received an email directly from Qualtrics requesting participation and issuing a unique link to the survey instrument. The link brought the participant to an informed consent and confidentiality form. A Qualtrics “rule” was set up to prevent multiple submissions by the same participant

while ensuring protection of the participant’s identity. I was not privy to the identity of survey participants. Participants were able to stop or pause the survey and resume it at a later time.

The results of the quantitative online survey were not statistically useful for generalization because of a very low participation rate (see Chapter 4, Results, for additional details). However, survey results helped to inform the qualitative key informant interview guide.

See Appendix E, Select Results from Qualtrics Survey, and Appendix G, Key Informant

Interview Coding Guide.

Key Informant Interviews (Qualitative Focus) [See Appendix B for Key Informant Interview Question Guide and Consent Forms.]

Key informant interviews comprised the main qualitative research component. A draft of the semi-structured interview question guide was developed for all interviewees regardless of type of stakeholder (see Appendix B) and was slightly modified based on the results of the quantitative online survey and relevant legislative history. [For a list of sources and factors that influenced the development of the key informant interview script, see Appendix F.] The interview guide contained 15 questions in multiple parts consisting of both closed and open- ended questions.200 The respondents were asked primarily open-ended questions designed to elicit general information about the legislative process and capture information on any external factors not previously contemplated. Respondent answers to open-ended questions often led to free-flow commentary and additional follow-up questions.

Legislative records and media sources were used to identify interviewees who could provide diverse viewpoints. The four types of informants were categorized as legislative branch representatives, executive branch representatives, lobbyists, or constituencies. With time considerations and conservative expectations following a low number of survey responses, the following breakdowns were goal respondents for each bill:

• three from the legislative branch with preference for at least one sponsoring

legislator, and representation of both majority and minority parties;

• three lobbyists (multi-client or in-house) with preference toward lobbyists

publicly known or known to be active on the particular bill;

• two from the executive branch; and

• two from constituencies.

Table 4. Initial key informant interview goals

Stakeholder Category Examples of Stakeholder Titles # of # bills Totals Interviews Per Bill Legislative Branch • Chairman, Florida Senate Health Policy 3 2 6 Committee • Ranking member, Florida House Health & Human Services Committee

Include two representatives and one senator, with at least one legislator from the minority party Lobbyists Professional • Testifying lobbyist representing payers 3 2 6 (Multi-client) • Lobbyist of record representing or providers In-House Executive Branch • Deputy chief of staff, Executive Office 2 2 4 of the Governor • Bureau chief, Florida Department of Health • Legislative director, Florida Department of Children and Families Constituencies • John A. Smith, Medicaid recipient from 2 2 4 (General Public/ Miami, testifying before committee Individual Stakeholders) • Sally Q. Jones, health policy director for state economic watchdog organization Totals 20

Out of 40 purposively selected contacts, 20 key informants agreed to participate. Some respondents were able to comment on both bills: Seven of the twelve individuals originally interviewed for the medical cannabis bill were able to provide additional feedback on the needle exchange bill. Four of the eight individuals originally interviewed for the needle exchange bill

provided additional feedback on the medical cannabis bill. This resulted in 16 key informants (12 original plus four crossovers) providing information on the medical cannabis bill and 15 key informants (eight original plus seven crossovers) providing information on the needle exchange bill.

Because of privacy concerns and the possible identification of key informants through their titles, I am unable to present respondents’ actual titles as in the examples listed in column 2 of Table 4. With this consideration in mind, I present generalized key informant data in Table 5 below.

Table 5. Description of the categories of key informants interviewed for each bill

Key Informant Category Medical Cannabis Needle Exchange Total (Original/Crossover) Total (Original/Crossover) (n=12/4) (n=8/7) Constituencies 6 (5/1) 4 (2/2) Executive Branch 2 (1/1) 3 (2/1) Legislators 5 (3/2) 6 (3/3) Lobbyists 3 (3/0) 2 (1/1)

Key Informant Category Medical Cannabis Needle Exchange Total (Original/Crossover) Total (Original/Crossover) Republican 8 (5/3) 9 (5/4) Democrat 7 (6/1) 6 (3/3) No Party Affiliation 1 (1/0) 0 (0/0)

IRB Approval

As this study involved human subjects, approval was sought from the University of North

Carolina at Chapel Hill’s Institutional Review Board (IRB). Approval was granted in September

2017, IRB # 17-2311.

Consent & Confidentiality

All participants in both the quantitative and qualitative research components gave consent before participation. The quantitative survey included a Click-to-Consent form before accessing

the survey. Identifying information was not collected or kept as data in any form. Otherwise, only a general self-identification into one of thirteen (13) stakeholder categories (e.g., state representative, executive branch employee, professional lobbyist, constituent) was asked of the participant. The broad groupings and large participant pool prevented the identification of individuals. Responses were captured in the aggregate through Qualtrics and printed for coding and analysis purposes without identifiers. Information was physically stored in a locked cabinet and electronically stored in password-protected files on a password-protected computer in my office. All materials will be destroyed at the conclusion of the study to further protect participants.

Qualitative interviews were conducted in person whenever possible, and otherwise via telephone. The consent forms for the interviews varied based on interview location: Those interviewed in person completed a paper consent form, all others gave consent orally.

Respondents were required to give permission for the interview to proceed and be recorded. I used a digital voice recorder with built-in USB drive to record the interview in a manner consistent with the IRB-approved informed consent and protocol. To maintain confidentiality of data in the interview component, each subject was given a numeric identifier so their specific comments could not be linked to the data. Immediately after each interview, the digitally recorded audio file was uploaded and saved on a password-protected computer in my office. The interview files were run through Dragon NaturallySpeaking Premium for transcription.

However, because the audio quality was low, I employed a professional transcription service that included a confidentiality agreement. I checked the accuracy of the transcriptions and adjusted errors by comparing them to the recordings. My handwritten notes, which did not include any identifying information, augmented the transcriptions.

Upon the completion of the study, all recordings, transcripts, and handwritten notes were destroyed to ensure information cannot be linked to any participants. Results were published in the aggregate. The only descriptors of key stakeholders included a general stakeholder category

(e.g., state representative, executive branch employee, lobbyist, or constituent). No names were kept or included to maintain confidentiality.

Interview Recording Procedures

Interviews were conducted from the spring of 2018 to the spring of 2019. They were conducted at a time and location of the interviewee’s preference. Checks for accuracy and completeness were conducted following each interview. Handwritten notes were scanned to

Adobe Acrobat (.pdf) format for electronic archiving and subsequently printed for a backup paper copy. In addition, the handwritten notes were integrated into and corroborated with the transcription for later use in MAXQDA data analysis.

Data Analysis Strategy

Quantitative Analysis

The online survey provided quantitative data. After tallying counts for each section, I reviewed the data and ranked the more influential and less influential factors for Part 1, and the more influential and less influential stakeholders for Part 2. The data were insufficient to categorically group or analyze data by influential stakeholder group, type of survey participant, or political affiliation.

Coding Guide

After checking and review of the interview transcript was completed, a content analysis to identify themes was used to create a themed coding guide. The Coding Guide was developed using literature review findings, survey results, and researcher preferences to improve

consistency in text unit coding. Appendix D and Appendix F formed the initial basis for such

Coding Guide.

Key Informant Interviews

Following professional transcription and review for errors, transcripts were processed in

MAXQDA201 and coded by paragraph according to the predetermined coding scheme in the

Coding Book (see Appendix G). The Code Book included 39 codes. All interviews were systematically coded and analyzed, with the interviewer’s handwritten notes referenced to cull out additional data. The open-ended questions in the online survey and interview phases were coded using identical codes. This allowed me to compare language phrasing and themes. Fill-in responses from the online survey and the key informant interview transcriptions were entered into MAXQDA software. I reviewed each interview and coded sections of text using the Coding

Guide.

To increase study reliability, a second coder was engaged to independently code key informant interview results, to assist in refining the codebook, and to confirm investigator coding until an acceptable level of interrater reliability was reached. The second coder coded five key informant interviews in MAXQDA, or 25% of the 20 total unique interviews. MAXQDA software was used to run statistical comparisons of researcher coding against the second coder’s coding. An interrater reliability kappa score of 0.75 was reached by the second coded document and a kappa score of 0.91 was reached by the fifth document. These kappa scores demonstrate a level of “substantial,” “very good,” or “excellent” interrater agreement.202, 203

CHAPTER 4: RESULTS

Summary of Qualtrics Survey Results

The Qualtrics surveys on factors influencing Florida legislation yielded low response rates that did not provide enough information for quantitative analysis. The medical cannabis bill survey was sent to 169 individuals (with active email addresses) associated with the bill, started by 14 of those individuals, and completed by 12 individuals (7.1% response rate). Among those who completed the survey, there was a question completion response rate of 79%. The needle exchange bill survey was sent to 164 individuals (with active email addresses) associated with the bill, started by 13 individuals, and completed by 12 individuals (7.3% response rate). Among those who completed the survey, there was a question completion response rate of 46%. Despite the lack of responses, information gathered from the survey was useful in informing questions for the key informant interviews. See Appendix E for survey result highlights.

Medical Cannabis

For the medical cannabis bill, survey-takers ranked the following items as more influential (“4” and “5” ratings combined) in the bill’s outcome: 1. persuasive health benefit arguments, 2. the amount of media attention, 3. sponsorship by the majority party, 4. a special interest group’s legislative testimony or direct discussions with legislators, 5. the amount of constituent support, and 6. the support of legislative leadership. They further ranked the following types of stakeholder groups as more influential (“4” and “5” ratings combined) in the bill’s outcome: 1. general public/individual stakeholder, 2. legislative leadership, 3. bill sponsor

(Senate), and 4. bill sponsor (state representative). Survey participants noted that legislative

relationships (member-to-member and family) and legislator influence were important in bill outcome. Several participants mentioned public testimony with children present and “heart- wrenching” pleas from parents that left legislators “soul searching” and voting it “to the next committee just to get it over with” were highly influential. A CNN story, a proposed constitutional amendment with the possibility that passage of the legislation would “reduce the interest of voters in the ballot measure,” and a “very conservative regulatory framework” for the bill were cited as other influential factors. One participant recommended that “the best way to get to someone” is to research “if the legislator has been personally affected or knows someone who has been personally affected.”

Needle Exchange

Participants in the needle exchange bill survey ranked the following items as more influential (“4” and “5” ratings combined) in the bill’s outcome: public education or grassroots mobilization campaign, the political power of a sponsoring legislator, the support of legislative leadership, professional lobbyist work, state agency support, governor’s office support, and persuasive health benefit arguments. They further ranked the following types of stakeholder groups as more influential (“4” and “5” ratings combined) in the bill’s outcome: state representative—committee chair, state agency, general public/individual stakeholder, governor’s office, bill sponsor (Senate), state senator—committee chair, bill sponsor (state representative), and legislative leadership. One participant noted that there was a “perception that government was condoning illegal drug abuse.”

Summary of Key Informant Interview Results

For the following section on key informant interview results, these descriptors have the following meanings: “few” means three to four persons, “some” means four to six persons,

“several” means seven to eight persons, “many” or “most” means nine or more persons, and

“nearly all” means all but one or two persons.

Medical Cannabis

The key informant interviews outlined several factors in the passage of the

Compassionate Medical Cannabis Act of 2014 (SB 1030), which sought to permit prescriptions of low-THC cannabis for patients with certain medical conditions such as intractable epilepsy and cancer. It would also amend Florida’s Controlled Substances Act to remove such prescription and usage from criminal penalty. It further required physician education, created a compassionate use registry and Office of Compassionate Use, and funded research on cannabidiol (CBD) and low-THC cannabis. The bill passed out of committees in both the House and Senate and passed both chambers after a last-minute amendment on the House floor. It was signed into law by Governor Rick Scott on June 16, 2014. (See Chapter 1 for additional information.)

In the medical cannabis case study, I first discuss what factors and unique confluence of events led to the opening of a window of opportunity for the bill. Then, I explore which persuasive arguments were used, and how grassroots and constituency advocacy efforts impacted the bill. Next, I move to a review of lobbyist involvement in the advocacy efforts. The impact of legislative perceptions and relationships is explored as well, followed by the influence of the executive branch. Finally, I recount what happened in the final hours of the legislative session through the perspective of the respondents.

Window of Opportunity: An Unlikely Perfect Storm

According to one respondent, “Lawmakers were looking at a perfect storm …” for consideration of a medical cannabis bill that included a unique confluence of events: a heated gubernatorial election, a simultaneous push to pass a constitutional amendment that was largely a

citizen-driven initiative, similar bills passed in other states, an influential CNN documentary, and emotionally moving family advocates.

The Sanjay Gupta Factor

Most respondents referenced a national news documentary as the unlikely genesis of SB

1030. In August 2013, Dr. Sanjay Gupta and CNN reported on medical cannabis in a nationally broadcast documentary that focused on sick children rather than adult patients.204 It was cited as greatly influencing a shift in public opinion in Florida and across the nation. “The Sanjay Gupta story brought it mainstream … we had sort of a tipping point in the nation.” Dr. Gupta’s changing view on medical cannabis “gave credibility to the discussion.” The CNN report shared the story of Charlotte Figi who benefited from a form of medical cannabis that had high- cannabidiol (CBD) and low tetrahydrocannabinol (low-THC) content. The Stanley Brothers, in

Colorado, developed Charlotte’s Web, a form of medical cannabis to help Charlotte Figi, and this was featured on the CNN report. This “American success story for kids” was helpful to politicians in an election year who worried they would be branded a “pot supporter” and passed over by more conservative Republicans in their districts. One respondent explained, “All of a sudden, kids were the best message for medical marijuana. I think that was a big deal influencing public opinion in Florida, across the country.”

According to respondents, people from Florida independently reached out to the Stanley

Brothers after coincidentally watching the same CNN story. Among these people were then-

Representative Matt Gaetz and a family, the Moseleys, in/near his district who had a child with intractable epilepsy. “The genesis of the bill really came from the constituents of Gaetz in the panhandle … Moseley … [their] daughter had severe epileptic seizures—dozens a day … [they]

had been to Colorado to find a THC chemist for [their] daughter and thought that Florida should have a bill.”

Joel Stanley of the Stanley Brothers put Representative Matt Gaetz in contact with the

Moseleys. Gaetz invited the Moseleys to work with him on his medical cannabis House bill, which evolved into the language passed in Senate Bill 1030. Many families shared their stories during a workshop in December 2013. Inspired by the momentum, some families hired lobbyists or even media consultants, while others formed or joined nonprofit organizations to help organize support. They traveled to Tallahassee before and during the session to meet with legislators.

The parent advocates were “very careful to explain the difference between CBD and

THC” and remind legislators that the bill was exclusively a CBD bill. Families were invited to speak at committee meetings. They “weren’t asking for recreational cannabis” or THC but “just asking for access to high-CBD oil.” The bill language contained a restriction to keeping THC below 0.8% and more than 10% CBD, which respondents agreed was “an easy starting point for people to consider, instead of just jumping right into a bigger bill.” Respondents commented that

“they found a sweet spot in the language of the bill … [medical cannabis] for a limited use, and for a very select group of people, and very low dosage form … a lot of smart political positioning.” With that step, “you’ve now broken the stigma … the camel will get his head under the tent … [soon] you’re going to have the whole camel inside the tent,” one respondent commented.

Momentum

Medical marijuana was the subject of widespread national and state lobbying efforts, which caused Florida legislators to consider keeping up with other states. Several respondents

stated that “it was time in Florida to pass the Cannabis Bill.” Another respondent noted, “They wanted to be proactive and to make sure that the state of Florida was ready.”

Despite this, respondents noted that it was important that Florida’s consideration arose

“from local concerns, not San Francisco … any reference to Colorado was seen as very negative—California, Colorado … bad places. We don’t want to be like … those wild-eyed hippies out there.” Also, some problems were noted in Colorado, making Florida legislators think they “should take this in small steps and not jump into it.” Florida legislators “did not want to have a pot shop on every corner.” As to reasons why SB 1030 passed, one respondent stated,

“The first obvious [reason] is just compassion … then they saw other states doing this … then there was the potential for growth in Florida.” Another respondent believed the bill’s momentum was:

a combination of political pressure from people that had seen the positive effect … People were moving to Colorado to seek treatment … also, since it was being widely accepted in many other states, I think because it was generating new revenues, it was lowering healthcare costs—pharmaceutical costs.

Persistence in a Conservative Government Environment

As discussed in Chapter 1, cannabis legislation had been attempted unsuccessfully in prior legislative sessions. According to several respondents, “the year before, nobody would have touched [cannabis] with a ten-foot pole. Then, all of a sudden, it went through the entire legislative process on its first try.” As one respondent stated, “For some people it’s going to be super controversial. It’s not going to be anybody’s priority. It will most likely die, but if they keep coming back for two, three, or four sessions, it will most likely pass.” One respondent commented that conservatives thought, “The crazy lefties have been talking about this for ten years now … maybe there’s actually something here we can latch on to.”

Political Timing of an Amendment in an Election Year

Political timing was “a huge factor” in the 2014 passage of medical cannabis. A referendum to legalize medical marijuana by constitutional amendment was placed on the

Florida General Election ballot in February 2014, just before the March start of the legislative session. Then-Democratic “super” attorney John Morgan and others pushed the referendum.

Morgan is a politically active attorney in Florida who founded the Morgan & Morgan law firm.

In 2014, former Governor Charlie Crist, a Republican-turned-Democrat, was employed by

Morgan & Morgan, a substantial contributor to his gubernatorial campaign against incumbent

Republican Governor Rick Scott that year. Most respondents believed that Morgan was bankrolling both Crist’s campaign and the constitutional amendment to increase Democratic voter turnout and regain Democratic control of Florida government. All respondents believed that the ballot initiative played a significant role in the passage of SB 1030. Several of these respondents suggested that the referendum was the key factor or the “number one factor” in the bill’s successful passage. One respondent stated, “It was the pressure of the constitutional amendment hanging out there … most likely the legislature probably wouldn’t have done anything if they didn’t think that there was a ballot amendment coming.”

Preemptive Strike

Many respondents viewed SB 1030 as a “preemptive strike” and a “strategic decision by the majority party to blunt the importance of the constitutional amendment,” which was “wide open” with language that permitted cannabis use for “10 different medical conditions, [with] no limits on THC.” A few respondents believed that SB 1030 was an attempt to confuse voters into thinking the medical marijuana issue had been addressed, and they did not have to vote on it again during the general election through the referendum. The Republican majority “saw the

writing on the wall that it was becoming a much more popular concept and so they acted on it.”

Many respondents surmised that Republican (majority) legislators “wanted to be ahead of the game, ahead of the curve, ahead of the amendment.” Many respondents explained that affected families were in favor of the bill. They also wanted “something going simultaneously with the amendment” because they were not willing to “put all [their] eggs in the basket of the voters at the time.”

The Crist Factor

According to a few respondents, the ballot initiative was about much more than medical cannabis. One respondent commented that the re-election was “inseparable” from the referendum as an issue. Governor Rick Scott, Republican incumbent, was running against former Governor

Charlie Crist who, while Republican during his governorship, was now running as a Democrat.

A few respondents commented that Republicans in 2014 were “absolutely terrified of having medical marijuana on the ballot” because it would motivate Democrats and unlikely voters to vote. “This was Rick Scott’s re-election. They were … terrified of the prospect of Charlie Crist being Governor.” As one respondent commented:

[Charlie Crist] was working for John Morgan, runs for Governor, runs as a Democrat. If you put a ballot initiative on for cannabis, you are going to increase the number of Democrat voters by a few percentages … it could be the thing that tips you over the scale in the gubernatorial race, which … was won by 50,000 votes.

There was also concern that “younger folks are going to turn out” and they would not be conservative. The “national mood had shifted in favor of medical cannabis … so you were starting to see the younger generation getting more politically engaged in the conversation. You had seen the legalization of it around the country.” According to a few respondents, Republicans believed there would be less interest and decreased turnout by Democratic voters if a medical

cannabis bill had already passed at the time of the election, because the issue would have been

“addressed.”

The Polling Factor

As one respondent explained, “Public opinion was growing in strength for legislation, whether it was statutory or constitutional.” Through a ballot initiative, California was the first state to legalize medical cannabis in 1996, and Colorado and Washington were the first states to legalize the use of recreational cannabis in 2012.205 Hawaii was the first state to legalize medical cannabis through the state legislature in 2000 and, by January 2014, 20 states and the District of

Columbia had approved the use of medical cannabis. 206

Public opinion and polling research in the election year played a role, and polls prior to the 2014 legislative session showed that most Floridians polled supported medical marijuana.207

None of the polls showed support below 60%, the threshold for referendum passage in Florida.

“Public opinion was strong. Different polls put it in the 80s, some in the 60s.” One respondent explained that legislators had a “[S]ense of … this thing … polling so high. If I’m on the wrong side of this, I’m on the wrong side of history.” A few respondents believed that “the Republican party had to get out in front of this issue and show some progress on it, otherwise it wasn’t going to end well for them.”

Legislators had “noticed through many town hall meetings and especially with constituents that they wanted medical marijuana to be an option.” One respondent noted, “The hardworking taxpayers that I represented wanted access … [and] they saw cannabis as a product

… as a medical solution to address a variety of different issues and it was time for Florida to have a policy on that.”

Persuasive Arguments: Health Considerations, Economic Considerations, and Research

Arguments against medical cannabis included addiction issues and use of marijuana as a gateway drug. Some respondents explained that there was also legislative concern regarding the use of painkillers. Some legislators had a “hard stand on unlawful drugs including marijuana as a gateway drug … [it] caught some opposition, particularly among Republicans.”

Most respondents said that educating legislators on the bill topic was essential because there was “90 years-worth of misinformation.” For example, respondents claimed that at the start of the legislative session, there was widespread misunderstanding among legislators regarding the difference between medical marijuana and marijuana that people use to get high.

Strategy turned toward educating legislators that medical cannabis was less harmful than alternative therapies and could lead to reduced use of prescription medications. A couple of respondents commented that legislators began supporting the bill when they learned that medical cannabis “is a benign therapy with minimal side effects … if there are side effects, they are positive … increased appetite or things like that.”

However, it was the specific highlighting of ill children that was cited by all respondents as a key reason the 2014 medical cannabis bill was viewed differently than prior legislative attempts. One respondent stated, “It wouldn’t have started without the families. It wouldn’t have gotten the traction early on without … the recognition … that it really helps really sick kids.”

Parent advocates and organizations enlisted the assistance of a medical consultant to explain that a child with intractable epilepsy may need a strong medication like clonazepam

(Klonopin) daily, which has “a huge warning label that lists side effects and that the long-term effects are unknown.” In addition, parents reported stories of physicians suggesting that the parents “cut [the child’s] brain in half” and “say [their] goodbyes” to their children. In contrast,

“all parents want to do is just try a CBD oil that would not get [the child] high.” This was a

persuasive argument for many legislators. Having “access to something that’s way less harmful” in Florida seemed a reasonable option.

The medical cannabis in the bill would not be smoked, which was “really important to so many of our lawmakers … [who] would have been doing anti-smoking campaigns for … many decades.” As it was low-THC, it was low euphoria, which was “definitely a selling point” for lawmakers.

Although the 2014 bill “started out by focusing on kids with intractable epilepsy” as the main purpose, the constituency for medical cannabis expanded. A few respondents noted that patients with cancer were also helpful in engaging and garnering support from legislators who would not normally support any medical cannabis use.

Additionally, as one respondent noted:

[P]eople realized that it might be good economically, not necessarily to raise more taxes, but to lower the cost of the pharmaceuticals—the Medicaid issues—because Medicaid is a large portion of the budget. And a lot of that is the drug costs.

Several respondents commented on the lack of evidence-based studies and medical research at the time. “Because there is so little medical research and mobilized evidence, the only thing that really is compelling are the anecdotal stories from people for whom it makes a huge difference.” The bill attempted to address the paucity of research with a $1 million allocation to

Florida-based research on the use of CBD oil for patients with epilepsy. The “educational component was a big selling point with Republicans” who liked the idea of studying the efficacy of medical cannabis. One respondent commented that “sensible policy” would:

Start with a small subset of patients, spend some money on some research. We’re talking about public policy, right? What’s good public policy? Do a small, limited program; do it for a subset of patients; watch it carefully; invest some money and follow the research; expand the program as you see viability and positive results—and, ideally, in the clinical setting, if not in third-party, double-blinds, placebo. If you can’t get that, at least you can get clinical results.

Grassroots Work & Constituents as Powerful Advocates

When ranking influential factors in the bill passage, on respondent stated, “a lot of people say the Constitutional amendment was the top thing that motivated them, but ... I think it was three years of grass-roots advocacy—an idea has to take time to percolate,” referencing the years leading up to the introduction of SB 1030. “We had used a lot of grassroots tactics to push public opinion—including professional advocacy campaigns,” which included the use of a program that allows advocates to send pre-written letters to lawmakers. Parents were traveling to Tallahassee with their children and staying for the legislative session, “maybe 10 or 12, the core group” who essentially “put everything on hold to become lobbyists.” One respondent described the environment:

Moms and dads [were] coming up every day, walking the halls. Moms from Pensacola, moms from Jacksonville, moms from Tampa, moms from Gainesville, moms from South Florida—and moms and dads, and aunts and uncles. And the patient groups had seen that on Sanjay Gupta, and they were talking. And we had … Facebook …

Mothers of children with medical conditions who could benefit from medical cannabis worked together as a driving force in advocacy. Many respondents spoke of the passion and persistence of the “mama bears” with testimony “pulling on heart strings.” The mother advocates

“got more organized as they progressed,” forming a still-active group called the “canna-moms.”

Several respondents noted that parent advocates made it a point to “bring lots of families” to committee meetings so legislators would understand “these were kids in the state of Florida who could really benefit from this.”

Bringing people from multiple districts to meet with their representatives, in combination with emails and phone calls, was an effective strategy. All respondents commented that personal stories shared by families—particularly stories regarding suffering children—ranked among the top three factors influencing the passage of SB1030. “Politics and sick kids were one and two,”

one respondent stated. Several respondents shared the view. Legislators had “families sitting in their offices in tears, desperate for their kids or themselves to be able to access medical marijuana … that played an enormous part in it.” Most respondents claimed that the most persuasive argument was bringing in actual people with serious illness, “not just numbers,” and allowing legislators to see their suffering.

All respondents characterized the testimonies of parents as “heartbreaking,” “heart- wrenching,” or “hard to ignore.” Mothers testified in legislative committee hearings about how they had exhausted all prescription medication options to help treat their children. A few respondents recalled in detail the testimony of a mother that “the suffering of her child had gotten so bad, every night she prayed to God for God to take her child.” One respondent recalled a father with a special needs child testifying, “almost in tears, [he would] chastise and challenge these legislators” saying that he had “broken the law to save [his] son. Put me in jail if you want.

But that’s what I had to do.”

A few respondents recalled stories of families who considered moving from Florida to

Colorado to gain access to Charlotte’s Web. They recalled commentary that families “shouldn’t have to move” out of state to access medical cannabis. That Florida families would leave without in-state access was a significant concern for lawmakers.

Parent advocates were permitted to distribute photos of children during the committee meetings with the intent of wanting legislators to “feel like it was their [child] so they would be fighting … just as hard” as the parents. As one respondent described, “it was the human element thing, first and foremost … there were very compelling videos of almost instantaneous responses for seizure activity. If that’s not compelling, I don’t know what is.”

These stories “resonated” with legislators, who could “absolutely identify” with the public testimony across various medical issues, according to several respondents. “Republican senators and representatives and their communities … could identify with … rural, suburban, well-educated families with kids who were having seizures.” The testimonies evoked “personal emotional issues,” and as one respondent noted, “All of us have somebody in our family who has died of cancer … Politics is all about the framing of it.” Another respondent stated, “We all have our stories. If you have a family, you’re going to have somebody you love that has a condition or a situation if you’re around long enough” that could benefit from medical cannabis.

Professional Lobbyists and Varying Cannabis Interests

Most respondents did not recall the influence of professional lobbyists for or against the bill. Several respondents (inclusive of lobbyists) thought that the bill likely would have passed without professional lobbying. This was, in part, because few professional lobbyists were being paid to lobby on the issue at the beginning of the session. Many respondents noted that one known health lobbyist “ended up getting up and speaking at every meeting” but may have been acting “in a personal capacity” because he had recently lost a child to cancer. A few respondents commented that “none of the other [well-known] lobbyists were really terribly involved with this first [2014] bill.” A couple of respondents stated that a few known lobbyists quietly worked pro bono behind the scenes because of personal connections with the topic. One respondent noted that two influential lobbyists were “given money to keep an eye on the program” and “were certainly working in the background.”

Generally, only toward the end of the legislative session or after passage of SB 1030 did professional lobbyists get involved to shape related public safety and business polices. One respondent believed lobbyists were “probably 35% to 40% responsible” for getting SB 1030 to the finish line, incentivized by the “amount of money that they might be paid in the future by the

applicants who were successful in getting licenses” in Florida, the “third largest populace [sic] state.” Lobbyists and businesses watched legislation closely, and out-of-state parties contacted

Florida lobbyists. (See Final Hours of Legislative Session within this Section for more information.)

“Most of the time … lobbyists can wield [influence] if they care enough to … if not to get it passed, to get it nuanced.” One respondent described the professional lobbyists covering medical cannabis as generally falling into one of three categories: those wanting access to medical cannabis only for their clients to financially profit; those that just wanted access; and a

“third group of lobbyists that wanted smokables and expanded disease states.”

Professional lobbyists wanted access to medical cannabis, but they wanted it for just their clients to sell … for the ones that had clients that wanted to get into the business and be licensees. Their goal was to limit the amount [sic] of licenses available in the state … so that the capital required to get into the business would be astronomical, and so that most people would stay out of it.” One respondent commented, “There was probably a lot more going on behind the scenes … that thing evolved from an affirmative defense to possess cannabis … [to] this convoluted, politically integrated system where … they have a monopoly.

Among those just wanting access, patients were “hiring people to advocate for patient needs and patient care.” A few respondents noted that “the Epilepsy Foundation, pediatric physicians, psychologists … [and] others were very supportive.” There were also “political characters like John Morgan, who just wanted more access … in general.” However, some wanted to address additional health conditions, such as post-traumatic stress disorder, in the bill.

Parent advocates were approached by those who wanted full legalization of cannabis, but strategically did not expand the scope of their advocacy because the limited bill “was already a big ask” in “such a conservative state.” One respondent stated that “decriminalization … was discussed, but it wasn’t part of this. This was a medical healthcare issue.”

A few respondents commented that factions developed, which made it “difficult to compromise” among “hardline, anti-drug groups” that thought a bill would go too far, and pro- marijuana groups that wanted “something more extensive than Charlotte’s web, so they were not particularly excited about it” as the bill did not go far enough in their opinions.

A few respondents noted that a handful of groups, such as Drug-Free America, vocally opposed the bill. They argued that cannabis was “a gateway drug.” Other groups appeared to initially oppose the bill, then support the bill by the end of the session. For example, while the

Florida Medical Association (FMA) initially opposed the bill, it ended up supporting it after bill language was added to include eight hours of continuing education for physicians. Respondents were mixed on whether the law enforcement groups were initially supporters or opponents.

However, everyone agreed that they were on board or neutral at the end. Florida Cannabis

Action Network, Moffitt Cancer Center, University of Florida, the Medical Marijuana Growers

Association, and the Stanley Brothers were mentioned as other supportive stakeholders.

Legislative Motivation and Perception

Respondents had varying opinions on what personally motivated legislators to pass the

2014 medical cannabis bill. One respondent stated:

Honestly, different factors for different issues affect different lawmakers in different ways. So, there were some who were truly, I believe, concerned, with the well-being and the possibility of medical marijuana helping, for instance—patients with epilepsy and ALS and other things. And then there were legislators who looked at it as though it could potentially be a new source of revenue. I mean, different legislators, I think, had different takes on it. And then of course, there were those who were adamantly opposed.

Another respondent commented that, with legislators:

The first question is, is this going to make me look good? Second question is, is this going to help the people who are financially supporting me? Third, is it good public policy? … They are not looking to hurt people … but improving the lives of the state of Florida is not necessarily the top priority, unfortunately.

Legislative Relationships and Power

Relationships drive the process. I’m sure there were relationships specifically to people that helped facilitate the conversations, and that ultimately helped the outcome. No doubt about that.

A few respondents noted that several legislators shared stories of family members who had suffered without access to medical cannabis. There were many “powerful stories” and “a lot of anecdotal comments made by legislators both in private … in committee, and on the floor.”

Other respondents noted, “Legislators had loved ones that would benefit from this.” One respondent noted, “Once it hit the papers and the news and all over the state, people would say,

‘There was no reason to tell you before, but now, yes, this is important because my cousin Fred has PTSD.’” One respondent remarked that:

People who are advocating certainly look for decision-makers who might have family affected. I’ve done that my whole career. And sometimes they want to ignore it to make it look as though they’re there not for parochial reasons, but for reasons of helping an entire constituency on everything. And I understand that.

A couple of respondents recounted surprise that Representative Charles Van Zant (R-

Keystone Heights), a Christian conservative known for praying during his in-office meetings, had ended up supporting the bill. Other respondents explained that Van Zant had recently watched a loved one suffer and “didn’t want that” for the parents and children he met, coming the conclusion that using such a product was “in the Bible” and that “there’s plants God has put here for us to cure us” after doing his own research.

Personal passions for medical cannabis extended beyond family members. One respondent recalled a story of Senate President Don Gaetz:

Don Gaetz was quoted in the Orlando Sentinel—in the midst of that legislative session … Don Gaetz admits to a reporter that when he was working for the hospice, that he procured cannabis illegally for a priest that he knew who was dying of cancer—and that he gave it to him.

Most respondents noted that the medical cannabis bill involved a unique overlap of family relationship and member-to-member relationships in that Senate bills sponsors Rob

Bradley and Aaron Bean were brothers-in-law, and House bill sponsor Matt Gaetz was the son of

Senate President Don Gaetz.

The Senate sponsors, Aaron Bean, Rob Bradley, and Jeff Brandes, were collectively referenced by several respondents as “The Three Bs” who made “a pretty powerful team.” A couple of respondents believed that Bean was lending additional support to his brother-in-law,

Bradley, by signing on to sponsorship. A couple of respondents commented that Bradley and

Bean supported each other’s legislative efforts as brothers-in-law and stated, “they’re close. and they work together on several issues … they look after each other. They’re family.”

Some respondents said that having Matt Gaetz on board “allowed him to reach across the chamber and get his dad on board,” and that the Senate president’s support seemed to be “a personal favor.” One person thought it was possible that the bill may not have passed if Don

Gaetz had not been Senate president at the time. A couple of respondents mentioned that Matt

Gaetz may have had additional compassion for persons with chronic illnesses and disabilities because his “mom is in a wheelchair.”

However, some respondents believe that it was Don Gaetz’s wife, Vicky Gaetz, rather than son Matt Gaetz, who secured Senate President Don Gaetz’s support. A couple of respondents stated that “the way to get to the Senate President is through Mrs. Gaetz,” and a few respondents recalled that parent advocates had met with Vicky Gaetz. One respondent recalled that Mrs. Gaetz then reached out to other Senate spouses to rally support and “keep their husbands accountable.”

In addition, many respondents noted that they heard “that a couple of the licensees had ties to legislators, either in the family or close relationships, maybe business relationships.”

Legislative Leadership Support

According to respondents, the support of legislative leadership is critical for the passage of Florida legislation. One respondent noted that it was “probably more of a function of leadership’s decision to decide what final product came to the floor.” “In a legislative session, particularly in a legislative session in an election year, if you’re not somebody in leadership’s number one priority, you ain’t going anywhere,” explained one respondent.

One respondent believed there was a “last minute deal” in which Senate President Don

Gaetz “made it one of his last big negotiating chips … in negotiations between the House and the

Senate over their priorities. It was pushed through as a result of both political will and the exercise of political will power.” Another respondent noted that medical cannabis was prioritized as a “top 10 issue for the Senate” in general, and for the Democratic caucus, in particular.

Legislative Staff Support

Many respondents did not recall staff as “having too much influence over the final product” except, perhaps, in drafting the bill or legislative analysis. “There’s a varying spectrum of influence from the staff on legislation … on this particular issue … more on the not influential side.” Another respondent noted, “I’ll say that we passed it despite staff.” This may have been because use of medical cannabis was still illegal. “In all fairness to [legislative staff] position[s], it’s still federally illegal,” which makes the choice of selectively ignoring a rule of law “a slippery slope.” Staff in the House, the more conservative body, tended to be more skeptical.

They were suspicious of the medical value as there were “no double-blind studies and nothing was proven.” While, in general, legislative staff members were not directly involved, some

respondents praised Senator Bradley’s staff as doing a lot of work on the bill and working well with the parent advocates. A couple of respondents explained that legislative aides for the sponsors were “actively involved, but the staff directors for the respective health care committees varied.”

Sponsoring Legislator’s Power, Influence, and Conservatism

According to several respondents, the medical cannabis bill was “a bipartisan effort on the House side by both Matt Gaetz and Katie Edwards.” One respondent commented, “You had such a weird marriage between bill sponsors. Matt Gaetz was hard-core Republican, yet Katie

Edwards was Democrat.” The bill garnered “more broad support from both sides because of that.”

A few respondents viewed Matt Gaetz as a visionary medical cannabis reformer who prominently promoted the issue. One respondent remarked, “Gaetz saw this coming … it was something that he knew … although I believe he’s very sincere in his efforts, he’s also smart.

This is something he could latch on to.” Respondents commented, “Nobody could have run the

House bill better than Matt did.” Another respondent stated:

Timing-wise, I think we just had the right voice. I think Matt Gaetz was one of the people who not only was in the right party at the right time, but also had influence in the other branch—being as his father was the Senate President … It was a combination of all of those things … plus we had bipartisan support with Katie Edwards.”

Success factors noted by respondents included that most bill sponsors were “very credible and conservative” and there were “other … red states doing this.” “To their credit, and to Gaetz probably more so, they decided to forge ahead with it and wholly under … a seriously conservative framework.” Respondents explained that “physicians had to go through an eight- hour course” and patient registration concerns were addressed so it “wasn’t going to be sold on the street corner and wasn’t going to be a gateway drug.”

In addition, Gaetz was also able to show that there were already legal products with THC available in the markets. At a first committee meeting, a couple of respondents recalled, Gaetz had the Florida Sheriffs Association test products that his staffers had procured at a “Whole

Foods type” store. They brought items such as “hemp lotion, hemp milk, and some other type of hemp product” for testing.

Two of the three came back positive for THC. [Gaetz] says ‘there are products in the store that have already tested positive for THC. We’re already offering this without knowing it. Why can’t we do this for kids who need it? Why can’t we get the oil here for kids who need it?’

A few respondents thought family testimonies provided conservative legislators with

“political cover … how can [they] say no to a kid who has these kids of seizures.” According to one respondent, conservatives “edged into this slowly and looked around to make sure that everyone was holding hands moving forward so they couldn’t be singled out necessarily.”

“It was an extremely popular piece of legislation because it had really opened up the door for a dialogue on the topic, which had never happened before.” Interested parties, such as

“Florida Cannabis Action Network [that] had been advocating for years in the desert” suddenly found that others were “all for it.” The bill was viewed as a “tipping point” to allow for discussion of both the “medical benefits as well as community standards.”

“In the Florida legislature, it is difficult for a Democrat to sponsor a bill and have it go anywhere.” Edwards was said to “sign on” to this bill after unsuccessful prior attempts to get a larger cannabis bill passed. A couple of respondents noted that Edwards took the time to “put together a huge binder … of the research articles … and passed it out to every single staff member, every single representative and senator.”

Other non-sponsoring legislators also played memorable roles according to respondents.

For example, Van Zant, known for being religious and conservative, changed his opinion and

supported medical cannabis. One respondent recalled Van Zant’s statement, repeating from recollection:

Well, when I was a young man, I went to seminary, and my first parish was up in the hills of Kentucky. And there in the hills and the hollers traveling along the riverbed, there was hemp. And back in World War II they used that hemp oil to oil their guns. And that hemp oil saved lives in World War II. And, well, it looks to me like that hemp oil’s going to save lives again.

Opponents were generally concerned that this bill would turn into a broader exemption for recreational marijuana use, would be a “slippery slope,” and that it would lead to greater drug use. However, the bill was narrowly drawn, and the focus on sick children made it difficult for opponents to defeat the bill.

Executive Branch Opposition

Interestingly, the executive branch was not seen as a supporter of this legislation. Almost all respondents noted that the state surgeon general was not in favor of the medical cannabis bill, presumably because of the use of recreational cannabis as a gateway drug. “Dr. [John]

Armstrong was no fan of any medical marijuana options regardless of what they were.” A few respondents recalled that the state surgeon general “actually came out and testified against the cannabis bill [in legislative committee meetings].”

Most respondents stated that Governor Scott was “not supportive” and “not a big fan of this [cannabis bill].” One respondent remarked that, “The Governor probably could have made it a little easier. He had a couple of opportunities to jump in and support and opted not to.” Another respondent stated that “[the legislature] made it veto-proof, and he had no choice but to be supportive.”

Final Hours: Last-Minute Push and Surprise Influence

Nearly all of the respondents did not believe the SB 1030 would pass in the 2014 legislative session. One interviewee explained, “ … it was a zero-hour passage. There were many

points where it was dead, or passage was far from assured. It was a pretty big surprise … when it finally did pass.” As one respondent described:

This was an atypical kind of bill getting to the finish line. It didn’t have the campaign donations tied to it that other bills might occasionally have … didn’t really have two sides fighting over an issue. You had history against you, and then you had sympathy with sick children.

Toward the end of the session, “it became more of an industry battle.” When proponents realized the bill would pass, it was “time to make sure that this farmer gets something or that farmer gets something,” and lobbyists helped “steer the way that the licensing went for the growers.” One respondent noted that “money certainly helped them over the finish line, when people knew there was a big windfall coming.” Big business had a strong incentive as “state economists estimated it would be worth $5 billion” with approximately 444,000 probable medical cannabis users. Some businesses, according to a couple of respondents, operated under the premise that medical cannabis (and even recreational cannabis) use would eventually gain approval and, therefore, they “wanted to get a license and hang on to it because inevitably John

Morgan is going to win.” The lingering questions were “who gets a license, the number of licenses, and restrictions.”

A few respondents reasoned that legislators specifically “didn’t want marijuana companies from outside of the state to come in and totally make the system out of their control.”

One respondent stated, “Basically, that was when the growers realized that they could have the upper hand here. That’s why you saw the nursery association get engaged.” “All these other little interests started becoming involved. They started seeing that it can be successful for Florida’s businessmen.”

As a result, in the last couple of days of the session, an amendment was made to SB 1030 that almost all respondents felt “came out of nowhere.” A respondent explained that as a proxy

for being a Florida business, “the Nurserymen’s association added language that said in order to be eligible for the license.” Requirements were an existing valid Florida certificate of registration issued for the cultivation of more than 400,000 plants, operation by a nursery grower as defined in statute, and operation as a registered nursery for at least 30 consecutive years. Only five dispensing organizations were permitted: one each in central, northwest, northeast, southeast, and southwest Florida. These five organizations were required to be vertically integrated and, therefore, could only sell products they grew themselves. Vertical integration required the five permitted dispensing organizations to be accountable for all supply chain processes from raw material (cultivation) to finished product (retail) without the option of outsourcing portions of the process and to sell only what they grow. According to several respondents, professional lobbyists

“were able to limit the amount of people that could actually get the business,” to “keep it being vertically integrated,” and to “create the cartel-style system that we have today.”

Most respondents commented that the vertical integration amendment remained a

“mystery” almost five years later and could not surmise the source behind the “last-minute amendment.” However, a couple of respondents believed that vertical integration “was put in by the nursery association at the behest of the Speaker.”

Horse-Trading

While respondents thought the general policy of medical marijuana was good, several shared a sentiment that “the way that Florida chose to implement it was the absolute worst way we could have done it in the country.” The legislation “restricted access.” It created a “cartel” and “divided up the market into the north region, the middle region, and the south region.” With the vertical integration requirement, one licensee could not sell product to another, and “if you don’t get one of the first five licenses, you never get a license.”

As one respondent explained, “Nobody really thought that it was a good piece of legislation … but it was better to have something on the books.” The Florida Senate was faced with a decision:

You have a question on day 58 … or day 59 of a 60-day session. Do you take a deal that’s on the table with a crappy provision that only restricts it to five, or do you wait another year and send it back without that? And so, the decision was made to just take it.

As one respondent remarked, “Even if you came up with a bill that wasn’t very good, you at least had some pathway for medical cannabis, and that was the kind of first step of the legislation. And while it is by no means perfect, at least it’s not prohibition.” A few respondents noted that they are “often willing to support bills that make some positive improvement even if they don’t go as far as [they] think they should in a given policy just to get an incremental change happening.”

Post-Passage

The immediate aftermath of SB 1030’s passage provides additional insights. The passage of SB 1030 was viewed by almost all respondents as the Florida Legislature being “out there saying marijuana is medicine.” Bill passage was viewed as “an excellent first step” even though

“it wasn’t perfect.”

One respondent commented, “Our thesis was correct … we needed to put forth legislation that supported [medical cannabis]. But frankly, as the public was telling us, we didn’t go far enough.” Another respondent noted, “We’ve seen since, with the constitutional amendment, where 72% of the voters came out and supported increased access to medical cannabis.”

Lobbyists and parent advocates saw business opportunities following the bill’s passage.

One respondent commented on a parent advocate turned businessperson, “at the end of the day

[they] thought they could get in this business too and it would translate into them being recognized a leader in the industry, which to some extent, they were.” Respondents described the

lengthy rule promulgation process for SB 1030, which included discussions about smokables, edibles, patches, compliance cameras, and the use of organic versus inorganic fertilizer with information provided in person by the Stanley Brothers and the mother of Charlotte Figi. One respondent described the situation:

There were only 72 growers that had been in business for 30 years, that had over 400,000 plants—that qualified. And so they were being bombarded by people who were licensed in other states, that understood the process from seed to sale, because that was part of the rules—it was from seed to sale—and a vertical integration system where only one company—or one entity—is involved in the growing, in the processing—the compliance, the processing, the extraction of the oils, the production of the products, the distribution, through the retail and through delivery. It was a very long arduous process. …

Qualifying nursery growers were inundated with offers to buy. Many respondents commented that the vertical integration system was not working, “It was a mess … the

Department of Health is still trying to implement that thing.” As SB 1030 and subsequent bill iterations moved through the regulatory and legislative processes, more business-type organizations were formed that leveraged funders, growers, and 30-year nursery licensees. One respondent commented, “When you see license holders selling their license for millions and millions of dollars but have never grown a plant of marijuana, they simply own the licensee, you see how corrupt the system is.” Most respondents knew of people who were “really in it to help people, not to make money.” However, that was not the case for all new investors. One respondent cut business ties after receiving feedback that:

This is not about helping people … This is about getting a license and 10 years later, or 5 years later, or whenever, the Feds remove this Schedule 1 status, the pharmaceuticals are going to come in here and pay the half a billion—half a billion dollars for this license. So that’s what this is about—this is about money. [If] you think this is about anything else but money, you’re fooling yourself.

Another respondent commented, “At this point, medical marijuana is not about public policy, it’s about profitability and feasibility of the drug product.”

Brief Summary of Respondent-Generated Key Factors

In the medical marijuana case study, based on respondent statements, the most important factors influencing the outcome of the bill (passage) appeared to be: compelling stories of children suffering, threat of a constitutional amendment, consistent and impassioned advocacy of affected families, member-to-member relationships, strong sponsors, the support of legislative leadership, and the likelihood of financial profit.

Needle and Syringe Exchange

The Infectious Disease Elimination Act of 2014 (“IDEA”) (SB 408) was more frequently referred to as the “Needle Exchange Bill for Miami-Dade County” or simply the “Needle

Exchange Bill” among legislators. This legislation sought to create a five-year pilot program in

Miami-Dade to exchange dirty needles for clean needles and to decriminalize the possession of syringes. The bill passed out of committees in both the House and Senate and passed off the floors of both the House and Senate, only to die in return messages to the Senate. (See Chapter 1 for a more complete description.)

In the needle exchange case study, I first discuss what factors led to the opening of a window of opportunity for the bill. Then, I explore which persuasive arguments were useful, and how grassroots and constituent advocacy efforts impacted the bill. Next, I review the impact of legislative perceptions and relationships on the bill. In addition, I discuss respondents’ perspectives of how the state health agency influenced legislative perception. Finally, I recount what respondents believed were the hidden reasons why the bill ultimately failed to pass in 2014.

Window of Opportunity

While respondent reports varied greatly as to when a needle exchange bill was first considered by the state legislature, most key informants spoke of persistence in advocacy efforts

and newly publicized research as positively impacting IDEA’s progress through the legislative process in 2014.

Most respondents referred to the needle and syringe exchange bill as being in its first year of consideration. Two respondents spoke of 2013 rather than 2014 as the first year the needle exchange bill appeared, sponsored by Gwen Margolis in the Senate, and Mark Pafford in the

House. However, one respondent who had witnessed many years of legislative sessions explained that variously worded needle and syringe exchange bills had been brought unsuccessfully before previous legislatures from seven to 10 times during the 1990s and 2000s, coming close to passage on more than one occasion. Among the state reasons that prior bill attempts failed: opposition by Governor Jeb Bush’s drug “czar,” Colonel Jim McDonough, concern by law enforcement that officers would be stuck with needles as they frisked people, and concern that the exchange would lead to increased heroin use. In addition, lessons from prior bill attempts, including “buzz words and the do’s and don’ts,” counterarguments to concerns, and extensive literature, were shared with University of Miami medical students who led grassroots

IDEA advocacy efforts during the 2014 legislative session.

By 2012, Hansel Tookes, then a University of Miami medical student, had conducted research comparing the number of discarded syringes on the streets of Miami in comparison to

San Francisco and interviewing persons who inject drugs. The Miami Herald featured his research on the front page. With the support of the University of Miami and the medical student section of the Florida Medical Association (FMA), the exchange concept was brought before the

FMA Board of Governors and then brought as a resolution to the House of Delegates. While there was concern and opposition, the resolution passed, and FMA actively supported bringing a bill in the 2013 legislation session and thereafter. FMA Chief Executive Officer Tim Stapleton

was noted as helping Tookes reach out to the legislature and narrowing the focus of the bill to

Miami-Dade initially.208 In 2013, the Florida Sheriffs Association opposed the bill. Miami’s state attorney209 who facilitated an introduction between the medical students and the Florida Police

Chiefs Association, was willing not to prosecute people for possession of drug paraphernalia.

The combination of state attorney support and limiting the bill to Miami-Dade encouraged

Miami law enforcement and the Sheriffs Association to support the bill in 2014.

Persuasive Arguments: Health Benefits, Economic Benefits, and Bipartisan Support

Many respondents explained that the bill was viewed as being good for health in that it could reduce or prevent HIV/AIDS, hepatitis, and other infections. IDEA allowed dirty needles and syringes to be returned in exchange for clean needles and syringes. Respondents reported that clean exchange could not only safeguard drug users from infections, but it could reduce the number of dirty needles “just laying around.” Children and families were perceived at risk for encountering dirty needles in public locations such as beaches and parks. A few respondents viewed the bill as an opportunity to clean up public areas and create a healthier environment.

In addition, a few respondents noted that advocates and bill sponsors argued that many in the drug-using population could not afford health care, leaving the cost of providing medical care for conditions such as HIV/AIDS to the state. By preventing HIV infections alone, it would reduce the health costs to the state and the taxpayer by more than $120 million. A couple of respondents viewed the bill as a chance to reduce health disparities across ethnicity and/or income in Miami-Dade, where the population is greater than 18% black/African American population and greater than 65% Hispanic/Latino. One respondent commented that legislative support was influenced by a “strong desire to sponsor legislation that had a known track record for improving public health.”

However, one respondent commented that it was a mistake for advocates to push needle/syringe access without concretely tying the issue to substance abuse treatment. As a standalone issue, it could more easily fail: “There’s a saying in Tallahassee, ‘if you stand up by yourself, you get shot.’” Other respondents provided a slightly different perspective. They noted that “perception was everything.” The needle/syringe exchange program in fact provided a breadth of additional services addressing treatment concerns. “There were just true misunderstandings about what a needle exchange really is about.” These respondents cited data- driven arguments backed by studies showing that locations (e.g., San Francisco) with existing needle or syringe exchange programs had a notable reduction in new cases of infectious disease such as HIV/AIDS and hepatitis among the injection drug-using population. They also noted that the exchange presented opportunities to connect injection drug users with services otherwise challenging to access, including basic health care, counseling, and drug treatment referrals.

Various health facilities such as hospitals, health clinics, and substance abuse programs would operate the exchange program.

As the legislative session progressed, several respondents recalled, needle and syringe exchange came to be viewed as a universal, nonpartisan issue. Some respondents attributed this viewpoint to the information provided by Tookes (a fourth-year medical student in 2014), while other respondents attributed it to Senate sponsor Oscar Braynon’s ability to gain support across party lines. One respondent noted, “When someone is infected or impacted by HIV or AIDS, it doesn’t see party registration, it doesn’t see zip code.” Another respondent noted that the needle and syringe exchange was important and timely as the opioid epidemic was escalating, and people were moving from pills to needles.

However, a few respondents recalled that the bill was an easier sell to legislators representing constituencies that did not have similar drug-related concerns (e.g., rural counties) because it was viewed as a Miami-Dade bill and limited to a pilot, “Miami was the only way to get it done … A lot of [legislators] viewed [it] as a foreign country.” In effect, it was considered by many to be a local bill with a universally appealing objective that allowed members to support both the Miami-Dade delegation and realize health benefits for a specific population. In addition, respondents noted that limiting the bill to a pilot allowed hesitant legislators to proceed more confidently. If the pilot failed, little harm was done, and if the pilot succeeded, the legislature would be credited for passing a good bill that could be replicated across the state.

A couple of other respondents suggested that the strategic decisions to limit the scope of the bill, including focusing on one county, designing the model as a five-year ‘pilot,’ ensuring no state dollars were used, and including an evaluation aided in appeasing concerns and helping the bill progress toward final passage, despite its ultimate failure to pass. “You couldn’t get the whole piece. You got as much as you can. And guess what you do? You come back in subsequent years and try to make your bill better.”

Grassroots and Constituent Advocacy Work Drives Bill

All respondents viewed Tookes as the main non-legislator, non-lobbyist advocate for

IDEA. Tookes traveled regularly to Tallahassee during the session to meet with legislators and executive branch members to educate them and provide testimony on the benefits of IDEA. He presented patient stories and pictures of impacted individuals and drug paraphernalia in public places such as neighborhood playgrounds.

Several respondents noted that Tookes was “relentless,” “polished,” and “persistent,” building a network of contacts, texting and calling legislators, and stopping by legislative offices to explain “all the science” and answer questions. Once Tookes had a legislator’s buy-in, he

would ask the legislator to introduce him to yet another legislator or even ask the legislator to speak to other legislators and explain the bill’s importance. “He used the network that he had built but then got that network to go and talk to other people and other legislators that might not know anything about the bill.” A couple of respondents commented that Tookes’s youthful appearance and student status were suggestive of younger voter/constituent support to legislators.

This allowed his message to be better received than if a more experienced medical doctor had delivered it. The bill was referred to by some as “the medical student’s bill” or “Hansel’s bill,” a couple of respondents noted.

While Tookes led the effort, University of Miami medical students as group were “the true proponents of this legislation” and “stewards of public health,” and they provided a

“constant stream of boots on the ground advocacy,” a few respondents explained. Medical students would meet with members from legislative committees of reference throughout the process, explaining both the health benefits and potential cost savings of needle exchange from reduced infectious disease transmission.

Advocacy, But Not Necessarily Professional Lobbying

Nearly all respondents commented on the lack of professional lobbyists who worked on the IDEA bill. Many deemed this to be unusual. At minimum, they would have expected that lobbyists would show support for a bill progressing as well as IDEA did.

While professional lobbying efforts fell below the radar of most respondents, health care advocacy groups with common interests encouraged each other to, at minimum, advocate by appearing at committee hearings and waiving in support (i.e., going on record as supporting the bill without using allotted time to provide substantive testimony). Interest groups that waived in support at committee meetings included the AIDS Institute, the AIDS Healthcare Foundation, the

Florida Medical Association (FMA), and the Florida Osteopathic Medical Association (FOMA).

A few advocates, instead of waiving their time in favor of the bill, spoke of the bill’s benefits to people.

Other organizations mentioned by respondents as supporting the bill included the Florida

Hospital Association, the Florida Association of Nurse Practitioners, and the Florida Sheriffs

Association. A couple of respondents noted that it was important to ensure that the Sheriffs

Association and the Dade County Police (the chief, in particular) were not actively opposed to the bill.

One respondent noted that legislative members do not like it if there are any (large organizational) opponents, “The members don’t like that. They want … no opposition.” Most respondents did not recall any open opposition in 2014 or negative publicity, and they did not believe that public opinion impacted the bill’s outcome.

Instead of a lobbyist push, several respondents viewed the bill drive as a grassroots advocacy endeavor. A few respondents commented that it was a bit unusual for grassroots advocacy to lead the charge on the bill. However, the “story and intentions” of the legislation were not unusual. The bill was “truly a public health measure for the greater good.”

Legislative Perceptions

A few respondents noted that certain legislators had difficulty with the concept of distributing syringes and needles to “drug addicts” or “drug users,” and that state government funding should not aid in drug-related illegal activities. A couple of respondents suggested that the choice of wording made the bill less appealing than it could have been because “needle exchange” evokes a different mental picture and emotional response than “syringe access” or

“access to sterile syringes.” Respondents conveyed some legislators’ beliefs that “having a bill passed like this would promote drug use, and almost send a statement that it’s okay … to use drugs. We’re going to give you the needles.” This argument was countered by the opportunity to

provide drug-cessation education to users and the increased economic costs of taxpayer-funded indigent care at hospitals for individuals contracting illness, particularly HIV/AIDS, from dirty syringes and needles. One respondent noted that particular arguments, either the health argument or fiscal argument, “played a greater role depend[ing] on the political affiliation of the legislator.” Fiscal arguments carried slightly more weight among more conservative legislators.

“Concern by other legislators of the optic of handing out syringes” thwarted the original bill objective to implement IDEA statewide. One respondent explained that “public policy moves incrementally” and “you try to get what you can, and you move incrementally as long as it doesn’t violate your core [political] values.”

Many respondents noted their belief that the House speaker and Senate president might have more actively supported the legislation if it appeared that the governor’s office, Department of Health (DOH), and/or FMA supported IDEA. A few respondents mentioned that a House speaker’s receptivity to health issues such as these depended largely on the particular speaker’s level of conservativism. Further, if the speaker “doesn’t want a bill to pass, it’s not going to get a hearing in a committee,” because directives were given in a “top down” fashion in the Florida

House. IDEA passed all committees and initial floor votes in both chambers but was not prioritized in the final hours of the legislative session. A couple of respondents stated that leadership had “mixed feelings” about the bill.

Legislative Relationships and Power

Senate sponsor Oscar Braynon210 was the minority (Democratic) whip and was in succession to become the minority leader pro tempore and then minority leader, and House sponsor Mark Pafford211 was Democratic policy chair and slated to become the next minority leader. By all respondent reports, Senator Braynon212 acted as a legislative champion who was able to reach across the aisle to gain Republican support and ensure the bill’s objective was

viewed from a more universally beneficial, nonpartisan perspective. Senator Braynon spoke with his colleagues about constituents in his community who had been impacted. The stories resonated on a personal or social level for legislators from across the state despite the bill focusing the pilot on Miami-Dade. As one respondent noted, “It comes back down to relationships in this process. You can have the greatest public policy, but if you … have an A in public policy, but you have an F in member-to-member relationships, you will not succeed in moving your public policy forward.” Senator Braynon also facilitated Hansel Tookes’ meeting with legislators and members of the executive branch.

Senator Anitere Flores,213 a Miami Republican, chair of the Senate Committee on

Communications, Energy, and Public Utilities, and vice chair of the Appropriations

Subcommittee on Health and Human Services, was cited by respondents as be a “very active proponent” as was Representative Eduardo “Eddy” Gonzalez,214 who was in his final year in office and the chair of the Dade delegation. One respondent commented that Gonzalez “whipped the vote,” inspiring members to vote for the bill with comments like “Come on. You see these people with abscesses—can’t we help them out, throw them some clean syringes?” Gonzalez is also credited with convincing the chair of Government Operations Subcommittee in the House,

Frank Artiles,215 to hear the bill in committee after it was delayed for reading. House sponsor

Mark Pafford was noted by a couple of respondents as successfully promoting IDEA among state representatives. Other significant proponents216 of the bill noted by respondents included legislators who were health care professionals, members of the Florida Legislative Black Caucus, members of the Miami-Dade delegation, and key state senators including the chair of Senate

Committee on Health Policy, which was the first committee stop for SB 408.

In 2014, Miami-Dade was represented by six of the state’s 40 senators and 18 of the state’s 120 representatives.217 The only opponent among the Miami-Dade delegation was

Representative Mike Bileca.218 Senator John Thrasher,219 chair of Senate Committee on Rules, was the only nay vote for SB 408 in committee.

Although it was generally noted by a few respondents that staff directors have “a lot of influence with the Chairman,” most respondents did not feel that legislative staff had a significant impact on this bill’s outcome. However, one respondent explained that there were meetings behind the scenes with legislative staff, who “did a lot of work” conducting research and locating current, quality information to increase legislator(s)’ comfort with, and support of, the bill. Involvement transcended the legislative aide level and went up to chief of staff level.

Another respondent noted that House of Representatives Health and Human Services (HHS)

Committee staff director and former Agency for Health Care Administration (AHCA) Secretary

Christa Calamus had some influence in the bill advancing. Legislative analysis was deemed fair by most respondents, and one respondent recalled that the projected fiscal savings was more than

$120 million if even 10% of injection drug users avoided HIV infection and corresponding treatment costs, which “helped boost this initiative, particularly in the more conservative legislative minds.”

State Health Agency Influences Legislative Perception

The Florida Medical Association (FMA) is a major political contributor to campaigns.

Respondents offered mixed responses when asked about FMA’s support of this legislation, with some noting FMA’s support (“waiving in” support for the bill) and others arguing that it quietly opposed the bill. But others suggested that FMA’s speculated opposition was without foundation or confirmation and that the source of the rumor was believed to be the State Surgeon General

John Armstrong, who was thought to have a close relationship with FMA. A couple of

respondents stated that the state surgeon general had refused to meet with medical students at the time because of their student status and had requested instead that bill proponents meet with the

Statewide Drug Policy Advisory Council. The request was viewed as a tactic to potentially derail or delay bill progress as the council took the time to review the bill’s policy implications. A few respondents heard—but could not verify—that the state surgeon general “singlehandedly was airing concerns with legislators.” Nearly all respondents cite lack of support from the state surgeon general and DOH as key in the bill’s failure to pass. “In the Department of Health … there’s basically three positions—neutral, opposed, and support.” While a couple of respondents labeled DOH’s position to be neutral, more respondents believed DOH to be actively opposed.

According to a few respondents, the opposition of the state surgeon general was not discovered by key parties until late in the session, which made it difficult to resolve. It was also believed that the state surgeon general ordered negative changes to DOH bill analyses in addition to engaging in direct and indirect advocacy against the bill. Heads of medical schools across the state and proponent organizations worked to undo any damage. Respondents explained that

Armstrong did not reach out to the bill sponsors to express concerns or opposition, which was perceived as disrespectful by many legislators. Armstrong, who had been serving as the

Governor’s appointee, was also slated for formal Senate confirmation during the 2014 session.

Respondents stated that his handling of the bill was a major factor in his inability to get confirmed.

Final Hours: Gubernatorial Casualty of War and “Kill Bill” Theories

In the 2014 election year, Governor Rick Scott ran for reelection against former Governor

Charlie Crist. According to a few respondents, the bill’s House Sponsor, Mark Pafford, went public with unfavorable statements concerning Governor Scott. In addition, Governor Scott had tried repeatedly to have his state surgeon general nominee (Armstrong) confirmed without

success, and confirmation would be an accomplishment if 2014 were to be Scott’s last year as governor. Many respondents stated that the bill’s Senate sponsor, Oscar Braynon, actively opposed the state surgeon general nominee’s confirmation. With both the House and Senate sponsors causing Rick Scott angst, concerns emerged that the governor would veto IDEA if it passed. Many respondents believe that this is the core reason that IDEA did not ultimately pass.

The Senate, understanding that there would be a veto, opted to expend political capital elsewhere that year and take the bill up again when there could be a new surgeon general, a new sponsor, and possibly a new governor. A few respondents stated that the governor’s office had no substantive objections to IDEA regardless of Dr. Armstrong’s position, and that IDEA’s demise was merely a political “casualty of war.”

A couple of respondents believed that time simply ran out for the bill during the busy

2014 legislative session, and that more education should have been done in the interim session to educate people before the regular session. “When push comes to shove in those last days—even in the last hours of session, there’s just a limited number of things that they can get done by midnight on that Friday—because everyone wants to go home.” One respondent explained that many bills successfully pass out of committee such as IDEA did but “never quite make it across the finish line for one reason or another.” A mix of factors intervened, including a sense of urgency, prioritization, and where the bill is placed on the agenda.

According to a couple of respondents, a deal was cut on the last day of the legislative session that the House would vote on the bill only if the University of Miami was designated the administrative burden of running the exchange program instead of the Department of Health or its designee, as the Senate’s version stated. The House passed the bill amended with that caveat,

but it died in return messages to the Senate without the Senate taking up the amended bill for final reading.

Brief Summary of Respondent-Generated Key Factors

In the needle exchange case study, based on respondent statements, the most important factors influencing the outcome of the bill (near passage, but ultimately failure to pass) appeared to be: a constituent champion, strategic leveraging of legislative contacts to build access, a strong legislative sponsor, member-to-member relationships, legislator education on topic by credible medical students, and repositioning the bill as only a pilot project limited to one county. The state health agency’s opposition and intergovernmental tensions appeared to have negatively impact the bill. For a summary of medical cannabis and needle/syringe exchange legislation following the 2014 Florida legislative session, see Appendix H.

Study Limitations

This research has several limitations. Foremost, the results and conclusions cannot be generalized because this study examined only two cases of legislation during one legislative session in a single state. While the case studies provided deeper insights into the passage and failure in two specific instances of legislation, they could not capture a complete picture of every interpersonal and political transaction that transpired to yield the final outcome. Any number of other factors, which are not addressed in this study, may have influenced the successful passage of state health legislation. It is not feasible to fully estimate or describe the impact of each variable because no variable exists in a vacuum independent of other factors. Also, while data analysis suggested that some factors were more influential than others, the study did not explore whether, how, or in what combination the factors worked together to be effective.

In addition, the process of gubernatorial review and approval was beyond the scope of this research study. The original independent variables selected for this study were a subjective

synthesis of several unconnected research studies that may or may not be directly relevant to how Florida health legislation is passed. To that end, this study tests the boundaries and applicability of prior case studies while adding a component of original research variables through the open-ended portions of the online survey and the interviews. In addition, the study involved the participation of 20 purposively selected stakeholders across bills and stakeholder categories for the key informant interviews. It is possible that stakeholders choosing to participate have stronger opinions that may not be representative of others within their stakeholder grouping.

Furthermore, the study cannot predict with any certainty what would happen if the state of Florida significantly changes lobbying restrictions, legislator access, Republican Party dominance, elections laws, or government leaders. Finally, external validity/generalizability remains problematic, as any one of a multitude of factors (e.g., politics, ideology, economy, population demographics) may change the prioritization of health-related issues in other states.

Standard basic interview protocol, uniform definitions, a Coding Guide, MAXQDA coding software, and a second coder were used to increase validity and reliability. (See Chapter

3, Methods.) Various data sources were also triangulated, including legislative records, media sources, survey results, interview results, and organizational notes. As the measurements of the variables and the instrument proposed appear reasonable, face validity is arguably moderate.

Construct validity is also presumed to be relatively solid given the studies identified in the literature review. The sources of variable data were fairly reliable for gauging the comparative level of influence of legislative factors, and the additional factors provided by participants captured novel items for testing in later studies. Internal validity of this qualitative study is expected to be high as perceptions were measured and gauged in comparison to the responses of

other citizen stakeholders, legislators, agency officials, and lobbyist participants. Because the questions in the online survey are an extension of current theories found in literature review results and cross-referenced with the key informant interviews, content validity should be relatively high. External validity was challenging, but results may be applicable to future research in similar legislative endeavors within the Republican-controlled Florida Legislature. A replication of this study with similar results in other Republican-controlled states with bicameral legislatures may suggest a much broader range of applicability. However, to achieve a higher external validity in subsequent studies, a review of other states with Democratic-controlled legislative action or mixed party control would be necessary.

Selection bias will necessarily alter study results. Multiple points of selection bias have been considered, including critical bias by the researcher in bill selection and representative stakeholder selection. The researcher concedes personal preferences and biases that may impact direct responses and stakeholder selection, such as perceived personal knowledge of Florida’s legislative process. As study participation is voluntary, stakeholders who interviewed may be different in some substantive ways than stakeholders who declined participating in the key informant interviews. In addition, recall bias must be considered given the time elapsed both from the 2014 legislative session to the online survey and in between the survey and key informant interview components. Furthermore, stakeholder responses may have been affected by intervening changes in public perception (e.g., increased acceptability of medical marijuana use) or the implementation of bills passed after 2014 (the needle/syringe exchange program eventually passed in 2016). Stakeholders may have given “socially acceptable” responses, rather than raise questions regarding legislative choices that appear “political” or “tainted.” Identified stakeholders who are personally known to the researcher may be more likely, or less likely, to

participate or to answer forthrightly because of individual sentiment toward the researcher or research. Participants may be passionate about the topic or may want to use research outcomes to their monetary advantage (e.g., lobbyists).

CHAPTER 5: SUMMARY/INTERPRETIVE ANALYSIS

This chapter will summarize how specific factors influenced the fates of the two bills and how these examples may guide policy advocates in future efforts to develop and influence public health policy. In the two case studies, as in prior studies discussed in the literature review, several well-researched policy guiding factors were present, including:

1. a window of opportunity,

2. persuasive health and/or economic arguments with quantifiable return on investment,

3. grassroots mobilization with in-person constituent advocacy and policy entrepreneurship, and

4. legislative power and legislative perception.

Factors less discussed in the literature, such as the importance of legislative relationships, were found to be influential in the two bills’ outcomes. Unexpectedly, professional lobbying, support of the governor’s office, and support of the state health agency did not play as important roles in the 2014 consideration of both the medical cannabis and needle exchange bills.

Window of Opportunity

Among general factors influencing legislation, a “window of opportunity”220 has been cited as highly influential. This window may vary depending on factors such as media attention221 and the number of times the issue has been brought before the legislature.222

Windows of opportunity existed in both SB 1030 (medical cannabis) and SB 408 (needle exchange), however, they manifested differently, and these differences impacted the strength of this factor.

In 2014, Florida’s election year politics were in play. Discussions of elections, re- elections, constitutional amendments, confirmation of appointees, fundraising, media attention, and political posturing pervaded the Florida legislative scene. Both medical cannabis and needle and syringe exchange had been previously considered. However, persistent efforts had not resulted in bill passage for either topic.

A large window of opportunity had opened for the medical cannabis bill (SB 1030) that allowed the entrance of a “perfect storm,” or unique confluence, of complex conditions for successful passage. The national media spotlighting of Charlotte’s Web through Dr. Sanjay

Gupta’s CNN documentary,223 viewed by a Florida legislator ascending in power and an advocate family that later helped with the bill, led to a renewed interest and different direction for medical cannabis bill language that had floundered in previous attempts. In addition, the threat of a medical cannabis constitutional amendment on the general election ballot that would limit the legislature’s ability to set parameters for medical cannabis occurred in this election year that pitted a Republican-turned-Democrat former governor against a Republican incumbent.

Further, public polling suggested that more than 60% of Floridians supported the “concept” of medical cannabis.224 The combination of circumstances led to a Republican majority-party interest in a successful medical cannabis bill before the election, which could have drawn more liberal and youthful voters were medical cannabis to remain unaddressed.

In the Infectious Disease Elimination Act (IDEA), a new window of opportunity opened following research on discarded needles and syringes in Miami by Hansel Tookes that was featured on the front page of The Miami Herald. In addition, new data showed reductions in infectious disease in locations with existing exchange programs. This led to a renewed focus on

the issue of needle and syringe exchange that had been raised unsuccessfully in the 1990s and

2000s.

The strength of the window of opportunity in the medical cannabis bill far eclipsed that of the IDEA bill. While IDEA was considered in the same legislative session and election year, it did not have the medical cannabis bill’s added political leverage of being the subject of a constitutional amendment that could usurp legislative preference or change gubernatorial race outcomes, nor the added political assurance of a poll that a majority of Floridians supported needle exchange. That it was an election year may have worked against the needle exchange bill because of political intrigue surrounding the governor’s selection of state surgeon general. In addition, unlike the medical cannabis bill, the needle and syringe exchange bill did not have a national health expert and thought leader such as Dr. Sanjay Gupta bringing stories of need and efficacy directly into the homes of millions of viewers. While Gupta is a health-related celebrity, his documentary coverage did not rise to the level of endorsement for Florida’s medical cannabis bill. However, celebrity endorsement has been found to influence bill outcomes.225

Persuasive Arguments and Economic Considerations

Educating legislators on medical cannabis and needle and syringe exchange needs and benefits was critical in advancing the bills toward final legislative consideration. Research,226 the actions of other states, health benefits,227 and the potential cost of action or inaction as state financial gain or loss228 all weighed in to strengthen or weaken the case for bill passage. In addition to overt costs and benefits for each bill, policymakers also considered whether passage would promote drug use and whether the impacted individuals could have acted to prevent or mitigate their situations (e.g., individual responsibility for injectable drug use). Legislators further considered individual costs and benefits of supporting legislation (e.g., constituent

approval in an election year, financial benefits from a last-minute vertical integration amendment to the medical cannabis bill).

Despite anecdotal evidence, legislators found a lack of expert reviews or peer-reviewed, evidence-based research to support claims that medical cannabis was effective for various health conditions as claimed. The lack of research was offset by the in-person and video testimonies of families suggesting that inaction could lead to continued or worsening health conditions, extreme treatments, death, or the movement of impacted families out of state because of lack of access. In addition, some states that had adopted medical cannabis legislation were viewed as being influenced by “bleeding-heart” liberals by Florida’s conservative legislature. Limiting the bill to pain-relieving/symptom-reducing properties of medical cannabis (i.e., found in the CBD component) rather than euphoria properties (i.e., found in the THC component) permitted a shift in discussion from cannabis as an illegal, gateway drug to cannabis as compassionate medicine.

Legislative analysis further suggested that medical cannabis could result in a multibillion-dollar industry in the state of Florida. The combination of these critical factors set the stage for passage of medical cannabis.

In contrast to medical cannabis, the research in IDEA was more robust. In cities such as

San Francisco with existing needle and syringe exchange programs, new cases of infectious diseases such as HIV/AIDS and hepatitis were reduced among the injection drug-using population, and health care and drug treatment referrals were increased. Hansel Tookes’s study also demonstrated the need for an exchange program to reduce the dirty needles/syringes left in public areas in Miami-Dade to reduce transmission of infectious disease to the general population. In addition, the bill was limited to Miami-Dade, where the highest rates of related infectious diseases were found. The health benefits to users, protection for the general public,

and cost-savings generated from avoiding costly infectious disease treatments were strong arguments that offset many concerns. Nonetheless, the perception that self-manifested drug users were being given paraphernalia to continue a dangerously destructive and illegal habit was challenging to overcome.

Both bills involved the potential to initiate, encourage, or continue illegal drug use. Both bills were universally appealing to the extent they would help people address pain, health, or both. However, in the case of medical cannabis, patients were viewed as both in need and without blame. Legislators were more likely to view children with epilepsy and cancer patients as innocent victims of their diseases or health conditions. The frames of “protection” and

“worthiness” or “deservingness,” or even unconscious racial/ethnic attributions (medical cannabis use associated with Caucasians) may have influenced perceptions of medical cannabis.229 For these reasons, it was easier for legislators to support medical cannabis for treatment of pain relief that traditional medications could not provide. In contrast, the drug-using population was not viewed as blameless, regardless of need. The frames of “illicit drug use” and

“unworthiness” or “lack of deservingness,” or even unconscious racial/ethnic attributions

(injectable drug use associated more with people of color) may have influenced perceptions of needle and syringe exchange.230 It was arguably within the control of drug users to start using illegal drugs. Addiction was not easily divorced from choice and not readily viewed as a disease state or faultless medical condition. This distinction between the bills and the accompanying perception created put IDEA at a disadvantage and worried legislators regarding voter perception.

Grassroots Mobilization, Persistent Constituent Advocacy, and the Children

Constituents coalescing into interest groups were the lead advocates for both the medical cannabis and needle exchange bills. The impact of legislative testimony and in-person discussions contributed to the advancement of both bills, albeit to different degrees.231

The Moseleys and other families, backed by long-time, pro-cannabis special interest groups such as the Florida Cannabis Action Network, served as key advocates for the medical cannabis bill. Parents and children were in the Capitol building daily during the legislative session, meeting with legislators and testifying, serving as a visual reminder that the need for medical cannabis was real and could not be ignored. They shared heartbreaking, relatable stories of children and family members suffering from painful conditions through photos, videos, and in-person testimony. Parents testified at the agony of watching their children suffer to the point of despair. Similar to other studies, grassroots mobilization in this study extended to public education and mass emails to constituents, support of the constitutional amendment, letters to legislators, affected individuals and families going to the Capitol, media buzz and, on occasion, the hiring of consultants for media or lobbying.232

In the case of IDEA, constituents such as Hansel Tookes became policy entrepreneurs, creating windows of opportunity and calling attention to health-related policy issues. Medical student and researcher Tookes served as key advocate for the needle exchange bill, speaking as both a professional and a concerned Miami-Dade resident/constituent. With the backing of the

University of Miami, he and a handful of other medical students visited legislator offices and spoke in committee meetings. Tookes used initial legislative and organizational contacts to build additional contacts, forming an eventual network of contacts for education and advocacy. Tookes and supporters spent time before the start of the 2014 legislative session to develop “conceptual

buy-in” or reduce oppositional concerns from major special interest stakeholders such as the

Florida Medical Association and the Florida Sheriffs Association. Every day during the legislative session, Tookes and supporters were seen and heard throughout the Capitol building advocating for the needle exchange bill.

As noted by many interviewed on medical cannabis, it was difficult to ignore the families and the children. Seeing sick children and hearing stories of sick children every day of the legislative session in committee meetings, in legislator offices, and in the Capitol’s halls left a deep impression of need and urgency. While Tookes and colleagues presented patient stories and pictures both of impacted individuals and of potentially harmful situations such as drug needles in local playgrounds, the impression of need and urgency was not as strong as in medical cannabis. As conveyed by the advocates, a vote for medical cannabis could help a child cope with life-threatening seizures and could help a parent not to pray for God to take their child to ease their suffering. A vote for needle exchange did not appear to resonate at that level, and some believed it would have little to no impact on injectable drug use itself.

Professional Lobbying

Literature suggests that professional lobbying is one of the most important factors in the ascension and passage of health-related legislation.233 Interview results across both medical cannabis and needle exchange bills suggest that in these specific bills, professional lobbying played a surprisingly diminished role in bill progression and consideration.

While a small handful of lobbyists worked on the medical cannabis bill from the beginning, many in a pro bono capacity based on personal interest and impact, it was suggested that most paid lobbyists did not take interest in the bill until passage was a near certainty, and in the immediate post-passage period. The historical failure of cannabis-related bills suggested that

time spent lobbying would not result in a win for clients. As the session neared an end and passage was increasingly likely, professional lobbyists recognized that medical cannabis—from growing and selling to regulatory issues—presented a lucrative opportunity in which an increasing number of clients would want to partake. The nursery growers were noted as having an early interest and benefiting from the last-minute addition of language creating requirements for a vertically integrated growing, production, and distribution system.

Interview results suggest that professional lobbyists were not actively or visibly engaged in the needle exchange bill that year. Interest groups expressed support by “waiving in support” during committee stops without actual testimony, but almost all respondents found the absence of lobbyists to be unusual for a bill progressing as well as IDEA did.

The lack of professional lobbyist involvement in both bills was noticeable and unusual to those interviewed. With constituent advocacy working well, legislative champions, lack of vocal big organization opposition, and little-known financial incentives during the committee process, these bills may have been periodically monitored but not actively advocated by lobbyists. In addition, with both bills related to drugs, lobbyists may have preferred a “wait-and-see” approach. Because lobbying was not prevalent in these bills, the impact of time spent lobbying,234 money paid to lobbyist,235 and legislative funding credited to a lobbyist236 could not be assessed. However, for the medical cannabis bill, the prospect of future money for lobbyists was a last-minute factor of influence.

Legislative Relationships

Whether legislative member-to-member, family and friends, or non-legislator connections in the legislative process, almost all interviews suggested that legislative relationships drove the consideration of both the medical cannabis and needle exchange bills.

In the medical cannabis bill, member-to-member relationships allowed for bill sponsorship across party lines. Member-to-member relationships also included family relationships. The House bill sponsor was related to the Senate president, and two of the Senate sponsors were related by marriage. It was a strategic objective of the family advocates to have legislators relate to the stories of the children and family members. Family testimony led many legislators to speak openly of their own family members and friends who had suffered without the benefits of medical cannabis. Family advocates were said to develop enduring relationships with legislative sponsors. Connections between legislators and those in the legislative process are believed to have led to the vertical integration amendment added at the final hour before passage.

In IDEA, member-to-member relationships were noted as particularly important in gaining momentum and bipartisan support. This included individual member-to-member relationships in addition to regional delegation (Miami-Dade) and Democratic caucus support. A handful of legislators were known to have family members or friends impacted by drug addiction. Legislators representing districts with similar demographics to Miami-Dade and legislators representing geographic areas close to Miami-Dade were noted as being additionally supportive. The constituent advocates were noted as developing working relationships and gaining the admiration of legislators as the session progressed.

Across both bills, legislative relationships allowed for bill negotiations and horse- trading.237 The medical cannabis bill was viewed as imperfect and language compromises were made, but it was considered a foothold that could not be lost in subsequent statutory iterations.

For the needle exchange bill, final bill negotiations resulted in the saving of political capital for another year and possibly another gubernatorial administration and state surgeon general.

Legislative Power and Perception

Legislative power, influence, and perception were common themes across the medical cannabis and needle exchange bills. The political power of a sponsoring legislator who acts as a policy entrepreneur can impact a bill’s outcome.238

The rising political power and charisma of Republican Representative Matt Gaetz (now

US representative), bolstered by support of Democratic cosponsorship of Representative Katie

Edwards, and the perception of backing by his Senate president father, made Matt Gaetz a formidable legislative champion of the medical cannabis bill. In the Senate, the “Three Bs”

(Senators Bean, Bradley, and Brandes) were perceived as a political medical cannabis powerhouse backed by the Senate president. These legislators influenced organizations and fellow legislators to support the medical cannabis bill, which was perceived as both alleviating the suffering of blameless children and families and a solid “win” for supportive legislators in an election year.

The rising political power and influence of Democratic Senator Oscar Braynon, minority whip and designated future minority leader, bolstered by the support of Republican senators such as Committee Chair Anitere Flores, the Miami-Dade delegation, and the Democratic caucus, made Braynon a powerful legislative champion of the needle exchange bill. He rallied bipartisan support both in the Senate and House. In the House, sponsor Mark Pafford garnered support as

Democratic policy chair and designated next minority leader. But, legislative perception of individual addiction/drug use responsibility remained a factor of consideration. After limiting the bill to Miami-Dade, more legislators were willing to support IDEA because it was perceived to have less of a negative impact on voter approval outside of Miami-Dade, particularly among

Republican legislators. Legislative (mis)perception that the Florida Medical Association was

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against the bill, in addition to concerns regarding a gubernatorial veto, may have made needle exchange an unnecessary political risk in an election year.

For each bill, legislators perceived a benefit to their constituents that influenced their support.239 Medical cannabis was viewed as benefiting constituents throughout the state of

Florida, while needle exchange was limited to potentially helping constituents in Miami-Dade.

Medical cannabis, as a result of grassroots efforts and polling, was perceived as having significant constituent support, which impacted legislative support.240 In addition, majority party sponsorship of the medical cannabis bill was noted as contributing to its success, consistent with findings in other studies.241 Furthermore, legislative leadership impacted the bills’ outcomes, particularly in the case of medical cannabis, which the Senate president supported.242

Studies have found that legislative staff members, including committee staff,243 staff directors, and legislative aides,244 to be influential in the progress and outcome of health-related legislation. However, respondents in this study did not find legislative staff to have a strong impact on either the medical cannabis or needle exchange bills.

Governor’s Office Impact and State Health Agency Influence

Support by the governor’s office has been cited as critical to the passage of health-related legislation.245 In addition, studies have found the support of the state health agency as influential.246 Despite a known anti-drug stance by the governor, neither the medical cannabis bill nor the needle exchange bill received active support or opposition from the governor’s office to the extent known. However, the state surgeon general and the Florida Department of Health overtly and/or covertly opposed both bills. This impacted one bill but not the other. As a result of the anti-drug positioning of the Department of Health, agencies discussions were limited and non-impactful, differing from other studies.247

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State Surgeon General Armstrong testified against medical cannabis during committee meetings. Regardless, the compelling testimonies of the families in combination with election- year political objectives were enough to garner powerful legislative support. Helping sick children in pain, a repeated theme across interviewees, was a political win in an election year.

Although there were short-lived rumors of a gubernatorial veto, they did not impede the bill’s progress and were found unsubstantiated as the governor signed the enrolled bill into law.

In contrast, the needle exchange bill was the subject of behind-the-scenes intrigue, with possible direct lobbying of legislators, rumors of Florida Medical Association opposition (despite

FMA’s favorable support in committee), and rumors of a veto. The state surgeon general was believed to have acted against the bill in the last days of the legislative session. The bill may have also been a “casualty of war,” caught in the crosshairs of negative comments made by the bill sponsor against the governor in an election year and unsuccessful attempts at Senate confirmation of the governor’s selected state surgeon general, John Armstrong. The political gamesmanship surrounding the needle exchange bill may not have made it a safe or attractive allocation of political capital for legislators in the final hours of that legislative session.

Conclusion

Several factors common in other studies were present in these two legislative campaigns, including policy entrepreneurs, windows of opportunity, and the role of citizen/constituent lobbying. However, certain factors were less important in the 2014 legislative session, including the role of the governor, executive agencies, and professional lobbyists. Notably, while these three factors were less important for key informant interview participants, they were rated as more influential for bill outcome by the smaller number of Qualtrics survey participants. A major distinction between the two bills, which helps explain the success of the medical cannabis bill

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and the failure of the needle exchange bill, seems to rest on the extent of the window of opportunity and the sympathy toward the intended beneficiaries of the legislation. Children with intractable epilepsy and cancer were perceived as blameless, but drug users were not. Thus, it was easier to support medical cannabis for children, while opposing clean needle legislation for drug users. Similarly, the prospect of a constitutional amendment, viewed as motivating to

Democrat voters during an election year, was a sufficient threat to drive some conservative legislators to support the medical cannabis bill who would otherwise oppose it. Table 6 summarizes and compares the key factors for both bills.

Table 6. Comparison of key factors across the medical cannabis and needle exchange bills

Cannabis Needle Exchange Factor Comment Comment Window of • History of broader legislative attempts • History of similar legislative attempts Opportunity • Proposed constitutional amendment • Newly published research encouraged legislature to act first • Support of the Florida Medical Association, • National media (Gupta) local state attorney, law enforcement • High favorable polling numbers • Election year—partisan positioning • Gubernatorial race Persuasive • Weak empirical evidence • Strong empirical evidence Arguments • Limited approved conditions—not • Low sympathy for affected individuals (Health, recreational (drug users)—however, bill could protect Economic, innocent people etc.) • Strong sympathy for affected individuals (innocent children) • Educating legislators important but did not • Educating legislators important and have the impact of cannabis legislative effective because individuals viewed as effort because individuals viewed as drug victims users by choice • Recognition that medical cannabis could • Limited to Miami-Dade and only a pilot be a lucrative industry • Bill made legislators appear to support • Bill made legislators appear to support illicit drug use medicinal rather than illicit drug use • Original opposition based on perception of • Original opposition based on cannabis as a condoning or enabling drug use “gateway drug” • Moderate economic benefit • Large economic benefit Grassroots • Legislators as policy entrepreneurs • Constituents as policy entrepreneurs Mobilization with In-

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Person • Strong, consistent, and large constituent • Strong, consistent, but smaller constituent Constituent representation representation Advocacy, • In-person advocacy with multiple • In-person advocacy not as visible as Policy advocates involved daily cannabis families Entrepreneur- ship • Emotional/compelling testimony that resonated with legislators Legislative • Majority party support and sponsorship • Certain legislators had difficulty with the Power and (bipartisan sponsorship in House) concept of distributing clean supplies to Legislative • Member-to-member relationships drug users Perception (especially when related) • Concern over how bill support would • Strong support by legislative leadership affect voting in election year (Senate president) • Member-to-member relationships important • Legislators related to personal stories in earning bipartisan support • Lukewarm, less supportive legislative leadership

Executive • Overt state health agency opposition did • Covert state health agency opposition Branch not thwart bill efforts cast doubt on bill at the end of the session Influence • Governor did not support bill, but signed bill into law upon passage

Other Factors • Professional lobbyists only involved at end • Professional lobbyist involvement not of the session recalled by respondents • Big business interest at end of the session • House sponsor’s remarks against the (leading to vertical integration language) governor may have impacted bill • Senate’s refusal to confirm governor’s pick for state surgeon general may have impacted bill

(See also Appendix F: Factors of Influence, Description, Sources of Concept, General Interview Findings)

Note: Bold denotes factors of greatest influence as identified by multiple respondents.

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CHAPTER 6: RECOMMENDATIONS AND PLAN FOR CHANGE

Recommendations

The following eight recommendations are drawn from the combined lessons of the medical cannabis and needle exchange case studies. They are intended to help groups successfully advocate for health-related legislation. While these bills were considered under very specific circumstances as previously described in the Results section (e.g., during an election year with a Republican legislature and Republican governor), some lessons may be applicable across health-related bill topics and locations.

These recommendations are targeted to grassroots health-related efforts, community- based organizations, family advocates, and student-based groups without significant financial and/or lobbying influence. Nonetheless, they may still provide useful information for lobbyists, advocates, and even government agencies seeking to promote or defeat health-related legislation.

1. Thoroughly Assess the Sociopolitical Environment

Key informants in both case studies underscored the importance of understanding the sociopolitical environment. This involves searching for both the “window of opportunity” and gathering additional insights to predict a “perfect storm.” To the extent possible, a 360-degree assessment of the environment should be conducted to include current sociopolitical views (e.g., limited-use medical cannabis gaining support), political events (e.g., upcoming election, constitutional amendment), national and local media attention (e.g., Dr. Sanjay Gupta/CNN special), the number of times similar bill language has been proposed, legislative leanings, special interest group efforts, and executive branch positioning. Knowing the landscape before

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proposing bill language will inform a strategic approach on how to create a more favorable environment. For example, community groups may consider creating a window of opportunity by garnering positive media attention, petitioning for a constitutional amendment, or laying the groundwork for bill passage through legislator education and discussion in consecutive years.

2. Thoroughly Assess the Target Audience

Learning the state’s legislative players and process was critical in both case studies.

Research and assessment of the target audience should also be done from all angles, inclusive of legislators, executive branch stakeholders, lobbyists, special interest groups, likely proponents and opponents, and unlikely or remote stakeholders (e.g., industries that would not immediately or directly feel the impact of legislation and, therefore, are not obvious targets, such as the gambling industry for medical cannabis). Each stakeholder group may have unique interests in the bill, as the medical cannabis case study suggests.

It is not enough to research a legislator’s voting record. Thorough research should include knowledge of a legislator’s professional, business, and personal interests to better understand motivation for support or opposition, with similar research conducted for key executive branch members, such as the governor and the heads of health-related state agencies. Key legislators, especially leadership, may have strong positive or negative sentiments regarding personal or political experiences with the bill sponsors. Member-to-member relationships can impact bipartisan support or acceptance, bill prioritization, and bill progression. Legislative spouses should be viewed as influential and considered for bill education and advocacy purposes. The proposed bill may go against personal beliefs, constituent leanings, a previous public campaign platform, or the majority party view. Legislator connections to key bill proponents and opponents, including personal, business, and campaign contribution interactions provide

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additional insight into the likelihood of legislative support. Considerations may change during an election year, lending added factors of whether a legislator’s bill support will be viewed favorably by a constituency and further chances of reelection. Less public motivations should be assessed to the extent possible (e.g., horse-trading support of one bill for another).

Similarly, it is not enough to know whether a lobbyist or other non-legislative stakeholder supports or opposes a bill. Stakeholder assessment should include length of involvement and prior actions regarding the bill topic, the publicly stated grounds for support or opposition, relationships and financial dealings with legislators and lobbyists, whether the stakeholder publicly espouses majority viewpoints, and any hidden motivations (e.g., expected profit or loss depending on bill disposition). The strength of a lobbyist’s relationship with a legislator can influence a bill’s prioritization and progress.

Researching publicly available legislative history (e.g., legislator biographies, voting records, prior legislative attempts for the bill topic, leadership and slated successors), legislative and executive branch state lobbyist registrations, campaign donations, public polling, and media sources provide a solid start to understanding the legislative process environment. Opposition research across actors (e.g., special interest groups, negative lobbying efforts) is equally important. Adding a professional lobbyist to the team may be helpful in learning deeper-level and historical insider knowledge. When selecting a lobbyist, consider past and present relationships (and therefore access) with legislators, particularly those in leadership. Consider also the lobbyist’s personal interest in the bill topic. Higher personal investment for a lobbyist, whether through personal interest, time spent, or expected monetary compensation, makes it more likely that the lobbyist will vigorously advocate the issue and prevent the bill language

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from being lost to amendments, horse-trading, or last-minute “trains” (i.e., being used as a “shell bill” or omnibus bill to pass a group of desired issues).

Assessment of the target audience can also help to identify advocacy allies. Working with other groups that have similar interests and objectives and building a supportive coalition can strengthen the impact of advocacy efforts. A coalition of groups working together through coordinated advocacy on an issue gives the appearance of broad support, which may increase legislator interest in supporting the bill.

3. Strategically Select the Health Issue to Bring Forward as Legislation

To the extent possible, the bill topic should involve a universally appealing issue that has the potential to transcend political party lines. The health-related issue addressed should be hard to ignore, personally relatable, “for the greater good,” and likely to resonate with constituents.

However, controversial bills do not generally meet these criteria, and even the concept of medical cannabis for sick children was not viewed as universally appealing to some conservative legislators because it dealt with marijuana.

If universal appeal is not immediately evident in the public health issue put forward, the issue should be dissected and analyzed until there is a major aspect of the issue upon which substantial bipartisan agreement can be reached, a common denominator (e.g., children are suffering).248 Ideally, the topic should be prominent and foregrounded in the national and/or state arenas. If it is not, consider ways to increase positive media attention around the chosen issue.

The topic should be uniquely relevant to state residents and, when possible, should impact districts or regions that are well-represented by policymakers in a position of power (e.g., legislative leadership) or where there is a strong legislative representation (e.g., Florida’s Miami-

Dade delegation).

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Health issues that have extensive evidence-based research that demonstrate both a health benefit and an economic benefit are more easily supported by legislators and justifiable to their constituents. However, research typically is not enough. The issue must be foregrounded as urgent and timely, with a compelling narrative to accompany the bill language. Short-term impacts, long-term impacts, and unintended consequences of the bill should be considered as part of an initial assessment before proposal.

Health-related issues that are controversial because of diverse political and social viewpoints, such as illegal drug use in these case studies, require additional consideration and strategy before bill proposal. This includes topics perceived as morally or ethically challenging, in which the health actor’s choices play a significant role in whether they are impacted (e.g., smokers may be perceived as socially or morally responsible for contracting lung cancer). For controversial issues, research of the sociopolitical environment and of legislative process audiences should be conducted earlier to better anticipate objections and provide effective counterarguments.

4. Carefully Craft the Message and Select the Messenger

Health-related issues put forward as legislation should be carefully framed and delivered.249 In both case studies, legislative champions and crafted messaging played key roles in obtaining broader legislative support.

A health-related idea that “helps people” or “prevents disease” does not always rise to legislative interest. A succinct story demonstrating the topic’s urgency, timeliness, health benefits, and significant state cost savings or profit, blended with a common denominator (e.g., children are suffering; increased costs and new cases of HIV/AIDS) create a strong, sellable message. The message should be reinforced with emotive personal stories, research, and

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examples from other states, especially states with similar population and political demographics.

The message should also anticipate and address opposing arguments. Comparative state information should include whether similar bill language has been adopted or a similar bill topic has been considered. Supportive peer-reviewed, evidence-based research should be readily available to legislators and legislative staff. The message, when carefully crafted and supported, should make it easy and worthwhile for a legislator to support the bill. At minimum, the message should make it difficult for a legislator to justify opposing the bill. Strategic research on legislators should indicate with whom the message will most strongly resonate, and which concerns and barriers need to be addressed in advance of presenting the issue to a legislator resistant or opposed to the message.

Selecting the right messenger or champion to serve as a spokesperson for the cause at the grassroots/constituent level can significantly impact the bill outcome. Grassroots or constituent champions, as demonstrated in the medical cannabis and needle exchange case studies, may advocate more effectively with legislators when they have a background or expertise in health care (e.g., fourth-year medical student advocating for needle exchange), have a powerful personal story (e.g., parents of children with intractable epilepsy), and are perceived as credible and reasonable (e.g., able to work well with a conservative legislature). If there is no measurable movement over the course of three legislative attempts (e.g., a key informant interviewee’s comment of “your bill three times to get through”), selection of different messengers may change the outcome. Practically, annual post-session debriefings should include a review of the effectiveness of both the message and the messenger with adjustments as needed.

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5. Locate a Legislative Champion or Legislative Champions

Ideally, locate a legislative champion in both the House and Senate, with a least one prominent or rising in the majority party. In the medical cannabis case study, even though the topic had been put forward for many years by special interest groups and legislators, it did not move as desired until a majority party legislative champion picked it up and families that had not actively advocated in past legislative sessions delivered it as a compelling story. The right legislative champion should be in a position of influence or rising in leadership, with the ability to garner bipartisan support. Also, they should have the ability to access current legislative leadership and influence bill prioritization throughout the legislative session, preferably introducing the bill as a committee bill as permitted by legislative guidelines. The legislative champion should be well-educated on the issue and supplied with all research. When possible, the champion should have demonstrated personal or professional interest in the bill topic as shown by previous sponsorship, voting record, or public statement. Legislators who function as policy entrepreneurs may be more willing to take on controversial health-related topics as demonstrated in the medical cannabis and needle exchange bills.

6. Focus on Visibility, Influence, and Persistence in Advocacy Efforts

A consistent theme across both case studies was the need for persistent, visible, and vocal in-person advocacy. While respondents were aware of grassroots campaigns (e.g., email your legislator in support of the bill), it was the in-person presence of grassroots champions and allies that left a deep, lasting impression. Whether the Moseleys or other families for the medical cannabis bill, or Hansel Tookes or other medical students for the needle exchange bill, legislators were continuously reminded of the respective bill’s objectives by seeing dedicated supporters and constituent champions in the halls of the Florida Capitol building. By repeatedly meeting

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one-on-one with legislators and legislative staff, providing compelling testimony with visual aids

(e.g., photos, videos), having impacted individuals (including children) attend committee meetings, and generally being “seen” daily in the legislative process, grassroots advocates created a memorable sense of urgency and importance around their bills. Seeing suffering families and children and directly hearing from rising medical doctors made the bill issues difficult to ignore or deprioritize.

Strategically mapping out and leveraging key member-to-member and member-to-non- legislator relationships can help to maximize an advocate’s circle of influence. For example, respondents noted that for the needle exchange bill, the most prominent constituent advocate not only met with legislators to provide education on the bill topic but also reportedly requested that those legislators introduce them to additional legislators and/or assist them in scheduling meetings with members of legislative leadership. Understanding and leveraging legislator relationships may provide a path to accessing legislator leaders that are more challenging to access. In addition, leveraging relationships of allies or coalition members may lead to greater access.

Persistence and resilience in legislative attempts may eventually result in success. It may take several bill attempts to gain momentum toward passage. Educating legislators, legislative staff, executive branch members, lobbyists, and special interest groups takes time. Open-minded, open-ended dialogue with legislators is necessary to build rapport, understand their philosophical beliefs, and understand personal relationships with a bill topic (e.g., family member died of drug overdose). Finding areas of compromise involves carefully listening to legislator concerns.

Expecting a bill to pass on its first attempt may not be realistic. If the bill is too detailed, legislators may disagree. Bill proponents should decide what parts of the bill language are

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necessary to their cause and what parts are desired. They should have a basic, stripped-down version of the bill ready in case a strike-all amendment (an amendment that removes all current bill language) is filed or additional concessions are needed to reduce disagreement that would kill the bill. This “foot-in-the-door” bill, like the 2014 medical cannabis bill, may not be considered ideal, but it allows for future fine-tuning of an existing statute rather than the heavier lift of initial legislation. Even if most of the desired bill language is adopted, there will likely be a need for annual “tweaking” to address unforeseen concerns. Proponents should plan for a longer marathon of proposals and refinements, rather than a shorter sprint to the proverbial finish line.

7. Remain Vigilant in the Final Hours of the Legislative Session

As the results of both medical cannabis and needle exchange demonstrate, positions and bill language can change rapidly, particularly in the last days of the legislative session when deals are cut, and the state budget is finalized. Therefore, if the proposed bill is still being considered in the final days and hours, advocates should monitor not only their bill, but all major bills, political trade- offs, and inter-chamber or intergovernmental branch posturing. That vigilance may save bill language from being eliminated or changed in a way that defeats the original purpose. However, it should be anticipated that the language may be amended, and additional compromises may need to be made. In this case, having the skeleton bill (i.e. simplified bill of only required components and language) that meets its intended purpose provides a basis for negotiation. Any possible gubernatorial veto or state agency opposition should have been researched and addressed well before final legislative days, leaving no room for last-minute speculation or intentionally created misperceptions by opponents.

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8. Evaluate and Plan for Continuous Strategic Advocacy Improvement

Following the legislative session, it is critical to perform an “After-Action Review” or evaluation of advocacy efforts. Careful consideration of areas of success and challenge provides valuable insights into what strategic improvements are needed. Reviewing the efficacy of the messenger and the message in communications with legislators, unexpected barriers encountered, and opportunities to garner support allows the advocate to plan for the financial and human capital needed to increase the chances of success.

Striving for continuous strategic advocacy improvement will entail revising the strategic approach as needed. Advocacy efforts should “move the needle” on the selected health policy issue. Lessons learned from the After-Action Review should guide any needed revisions to the strategic approach. Small adjustments can have a large impact. Adjustments may include hiring another lobbyist, researching committee members more thoroughly, proposing different bill language, collaborating with new partners, or having more advocates/supporters physically present in the Capitol building during the legislative session. Advocacy should occur throughout the calendar year, allowing for new opportunities to garner support.

Plan for Change

The following Plan for Change is based on aspects of the Diffusion of Innovations

Theory by Everett M. Rogers. The Plan focuses on dissemination of information through presentations and webinars to two select stakeholder categories that would likely be innovators or early adopters of the recommendations. In addition, the Plan provides a practical tool for use by adopters in the form of an advocacy checklist/workbook with resources. The checklist details the recommendations and can be adapted for use in different states or adjusted to meet the needs of the adopter.

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Diffusion of Innovations Theory

From 1962 to 2003, Everett Rogers published five editions of his Diffusion of Innovations book, which presented a model of diffusion of innovations. Rogers (2003)250 defines diffusion as the “process by which an innovation is communicated through certain channels over time among the members of a social system … a special type of communication in which the messages are about a new idea … a kind of social change.”251 Dearing and Cox (2018)252 further define diffusion as a “social process that occurs among people in response to learning about an innovation such as a new evidence-based approach for extending or improving health care.”

The model uses a normal frequency (S-shaped) distribution to categorize adopters into five categories: innovators, early adopters, early majority, late majority, later majority, and laggards.253

Figure 3: Modified Diffusion of Innovations Model: Distribution of Adopter Innovativeness Based on Time of Adoption.254

While full diffusion is “an atypical outcome” because most innovations do not diffuse or follow the S-shaped curve,255 the model is useful to show best practices and a need for long-term strategic dissemination of innovations beyond training and toward use in funded practice

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collaboratives. This Plan for Change will focus on initial strategic dissemination of recommendations and findings to innovators and early adopters. An innovation’s attributes, adopters’ characteristics and perceptions, and the larger sociopolitical environment (including timing, framing, and salience) impact the progress of diffusion.256 Communication channels and methods also impact the rate of innovation adoption.257 Within perceived innovation attributes, relative advantage, compatibility, complexity, trialability, and observability are concepts considered by potential adopters.258

The recommendations may be perceived as providing a relative advantage, or “degree to which an innovation is perceived as being better than the idea it supersedes,” for adopters in that they combine many existing theories into practical advocacy advice supported by statements from key informants with experience in the legislative process.259 The recommendations may also result in time and money saved through focus on more effective actions. Compatibility, or the “degree to which an innovation is perceived as consistent with the existing values, past experiences, and needs of potential adopters,” will depend on whether the potential adopter has previously been involved in the legislative process and currently desires to advocate for legislation.260 Where there is a need for cost-conscious, time-conscious advocacy, compatibility may be high. Complexity, or the “degree to which an innovation is perceived as relatively difficult to understand and use,” will be moderate to high in that the recommendations involve in-depth social and political research.261 However, it is not anticipated to be a significant barrier to adoption among those individuals and organizations that are highly motivated to advocate effectively for health-related legislation. Trialability, or how an “innovation may be experimented with on a limited basis,” will depend on whether the adopter is pushing a legislative bill and the importance of the topic.262 Higher priority bills that have previously failed

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to pass may be strategic choices for trying the recommendations. Finally, observability, or the

“degree to which the results of an innovation are observable to others,” will be greatest following use in a legislative session.263 However, partial results may be seen during a legislative session in terms of being able to observe legislator receptiveness, legislative processes, and access to legislative leadership.

Dissemination of Recommendations

Dissemination of case study findings will be made through the offering of webinars and presentations to two targeted groups of potential adopters: health care profession students, and select health-related, small-to-medium organizations. These groups are likely to lack formal paid lobbyists and may be more in need of this type of information.

Health Care Profession Students

In the needle exchange case study, University of Miami medical students were influential in advancing the bill. Students attending schools for their respective health care professions are poised for learning how to shape health-related ideas into successful legislation. Such students are more likely to view the study’s recommendations as novel and to consider adoption as innovators or early adopters. In addition, health care profession students have the added benefit of some health-related and medical knowledge, which lends credibility in advocacy and resonates with policymakers as suggested by the case studies.

Initial dissemination would target students in accredited Florida schools of public health, nursing, physician assistance, and medicine. Professional associations are not initial targets as the study results may not be particularly unknown to those organizations, especially if they have previously hired professional lobbyists. The Council on Education for Public Health (CEPH) lists 10 accredited Florida universities that offer baccalaureate and higher degree programs.

According to the Florida Department of Health, there are 66 accredited associate degree in

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nursing (ADN) programs leading to Registered Nurse (RN) status and 52 accredited bachelor’s degree in nursing (BSN) programs. Because of the large number of nursing programs, dissemination would be targeted at accredited nursing schools that offer both ADN and BSN programs (e.g., Keiser University) and those offering either accredited program in major metropolitan hubs such as Miami or Tampa. The Physician Assistant Education Association

(PAEA) lists eight actively accredited (i.e., not on probation or provisional status) physician assistant schools in the state of Florida. The Association of American Medical Colleges (AAMC) and American Board of Medical Specialties (ABMS) report seven schools of allopathic medicine and two schools of osteopathic medicine.

Other avenues of dissemination to Florida health profession students could include related professional organizations such as the student membership/chapters of the American

Public Health Association, American Nurses Association, National Student Nurses’ Association,

American College of Physicians, the American Academy of Physician Assistants, and American

Clinical Social Work Association.

Health-Related, Small-to-Medium Organizations

Case study findings may benefit small-to-medium organizations or grassroots movements that either do not have professional lobbyists on board, were recently formed or reorganized, or would like suggestions on maximizing the use of time and funding for advocating health-related legislation and policy.

Interested organizations may include those based in health-related professions in which recommendations may be disseminated as professional development (e.g., public health professionals in the Florida Public Health Association (FPHA), and the Florida Institute for

Health Innovation (FIHI), formerly known as the Florida Public Health Institute (FPHI); nurses in the Florida Action Coalition), those based on a specific health condition (e.g., local autism

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advocacy groups), and those recently seeking health-related solutions (e.g., cannabis groups). In addition, health care coalitions in the state of Florida may benefit from the case study recommendations. A sample list of potential target organizations is attached as Appendix I.

Moving Toward Diffusion of Innovations: The Advocacy Checklist

A draft of a practical tool that encompasses this study’s recommendations, an Advocacy

Checklist, has been developed. I will work with stakeholder groups to get feedback before finalizing it following completion of the dissertation. It will be field-tested among target populations for usability and refined as needed. This Advocacy Checklist was tailored to adopters in the state of Florida for use in developing health-related advocacy efforts. This multipage checklist acts as a strategic roadmap by breaking down the eight recommendations into actionable components, lending greater insight into the strategic thought processes within each recommendation, and providing weblinks to resources under each subsection to assist adopters in implementing the recommendations. The Advocacy Checklist will be offered to all potential adopters in conjunction with presentations/webinars. In addition, the tool can be tailored to adopters in other states by updating relevant resource links and accounting for legislative variances (e.g., unicameral legislature). The Advocacy Checklist can also be adjusted by the adopter to meet its unique needs for a bill issue or advocacy year, and such adaptation lends itself to sustainable use.264 A draft Advocacy Checklist is attached as Appendix J.

Through the dissemination of this study’s results and recommendations to health care profession students and to smaller health-related organizations that are likely to be innovators or early adopters, this research may help public health advocates to strategically maximize their chances of getting health-related legislation passed. The Advocacy Checklist provides an additional practical tool for implementing the recommendations with resources that can be

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customized to various states. The Plan for Change provides a tactical roadmap that allows newer health advocates to quickly gain insights customarily obtained only over time through trial and error. For more seasoned health advocates, the Recommendations and Plan for Change provide suggestions to ensure that no major opportunities are missed, and that a robust advocacy strategy is in place.

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APPENDIX A: QUANTITATIVE SURVEY AND CONSENTS

FLORIDA LEGISLATION INFLUENCE STUDY—ONLINE SURVEY Research Participant Information and Consent Form

Explanation of the Research You are being asked to participate in a research study of factors that influence the final outcomes (passage or failure) of health-related legislation in the State of Florida.

This research is in support of a doctoral-level dissertation at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. The entire survey is estimated to take up to 10 minutes to complete.

You will be asked to respond to a series of questions about a particular health bill that was passed into law. Specifically, you will be asked whether you believe that the topic listed was influential in helping the bill to pass and, if you think it was influential, rank how influential it seemed to be.

Your Rights to Participate, Say No, or Withdraw Participation in this research project is completely voluntary. You have the right to say no. You may change your mind at any time and withdraw. You may choose not to answer specific questions or to stop participating at any time in the process. Whether you choose to participate or not will not be reported to your employer.

Confidentiality Your participation will be kept confidential. You have been given a unique identifier, and your name will not be collected. Your identifier will not be made public, although your general position and branch of government (e.g., legislative branch, executive branch, lobbyist, individual stakeholder) will be noted as part of survey results.

Contact Information If you have questions following participation, you may contact the researcher, Tamara Demko, JD, MPH, at (850) 631-0386; Pam Silberman, JD, DrPH, Faculty Advisor at (919) 966-4525; or the UNC Institutional Review Board (IRB), at (919) 966-3113, referencing IRB # 17-2311.

Consent You must be at least 18 years old to participate in this research and be legally able to consent.

I authorize the researcher to share any analysis from this online survey in any publishable form, barring my personally identifiable information as described above in the Confidentiality section.

Signature Box

By clicking on the button below, you indicate your review of the Research Participation & Consent Form and your voluntary agreement to participate in this online survey. Furthermore, you attest that you have not previously taken this survey.

CLICK HERE

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Why Did That Bill Pass or Fail? Online Qualtrics Survey

The purpose of this brief survey is to better understand what factors are more influential in the final outcome (passage or failure) of health legislation in Florida. You have been identified as having an interest in the passage of (INSERT BILL NUMBER, INSERT SHORT TITLE DESCRIPTION), which was successfully passed by the state legislature in 2014. The entire survey is estimated to take up to 10 minutes to complete.

Please respond to all parts honestly based on your personal perception. All answers are confidential, and no personally identifying information will be reported.

RATE—SCALE OF INFLUENCE: For each statement, please check one box corresponding to how influential the listed factor was in this particular bill’s outcome on a scale from 1 (less influential) to 5 (more influential).

If needed, hover your cursor over a factor for additional descriptions. (For example, “scientific or research backing,” refers to when “researchers or research organizations have published materials in support of what this bill addresses and it impacted the outcome.”)

# Rate the Listed Factors Don’t 1 2 3 4 5 Know Less More In the passage or failure of the bill, the Influential Influential listed factor [below] was … [Check one box only for each factor]. A. A new window of opportunity opening up. B. A previous attempt to pass similar legislation. C. The amount of media attention. D. Scientific or research backing. E. A public education or grassroots mobilization campaign. F. A special interest group’s legislative testimony or direct discussions with legislators. G. The political power of a sponsoring legislator. H. The amount of constituent support as perceived by a supporting legislator. I. Overall benefit to the state as perceived by a supporting legislator. J. Professional lobbyists’ work. K. The amount of time spent by lobbyists on the issue. L. The amount of money paid to lobbyist. M. Financial support to legislators by any source credited to a particular lobbyist or lobbying firm. N. Sponsorship of the bill by the political party in power (legislative majority).

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O. Support of a particular legislative staff member. P. Support of legislative leadership. Q. Support of a particular legislative committee. R. Support of a particular state agency. S. Support of the governor’s office. T. “Horse Trading.” U. Persuasive economic benefit arguments. V. Persuasive health benefit arguments. Z1. Unlisted factor (Type your factor______) (Optional) Z2. Unlisted factor (Type your factor______) (Optional) Z3. Unlisted factor (Type your factor______) (Optional)

# Stakeholder Group Influence Don’t 1 2 3 4 5 Know Less More Rate the influence of the following Influential Influential stakeholder groups on the outcome of health legislation from less influential to more influential. Mark only one answer per row. 1. General public/individual stakeholders 2. Organizational stakeholder 3. In-house lobbyist (only one client) 4. Professional lobbyist (more than one client) 5. State agency 6. Governor’s office 7. State senator–bill sponsor 8. State senator–committee Chair 9. State representative–bill sponsor 10. State representative–committee chair 11. Legislative leadership 12. Legislative staff 13. Media/press 14. Other unlisted stakeholder (Type) 15. Other unlisted stakeholder (Type) 16. Other unlisted stakeholder (Type)

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WHAT WAS YOUR ROLE? Please check the box that most closely describes your role in the passage of this bill at the time the bill was passed. Check one box only.

General Public/Individual Stakeholder Organizational Stakeholder In-House Lobbyist (only one client) Professional Lobbyist (more than one client) State Agency Employee Governor’s Office State Senator State Representative Legislative Leadership Legislative Staff Media/Press Prefer Not to Answer

VOTER AFFILIATION? Please check the box that most closely describes your political party as listed on your voter registration card at the time the bill was passed (2014). Check one box only.

Republican Party Democratic Party No Party Affiliation (NPA) Other Not Registered Prefer Not to Answer

ADDITIONAL THOUGHTS OR FACTORS? (optional): Please type below any additional thoughts on factors listed above or on anything you feel influences the outcome of Florida health legislation that is NOT listed above.

Thank you for your time Your participation will help to improve processes for passing good health legislation!

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APPENDIX B: QUALITATIVE KEY INFORMANT INTERVIEW AND CONSENTS

FLORIDA LEGISLATION INFLUENCE STUDY—KEY INFORMANT INTERVIEW Research Participant Information and Consent Form for In-Person Interviews

Explanation of the Research You are being asked to participate in a research study of factors that influence the final outcomes (passage or failure) of health legislation in the State of Florida.

You will be asked to respond to a series of questions about a particular health bill that was passed into law. Specifically, you will be asked whether you believe that the topic was influential in helping the bill to pass and, if you think it was influential, how influential it seemed to be.

Confidentiality Your participation will be kept confidential. No personally identifying information will be collected or made public, nor will anything be quoted without permission, although your general position and branch of government may be noted (such as “state representative”).

Consent You must be at least 18 years old to participate in this research and be legally able to consent.

I understand that I may ask questions of the interviewer at any time, stop the interview entirely, or withdraw from participation whenever I so choose. I understand that my personally identifying information or participation status will not be shared with my employer or otherwise disclosed without my express permission in separately signed document. I am volunteering for this research of my own free will, have had the opportunity to ask questions, and desire to participate. I authorize the researcher to record this interview in audio and written format, and to share any observations from this interview in any publishable form, barring my personally identifiable information as described above in the Confidentiality section.

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Recording (Please check one and initial next to your choice.) I give the researcher permission to use audio equipment to record this interview. I do not give the researcher permission to use audio equipment to record this interview.

Your signature below means that you voluntarily agree to participate in this research study.

Signature Date

Print Name

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FLORIDA LEGISLATION INFLUENCE STUDY—KEY INFORMANT INTERVIEW Additional Research Participant Information and Consent Script for Remote Interviews

Consent You must be at least 18 years old to participate in this research and be legally able to consent.

No personally identifying information or participation status will be shared with your employer or otherwise disclosed without your express permission in separately signed document.

Do you understand the conditions and consent to participate in this research study?

Recording To assist the researcher in remembering your responses, do you authorize the researcher to record this interview in audio and written format, and to share any observations from this interview in any publishable form?

(If Yes to Both) Thank you. I will repeat those two questions after I turn the voice recorder on to document your consent and permission for recording.

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Why Did That Bill Pass or Fail?—Select Key Informant Interviews

Introductory Script for All Key Informant Interviews • Introduction—Hello, I am Tamara Demko, a DrPH student at the University of North Carolina, Chapel Hill, and am conducting dissertation research to better understand what factors are more influential in the final outcome (passage or failure) of health-related bills in Florida. • You will be asked to respond to a series of questions about a particular health bill that was passed into law. Specifically, you will be asked whether you believe that the topic was influential in helping the bill to pass and, if you think it was influential, how influential it seemed to be. • Participation in this research project is completely voluntary. You have the right to say no. You may change your mind at any time and withdraw. You may choose not to answer specific questions or to stop participating at any time in the process. • Your participation will be kept confidential. No personally identifying information will be collected or made public, nor will anything be quoted without permission, although your general position and branch of government may be noted (such as “state representative”). • Thank you for taking time to talk with me today. The interview will be up to 30 minutes or so. There are no right or wrong answers. I’d like to know more about things that help health bills to pass in the legislature and what stakeholders think is important. • For this interview, we’ll only be discussing one bill, the successful265 passage of (House/Senate) Bill #____ (short title of bill) in the 2014 legislative session.

1. What was your position and title at the time this bill was considered?

2. Please describe your role or interest in the consideration and outcome of (House/Senate) Bill #____ (short title of bill) in the 2014 legislative session? [PROMPT: If legislator, were you a primary sponsor? If lobbyist, about what percentage of your workweek did you spend on this legislation? Was it a major concern or one of multiple pieces of legislation you were following? What client were you representing?]

3. What factors influenced the outcome of the bill in your opinion? [PROMPT: Did certain stakeholders, legislators, or events impact the outcome of this bill more than others? What do you think made this bill ultimately pass or not pass?]

4. Was political timing a factor in getting the bill passed? (If so, please explain) [PROMPT: Do you believe there was a window of opportunity that was created by some external event? If so, please describe. Was that event influential in the passage/defeat of the legislation? Had there been previous efforts made to pass the bill? If so, why was this bill enacted when others were not (if applicable).]

5. Did public opinion impact the bill’s outcome? If so, how? How did the public learn about the issue?

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[PROMPT: Was there a media or public education campaign? Grassroots mobilizing efforts? If yes (to either), please describe]

6. What actions, if any, did special interest groups take that effectively supported or opposed the bill? [PROMPT: Did a group’s public testimony have an effect? What about groups that opposed this legislation? What arguments do you think were the most successful in the passage/defeat of this legislation?]

7. Do you have any ideas of what influenced the sponsoring legislator to sponsor the bill?

[PROMPT: Did the bill fit party goals? Did the bill represent the legislator’s area of concern/passion? Any other factors that might explain why the legislator sponsored the legislation?]

8. What influenced legislators who voted in support of the bill? [PROMPT: Was there constituent support? Pressure from leadership? Other factors that influenced legislators?] What about those who opposed the bill?

9. What impact, if any, did legislative staff members (names or titles) have on the outcome of the bill? [PROMPT: Did staff directors, committee staffers, or aides have influence?]

10. What impact, if any, did members of the executive branch (names or titles) have on the outcome of the bill? [PROMPT: Did agency heads or the governor weigh in?]

11. What impact, if any, did professional lobbyists have on the outcome of the bill? What made a lobbyist successful?

[PROMPT: Would the bill have passed without professional lobbying? Did more money or subject-matter knowledge mean better results? Did lobbyists use other key strategies to help support or oppose the legislation?]

12. What arguments were more persuasive in achieving the outcome (passage/defeat) of this bill? [PROMPT: What were the best arguments for and against this bill? How did these points resonate with voting legislators?]

13. Do you have any other thoughts or observations about the outcome of the bill that you would like to share?

14. (For cannabis:) Why do you think this bill was successful in 2014, when other bills like the clean needle exchange program, were not? (For needle exchange:) Why do you this health- related bill ultimately failed in 2014 when other bills such as cannabis passed?

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15. Finally, what was your political party affiliation in 2014 (what was listed on your voter registration card?)

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APPENDIX C: KEY TERMS DEFINED

“Committees of Reference” include all committees in the Florida Senate and the Florida House of Representatives to which a particular bill was referenced for consideration and voting in order to progress on the pathway to being enacted into law.

“Companion Bill,” as used by the Florida Legislature, refers to “a bill introduced in one house that is substantially the same and identical as to specific intent and purpose as a bill introduced in the other house. The use of companion bills allows bills in each body to move through the committee process at the same time,”266 which increases the chances of a timely review toward possible passage.

“General Public/Individual Stakeholders” include all identified stakeholders who are not affiliated with any one particular interest group, nor employed by the legislative branch, the executive branch, state agency, or as a lobbyist.

“Governor’s Office” and “Governor’s Office Employees” includes all individuals whose employment is considered to be under the Executive Office of the Governor rather than a state agency. “Governor’s Office” includes the Office of Policy and Budget (OPB).

“In Messages” or “In Return Messages,” as used by the Florida Legislature, refers to when a bill passed by one chamber is en route to, or is held in, the other chamber for consideration.267

“In-House Lobbyists” include all individuals paid and registered as lobbyists who serve only one exclusive client. They are distinguished here from “Professional Lobbyists” because they only represent the interests of one entity and have different leverage capabilities than lobbyists representing multiple interests.

“Key Stakeholders” is a broad, encompassing catchphrase that references actively involved stakeholders known via public record or media sources and includes the bill sponsors, committee members of committees of references in which the bill passed (includes chairmen), any individuals and groups that provided written or oral testimony to the state legislature on record, lobbyists of record, an authoritative representative of any state health agency or the Executive Office of the Governor reviewing the bill, and the legislative staff directors (health policy or budget as applicable).

“Legislative Leadership” includes all senators and representatives designated and recognized as leaders within their respective chamber, including the titles of Senate president, Senate president pro tempore, Senate majority leader, Senate minority leader, Senate minority leader pro tempore, Senate president designate; House Speaker, House Speaker pro tempore, House majority leader, House minority leader, House minority leader pro tempore, and House Speaker designate.

“Legislative Staff” includes all individuals employed by the legislature or a legislator, including, but not limited to legislative aides, committee staff, staff directors, and the Office of Program Policy Analysis and Government Accountability (OPPAGA).

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“Media/Press” include all recognized members of the media/press who either bear credentials or self-report as members of the media/press.

“Organizational Stakeholder” includes all identified stakeholders who identify as affiliates of special interest and political groups and who are not registered to lobby for any client.

“Professional Lobbyist” includes all individuals representing more than one client who are separately paid to advocate a position before the executive or legislative branches and whose names are included as registered in the State of Florida’s lobbying directory.

“State Agency” and “State Agency Employees” include all individuals employed by a Florida state agency, whether a governor’s agency or a cabinet agency, who do not otherwise fall under the definition of employment by the executive office of the governor. This includes individuals working on any task force, council, or committee created by statute or executive order in any capacity.

“Successful” legislation is limited in definition, for the purposes of this study, to passage into law (ordered enrolled) by both legislative Florida bodies, and does not seek to account for the approval or vetoing of a bill by the governor’s office, or factors of influence therein. However, to avoid any confusion, all passing legislation used in this study will also have been approved by the governor’s office. There are significant intervening factors that impact the quality of implementation and rulemaking for any given piece of legislation, and the objective of this study is limited to achieving an often-necessary first step in public health policy.

For additional and formal Florida legislative process definitions, please see the Florida Senate’s Glossary Reference at https://www.flsenate.gov/Reference/Glossary.

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APPENDIX D: QUALTRICS SURVEY QUESTION CODING AND HOVER FUNCTION DESCRIPTIONS

Influential Factors/Survey Question Coding & Hover Function Descriptions. Coding “numbers” and category “ZZ” are assigned for tallying purposes.

Letter Coding & Hover Function Descriptions for Surveys (22 Primary Codes) Code # Code Name Research Team—Internal Explanation [Survey- Taker Explanatory Note for Survey Hover Function] A Window of Opportunity A new window of opportunity opening up. [Recent current events made the topic of this bill a publicly supported, priority issue, and it impacted the outcome.] B Persistence A previous failed attempt(s) to pass the bill. [A bill covering this issue has been heard by the legislature in past years but did not pass, and it impacted this bill's outcome.] C Media Attention The amount of media attention. [This issue was deemed newsworthy and was covered by well-known newspapers, radio, or TV, and it impacted the outcome.] D Research Scientific or research backing. [Researchers or research organizations have published materials in support of what this bill addresses, and it impacted the outcome.] E Public Education and A public education and grassroots campaign. [Organizations have Grassroots Mobilization attempted to educate the public on this issue though social media, print, TV campaigns, or “contact your legislator” appeals, and it impacted the outcome.] F Legislative A special interest group’s legislative testimony or direct discussions Testimony/In-Person with legislators. [Public testimony in legislative committees or Discussion private, scheduled meetings with legislators by special interest groups impacted the outcome.] G Sponsoring Legislator’s The political power of a sponsoring legislator. (May suggest policy Power entrepreneur.) [The sponsoring legislator had significant political clout that impacted the outcome.] H Legislator’s Perception The amount of constituent support as perceived by a supporting of Constituent Backing legislator. [A supporting legislator perceived significant constituent support on the subject of the bill in the form of letters, calls, or contributions, and it impacted the outcome.] I Legislator’s Perception Overall benefit to the state as perceived by a supporting legislator. of State Benefit [A supporting legislator made statements or had known positions suggesting that the state of Florida as a whole would benefit from the bill, and it impacted the outcome.] J Professional Lobbyist Professional lobbyists’ work. [Paid, registered lobbyists were a work driving force behind this bill.] K Time Spent by Lobbyist The amount of time spent by lobbyists on the issue. [Lobbyists spent significant time on this issue, and that impacted the outcome.] L Money Paid to Lobbyist The amount of money paid to lobbyist. [Lobbyists were paid significant amounts of money (from any source) for this issue, and that impacted the outcome.] M Legislative Funding Financial support to legislators provided directly via a lobbyist or Credited to Lobbyist lobbying firm or provided indirectly but credited to a particular lobbyist. [Lobbyists or lobbying firms known to support this bill provided financial contributions directly or indirectly to legislators, and it impacted the outcome.]

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N Majority Party Sponsorship of the bill by the political party in power (legislative Sponsorship majority). [Introduction of this bill by the majority party impacted the outcome.] O Legislative Staff Support Support of a legislative staff member. [A legislative staff member (legislative aide, committee staff, staff director) supported the bill, and it impacted the outcome.] P Legislative Leadership Support of legislative leadership. [Legislative leadership supported Support the bill, and it impacted the outcome.] Q Legislative Committee Support of a particular legislative committee. [A particular Support legislative committee supported the bill, and it impacted the outcome.] R State Agency Support Support of a particular state agency. [A particular state agency supported the bill, and it impacted the outcome.] S Governor’s Office Support of the governor’s office. [The governor’s office supported Support the bill, and it impacted the outcome.] T “Horse Trading” Trading bill support or opposition to achieve desired ends. [Working with other legislators or lobbyists to achieve their desired results on another bill in exchange for desired results on this bill.] U Economic Argument Persuasive economic or business argument. [A strong economic benefit, return-on-investment (ROI), or cost-effectiveness argument was made that impacted the outcome.] V Health Argument Persuasive health benefit argument. [A strong public health benefit, improved patient outcome, or improved health care (noneconomic) argument was made that impacted the outcome.] ZZ Other (Previously Un- Other previously uncoded, contributing factor to successful passage coded) of state legislation. This includes actions or circumstances that do not logically correspond to a clear actor encompassed by another category, and relate to time, generalized foregrounding of issue, or unique circumstance such as sole backing by nongovernmental public figure.

Stakeholder Groupings & Hover Function Descriptions Code Code Specific Role Description # Group AZ-1a- Legislative State Senator–Bill 2014 member of the Senate on record as the bill’s 1 Branch Sponsor sponsor. AZ-1a- Legislative State Senator– 2014 member of the Senate on record as a 2 Branch Committee Chair Committee Chair for a committee of reference assigned to the bill. AZ-1b- Legislative State Representative– 2014 member of the House of Representatives on 1 Branch Bill Sponsor record as the bill’s sponsor. In this case, the companion bill’s sponsor. AZ-1a- Legislative State Representative– 2014 member of the House of Representatives on 2 Branch Committee Chair record as a Committee Chair for a committee of reference assigned to the bill. In this case, the companion bill’s sponsor. AZ-1c Legislative Legislative Leadership Includes all senators and representatives designated Branch and recognized as leaders within their respective chamber, including the titles of Senate president, Senate president pro tempore, Senate majority leader, Senate minority leader, Senate minority leader pro tempore, Senate president designate; House Speaker, House Speaker pro tempore, House

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majority leader, House minority leader, House minority leader pro tempore, and House Speaker designate. AZ-1d Legislative Legislative Staff Individuals or teams previously or currently Branch employed by the Legislature in any capacity. Includes staff directors, legislative aides, committee staff, the Office of Program Policy Analysis and Government Accountability (OPPAGA), etc. AZ-2a Executive Governor’s Office Individuals working on behalf of the Executive Branch Office of the Governor in any capacity. Includes the Office of the General Counsel and the Office of Planning and Budget (OPB). AZ-2b Executive State Agency Individuals or teams previously or currently Branch employed by, or within the oversight of, a state agency, whether a governor’s agency or cabinet agency. Also includes individuals working on any task force, council, committee, or organization created by statute or executive order in any capacity, within the oversight of a state agency. AZ-3a Lobbyist Professional Lobbyist Individual representing more than one client who is specifically paid to influence legislative outcome at the time of bill consideration and is registered in the state to lobby. AZ-3b Lobbyist In-House Lobbyist Individual representing only one client who is specifically paid to influence legislative outcome at the time of bill consideration and is registered in the state to lobby. AZ-4a Constituencies Organizational Individual belonging to an organized special interest Stakeholder group/organization that seeks to influence legislative outcome at the time of bill consideration. Includes government relations staff representing a single entity who are NOT registered to lobby with the state. AZ-4b Constituencies General Individual who does not belong to an organized Public/Individual special interest group/organization, and is NOT Stakeholder registered to lobby with the state, but who independently seeks to influence legislative outcome at the time of bill consideration. AZ-5 Other Category not listed Media/Press stakeholder category from survey and optional type-in responses (stakeholders not explicitly listed.)

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APPENDIX E: SELECT RESULTS FROM QUALTRICS SURVEY

Medical Cannabis Factor of Influence (11 Participants) More Influential Number of (4 and 5 Participants combined) Voting as or Less Influential More or (1 and 2 Less combined) Influential V. Persuasive health benefit arguments. More 9 C. The amount of media attention. More 8 N. Sponsorship of the bill by the political party in More 8 power (legislative majority). F. A special interest group’s legislative testimony or More 7 direct discussions with legislators. G. The political power of a sponsoring legislator. More 7 H. The amount of constituent support as perceived by More 7 a supporting legislator. P. Support of legislative leadership. More 7 E. A public education or grassroots mobilization More 6 campaign.

B. A previous attempt to pass similar legislation. Less 8 L. The amount of money paid to a lobbyist on the Less 8 issue. U. Persuasive economic benefit arguments. Less 7 O. Support of a particular legislative staff member. Less 6 R. Support of a particular state agency. Less 6 S. Support of the Governor’s Office. Less 6

Stakeholder Influence (11 Participants) More Influential Number of (4 and 5 Participants combined) Voting as or Less Influential More or (1 and 2 Less combined) Influential 1. General Public/Individual Stakeholder More 8 11. Legislative Leadership More 8 7. State Senator–Bill Sponsor More 7 9. State Representative–Bill Sponsor More 7 13. Media/Press More 6

5. State Agency Less 6 6. Governor’s Office Less 6

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12. Legislative Staff Less 6

The three largest participant groups were legislative staff members, professional lobbyists, and general public/individual stakeholders. More Democrats participated in answering the voter affiliation question than Republicans and those with no party affiliation.

Needle Exchange

Factor of Influence (7 Participants) More Influential Number of (4 and 5 Participants combined) Voting as or Less Influential More or (1 and 2 Less combined) Influential E. A public education or grassroots mobilization More 4 campaign. G. The political power of a sponsoring legislator. More 4 P. Support of legislative leadership. More 4 J. Professional lobbyists’ work. More 3 R. Support of a particular state agency. More 3 S. Support of the Governor’s Office. More 3 V. Persuasive health benefit arguments. More 3

F. A special interest group’s legislative testimony or Less 4 direct discussions with legislators. L. The amount of money paid to a lobbyist on the Less 4 issue. M. Financial support to legislators by any source Less 4 credited to a particular lobbyist or lobbying firm H. The amount of constituent support as perceived by Less 3 a supporting legislator. K. The amount of time spent by lobbyists on the Less 3 issue.

Stakeholder Influence (6 Participants) More Influential Number of (4 and 5 Participants combined) Voting as or Less Influential More or (1 and 2 Less combined) Influential 10. State Representative–Committee Chair More 5 5. State Agency More 4 1. General Public/Individual Stakeholder More 3 2. Organizational Stakeholder More 3 6. Governor’s Office More 3 7. State Senator–Bill Sponsor More 3

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8. State Senator–Committee Chair More 3 9. State Representative–Bill Sponsor More 3 11. Legislative Leadership More 3

13. Media/Press Less 4 12. Legislative Staff Less 3

The three largest participant groups were state legislators, general public/individual stakeholders, and legislative staff members. An equal number of Democrats, Republicans, and those with no party affiliation participated in answering the voter affiliation question.

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Determinants of Successful State Health Legislation - Quantitative Survey Results: Medical Cannabis

A. ~ A new window of opportunity opening up.

B. ~ A previous attempt to pass similar legislation.

C. ~ The amount of media attention.

D. ~ Scientific or research backing. E. ~ A public education or grassroots mobilization campaign. F. ~ A special interest group's legislative testimony or direct discussions with legislators. G. ~ The political power of a sponsoring legislator. H. ~ The amount of constituent support as perceived by a supporting legislator. I. ~ Overall benefit to the State of Florida as perceived by a supporting legislator. J. ~ Professional lobbyists' work.

K. ~ The amount of time spent by lobbyists on the issue.

L. ~ The amount of money paid to a lobbyist on the issue. M. ~ Financial support to legislators by any source credited to a particular lobbyist or lobbying firm. N. ~ Sponsorship of the bill by the political party in power (legislative majority).

O. ~ Support of a particular legislative staff member. Determinants of Health Legislation Passing LegislationHealth of Determinants P. ~ Support of legislative leadership.

Q. ~ Support of a particular legislative committee.

R. ~ Support of a particular state agency.

S. ~ Support of the Governor's Office.

T. ~ "Horse trading."

U. ~ Persuasive economic benefit arguments.

V. ~ Persuasive health benefit arguments.

0 2 4 6 8 10 Combined 5 4 Number of Survey Participants Voting Factor as More Influential to Bill Passage by Type Ranks of 4, 5, and 4 and 5 Combined [Scale of 1 (less influential) to 5 (more influential)]

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Determinants of Successful State Health Legislation - Quantitative Survey Results: Needle Exchange

A. ~ A new window of opportunity opening up.

B. ~ A previous attempt to pass similar legislation.

C. ~ The amount of media attention.

D. ~ Scientific or research backing.

E. ~ A public education or grassroots mobilization…

F. ~ A special interest group's legislative testimony or…

G. ~ The political power of a sponsoring legislator.

H. ~ The amount of constituent support as perceived…

I. ~ Overall benefit to the State of Florida as perceived…

J. ~ Professional lobbyists' work.

K. ~ The amount of time spent by lobbyists on the…

L. ~ The amount of money paid to a lobbyist on the…

M. ~ Financial support to legislators by any source…

N. ~ Sponsorship of the bill by the political party in…

O. ~ Support of a particular legislative staff member. Determinants of Health Legislation Passing Legislation Health of Determinants P. ~ Support of legislative leadership.

Q. ~ Support of a particular legislative committee.

R. ~ Support of a particular state agency.

S. ~ Support of the Governor's Office.

T. ~ "Horse trading."

U. ~ Persuasive economic benefit arguments.

V. ~ Persuasive health benefit arguments.

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Combined 5 4 Number of Survey Participants Voting Factor as More Influential to Bill Passage by Type Ranks of 4, 5, and 4 and 5 Combined [Scale of 1 (less influential) to 5 (more influential)]

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APPENDIX F: FACTORS OF INFLUENCE, DESCRIPTIONS, SOURCES OF CONCEPT, AND GENERAL INTERVIEW FINDINGS

Needle/ Factor of Influence Description Source of Concept Cannabis Bill Syringe Bill General Factors (6) Constitutional amendment. [Threat of a Constitutional looming constitutional Survey YES NO Amendment amendment was influential in the outcome of the bill.] Election-year politics. [Strategy to drive political Election-Year outcomes in an election Survey YES YES Politics year influenced the outcome of the bill.] The amount of national media attention. [This issue was deemed • Meier, et al. (2009) Media Attention— newsworthy and was • Paul-Shaheen (1998) YES SOME National covered by well-known • Shelov (1995) national newspapers, • Zakocs, et al. (2001) radio, or TV, and it impacted the outcome.] The amount of state or local media attention. [This issue was deemed Media Attention— newsworthy and was • Survey • Implied in national media YES SOME State/Local covered by well-known attention sources state or local newspapers, radio, or TV, and it impacted the outcome.] A previous failed attempt(s) to pass the bill. [A bill covering this issue • Meier, et al. (2009) YES YES has been heard by the • Pacheco and Boushey Persistence (2014) variant goal not well- legislature in past years • Paul-Shaheen (1998) (as and language known but did not pass, and it continuum/incremental) impacted this bill’s outcome.] A new window of opportunity opening up. [Recent current events Window of YES made the topic of this bill Paul-Shaheen (1998) YES Opportunity perfect storm a publicly supported, priority issue, and it impacted the outcome.]

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Argument & Needle/ Description Source of Concept Cannabis Bill Persuasion (5) Syringe Bill Persuasive economic or business argument. [A • Bourdeaux and strong economic benefit, Fernandes (2007) return-on-investment • Hadorn (1991) Economic Argument • Harkreader (1999) (as LATENT LATENT (ROI), or cost- fiscally effectiveness argument legitimate/consistent) was made that impacted • Jewell and Bero (2008) the outcome.] Educating legislators on bill topic. [Educating Educating Legislators legislators on the bill Survey YES YES on Bill Topic topic was an important factor that impacted the outcome.] Persuasive health benefit argument. [A strong public health benefit, • Brownson, et al. (2011) YES improved patient good • Dodson, et al. (2013) YES Health Argument outcome, or improved • Flynn, et al. (1998) examples of but anecdotal health care • Jewell and Bero (2008) other state (noneconomic) argument • Meier et al. (2009) program was made that impacted the outcome.] Scientific or research backing. [Researchers or • Brownson, et al. (2011) NO research organizations • Dodson, et al. (2013) anecdotal or • Heller, et al. (2014) (via Research have published materials universities) weak; bill YES in support of what this bill • Jewell and Bero (2008) funds added addresses, and it impacted • Meier et al. (2009) research the outcome.] YES Universally appealing YES significant issue. [Bill issue was little/no judgment of Universally universally appealing and judgment of person using Observational Appealing Issue transcended political person using needles and lines. This impacted the medical syringes for outcome.] cannabis recreational drug use Needle/ Constituencies (3) Description Source of Concept Cannabis Bill Syringe Bill A special interest group’s legislative testimony or direct discussions with legislators. [Public Legislative • Jewell and Bero (2008) testimony in legislative Testimony/In-Person • Madler, et al. (2014) YES YES committees or private, • Meier, et al. (2009) Discussion scheduled meetings with • Zakocs, et al. (2001) legislators by special interest groups impacted the outcome.]

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Personal stories. [Stories shared by constituents Personal Stories— with legislators, either in Survey SOME YES Adults committee meetings or during office visits, influenced the outcome.] Personal stories–Children. [Stories shared Personal Stories— specifically about Children and Parents children by constituents Survey YES NO Discussing Their with legislators, either in Children committee meetings or during office visits, influenced the outcome.] Needle/ Lobbyists (2) Description Source of Concept Cannabis Bill Syringe Bill Last-minute influence. NO [Specific last-minute State additions or alterations to YES Surgeon Last-Minute bill language suggested Vertical Observational General Push/Influence by lobbyists while under integration; Armstrong final chamber Gaetz behind the consideration that scenes influenced the outcome.] • Ahrens, et al. (2011) • Bullock and Padgett (2007) Professional lobbyists’ • Jewell and Bero (2008) Professional Lobbyist work. [Paid, registered • Madler, et al. (2014) LITTLE NO Work lobbyists were a driving • McKay (2012) (as force behind this bill.] negative lobbying) • Seymour and Seymour (2013) • Zakocs et al. (2001) Needle/ Legislature (13) Description Source of Concept Cannabis Bill Syringe Bill The amount of constituent support as perceived by a supporting legislator. [A supporting legislator Constituent Backing perceived significant • Dodson, et al. (2013) LOCAL (Legislative YES constituent support on the • Flynn, et al. (1998) ONLY Perception of) subject of the bill in the form of letters, calls, or contributions, and it impacted the outcome.] Legislators as respected health experts. Health Experts [Legislators who are also (Legislators as respected as licensed Observational SOME LITTLE Respected Health health professionals Experts) influenced the outcome of the bill.]

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“Horse trading.” / Trading bill support or opposition to achieve desired ends. [Working with other • Ainsworth (1997) • Bullock and Padgett Horse-Trading legislators or lobbyists to (2007) SOME SOME achieve their desired • Jewell and Bero (2008) results on another bill in exchange for desired results on this bill.] Perception of individual responsibility for health issue. [Perception or Individual belief by the Legislature Responsibility for YES that a person or group of Survey; Observational; NO Health Issue Ryan (1976) (as “blaming attributed persons should or should lack of blame (Legislative the victim”) blame not bear the responsibility Perception of) for the health issue addressed in the bill influenced the outcome.] Support of a particular legislative committee. [A YES SOME Legislative particular legislative • Eyler, et al. (2012) but not as but not as Committee Support committee supported the standalone standalone bill, and it impacted the outcome.] Support of legislative • Flynn, et al. (1998) leadership. [Legislative Legislative • Harkreader and leadership supported the Imershein (1999) YES SOME Leadership Support bill, and it impacted the • Paul-Shaheen (1998) outcome.] • Weissert, C. (1991) Support of a particular legislative staff director/legislative aide. / Support of a legislative • Brownson (2011) (as staff member. [A Legislative Staff committee staff) legislative staff member • Weissert & Weissert SOME SOME Support (Combined) (legislative aide, (2000) (for staff director or committee staff, staff legislative aide) director) supported the bill, and it impacted the outcome.] Sponsorship of the bill by the political party in NO power (legislative • Ellickson (1992) Majority Party • Lindley (2014) Support only majority). [Introduction of YES Sponsorship • Lukens (2014) without this bill by the majority • Paul-Shaheen (1998) sponsorship party impacted the outcome.] Special relationships: family and friends. Special [External non-legislative Relationships: Family relationships of legislators Survey; Observational YES SOME and Friends influenced the outcome. For example, a legislator has a family member

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impacted by the topic of the bill.] Special relationships: member-to-member. Special [Internal legislative Relationships: relationships Survey; Observational YES YES Member-to-Member between/among legislators influenced the outcome.] Special relationships– non-legislator. Government process. Special [External non-legislative Relationships: Non- relationships of legislators Observational YES SOME Legislator with others in the political Government Process process (lobbyists, other government branches) influenced the outcome.] The political power of a • Ainsworth (1997) (as sponsoring legislator. selective associations) • Bourdeaux and (May suggest policy Fernandes (2007) Sponsoring entrepreneur.) [The • Bullock and Padgett YES YES Legislator’s Power sponsoring legislator had (2007) significant political clout • Ellickson (1992) • Gray and Lowery (2000) that impacted the • Meier, et al. (2009) outcome.] • Weissert, C. (1991) Overall benefit to the state or constituency as perceived by a supporting legislator. [A supporting • Bourdeaux and legislator made Fernandes (2007) State/Constituency statements or had known • Flynn, et al. (1998) Benefit (Legislative • Hadorn (1991) SOME YES positions suggesting that Perception of) • Heinrich, et al. (2013) (as the state of Florida as a important topic) whole or a specific • Meier ,et al. (2009) constituency would benefit from the bill, and it impacted the outcome.] Executive Branch Needle/ Description Source of Concept Cannabis Bill (4) Syringe Bill Support of the governor’s office. / Support of the governor’s office. • Flynn, et al. (1998) NOT IN NOT IN [Working with other • Harkreader and Governor’s Office FAVOR FAVOR legislators or lobbyists to Imershein (1999) Support • Lindley, et al. (2014) no overt no overt achieve their desired • Meier ,et al. (2009) actions actions results on another bill in • Pacheco (2014) exchange for desired results on this bill.] Governor’s veto. [Threat YES Governor’s Veto of gubernatorial veto Survey; Observational Rumored NO (Threat of) influenced the outcome.] threat

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Support of a particular • Bourdeaux and state agency. / Support of Fernandes (2007) a particular state agency. • Brownson, et al. (2011) State Agency Support • Burris, et al. (2012) NO NO [A particular state agency • Harkreader and supported the bill and it Imershein (1999) impacted the outcome.] • Meier, et al. (2009) State surgeon general. [Actions directly by the State Surgeon state surgeon general, not Survey; Observational NO NO General known to be attributable to the governor’s office, influenced the outcome.] Literature Review but Not Asked Needle/ Description Source of Concept Cannabis Bill Specifically in Syringe Bill Interview (7) • Demaine (2009) YES Celebrity Backing Celebrity endorsement. • Marsh, et al. (2010) Dr. Sanjay NO • Various Florida sources Gupta • Ann Christopher (2015) (using patient case studies) • Dodson, et al. (2013) • Gray and Lowery (2007) • Harkreader and Imershein (1999) (as unified health care elite) Public Education and A public education or • Holm and Shaheen Grassroots grassroots mobilization (1995) YES SOME Mobilization campaign. • Lukens (2014) • Madler, et al. (2014) • Meier, et al. (2009) • Pacheco and Boushey (2014) • Paul-Shaheen (1998) • Quadrango (2011) • Zakocs, et al. (2001) A special interest group’s direct discussion with • Madler (2014) Agency Discussion • Meier, et al. (2009) NO Attempted government agency • Zakocs, et al. (2001) officials. • Bourdeaux and Fernandes (2007) • Bullock and Padgett Legislator Champion The willingness of a (2007) YES YES and/or particular legislator to • Ellickson (1992) • Meier, et al. (2009) Gaetz Braynon Policy Entrepreneur champion the bill. • Paul-Shaheen (1998) • Weissert, C. (1991) (as policy entrepreneurs/opportunists) Time Spent by The amount of time spent ·Ahrens, et al. (2011) NO NO Lobbyist by lobbyists on the issue. Money Paid to The amount of money • Ahrens, et al. (2011) YES • Landers and Sehgal NO Lobbyist paid to lobbyist. (2004) Prospect of Financial support to • Bullock (2007) NO Legislative Funding legislators provided via a • Jewell and Bero (2008) Prospect of at NO via Lobbyist particular lobbyist or • Seymour and Seymour end lobbying firm. (2013)

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MISCELLANEOUS & NEW Needle/ Description Source of Concept Cannabis Bill EMERGING Syringe Bill THEMES Other, previously uncoded, contributing factor to successful passage of state legislation able to be categorized as a “general factor.” This includes MISCELLANEOUS actions or circumstances - General: that do not logically Other Previous correspond to a clear Uncoded, actor encompassed by Uncategorized another category, and relate to time, generalized foregrounding of issue, or unique circumstance such as sole backing by nongovernmental public figure. Constituent YES YES

Champion Moseley Tookes YES Constituents as YES Tookes and Active Moseley and University Advocates/Lobbyists Other Families of Miami

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APPENDIX G: CODING GUIDE FOR KEY INFORMANT INTERVIEWS

Coding Group Categories for Data Analysis of Qualitative Components 7 Major Groupings—39 Total Codes (32 unique + 7 miscellaneous)

General Factors (6) • Constitutional Amendment • Election-Year Politics • Media Attention—National • Media Attention—State/Local • Persistence • Window of Opportunity Argument and Persuasion (5) • Economic Argument • Educating Legislators on Bill Topic • Health Argument • Research • Universally Appealing Issue Constituencies (3) • Legislative Testimony/In-Person Discussion • Personal Stories—Adults • Personal Stories—Children and Parents Discussing Their Children Lobbyists (2) • Last-Minute Push/Influence • Professional Lobbyist Work Legislature (13) • Constituent Backing (Legislative Perception of) • Health Experts (Legislators as Respected Health Experts) • Horse-Trading • Individual Responsibility for Health Issue (Legislative Perception of) • Legislative Committee Support • Legislative Leadership Support • Legislative Staff Support • Majority Party Sponsorship • Special Relationships: Family and Friends • Special Relationships: Member-to-Member • Special Relationships: Non-Legislator Government Process • Sponsoring Legislator’s Power • State/Constituency Benefit (Legislative Perception of)

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Executive Branch (4) • Governor’s Office Support • Governor’s Veto (Threat of) • State Agency Support • State Surgeon General

Miscellaneous (7) • Miscellaneous—General Factors • Miscellaneous—Argument and Persuasion • Miscellaneous—Constituencies • Miscellaneous—Lobbyists • Miscellaneous—Legislature • Miscellaneous—Executive Branch • Miscellaneous—Other

Category Code Name Research Team—Internal Explanation of [Survey-Taker Explanatory Note for Survey Hover Influential Function] Factors General Constitutional Constitutional amendment. [Threat of a looming constitutional Amendment amendment was influential in the outcome of the bill.] General Election-Year Election-year politics. [Strategy to drive political outcomes in an Politics election year influenced the outcome of the bill.] General Media The amount of media attention. [This issue was deemed newsworthy Attention— and was covered by well-known newspapers, radio, or TV, and it National impacted the outcome.] General Media The amount of media attention. [This issue was deemed newsworthy Attention— and was covered by well-known newspapers, radio, or TV, and it State/Local impacted the outcome.] General Persistence A previous failed attempt(s) to pass the bill. [A bill covering this issue has been heard by the Legislature in past years but did not pass, and it impacted this bill’s outcome.] General Window of A new window of opportunity opening up. [Recent current events made Opportunity the topic of this bill a publicly supported, priority issue, and it impacted the outcome.]

Argument and Economic Persuasive economic or business argument. [A strong economic Persuasion Argument benefit, return-on-investment (ROI), or cost-effectiveness argument was made that impacted the outcome.] Argument and Educating Educating Legislators on bill topic. [Educating legislators on the bill Persuasion Legislators on Bill topic was an important factor that impacted the outcome.] Topic Argument and Health Argument Persuasive health benefit argument. [A strong public health benefit, Persuasion improved patient outcome, or improved health care (noneconomic) argument was made that impacted the outcome.] Argument and Universally Universally appealing issue. [Bill issue was universally appealing and Persuasion appealing Issue transcended political lines. This impacted the outcome.]

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Argument and Research Scientific or research backing. [Researchers or research organizations Persuasion have published materials in support of what this bill addresses and it impacted the outcome.]

Constituencies Legislative A special interest group’s legislative testimony or direct discussions Testimony/In- with legislators. [Public testimony in legislative committees or private, Person Discussion scheduled meetings with legislators by special interest groups impacted the outcome.] Constituencies Personal Stories- Personal stories. [Stories shared by constituents with legislators, either Adults in committee meetings or during office visits, influenced the outcome.] Constituencies Personal Stories— Personal stories—Children. [Stories shared specifically about children Children and by constituents with legislators, either in committee meetings or during Parents office visits, influenced the outcome.] Discussing Their Children

Lobbyists Last-Minute Last-minute Influence. [Specific last-minute additions or alterations to Influence bill language suggested by lobbyists while under final chamber consideration that influenced the outcome.] Lobbyists Professional Professional lobbyists’ work. [Paid, registered lobbyists were a driving Lobbyist work force behind this bill.]

Legislature Constituent The amount of constituent support as perceived by a supporting Backing legislator. [A supporting legislator perceived significant constituent (Legislator’s support on the subject of the bill in the form of letters, calls, or Perception of) contributions, and it impacted the outcome.] Legislature Health Experts Legislators as respected health experts. [Legislators who are also (Legislators as respected as licensed health professionals influenced the outcome of Respected Health the bill.] Experts) Legislature “Horse Trading” Trading bill support or opposition to achieve desired ends. [Working with other legislators or lobbyists to achieve their desired results on another bill in exchange for desired results on this bill.] Legislature Individual Perception of individual responsibility for health issue. [Perception or Responsibility for belief by the Legislature that a person or group of persons should or Health Issue should not bear the responsibility for the health issue addressed in the (Legislative bill influenced the outcome.] Perception of) Legislature Legislative Support of a particular legislative committee. [A particular legislative Committee committee supported the bill, and it impacted the outcome.] Support Legislature Legislative Support of legislative leadership. [Legislative leadership supported the Leadership bill, and it impacted the outcome.] Support Legislature Legislative Staff Support of a legislative staff member. [A legislative staff member Support (legislative aide, committee staff, staff director) supported the bill, and it impacted the outcome.] Legislature Majority Party Sponsorship of the bill by the political party in power (legislative Sponsorship majority). [Introduction of this bill by the majority party impacted the outcome.] Legislature Special Special Relationships: Family and Friends. [External non-legislative Relationships: relationships of legislators influenced the outcome. For example, a Family and legislator has a family member impacted by the topic of the bill.] Friends

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Legislature Special Special relationships: member-to-member. [Internal legislative Relationships: relationships between/among legislators influenced the outcome.] Member-to- Member Legislature Special Special relationships—non-legislator. Government process. [External Relationships— non-legislative relationships of legislators with others in the political Non-legislator process (lobbyists, other government branches) influenced the Government outcome.] Process Legislature Sponsoring The political power of a sponsoring legislator. (May suggest policy Legislator’s entrepreneur.) [The sponsoring legislator had significant political clout Power that impacted the outcome.] Legislature State/Constituency Overall benefit to the state or constituency as perceived by a supporting Benefit legislator. [A supporting legislator made statements or had known (Legislator’s positions suggesting that the state of Florida as a whole or a specific Perception of) constituency would benefit from the bill, and it impacted the outcome.]

Executive Governor’s Office Support of the governor’s office. [Working with other legislators or Branch Support lobbyists to achieve their desired results on another bill in exchange for desired results on this bill.] Executive Governor’s Veto Governor’s veto. [Threat of gubernatorial veto influenced the Branch (Threat of) outcome.] Executive State Agency Support of a particular state agency. [A particular state agency Branch Support supported the bill and it impacted the outcome.] Executive State Surgeon State surgeon general. [Actions directly by the state surgeon general, Branch General not known to be attributable to the governor’s office, influenced the outcome.]

Miscellaneous MISC-General: Other, previously uncoded, contributing factors to successful passage Other Previous of state legislation able to be categorized as a “general factor.” This Uncoded, includes actions or circumstances that do not logically correspond to a Uncategorized clear actor encompassed by another category, and relate to time, generalized foregrounding of issue, or unique circumstance such as sole backing by nongovernmental public figure. Miscellaneous MISC-Argument Other, previously uncoded, contributing factors to successful passage and Persuasion: of state legislation able to be categorized as “argument and Other Previous persuasion.” This includes rationale, logic, thought and policy Uncoded, processes, evidence-based, and fact-based arguments. Uncategorized Miscellaneous MISC-Lobbyists: Other, previously uncoded, contributing factors to successful passage Other Previous of state legislation able to be categorized as “Influence of Professional Uncoded, Lobbyists.” This includes specific actions taken by a paid lobbyist. Uncategorized Miscellaneous MISC- Other, previously uncoded, contributing factors to successful passage Constituencies: of state legislation able to be categorized as “Influence of Other Previous Constituencies.” This includes direct action by an individual citizen or Uncoded, organized special interest group. Uncategorized Miscellaneous MISC-Legislature: Other, previously uncoded, contributing factors to successful passage Other Previous of state legislation able to be categorized as “Influence of the Uncoded, Legislature.” This includes direct actions, beliefs, and incentives Uncategorized specific to all individuals (including employees and elected officials) within the House of Representatives or Senate. Miscellaneous MISC-Executive Other, previously uncoded, contributing factors to successful passage Branch: Other of state legislation able to be categorized as “Influence of the Executive

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Previous Branch.” This includes supportive actions by the governor’s office Uncoded, (general counsel or chief of staff level, Office of Policy and Budget), or Uncategorized by a state agency (Department of Health or similar). Miscellaneous MISC-Previously Other, previously uncoded, contributing factors to successful passage Uncoded + of state legislation previously uncategorized. This includes all other Uncategorized responses in the fill-in section of the Quantitative Phase survey, and Qualitative Phase interviews that are not encompassed in any of the previously defined categories.

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APPENDIX H: POSTSCRIPT TO THE 2014 FLORIDA LEGISLATIVE SESSION: MEDICAL CANNABIS AND NEEDLE EXCHANGE EFFORTS

Medical Cannabis

By the end of 2014, 24 states (including California and New York) and Washington, DC, had comprehensive medical marijuana laws in place while Florida had passed only a low-dose version. In the years that followed the initial bill passage, several cannabis-related bills268 were filed in the Florida House and Senate that sought to clarify and expand the work done in 2014. In

2015, none of these bills269 passed.

Five additional states, including Florida, had enacted broader medical marijuana laws by the end of 2016.270 One of Florida’s many cannabis-related bills271 passed in 2016. The Medical

Use of Cannabis bill272 (HB 307) was signed into law. The legislation included extensive changes to 2014 provisions, including revisions to medical cannabis definitions and physician requirements. In November 2016, a constitutional amendment allowing the use of medical marijuana for debilitating conditions and setting the Florida Department of Health as the regulatory agency, passed on the general election ballot.273 The ballot initiative was sponsored by

People United for Medical Marijuana, whose listed chairperson was John Morgan.274 The amendment clearly removed criminal liability, civil liability, and sanctions under Florida law for qualifying patients, their caregivers, physicians, and registered Medical Marijuana Treatment

Centers. In addition, the list of debilitating conditions275 was expanded to include “debilitating medical conditions of the same kind or class as or comparable to those enumerated, and for which a physician believes that the medical use of marijuana would likely outweigh the potential health risks for a patient,” giving significant discretion to physicians.

Of the 2017 cannabis-related bills,276 only the Industrial Hemp Pilot Projects bill277 (SB

1726) was passed into law. The legislation directed the Department of Agriculture and Consumer

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Services to authorize and oversee industrial hemp pilot project development for universities. In

June 2017, a special session of the legislature was convened to address the implementation of the constitutional amendment. Senate Bill 8-A, the Medical Use of Marijuana Act278 was passed into law along with more than $15 million in appropriations. The bill converted existing dispensing organizations to Medical Marijuana Treatment Centers, expanded the number of organizations to

17, and allowed for additional licenses and storefronts depending on qualifying patients in the registry.279 In addition, the legislature passed the Public Records/Medical Marijuana Use

Registry/Physician Certification for Marijuana and Dispensing/Department of Health bill280 (SB

6-A), which exempted personally identifying information of patients, caregivers, and physicians from public records requirements.

In 2018, among the cannabis-related bills,281 the Medical Marijuana Growers bill282 (HB

6049) passed into law, amending a requirement for medical marijuana treatment centers. House

Bill 4393, Moffitt Cancer Center–Coalition for Medical Cannabis Research and Education,283 was an appropriations project that passed as part of the general appropriations bill. More cannabis-related bills284 followed in 2019, and two bills were passed into law: the Medical Use of Marijuana bill285 (SB 182), which expanded the definition of medical cannabis to include the smoking of marijuana except in certain locations; and the State Hemp Program bill286 (SB 1020), which created the state hemp program within the Department of Agriculture and Consumer

Services.

In July 2019, the Florida First District Court of Appeals upheld part of an injunction issued by a Leon County Circuit Court that included finding the vertical integration requirement continued in the 2017 law to be unconstitutional. The Supreme Court of Florida will hear the case, although dates for oral arguments have not been determined.287 For the upcoming 2020288

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legislative session, cannabis-related bills relating to medical marijuana retail facilities, cannabis offenses, and medical cannabis use in schools have been filed.

Needle and Syringe Exchange

By 2015, 16 states, including California and New York, had passed laws that authorized needle exchanges, and other states were working to decrease barriers and remove syringes from statutory criminal drug paraphernalia definitions.289 In 2015, Senator Oscar Braynon sponsored the Infectious Disease Elimination Pilot Program bill (SB 1040), which would have that created the Miami-Dade Infectious Disease Elimination Act (IDEA). It died on second reading calendar.

Representative Katie Edwards sponsored identical HB 475, which died in committee.

By March 2016, syringe possession laws varied, often written into controlled substance and drug paraphernalia laws. Five states, including California, required a prescription for syringe possession, while 10 states (including Massachusetts and Colorado) and Washington, D.C. expressly removed syringes from drug paraphernalia definitions.290 In 2016, Senator Oscar

Braynon sponsored the Infectious Disease Elimination Pilot Program bill291 (SB 242), which created the Miami-Dade Infectious Disease Elimination Act (IDEA). It was passed on March 2,

2016, signed into law, and became effective on July 1, 2016. The University of Miami was authorized to establish a sterile needle and syringe exchange pilot program in Miami-Dade

County. In addition, the “possession, distribution, or exchange of needles and syringes under the pilot program” was found not to be a violation of the Florida Comprehensive Drug Abuse

Prevention and Control Act or other laws.

In 2018,292 Senator Braynon and other legislators sought to extend the IDEA pilot from

Miami-Dade to Broward and Palm Beach counties or, alternatively to Palm Beach County only.

No related bill succeeded.

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In 2019, the Senate Appropriations Committee, Senate Health Policy Committee, and

Senator Oscar Braynon sponsored the Infectious Disease Elimination Programs bill (SB 366), which293 provided that any county commission could authorize a sterile needle and syringe exchange program. It passed on May 2, 2019, was signed into law by the governor, and became effective July 1, 2019. This effectively expanded IDEA across the state of Florida to any county desiring the option. No related bills have been filed for the upcoming 2020 legislative session.

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APPENDIX I: SAMPLE OF SMALL TO MEDIUM HEALTH-RELATED ORGANIZATIONS

Florida Public Health Association 14646 NW 151st Blvd. Alachua, FL 32615 [email protected] https://fpha.wildapricot.org/

Florida Institute for Health Innovation (FIHI), formerly known as the Florida Public Health Institute (FPHI) 2701 N. Australian Avenue, Suite 204 West Palm Beach 33407 P: 561.838.4444 F: 561.838.4495 https://flhealthinnovation.org/

Florida Health Care Coalitions Sources: Florida Department of Health http://www.floridahealth.gov/programs-and-services/emergency-preparedness-and- response/community-preparedness/healthcare-coalitions.html

Florida Department of Health http://www.floridahealth.gov/programs-and-services/emergency-preparedness-and- response/healthcare-system-preparedness/_documents/hcctf-map.pdf

Coalition Information by Regional Domestic Security Task Force (RDSTF) Region

Region General Area Coalition Name Website # 1 Florida Panhandle Emerald Coast Healthcare Coalition https://emeraldcoasthcc.org/ (Far Northwest Florida) 2 Northwest Central Big Bend Healthcare Coalition bbhcchome.org Florida (includes Tallahassee) 3 North Central and • Northeast Florida Healthcare • http://www.neflhcc.org/ Northeast Florida Coalition (NEFLHCC) (includes Jacksonville) • North Central Florida HealthCare • http://www.ncfhcc.org/ Coalition

• Coalition for Health and Medical • https://www.marionchamp.org/ Preparedness (CHAMP)

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4 West Central Tampa Bay Health and Medical http://www.tampabayhmpc.org/ Florida Preparedness Coalition website (includes Tampa) 5 Central Florida Central Florida Disaster Medical http://www.centralfladisaster.org/ (includes Orlando) Coalition

6 Southwest Florida • Health Planning Council of • http://www.hpcswf.com/health- (includes Sarasota, Southwest Florida planning/disaster-planning- Naples) coalition/

• Heartland Healthcare Coalition • http://www.hpcswf.com/health- planning/disaster- planningcoalition/heartland/

• Suncoast Disaster Healthcare • http://www.hpcswf.com/health- Coalition planning/disaster-planningcoalition/suncoast/

• Lee County Healthcare Coalition • http://www.hpcswf.com/health- planning/disaster-planningcoalition/lee/

• Collier Healthcare Emergency • http://www.hpcswf.com/health- Preparedness Coalition planning/disaster-planningcoalition/collier-county/

7 Southeast Florida • Palm Beach County Healthcare • https://pbcherc.org/ and the Keys Emergency Response Coalition (includes West (HERC) Palm Beach, Fort Lauderdale, Miami) • Broward County Healthcare • http://www.bchconline.com/ Coalition

• Miami-Dade County Healthcare • https://www.mdchpc.org/ Preparedness Coalition

• Keys Health Ready Coalition • http://keyshrc.org/

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APPENDIX J: DRAFT ADVOCACY CHECKLIST

The Advocacy Checklist

This Advocacy Checklist is designed for individuals and organizations preparing to advocate for public health and health-related legislation. The suggested strategies may help to ensure that time, money, and manpower are used efficiently. Please see Appendix K, Florida-Specific Resources for Advocacy, for a robust list of informational links to assist in carrying out each of the recommendations. Advocates should know the schedule and dates for the legislative session and pre-session committee meetings to maximize and appropriately time use of the Advocacy Checklist.

Recommendation 1: Thoroughly assess the sociopolitical environment.

✓ Identify or Create a Window of Opportunity. Assess whether there is a social or political opening for your topic. For example, are there recent news reports discussing your topic as something that needs to be addressed urgently, or has political sentiment recently shifted on your topic? Look for opportunities to create a fertile climate for change, to create an opening if one is not readily apparent. For example, consider using polling to determine constituent support, bringing the issue as a constitutional amendment by citizen initiative if you think there will be lots of support for the issue, or generating press coverage to create the appearance of urgency or crisis. (Note that some states may allow citizen initiatives for statutory changes.) ✓ Assess Current Leadership. Examine the political makeup and positional leanings of the legislative and executive branches, including leadership positions and key staff members. For example, check for gubernatorial executive orders or state health agencies publications on the bill topic. ✓ Use the Media. Determine the level of national, state, and local media attention for topic. For example, review recent attention and social media stories on the topic; set Google alerts for similar news articles. ✓ Think About Current Political Events. Assess surrounding current and upcoming political events to determine the potential impact on the legislation. For example, are you pushing a controversial issue that would be difficult to pass in a gubernatorial election year? Has a constitutional amendment been proposed for the topic? ✓ Research Prior Related Bill History. Determine whether this topic has been discussed in the legislature previously, how many times, disposition, subtle changes in proposed language, and key sponsors and opponents. ✓ Identify Special Interest Groups. Determine which groups/organizations are likely to be interested in the topic and prior legislative efforts, such as health-related groups and groups that may be impacted by bill passage positively or negatively (can be a remote connection). You may be able to get this information through media stories or by asking known interest groups.

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Recommendation 2: Thoroughly assess the target audience.

✓ Research Legislators’ Backgrounds. Research the background and positions of key legislators. This includes party leadership and other committee members in applicable committees where the bill is likely to be sent. Research the backgrounds of people you are considering for sponsorship. Learn everything you can about the legislators’ backgrounds, such as their education, family, faith, and membership in civic groups. Know their committee memberships, political membership (majority vs. minority party), voting records, and any campaign promises they may have made related to your topic. ✓ Identify People Who Can Influence Key Legislators. Find out who might influence a legislator’s policy positions. Research who contributed to the legislator’s campaign, the legislator’s spouse, information about other close connections (family, lobbyists, business partners), and historical and current positions of constituents. Some of this information may be found through monitoring social media, local newspapers, election results for local referenda, or a sampling of emails to legislators obtained through a public records request. ✓ Research Executive Branch Members’ Backgrounds. Know the background and positions of key executive branch members including the governor, state agency heads, legislative affairs, and key staff members of the Governor’s Office of Policy and Budget (e.g., Health and Human Services policy coordinator and budget chief, overall director). ✓ Research Special Interest Groups. Find out which groups are likely to have an interest in this issue. Identify proponents, opponents, and others who might later become active in your issue. Some may be obvious (such as a medical society for issues affecting physicians). However, others may take more work to identify special interest groups. One way to do this is by talking to others who already have legislative experience—to see which groups usually work on similar types of issues. Once you identify likely proponents and opponents, look at their legislative involvement and resources. You can find out whether the group has paid lobbyists or whether the group has made campaign contributions. Search their websites to see if they have publicly stated grounds for support or opposition. ✓ Examine Lobbyists’ Backgrounds. After you identify key stakeholders, research their lobbyists. Identify lobbyists who are likely to work on this issue. Research current and historical information for each registered lobbyist known to represent a client with a position on the bill or known to have a strong personal position on the bill. Your research should include a review of lobbying registrations (legislative and executive branches), campaign contributions, relationships (personal or business), and financial dealings with legislators. Consider hiring a lobbyist for deeper-level and historical insider knowledge in addition to increased legislative access. ✓ Build a Supportive Coalition. Identify and work with other groups that have similar interests and objectives that can support your advocacy efforts by working together. A coalition of groups working together through coordinated advocacy on an issue gives the appearance of broad support, which may increase legislator interest in supporting the bill.

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Recommendation 3: Strategically select the health issue to bring forward as legislation.

✓ Critically Analyze the General Appeal of the Issue. Look critically at your bill topic to assess the general appeal of your topic. Ask others who are not as directly involved in your topic to give you feedback on the issue. Does the issue have the potential to transcend political party lines? If not, reframe or reconsider the issue. ✓ Reframe Your Issue, When Needed. There are many ways to reframe an issue. For example, you can try to identify a sympathetic group that the bill will help, for example, by focusing on the benefits of the bill on children, people with developmental disabilities, or those with cancer. Most legislative issues are statewide, so you will need to show how the issue impacts people across the state. However, if the issue has more of an impact in a particular legislative district, you might want to focus your message on that district. Reframe your issue to make it difficult for a legislator to argue against. For example, the issue should come across as hard to ignore, personally relatable, for the greater good, and attractive for positive media attention. Issues become more attractive if they are directly relevant to state residents and impactful to districts or regions that are either well-represented by policymakers in a position of power (e.g., legislative leadership) or geographically positioned where there is a strong legislative representation (e.g., Florida’s Miami-Dade delegation). ✓ Think about Long- and Short-Term Impacts of the Bill. Consider foreseeable short-term and long-term impacts across stakeholders. However, you also want to anticipate that your bill will have unintended consequences for some groups or actors. Strategically consider any hypothetical ripple effects of your proposed legislation. Those who may be impacted indirectly should also be considered as stakeholders. If they can foresee an impact that you have not considered or addressed, these indirect stakeholders may advocate against your bill behind the scenes.

Recommendation 4: Carefully craft the message and select the messenger.

✓ Carefully Develop and Frame the Message. Craft a succinct message that explains why your issue is both urgent and timely. Know who this issue affects and how many people the bill will help. When possible, use a compelling, emotive narrative to accompany bill language and convey a nonpartisan, “common denominator” message (e.g., children are suffering; increased costs and new cases of HIV/AIDS). ✓ Research to Support Your Issue. If possible, find evidence-based research to back your issue and demonstrate urgency. Show both a health-based and economic-based benefit for the bill. Find out if similar legislation has been introduced in other states, and if so, what happened. Highlight success stories from other states—particularly from states demographically and/or political similar to yours. ✓ Anticipate Your Opponents’ Arguments. For controversial issues, conduct research early to better anticipate objections and provide effective counterarguments. ✓ Carefully Select the Right Messengers or Champions. Consider initial messaging by someone in the majority party or someone with demonstrated bipartisan communication skills. In addition, it is always helpful to have a well-known spokesperson who can speak in support of the bill. Individuals with a background or expertise in health care, and those who

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have powerful personal stories can also be helpful messengers. When you are trying to identify the “right” messengers, think about the person’s past relationships with key policy makers, their prior advocacy efforts, and their reputation and ability to access legislators and legislative leadership. Be flexible in messenger choice and consider changing messengers if there is no movement over the course of three legislative sessions. ✓ Evaluate Your Messaging and Advocacy Efforts. Hold annual post-session debriefings to review of the effectiveness of both the message and the messenger and adjust both as needed. Recommendation 5: Locate a legislative champion or legislative champions.

✓ Select Legislative Champions. Locate a champion in both the House and Senate. It is generally helpful to have your primary bill sponsor be prominent or a rising star in the majority party. However, when possible, you may also want to identify a key champion in the minority party to make the bill bipartisan. ✓ Seek a Legislative Champion Who Will Actively Support Your Legislation. Ideally, find a legislative sponsor who is well-educated or interested in the issue, and someone who has the ability and commitment to push the bill as a priority throughout the legislative session. Depending on the complexity of the issue, you may need to identify a policy “entrepreneur” who can carry a new idea or lead a controversial health-related topic. ✓ Educate Your Key Sponsors. Once you have identified your key legislative sponsors, supply them with all the key research, talking points in support of your bill, and data to counter your opponent’s arguments. Your sponsor will also want to know who the key stakeholders are, and their likely positions in support of or opposition to the legislation. Recommendation 6: Focus on visibility, influence, and persistence in advocacy efforts.

✓ Increase Your Visibility. You want your issue to be visible every day of legislative session. Your group of allies should schedule meetings with legislators, legislative leadership, and relevant legislative staff directors. Testify in committees where the bill is being heard. When possible, augment your testimony with visual aids such as photos and videos. Have impacted individuals present in the committee room (e.g., sick children) to demonstrate need, show support, and provide testimony when possible. You should plan to attend pre-session committee work meetings. When the bill is not being heard or you are not meeting with legislators, members of your coalition should sit in related committee meetings to be seen. It helps to create a sense of urgency and importance by being seen in the halls of the Capitol building. ✓ Build Relationships. Relationships are key to success in the legislature. Always appear to be reasonable, approachable, receptive, polite, trustworthy, responsive and knowledgeable about your issue, and be considerate of legislative concerns/needs. Work with both sides of the political “aisle” to avoid partisan politics. Who are the main legislative contacts, colleagues, and friends of the legislator you are meeting? Can the legislator help with an introduction to a specific legislator or legislative leadership or directly advocate your cause? Build rapport with a legislator and, when possible, enlist their help in reaching harder-to-access legislators. Grow support and create trust with legislators and other stakeholders through open-minded, open-ended conversation.

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✓ Leverage Your Influence. Ensure that legislators hear from constituents who are directly impacted by the issue. It is particularly effective if the constituents are from the legislator’s district. Present testimony by individuals with evidence-based knowledge or training on the topic (e.g., health professionals and related students near graduation). Strategically map out and leverage key member-to-member and member-to-non-legislator relationships to determine circles of influence. Also map out and leverage your coalition members’ connections. Continue mapping out relationships until you have found a way to access all key legislators. ✓ Develop a One-Page Issue Brief and Key Talking Points. Never miss an opportunity to succinctly educate legislators. Have a one-page advocacy document, research, and elevator speech ready to go. A one-page document should concisely list the problem issue, the solution including relevant bill impacted/language, financial and health returns-on- investment, and brief research highlights that includes similar actions by other states. Bring the one-pager to every legislative meeting and leave it with the legislator and/or legislative aide. Have copies of the most supportive research to leave with the legislator and/or legislative aide. Have a concise “elevator speech” ready to go to pique interest in the event you pass a legislator in the hallway or elevator. ✓ Exercise Persistence. You should not expect your bill to pass on the first attempt. Regardless, you should work as if it will. Think marathon, not sprint. Build momentum. If your bill does not pass, it does not mean failure if you have successfully laid the groundwork and support for the issue in the next legislative session. Give best efforts for each attempt. Take the time needed to educate legislators, legislative staff (committee staff directors, legislative aides, leadership staff), executive branch members, lobbyists, and special interest groups. Build support and momentum over time while watching for larger windows of opportunity or a perfect storm of favorable social and political conditions. Be prepared for multiple legislative attempts and flexible in adjusting bill language or champions.

Recommendation 7: Remain vigilant in the final hours of legislative session.

✓ Track Your Legislation. - Use a legislative tracking service throughout the legislative session to notify you regarding any bill actions. Such services are available free via legislative links or through paid subscription services. ✓ Anticipate Sudden Bill Actions. Know the likelihood of your bill being used as a “train” or omnibus, catch-all bill for any issue that falls under the umbrella of “health.” Conversely, if the session is ending and your bill has not passed, consider finding a “catch-all” bill that is likely to pass and attach your bill language. Understand the likelihood of last-minute amendments and have a basic skeleton bill ready as a back-up or compromise, when appropriate. ✓ Monitor Leadership Changes. Look out for any last-minute changes of support, position, or prioritization of the bill across the legislative and executive branches. ✓ Watch for Horse-Trading. Determine if the bill is being used to horse-trade support on another bill. If so, monitor both bills closely. You should also monitor all “finish line” bills (bills likely to pass) generally. In addition, monitor whether your bill is being held as

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leverage for political issues (e.g., Senate confirmation of gubernatorial appointments) or being held until bill language is tweaked to provide economic or other benefits to special interest groups. Monitor and quickly counter any lobbying against your bill. If your bill is passed, continue to monitor for the possibility of veto and any challenges to regulatory implementation.

Recommendation 8: Evaluate and Plan for Continuous Strategic Advocacy Improvement.

✓ After-Action Review. Evaluate the success of your advocacy efforts: what worked well and what could have gone better. Some items would include reviewing an individual advocate’s performance and legislative access, whether certain messages resonated with legislators, and what unexpected barriers were encountered. ✓ Revise Strategic Approach as Needed. Strive for continuous strategic/advocacy improvement. Consider whether your advocacy efforts are actually “moving the needle” on your health policy issue. Use the lessons from the After-Action Review to guide any needed revisions to the strategic approach. For example, legislators may be more receptive to different bill language or to a particular advocate or lobbyist. Perhaps additional knowledge of legislative relationships or more in-person advocacy was needed. Consider also collaborating with new partners across business sectors and engaging in year-round advocacy for new opportunities to gain support.

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APPENDIX K: FLORIDA-SPECIFIC RESOURCES FOR ADVOCACY

This is a non-exhaustive list of helpful Florida-specific resources for use in conjunction with The Advocacy Checklist in Appendix I.

House of Representatives • General site—https://www.myfloridahouse.gov/ • House Bill Tracker sign-up— https://www.myfloridahouse.gov/Sections/MyHouse/accountcreation.aspx • House Bill search by session/number— https://www.myfloridahouse.gov/Sections/Bills/bills.aspx • House Leadership page and descriptions— https://www.myfloridahouse.gov/Sections/LeadershipOffices/LeadershipOffices.aspx?Ca tegory=PublicGuide&File=Leadership.html • House Majority Office— https://www.myfloridahouse.gov/FileStores/Web/HouseContent/Approved/ClerksOffice/ HouseDirectory.pdf • House Minority Office— https://www.myfloridahouse.gov/Sections/LeadershipOffices/HouseMinority/HouseMino rity.aspx • House member pages by Speaker— https://www.myfloridahouse.gov/Sections/Representatives/representatives.aspx • House member directory showing committees and staff— https://www.myfloridahouse.gov/FileStores/Web/HouseContent/Approved/ClerksOffice/ HouseDirectory.pdf • District maps— https://www.myfloridahouse.gov/contentViewer.aspx?Category=PublicGuide&File=Abo ut_The_Representatives_--_House_Districts_Maps.html

Senate • General site—https://www.flsenate.gov/ • Senate Bill Tracker sign-up—https://www.flsenate.gov/Tracker/Signup • Senate Bill search by session/number/term—https://www.flsenate.gov/Session/Bills/2020 • Office of the Senate President— https://www.flsenate.gov/Offices/President • Senate Majority Office—https://www.flsenate.gov/Offices/Majority/ • Senate Minority Office—https://www.flsenate.gov/Offices/Minority • Senate member pages by Senate President—https://www.flsenate.gov/Senators • Senate directory showing committees and staff— https://www.flsenate.gov/PublishedContent/ADMINISTRATIVEPUBLICATIONS/SDI R.pdf • District maps—http://www.flsenate.gov/senators/districts

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• Florida Senate Archives— http://archive.flsenate.gov/Welcome/index.cfm?CFID=1636962&CFTOKEN=80147398

Executive Branch • Executive Office of the Governor—https://www.flgov.com/ o EOG Organizational Chart (updated periodically)—https://www.flgov.com/meet- staff/ o EOG Legislative Affairs—https://www.flgov.com/legislative_affairs/ o EOG Office of Policy and Budget (OPB)—https://www.flgov.com/opb/ o Current executive orders—https://www.flgov.com/2019-executive-orders/ o Prior executive orders—https://www.flgov.com/all-executive-orders/ • Health-Related State Agencies (some may fall as Cabinet, rather than gubernatorial agencies) o Agency for Healthcare Administration (AHCA)—https://ahca.myflorida.com/ o Agency for Persons with Disabilities (APD)—http://apd.myflorida.com/ o Department of Children and Families (DCF)—https://www.myflfamilies.com/ o Department of Education (DOE)—http://www.fldoe.org/ o Florida Department of Elder Affairs (DOEA)—http://elderaffairs.state.fl.us/ o Department of Health (DOH)—http://www.floridahealth.gov/ o Department of Revenue (DOR)—https://floridarevenue.com/pages/default.aspx o Florida Department of Veterans Affairs (FDVA)—http://floridavets.org/ o Division of Blind Services—http://dbs.myflorida.com/Information/index.html o Division of Vocational Rehabilitation—http://www.rehabworks.org/

Election Year • Contributions-Campaign Finance Database—https://dos.elections.myflorida.com/campaign- finance/contributions/ • Election Results– https://dos.myflorida.com/elections/data-statistics/elections-data/

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Constitutional Amendments • https://dos.myflorida.com/elections/laws-rules/constitutional-amendments/

Public Records Requests • https://myfloridalegal.com/pages.nsf/Main/321B47083D80C4CD8525791B006A54E3

Lobbying • General lobbying information with lobbying firms, lists, compensation reports— https://www.floridalobbyist.gov/ • Registered Legislative Lobbyists— https://www.floridalobbyist.gov/LobbyistInformation/RegisteredLegislativeLobbyists • Registered Executive Branch Lobbyists— https://www.floridalobbyist.gov/LobbyistInformation/RegisteredExecutiveLobbyists • Legislative intelligence, bill tracking, and news service (paid subscription)— https://www.lobbytools.com/

News and Historical • List of various Capital coverage news sources—https://thecapitolist.com/mediaguide/ • The Florida Channel—https://thefloridachannel.org/ • The Florida Channel video archives of past committee meetings and Capitol Updates— https://thefloridachannel.org/videos/

Research • Office of Economic and Demographic Research (EDR)— http://www.edr.state.fl.us/Content/ • Florida Legislature’s Office of Program Policy Analysis and Government Accountability (OPPAGA)—http://www.oppaga.state.fl.us/ • Florida State University College of Law Florida Research Center-Legislative History Sources—https://guides.law.fsu.edu/c.php?g=84905&p=547304

Political Parties • Republican Party of Florida (RPOF/Florida GOP)—https://florida.gop/ • Florida Democratic Party—https://www.floridadems.org/

Select Major Organizational Influencers (not limited to health) • Florida Medical Association (FMA)—https://www.flmedical.org/florida/ • Florida Osteopathic Medical Association (FOMA)—https://www.foma.org/ • Florida Hospital Association (FHA)—http://www.fha.org/ • Associated Builders and Contractors (ABC) of Florida—http://www.abcflorida.com/ • Associated Industries of Florida (AIF)—http://aif.com/index.html • Florida Chamber of Commerce—https://www.flchamber.com/ • Florida United Businesses Association (FUBA)—https://fuba.org/ • Florida Fraternal Order of Police—http://www.floridastatefop.org/Home.asp

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• Florida Hospitality Industry Association—https://floridahia.com/ • Florida Justice Association (formerly Trial Lawyers Association)— https://www.floridajusticeassociation.org/ • Florida Realtors—https://floridarealtors.org • Florida Sheriffs Association—https://www.flsheriffs.org/

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ENDNOTES

1 See National Institutes of Health. (2019). Genetic home reference: What disorders are included in newborn screening? Retrieved from https://ghr.nlm.nih.gov/primer/newbornscreening/nbsdisorders

2 The United States Census Bureau’s National Population Totals Datasets: 2010-2015 show Florida at 19.9 million in estimated population for 2014 and at 18.8 million for 2010. United States Census Bureau. (n.d.). National population totals datasets: 2010-2015. Retrieved from https://data.census.gov/cedsci/table?q=National%20Population%20Totals%20Datasets%3A%20- 2015&g=0400000US12&tid=ACSDT1Y2014.B01003&t=Population%20Total&y=2014&vintage=2015 &hidePreview=true&d=ACS%201-Year%20Estimates%20Detailed%20Tables

3 United States Census Bureau. (2014, December 23). Florida passes New York to become the nation’s third most populous state, census bureau reports. Retrieved from http://census.gov/newsroom/press- releases/2014/cb14-232.html

4 See United Health Foundation (2016). America’s health rankings: State Data-FL. Retrieved from http://www.americashealthrankings.org/FL. References to overall health trends and uninsured population in the last few years.

5 See, e.g., Patton, C. (2015, November 14). Florida, like nation, faces a shortage of physicians over next decade. The Florida Times-Union. Retrieved from http://jacksonville.com/news/health-and-fitness/2015- 11-14/story/florida-nation-faces-shortage-physicians-over-next-decade; McGrory, K. (2016, February 1). Florida facing a ‘nursing shortage tsunami’ due to increased population, more insured patients. Tampa Bay Times. Retrieved from http://www.tampabay.com/news/health/florida-facing-a-nursing-shortage- tsunami-due-to-increased-population-more/2263588.

6 See, e.g., Taylor, P. (2016). The demographic trends shaping American politics in 2016 and beyond. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2016/01/27/the- demographic-trends-shaping-american-politics-in-2016-and-beyond/

7 United States Census Bureau. (2014). 2014 American Community Survey 1-year population estimates: Florida – ACS demographic and housing estimates. Retrieved from https://data.census.gov/cedsci/all?q=2014%20Florida%20population%20estimates&g=0400000US12&hi dePreview=false&tid=ACSDP1Y2014.DP05&t=Counts,%20Estimates,%20and%20Projections&y=2014 &vintage=2014&layer=VT_2014_040_00_PY_D1&cid=DP05_0001E; United States Census Bureau. (2014). 2014 American Community Survey 1-year population estimates: United States – ACS demographic and housing estimates. Retrieved from https://data.census.gov/cedsci/table?q=2014%20united%20states%20population%20estimates%20ACS% 20demographic%20and%20housing&g=0100000US&tid=ACSDP1Y2014.DP05&t=Counts,%20Estimate s,%20and%20Projections%3AHousing&y=2014

8 See, e.g., Benton, J. E. (Ed.). (2008). Government and politics in Florida (3rd ed.). Gainesville, FL: University Press of Florida.

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9 Weissert, C.S. & Weissert, W.G. (2008). Florida’s health care policy: Making do on the cheap. In J.E. Benton (Ed.), Government and Politics in Florida (3rd ed., pp. 357-382). Gainesville, FL: University of Florida Press. See p. 365. Noting Florida being a leading state in addressing controversial public health issues, such as a right-to-die.

10 America’s Health Rankings. (2014). 2014 Annual report. Retrieved from http://assets.americashealthrankings.org/app/uploads/americas-health-rankings-2014-edition.pdf. See p. 93.

11 America’s Health Rankings. (2014). 2014 Annual report. Retrieved from http://assets.americashealthrankings.org/app/uploads/americas-health-rankings-2014-edition.pdf. See p. 47.

12 America’s Health Rankings. (2014). 2014 Annual report. Retrieved from http://assets.americashealthrankings.org/app/uploads/americas-health-rankings-2014-edition.pdf. See p. 93.

13 Pew Research Center. (2017). Party affiliation by state (2014). Retrieved from http://www.pewforum.org/religious-landscape-study/compare/party-affiliation/by/state/

14 “Bills introduced in the House and Senate that are identical or substantially similar in wording are known as companion bills. The use of companion bills allows bills in both bodies to move through the committee process at the same time.” Florida House of Representatives. (n.d.). Legislative glossary. Retrieved from https://www.myfloridahouse.gov/Sections/PublicGuide/Glossary.aspx

15 See Florida Legislature. (1999). The committee process. Retrieved from http://www.leg.state.fl.us/cgi- bin/View_Page.pl?Tab=info_center&Submenu=2&File=process.html&Directory=Info_Center/about_legi slature/&Location=app

16 Compiled data from Florida Legislature. (n.d.). Regular session statistics reports (2012-2016). Retrieved from https://www.flsenate.gov/Session/Reports/

17 Florida Legislature. (2014). Regular session – 2014 – statistics report. Retrieved from http://www.leg.state.fl.us/data/session/2014/citator/Daily/stats.pdf

18 Florida Legislature. (2014). Regular session – 2014 – statistics report. Retrieved from http://www.leg.state.fl.us/data/session/2014/citator/Daily/stats.pdf

19 See, e.g., Brasher, H., Lowery, D., & Gray, V. (1999). State lobby registration data: The anomalous case of Florida (and Minnesota too!). Legislative Studies Quarterly, 24, 303–314.

20 Gray, V. & Lowery, D. (2017). Interest groups registered in lobby in the states: 1980-2007. Unpublished data, Department of Political Science, University of North Carolina, Chapel Hill. Data supplied by V. Gray, personal communication (June 12, 2017).

21 Gray, V. & Lowery, D. (2017). Interest groups registered in lobby in the states: 1980-2007. Unpublished data, Department of Political Science, University of North Carolina, Chapel Hill. Data supplied by V. Gray, personal communication (June 12, 2017).

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22 National Institute on Money in State Politics. (2017). Lobbyist link. Retrieved from https://www.followthemoney.org/tools/lobbyist-link/

23 National Institute on Money in State Politics. (2017). Lobbyist link. Retrieved from https://www.followthemoney.org/tools/lobbyist-link/

24 Florida Legislature. (2014). Regular session – 2014 – statistics report. Retrieved from http://www.leg.state.fl.us/data/session/2014/citator/Daily/stats.pdf. In 2014, the final year selected, 112 bills were referred to the House Health & Human Services Committee. It was often, but not always, the final committee stop before the House floor.

25 Florida Legislature. (2014). Regular session – 2014 – statistics report. Retrieved from http://www.leg.state.fl.us/data/session/2014/citator/Daily/stats.pdf. In 2014, the final year selected, 97 bills were referred to the House Health and Human Services Committee. It was generally not the final committee stop before the Senate floor.

26 Florida Senate. (n.d.). Legislative bill information, 2014 Reg. Sess. CS for CS for SB 1030 (Bill history, versions, and analyses). Retrieved from https://www.flsenate.gov/Session/Bill/2014/1030

27 See, e.g., Maule, W. J. (2015). Medical uses of marijuana (Cannabis sativa): Fact or fallacy? British Journal of Biomedical Science, 72(2), 85-91 (discussing history of medical marijuana use, legality, and potential for addition); Bowles, D. W., O’Bryant, C. L., Camidge, D. R., & Jimeno, A. (2012). The intersection between cannabis and cancer in the United States. Critical Reviews in Oncology/Hematology, 83(1), 1-10 (discussing legality of cannabis and its exploration for use in cancer therapies in the United States).

28 More than 1.6 million new cases of cancer were expected to be diagnosed in 2015, with more than 500,000 Americans expected to die from cancer in 2015. In the United States, cancer accounts for one in four deaths, second only to heart disease. See American Cancer Society. (2015). Cancer facts & figures. Retrieved from http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc- 044552.pdf

29 See, e.g., Hussain, S. A., Zhou, R., Jacobson, C., Weng, J., Cheng, E., Lay, J., & Sankar, R. (2015). Perceived efficacy of cannabidiol-enriched cannabis extracts for treatment of pediatric epilepsy: A potential role for infantile spasms and Lennox-Gastaut syndrome. Epilepsy & Behavior, 47, 138-141 (suggesting that certain cannabis forms may positively benefit refractory childhood epilepsy but that clinical trials are needed to truly assess safety and efficacy).

30 See, e.g., Carter, G. T., Abood, M. E., Aggarwal, S. K., & Weiss, M. D. (2010). Cannabis and amyotrophic lateral sclerosis: Hypothetical and practical applications, and a call for clinical trials. American Journal of Hospice and Palliative Medicine, 27(5), 347-356 (preclinical and existing scientific data suggested that cannabis may be beneficial to ALS for symptom management, may have antioxidative and anti-inflammatory effects, and may actually slow ALS progression). About 6,400 new cases of ALS are diagnosed in the United States annually. See The ALS Association (2015). Facts you should know. Retrieved from http://www.alsa.org/about-als/facts-you-should-know.html

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31 See, e.g., Wilsey, B., Marcotte, T., Deutsch, R., Gouaux, B., Sakai, S., & Donaghe, H. (2013). Low- dose vaporized cannabis significantly improves neuropathic pain. The Journal of Pain, 14(2), 136-148 (double-blind, placebo-controlled, crossover study suggesting that vaporized cannabis, even at low doses, can significantly decrease neuropathic pain).

32 See, e.g., Rosenberg, K. (2015). Medical cannabis effective for chronic pain, other indications. American Journal of Nursing, 115(10), 53-53 (examining systematic reviews that explore medical cannabis for a variety of health conditions such as HIV, glaucoma, chemotherapy-induced nausea and vomiting, and Tourette’s syndrome).

33 The ALS Association (2015). Facts you should know. Retrieved from http://www.alsa.org/about- als/facts-you-should-know.html. See pp. 5-6.

34 See. The ALS Foundation, Florida Chapter (2015). About us. Retrieved from http://webfl.alsa.org/site/PageServer?pagename=FL_2_about_our_chapter

35 See, e.g., Epilepsy Foundation of Florida. (2015). About us. Retrieved from http://www.efof.org/index.php/about-us. See also Mitchell, T. & Klas, M.E. (2014). Gov. Rick Scott signs ‘Charlotte’s Web’ medical marijuana bill. Tampa Bay Times. Retrieved from http://www.tampabay.com/news/politics/stateroundup/gov-scott-signs-charlottes-web-marijuana-bill-into- law/2184590

36 See Florida Senate. (n.d.). Legislative bill information, 2014 Reg. Sess. CS for CS for SB 1030 (Bill history, versions, and analyses). Retrieved from https://www.flsenate.gov/Session/Bill/2014/1030

37 See Florida House of Representatives (n.d.). Retrieved from www.myfloridahouse.gov

38 See CBS Miami. (2014, June 14). Governor Scott signs medical marijuana bill. Retrieved from http://miami.cbslocal.com/2014/06/16/governor-scott-signs-medical-marijuana-bill/.

39 Fla. CS for CS for SB 1030 (2014) (The Compassionate Medical Cannabis Act of 2014, Ch. 2014-157, Florida Laws).

40 Florida Department of Health. (2013). Epidemiology of HIV infection trends in Florida reported through 2013. Retrieved from http://www.floridahealth.gov/diseases-and- conditions/aids/surveillance/_documents/HIV-AIDS-slide%20sets/state-trends-2013.pdf

41 Florida Department of Health. (2014). HIV/AIDS surveillance, 2014 monthly surveillance report, February 2014, Number 350. Retrieved from http://www.floridahealth.gov/%5C/diseases-and- conditions/aids/surveillance/_documents/msr/2014-msr/MSR0214.pdf

42 Florida Department of Health. (2014). HIV/AIDS surveillance, 2014 monthly surveillance report, February 2014, Number 350. Retrieved from http://www.floridahealth.gov/%5C/diseases-and- conditions/aids/surveillance/_documents/msr/2014-msr/MSR0214.pdf

43 Care Resource. (2017). HIV/AIDS statistics. Retrieved from http://www.careresource.org/hivaids/statistics/

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44 See, e.g., Centers for Disease Control and Prevention. (2016). Access to clean syringes. Retrieved from https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html

45 See Florida House of Representatives (n.d.). Retrieved from www.myfloridahouse.gov

46 Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., The PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097

47 Kingdon, J. W. (2010). Agendas, alternatives, and public policies (Rev. 2nd ed.). New York, NY: Pearson Longman.

48 Kingdon (2010), at 227-29.

49 Kingdon (2010), at 200-05.

50 Lindblom, C. E. (1959). The science of “muddling through.” Public Administration Review, 19(2), 79- 88. doi:10.2307/973677; and Lindblom, C. E. (1979). Still muddling, not yet through. Public Administration Review, 39(6), 517-526.

51 Cohen, M. D., March, J. G., & Olsen, J. P. (1972). A garbage can model of organizational choice. Administrative Science Quarterly, 17(1), 1-25. For additional discussion of the garbage can model in conjunction with saliency issues, see Weissert, W. G., & Weissert, C. S. (2012). Governing health: The politics of health policy (4th ed.). Baltimore, MD: The Johns Hopkins University Press.

52 Lindblom (1959). See also discussion in Kingdon (2010).

53 Stone, D.A. (2011). Policy paradox: The art of political decision making (3rd ed.). New York, NY: Norton.

54 Stone (2011), at 380.

55 See Stone (2011). See also Feldstein, P.J. (2006). The politics of health legislation: An economic perspective (3rd ed.). Chicago, IL: Health Administration Press; Ricketts, T. (2009). Public health policy and the policy making process. In F. D. Scutchfield & W. Keck (Eds.), Principles of public health practice (pp. 86-115). Clifton Park, NY: Delmar Cengage Learning.

56 Interest groups may act dispersedly as policy brokers and work in conjunction with political parties and lobbying groups to increase their profile and effectiveness. See Heaney, M. T. (2006). Brokering health policy: Coalitions, parties, and interest group influence. Journal of Health Politics, Policy and Law, 31(5), 887-944.

57 See, e.g., Hackey, R.B. & Rochefort, D.A. (Eds.). (2001). The new politics of state health policy. Lawrence, KS: University Press of Kansas.

173

58 Within health policy research, economic evaluations and cost-benefit analyses can be useful to health policymaker decisions. See, e.g., Grosse, S.D. (2011). Lessons from cost-effectiveness research for United States public health policy. Annual Review of Public Health, 28, 365-391.

59 Health policymakers are more likely to use health services research when it is timely, submitted with supporting documentation, and provided in a context of personal contact. See Innvær, S., Vist, G., Trommald, M., & Oxman, A. (2002). Health policy-makers’ perceptions of their use of evidence: A systematic review. Journal of Health Services Research and Policy, 7(4), 239-244; and Lavis, J. N., Ross, S. E., Hurley, J. E., Hohenadel, J. M., Stoddart, G. L., Woodward, C. A., & Abelson, J. (2002). Examining the role of health services research in public policymaking. The Milbank Quarterly, 80(1), 125–154. In addition, evidence-based research made relevant at the local level, in conjunction with ongoing legislative communication by public health practitioners, may increase the influence of research on health policymaking. See Jones, E., Kreuter, M., Pritchett, S., Matulionis, R.M., & Hann, N. (2006). Health policy makers: What’s the message and who’s listening? Health Promotion Practice, 7(3), 280- 286.

60 See generally Leatt, P., & Mapa, J. (Eds.). (2003). Government relations in the health care industry. Westport, CT: Praeger Publishers.

61 See, e.g., Heymann, P.B. (2008). Living the policy process. New York, NY: Oxford University Press.

62 Carpenter, D. (2012). Is health politics different? Annual Review of Political Science, 15(1), 287-311.

63 Brown, L.D. (2010). The political face of public health. Public Health Reviews, 32(1), 155–173.

64 See Gray, V., Lowery, D., & Godwin, E. K. (2007). Public preferences and organized interests in health policy: State pharmacy assistance programs as innovations. Journal of Health Politics, Policy and Law, 32(1), 89-129. doi:10.1215/03616878-2006-029

65 See, e.g., Morone, J.A., & Ehlke, D.C. (2014). Health politics and policy (5th ed.). Stamford, CT: Cengage Learning.

66 See, e.g., public policymaking process described in Longest, B.B. (2010). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press; and description of a “stage-sequential model” in Mason, D.J., Leavitt, J.K., & Chaffee, M.W. (2007). Policy & politics in nursing and health care (5th ed.). St. Louis, MO: Saunders.

67 Oliver, T. R. (2006). The politics of public health policy. Annual Review of Public Health, 27(1), 195- 233, at 224.

68 Legislation can be a critical preliminary step to changing societal health patterns. See, e.g., Lankford, T., Hardman, D., Dankmeyer, C., & Schmid, T. (2013). Analysis of state obesity legislation from 2001 to 2010. Journal of Public Health Management and Practice, 19(3), S114-S118.

174

69 Gostin, L.O. (2008). Public health law: Power, duty, restraint (Rev. 2nd ed.). Berkeley, CA: University of California Press; Gostin, L.O., Areen, J., King, P.A., Goldberg, S., & Jacobson, P.D. (2005). Law, science, and medicine (3rd ed.). New York, NY: Foundation Press; and Patel, K., & Rushefsky, M.E. (2014). Healthcare politics and policy in America (4th ed.). New York, NY: Routledge.

70 Gostin (2008), at 81.

71 See, e.g., Karch, A. (2012). Vertical diffusion and the policy-making process: The politics of embryonic stem cell research. Political Research Quarterly, 65(1), 48-61. doi:10.1177/1065912910385252

72 Boeckelman, K. (1992). The influence of states on federal-policy adoptions. Policy Studies Journal, 20(3), 365-375. doi:10.1111/j.1541-0072.1992.tb00164.x

73 Weissert, C. S., & Scheller, D. (2008). Learning from the states? Federalism and national health policy. Public Administration Review, 68(1), S162-S174. doi:10.1111/j.1540-6210.2008.00986.x

74 Weil, A. R., & Tallon, J. R. (2008). The states’ role in national health reform. The Journal of Law, Medicine & Ethics, 36(4), 690-692. doi:10.1111/j.1748-720X.2008.00323.x

75 Pacheco, J., & Boushey, G. (2014). Public health and agenda setting: Determinants of state attention to tobacco and vaccines. Journal of Health Politics, Policy and Law, 39(3), 565-589. doi:10.1215/03616878-2682612

76 Weissert, C. S., & Schram, S. F. (1998). The state of American federalism, 1997-1998. Publius, 28(1), 1-22. doi:10.1093/oxfordjournals.pubjof.a029942

77 Regan, P. M., & Deering, C. J. (2009). State opposition to REAL ID. Publius, 39(3), 476-505. doi:10.1093/publius/pjp004

78 See, e.g., Sabatier, P. A. (Ed.). (1999). Theories of the policy process. Boulder, CO: Westview Press.

79 Carpenter, D. (2012). Is health politics different? Annual Review of Political Science, 15(1), 287-311.

80 See, e.g., Oliver, T. R. (2006). The politics of public health policy. Annual Review of Public Health, 27(1), 195-233. Public health policymaking involves a broad spectrum of interest groups and actors.

81 Paul-Shaheen, P. (1998). The states and health care reform: The road traveled and lessons learned from seven that took the lead. Journal of Health Politics, Policy and Law, 23(2), 319-361.

82 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

83 Pacheco, J., & Boushey, G. (2014). Public health and agenda setting: Determinants of state attention to tobacco and vaccines. Journal of Health Politics, Policy and Law, 39(3), 565-589. doi:10.1215/03616878-2682612

175

84 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

85 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH

86 Zakocs, R.C., Earp, J.L, & Runyan, C.W. (2001). State gun control advocacy tactics and resources. American Journal of Preventive Medicine, 20(4), 251-257.

87 Brownson, R. C., Dodson, E. A., Stamatakis, K. A., Casey, C. M., Elliott, M. B., Luke, D. A., … Kreuter, M. W. (2011). Communicating evidence-based information on cancer prevention to state-level policy makers. Journal of the National Cancer Institute, 103(4), 306-316. doi:10.1093/jnci/djq529

88 Dodson, E., Stamatakis, K., Chalifour, S., Haire-Joshu, D., McBride, T., & Brownson, R. (2013). State legislators’ work on public health-related issues: What influences priorities? Journal of Public Health Management and Practice, 19(1), 25-29. doi:10.1097/PHH.0b013e318246475c

89 Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x

90 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

91 Heller, D. J., Hoffman, C., & Bindman, A. B. (2014). Supporting the needs of state health policy makers through university partnerships. Journal of Health Politics, Policy and Law, 39(3), 667-677. doi:10.1215/03616878-2682641

92 Brownson, R. C., Dodson, E. A., Stamatakis, K. A., Casey, C. M., Elliott, M. B., Luke, D. A., … Kreuter, M. W. (2011). Communicating evidence-based information on cancer prevention to state-level policy makers. Journal of the National Cancer Institute, 103(4), 306-316. doi:10.1093/jnci/djq529

93 Dodson, E., Stamatakis, K., Chalifour, S., Haire-Joshu, D., McBride, T., & Brownson, R. (2013). State legislators’ work on public health-related issues: What influences priorities? Journal of Public Health Management and Practice, 19(1), 25-29. doi:10.1097/PHH.0b013e318246475c

94 Flynn, B.S., Goldstein, A.O., Solomon, L.J., Bauman, K.E., Gottlieb, N.H., Cohen, J.E., Munger, M.C., & Dana, G.S. (1998). Predictors of state legislators’ intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157-165.

95 Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x

176

96 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

97 Bourdeaux, C., & Fernandes, J. (2007). A legislative perspective on program budgeting for public health in Georgia. Journal of Public Health Management and Practice, 13(2), 180-187.

98 Hadorn, D. C. (1991). The Oregon priority-setting exercise: Quality of life and public policy. The Hastings Center Report, 21(3), 11-16.

99 Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x

100 Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371

101 Demaine, L. J. (2009). Navigating policy by the stars: The influence of celebrity entertainers on federal lawmaking. The Journal of Law & Politics, 25(2), 83.

102 Marsh, D., Hart, P., & Tindall, K. (2010). Celebrity politics: The politics of the late modernity? Political Studies Review, 8(3), 322-340. doi:10.1111/j.1478-9302.2010.00215.x

103 See, e.g., Miami Herald. (2013, May 2). Marino: Weatherford thinks Dolphins bill has ‘good chance’ of clearing house. Retrieved from http://miamiherald.typepad.com/nakedpolitics/2013/05/as-dolphins- bill-still-stalls-dan-marino-shows-up-at-florida-house.html (noting Dan Marino visiting legislature regarding Miami Dolphins and autism); Flagler Live (2014, March 24). David Beckham lobbies Tallahassee for tax breaks on a soccer stadium in Miami. Retrieved from https://flaglerlive.com/65475/david-beckham-florida/

104 Ainsworth, S. H. (1997). The role of legislators in the determination of interest group influence. Legislative Studies Quarterly, 22(4), 517-533, at 520.

105 See Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x

106 See Bullock, C.S. & Padgett, K.L. (2007). Partisan change and consequences for lobbying: Two-party government comes to the Georgia legislature. State & Local Government Review, 39(2), 61-71.

107 Bourdeaux, C., & Fernandes, J. (2007). A legislative perspective on program budgeting for public health in Georgia. Journal of Public Health Management and Practice, 13(2), 180-187.

108 Bullock & Padgett (2007).

177

109 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

110 Eyler, A. A., Nguyen, L., Kong, J., Yan, Y., & Brownson, R. (2012). Patterns and predictors of enactment of state childhood obesity legislation in the United States: 2006-2009. American Journal of Public Health, 102(12), 2294-2302. doi:10.2105/AJPH.2012.300763

111 Dodson, E., Stamatakis, K., Chalifour, S., Haire-Joshu, D., McBride, T., & Brownson, R. (2013). State legislators’ work on public health-related issues: What influences priorities? Journal of Public Health Management and Practice, 19(1), 25-29. doi:10.1097/PHH.0b013e318246475c

112 Flynn, B.S., Goldstein, A.O., Solomon, L.J., Bauman, K.E., Gottlieb, N.H., Cohen, J.E., Munger, M.C., & Dana, G.S. (1998). Predictors of state legislators’ intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157-165.

113 Heinrich, K. M., Stephen, M. O., Vaughan, K. B., & Kellogg, M. (2013). Kansas legislators prioritize obesity but overlook nutrition and physical activity issues. Journal of Public Health Management and Practice, 19(2), 139-145. doi:10.1097/PHH.0b013e318254cc57

114 Bourdeaux, C., & Fernandes, J. (2007). A legislative perspective on program budgeting for public health in Georgia. Journal of Public Health Management and Practice, 13(2), 180-187.

115 Flynn et al. (1998).

116 Hadorn, D. C. (1991). The Oregon priority-setting exercise: Quality of life and public policy. The Hastings Center Report, 21(3), 11-16.

117 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

118 Gray, V., & Lowery, D. (2000). Where do policy ideas come from? A study of Minnesota legislators and staffers. Journal of Public Administration Research and Theory, 10(3), 573-597. doi:10.1093/oxfordjournals.jpart.a024282

119 Weissert, C. S. (1991). Policy entrepreneurs, policy opportunists, and legislative effectiveness. American Politics Quarterly, 19(2), 262-274.

120 Ellickson, M.C. (1992). Pathways to legislative success: A path analytic study of the Missouri house of representatives. Legislative Studies Quarterly, 17(2), 285-302.

121 Ellickson (1992), at 286.

122 Ainsworth, S. H. (1997). The role of legislators in the determination of interest group influence. Legislative Studies Quarterly, 22(4), 517-533.

178

123 Flynn, B.S., Goldstein, A.O., Solomon, L.J., Bauman, K.E., Gottlieb, N.H., Cohen, J.E., Munger, M.C., & Dana, G.S. (1998). Predictors of state legislators’ intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157-165.

124 Brownson, R. C., Dodson, E. A., Stamatakis, K. A., Casey, C. M., Elliott, M. B., Luke, D. A., … Kreuter, M. W. (2011). Communicating evidence-based information on cancer prevention to state-level policy makers. Journal of the National Cancer Institute, 103(4), 306-316. doi:10.1093/jnci/djq529

125 Weissert, C. S., & Weissert, W. G. (2000). State legislative staff influence in health policy making. Journal of Health Politics, Policy and Law, 25(6): 1121-1148.

126 Weissert & Weissert (2000).

127 Dodson, E., Stamatakis, K., Chalifour, S., Haire-Joshu, D., McBride, T., & Brownson, R. (2013). State legislators’ work on public health-related issues: What influences priorities? Journal of Public Health Management and Practice, 19(1), 25-29. doi:10.1097/PHH.0b013e318246475c

128 Gray, V., Lowery, D., & Godwin, E. K. (2007). Public preferences and organized interests in health policy: State pharmacy assistance programs as innovations. Journal of Health Politics, Policy and Law, 32(1), 89-129. doi:10.1215/03616878-2006-029

129 Lukens, G. (2014). State variation in health care spending and the politics of state Medicaid policy. Journal of Health Politics, Policy and Law, 39(6), 1213-1251. doi:10.1215/03616878-2822634

130 Madler, B. J., Kalanek, C. B., & Rising, C. (2014). Gaining independent prescriptive practice: One state’s experience in adoption of the APRN consensus model. Policy, Politics & Nursing Practice, 15(3- 4), 111-118. doi:10.1177/1527154414562299

131 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

132 Pacheco, J., & Boushey, G. (2014). Public health and agenda setting: Determinants of state attention to tobacco and vaccines. Journal of Health Politics, Policy and Law, 39(3), 565-589. doi:10.1215/03616878-2682612

133 Quadagno, J. (2011). Interest-group influence on the patient protection and affordability act of 2010: Winners and losers in the health care reform debate. Journal of Health Politics, Policy and Law, 36(3), 449-453. doi:10.1215/03616878-1271081

134 Ann Christopher, M., Duhl, J., Rosati, R.J., & Sheehan, K.M. (2015). Advocacy for vulnerable patients: How grassroots organizations can influence health care policy. American Journal of Nursing, 115(3), 66-69. doi:10.1097/01.NAJ.0000461810.34602.58

135 Holm, R. S., & Shaheen, P. N. (1995). Influencing the political process through coalitions: The Michigan council for maternal and child health. Pediatric Annals, 24(8), 409-412. doi:10.3928/0090- 4481-19950801-07

179

136 Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371

137 Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x

138 Madler, B. J., Kalanek, C. B., & Rising, C. (2014). Gaining independent prescriptive practice: One state’s experience in adoption of the APRN consensus model. Policy, Politics & Nursing Practice, 15(3- 4), 111-118. doi:10.1177/1527154414562299

139 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

140 Zakocs, R.C., Earp, J.L, & Runyan, C.W. (2001). State gun control advocacy tactics and resources. American Journal of Preventive Medicine, 20(4), 251-257.

141 Madler et al. (2014).

142 Zakocs et al. (2001).

143 Lowery, D. (2013). Lobbying influence: Meaning, measurement and missing. Interest Groups & Advocacy, 2(1), 1-26. doi:http://dx.doi.org/10.1057/iga.2012.20

144 Ahrens, D., Jones, N., Pfister, K., & Remington, P.L. (2011). An analysis of lobbying activity on tobacco issues in the Wisconsin legislature. Wisconsin Medical Journal, 110(2), 74-77.

145 Landers, S. H., & Sehgal, A. R. (2004). Health care lobbying in the United States. The American Journal of Medicine, 116(7), 474-477. doi:10.1016/j.amjmed.2003.10.037

146 Landers & Sehgal (2004), at 477.

147 Bullock, C.S. & Padgett, K.L. (2007). Partisan change and consequences for lobbying: Two-party government comes to the Georgia legislature. State & Local Government Review, 39(2), 61-71.

148 McKay, A. (2012). Negative lobbying and policy outcomes. American Politics Research, 40(1), 116- 146. doi:10.1177/1532673X11413435

149 See Yackee, S. W. (2015). Invisible (and visible) lobbying: The case of state regulatory policymaking. State Politics & Policy Quarterly, 15(3), 322-344. doi:10.1177/1532440015588148; Barrilleaux, C. (2015). A mini-symposium on regulation in the states. State Politics & Policy Quarterly, 15(3), 319-321. doi:10.1177/1532440015589315

150 Bullock & Padgett (2007).

180

151 Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x

152 Seymour, W. N., & Seymour, G. N. (2013). Dollars, lobbying, and secrecy: How campaign contributions and lobbying affect public policy. Reviews on Environmental Health, 28(4), 173-180. doi:10.1515/reveh-2013-0500

153 Monardi, F., & Glantz, S. A. (1998). Are tobacco industry campaign contributions influencing state legislative behavior? American Journal of Public Health, 88(6), 918-923. doi:10.2105/AJPH.88.6.918

154 Bourdeaux, C., & Fernandes, J. (2007). A legislative perspective on program budgeting for public health in Georgia. Journal of Public Health Management and Practice, 13(2), 180-187.

155 Brownson, R. C., Dodson, E. A., Stamatakis, K. A., Casey, C. M., Elliott, M. B., Luke, D. A., … Kreuter, M. W. (2011). Communicating evidence-based information on cancer prevention to state-level policy makers. Journal of the National Cancer Institute, 103(4), 306-316. doi:10.1093/jnci/djq529

156 Burris, S., Mays, G. P., Scutchfield, F. D., & Ibrahim, J. K. (2012). Moving from intersection to integration: Public health law research and public health systems and services research. The Milbank Quarterly, 90(2), 375-408. doi:10.1111/j.1468-0009.2012.00667.x

157 Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371

158 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

159 Flynn, B.S., Goldstein, A.O., Solomon, L.J., Bauman, K.E., Gottlieb, N.H., Cohen, J.E., Munger, M.C., & Dana, G.S. (1998). Predictors of state legislators’ intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157-165.

160 Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371

161 Lindley, L. C., Edwards, S., & Bruce, D. J. (2014). Factors influencing the implementation of health care reform: An examination of the concurrent care for children provision. American Journal of Hospice and Palliative Medicine, 31(5), 527-533. doi:10.1177/1049909113494460

162 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

163 Pacheco, J., & Boushey, G. (2014). Public health and agenda setting: Determinants of state attention to tobacco and vaccines. Journal of Health Politics, Policy and Law, 39(3), 565-589. doi:10.1215/03616878-2682612

181

164 Crew, R. E., & Lewis, C. (2011). Verbal style, gubernatorial strategies, and legislative success. Political Psychology, 32(4), 623-642. doi:10.1111/j.1467-9221.2011.00832.x

165 Flynn, B.S., Goldstein, A.O., Solomon, L.J., Bauman, K.E., Gottlieb, N.H., Cohen, J.E., Munger, M.C., & Dana, G.S. (1998). Predictors of state legislators’ intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157-165.

166 Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371

167 Paul-Shaheen, P. (1998). The states and health care reform: The road traveled and lessons learned from seven that took the lead. Journal of Health Politics, Policy and Law, 23(2), 319-361.

168 Weissert, C. S. (1991). Policy entrepreneurs, policy opportunists, and legislative effectiveness. American Politics Quarterly, 19(2), 262-274.

169 Oliver, T. R., & Paul-Shaheen, P. (1997). Translating ideas into actions: Entrepreneurial leadership in state health care reforms. Journal of Health Politics, Policy and Law, 22(3), 721-788. doi:10.1215/03616878-22-3-721

170 Frameworks Institute (2002). Framing public issues. Retrieved from http://www.frameworksinstitute.org/assets/files/PDF/FramingPublicIssuesfinal.pdf. See p. 3.

171 Frameworks Institute (2002), at 1-4.

172 Ostrom, E. (2007). Institutional rational choice: An assessment of the institutional analysis and development framework. In P.A. Sabatier (Ed.), Theories of the policy process (2nd ed., pp. 21-24). Boulder, CO: Westview Press.

173 Sabatier, P.A., & Weible, C.M. (2007). The advocacy coalition framework: Innovations and clarifications. In P.A. Sabatier (Ed.), Theories of the policy process (2nd ed., pp. 189-196). Boulder, CO: Westview Press.

174 Frameworks Institute (2002), at 4.

175 Frameworks Institute (2002), at 4.

176 Lakoff, G. (2014). The all new don’t think of an elephant!: Know your values and frame the debate. White River Junction, VT: Chelsea Green Publishing. See p. xii.

177 Frameworks Institute (2002), at 8, 46.

178 Lakoff (2014), at xii-xiii.

179 Lakoff (2014), at 3-4, 33-34.

180 Frameworks Institute (2002).

182

181 Frameworks Institute (2002), at 45.

182 Frameworks Institute (2002), at 10.

183 Ryan, W. (1976). Blaming the victim (Revised, updated ed.). New York, NY: Random House.

184 Ryan (1976), at 17-18, 301-303.

185 Ryan (1976), at 18.

186 Ryan (1976), at 15, 163-166.

187 Morone, J. (1997). Enemies of the people: The moral dimensions to public health. Journal of Health Politics, Policy and Law, 22(4):993–1020. See p. 1007.

188 Morone (1997), at 1008.

189 Netherland, J., & Hansen, H. (2017). White opioids: Pharmaceutical race and the war on drugs that wasn't. BioSocieties, 12(2), 217-238. doi:10.1057/biosoc.2015.46

190 See, e.g., Morone (1997), at 1007-1010; Netherland, J., & Hansen, H. (2016). The war on drugs that wasn’t: Wasted whiteness, “dirty doctors,” and race in media coverage of prescription opioid misuse. Culture, Medicine and Psychiatry, 40(4), 664-686, at 664-668. doi:10.1007/s11013-016-9496-5

191 See, e.g., Netherland & Hansen (2017).

192 Blau, M. (2019, March 18). African Americans missing out on southern push for legal pot. Stateline. Retrieved from https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/03/18/african- americans-missing-out-on-southern-push-for-legal-pot

193 Blau (2019).

194 Hansen, H., & Netherland, J. (2016). Is the prescription opioid epidemic a white problem? American Journal of Public Health, 106(12), 2127-2129. doi:10.2105/AJPH.2016.303483

195 Lowery, D. (2013). Lobbying influence: Meaning, measurement and missing. Interest Groups & Advocacy, 2(1), 1-26. doi:http://dx.doi.org/10.1057/iga.2012.20. See p. 8.

196 Study design resources included: Creswell, J.W. (2009). Research design (3rd ed.). Thousand Oaks, CA: Sage; Creswell, J.W. & Plano Clark, V.L. (2011). Designing and conducting mixed methods research (2nd ed.). Thousand Oaks, CA: Sage; and Yin, R.K. (2013). Case study research: Design and methods (5th ed.). Los Angeles, CA: Sage Publications.

197 See, e.g., Buse, K. (2008). Addressing the theoretical, practical and ethical challenges inherent in prospective health policy analysis. Health Policy Plan, 23(5), 351-360. doi: 10.1093/heapol/czn026

183

198 Based on Ivankova, N. V., Creswell, J. W., & Stick, S. L. (2006). Using mixed-methods sequential explanatory design: From theory to practice. Field Methods, 18(1), 3-20. doi:10.1177/1525822X05282260

199 For the bill that failed to pass, the question will be “Why Did That Bill Nearly Pass?” with identical questions except for an additional open-ended question to type in up to 100 characters. This additional question will read “In your opinion, why did this bill ultimately fail to pass?”

200 Only for the bill that failed to pass, an additional question will ask what the ultimate cause of the bill’s failure was, in the stakeholder’s opinion, and the modifier “near” or “nearly” will be placed in front of “successful passage” with the remaining portions of the questions remaining the same.

201 VERBI Software. (2018, September). Teamwork. In MAXQDA 2018 manual. Retrieved from https://www.maxqda.com/help-max18/teamwork/can-maxqda-support-teamwork

202 Gwet, K.L. (2012). Handbook of inter-rater reliability: The definitive guide to measuring the extent of agreement among multiple raters (3rd ed.). Gaithersburg, MD: Advanced Analytics.

203 McHugh, M. (2012). Interrater reliability: The kappa statistic. Biochemical Medicine, 22(3), 276-282. Retrieved from http://www.ncbi.nlm.nih.gov.libproxy.lib.unc.edu/pmc/articles/PMC3900052/?report=printable

204 Weed: Dr. Sanjay Gupta Reports (CNN) first aired on August 11, 2013. Cable News Network. (2013, August 11). Weed: Dr. Sanjay Gupta reports [Television broadcast]. Atlanta, GA: CNN. See also Gupta, S. (2013, August 8). Why I changed my mind on weed. Cable News Network. Retrieved from https://www.cnn.com/2013/08/08/health/gupta-changed-mind-marijuana/index.html

205 National Conference of State Legislatures. (2019). State medical marijuana laws. Retrieved from https://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.

206 National Conference of State Legislatures (2019). See also Lee, J. (2014). Which states have legalized medical marijuana? USA Today. Retrieved from https://www.usatoday.com/story/news/nation- now/2014/01/06/marijuana-legal-states-medical-recreational/4343199/

207 See, e.g., Adams, D., & Fagenson, Z. (2014). Analysis: Florida democrats may get buzz from medical marijuana. Reuters. Retrieved from https://www.reuters.com/article/us-usa-florida-marijuana- analysis/analysis-florida-democrats-may-get-buzz-from-medical-marijuana-idUSBREA0R01C20140128

208 Interviewed in a post-2014 article that confirmed his support. The article also noted that Surgeon General Armstrong tried to “torpedo” the bill. See Schultz, H. & Chandrasekaran, R. (2017, October 20). Upstanders: One doctor’s needle fix. Upstanders. Retrieved from https://stories.starbucks.com/stories/2017/upstanders-one-doctors-needle-fix/

209 Katherine Fernandez Rundle.

210 D-Part of Miami-Dade, District 36 (2014).

184

211 D-Part of Palm Beach, District 86 (2014). Also sponsored 2013 bill.

212 Vice Chair, Senate Committee on Regulated Industries.

213 R-Part of Miami-Dade, Senate District 37 (2014).

214 D-Part of Miami-Dade, House District 111 (2014).

215 R-Part of Miami-Dade, House District 118 (2014).

216 Gonzalez is also credited with convincing the chair of Government Operations Committee in the House, Frank Artiles, to hear the bill in committee after it was delayed for reading. House Sponsor Mark Pafford was noted by a couple of respondents as successfully promoting IDEA among state representatives. Other significant proponents of the bill noted by respondents included State Representatives Cary Pigman, an emergency medicine physician; Ken Roberson, chair of the Health Quality Subcommittee in the House; David Richardson; Patrick Rooney Jr.; Daphne Campbell, a nurse; José Javier Rodríguez “JJR;” and Alan Williams. Other noted proponents included Senators René Garcia, Gwen Margolis, 2013 bill sponsor; and Aaron Bean, chair of Senate Committee on Health Policy, which was the first committee stop for SB 408, IDEA.

217 In the Senate (2014): Gwen Margolis (D-35), Oscar Braynon II (D-36, Minority Whip), Anitere Flores (R-37), René Garcia (R-38), Dwight Bullard (D-39), Miguel Diaz de la Portilla (R-40). In the House (2014): Joseph “Joe” Gibbons (D-100), Sharon Pritchett (D-102), Manny Diaz Jr. (R-103), Carlos Trujillo (R-105), Barbara Watson (D-107), Daphne Campbell (D-108), Cynthia Stafford (D-109), José Oliva (R- 110, Eduardo “Eddy” Gonzalez (D-111), José Javier Rodríguez “JJR” (D-112), David Richardson (D- 113), Erik Fresen (R-114), Michael Bileca (R-115), Jose Félix Diaz (R-116), Kionne McGhee (D-117), Frank Artiles (R-118), Jeanette Nuñez (R-119, currently Lieutenant Governor of Florida), Holly Merrill Raschein (R-120).

218 R- Part of Miami-Dade, District 115 (2014).

219 R-Flagler, Putnam, St. Johns, part of Volusia, District 6 (2014).

220 See Kingdon, J. W. (2010). Agendas, alternatives, and public policies (Rev. 2nd ed.). New York, NY: Pearson Longman.

221 Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913; Paul- Shaheen, P. (1998). The states and health care reform: The road traveled and lessons learned from seven that took the lead. Journal of Health Politics, Policy and Law, 23(2), 319-361; Shelov, S. P. (1995). The use of media to impact on legislation. Pediatric Annals, 24(8), 419-420, 422. doi:10.3928/0090-4481- 19950801-09; Zakocs, R.C., Earp, J.L, & Runyan, C.W. (2001). State gun control advocacy tactics and resources. American Journal of Preventive Medicine, 20(4), 251-257.

185

222 Meier et al. (2009); Pacheco, J., & Boushey, G. (2014). Public health and agenda setting: Determinants of state attention to tobacco and vaccines. Journal of Health Politics, Policy and Law, 39(3), 565-589. doi:10.1215/03616878-2682612; Paul-Shaheen (1998).

223 Cable News Network. (2013, August 11). Weed: Dr. Sanjay Gupta reports [Television broadcast]. Atlanta, GA: CNN.

224 See, e.g., Adams, D., & Fagenson, Z. (2014). Analysis: Florida democrats may get buzz from medical marijuana. Reuters. Retrieved from https://www.reuters.com/article/us-usa-florida-marijuana- analysis/analysis-florida-democrats-may-get-buzz-from-medical-marijuana-idUSBREA0R01C20140128 (notes that a November 2013 Quinnipiac University poll showed 70% of registered Republicans in Florida, 87%of registered Democrats, and 88% of independents favored medical marijuana).

225 Demaine, L. J. (2009). Navigating policy by the stars: The influence of celebrity entertainers on federal lawmaking. The Journal of Law & Politics, 25(2), 83; Marsh, D., Hart, P., & Tindall, K. (2010). Celebrity politics: The politics of the late modernity? Political Studies Review, 8(3), 322-340. doi:10.1111/j.1478-9302.2010.00215.x

226 Brownson, R. C., Dodson, E. A., Stamatakis, K. A., Casey, C. M., Elliott, M. B., Luke, D. A., … Kreuter, M. W. (2011). Communicating evidence-based information on cancer prevention to state-level policy makers. Journal of the National Cancer Institute, 103(4), 306-316. doi:10.1093/jnci/djq529; Dodson, E., Stamatakis, K., Chalifour, S., Haire-Joshu, D., McBride, T., & Brownson, R. (2013). State legislators’ work on public health-related issues: What influences priorities? Journal of Public Health Management and Practice, 19(1), 25-29. doi:10.1097/PHH.0b013e318246475c; Heller, D. J., Hoffman, C., & Bindman, A. B. (2014). Supporting the needs of state health policy makers through university partnerships. Journal of Health Politics, Policy and Law, 39(3), 667-677. doi:10.1215/03616878- 2682641; Jewell, C. J., & Bero, L. A. (2008). “Developing good taste in evidence”: Facilitators of and hindrances to evidence-informed health policymaking in state government. The Milbank Quarterly, 86(2), 177-208. doi:10.1111/j.1468-0009.2008.00519.x; Meier, B. M., Hodge, J. G., Jr, & Gebbie, K. M. (2009). Transitions in state public health law: Comparative analysis of state public health law reform following the turning point model state public health act. American Journal of Public Health, 99(3), 423-430. doi:10.2105/AJPH.2008.140913

227 Brownson et al. (2011); Dodson et al. (2013); Flynn, B.S., Goldstein, A.O., Solomon, L.J., Bauman, K.E., Gottlieb, N.H., Cohen, J.E., Munger, M.C., & Dana, G.S. (1998). Predictors of state legislators’ intentions to vote for cigarette tax increases. Preventive Medicine, 27, 157-165; Jewell and Bero (2008); Meier et al. (2009).

228 Bourdeaux, C., & Fernandes, J. (2007). A legislative perspective on program budgeting for public health in Georgia. Journal of Public Health Management and Practice, 13(2), 180-187; Hadorn, D. C. (1991). The Oregon priority-setting exercise: Quality of life and public policy. The Hastings Center Report, 21(3), 11-16; Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371; Jewell and Bero (2008).

186

229 See, e.g., Ryan, W. (1976). Blaming the victim (Revised, updated ed.). New York, NY: Random House; Morone, J. (1997). Enemies of the people: The moral dimensions to public health. Journal of Health Politics, Policy and Law, 22(4):993–1020; Hansen, H., & Netherland, J. (2016). Is the prescription opioid epidemic a white problem? American Journal of Public Health, 106(12), 2127-2129. doi:10.2105/AJPH.2016.303483

230 See, e.g., Ryan (1976); Morone (1997); Hansen & Netherland (2016).

231 Jewell and Bero (2008); Madler, B. J., Kalanek, C. B., & Rising, C. (2014). Gaining independent prescriptive practice: One state’s experience in adoption of the APRN consensus model. Policy, Politics & Nursing Practice, 15(3-4), 111-118. doi:10.1177/1527154414562299; Meier et al. (2009); Zakocs, R.C., Earp, J.L, & Runyan, C.W. (2001). State gun control advocacy tactics and resources. American Journal of Preventive Medicine, 20(4), 251-257.

232 Ann Christopher, M., Duhl, J., Rosati, R.J., & Sheehan, K.M. (2015). Advocacy for vulnerable patients: How grassroots organizations can influence health care policy. American Journal of Nursing, 115(3), 66-69. doi:10.1097/01.NAJ.0000461810.34602.58; Dodson et al. (2013); Gray, V., Lowery, D., & Godwin, E. K. (2007). Public preferences and organized interests in health policy: State pharmacy assistance programs as innovations. Journal of Health Politics, Policy and Law, 32(1), 89-129. doi:10.1215/03616878-2006-029; Harkreader, S., & Imershein, A. W. (1999). The conditions for state action in Florida’s health-care market. Journal of Health and Social Behavior, 40(2), 159-174. doi:10.2307/2676371; Holm, R. S., & Shaheen, P. N. (1995). Influencing the political process through coalitions: The Michigan council for maternal and child health. Pediatric Annals, 24(8), 409-412. doi:10.3928/0090-4481-19950801-07; Lukens, G. (2014). State variation in health care spending and the politics of state Medicaid policy. Journal of Health Politics, Policy and Law, 39(6), 1213-1251. doi:10.1215/03616878-2822634; Madler et al. (2014); Meier et al. (2009); Pacheco, J., & Boushey, G. (2014). Public health and agenda setting: Determinants of state attention to tobacco and vaccines. Journal of Health Politics, Policy and Law, 39(3), 565-589. doi:10.1215/03616878-2682612; Paul-Shaheen, P. (1998). The states and health care reform: The road traveled and lessons learned from seven that took the lead. Journal of Health Politics, Policy and Law, 23(2), 319-361; Quadagno, J. (2011). Interest-group influence on the patient protection and affordability act of 2010: Winners and losers in the health care reform debate. Journal of Health Politics, Policy and Law, 36(3), 449-453. doi:10.1215/03616878- 1271081; Zakocs et al. (2001).

233 Ahrens, D., Jones, N., Pfister, K., & Remington, P.L. (2011). An analysis of lobbying activity on tobacco issues in the Wisconsin legislature. Wisconsin Medical Journal, 110(2), 74-77; Bullock, C.S. & Padgett, K.L. (2007). Partisan change and consequences for lobbying: Two-party government comes to the Georgia legislature. State & Local Government Review, 39(2), 61-71; Jewell and Bero (2008); Madler et al. (2014); McKay, A. (2012). Negative lobbying and policy outcomes. American Politics Research, 40(1), 116-146. doi:10.1177/1532673X11413435 (as negative lobbying); Seymour, W. N., & Seymour, G. N. (2013). Dollars, lobbying, and secrecy: How campaign contributions and lobbying affect public policy. Reviews on Environmental Health, 28(4), 173-180. doi:10.1515/reveh-2013-0500; Zakocs et al. (2001).

234 Ahrens et al. (2011).

235 Ahrens et al. (2011); Landers, S. H., & Sehgal, A. R. (2004). Health care lobbying in the United States. The American Journal of Medicine, 116(7), 474-477. doi:10.1016/j.amjmed.2003.10.037

187

236 Bullock & Padgett (2007); Jewell and Bero (2008); Seymour and Seymour (2013).

237 Ainsworth, S. H. (1997). The role of legislators in the determination of interest group influence. Legislative Studies Quarterly, 22(4), 517-533; Bullock and Padgett (2007); Jewell and Bero (2008).

238 Ainsworth (1997); Bourdeaux and Fernandes (2007); Bullock and Padgett (2007); Ellickson, M.C. (1992). Pathways to legislative success: A path analytic study of the Missouri house of representatives. Legislative Studies Quarterly, 17(2), 285-302.; Gray, V., & Lowery, D. (2000). Where do policy ideas come from? A study of Minnesota legislators and staffers. Journal of Public Administration Research and Theory, 10(3), 573-597. doi:10.1093/oxfordjournals.jpart.a024282; Meier et al. (2009); Weissert, C. S. (1991). Policy entrepreneurs, policy opportunists, and legislative effectiveness. American Politics Quarterly, 19(2), 262-274.

239 Bourdeaux and Fernandes (2007); Flynn et al. (1998); Hadorn (1991); Heinrich, K. M., Stephen, M. O., Vaughan, K. B., & Kellogg, M. (2013). Kansas legislators prioritize obesity but overlook nutrition and physical activity issues. Journal of Public Health Management and Practice, 19(2), 139-145. doi:10.1097/PHH.0b013e318254cc57; Meier et al. (2009).

240 Dodson et al. (2013); Flynn et al. (1998).

241 Ellickson, M.C. (1992). Pathways to legislative success: A path analytic study of the Missouri house of representatives. Legislative Studies Quarterly, 17(2), 285-302; Lindley, L. C., Edwards, S., & Bruce, D. J. (2014). Factors influencing the implementation of health care reform: An examination of the concurrent care for children provision. American Journal of Hospice and Palliative Medicine, 31(5), 527-533. doi:10.1177/1049909113494460; Lukens (2014); Paul-Shaheen (1998).

242 Flynn et al. (1998); Harkreader and Imershein (1999); Paul-Shaheen (1998); Weissert, C. (1991).

243 Brownson (2011).

244 Weissert & Weissert (2000).

245 Flynn et al. (1998); Harkreader and Imershein (1999); Lindley et al. (2014); Meier et al. (2009); Pacheco & Boushey (2014).

246 Bourdeaux and Fernandes (2007); Brownson et al. (2011); Burris, S., Mays, G. P., Scutchfield, F. D., & Ibrahim, J. K. (2012). Moving from intersection to integration: Public health law research and public health systems and services research. The Milbank Quarterly, 90(2), 375-408. doi:10.1111/j.1468- 0009.2012.00667.x; Harkreader and Imershein (1999); Meier et al. (2009).

247 Madler (2014); Meier et al. (2009); Zakocs et al. (2001).

248 Reframe the issue. See, e.g., Lakoff, G. (2014). The all new don’t think of an elephant!: Know your values and frame the debate. White River Junction, VT: Chelsea Green Publishing; Frameworks Institute (2002). Framing public issues. Retrieved from http://www.frameworksinstitute.org/assets/files/PDF/FramingPublicIssuesfinal.pdf

188

249 See, e.g., Lakoff (2014); Frameworks Institute (2002).

250 Rogers, E.M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.

251 Rogers (2003), at 5-6.

252 Dearing, J.W., & Cox, J.G. (2018). Diffusion of innovations theory, principles, and practice. Health Affairs, 37(2):183-190. doi:10.1377/hlthaff.2017.1104

253 Rogers (2003), at 280.

254 Dearing and Cox (2018), modified from Rogers (2003), at 281. Copyrighted and published by Project HOPE/Health Affairs as: James Dearing and Jeffrey Cox “Diffusion Of Innovations Theory, Principles, And Practice.” Health Affairs (Millwood) 2018. Vol. 37, No. 2, 183-190. The published article is archived and available online at www.healthaffairs.org. Reused with permission from Project HOPE/Health Affairs. (Modified from Rogers, 2003, p. 281).

255 Dearing and Cox (2018).

256 Dearing and Cox (2018).

257 Rogers (2003), at 222.

258 Rogers (2003), at 222.

259 Rogers (2003), at 229.

260 Rogers (2003), at 240.

261 Rogers (2003), at 257.

262 Rogers (2003), at 258.

263 Rogers (2003), at 258.

264 Dearing, J.W. (2009). Applying diffusion of innovation theory to intervention development. Research on Social Work Practice, 19(5): 503-518. doi:10.1177/1049731509335569

265 For the bill that did not pass, the modifier “near” or “nearly” was added in front of “passage,” and an additional question asked, “In your opinion, why did the bill ultimately fail to pass?”

266 Florida Senate (2019). Reference: Glossary. Retrieved from https://www.flsenate.gov/Reference/Glossary

267 Florida Senate (2019). Reference: FAQ. Retrieved from https://www.flsenate.gov/Reference/FAQ/

189

268 Senate Bills 2015: SB 528 (Brandes) Medical Use of Marijuana died in committee, SB 902 (Clemens) Hemp Production died in committee, SB 1176 (Bullard) Recreational Marijuana died in committee, SB 1294 (Bullard) Cannabis died in committee, SB 7066 (Regulated Industries) Low-THC Cannabis died on second reading calendar. House Bills 2015: HB 363 (Rehwinkel Vasilinda) Hemp Production died in committee, HB 683 (Steube and Wood) Medical Use of Marijuana died in committee, HB 1097 (Wood) Public Records/Medical Marijuana Patient Registry died in committee, HB 1297 (Bracy) Recreational Marijuana died in committee, HB 4041 (Rehwinkel Vasilinda) Cannabis died in committee.

269 Senate Bills 2015: SB 528 (Brandes) Medical Use of Marijuana died in committee, SB 902 (Clemens) Hemp Production died in committee, SB 1176 (Bullard) Recreational Marijuana died in committee, SB 1294 (Bullard) Cannabis died in committee, SB 7066 (Regulated Industries) Low-THC Cannabis died on second reading calendar. House Bills 2015: HB 363 (Rehwinkel Vasilinda) Hemp Production died in committee, HB 683 (Steube and Wood) Medical Use of Marijuana died in committee, HB 1097 (Wood) Public Records/ Medical Marijuana Patient Registry died in committee, HB 1297 (Bracy) Recreational Marijuana died in committee, HB 4041 (Rehwinkel Vasilinda) Cannabis died in committee.

270 National Conference of State Legislatures. (2017). Deep Dive: Marijuana. State Marijuana Policies Timeline. Retrieved from http://www.ncsl.org/bookstore/state-legislatures-magazine/marijuana-deep- dive.aspx

271 Senate Bills 2016: SB 460 Medical Use of Cannabis (Bradley) laid on table and companion bill passed, SB 554 Hemp Production (Clemens) died in committee, SB 616 Cannabis (Bullard) died in committee, SB 852 Medical Marijuana (Brandes) died in committee, SB 1608 Florida Agricultural and Mechanical University Industrial Hemp Program (Montford) died in committee. House Bills 2016: HB 63 Medical Use of Low-THC Cannabis (Steube) withdrawn prior to introduction; HB 65 Public Records/Low-THC Cannabis Patient Registry/DOH (Steube) withdrawn prior to introduction, HB 271 Industrial Hemp Programs (Agriculture & Natural Resources Subcommittee, Rehwinkel Vasilinda, Dudley) died in committee, HB 307 Medical Use of Cannabis (Health & Human Services Committee, Health Care Appropriations Subcommittee, Criminal Justice Subcommittee (Gaetz, Brodeur, Edwards- Walpole), signed into law, HB 1183 Medical Use of Marijuana (Wood) died in committee, HB 1185 Public Records/Medical Marijuana Patient Registry (Wood) died in committee, HB 1257 Florida Agricultural and Mechanical University Industrial Hemp Program (Dudley, Rehwinkel Vasilinda) died in committee HB 1313 Low-THC Cannabis for Medical Use (Brodeur, Steube) laid on table, HB 4021 Cannabis (Rehwinkel Vasilinda) died in committee.

272 Sponsored by the Health & Human Services Committee, Health Care Appropriations Subcommittee, Criminal Justice Subcommittee, and Representatives Gaetz, Brodeur, and Edwards.

273 2016 Constitutional Amendment passed by a vote of 6,518,919 to 2,621,845 (71.3% of voters). Florida Division of Elections. (n.d.). Use of marijuana for debilitating conditions, 15-01. Retrieved from https://dos.elections.myflorida.com/initiatives/initdetail.asp?account=50438&seqnum=3

274 See Florida Division of Elections (n.d.).

190

275 “‘Debilitating Medical Condition’ means cancer, epilepsy, glaucoma, positive status for human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), post-traumatic stress disorder (PTSD), amyotrophic lateral sclerosis (ALS), Crohn’s disease, Parkinson’s disease, multiple sclerosis, or other debilitating medical conditions of the same kind or class as or comparable to those enumerated, and for which a physician believes that the medical use of marijuana would likely outweigh the potential health risks for a patient.” Fla. Const. art. X, § 29(b)(1).

276 Senate Bills 2017: SB 406 Compassionate Use of Low-THC Cannabis and Marijuana (Bradley) laid on table, SB 614 Medical Marijuana (Brandes) died in committee, SB 1388 Medical Cannabis (Artiles) withdrawn, SB 1472 Medicinal Cannabis Research and Education (Galvano) died in committee, SB 1662 Cannabis (Clemens) died in committee, SB 1666 Medical Use of Marijuana (Braynon) died in committee, SB 1726 Industrial Hemp Pilot Projects (Montford) passed into law, SB 1758 Medical Use of Marijuana (Grimsley) withdrawn, SB 1844 Public Records/ Compassionate Use Registry (Bradley) laid on the table. House Bills 2017: HB 1177 Medical Cannabis Research & Education (Toledo) died in committee, HB 1217 Industrial Hemp Programs (Commerce Committee, Appropriations Committee, Agriculture & Property Rights Subcommittee, Massullo) laid on table and companion bill passed (SB 1726), HB 1303 Synthetic Cannabinoids (Latvala) died in committee, HB 1397 Medical Use of Marijuana (Health & Human Services Committee, Appropriations Committee, Rodrigues, R., Edwards-Walpole) passed both chambers and was highly amended eventually dying in House, HB 1403 Cannabis (C. Smith) died in committee, HB 7095 Public Records/Medical Marijuana Use Registry (Health & Human Services Committee, Health Quality Subcommittee, Plasencia) passed both chambers and was highly amended eventually dying in House.

277 Sponsored by Senator Montford.

278 Sponsored by Senator Bradley.

279 Greenberg, J. (2017, November). Florida’s medical marijuana industry remains hazy. Florida Bar Journal, 91(9), 18. Retrieved from https://www.floridabar.org/the-florida-bar-journal/floridas-medical- marijuana-industry-remains-hazy/

280 Sponsored by Senator Bradley.

281 Senate Bills 2018: SB 726 Smoking Marijuana for Medical Use (Farmer) died in committee, SB 986 Medical Use of Marijuana in Schools (Montford) died in committee, SB 1134 Department of Health Responsibilities Related to the Medical Use of Marijuana (Rouson) was laid on the table and companion bill passed (HB 6049), SB 1336 Medical Marijuana Retail Facilities (Thurston) died in committee, SB 1602 Cannabis (Bracy) died in committee. House Bills 2018: HB 1053 Medical Marijuana Retail Facilities (DuBose) died in committee, HB 1203 Cannabis (C. Smith) died in committee, HB 1291 Medical Use of Marijuana in Schools (Drake) died in committee, HB 4393 Moffitt Cancer Center– Coalition for Medical Cannabis Research and Education (La Rosa) passed in Appropriations HB 5001 line item 457A, HB 6049 Medical Marijuana Growers (Jones, Newton) passed into law.

282 Sponsored by Representatives Jones and Newton.

283 Sponsored by Representative La Rosa.

191

284 Senate Bills 2019: SB 154 (Thurston) Medical Marijuana Retail Facilities died in committee, SB 182 (Brandes) Medical Use of Marijuana passed into law, SB 372 (Farmer) Smoking Marijuana for Medical Use died in committee and companion bill passed (SB 182), SB 384 (Montford) Medical Use of Marijuana in Schools died in committee, SB 1020 State Hemp Program (Bradley) passed into law, SB 1058 State Hemp Program (Albritton) died in committee and companion bill passed (SB 1020), Senate Joint Resolution (SJR) 1298 Adult Right to Cannabis (Bracy) died in committee, SB 1312 Cannabis (Pizzo) withdrawn, SB 1322 Availability of Marijuana for Medical Use (Brandes) died in committee and companion bill passed (SB 182), SB 1714 Cannabis (Bracy) died in committee, SB 1780 Adult Use Marijuana Legalization (Farmer) died in committee, SB 7102 Hemp (Innovation, Industry, and Technology) died on calendar and companion bill passed (SB 1020). House Bills 2019: HB 333 (State Affairs Committee, Agriculture & Natural Resources Subcommittee, Massullo and Killebrew) State Hemp Production laid on table and companion bill passed (SB 1020), HB 461 (Thompson) Medical Marijuana Retail Facilities died in committee, HB 1093 (Jenne) Cannabis died in committee, HB 1117 (Grieco and C. Smith) Adult Use Marijuana Legalization died in committee, HB 1191 (Silvers) Banking Services for Medical Marijuana Treatment Centers died in committee, HB 1289 (C. Smith) Cannabis died in committee, HB 7015 (Appropriations Committee and Health & Human Services Committee and Rodrigues, R.) Medical Use of Marijuana laid on table and companion bill passed (SB 182), HB 7117 (Appropriations Committee and Health & Human Services Committee and Rodrigues, R.) Medical Use of Marijuana died on second reading calendar and companion bill passed (SB 182), HB 9245 (Alexander) Holistic Cannabis Community–Medical Marijuana Education died in committee.

285 Sponsored by Senator Brandes.

286 Sponsored by Senator Bradley.

287 Saunders, J. (2019, December 18). Florida house defends marijuana law in state supreme court in high stakes case. Orlando Weekly. Retrieved from https://www.orlandoweekly.com/Blogs/archives/2019/12/18/florida-house-defends-marijuana-law-in- state-supreme-court-in-high-stakes-case

288 Proposed Senate Bills 2020: SB 212 (Thurston) Medical Marijuana Retail Facilities, SB 242 (Braynon) Cannabis Offenses, SB 720 (Montford) Medical Use of Marijuana in Schools. Proposed House Bills 2020: HB 25 (Jones) Cannabis Offenses, HB 149 (Sabatini) Medical Marijuana Treatment Centers, HB 797 (Thompson) Medical Marijuana Retail Facilities

289 Council of State Governments. (2015). Needle exchange legality by state. Retrieved from http:/knowledgecenter.csg.org/kc

290 Policy Surveillance Program. (2016). Syringe distribution laws. Retrieved from http://lawatlas.org/datasets/syringe-policies-laws-regulating-non-retail-distribution-of-drug-parapherna

291 Representative Katie Edwards sponsored similar HB 81, which was laid on the table for the companion bill.

192

292 In 2018, SB 800, sponsored by Senator Braynon, sought to extend the IDEA pilot to Broward and Palm Beach counties. While it passed out of the Senate, it died in messages to the House. Identical HB 579 (sponsored by the Health and Human Services Committee, the Health Quality Subcommittee, Jones, and Plasencia) passed committees and died on the House calendar. Alternative SB 1320 (Braynon) and HB 945 (Newton), which would have extended IDEA to Palm Beach County only, both died in committee.

293 Similar HB 171 (Jones and Plascencia) was laid on the table in favor of the Senate bill.

193

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