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Frameworks for action in policy and politics Chapter 1 Lauren Underwood, a registered nurse with supraventricular tachycardia, was inspired by health professionals who treated her. She became a registered nurse after discovering she had a preexisting condition that made health insurance...
Frameworks for action in policy and politics Chapter 1 Lauren Underwood, a registered nurse with supraventricular tachycardia, was inspired by health professionals who treated her. She became a registered nurse after discovering she had a preexisting condition that made health insurance inaccessible for many Americans before the Affordable Care Act (ACA). After the 2016 elections, President Donald Trump and a Republican-controlled Congress renewed efforts to roll back the ACA under campaign promises to "repeal and replace Obamacare." Congressman Randy Hultgren, Underwood's congressional representative, promised to support legislation repealing Obamacare that protected coverage for people with preexisting conditions. He then proceeded to vote for the 2017 American Healthcare Act, ending the preexisting condition protections. Underwood, a Black nurse from Illinois, conducted a grassroots campaign that reached all-White neighborhoods and households that may never have considered voting for a person of color for their congressional representative. She spoke directly to the benefits of the ACA, as a nurse who had seen what happens to people who do not have health insurance and cannot afford care. She showed that she understood the issues people cared about, such as healthcare, mental health, jobs, and family, and was skilled in interacting with people. Against the odds, Underwood defeated six Democratic men in the primary elections and became the public face of the dramatic 2018 midterm elections in which Democrats took back control of the U.S. House of Representatives. She is regarded as one of the smart, new women leaders in our federal government and joins fellow nurses Eddie Bernice Johnson (D-TX), the first nurse to be elected to Congress; and Karen Bass (D-CA), a member of Congress since 2011. Nurses have awakened to their potential for shaping and leading the development of health and social policies in their own communities, states, and the nation. The forces of policy that form our lives as constituents and nurses are real, and it is time for us to seize the opportunities for shaping our worlds. This chapter provides a foundation for learning how policy and its political context can be advanced to promote the health of individuals, families, communities, and nations. Focus on policy: What policy? The ACA is a major federal policy aimed at improving access to health care, particularly through affordable coverage for essential services. However, access to coverage does not necessarily mean access to care or a healthy population. Health care access means receiving the right type of care when needed at an affordable price. The U.S. health care system is based on expensive, high-tech acute care that does not produce desired health outcomes and often damages instead of heals. Despite spending more per person on health care than any other nation, the U.S. performs worse on quality, efficiency, access, and other organizational performance measures. Preventable medical errors are estimated to be the third leading cause of death in the country. The nation also ranks at the bottom on certain health outcomes, including life expectancy at birth, infant mortality rate, suicide and cardiovascular disease mortality rates, and the prevalence of diabetes and obesity in children. The affordable care act The ACA included elements to change this picture by focusing on creating more value in health care, improving care coordination, expanding access to coverage or health insurance, and reforming how we pay for care. Fig. 1.1 illustrates these four cornerstones. The ACA aimed to move the health care system in the direction of keeping people out of hospitals, in their own homes and communities, with an emphasis on wellness, health promotion, and better management of chronic illnesses. In addition, it included provisions to hold hospitals and other health care organizations accountable for both their spending and outcomes. The ACA is arguably the most significant piece of social legislation passed in the United States since the enactment of Medicare and Medicaid in 1965 (see Chapter 18 for a detailed discussion of the ACA). Implementation continues to be a vexing process that requires tweaking, much as the Social Security Act did when it was passed in 1965 (Social Security Administration, n.d.). But the ACA became a political flashpoint, defining the ideologies of U.S. political parties. Democrats committed to the law but called for refining it, whereas Republicans overtook the House of Representatives in 2012 with calls for “repealing and replacing Obamacare.” The public remained largely uninformed and misinformed about the legislation; 3 years after its passage, 4 out of 10 Americans were still unaware of many of its provisions and unsure that the ACA had become law (KFF, 2013). When the Trump Administration began to use executive orders to scale back and reverse regulations for implementing the ACA, the public became confused about whether the ACA and Obamacare were the same thing. Most of those who now had health coverage under the ACA wanted to keep their insurance but did not realize that this was Obamacare (Dropp & Nyhan, 2017). Confusion is likely to continue as attacks on the ACA persist. In 2018 a federal court in Texas ruled that the ACA was unconstitutional, a decision that was reviewed by the Fifth Circuit Court of Appeals and may go to the Supreme Court. In 2019, the U.S. Department of Justice said that it would support the Texas court’s decision, despite the department’s usual practice of defending federal laws. Upstream factors: Social determinants of health Promoting health requires a comprehensive approach that considers the social determinants of health, which are factors that can undermine or promote health. These factors include factors such as safe environments, adequate housing, economically thriving communities with employment opportunities, access to affordable and healthful foods, and models for addressing conflict through dialogue rather than violence. Health disparities, which disproportionately affect racial and ethnic minorities, require effective interventions that address upstream factors both within and outside healthcare systems. The health care system must change its model from strictly biomedical to one that recognizes that health is in large part determined by psychosocial factors. For example, those living in poverty have shorter life expectancies and experience more illness than those who are wealthy, resulting in high costs in human and financial terms. However, most focus on reducing disparities has been on health policy that addresses access, coverage, cost, and quality of care once an individual has entered the health care system. This lack of knowledge about the political aspects of the social determinants of health is essential for changing our nation's poor performance on health care and the health of its people. The social determinants of health significantly determine the health of individuals and populations. They produce great inequities in health within and between societies, with the poor and disadvantaged experiencing worse health than the rich, having less access to care, and dying younger in all societies. Measurement and description of these social determinants provide evidence that can serve as the basis for political action. Evidence is generated and used in a continuous cycle of evidence production, policy development, implementation, and evaluation. Upstream factors: Social determinants of health The Affordable Care Act (ACA) has emphasized the role of the healthcare system in addressing upstream factors, such as community health. Nonprofit hospitals are required to conduct community health assessments, develop community health improvement plans, and partner with others to implement them. This aligns with a growing emphasis on population health, which is essential for all health care organizations. To improve the health of the U.S. population and reduce healthcare costs, we must build in better ways to address social determinants of health and enhance health promotion and wellness, disease prevention, and chronic care management. Nurses play a critical role in this shift from disease care to preventing illnesses, promoting health, and coordinating health care. A 2017 report by the Josiah Macy, Jr. Foundation called for a more robust primary care system that builds its capacity by using registered nurses as care team leaders. Nurses have led changes in health promotion and healthcare delivery but have not been formally measured or identified. However, there are notable exceptions to this invisibility. The American Academy of Nursing's Raise the Voice Campaign has identified nurses who have developed innovative models of care, known as "Edge Runners," that provide evidence-based models that can help transform the health care system. Many also address social determinants of health. Some of these models of care were included as programs to scale up under the ACA, such as transitional care, the Living Independent for Elders, home visitation programs for high-risk pregnant women, and nurse-managed health centers (NMHCs). The 11th Street Family Health Services, a federally qualified NMHC located in an underserved neighborhood in North Philadelphia, is one of over 200 NMHCs in the United States that have improved clinical and financial outcomes by addressing the needs of individuals, families, and communities. The ACA did not go far enough in shifting attention from acute care to promoting the health of communities and populations. Another approach to this shift is that of "health in all policies," which considers the health implications of social and economic policies that focus on other sectors, such as education, community development, tax codes, and housing. As health professionals who focus on the family and community context of patients they serve, nurses can raise questions about the potential health impact of public policies in every environment in which they work. The Quadruple Aim The Quadruple Aim, first introduced by Don Berwick and colleagues at the Institute for Healthcare Improvement (IHI) in 2008, is a value-based healthcare system that focuses on improving population health, improving patient experience, and reducing per capita costs. This framework aligns with the Affordable Care Act (ACA) and has been modified to include clinician and staff satisfaction. The Quadruple Aim is a balanced approach that helps healthcare organizations and society identify system problems and direct resources to activities that have the greatest impact. By examining a healthcare delivery problem from all four dimensions, solutions must be evaluated from these interdependent dimensions. To achieve the Triple Aim, the IHI identified components of any approach: a focus on individuals and families, a redesign of primary care services, population health management, a cost-control platform, and system integration and execution. These components address the goal of creating a high-performing healthcare system but do not focus on geographic communities or social determinants. The success of the nursing profession's continued evolution will depend on its ability to address the Quadruple Aim by taking on new roles, engaging more creatively with patients, and stepping into executive and leadership roles in every sector of healthcare, society, and government. Nurses must lead efforts to break down health professions' silos and hierarchies, keeping the patient and family at the center of care. Nursing and health and social policy Health policy significantly impacts nursing practice, determining who receives what type of healthcare, when, how, from whom, and at what cost. Nursing studies play a crucial role in professional development, aiming to advance a healthier society, promote a safer health care system, or support nursing's ability to care for people with equity and skill. Nurses are needed to create compelling cases and actively influence better health policies at every level of governance. A 2018 study found that nurses were cited as sources in only 2% of health news stories and never in policy stories. This invisibility is attributed to nurses' reluctance to respond to requests for interviews, failure to promote important research, and nursing associations being largely invisible to newsrooms. Journalists pointed out that they, their newsrooms, and public relations staff in health care organizations and universities are biased about women, nurses, and positions of authority in health care. Nursing has great potential power but faces social barriers due to societal inaccuracies about nurses' expertise and roles. The #MeToo movement may help make these biases visible and ameliorate them, but nurses must be proactive in changing them. The Institute of Medicine's report, The Future of Nursing: Leading Change, Advancing Health (2011), called for nurses to be leaders in redesigning health care and be at all decision-making tables on health and health care. An interim evaluation of progress made on the report's recommendations found evidence of progress but noted more attention needed to developing nurses' leadership skills. Policy and the policy process Policy is defined as authoritative decisions made by governments to influence citizens' actions, behaviors, or decisions. However, this definition limits its application to sectors outside of government, such as healthcare organizations that affect employees, patients, and surrounding communities. A broader definition of policy is a relatively stable, purposive course of action or inaction followed by an actor or set of actors in dealing with a problem or matter of concern. Public policy is policy crafted by governments, with the intent of influencing health or health care. Social policies identify courses of action to deal with social problems. Private policies are those made by nongovernmental entities, such as health care organizations and insurers. Policies can limit APRN practice even in states that have removed laws requiring physician supervision or collaboration. Policies are crafted everywhere, from small towns to Capitol Hill. States use policies to specify requirements for health professions' licensure, set criteria for Medicaid eligibility, and require immunization for public university students. Hospitals use policies to direct when visitors may visit patients, manage staffing, and respond to disasters. Public schools use state policies to specify who may administer medications to schoolchildren and what may be sold from a school vending machine. Towns, cities, and municipalities use policies to manage public water, define who may run for office, and decide if residents may keep exotic pets. In a capitalist economy like the United States, private markets can control the production and consumption of goods and services, including health care. The government often intervenes with policies when private markets have failed to achieve desired public objectives. There are two types of public policies the government develops: allocative policies, which provide benefits to a distinct group of individuals or organizations at the expense of others, and regulatory policies, which influence the actions, behavior, and decisions of individuals or groups to ensure a public objective is met. Policymaking is an unpredictable dance that requires a high degree of political competence. Values Values are the foundation of policies and influence political and policymaking activities. Public policies reflect a society's values and conflicts in values. Policy decisions prioritize values, and they reveal the underlying values that shape them. Policy choices can disadvantage some groups when resources are finite. To support or oppose a policy, value judgments are required. Conflicts between values were evident in the debates on the Affordable Care Act (ACA). For example, despite advocates for a government-run, nonprofit insurance option, the insurance industry opposed it, viewing it as an increase in government control. This issue was not included in the law but continued to be discussed during the Democratic 2020 presidential campaign. Politics Politics involves the use of relationships and power to influence policy and resource allocation among competing stakeholders. It involves understanding the positions of key stakeholders, political parties, electoral processes, public opinion, and media coverage. Understanding politics allows policymakers to align the health of the public with their interests, rather than misuse power or information. For instance, a congresswoman may have focused on improving the economy, but may not have linked the rising obesity epidemic to the macroeconomy and American productivity. Nurses can use their power to create urgency about pressing public health issues by describing the catastrophic direct and indirect costs of the obesity epidemic and how it is making the United States less competitive in a global market. This approach allows nurses to use their power to create urgency about pressing public health issues and ensure the health of the public is prioritized. Science and research The information age has emphasized evidence-based practice and policies, but we may face a world that eschews evidence. Scientific findings play a crucial role in the policy process, bringing attention to problems and moving them to the agenda. Research can define the size and scope of a problem, substantiating policy recommendations, and obtaining support for a proposed policy. Evidence should inform policy debates and shape policy choices to ensure effective solutions. However, evidence is not enough to determine if policies are supportive or punitive. Understanding policies in context is necessary to avoid unintended consequences. For example, pregnant people may delay prenatal care due to fear of criminalization or loss of their children. Therefore, both policies and their implementation should be informed by rigorous evidence. However, evidence is essential but may not be sufficient to advance policies. Politics and values often surpass rigorous data and dominate conversations about what is considered evidence. This has been evident in recent debates over climate change and childhood vaccinations. Despite evidence showing human contributions to climate change and childhood vaccinations not causing autism, debates continue to affect whether policies are adopted to address these issues. Policy analysis and analysts Policy analysis involves examining an object or process to understand it better. It uses various methods to assess problems and determine possible solutions. Policy analysts, with professional training and experience, analyze problems and weigh potential solutions. They encourage critical thinking, identify ways to respond, evaluate alternatives, and determine the most desirable policy choice. Policy analysis can also help citizens understand problems, alternatives, and potential implications of policy choices. Advocacy and activism Nurses play a crucial role in patient advocacy, utilizing their expertise in policy and politics. The American Nurses Association's Social Policy Statement emphasizes advocacy as a professional responsibility. Political activism includes various strategies like blogging, arguing evidence for policy choices, and garnering media attention. Nurses' advocacy is not limited to protests but has evolved to include various tactics. Interest groups and lobbyist Interest groups and lobbyists play a significant role in advocating for policies beneficial to their members. In 2018, the Center for Responsive Politics reported that in the United States, $2.59 billion was spent on lobbying, down from $3.51 billion in 2010. The number of registered lobbyists decreased from 14,826 in 2007 to 11,272 in 2018. Health care ranked first in spending on lobbying, with $421.5 million. The National Council of State Boards of Nursing spent more on lobbying than any other nursing organization, but ranked 30th overall. The American Medical Association spent more than $15 million in 2018 and ranked first among all health professions organizations. The media The media plays a crucial role in political campaigns, delivering messages that resonate with the values and emotions of a target audience. The strategic use of media is essential in today's information age, as it allows for the persuasion of the audience to behave the way the target wants. In this information age, nurses must proactively use media to influence policy and speak with journalists about policy matters. However, they may not always be eager to enter the media spotlight, especially when talking with journalists. Social media offers nurses an opportunity to control their message and influence policymakers. The power of presidents and other leaders The president, as the only representative of the entire nation within the federal government, holds significant power in shaping the nation's policy agenda. They can set policy agendas for Congress, work with their party's representatives, and provide draft legislation and legislative guidance. The president's legislative priorities are at the top of the congressional agenda, depending on their party's majority in Congress. They can also issue executive orders without congressional support. The three branches of government serve as a check-and-balance system, ensuring democracy and equal representation of citizens' interests. In health policy, the president and executive branch play a crucial role in setting the tone, providing vision, and engaging the public in determining effective health policies. This ensures that all individuals can function as full citizens in society. The framework for action Nursing has a covenant with the public, and its practice laws, standards, and ethics are rooted in activism for social justice. Nurses must continuously consider the policy context of their daily practice in any setting to address the most intractable health care problems, such as perverse payment mechanisms, social injustice, and ethnic and racial disparities. The public trusts nurses' honesty and ethical standards more than any other profession, placing a moral imperative on them to vigorously engage in influencing policy. The Framework for Action illustrates that nurses operate in four spheres: government, workplace, interest groups (including professional organizations), and community to influence policies that affect health and health care and core/social determinants of health. The focus in all spheres is on health, with optimal health being the central goal of nursing's policy efforts. Nursing embraces a broad definition of health that aligns with WHO (1948): "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." This definition requires a focus on social determinants of health and creating communities that thrive economically, have safe environments, and use resources to ensure access to good nutrition and other elements that can promote health. Policy can be shaped in more than one sphere at a time, and action in one sphere can influence others. For example, nurses may work in their own organization to alter policy to increase access to care for the uninsured, use political strategies in the media, or work with a professional association or interest group to communicate their views to policymakers. The goverment Government action and policy significantly impact lives from birth to death, affecting prenatal care, food inspection, safety of toys and cars, schools, highways, and airwave transmission. The government provides for the common defense, fire and police protection, and financial assistance to the poor, aged, and those who cannot maintain a minimal standard of living. It responds to disasters, subsidizes agriculture, and licenses funeral homes. In the U.S., much of health care is paid for and regulated by the government, making the government's role in crafting health policy crucial. The government plays a significant role in influencing nursing and nursing practice, with states determining the scope of professional activities considered nursing. Federal and state governments determine eligibility for care under specific benefit programs and reimbursement for providing care. The Congressional Nursing Caucus, an informal bipartisan group of legislators, lobbies for federal funding for nursing education in the House of Representatives. Nurses can influence policymaking in the government sphere at local, state, and federal levels of government through various means, including obtaining appointments to influential government positions, serving in federal, state, and local agencies, serving as elected officials, working as paid lobbyists, communicating positions to policymakers, providing testimony at government hearings, and participating in grassroots efforts to draw attention to problems. The workforce and workplace Nurses work in various settings, including hospitals, clinics, schools, private sector firms, government agencies, military services, research centers, nursing homes, and home health agencies. These environments are political and finite, and nurses must work to influence resource allocation. Policies guide nursing activities, including internal organizational policies such as staffing policies, clinical procedures, and patient care guidelines. External policies, such as state laws regulating nursing licensure and federal laws like the Occupational Health and Safety Administration regulations, also impact the size and composition of the nursing workforce. The Affordable Care Act (ACA) authorized increased funding for scholarships and loans for nursing education, potentially augmenting existing workforce programs. The Commission on Graduates of Foreign Nursing Schools ensures that nurses and other healthcare professionals educated outside the United States are eligible and qualified to meet U.S. licensure, immigration, and practice requirements. The National Council of State Boards of Nursing brings together state boards of nursing to act on matters affecting public health, safety, and welfare, including licensing examinations in nursing. Associations and interest groups Professional nursing associations play a crucial role in influencing practice by having legislative or policy committees that advocate policies supporting their members' practice and patient populations. Working with these associations increases the effectiveness of advocacy, provides resources sharing, and enhances networking and learning. They can also serve as excellent training grounds for novice nurses to learn about policy and political action. When nursing organizations join forces through coalitions, their influence can be multiplied. For example, the Nurses on Boards Coalition is a group of national nursing organizations, schools of nursing, healthcare organizations, and strategic partners working on the Future of Nursing report's recommendation to increase nurse appointments to commissions, task forces, boards, and other entities. Nurses can also be influential by working with other interest groups, such as the American Public Health Association or the Sierra Club, which have a broad portfolio of policy interests or focus on specific issues. The community Nurses have a rich history of community activism, with leaders like Lillian Wald, Harriet Tubman, and Ruth Lubic providing examples. Today, nurses like Lucia Alfano, Gina Miranda-Diaz, Danielle Pendergrass, and McClemore are designated as "Breakthrough Leaders in Nursing" by the Campaign for Action. Communities are groups of people who share common interests and interact with one another, whether in neighborhoods, cities, online groups, or faith-based networks. Nurses can be influential in communities by identifying problems, strategizing, mobilizing support, and advocating change. In residential communities, there are opportunities to serve in positions that influence policy, such as planning boards, civic organizations, and parent-teacher associations. Overall, nurses have the opportunity to influence health and social policy in their communities, demonstrating their leadership and commitment to their communities. Policy and political competence Policy and political competence is a critical aspect of healthcare leadership, advocating for others, and shaping policy. It involves a combination of knowledge, skills, and behaviors that improve performance. Nurses often hesitate to become involved in policy due to the negative reputation associated with political skill. However, true political skill is essential in health care leadership, advocating for others, and shaping policy. Political skill can be defined by four components: social astuteness, interpersonal influence, networking ability, and apparent sincerity. Policymakers are generalists who make decisions on a broad range of issues. Nurses can have a profound impact on policymaking by using their knowledge to frame and define health policy alternatives. Influencing policy at all levels requires a strong set of interpersonal skills, integrity, and knowledge. Political competency can be defined by three main elements: deep knowledge, political antennae, and power. Deep knowledge involves freely sharing expertise and gaining the knowledge needed from others. Political antennae involves scanning the environment and identifying opportunities to offer solutions to policy problems, focusing not just on nursing but also on broader health and health care issues. Active listening to understand policymakers' values and motives, and composing messages and responses to fit their political objectives is essential. Learning how to navigate differences and agree to disagree without being disagreeable are important political skills. Power is the ability to act to achieve a goal. In the policy process, this means recognizing policymakers with power, who are on which congressional committee, and who are the thought-leaders in the community. Creating coalitions with individuals and groups with similar goals is an important way nurses can augment their policymaking power. An individual nurse can claim power by being knowledgeable, articulate, and having an "elevator speech" that can spark interest in a policymaker or staff member. Application of power requires raising one's awareness about what is true and false, such as the value of human caring and the role that nursing can have on individuals and populations. To be effective in the policy arena, Nursing essentials The American Association of Colleges of Nursing (AACN) publishes curriculum content and expected competencies for nursing school graduates, ensuring policy competency in 21st-century nursing practice. These documents build on nursing knowledge, theory, and research from various fields. A study by Byrd and colleagues (2012) found that undergraduate nursing students are often unaware of the importance of political activity for nurses. However, participating in public policy learning activities can help students develop skills like inquiry, critical thinking, and complex problem-solving. The study emphasizes the importance of increasing students' awareness of participating in the political process and encouraging their involvement in student and professional organizations. For each level of nursing education, there are clear expectations for nursing graduates to have policy competency. DNP graduates are expected to design, implement, and advocate health policies that improve population health, and integrate these practice experiences with the ability to analyze the policy process and engage in politically competent action. Conclusion The United States' 4 million registered nurses can be consolidated by engaging with professional nursing organizations and addressing policy limitations. The Future of Nursing report, released in 2011, aimed to change state laws and regulations that restrict full practice authority for APRNs. The report's recommendations are expected to broaden to include building a health culture in communities and the nation. Effective use of power by nurses is a valuable asset, requiring knowledge, humility, problem-solving attitude, and a patient-centered lens. These activities strengthen interpersonal power and integrity, inspiring others to improve healthcare and community health. Together, we can improve health care and communities' health, both locally and globally.