ORGANIZATIONS

Nurses are members of many organizations involved in and influencing the development of health policy and health care–related legislation. Nonlegislative citizens also play a political role in health policy development and implementation through participation in and support of civic organizations and activities, such as the American Association of Retired Persons (AARP), Mothers Against Drunk Driving (MADD), American Diabetes Association (ADA), the March of Dimes, the National Organization of Women (NOW), and the National Rifle Association (NRA). Most professional organizations (e.g., American Medical Association [AMA], American Hospital Association [AHA], American Academy of Nursing [AAN], Coalition for Patients’ Rights [CPR]) develop legislative agendas, support political candidates, and employ lobbyists at state and federal levels. (See Box 6-1 for a list of government and health care organizations referred to in this chapter.) In 2004, the ANA moved its headquarters from Kansas City to Washington, D.C., to increase visibility and access to federal agencies and Congress. State nursing associations often have lobbyists to ensure state laws for advanced practice licensure, Medicaid benefits and coverage, and work environment protections. Lay, civic, and professional organizations, whether or not associated with a political party—such as the AARP, the National Association for the Advancement of Colored Persons (NAACP), the NRA, the ANA, the National Home Care Association (NHCA), and the America’s Health Insurance Plans (AHIP)—use grassroots activity, paid lobbyists, campaign support, advertisements, and organized rallies to make an impact on health policies affecting their members and special interest groups. Most health care professional organizations, including the ANA, have a paid lobbyist in each state capital and at least one in Washington, D.C. Because these organizations fund political and lobbying activity, a proportion of membership dues to these organizations are not tax deductible. For example, the ANA uses approximately 25% of its dues for lobbying activities and has a full-time lobbyist in Washington. Many state nursing associations have their own lobbyist or contract for this work in their state legislature.

POLITICAL PARTIES

Three major political parties have been involved in legislation: the Republican National Committee (RNC), the Democratic National Committee (DNC), and the Independent Reform Party (IRP). More recently, the Libertarian Party (LP) has become more involved. Political parties set forth the major issues of concern through party platforms during presidential conventions, website postings, and paid media advertisements. The party platforms consist of “planks” that delineate the party’s philosophy and stand on issues of the day. Platforms are a consensus of the convention delegates, but they also mirror the presidential candidate’s stand and arguments to be used during the campaign. Platform issues, then, often become the agendas for state legislatures and the U.S. Congress. Many of the issues during the 20th century were health related, such as gun control, abortion, and Medicare. In the early part of the 21st century, issues surrounding stem cell research, prescription drug coverage, bioterrorism, and electronic health records have emerged. The most recent platforms and priority issues can be reviewed on party websites or received from each party’s national or state offices. The ANA has traditionally supported more of the Democratic Party’s health issue planks.

POLITICAL ACTION AND 527 COMMITTEES

Registered political action committees (PACs) can be established independently or as a part of a formal organization to (1) raise, spend, and contribute money; (2) assist with campaigns; and (3) lobby on behalf of special interest groups, industries, or segments of society. PACs initiate much of the legislative activity or inactivity on both the state and federal levels. For example, Roe v. Wade, which legalized abortion, continues as a major PAC focus. PACs pay for television advertisements, hold public rallies and demonstrations, distribute literature, and invite political and other famous figures to events supporting their positions. Originally, PACs represented persons with specific needs who had been overlooked or not protected by society (e.g., those with AIDS, older adults, the homeless, poor children). In the late 1990s, PACs became more commonly representatives of particular groups of persons that banded political, human, and financial resources to get policies initiated, funded, extended, or terminated for social and corporate agendas. For example, the ANA has a PAC to address issues related to the health and nursing workforce, including staffing, mandatory overtime, and supervision and delegation. The pharmaceutical industry also has multiple PACs to lobby Congress.

These focused activities, as well as financial support for and against politicians who have voted or will vote on bills relating to an issue, make PACs some of the most powerful entities influencing health policy decisions, especially those related to regulation and allocation of funds. The large amount of funding used for and against campaigns has changed how legislation is formed, what is passed, and the amount and type of appropriations approved. Legislators are finding it more difficult to meet the needs of one special interest group and not offend another group. For example, when political power shifts in state and federal legislatures, the influence of PACs change. The passage or failure of bills to protect the environment, reauthorize labor union and workers’ rights and safety, change gun control, revise tort reform, cut or raise taxes, or increase the minimum wage may depend on which party is in power. One result of legislators trying to remain supportive of their funding sources is that a higher number of bills pass that require additional federal monies or require states to increase dollars allocated to programs or allow elected officials to vote for or against an issue with no simultaneous action. The No Child Left Behind legislation is an example of one unfunded mandate in which federal legislation required action but did not result in federal funding to states.

FINANCING

A major concern over the past two decades has been the influence of money on campaigns, resulting in increased access to legislators and greater influence on legislation by PACs and financial contributors. The Federal Elections Commission (FEC) regulates the type, amount, and reporting of such funds. State commissions handle funds within state, county, and municipal governments. Each candidate, political party, and PAC is required to register and submit quarterly, monthly, or annual financial reports. This is traditionally referred to as “hard money.” “Soft money” is less regulated and refers to funds given to the party but for no specific purpose. Soft money is often used to support campaign activities but under a different guise. For example, instead of giving money to a senatorial campaign for travel to a state capital, the party supports a high school student workshop on a topic that invokes the candidate’s position, thus averting the campaign finance rules constraining usage. Campaign finance reports, as well as documentation of PACs, corporate, and other large contributors to each party and candidate, are required by the FEC and are available to the public (see www.fec.gov). Monies spent on media, travel, and food by campaigns have increased tremendously in the past decade. Many of the organizations noted above—as well as many nurses, doctors, physical therapists, and patients—donated to these campaigns. In federal campaigns in 2007 and 2008, individual contributions were limited to $2300 per candidate and $28,500 per national party, or a total of $42,700 to all candidates combined and $65,500 to all PACs or committees combined. In contrast, national, state, or local party committee contributions were limited to $5000 per candidate per election, unlimited to political parties yearly, and limited to a maximum of $39,900 to a U.S. Senate candidate per campaign (FEC, 2009a). However, in January 2010, the U.S. Supreme Court ruled that campaign contribution limits were an unconstitutional denial of free speech. It is unclear what effect this will have on future campaign financing.

Many state political contribution limits are similar to national levels or are based on population and candidate numbers each election cycle. In addition to funds raised by candidates, the government provides funds from the taxpayer-supported Presidential Election Campaign Fund (PECF). These monies are designated on federal income tax forms and then distributed to candidates after they raise a specified amount. A cap of $40 million is placed on what can be spent on primaries or preconvention efforts for presidential candidates who choose to accept these funds. In 2008, $103 million in federal funds were used in the presidential primaries and campaign. President (then Senator) Obama chose not to accept federal dollars; Senator McCain “opted in” to the system and received 84 million federal taxpayer dollars (FEC, 2009b). As was true in 2004, both candidates benefited greatly from the amounts the parties or PACS spent on advertisements and other media to support them. Before the 2000 election, the FEC reported that eight candidates for the presidency had raised a total of $181 million (FEC, 2000). In the 2004 election, presidential candidates Kerry and Bush both raised more than $298 million for their respective campaigns, and more than $1 billion was used by parties, candidates, and federal funds combined (FEC, 2005). Similarly, McCain, Obama, their rivals, and political parties raised more than $1.67 billion for the presidential primaries and campaign for the 2008 election (FEC, 2009b). This is more than the initial year of spending for the Medicare Prescription Drug Plan (PDP).

Two new modes of funding appeared in the 2004 presidential campaign. Howard Dean, MD, was the first candidate to formally use the Internet to solicit and receive contributions. Second, a new type of committee called 527 political groups arose and altered political fundraising and campaign activities. These groups can engage in voter mobilization efforts, issue advocacy, and other activity short of expressly advocating the election or defeat of a federal candidate. There are no limits to how much they can raise. These organizations are regulated by the Internal Revenue Service (IRS), but not necessarily the FEC if they do not explicitly advocate for an individual’s election or defeat or do not directly subsidize federal elections. Thus this is a major loophole to raising and using soft money. In the 2004 campaign, these entities ran oppositional, and personal, attacks on candidates. Swift Boat Veterans for Truth, Progress for America, MoveON.org, and Voices for Working Families are just a few of the organizations that provided significant media coverage and had a considerable impact on the election. In 2008, these organizations ran advertisements that showed candidates’ positions in a very demonstrative and stark manner. For example, John Kerry was portrayed as unpatriotic even though he volunteered and served in Vietnam. George W. Bush was portrayed as supporting child labor because of the large deficits, even though child labor laws were not changed during his term.

Additionally, lobbyists often provide for expenses incurred in “program-related” trips. These payments have caused scandals for national congressional representatives as well as state legislators and governors in the past decade, resulting in calls for and changes to ethics rules so that all persons have access to legislators regardless of socioeconomic means. The same issue has been found at state levels, and recently some officials have been found criminally responsible for taking bribes or inappropriately using their governmental positions to influence policy based on financial donations and arrangements.

ADMINISTRATION AND COMMITTEES

In addition to the constitutionally mandated process and structure, each Congress or state legislature establishes its own rules for administration and governance that affect how policies are made and which issues are considered. Rules include the number, type, and focus of committees where most of the legislative work takes place. In fact, committee chairpersons, assigned because of seniority, develop the calendar of issues and legislation to be discussed. In the past, and probably continuing into the future, bills that are brought forth for discussion and passage are not necessarily the purview of the particular committee. Rather, these issues may be germane to the constituents of the ranking majority or minority leader, based on the leader’s personal beliefs and experience, or related to financial support received from individuals, organizations, and corporations.

Committee structure is also determined for each Congress, with the exception of several mandated committees by U.S. or state constitution. In Congress, committee structure was fairly stable from the 1960s through the early 1990s, years during which the Democrats controlled the House of Representatives and often the Senate. During that time, the Committee on Labor and Human Resources had primary responsibility for health care legislation and issues. With a new Republican majority in the House of Representatives beginning in 1994 and that party’s control over the Senate and White House from 2001 to 2008, committee structure was altered and updated. Several committees were terminated, and the names and jurisdictions were changed. A new Health, Education, Labor, and Pensions Committee in the Senate was charged with primary health policy jurisdiction. However, many committees develop health-related bills and send forth authorizations and appropriations for those bills, such as the Senate Agriculture, Nutrition, and Forestry Committee (nutrition bill) and the House International Relations Committee (American Red Cross bill).

CONGRESSIONAL SESSIONS

Each U.S. Congress has two sessions for developing legislation. The 111th Congress began in January 2009 with the first session; the second session began in January 2010. Legislation that has passed both Houses, been resolved in conference committee, been enrolled to the president, and is signed, becomes public law. Laws are signified by the Congress in which they are passed, as well as their chronological order of passage (e.g., PL 110-361: law number 361 passed the 110th Congress). Financial allocations—more precisely, appropriations—are included in bills and usually include funding for 3 to 5 years. However, appropriations depend on the budget bills passed for each calendar year and thus can be revised, reauthorized, or repealed by subsequent congressional action.

CHAMBER RESPONSIBILITIES

A constitutional directive mandates that all budget bills, including an increase in federal income taxes, originate in the U.S. House of Representatives. Thus the Senate cannot initiate an income tax increase, but it can increase spending limits and develop new programs that may result in the need for increased taxes. Either chamber can be the origin of bills that establish or increase funds through other means, such as airport, gasoline, or Medicare fees and taxes. The Ways and Means, Appropriations, and Finance committees have input to the budget and review legislation originating in other committees that require new or continuing appropriations. Any legislation that includes appropriations, whether continuing or new, is required to be submitted by committees and subcommittees to the chamber budget committees for calculation, inclusion in the fiscal year appropriations bills, and estimations of spending in the outlying years. On most occasions the budget committees change or alter the recommended allocations and refer these changes to the committee charged with a specific piece of legislation as well as to the committee of primary responsibility for that specific area (e.g., health care, education, transportation). The Senate has primary responsibility for approval of political appointments, such as judges, ambassadors, the surgeon general, cabinet members, and federal agency directors. In the 1990s the approval hearings were contentiously political and philosophical. Health-related issues such as sexual harassment, sex education, family planning, refugee support, and immigration laws served as litmus tests for appointee approval. Two other health issues, abortion and the death penalty, continue to be major points for discussion that affect health policy and the appointment of judges to state, appellate, and federal courts and the U.S. Supreme Court. More recently, universal health care, terrorism, and environmental issues have resulted in enthusiastic legislative discussions.

STATE ACTIVITIES

Many state legislatures also have two chambers, and leadership is similar to that of the national Congress in that a speaker of the house, a senate majority leader, and party leaders provide day-to-day administration of the legislative body. Chamber and committee leadership is determined by seniority, past party leadership, respective party caucuses, and persons who aspire to the party ideology and philosophy in setting legislative agendas. State legislatures play a large role in the budgetary decisions and health policy and nursing practice, including Medicaid services, health department auspices, certification of hospitals and nursing homes, and nursing licensure and prescriptive privileges within the state. Many state constitutions require a balanced budget submitted by the governor and approved by the legislature. Thus, even in states, health programs and nursing services can be advanced or be in jeopardy depending on annual budgetary decisions. Several states have instituted lotteries or video gambling to increase revenues directly tied to education or specific health programs. Public health initiatives, such as adolescent tobacco use reduction, drunk driving prevention, and school health programs, may be funded with these nonrecurring funds. Public education may also be supported by this type of fund or by recurring income tax funds. In that case, state-supported community colleges, universities, and public schools (e.g., medical, nursing, pharmacy) can increase enrollment and faculty or offer more online and alternate-schedule courses. Similarly, hospitals and health departments are supported by state and local allocations that affect bed capacity, working environment, salaries, and services provided.

State legislation also may include mandated overtime or nurse staffing levels in health care facilities. Most recently, states have passed bills that do not allow mandatory overtime for nurses. Another route to the same result is for nursing boards or other licensing boards to develop regulations concerning appropriate and safe working hours or limitations on overtime. Approximately one third of states have such statutes. This is where nurses can actively participate in the policy decisions to ensure a quality working situation and maximal patient safety and care. The ANA National Database of Nursing Quality Indicators (NDNQI) and Safe Staffing Saves Lives (SSSL) Initiatives, as well as research by Peter Buerhaus, Linda Aiken, and Susan Letvak and their colleagues, provide a foundation for those efforts.

AUTHORIZATION OF PROGRAMS

Authorization bills reauthorization (with funding requests) are required to establish or continue programs as well as to fund those mandates. The initial authorization is usually a separate bill named for the issue or program being established—for example, the Older Americans Act, the Ryan White AIDS Act, and the Public Health Service Act. New governmental agencies may be initiated or established, as was the case with the Administration on Aging in 1965 and the Department of Homeland Security (DHS) in 2002. Future authorization and reauthorization bills are required to make changes in governmental agencies, to expand programs, and to continue or alter funding levels. However, some authorization bills that are passed do not contain any funding levels. Rather, these bills are used to establish programs that are to be funded by governmental departments within present allocations or by individual states, or they are unfunded mandates. For example, the Brady Bill gun control legislation requires background checks on gun purchasers before a license is issued. This 1993 act was named after James Brady, who was shot during an attempted assassination of President Reagan in 1981. Brady was paralyzed. The federal law contained no continuing funds; thus states must provide funds or be in violation of the law, and as a result often suffer loss of government monies for law enforcement. The No Child Left Behind bill is similar in federal mandate and state funding. Some authorization bills purposely contain no funding recommendations so that members of Congress can support the issue without providing funding. The congressional decision is unfunded (the actual bill has no funding) or underfunded. The regulatory body may not be provided funding to oversee state implementation of the act. Mandating the Culturally and Linguistically Appropriate Services (CLAS) standards is another example where a federal law required states to implement statutes with little or no funding provided.

FISCAL RESPONSIBILITY

Several efforts were made in previous decades to mandate a balanced budget at the federal level. The Gramm-Rudman-Hollings law was passed in 1985 (PL 99-177), but the U.S. Supreme Court subsequently found this law to be unconstitutional. During the 104th Congress, a major effort by the newly Republican-controlled House of Representatives was launched to pass an amendment to the U.S. Constitution to require a balanced federal budget. This attempt failed in Congress; thus citizens did not vote on the constitutional amendment. Congress passed a Balanced Budget Act in 1997, which required a balance of expected revenues and expenditures by the federal government for the 1998 fiscal year. The next year, Congress passed the Taxpayer Relief Act of 1998 as the reconciliation bill that included additional childcare exemptions and capital gains tax reform. In 1999, the reconciliation bill was the Taxpayer Refund and Relief Act. Although it passed both chambers of Congress, President Clinton vetoed the bill. Similar actions occurred with President Bush and the 110th Congress.

Appropriation or budget bills are required for the functioning of the federal government or other legislation, and thus specialized “pet” programs are often attached to the budget bills to get them enacted. For example, several times the Nurse Education Act’s appropriation bills were tacked on to the budget to ensure that they were passed during that fiscal year before Congress adjourned. Much of the time, pork-barrel amendments are approved to gain the votes of specific members of Congress. Even though the spending will benefit constituencies, the programs often are not federal mandates or related to the responsibilities of the government. Because many of these amendments are added at the eleventh hour and at times in conference committee to resolve the House and Senate differences, the public and some legislators are often not aware of these expenditures until they have been approved. The president does not have line-item veto authority and therefore must accept or veto each appropriation bill in its entirety to enact the fiscal year budget. Similar actions occur in state legislatures for appropriation bills for services such as museums, bypass highways, and new post offices.

ECONOMICS

A majority of the budget for the U.S. Department of Health and Human Services (USDHHS) is for entitlement programs, which means that only a third or less of the amount appropriated by Congress for this department can be controlled or used in discretionary ways. The NIH, the Centers for Medicare and Medicaid Services (CMS), and the Bureau of Health Professions (BHP) are included in the USDHHS budget. Nursing leaders and others have continually worked to increase these budgets, and these efforts resulted in budget increases during the late 1990s and early 2000s. More recently, those appropriations have been more stagnated. In calendar year 2008, CMS expenditures totaled more than $556.7 billion, with federal Medicaid obligations totaling $267 billion and federal Medicare obligations totaling $283 billion (CMS, 2008). The NIH fiscal year 2008 budget was $27.8 billion, and the National Institute of Nursing Research (NINR) budget was $134.7 million (NIH, 2008). Overall health care spending grew 6.1% from 2006 to 2007, averaging $7421 per person. The health care portion of the gross domestic product (GDP) increased from 16% to 16.2% (Hartman et al., 2009) This is the slowest growth in 10 years, but hospital care still provided for a third of all expenditures. Various agency heads make budget requests to congressional committees each year through letters, hearings, and routine budgetary processes.

In 1999, a federal surplus of $170 billion resulted from a thriving economy, a leaner governmental structure, and the Balanced Budget Act of 1997. However, Congress has been borrowing from the Social Security Trust Fund since the early 1980s to meet annual operating costs and appropriations across the government. The retirement income and Medicare programs that are funded by current worker payroll taxes do not contain enough money to fund those same workers when they reach 65 years of age. The General Accounting Office (GAO) estimates that the Social Security (SS) Trust Fund will be unable to meet its obligations starting in the year 2040. Debate continues over how a government with a large national debt and a large tax base can best serve its citizens, given the promises made to citizens regarding retirement and health insurance in old age. In 2005, major efforts were proposed to change SS through decreased benefits to younger workers, initiation of private health savings accounts, gradually increasing the salary cap for paying SS taxes, and a means-tested eligibility for full benefits. Some of these passed, but not much change resulted for the long-term commitment of the fund. The financial crisis of 2008 may require the 111th Congress to revise both SS retirement income and Medicare. State legislators also must deal with budget shortfalls and use hiring freezes, layoffs, program cuts, new fees, and increased taxes to meet needs. Local agencies and school boards are often the most successful in dealing with budget shortfalls because they have not had—or have not chosen to use—the ability to borrow funds, incur long-term debt, or move costs from one budget year to another. More detail on the budget and health care costs can be found in Chapter 7.

IMPLEMENTATION AND REGULATION

Multiple governmental agencies plan, implement, and evaluate health policy in the United States. The major agencies are headed by political appointment cabinet officials, directors, and administrators but are staffed by career civil servants. For example, the U.S. House of Representatives has 435 elected members, but 10,000 staff members are employed for duties such as cleaning, moving, painting, preparing and serving food, providing mail and phone services, and staffing the infirmary. Congressional legislation and presidential executive orders and mandates can alter workings across staff divisions of the executive, judicial, and legislative branches of government. The last major revisions occurred in 1996 after the Republican Congress and the Democratic vice president requested and mandated streamlining and reorganization of the government. The Balanced Budget Act of 1997 also mandated changes in the administration and implementation of federal programs. Before the 1990s most federal departments or regulatory oversight had changed very little. The Government Performance and Results Act of 1993 was a major effort to enhance accountability of agencies. The Federal Funding Accountability and Transparency Act of 2006, signed by President Bush, was another attempt to clarify governmental action and spending to the public. Several years passed, however, before actual changes occurred. In the 110th Congress, Senator Obama introduced a revision titled the Strengthening Transparency and Accountability in Federal Spending Act of 2008, but the bill died when that congressional session ended.

The USDHHS is charged with protecting and ensuring the health of the nation and is headed by the Secretary of Health. Multiple agencies and divisions are included in the USDHHS, and several assistant secretaries are responsible for administrative aspects. The Surgeon General (SG) is an Assistant Secretary of Health and heads the Office of Public Health and Science (OPHS). An Assistant Secretary for Aging heads the Administration on Aging (AOA) and the Administration for Children and Families (ACF). Other agencies are headed by a commissioner (e.g., FDA) or director (e.g., NIH). Agencies include several sections or divisions. For example, the NIH has 27 institutes or centers, including the NINR, the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD), and the National Institute on Mental Health (NIMH). In Atlanta and other regional offices, the Centers for Disease Control and Prevention (CDC) houses 14 centers, institutes, and offices, including the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), the National Office of Public Health Genomics (NOPHG), the National Center for Health Statistics (NCHS), and the Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) (CDC, 2009). Most federal government agencies and state agencies have civil rights, legal, public relations, and budget sections staffed by career employees. These agencies have public Internet sites for consumers and professionals to obtain program and contact information. Many political, professional, and health-related agencies and organizations also house websites for rapid and wide public access and dissemination of information.

Each federal agency has specific auspices or sponsorship, although these are not always consistent with the appropriation focus. The Department of Agriculture (DA) directs the commodity distribution program (e.g., nonfat dry milk, cheese products), the national school lunch program, farm programs, and food inspection. CMS directs Medicare, Medicaid, and Children’s Health Insurance Programs; the Department of Labor houses the Occupational Safety and Health Administration (OSHA); and the CDC houses the National Institute of Occupational Safety and Health (NIOSH). Most states have similar agencies and auspices to manage public programs. For example, the Tennessee Department of Health (TDH) houses the Tennessee Bureau of TennCare (TBOT) to administer the Medicaid waiver program, and Kansas has a State Secretary for Social and Rehabilitation Services (SRS).

Whereas laws are written in broad language, the rules and regulations to implement these laws are very specific and often can be revised without changing the original law. Agencies are charged with implementation, financial oversight, legislative interpretation, and the development of regulations and rules governing their respective programs. Often agencies are required to interpret the purpose and intent of congressional or state legislation to implement such laws. The perceptions, political savvy, and experiences of the agency’s director, staff, and proponents have an impact on this interpretation of the issue under consideration. For example, former USDHHS Secretary Tommy Thompson reworded family planning regulations to include abstinence-only programs, President Clinton used presidential directives for regulations to allow stem cell research on embryos not used by couples who went through in vitro fertilization procedures, and President Bush wrote executive orders to allow only currently available stem cell lines to be used rather than new embryonic lines. Interpretations and changes in regulations can be related to the number and types of citizens served in a particular program, the increase or decrease in appropriations, the social or ethical values of directors and department heads, and societal crises.

In some instances, the auspices and appropriations are not consistent. The DA receives appropriations for the elder nutrition programs, but these are administered under the AOA through the state, regional, and local agencies. The Department of Labor (DL) has administrative responsibility for the Senior Community Service Employment Program (SCSEP), which is under the auspices of the AOA. The Bureau of Census (BOC) collects vital data, but the NCHS and the DL analyze those data for developing policy and allocation decisions. Thus some health-related policy legislation and appropriations require extra effort to determine the auspices, regulation, and implementation and whether duplication or omission occurs.

As the health care industry evolves with new emphases, programs, and services, the governmental agencies must develop new strategies for evaluation of their implementation. Evaluation for specific policies and their implementation only recently began at the federal level. This evaluation of process, structure, and outcomes has become an emphasis, especially for the SS, Medicare, and Medicaid programs. Process and structure are often difficult to change in large, bureaucratic organizations of state and federal government. Annual performance plans now required of agencies should assist in more clearly evaluating program effectiveness and efficiency. The recent emphasis on outcomes should lead to changes in process and structure to meet the objectives set forth. Two such health-related efforts are the Healthy People 2010 and proposed 2020 national objectives and the initiatives to eliminate racial and ethnic disparities at the USDHHS. As these two efforts are revised to reflect new targets and new census health data, they will guide federal, state and local efforts to improve the health of our community through system, policy, and funding decisions. Nursing has a vested interest in those efforts.