Health Policy and Politics: Get Involved!

Health Policy and Politics

Get Involved!

Virginia Trotter Betts, MSN, JD, RN, FAAN and Barbara Cherry, DNSc, MBA, RN, NEA-BC

Key Terms


A citizen who has the opportunity to vote for candidates in elections for representation at the local, state, and federal level.

Constituent/State Nurses Association (C/SNA)

The professional organizational unit member of the American Nurses Association that represents all professional nurses within a state or territory or other defined organizational entity or boundary—also known as the state nurses association (SNA).

Grassroots lobbying

Personal advocacy by individual constituents—everyday citizens—in support of a problem/position/option related to a policy issue.

Health policy

A set course of action undertaken by governments or health care organizations that results in a course of action for a health outcome. Private health policy is made by health care organizations, such as hospitals, whereas public health policy refers to local, state, and federal legislation, regulation, and court rulings that govern health care within a certain arena. Health policy as used in this chapter most often refers to public policies directly related to the health care workforce, the structure of the health system, health service delivery, and/or reimbursement.


The act of persuading or otherwise attempting to educate and/or convince policymakers to respond positively to a particular position on an issue or to follow a particular course of legislative or regulatory action.


The statement of principles and policies of a political party, candidate, or elected official.


A local, state, or federally elected or appointed official who can propose legislation, regulations, or programs that can become actualized.


Rules used to implement legislation and translate concepts into actions that can be put into practice.


Individuals, groups, or organizations who have a vested interest in and may be affected by policy decisions and actions being taken and thus may attempt to influence those decisions and actions.


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Juan Hernandez is one of only four registered nurses (RNs) now staffing the 7 am to 7 pm shift in a 12-bed medical intensive care unit (MICU) as two RNs colleagues have just transferred to positions in the hospital’s growing case management service. The chief nursing officer (CNO) and MICU nurse manager are actively recruiting permanent RNs for the vacant positions but have not been successful as yet. Temporary service RNs and nursing assistive personnel are filling in within the staffing mix. Juan reviewed the position postings and noticed that, throughout his hospital, all advertisements for RNs now include “BSN-preferred” as a descriptor. He wonders how these credentials will affect the recruitment process and how they fit into the hospital’s recently announced plans for achieving Magnet® Hospital status.

Juan wonders what the issues are in filling the care team with BSN-prepared nurses. Juan seeks out the MICU nurse manager to try to better understand the reasons for the delay in hiring RNs, to voice his professional concerns, and to offer to assist in the recruiting process. He is both relieved and alarmed by what he hears. First, the hospital administrators clearly support his position that adequate numbers of well-educated RNs are required to provide high-quality, safe patient care, and they are actively seeking applicants who can provide care throughout the hospital’s rapidly evolving care models by giving a preference to nurses with a BSN or above. Second, an underlying issue for Juan’s state and region is that the numbers of nurses with the needed education and credentials simply are not adequate to meet the demand, and hiring is taking much longer than in the past.

Juan realizes that, based on the nurse practice act (NPA) in his state, he has a professional responsibility to implement measures to promote a safe environment for patients. He further understands that he is individually professionally accountable for his daily practice with each patient. Juan calls his state nurses association (SNA) to discuss his concerns and to learn more about the nursing workforce trends. Through that call, he discovers that other nurses across the United States are facing many of the same dilemmas. Meeting the current professional responsibility to provide and advocate for safe care for patients is running head on into the larger national and employer issues of securing an adequate number of better educated, broadly skilled nurses to meet the rapidly evolving expectations in complex care systems focused on patient quality, safety, and satisfaction. Therefore, Juan makes a commitment to engage in discussions about policy and political strategies that are needed now to promote and protect models of care that will facilitate professional nursing practice; promote development of a highly educated nursing workforce to meet his state’s and region’s needs; and assure his ability to grow in his own professional career as the health care system expects and rewards new knowledge, skills, abilities, and credentials for RNs.

Chapter Overview

Perhaps at no other time in the history of the nursing profession has there been such an imperative for strong, involved, informed nursing leadership. The challenges currently faced by the U.S. health care system—ongoing and serious patient safety issues; a shortage of appropriately educated and geographically dispersed nursing and other health professionals; complex, high-tech work environments; a fragmented delivery system; an aging population; and dramatic overall health care system changes in response to national health reform—confront the health and well-being of patients, families, and communities across the country. Nurses can no longer simply move forward and participate in the delivery of patient care without also addressing these larger issues that impact the whole of the health care system. Frequently these critical issues can be understood, addressed, and resolved only through the policy process. Without a doubt, legislation, regulation, and health policy directly affect how health care is delivered and how the health care system responds to the very real challenges and opportunities it faces. Nurses must get involved now in the policy process and provide strong leadership among the health care professions to ensure evolution to an efficient, effective health care system that promotes and protects the health and well-being of each person in our society.

This chapter explores the effect of governmental roles, structures, and actions on health care policy and demonstrates how participation in the policy process can shape the U.S. health care system. Local, state, and federal legislative concerns including the involvement of professional nursing organizations in policy and politics are discussed. The nurse’s very important role in the policy process and involvement in political advocacy and campaigns is described. This chapter provides the reader with a basic understanding of policy development and political processes, tools to gain political savvy, and methods for getting politically involved.

Nurses’ Involvement in Health Policy and Political Action

Nurses’ involvement in policy and politics has become considerably more important in recent years for the following reasons:

• State and federal governments play an increasingly important role in health care, especially as federal and state governments and multiple private players embark on implementation of The Patient Protection and Affordable Care Act (PPACA), which was signed into law in 2010.

• Nursing practice is directly affected by health policy development which is, in turn, affected by the political action of citizens—nurses and many, many others.

• Patient safety and quality; access to affordable health coverage and services; and costs, value, and outcomes of services have received national media attention and have become a major debate among policymakers, especially at the federal and state levels of government over the past few years.

• National attention on nurses and nursing has intensified—our numbers, education, scope of practice, and overall value to the health care system.

Decisions affecting the health care system, patient care, and the nursing profession will be made with or without the input of nurses. As the reader will see from health policy examples provided throughout this chapter, patient care and nursing practice are highly political endeavors with health policy determining the types of care systems in place and how that care is paid for. Thus, it is absolutely essential that nurses become actively engaged in the policy process and use effective political action to successfully achieve the development of health policies that are reflective of nursing’s perspective on the preferred future for the profession and for health and the health care delivery system in the United States.

What is health policy?

Health policy is a set course of action(s) undertaken by governments or health care organizations to obtain a desired outcome. Private health policy is made by health care organizations, such as hospitals, and includes those policies instituted to govern innumerable employer/employee practices and processes in the delivery of the health care services provided within the organization. A hospital’s specific plan to report errors in patient care is an example of private health policy. Public health policy refers to local, state, and federal legislation, regulations, and resource allocation related to health, health care service delivery, coverage, workforce, and reimbursement. The mandatory requirement for licensure to practice professional nursing is an example of public health policy. There is a close link between private and public policy in that the policies of health care organizations must conform to (and are actually frequently developed and implemented to comply with) a public policy. Although it is vital that the RN be an informed participant in policy development at one’s employing health care organization, this chapter focuses on the development of public or governmental health policy, which will be referred to simply as health policy.

Health Policy at the Local, State, and Federal Level

Health policies may be developed and implemented at the local, state, or federal level, and they apply to all residents within the jurisdiction of the respective governmental authority. Local health policy applies only to those people who are residents of that local community, whereas health policy enacted at the federal level applies to all residents in the United States.

Local Health Policy

At the local level, many cities or counties offer a variety of health care services to meet the needs of their residents. For example, as part of a city’s health policy, free or reduced-rate immunizations may be offered to all children in the community. Allocating funds to employ RNs as school nurses in public schools is another example of local health policy. A more comprehensive (and thus perhaps more controversial) policy is a community’s requirement for tobacco-free public areas such as restaurants and office buildings. Local health policy varies considerably across the United States, with some communities funding an extensive variety of health programs and others offering very limited health services or none at all. However, even the smallest communities are involved to some extent in health policy through partnerships with their state government to provide public health programs such as safe drinking water, enforcement for seat belt and child restraint laws, and emergency medical systems.

State Health Policy

Health policy at the state level has a powerful influence on the health and safety of each state’s residents. In addition to its lead role in governing nursing and other health professions’ scope, practice, and performance through the state’s professional practice acts, each state also has innumerable health policies that may not be visible. These policies include maintaining a safe meat supply through livestock inspections; ensuring safe food storage, preparation, and serving in restaurants; and ensuring that health care facilities provide safe, quality care through regulatory compliance. Only when these activities fall short of preventing problems—as in cases of Escherichia coli outbreaks—do most residents of the state realize the critical nature of these health policies.

State health policy also involves paying for some individual health care services. The Medicaid program is funded through a blend of state and federal funds and is a health insurance program for health care services for eligible people at (or below) a specific income level and other designated categories (as defined by a combination of federal and individual state standards). Most states also have a state Children’s Health Insurance Program (CHIP) that provides health insurance coverage to uninsured children who do not qualify for the Medicaid program. The CHIP is funded through a partnership between federal and state governments. State and federal governments are also the prime sources of funding for public mental health and substance abuse services, long-term care services for older adults and disabled persons, and health care services for prisoners.

A key piece of the PPACA is the opportunity for state development and implementation of State Health Insurance Exchanges (SHIEs). A SHIE is a set of state-regulated and standardized health care plans from which individuals may purchase health insurance eligible for federal subsidies; such plans offer affordable and credible coverage that meet national standards for covered services with individual state benchmarks.

Federal Health Policy

State government and state health policies have an enormous effect on people’s health and safety. Likewise, the federal government plays a vitally important leadership role in the health of Americans, including passage of the PPACA by the 111th Congress. The federal government’s role in health care includes significant funding for health and disease prevention and research; supplemental funding for education for health professionals, including nurses and physicians; and paying for individual health care services through Medicare, Medicaid, the CHIP, and the Veterans Administration and Indian Health Services care systems.

Federal health policies have played and continue to play a pivotal role in shaping nursing practice. The first federal policy to provide funding for nursing services was the Sheppard-Towner Act of 1921. This act, which was passed by Congress despite objections from the American Medical Association (AMA), provided states with matching funds to establish prenatal and child health centers staffed by public health nurses. The goal of the act was to reduce maternal and infant mortality rates by teaching women about personal hygiene and infant care. Eventually this highly successful program was discontinued when the AMA successfully persuaded Congress that physicians should perform these health activities (Starr, 1982), but these services were later reinstated (and continue today) within Title V of the Social Security Act of 1935.

Another example of legislation that has significantly influenced the context of nursing practice over the past six decades was the Hill-Burton Act of 1950. This act provided funding to local communities that resulted in a boom in the construction of hospitals across the country. As the number of hospitals increased rapidly, so did the need for nurses to staff them. Thus, the nurse’s role shifted from community and public health settings to be predominately in hospital/acute care settings. Federal legislation has affected nursing practice through expanding Medicare and Medicaid reimbursement directly to advanced practice nurses and implementing policies and programs to expand the nursing supply through enhancing access to nursing education at all levels of nursing from BSN to DNP and PhD. Table 23-1 provides some historic examples of how health policy enacted at the federal level affected nursing practice and health care. Current policy issues affecting nursing practice and health care are addressed later in this chapter.

TABLE 23-1


Nurse practice acts and registration of nurses were established (1910). Established scope of practice and minimal educational requirements for nurses; implemented by most states.
Sheppard-Towner Act (1921) funded prenatal and child health centers staffed by public health nurses. First federal policy to provide funding for nursing services.
Hill-Burton Act (1950), also known as the Hospital Survey and Construction Act, provided federal funding for hospital construction. Caused a boom in hospital construction, shifting nurses’ primary employment setting from public health to hospitals.
Nurse Training Act (1964) Public Law 88-581 (78 Stat. 908) provided enhanced funding for collegiate nursing programs. Expanded university education for nurses, and laid the groundwork for the development of APRNs.
Medicare program (1965) provided funding for health care services for older adults and the disabled. Led to an increased number of hospitalized older adults and an increased need for nurses in acute care settings.
Renal Disease Program (1972) provided funding for dialysis treatments and renal transplants for patients with kidney failure. Led to the development of a new area of nursing practice that is now a recognized specialty—nephrology nursing.
Diagnosis-related groups (DRGs) (1983) changed Medicare reimbursement to hospitals from a fee-for-service method to a fixed-fee method. Forced hospitals to reduce patients’ lengths of stay, cut costs, and initially reduce staff, including nurses; led to the development of new nursing roles—nursing case management and utilization review.
Balanced Budget Amendment (1997) Title 42 Sect 4511 CFR 410.75 and 410.76 provided for direct reimbursement of nurse practitioners and nurse clinical specialists, regardless of geographic location following state NPAs requirements for scope and practice. Expanded the practice opportunities for advanced practice registered nurses (APRNs), and further increased the importance of political action at the state level to remove barriers to APRN practice such as medical supervision or other unwarranted limitations on scope and independence.
Medicare Modernization Act (Medicare Part D) (2003) PL 108-173 117 Stat 2066 added a prescription drug benefit for Medicare enrollees. Provides needed access to medications for Medicare enrollees, and calls attention to cost-and-effectiveness outcome from policymakers, requiring nurses to stay alert to proposed legislation and to advocate for appropriate benefits for the nation’s older adults.
Mental Health Parity and Addictions Equity Act (MHPAEA) 2008 PL 110-343 Sect 511 removed discrimination in insurance coverage and benefits for mental illnesses and substance abuse disorders. Greatly increases access to a continuum of mental health/substance abuse services, and puts pressure on developing a nursing workforce with sufficient numbers and knowledge to address these illnesses as integrated with other chronic illnesses and as specialty services.

How is health policy developed?

The development of health policy at the state or federal level is a complex, dynamic process that occurs in the following three ways (Chaffee et al, 2011):

Numerous players (individuals and groups) are involved in developing health policy including: elected officials and their staffs; officials/staff of executive branch governmental agencies; individual experts in a health-related area; citizens who may be affected by a health problem; stakeholders, such as corporate representatives, who may be affected by a health problem or policy; and representatives from special interest groups who have a particular focused interest in one or more policy options. As a special interest group representing the interests of 3.1 million professional nurses throughout the United States, the American Nurses Association (ANA) carries a strong voice and high visibility in influencing health policy and nursing practice. At the state level, the SNAs of the ANA are the policy voice of the nursing profession with state governors and legislatures.

The development of health policy involves all three branches of government: executive, legislative, and judicial. A basic knowledge of the functions of the three branches of government is necessary to understand health policy development. Table 23-2 presents a brief review of the three branches of the federal government and their differing roles in health policy. Although most state governments parallel the structure and functions of the federal government, there are differences among states. Each nurse is encouraged to learn about the governmental structure of his or her state. In addition to understanding the branches of government, nurses also need to understand the influence of legislation and regulation on health policy as discussed in the following sections.

TABLE 23-2


Composition Office of the President and 15 executive departments (State, Treasury, Defense, Agriculture, Energy, Housing and Urban Development, Justice, Commerce, Education, Health and Human Services, Interior, Labor, Transportation, Veterans Affairs, and Department of Homeland Security) Senate and House of Representatives known collectively as Congress with 535 elected members U.S. Supreme Court, federal district courts, and U.S. circuit courts of appeals
Role in health policy Recommends legislation and promotes major policy initiatives Possesses the sole federal power to enact legislation and to tax citizens and allocate federal spending Judicial interpretations of the Constitution or various laws may have a policy effect
  Implements laws and manages programs after they have been passed by Congress through regulation, oversight, and presidential funding priorities Able to originate and promote major policy initiatives Resolves questions regarding agency regulations that may affect policy
  Writes regulations that interpret statutes (laws) Power to override a presidential veto  
  Has the power to veto legislation passed by Congress    
Restrictions to power Unable to enact a law without the approval of Congress (legislative branch) U.S. Supreme Court may invalidate legislation as unconstitutional Unable to recommend or promote legislative initiatives

Nov 6, 2016 | Posted by in NURSING | Comments Off on Health Policy and Politics: Get Involved!
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