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UNIT 1 64 Frameworks for action in policy and politics Diana J. Mason, Elizabeth Dickson, Monica R. McLemore, G. Adriana Perez “The most common way people give up their power is by thinking they don’t have any.” Alice Walker When Lauren Underwood was a young girl, she found out that she had supraventricular tachycardia for which she was treated. The health professionals who provided her initial treatment so inspired Underwood that she became a registered nurse. She is one of millions of Americans with a preexisting condition that made health insurance inaccessible for many people before the Affordable Care Act (ACA). Prior to that landmark legislation that reduced the number of people who were uninsured by 20 million (
Kaiser Family Foundation [KFF], 2018
), insurance companies could have either denied Underwood coverage or charged so much for a health plan that it would be unaffordable. 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.” A number of executive and legislative actions were taken to undo key features of the law, among them proposals to get rid of protections for people with preexisting conditions. At a community meeting hosted by the League of Women Voters, Congressman Randy Hultgren (R-IL), Underwood’s congressional representative at the time, promised he would only support legislation repealing Obamacare that protected coverage for people with preexisting conditions. He then proceeded to vote for the 2017 American Healthcare Act that included ending the preexisting condition protections. Underwood was in the audience and decided to act. She ran for Congress. As a Black nurse from Illinois who lived in a Republican-dominated congressional district, Underwood conducted a grassroots campaign that took her to some all-White neighborhoods and households that may never have considered voting for a person of color for their congressional representative. Underwood spoke directly to the benefits of the ACA, first as a nurse who had seen what happens to people who do not have health insurance and cannot afford care; and second, as a former special adviser to
the U.S. Department of Health and Human Services during the Obama administration. She showed that she understood the issues that people cared
about (health care, including 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 then 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. She follows another nurse, Diane Black (R-
TN), who lost her bid for reelection in 2018. These nurses are not alone in serving in important policymaking positions: 65 • Dawn Adams won another race-against-the-odds for Virginia’s state assembly (see Chapter 43
); • Bethany Hall-Long became the Lieutenant-Governor of Delaware after serving for a number of years in the state’s legislature (see Chapter 47
); • Rear Admiral Sylvia Trent-Adams served as the nation’s Acting Surgeon General in the first year of the Trump Administration and then as Deputy Surgeon General (see Chapter 44 and the Foreword); • Mary Wakefield was appointed by President Barak Obama to be the Acting Deputy Secretary of Health and Human Services after heading up its Health Resources and Services Administration; • Erin Murphy has served in the Minnesota legislature and ran for Governor in 2018. It seems that some 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. However, serving in an elected or appointed political office is not the only way to influence the development and implementation of health policy. The work that nurses do every day —
the care and advocacy for patients, their families, and communities—and the
lives we live, along with the places we work, play, and love, are shaped by local, state, and national policies. The forces of policy that form our lives as constituents and nurses are real—policy is being made around us constantly,
in Washington, DC, in our state capitols, and in our local city halls. 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. 66 Focus on policy: What policy? Many nurses and others in health care often think of policy as “health policy”
or “health care policy.” The ACA is an example of a major federal policy that aimed to improve people’s access to health care, particularly through providing affordable health coverage for essential services. However, access to coverage does not necessarily mean access to care, nor does it ensure a healthy population. Health care access means having the ability to receive the right type of care, when needed, at an affordable price. The U.S. health care system is grounded in expensive, high-tech acute care that does not produce the desired health outcomes we ought to have and want and too often damages instead of heals. Despite spending more per person on health care than any other nation, the United States performs worse than other nations on most indicators of quality, efficiency, access, and other organizational performance measures (
Papanicolas, Woskie, & Jha,
2018
; Schneider, et al., 2017
), and preventable medical errors are estimated
to be the third leading cause of death in the country (
Makary & Daniel, 2016
). The nation also ranks at the bottom on certain health outcomes, including life expectancy at birth for both men and women, infant mortality rate, mortality rates for suicide and cardiovascular disease, and the prevalence of diabetes and obesity in children (
National Research Council, 2013
). 67 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. FIG. 1.1 Four cornerstones of reform. Source: (From O’Grady, E. T., & Johnson, J. [2013]
. Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier Saunders.) 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 68
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. 69 Upstream factors: Social determinants of health Promoting health requires more than a high-performing health care system (
Tilden et al., 2018
). First and foremost, health is created where people live, love, work, learn, worship, and play. It is becoming clear that one’s health status may be more dependent on one’s zip code than on one’s genetic code
(Graham, 2016). Geographic analyses of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic inequities persist (
Marmot & Allen, 2014
). There are multiple ways in which exposure to
structural racism has been shown to harm the physical, social, and economic
health of individuals, families, and communities (
Bailey et al., 2017
). More so, the health of individuals and families is severely compromised in communities where good education, nutritious foods, safe places to exercise,
and well-paying jobs are scarce (
Artiga & Hinton, 2018
). Creating a healthier nation requires that we address “upstream factors”—the broad range of issues, other than health care, that can undermine or promote health—also known as “social determinants of health” (
World Health Organization [WHO], n.d.
). Upstream factors promoting health include 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 (
Fig. 1.2
). The key to reducing and eliminating health disparities, which disproportionately affect racial and ethnic minorities, is to provide effective interventions that address upstream factors both from within and outside of health care systems. FIG. 1.2 Social determinants of health. Source: (From Artiga, S., & Hinton, E. [2018]
. Beyond health care: The role of social determinants in promoting health and health equity. Henry J Kaiser Family Foundation. Retrieved from www.kff.org/disparities-policy/issue- brief/beyond-health-care-the-role-of-
social-determinants-in-promoting-health-and-health- equity/
.)
There is growing recognition that even the health care system has to change
its model
70 from one that is strictly biomedical to one that recognizes that health is in large part determined by psychosocial factors (
Adler et al., 2016
). How does someone with diabetes successfully manage their condition if they are homeless, without refrigeration for insulin or access to healthy food or safe parks for physical activity? A focus on such factors is essential for economic and moral reasons. Even in the most affluent nations, those living in poverty have substantially shorter life expectancies and experience more illness than
those who are wealthy, resulting in high costs in human and financial terms (
Khullar & Chokshi, 2018
). However, most of the focus on reducing disparities, including socioeconomic ones, has been on health policy that addresses access, coverage, cost, and quality of care once the individual has
entered the health care system—despite the fact that most health care problems begin long before people seek medical care (
Williams et al., 2008
). Thus changing our nation’s poor performance on health care and the health of its people requires knowledge about the political aspects of the social determinates of health. Political aspects of the social determinants of health appear in Box 1.1
. BOX 1.1 Political Aspects of the Social Determinants of Health
The health of individuals and populations is determined significantly by
social factors.
The social determinants of health produce great inequities in health
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