Chapter 10 Policy, Politics, Legislation, and Community Health Nursing Anita W. Finkelman, ∗ Objectives Upon completion of this chapter, the reader will be able to do the following: 1.Discuss how the structure of government impacts the policy development process. 2.Describe the legislative, judicial, and administrative (executive) processes involved in establishing federal, state, or local health policy. 3.Examine the power of nursing to influence and change health policy. 4.Discuss current health policy issues. 5.Identify the social and political processes that influence health policy development. 6.Discuss the nurse’s role in political activities. 7.Discuss nursing’s involvement in private health policy. ∗ The author would like to acknowledge the contributions of Linda Thompson Adams and Deborah M. Tierney, who wrote this chapter for the previous edition. Key Terms administrative agencies Clara Barton coalition Florence Nightingale government health policy institutional policies Lavinia Dock laws Lillian Wald lobby lobbyist Mary Wakefield nursing policy organizational policies organizations policy policy analysis political action committees politics public health law public policy Ruth Watson Lubic social policy Sojourner Truth statutes This chapter addresses the interrelationships of the processes through which health policies are determined and instituted. Politics and legislation are the routes through which public health policies are established. Policy, politics, and legislation are the forces that determine the direction of health programs at every level of government, as well as the private sector. Public Health Law Presentation

These programs are crucial to the health and well-being of the nation, the state, the community, and the individual. Nurses influence the maintenance and improvement of the health of individuals, groups, and communities by contributing to policy and legislative advancement. The health care delivery system, including nursing practice and research, is profoundly influenced by policies set by both government and private entities. Nurses who understand the system of health policy development and implementation can effectively interpret and influence policies that affect nursing practice, the health of individuals, families, groups, communities, and populations, and, when required, offer an international health perspective. Overview: Nurses’ Historical and Current Activity in Health Care Policy The more a nurse knows about the political process, the more he or she tends to become involved. Individual nurses may become politically active on a local, state, or national level. Nurses may work collectively within a group such as the National Student Nurses Association, the American Nurses Association (ANA), and state boards of nursing to lobby for health causes. There are about 3 million employed registered nurses (Kaiser Foundation, 2011). Together nurses can be patient advocates, change agents, and policy makers. Lawmakers respect nurses and thus are usually effective as consultants in both the legislative and executive branches at state and federal levels. It is the hallmark of the U.S. system of government that citizens have the right to have an influential voice in the governance of the community. Nurses are able to communicate concerns about conditions and issues in health care, the health care needs of individuals and communities, as well as the profession of nursing. United, nurses can influence political leaders to make changes to the health care system that are beneficial to all. Nurses experienced in the political arena can mentor novices to it. Many individual nurses in the past and present have been instrumental in working with legislation and politics. A few exemplary nurses who had an impact on public health are: Florence Nightingale was the first nurse to exert political pressure on a government (Hall-Long, 1995). She transformed military health and knew the value of data in influencing policy. She was a leader who knew how to use the support of followers, colleagues, and policy makers. As discussed in Chapter 2, Nightingale collected and analyzed data about health services and outcomes, an activity that now is a critical element of public health. Sojourner Truth became an ardent and eloquent advocate for abolishing slavery and supporting women’s rights. Her work helped transform the racist and sexist policies that limited the health and well-being of African Americans and women. She fought for human rights and lobbied for federal funds to train nurses and physicians (Mason, Leavitt, and Chaffee, 2007). Clara Barton was responsible for organizing relief efforts during the U.S. Civil War. In 1882, she successfully persuaded Congress to ratify the Treaty of Geneva, which allowed the Red Cross to perform humanitarian efforts in times of peace. This organization has had a lasting influence on national and international policies (Hall-Long, 1995; Kalisch and Kalisch, 2004). Lavinia Dock was a prolific writer and political activist.

She waged a campaign for legislation to allow nurses to control the nursing profession instead of physicians. In 1893, with the assistance of Isabel Hampton Robb and Mary Adelaide Nutting, she founded the politically active American Society of Superintendents of Training Schools for Nurses, which later became the National League for Nursing (Kalisch and Kalisch, 2004). She was also active in the suffrage movement, advocating that nurses support the woman’s right to vote (Lewinson, 2007). Lillian Wald’s political activism and vision were shaped by feminist values. Working in the early 1900s, she recognized the connections between health and social conditions. She was a driving force behind the federal government’s development of the Children’s Bureau in 1912. Wald appeared frequently at the White House to participate in the development of national and international policy (Mason et al., 2007). Mary Breckenridge worked to develop nursing in rural Kentucky in the 1920s, establishing the Frontier Nursing Service. Susie Walking Bear Yellowtail (1930-1960) was a Native American nurse who walked from reservation to reservation, working to improve health services for this population. She also established the Native American Nurses Association. Florence Wald was a nursing leader in establishing hospice care in the United States— modeled after similar services offered in the United Kingdom—in the 1970s. Dr. Ruth Watson Lubic is a nurse-midwife who crusaded for freestanding birth centers in this country. After developing the birth center model through the Maternity Center Association in New York City, Dr. Lubic expanded the model to Washington, DC, where the infant mortality rate was twice the national average. In 1993, Lubic was awarded the MacArthur Fellowship Grant and, in 2001, the Institute of Medicine’s Lienhard Award (Institute of Medicine, 2001; Lyttle, 2000). Public Health Law Presentation

Definitions Policy denotes a course of action to be followed by a government, business, or institution to obtain a desired effect. MerriamWebster’s Dictionary defines policy as “a definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions” (Merriam-Webster, 2014). Policy encompasses the choices that a society, segment of society, or organization makes regarding its goals and priorities and the ways it allocates its resources to attain those goals. Policy choices reflect the values, beliefs, and attitudes of those designing the policy (Mason et al., 2007). Public policy denotes precepts and standards formed by governmental bodies that are of fundamental concern to the state and the whole of the general public. The field of public policy involves the study of specific policy problems and governmental responses to them. Political scientists involved in the study of public policy attempt to devise solutions for problems of public concern. They study issues such as health care, pollution, and the economy. Public policy overlaps comparative politics in the study of comparative public policy with international relations in the study of foreign policy and national security policy, and with political theory in considering ethics in policy making. See the examples in Table 10-1. Health policy is a statement of a decision regarding a goal in health care and a plan for achieving that goal. For example, to prevent an epidemic, a program for inoculating a population is developed and implemented, and priorities and values underlying health resource allocation are determined. Nursing policy specifies nursing leadership that influences and shapes health policy and nursing practice. Nursing, and therefore nursing leadership, is shaped dramatically by the impact of politics and policy. Effective nursing leadership is a vehicle through which both nursing practice and health policy can be influenced and shaped. Institutional policies are rules that govern worksites and identify the institution’s goals, operation, and treatment of employees. Organizational policies are rules that govern organizations and their positions on issues with which the organization is concerned (Mason et al., 2007). Social policy is policy associated with individuals and communities. In very general terms, social policy can be TABLE 10-1 TERMINOLOGY EXAMPLE TOPIC EXAMPLE Public policy A local or regional effort to prevent the sale of tobacco or alcohol to minors. Public policy directs that the right to health of the majority must be preserved over individual freedoms and corporate interests. Public Health Law Presentation

Public health law New York State Public Health Law §2164: “Every person in parental (statute) relation to a child in this state shall have administered to such child an adequate dose of an immunizing agent against poliomyelitis, mumps, measles, diphtheria, rubella, varicella, Haemophilus influenza type B, and hepatitis B…” Common law The Supreme Court decision in Roe v Wade, making first-trimester abortion legal, is an example of how common law becomes enforceable. Regulation Reporting of communicable diseases to state and local health departments, which then report them to the Centers for Disease Control and Prevention. Treaty Multilateral treaty: Treaty to eliminate all forms of discrimination against women. defined as the branch of public policy that advances social welfare and enhances participation in society. Social safety nets, however, often contribute to social exclusion, especially in urban settings, instead of being universally accessible. In most Western societies, social protection usually depends on contributory social insurance schemes to which only regular job holders have access (either in their own right or as dependents). In the United States, this is particularly evident with respect to the way the health care system and Social Security retirement benefits work. Social justice argues that all individuals and groups receive fair treatment in society as well as impartially share in the benefits of that society (Almgren, 2007). Administrative agencies are departments of the executive branch with the authority to implement or administer particular legislation. Laws are rules of conduct or procedure; they result from a combination of legislation, judicial decisions, constitutional decisions, and administrative actions. Public health law focuses on legal issues in public health practice and on the public health effects of legal practice. Public health law typically has three major areas of practice: police power, disease and injury prevention, and the law of populations. Statute, ordinance, or code prescribes sanitary standards and regulation for the purpose of promoting and preserving the community’s health. Public health law consists of legislation, regulations, and court decisions enacted by government at the federal, state, and local levels to protect the public’s health. This includes case law and treaties. Statutes are any laws passed by a legislative body at the federal, state, or local level. Organizations are associations that set and enforce standards in a particular area; a group of individuals who voluntarily enter into an agreement to accomplish a purpose. A professional association (also called a professional body, professional organization, or professional society) is a nonprofit organization seeking to further a particular profession, the interests of individuals engaged in that profession, and the public interest. It is a volunteer group that seeks to join large numbers of individuals who have a significant wealth of knowledge and experience in a particular field. There are also pooled funds for lobbying purposes (Thomas, 1997). The roles of these professional organizations are viewed as maintaining the control and oversight of the professional occupation as well as safeguarding the public trust. There is an element of protecting the interests of the professional practitioners, as in a cartel or labor union. Inherent in these organizations is the promotion of general standards for the performance of its members and the expectation of continued professional development. Many professional bodies are involved in the development and monitoring of professional educational programs and the updating of skills, and thus they perform professional certification to indicate that a person possesses qualifications in the subject area. Sometimes membership in a professional body is synonymous with certification, though not always. Membership in a professional body, as a legal requirement, can in some professions form the primary formal basis for gaining entry to and setting up practice within the profession. Professional bodies also act as learned societies for the academic disciplines underlying their professions. A Major Paradigm Shift Policy is based on values, and the first step in forming policy is identification of the issue. Therefore, it would seem rational to define “health” as the starting point for any policy annexed to health care issues. Historically, health was defined in the context of infectious diseases. Public Health Law Presentation

Current definitions encompass prevention and management of chronic conditions. The World Health Organization (WHO) considers health to be the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Despite this broad definition, it is only in the most recent decades that the WHO is refocusing on its initial definition as it attempts to deal with environmental issues such as nuclear contamination and industrial toxins in industrialized nations and the exploration of carcinogenic commercial products such as tobacco products. On a global level, the WHO is working to eliminate antibiotic-resistant bacteria and find a way to solve the human immunodeficiency virus (HIV) pandemic. The emergence of HIV has changed the global health paradigm from the traditional notions of containment and treatment to a more comprehensive approach of social intervention. Thus there is a realization that health is a basic human right and that health problems are linked to government actions, and, hence affect human rights. Human rights violations occur when governments fail to provide their people with the infrastructure, services, and information necessary to promote health, reduce risk, and control disease. For example, for every year of education women have, their infant mortality is decreased by 10%; yet education of women is not a global reality. On a national level, an example of changing emphasis is the Centers for Disease Control and Prevention (CDC). It is committed to achieving true improvements in people’s lives by accelerating health impact and reducing health disparities. Box 10-1 describes this shift. All people, and especially those at greater risk of health disparities, will achieve their optimal lifespan with the best possible quality of health in every stage of life. However, a shift in the paradigm of health concepts would necessitate a substantial reallocation of resources because the vast majority of health spending is directed at medical care and biomedical research and, as such, reflects a viewpoint of health care as a commodity. If one considers that in 2011 47.9 million people in the United States younger than 65 years had no health insurance and 11.7% of children are uninsured, it becomes clear that the health and human rights relationship is not yet reflected in our health policies (Kaiser Family Foundation, 2012). Public Health Law Presentation

In addition, many people are underinsured. Their insurance coverage is not at the level it should be to cover full services BOX 10-1 SHIFTS IN PHILOSOPHY AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION FROM TO Disease orientation Health protection focus Designing and implementing sponsored programs Informing and guiding health system actors Allocating agency resources Leveraging resources to steer larger health system Emphasis on clinical prevention Focus on prevention and health protection Transaction-based relationships Partnerships and strategic alliances Program requirements Incentives for participation/cooperation Collecting and analyzing health data Creating integrated health information systems Issuing advisories and guidelines Building decision-support system From Centers for Disease Control and Prevention: State of the CDC: fiscal year 2008. Available from . or longer-term needs. The economics of health care are discussed further in Chapter 12. The publication of Healthy People 2000 by U.S. Surgeon General C. Everett Koop in 1990 led to a resurgence of interest by the federal government in the health and welfare of Americans. However, fiscal resources for public health interventions declined, and only marginal progress was made in meeting the goals. In early 2000, Healthy People 2010 marked the beginning of the new millennium and an enhanced focus on population-based health promotion strategies (U.S. Department of Health and Human Services [USDHHS], 2000). Many Healthy People 2010 objectives directly or indirectly involve health policy. The most recent update, Healthy People 2020 enhances the focus on the social determinants of health and adds even greater emphasis on health policy (USDHHS, 2013) (see the Healthy People 2020 box). Virtually all of the areas of Healthy People 2020 have multiple policy-related objectives, and the Healthy People box lists only a few of them. Building on previous iterations, the updated 2020 version has four “over-arching goals” for 2020: attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all age groups; create social and physical environments that promote good health for all; and promote quality of life, health development, and health behaviors across all life stages. The Healthy People 2020 box describes Healthy People content related to public health infrastructure. Another forward-looking recommendation is making Healthy People 2020 into a Web-accessible database that is searchable and interactive and allows users to tailor the document to the public’s needs. The intent is that enhanced focus on social determinants represents a “deliberate shift away from the perception that access to health care services will ever solve all of our health care problems” (USDHHS, 2013). HEALTHY PEOPLE 2020: Content Related to Public Health Infrastructure Goal To ensure that Federal, State, Tribal, and local health agencies have the necessary infrastructure to effectively provide essential public health services. Overview Public health infrastructure is fundamental to the provision and execution of public health services at all levels. A strong infrastructure provides the capacity to prepare for and respond to both acute (emergency) and chronic (ongoing) threats to the nation’s ..Public Health Law Presentation