Chapter 10Policy, Politics, Legislation, and Community Health .docx

Chapter 10
Policy, Politics, Legislation, and Community Health Nursing
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,
an imprint of Elsevier Inc.
Nurses Who Made a Difference…
Florence Nightingale
Sojourner Truth
Clara Barton
Lavinia Dock
Lillian Wald
Mary Breckenridge
Susie Walking Bear Yellowtail
Florence Wald
Ruth Watson Lubic
2
Nurses’ Historical and Current Activity in Health Care Policy
Florence Nightingale
First nurse to exert political pressure on a government
Transformed military health
Knew the value of data in influencing policy
Collected and analyzed data about health services and
outcomes, which now is a critical element of public health

3
Photo credit:
http://commons.wikimedia.org/wiki/Florence_Nightingale
(Cont.)
Sojourner Truth
Advocate for abolishing slavery
Supported women’s rights
Helped transform racist and sexist policies that limited health
and well-being of blacks and women
Fought for human rights
Lobbied for funds to educate nurses and physicians
4
Photo credit:
http://commons.wikimedia.org/wiki/File:Carte_de_visite.jpg
(Cont.)
Clara Barton
Organized relief efforts during U.S. Civil War
Persuaded Congress to ratify the Treaty of Geneva, which
allowed the Red Cross to perform humanitarian efforts in times
of peace
5
Photo credit:
http://commons.wikimedia.org/wiki/File:WcbbustCBarton.jpg

(Cont.)
Lavinia Dock
Prolific writer and political activist
Campaigned to allow nurses to control the nursing profession
Advocated for women’s right to vote
Worked closely with Isabel Hampton Robb and Mary Adelaide
Nutting to found forerunner to NLN
6
Photo
credit:http://commons.wikimedia.org/wiki/File:Lavinia_Lloyd_
Dock.jpg
(Cont.)
Lillian Wald
Recognized connection between health and social conditions
Advocate for development of the Children’s Bureau in 1912
Frequently appeared at White House in development of national
and international policy
7
Photo
credit:http://commons.wikimedia.org/wiki/File:Lillian_Wald_-
_William_Valentine_Schevill.jpg

(Cont.)
Mary Breckenridge
Developed nursing in rural Kentucky
Established Frontier Nursing Service
8
Photo credit:
http://commons.wikimedia.org/wiki/File:WENDOVER.jpg
(Cont.)
Florence Wald
Nursing leader in establishing hospice care in the United States
Modeled hospice after similar services offered in United
Kingdom
9
Photo credit:
http://commons.wikimedia.org/wiki/File:Hospice_Media_Logo.
png
(Cont.)
Susie Walking Bear Yellowtail
Walked from reservation to reservation to improve health
services for Native Americans
Established Native American
Nurses Association

10
Photo credit:
http://commons.wikimedia.org/wiki/File:Ketchican_totem_pole_
2.jpg
(Cont.)
Ruth Watson Lubic
Nurse-midwife who crusaded for freestanding birth centers in
the United States
Leader in community-based birth center movement
11
Photo credit:
http://commons.wikimedia.org/wiki/File:Silverton_Hospital_birt
h_center_-_Silverton,_Oregon.JPG
Definitions to Know
Social justice
Laws
Public health law
Statutes
Organizations
Professional associations
Policy
Public policy
Health policy
Nursing policy
Institutional policies

Organizational policies
Social policy
12
Definitions
Policy denotes a course of action to be followed by a
government, business, or institution to obtain a desired effect.
Public policy denotes precepts and standards formed by
governmental bodies (legislative, executive, or judicial) that
are of fundamental concern to the state and the whole of the
general public.
13
Definitions (Cont.)
Health policy is a statement of a decision regarding a goal in
health care and a plan for achieving that goal.
Nursing policy specifies nursing leadership that influences and
shapes health policy and nursing practice.
Institutional policies are rules that govern worksites and
identify the institution's goals, operation, and treatment of
employees.
14

Definitions (Cont.)
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
defined as the branch of public policy that advances social
welfare and enhances participation in society.
15
Definitions (Cont.)
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.
Statutes are any laws passed by a legislative body at the federal,
state, or local level.
16
Definitions (Cont.)
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 is a nonprofit organization seeking to
further a particular profession, the interests of individuals
engaged in that profession, and the public interest.
17
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.
Many Healthy People 2020 objectives directly or indirectly
involve health policy.
– Nies and McEwen, 2015
18
Shifts in Philosophy at the CDC
19
From Centers for Disease Control and Prevention: State of the
CDC: fiscal year 2008, The Author.From…To…Disease
orientationHealth protection focusDesigning and implementing
sponsored programsInforming and guiding health system
actorsAllocating agency resourcesLeveraging resources to steer
larger health systemEmphasis on clinical preventionFocus on
prevention and health protectionTransaction-based
relationshipsPartnerships and strategic alliancesProgram
requirementsIncentives for participation/cooperationCollecting
and analyzing health dataCreating integrated health information

systemsIssuing advisories and guidelinesBuilding decision-
support system
Healthy People 2020
Vision
A society in which all people live long, healthy lives.
Overarching Goals
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 groups.
Create social and physical environments that promote good
health for all.
Promote quality of life, healthy development, and healthy
behaviors across all life stages.
20
Nies: Power Points, Evolve Resources for Nies/McEwen:
Community Health Nursing, 4th ed.
20
Overview of Health Policy
Public Health Policies
Decisions made at all levels of government (local, state, or
federal)
Influence health care through monitoring, production, provision,
and financing of health care services
Everyone is affected, from providers to consumers
Influence all health care organizations

21
Overview of Health Policy (Cont.)
Public Health System
Authority for public health vested with states
Responsibility delineated by constitution
Compliance with federal program standards is voluntary but
impacted by revenue
Policies influenced by social and political theories
Economics is one factor in decision making
Decisions are slow and deliberate and more reactive
Needs determined by voting shifts, electoral realignment, and
term limits
22
Overview of Health Policy (Cont.)
Private Health Sector
Includes employers, professional organizations, nonprofit health
care organizations, and for-profit corporations that deliver,
insure, or fund health care services outside of government
control
Policies evolve differently—influenced by economics and
business management
Economics is central factor in decision making
Decisions are swift and proactive

Needs determined by consumerism, market trends, and
economics
23
How a Bill Becomes a Law
24
Figure 10-1. From publicdomainclip-
art.blogspot.com/2007_09_01_archive.html. Retrieved October
19, 2009.
Impact of Federal Legislation on Health Care
Prevention of illness by influencing the environment
Provision of funding to support programs that influence health
care
Increased the involvement of state and local governments in
health care
Promoted similarities of services in all states
Funding resulted in increased regulations
Standardized U.S. public health policy
25

Critical Federal Legislation Related to Health Care
Pure Food and Drug Act of 1906
Manufacturing, labeling, and sale of food
Children’s Bureau Act of 1912
Regulated unhealthy child labor practices
Shepherd-Towner Act in 1921 extended to infants
Social Security Act of 1935; 1965; 1972
Benefits for mothers, children, elderly, disabled
26
Critical Federal Legislation
Related to Health Care (Cont.)
Medicare (Title XVIII) in 1965
Health care services for people over 65, with permanent
disabilities, and those with end-stage renal disease
Medicaid (Title XIX) in 1965
Combined federal and state program
Access to care for poor and medically needy
27
Public Health Act of 1944
Consolidated all existing public health legislation into one law

Health services for migratory workers
Family planning services
Health research facilities
National Institute of Health (NIH)
Nurse training acts
Traineeships for graduate students in public health
Home health services for Alzheimer’s disease patients
Prevention and primary care services
Rural health clinics
Communicable disease control
28
McCarren-Ferguson Act of 1945
Gave states right to regulate insurance plans
Hill-Burton Act of 1946
Federal assistance in construction of hospitals with
stipulations about service for the uninsured
Health Amendments Act of 1956; Title II
Funds for RN education in administration, supervision, and
teaching
1964 Nurses Training Act: funds for loans and scholarships and
to develop more nursing schools
29

Occupational Safety and Health Act of 1970
Focused on health needs and risks in workplace and
environment
Health Maintenance Organization Act of 1973
Employers must offer federally qualified HMOs as health care
option to employees
States had oversight on HMOs
30
National Health Planning and Resources Act of 1974
Assigned responsibility for health planning to states and local
health system agencies
Required health care facilities to obtain prior approval for
expansion in form of Certificate of Need (CON)
31

Omnibus Budget and Reconciliation Acts
1981, 1987, 1989, and 1990
Enacted to reduce huge federal deficit
Impacted funding for nursing homes, home health agencies, and
hospitals
Established new guidelines and regulations including a move
from process to outcome evaluation, use of restraints, and
prescription drugs for Medicaid recipients
32
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
Amendment to SSA of 1935
Established PPS for Medicare, the DRG system
COBRA of 1985
Requires all EDs that participate in Medicare to provide care for
all, regardless of ability to pay
Ensures continuation of insurance after loss of job
Example of how federal government can affect state health care
practices
33

Family Support Act of 1988
Expanded coverage for poor women and children
Expanded Aid to Families with Dependent Children (AFDC)
Health Objectives Planning Act of 1990
Response to the first Healthy People report (1979)
United States began to identify and monitor national health
goals; Healthy People 2000, 2010, and 2020
34
Health Insurance Portability and Accountability Act (HIPAA) of
1996
Ensured portability of insurance coverage
Offered protection for patient privacy and confidentiality
Welfare Reform Act of 1996
Restricted eligibility for AFDC, Medicaid, etc.
TANF helped move recipients into work; welfare offered
temporary assistance
Many underserved lost Medicaid coverage
35

The State Child Health Improvement Act (SCHIP) of 1997;
2009
Provides insurance for children and families who cannot afford
health insurance
Medicare Modernization Act of 2003
Most significant law in 40 years for senior health care
Provides seniors and disabled with some Rx drug benefit
coverage, more choice, and better benefits
36
Nurse Reinvestment Act of 2003
Funding provided to increase enrollments and number of
practicing nurses
Mental Health Parity and Addictions Equity Act of 2008
Financial requirements (deductibles, co-payments) and
treatment limitations (number of visits; days of coverage) that
apply to mental health benefits must be no more restrictive than
the predominant financial requirements or treatment limitations
that apply to substantially all medical/surgical benefits
37

Patient Protection and Affordable Care Act of 2010
All U.S. citizens and legal residents to have qualifying health
coverage
Changes eligibility requirements for Medicaid and expands
CHIPS
Subsidizes premiums for lower and middle income families
Requires coverage of dependent adult children up to age 26
38
Patient Protection and Affordable Care Act of 2010 (Cont.)
Significant insurance reforms
Established high-risk pools
Covers preexisting conditions
No lifetime limits on coverage
Cannot drop policyholders when they get sick
Must provide preventive care and screenings without customer
cost-sharing
Fosters nonprofit, member-run exchanges
Implemented over several years
39
Patient Protection and Affordable Care Act of 2010 (Cont.)

Funded through new fees and taxes.
Taxes on indoor tanning
Medicare taxes for higher income brackets
Fees for pharmaceutical companies and medical devices
Penalties for those who do not obtain health insurance
Cost-cutting measures
Cuts to Medicare Advantage programs
Reductions in Medicare spending
Reduce administrative costs, streamline care, reduce fraud and
abuse
40
The health reform legislation in 2010 was strongly influenced
by the rising number of uninsured and underinsured.
The United States is only major developed country to not have
universal health coverage.
41
State Legislative Role
Focus on financing and delivery of services and oversight of
insurance to address the mission of public health throughout the
state
Assess health needs
Ensure adequate statutory base for health activities
Establish statewide health objectives
Ensure appropriate organized statewide effort to develop and
maintain essential services

Guarantee minimum set of essential health services
Support local service capacity
42
Effective Use of Nurses: A Policy Issue
Title VII funding (HRSA) provides the largest source of
federal funding for nursing education
Favors education for practice in rural and medically
underserved communities
Nursing shortage is a crisis
Economic impact on positions
Focus on hiring BSN graduates (not ADN)
Shortage of nursing faculty
Nurse Education, Expansion, and Development Act of 2009
amended above to increase funds for nursing schools
43
Nurses’ Roles in Political Activities
The Power of One and Many
…as Change Agents
…with Coalitions
…as Lobbyists
…on Political Action Committees (PACs)
…in Campaigning
…in Voting Strength
…in Public Office

44
Chapter 11
The Health Care System
U.S. Health Care System
2
Figure 11-1
U.S. Health Care System (Cont.)
Private health care subsystem
Focus on the individual
Nonprofit and for-profit agencies
Models of services
Solo practice
Single specialty group practice
Multispecialty group practice
Integrated health maintenance model
Community health center
Voluntary or nonofficial agencies

3
U.S. Health Care System (Cont.)
Public health care system
Mandated by the U.S. Constitution
Focus on the population
“promote the general welfare of its citizens.”
Federal policies and practices influence local and state
governments
Coordination of services under Department of Health and
Human Services
4
Public Health
Public health refers to the efforts organized by society to
protect, promote, and restore the people’s health.
Concerned with a healthy population
Concerned with a healthy environment
Scope is broad
Encompasses activities that promote good health
Organized into multiple levels (federal, state, local)
Provides services for those unable to obtain health care without
assistance
Establishes laws, rules, and regulations to protect the public

5
Public Health System
Federal level subsystem
U.S. Department of Health and Human Services
Surgeon General and numerous other agencies
Targets general population, special populations, and
international health
IOM Report, HHS in the 21st Century: Charting a New Course
for a Healthier America (2008), recommended transformation of
system
6
Current HHS Strategic Plan
Transform health care
Advance scientific knowledge and innovation
Advance health, safety, and well-being of the American people
Increase efficiency, transparency, and accountability of HHS
Strengthen the nation’s health and human services infrastructure
and workforce
7
Public Health System (Cont.)
State level subsystem

State health departments
Responsible for the health of their citizens
Central authorities in the public health care system
Dependent on federal level for guidance and resources
Establish own state laws
8
Public Health System (Cont.)
Local health department subsystem
Local health departments (LHD)
Responsible for direct delivery of public health services and
protection of the health of citizens
Not all communities have LHDs
Responsible for:
Community health services
Environmental health services
Personal health services
Mental health services
9
Health Care Providers
Provider organizations
Any organization that provides health care to the community
Health care professionals
The interprofessional health care team

Professionals and nonprofessionals
Nontraditional health care providers
Complementary and alternative therapies
10
Quality Care
To Err Is Human: Building a Safer Health System (IOM, 1999)
focused on safety within the health care delivery system
Crossing the Quality Chasm (IOM, 2001) focused on developing
a new health care system for the twenty-first century, one that
improves care
Leadership by Example (IOM, 2003) was a report requested by
Congress that examined the federal government’s quality
enhancement processes
11
Quality Care (Cont.)
Who Will Keep the Public Healthy? (IOM, 2003) brought
public health into the forefront by focusing on issues including
globalization, rapid travel, scientific and technological
advances, and demographic changes
In-depth exploration of educational needs for improved public
health
Need for appropriately prepared public health professionals

12
Who Will Keep the Public Healthy? (Cont.)
New content areas for public health professionals:
Informatics, genomics, communication, cultural competence,
community-based anticipatory research, global health, policy
and law, and public health ethics
Old content areas for public health professionals:
Epidemiology, biostatistics, environmental health, health
services administration, and social and behavioral science
13
Health Professions Education (IOM, 2003), the education of all
health professionals is viewed as a bridge to quality care.
Provide patient-centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics
14
Priority Areas for National Action (IOM, 2003) identified

priority areas that should be addressed to improve quality
Patient and family engagement
Population health
Safety
Care coordination
Palliative care
Overuse
Access
Health systems infrastructure capabilities
15
Keeping Patients Safe: Transforming the Work Environment
(IOM, 2004) addressed critical quality and safety issues with a
focus on nursing care and nurses
Focused on nurses in acute care and the work environment for
safer patient care
Also looked at nursing shortage, health care errors, patient
safety risk factors, nurse’s role in quality improvement, and
work environment threats to patient safety
16
The Future of Nursing. Leading Change, Advancing Health
(IOM, 2011) focuses on the nursing profession and how it might
fit into the change process
Nurses should practice to the full extent of their education and
training.

Nurses should achieve higher levels of education and training
through an improved education system that promotes seamless
academic progression.
17
The Future of Nursing. Leading Change, Advancing Health
(Cont.)
Nurses should be full partners with physicians and other health
professionals in redesigning health care in the United States.
Effective workforce planning and policy making require better
data collection and an improved information infrastructure.
18
Accreditation
Joint Commission
National Committee for Quality Assurance (NCQA)
Health Plan Effectiveness Data and Information Set (HEDIS)
American Healthcare Commission
Consumer Assessment of Healthcare Providers and Systems
(CAHPS)
Agency for Healthcare Research and Quality (AHRQ)
19
… the ultimate test of the public health subsystem is whether it

effectively serves the people by their measurements, not those
of the public health profession.
– Koop (1989)
20
Critical Issues in Health Care Delivery
Managed care
Information technology
Telehealth
Electronic medical records (EMRs)
Social media
Consumer advocacy and client rights
Client/consumer-centered health care
Coordination and access to care
Disparity in health care delivery
21
Critical Issues in Health Care Delivery (Cont.)
Globalization and international health
World has no real boundaries
CDC active in responding to preparedness and international
travel
WHO fosters collaborative global initiatives
ICN gives nursing perspective
Health care reform
The Clinton Health Reform Initiative

Patient Protection and Affordable Care Act of 2010
22
Future of Public Health
23
What services?
Who has access?
Who pays?
How is it delivered?
What is the role of government?
Impact on Community Health Nursing
Principles of change that focus on quality, access, and cost…
The need for patient-centered care
The need for stronger primary care services
The need to deliver more care in the community
The need for seamless, coordinated care
The need for reconceptualized roles for health professionals
The need for interprofessional collaboration
– The Future of Nursing. Leading Change,
Advancing Health (IOM, 2011)

24
Economics of Health Care
Chapter 12
Factors Influencing Health Care Costs
Historical payment systems
Unnecessary use of services
Lack of preventive care
Lifestyle/health behaviors
Societal belief that disease would be eradicated
Technological advances
Aging of society
Utilization of drugs
Shift from nonprofit to for-profit health care
2
Public Financing of Health Care: Medicare
Entitlement program to provide health care to the growing
population of those 65 years of age or older

Part A
Includes inpatient care in hospitals/skilled nursing facilities,
hospice care, some home health care
Must pay a deductible for health services
Does not pay for all health care costs of enrollees; co-
payments required after 60 days
3
Public Financing of Health Care: Medicare (Cont.)
Part B
Purchased by monthly fee
Not compulsory
Helps pay for out-of-pocket costs for physician services,
hospital outpatient care, durable medical equipment, and other
services, including some home health care
Enrollees must pay deductibles and coinsurance
4

Part C
Medicare Advantage Plans
Optional “gap” coverage
Provided by private insurance companies approved by, and
under contract with, Medicare
May include HMOs and PPOs
May include vision, hearing, dental care, and other services not
covered by Medicare Parts A, B, or D
5
Part D
Initiated in 2006 to help defray costs of
prescription drugs
Optional; must enroll in an approved prescription drug plan
Monthly premium, deductibles, and co-payments
Must pay 100% of costs when costs reach “coverage gap” or
“donut hole”
6

Public Financing of Health Care: Medicaid
Title XIX of the Social Security Act—a public welfare
assistance program
Provides universal health care coverage for the indigent and
children
A joint state and federal venture
Eligibility for this program depends on the size and income of
the family; federal government sets baseline eligibility
requirements, but states can lower eligibility
Priority participation is given to children, pregnant women, and
the disabled
7
Public Financing of Health Care: Medicaid (Cont.)
Federal government sets baseline services, but state
governments may provide more services
Must include inpatient and outpatient hospital care, pregnancy-
related care, vaccines for children, family planning services,
rural health clinics, home health care, lab and x-ray services,
and EPSDT
Care by pediatric and family nurse practitioners is covered
Children under 18 also eligible for Children’s Health Insurance
Program (CHIP)
8

Public Financing of Health Care: Governmental Grants
Directed toward funding large populations and different
aggregates
Historically for health promotion and disease prevention
measures
Administered by DHHS
“Block grants” provided to states to impact the health of the
public as a whole
Health care providers and programs compete for funds through
grant proposals and applications
Closely related to Healthy People 2020 objectives
9
Philanthropic Financing of Health Care
Often research or disease oriented
Eligibility for services limited to the specific disease or
population of interest
May include services rendered plus ancillary needs like
transportation, parental housing, or wigs
Informational and research activities constitute the majority of
services provided by these organizations
Examples include American Heart Association and the Shriners
10

Health Insurance Plans
First established in 1930s
Types of plans
Indemnity, HMO, PPO, POS
Private insurance, cooperatives, cafeteria plans
Reimbursement mechanisms
Retrospective and prospective plans
Scope of services covered
Routine care, catastrophic, ambulatory
11
Cost Containment
Capitated reimbursement
Prospective reimbursement for services
Access limitation
Primary care provider as gatekeeper
Managed care plans—preauthorization requirements for
additional services
Rationing
Determining the most appropriate use of health care or directing
the health care where it can do the most good
12
Trends in Health Financing

New and innovative health care approaches
Cost sharing
Health alliances
Self-insurance
Flexible spending accounts
Health promotion and disease prevention
13
Health Care Financing Reform
Lack of insurance is the major factor associated with lack of
access to medical care.
The current dilemma is how to provide health care to all
Americans that is acceptable and affordable.
14
Caring for the Uninsured
Should health care be one of those necessities available to all
without cost?
Should health care be a right for all rather than a commodity to
be available only to those who can afford it?
15

Access to Health Care—Barriers
Insufficient financial support
Physical barriers
Structural inaccessibility, lack of appropriate equipment, or
inability to communicate
Inequality in the distribution of services, transportation
difficulty, conflict with work hours, and failure to provide
services
Sociological barriers
Language difficulties and fear of reprisals
16
Health Care Reform 2010
Individual mandate
Employer requirements
Expansion of Medicaid
Expansion of CHIP
Premium and cost-sharing subsidies to individuals
Changes to private insurance
Cost-containment provisions
Prevention and wellness
17
Nurse’s Role in Economics

Researcher
Investigate efficient, cost-effective care, culturally sensitive
treatment modalities, health education, disease prevention, and
factors to change behaviors
Investigate, develop, and evaluate the effectiveness of health
promotion and disease prevention
18
Nurse’s Role in Economics (Cont.)
Educator
Health education is the foundation of community health nursing
practice
Understand that knowledge empowers clients to actively
participate in their health care
Demonstrate the effectiveness and value of education
Outcome measures for health education need to be established
19
Provider of care
Care must be appropriate, necessary, and cost effective.
Judicious application of the nursing process is imperative.
Serve as program service provider, health education provider,
and heath program participant
Participate in grant proposal process, program design, and
evaluation of these programs

Participate in statistical information–gathering process as basis
for determining needs
20
Advocate
Become more involved in the economics of health care
Increase knowledge of health care funding and policy making
Use political power to influence health care funding
Advocate for increase in health promotion/disease prevention
funding
Plan programs, seek funding, and evaluate program
effectiveness through outcome measures
21

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