NURS 3

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Chapter 3

▶ Introduction

It is not possible to separate politics from policymaking, whether the policy decisions are made in the public sector, the private sector, or at home. “Politic” is defined as being wise or shrewd, while “politics” is defined as methods, opinions, or scheming ( Goldman, 2000 ) or the process for influencing the allocation of scarce resources ( Chaffee, 2014, p. 307 ). Regardless of the definition used, many nurses and other healthcare professionals see “politics” as a negative term and perceive “playing politics” as a reason for not getting involved in political advocacy. That position means the expertise and insights that nurses and others possess by virtue of their hands-on experiences in caring for patients are not reflected in the policies that come out of Washington, D.C., state capitals, or boardrooms.

Because of the contributions nurses could and do make to the decision making that occurs in a variety of boardrooms, a coalition was formed to encourage more nurses to become members of policymaking boards. The Nurses on Boards Coalition ( 2016 ), which is made up of 24 nursing organizations plus strategic healthcare leadership and corporate partners, set a goal to have 10,000 nurses serving on corporate, health-related, and other boards by 2020. Such participation by nurses will help the public see the breadth of expertise nurses bring to the table and help develop a cadre of experienced nurses who can share their knowledge with other members of the nursing profession.

Some may believe involvement in policymaking is self-serving, concerned only with advancing selfish professional interests. Actually, the ultimate point in participating in policymaking is to improve patient outcomes. Focusing on “politic” (wisdom) rather than “politics” (influence) may make joining in the policy debate more relatable and palatable. This chapter provides insights into the processes that determine how policy is made and offers some opportunities to reflect on why certain outcomes occur but others do not. It will help readers find their way through the political maze by providing a basic understanding of some of the “rules of the game”—that is, how laws are made and who is on the field of play.

Before embarking on that journey, a word is in order about one of the most obvious displays of politics—elections. Elections matter, sometimes in ways that are not obvious on the surface. Never has that been more evident than in the aftermath of the 2016 presidential election. Trying to analyze what happened given the unprecedented nature of the campaign will occupy political scientists and others for years to come. Whether clear answers will emerge from a retrospective review remains to be seen, but it is certainly undeniable that the 2016 election will have lasting implications on many levels.

Clearly, election results determine who will hold office, who will be the president or governor, and who will be in the Senate or the House of Representatives. Will one party control two elected branches of government (legislative and executive), or will power be shared? Will the party in control have enough members to form a super-majority that allows it to ignore the concerns of the minority party, or will various perspectives be heeded so that bipartisan policies eventually emerge from the legislative process? Generally, some of these questions can be answered immediately after the votes are counted or shortly after the newly elected officials take office. For others, the answers emerge over time.

Elections matter on another level, too. As the newly elected Trump administration began to take shape, much rhetoric focused on the future of significant policy positions taken by the Obama administration as well as on the future of Medicare and Medicaid. Obamacare was in the headlines as Republicans saw their opportunity to finally repeal a law that had long been a thorn in their sides. Before the Republican majority had even been sworn in, debate began to rage about how to make the changes: repeal and replace Obamacare immediately, repeal immediately and replace later, or repeal later after a replacement strategy has been determined. Out of those discussions, held behind closed doors, one revelation emerged that seemed particularly telling. Moderate Republicans expressed concerns about the plan to repeal Obamacare within a year of Donald Trump’s inauguration as well as the plan to revise the long-standing Medicare and Medicaid programs. Because of all the technicalities associated with repeal or revision of these programs (e.g., changes in insurance), putting the changes into play—that is, implementing the changes—would run up against the next election cycle in 2018. Inevitable implementation problems might not bode well for the majority party’s ability to maintain its current stranglehold on both Houses of Congress ( Ferris & Wong, 2016 ).

The most telling insight that this peek behind closed doors offers is the realization (for better or worse) that policymakers are not necessarily focused on how real people will be affected by changes to Obamacare or Medicare and Medicaid but rather on how the changes will affect their own re-election chances. While some may find this focus disturbing, it demonstrates not just that election results do matter but also that even the threat of an upcoming election cycle affects what policymakers are willing or able to do. Awareness can be used in developing strategies for appealing to what really matters to policymakers. Being shrewd or “politic” is the takeaway lesson here. Timing is everything.

This chapter offers insight into the subtle rules governing political participation and sets out the options available to nurses for finding their way through the political maze. To navigate this environment successfully, the nurse must first have a basic understanding of how laws are made and who the participants in the lawmaking process are.

▶ Process, People, and Purse Strings

Process: How a Bill Really Becomes a Law

No one would presume to play a game of football without knowing the basic rules. Likewise, even simple board games, such as checkers or Monopoly, have rules that one must follow to have a chance of winning. Lawmaking is no different. In many ways it is a game, admittedly with very high stakes, and there is a process that determines what must happen for an idea, concept, or concern to become part of the U.S. Code or state statutes.

Most students complete a government course in high school. Although diagrams depicting how a bill becomes a law are important, they are also very rudimentary. There is much more to the process than can be neatly depicted on a chart. It is also important to realize that although the process may seem straightforward, it can be circumvented when the will of the party in control determines it is expedient to do so. For example, recent use of executive orders by the U.S. President and some governors is a non-legislative strategy that affects public policy in limited but significant ways. Parliamentary procedure maneuvers, filibusters, internal rule changes governing chamber proceedings, a lame-duck session , changes to committee appointments, and Christmas tree bills are all tactics or opportunities used to achieve one’s legislative goals expeditiously. Whether these tactics engender good public policy has been the subject of much debate among political scientists; however, regardless of the debate, nurses must be aware of these options so that they do not become the unwitting victims of a clever strategic move.

The Federal Process

Bills are ideas that a legislator has determined need to be enacted into law. These ideas can come from many sources: the legislator’s own experiences; issues brought forward by constituents , a special interest group , or a lobbyist on behalf of their clients; and not infrequently as a result of tragic events that trigger a public outcry for a new or amended law (e.g., school shootings that intensify the debate over gun control). Once the concept is drafted into the proper legislative language , it is introduced into the House of Representatives or Senate, depending on the chamber to which the bill’s chief sponsor belongs. Each bill is numbered sequentially, and it retains this number throughout the process.

Many bills are introduced during a legislative session, but few receive much attention in the form of committee consideration. Fewer still actually become law.

Committee Consideration

Once introduced, a bill is referred to a standing committee for further consideration. These standing committees are generally subject-matter focused, such that bills related to health care go to a health committee, finance issues to a banking committee, farm-related matters to an agriculture committee, and so on. Standing committees at the federal level tend to be permanent; at the state level, they can be configured differently over time depending on the vision of the leadership of the party in power at the beginning of each new legislative session. Subcommittees consider particular bills in greater detail. Bills are amended (revised) or “marked up” (voted on after being revised) in committee and subcommittee. Hearings offer affected parties (i.e., special-interest groups) opportunities to state their positions. A bill that emerges from committee may bear little resemblance to the original proposal, often because of the input received at a hearing.

Committee hearings are important, but they often appear to be more chaotic than productive, at least to the average observer. Much of the real business of lawmaking occurs behind the scenes, but one must also participate in the defined committee processes to earn a place at the more informal behind-the-scenes tables.

EXHIBIT 3-1 How to Find Legislation

Go to https://www.congress.gov

Select “Legislation” and search on a topic such as “health care”

Example: H.R. 315 is the 315th bill introduced in the 115th Congress. H.R.315—115th Congress (2017–2018) To amend the Public Health Service Act to distribute maternity care health professionals to health professional shortage areas identified as in need of maternity care health services.

Sponsor: Rep. Burgess, Michael C. [R-TX-26] (Introduced 01/05/2017)

Cosponsors: (2)

Committees: House—Energy and Commerce

Latest Action: 01/05/2017 Referred to the House Committee on Energy and Commerce. (All Actions)

Tracker: This bill has the status Introduced

Committee chairs (appointed by the political party in the majority) are extremely influential, particularly with respect to the subject areas that are the focus of the committee’s work. Chairs determine which bills will be heard and when, and they establish the procedural framework under which the committee operates. The chair’s position on an issue can determine the fate of a bill from the outset. Because of the extent of their power and influence, committee chairs are able to raise large sums of money from special-interest groups to support their re-election—and re-election is always an important consideration for lawmakers. The House and Senate leaders (elected by their colleagues) determine who will be named committee chairs. Certain committees are seen as more prestigious than others, so being named the chair of one of those committees is very important to an ambitious legislator. “Ranking members” are the appointed committee leaders for the political party in the minority.

Not surprisingly, political considerations play a role in this entire process. Being aware of the dynamics that are the foundation of the overall committee process helps ensure more effective representation by those who want to influence the outcome of the committee’s work.

Floor Action

If a bill is able to garner committee approval, it goes to the full chamber for a vote. The timing for scheduling a vote, as well as various attempts to amend the bill or delay the vote, are integral parts of the lawmaking process. Much maneuvering occurs backstage, and the ability to influence these less public interactions is as important as the words or concepts being debated. Again, people’s relationships and politics determine the ultimate results. To be effective in one’s efforts to influence outcomes, one must be aware of these relationships and take them into account. Once a bill is approved in either the House or Senate, legislators begin the process again in the other chamber.

Conference Committee

Seldom does a bill complete the journey through the second chamber without change, which means the originating chamber must agree to the new version of the bill. Without agreement, a bill will be referred to a conference committee made up of representatives from the House and Senate; they reconcile the differences in the two bills and ask their respective chambers to support the conference committee report. If agreement cannot be reached, the bill dies.

Chief Executive Signature

If the House and Senate reach agreement, the bill goes to the chief executive (president or governor), who must sign the bill before it can become law. If the chief executive vetoes the bill, it goes back to the legislature for a potential veto override, which requires a two-thirds majority of both chambers.

All this must happen within a single legislative cycle—2 years (a biennium). It is not surprising that it often takes several years for a particular legislative issue to finally become law, especially when powerful interest groups are on opposite sides of the proposal.

State legislatures typically follow the bicameral (two-chamber) structure of the federal government ( TABLE 3-1 ). The exception is Nebraska, which has a unicameral body.

TABLE 3-1 Congressional Structure
Senate	House of Representatives
100 members, 2 from each state.	435 members based on a state’s population. The number of representatives apportioned to each state changes every 10 years after the national census data are obtained. Drawing and redrawing congressional district lines is a very political process that each state implements according to its own laws.
6-year terms, with one-third up for re-election every 2 years, and no limit on the number of terms that can be served.	2-year terms, with no limit on the number of terms that can be served.
The vice president is the Senate leader, but a president pro tempore is elected each session by the majority party.	The majority party elects the Speaker of the House.

The number of legislators may vary from state to state, as may the length of the term in office for the senators. Some states (but not the federal government) have adopted laws that limit the number of consecutive terms a legislator may serve in any one chamber. These term limits were adopted to deal with legislators who served multiple years in their respective chambers. Their re-election was seldom challenged, and voters became convinced that policymaking would be better served by changing their lawmakers on a more regular basis.

Not surprisingly, term limits have had unintended consequences, some of which have changed the dynamics within the legislature and affected policymaking in general. Relationship and leadership development, which takes time, have been short-circuited. Ambitious lawmakers frequently seek leadership positions without the time-in-office foundations in place needed to be effective in these roles. Institutional memory has been lost with term limits, as has the depth of understanding of the complexity of the issues legislators must address. The interest in developing long-term solutions to challenging problems has been replaced with a more incremental immediate approach that focuses on short-term solutions rather than on the underlying cause of the problems. These realities affect the strategies adopted by interest groups seeking a legislative solution to their problem or concerns.

Although there may be subtle differences between the state and federal lawmaking processes, the political dynamics that affect the ultimate outcome of any policymaking initiative are quite similar regardless of the venue.

People: Players in the Game

One might believe that the only players in the lawmaking game are the elected officials—that is, the senators and representatives representing their respective states or districts. Although they are certainly integral to the process, many other individuals are keys to successfully achieving one’s legislative goals. In sports and other games, those who take game playing seriously spend time learning the strengths and weaknesses of the people on the field or at the table with them. They study game film and read scouting reports and use other resources to minimize surprises and help define their own strategies. That same attention to detail should apply to policymaking, but it is often sadly neglected.

Many people cannot identify their federal, state, or local elected officials. Although many can name the president of the United States, few will be able to say with assurance who represents them in the halls of Congress and fewer still can name their state senators or representatives. Every nurse should know the identity of his or her U.S. senators and congressional representative. It is equally or more important, however, for nurses to also know their state representative and senator because so much professional regulation occurs at the state level. Technology has made it easy to learn the identity of lawmakers at every level by simply going to federal or state government websites and entering ZIP code data. These sites also provide brief biographical information, photos, and other pertinent and helpful background material.

Why is this important? Politics is at heart a “people process.” As in other people-centered endeavors, the relationships among and between people determine outcomes in the political process. To have even the most basic conversation with elected officials, one must know who they are and what they care about.

Legislative Aides

In addition to knowing elected officials, one must make an effort to know staff members—aides and others—who often control access to their bosses and influence how various issues are perceived and prioritized. At the federal level, every legislator determines how his or her office will be staffed—usually using a chief of staff, legislative directors, press secretary, and legislative assistants/aides (LAs) ( TABLE 3-2 ). Federal lawmakers also maintain local or district offices with a small staff presence at each site. On the state level, the number of aides can vary, but as state legislatures have become more than part-time endeavors, the use of aides has increased. Typically, state officials have at least one aide who is usually a generalist, whereas the aides at the federal level are more issue focused.

TABLE 3-2 Federal Staffing Patterns
Staff Member	Role
Chief of staff	Senior staff person; answers directly to the member.
Administrative assistant	Oversight responsibilities for staff.
Legislative directors	Responsible for day-to-day legislative activities.
Press secretary	Responsible for press releases and public relations.
Legislative assistants/aides (LAs)	Responsible for specific legislative areas/issues—for example, health, agriculture, or Social Security. LAs have more than one area of responsibility. They provide staff assistance to the member at committee hearings, write policy briefs, and prepare the member’s statements and witness questions. They may help draft bills by working in concert with the legislative council.
Committee staff	Support the work of congressional committees. Separate staffs are allocated to the majority and minority parties, with a larger number serving the majority party. These individuals’ focus usually is narrower than that of the legislator’s personal staff, and they usually are older and more experienced. They plan the committee agenda, coordinate schedules, gather and analyze data, draft committee reports, and so on.

Regardless of whether an aide is in Washington, D.C., or at any of the statehouses across the country, elected officials rely on aides for the details and nuances associated with specific legislative initiatives. Aides delve more deeply into the issues and work closely with other aides in developing strategies and alternative concepts that they then present to their legislators for consideration.

Although communicating with legislators is important, nurses should not underestimate the importance of aides and other staff members, who may provide the last word to a legislator regarding the issue or concern. Including aides and other staff members in communications and making special efforts to respectfully integrate them into the entire process is a tactic that is likely to yield positive results.

Lobbyists

Although nurses may not know the identity of specific lobbyists, it is important to understand which role lobbyists play in the policymaking process and how their influence affects the game of politics. No bill becomes law without lobbyists’ input. Lobbying is the act of influencing—the art of persuading—a governmental entity to achieve a specific legislative or regulatory outcome. Although anyone can lobby, lobbyists are most often individuals who represent special-interest groups and are looked to as the experts by lawmakers who need information and a rationale for supporting or not supporting a particular issue.

The role of lobbyists has become even more critical as the complexity of legislation has increased. For example, the 1914 law creating the Federal Trade Commission was a total of 8 pages and the Social Security Act of 1935 totaled 28 pages, but the Financial Reform bill (conference version) of 2010 contained 2,319 pages ( Brill, 2010 ). Legislators, who are often pressed for time and/or newly elected to the legislature, rely on lobbyists’ expertise to help them understand what they are voting for or against. When the 21st Century Cures Act became law late in 2016, Senate disclosure records showed that more than 1,400 lobbyists worked on that legislation, which became a Christmas tree bill as the 114th Congress raced toward adjournment. Ultimately, the act included a wide range of provisions that addressed everything from Food and Drug Administration reform to substance abuse and the related mental health crisis to hospital readmission penalty revisions ( Muchmore, 2016 ).

A brief review of one year of lobbyist activity ( TABLE 3-3 ) provides insights regarding the emphasis some healthcare-sector associations place on lobbying to further or protect their own interests. Taking a longer-term view, from 1998 to 2016, the U.S. Chamber of Commerce spent $1,304,320,680 on its lobbying efforts. During that same time frame, the American Medical Association (AMA) spent $347,122,500 on lobbying, the American Hospital Association (AHA) spent $311,163,263, and the Pharmaceutical Research & Manufacturers of America (PHARMA) spent $305,515,300. The American Nurses Association (ANA), by comparison, spent $18,583,260 over this period, significantly less than other healthcare-related organizations ( Center for Responsive Politics, 2016b ).

TABLE 3-3 Lobbying the Federal Government in 2016
Entity	Total Spent *	Number of Lobbyists and Revolvers **	Entity	Total Spent *
American Medical Association	$15,290,000	24/5 revolvers	4⁄6 revolvers	14—Health issues; Medicare and Medicaid; education; veterans affairs; pharmacy
American Nurses Association	$854,973	5/1 revolvers	1⁄2 revolvers	3—Health issues; Medicare and Medicaid; federal budget and appropriations
American Association of Nurse Practitioners	$401,207	4/0 revolvers	2⁄5 revolvers	3—Federal budget and appropriations; health issues; veterans affairs
American Psychological Association	$865,647	14/5 revolvers	5⁄8 revolvers	12—Health issues; Medicare and Medicaid; federal budget and appropriations; law enforcement and crime; veterans affairs
American Association of Nurse Anesthetists	$830,000	6/4 revolvers	2⁄2 revolvers	6—Medicare and Medicaid; veterans affairs; education; health issues; insurance
American Society of Anesthesiologists	$660,000	6/0 revolvers	4⁄8 revolvers	5—Health issues; veterans affairs; Medicare and Medicaid; science and technology; federal budget and appropriations
American Academy of Physician Assistants	$420,000	4/0 revolvers	1⁄4 revolvers	1—Health issues
Data from Center for Responsive Politics. ( 2016b ). Influence & lobbying. Retrieved from http://www.opensecrets.org/influence * Costs include salaries, retainers, and expenses that lobbyists incur as part of their jobs. They could also include developing materials to support an initiative, or studies/surveys commissioned to support or refute a position. ** Revolvers (revolving-door lobbyists) are individuals who have served as elected officials or government agency or lawmaker staff members.

Former lawmakers, their staff members, and executive agencies’ staff members often become lobbyists after leaving public service. These so-called revolving-door lobbyists have unparalleled access, connections, and insights that serve their clients well. While ethics laws prohibit this kind of employment for a period of time immediately after leaving public service, these individuals may serve as consultants while waiting out their legally imposed hiatus. The number of revolving-door lobbyists working for a particular organization can be indicative of how much an organization values its lobbying efforts. In a world where these numbers matter, the gap between nursing organizations’ spending and that of other health-sector entities cannot be ignored.

On September 18, 1793, President George Washington laid the cornerstone for the U.S. Capitol. While the shovel, trowel, and marble gavel used for the ceremony are still displayed, repeated efforts to locate the cornerstone itself have been unsuccessful.

At times, policymaking seems as shrouded in mystery as the location of the Capitol’s cornerstone. That’s why you need an experienced partner (a.k.a. lobbyist) to help you unravel the mystery.

—A pitch for Capitol Tax Partners, a lobbying firm

Purse Strings: “Show Me the Money”

Game playing comes with a price in both athletic venues and legislative arenas. Not only are significant sums of money spent by special-interest groups in support of their lobbying efforts, but money is also critical to election and re-election campaigns. The role money plays in the policymaking process causes concern and discomfort for many nurses and other healthcare professionals. It is where the notion of “politics,” with all of its unfavorable connotations, is on full display, and it is the reason many nurses (and others) consider political participation to be something to avoid.

The amount of money that flows to and through the legislative process has raised serious questions as to whether the whole process is for sale to whoever has the deepest pockets. Unfortunately, winning an election or re-election, even at the local level, can be a very expensive proposition, costing millions of dollars. In the 2016 election, campaigning for the average U.S. Congress House seat cost $1 million, while campaigning for the average U.S. Senate seat cost tens of millions of dollars. Pennsylvania had the most expensive U.S. Senate race, with expenditures exceeding $46 million; the most expensive House seat race was in District 08 in Maryland, where the costs exceeded $20 million ( Center for Responsive Politics, 2016a ). The cost of getting elected means incumbents and challengers must focus their efforts on raising money during three of every five workdays ( Zakaria, 2013 , p. E8). The most likely sources from which to obtain the needed dollars are wealthy individuals and special-interest groups that are willing to invest in these decision makers. The return on the investment must be beneficial—otherwise, the money invested in political campaigns would not continue to increase.

In fact, this spending trend is likely to continue due to the U.S. Supreme Court decision in Citizens United v. Federal Election Commission (2010), which basically allows unlimited spending by corporations and unions during campaigns, provided these efforts are not coordinated with an individual’s campaign. In its Citizens United ruling, the Supreme Court struck down the 2002 federal campaign finance law prohibiting unions and corporations from spending money directly advocating for or against candidates. The First Amendment was the basis for the Court’s decision. The League of Women Voters has voiced its support of legislation that would require disclosure of the sources of such spending.

Not only has the amount of money flowing to campaigns increased dramatically, but the source of those dollars (who has the deep pockets) also has changed and is expected to change even more in the future. For the first time, the 2014 midterm elections saw more money going into campaigns but fewer people contributing. Spending by outside groups constituted 14.9% of all spending, which was an increase of almost 5% compared with 2010 ( Center for Responsive Politics, 2016b ). Although the number of 527 committees has increased, contributions from these entities have varied over time ( TABLE 3-4 ).

TABLE 3-4 527 Committee Fund Raising and Expenditures, 2010, 2014, and 2016
Entity: 2016	Receipts/Expenditures
Democrat/liberal	$31,645,812/26,647,731
Republican/conservative	$13,651,784/15,104,108
Women’s issues	$10,029,733/9,863,780
Health professionals	$987,693/800,491
Hospitals and nursing homes	$40,524/22,520
Entity: 2014	Receipts/Expenditures
Democrat/liberal	$27,130,578/23,342,697
Republican/liberal	$26,876,343/30,501,588
Women’s issues	$17,368,505/17,157,633
Health professionals	$1,475,284/1,546,829
Hospitals and nursing homes	$57,424/43,961
Entity: 2010	Receipts/Expenditures
Democrat/liberal	$24,151,559/26,806,934
Republican/conservative	$67,679,617/64,666,600
Women’s issues	$9,374,595/10,876,045
Health professionals	$1,147,486/1,945,807
Hospitals and nursing homes	Not reported
Data from Center for Responsive Politics. ( 2016b ). Influence & lobbying. Retrieved from http://www.opensecrets.org/influence

According to the Federal Elections Commission, as of November 28, 2016, the healthcare sector had contributed $236,399,000 to campaigns during the 2016 election cycle, with approximately 60% of that total going to Republican candidates. (The top overall sector was finance, insurance, and real estate, which contributed $962,165,528 to candidates in the 2016 elections.) Physicians and other healthcare professionals are traditionally the largest source of federal campaign contributions within the healthcare sector; however, comparing the dollars coming from physician-related entities as opposed to nursing organizations reveals that the amount contributed by nursing is significantly less than the amount given by physician groups ( TABLE 3-5 ). The only nursing organization listed among the top 20 healthcare-sector contributors during the 2016 elections was the American Association of Nurse Anesthetists, coming in at number 13. Other nursing organizations making contributions included the American Nurses Association, the American Association of Nurse Practitioners, and the American College of Nurse‒Midwives ( Center for Responsive Politics, 2016a ). Nurses’ willingness to pay this price remains an open question.

TABLE 3-5 Political Contributions by Physician Groups, 2015–2016
Organization	Amount Contributed
Cooperative of American Physicians	$1,945,015
American Society of Anesthesiologists	$1,926,150
American Medical Association	$1, 878, 563
American Association of Orthopedic Surgeons	$1,671,575
Data from Center for Responsive Politics. ( 2016a ). Health sector: PAC contributions to federal candidates. Retrieved from http://www.opensecrets.org/pacs/sector.php?txt=H01&cycle=2016

Although it may be distasteful, success in the halls of Congress and at statehouses is integral to the advancement of nurses’ legislative agenda. That agenda includes measures intended to advance the profession itself as well as efforts to promote societal values that are committed to better patient outcomes. Nurses want their issues advanced successfully, and that expectation comes with a price tag that nurses must expect to pay.

▶ Playing the Game: Strategizing for Success

Continuing the game-playing analogy, why are some teams more successful than others? If all the players know how to play the game, why are some consistent winners and others are not? Why are the legislative agendas of some groups adopted seemingly with minimal opposition, whereas others find it hard to get a place at the policy table? In athletic contests, the skill of the players, the expertise of the coaching staff, the financial investment of the team owners/supporters, and team chemistry all contribute to success on the field. Those same factors also determine success at the policymaking table.

Skill of the Players

Knowing the process and people, along with understanding how money affects the policymaking dynamics, is a start, but it is not sufficient to ensure success. To move to the next level, nurses and others must learn to think politically, to play politics, and to strategize with the political consequences and realities always at the forefront. In other words, they must apply their critical thinking skills in the policymaking context.

As political scientists have noted, politics underlies the process through which groups of people make decisions. It is the basis for the authoritative allocation of value. Simply put, politics is the effort and strategies used to shape a policy choice in all group relationships.

When one “plays politics,” one is considered to be shrewd or prudent in practical matters, tactful, and diplomatic; playing politics is also seen as being contrived in a shrewd way, or being expedient. When one thinks like a politician, it means he or she is looking beyond the issue itself and considering other forces and factors that affect what is likely to work and what has no chance of success. Deciding which of several policy options will lead to the greatest benefits and the fewest costs, in a world where re-election is a key consideration and media are a relentless presence, means the best solution may not be the path ultimately chosen. The scenario in Case Study 3-1 provides an example of what thinking politically might look like.

CASE STUDY 3-1: Workplace Safety

Emergency department (ED) nurses have expressed concern about workplace safety, with many experiencing physical attacks on a routine basis. Many employers have been reluctant to report assaults to law enforcement because of the bad publicity it might engender. Nurses and others in psychiatric settings have similar concerns, as do nurses working in home health.

Professional organizations representing these individuals, particularly ED nurses, formed a coalition to strategize about how to protect their members. Before the coalition had finished its work, the issue came to a head when an agitated family member assaulted a nurse, resulting in severe injuries to the nurse. Local media picked up the story, and a state legislator, who was a member of the minority party and facing a difficult re-election, was surprised to learn that although teachers and law enforcement officials are part of a “protected class,” attacking healthcare workers was a misdemeanor rather than a felony offense. For protected workers, the same assault carries the more stringent criminal designation that includes possible incarceration. The legislator decided to take on this issue, in part because he thought it might help his re-election efforts and because nurse organizations had supported his candidacy in the past.

Which factors must the politically savvy nurse consider if this issue is to move successfully from concept to legislation to law?

Clearly, success at the policy table involves more than the language of the proposal itself. Timing and the general political climate are key, unity is important, and quid pro quo is the reality in the statehouse halls. Politically savvy nurses must be willing to take risks but should be smart when doing so ( EXHIBIT 3-2 ). In other words, they should enter the policy arena fully prepared for the challenges they will face.

EXHIBIT 3-2 Political Astuteness

· Issues always have at least two sides, and maybe more, that are reasonable depending upon one’s point of view and experiences.

· Listen to what people are saying with an analytical ear. Critical thinking is not just for the practice setting. Apply theories and concepts about policymaking to the issues being considered. Use therapeutic communication techniques.

· Utilize a variety of sources; do not just rely on those that are consistent with your own ideology. Most sources have a bias, so broaden your reading and listening to get a more complete perspective and perhaps move a bit closer to the truth. Always consider the source of the information provided.

· Connect with others who are involved in the policymaking side of the profession. Share what you learn with colleagues.

▶ Thinking Like a Policymaker

Coaching Staff: Mentoring and Support

Given all the subtle factors that affect success on Capitol Hill or in state legislatures and the role money plays in the process, how can an individual hope to have sufficient knowledge or time to make a difference in the policymaking aspects of the profession? How can that nurse ever play the game effectively? Fortunately, the American Nurses Association (ANA) and its state constituent associations, as well as specialty nursing groups, can provide their members with the tools they need to be successful. The success of these organizations’ efforts in the legislative arena depends in large part on their members’ involvement with and understanding of the importance of an effective legislative presence on behalf of the profession in Washington, D.C., and in statehouses across the country. Many of these organizations offer opportunities for their members to come to Washington or to state capitals for lobbying days, which include briefings on both the issues and the ways to be effective spokespersons for the profession. These organizations know that it is the individual nurse—the so-called grassroots lobbyist—who has the most impact on the decisions made by elected officials. In fact, grassroots lobbying is seen by some as the most effective of all lobbying efforts (deVries & Vanderbilt, 1992).

Grassroots lobbyists are constituents who have the power to elect officials through their vote. When constituents have expertise and knowledge about a particular issue (such as nurses in healthcare policymaking), they are especially valuable resources for their elected officials. Although issues debated in Washington, D.C., are national in scope, members of Congress are still concerned about how those issues are perceived back home. The connections established by a nurse constituent with his or her lawmakers at the federal, state, and local levels may provide timely access and a listening ear at key points during the policymaking process.

Some professional organizations have established liaison or key-person programs that match members with their elected officials, train them to be effective in the grassroots lobbying role, and provide periodic updates and information to help the nurses communicate in a timely manner with relevant messages targeted to the specific official. In turn, grassroots lobbyists establish ongoing connections with their elected officials that transcend specific legislative initiatives and communicate regularly with the sponsoring nursing organizations regarding what they learn through their interactions.

Coaching and mentoring nurses who are willing to engage in these kinds of supported liaison relationships will benefit both the individual nurse and the organizations doing the coaching. The nurse can markedly increase a legislator’s understanding of nursing and the role nurses play in health care. With increased understanding, the legislator is more apt to be supportive of the profession’s legislative agenda.

Investment: Time and Money

A vision without resources is an hallucination.

—Thomas Friedman

How much are nurses willing to pay in both time and money to support the political activities of professional organizations? Are there sufficient human and financial resources available to make the vision of success a reality, or is it destined to be a hallucination? What does that payment look like?

Far too few nurses—only approximately 6% of all nurses ( Haylock, 2014, p. 613 )—pay the membership fees needed to support the activities of nursing organizations, including maintaining an effective presence at statehouses or on Capitol Hill. Many of these organizations must rely primarily on busy volunteers to do the essential work of tracking legislative action or regulatory proposals in a timely manner. They cannot afford paid staff, even on a part-time basis. As a consequence, the everyday work of developing key relationships and being seen as a nursing expert cannot or does not happen. If more nurses were to become members of professional nursing organizations, the necessary resources would significantly increase, as would nursing’s overall influence at the policy table.

Although the convergence of politics and money is not always pretty, ignoring the importance of financial contributions in moving a legislative agenda forward is naïve at best. Refusing to address this factor will ultimately undermine efforts to advance the positive aspects of the nursing profession’s agenda.

Some nurse organizations have established political action committees (PACs) that enable them to make contributions to political candidates and office holders who are supportive of nurses’ legislative agenda. The money comes from the organization’s members, so it again relies on the small number of nurses who belong to one of these organizations The amount of money raised for PAC purposes by nursing organizations pales in comparison to the amounts that other healthcare sector entities are able to contribute.

In addition to political contributions, special-interest groups may improve their chances for successful policymaking by endorsing candidates who are running for elective office. Candidates who want to demonstrate their appeal to the overall electorate prize these endorsements; this is particularly true for endorsements issued by nursing organizations such as ANA on the federal level and state constituent associations of ANA on the state level. This level of political activity occurs through the associations’ PACs and must adhere to requirements set out in federal and state election laws. The endorsement process requires significant membership involvement, which is difficult for small nursing organizations to mount successfully.

Both money and human resources are critical when considering the level of investment by the members of the nursing profession. Nurses account for the largest segment of the healthcare workforce, but far too few invest in their profession through membership in professional organizations. These low numbers significantly affect the amount of tangible and intangible resources available to associations for their work in the political arena. The strength of nurses lies in their numbers, and that strength is enhanced when nurses support the work of their professional associations through their dues and volunteerism.

Team Chemistry: Getting Along With One Another

Even with skilled players, strong support systems, and sufficient resources, a team will not succeed without an often elusive quality: team chemistry. Divisiveness has long plagued the nursing profession, and it remains an issue today. Disunity within the profession is a certain road to defeat and fuels the opposition’s fire. Opponents are well aware of the potential impact that a united nursing profession could have on health policy decisions and other important issues. Nurses’ numbers alone are formidable. For that reason, competing interests subtly and purposefully poke at the hot spots that typically divide nurses (e.g., educational preparation, union versus non-union debates). Nurses’ tendency to align themselves within specialty practice groups and to lobby or get involved only when an issue directly relevant to that particular group is being considered is encouraged without consideration of a broader perspective. Political astuteness would dictate that nurses recognize when they are being kept off balance by subversive divisive messages encouraged by those who benefit from nursing’s disunity and ignore the discordant rhetoric. Further, all nurses should have a basic understanding or awareness of the legislative initiatives of specialty groups. They should actively support the initiatives of their colleagues or, at a minimum, refrain from opposing the cause publicly. Concerns should be shared privately and diligent efforts made to find a compromise position outside of the public eye.

▶ Conclusion

Nurses with an understanding of how the policymaking process works can contribute to the political work of the organizations to which they belong and ultimately benefit the patients for whom they care. Such contributions are consistent with the obligations set forth in the profession’s social policy statement and its code of ethics. Nursing’s Social Policy Statement notes the connection between policymaking and the delivery of health care and the effect on the well-being of society. “Individual and inter-professional involvement is essential” ( ANA, 2010, p. 7 ). An essential feature of professional nursing is to “influence social and public policy to promote social justice” (p. 9). The Code of Ethics for Nurses ( ANA, 2015 ) repeatedly emphasizes the role nurses play in promoting, advocating, and striving to protect the health, safety, and rights of the patient, which extends to statehouses, boardrooms, and other arenas in which this advocacy can affect public policy. Moreover, the Future of Nursing report issued by the Institute of Medicine in 2010 states that “nurses should be full partners with physicians and other healthcare professionals, in redesigning health care in the United States” (p. S-3). This role will be played out, in part, in the health policy context, where nurses should participate in, and sometimes lead, decision making and be engaged in healthcare reform–related implementation efforts. To be ready to assume this responsibility, nurse education programs should include course content addressing leadership-related competencies for all nurses. These competencies include a firm grounding in politics and policymaking processes.

There is no substitute for visibility in the legislative arena. Showing up is what political activism is all about. “If you are not at the table, you are on the menu” is a sentiment frequently echoed in many policymaking venues. For too long, nurses have been on the menu rather than active participants in shaping public policy around health care. Simply watching the game and complaining about policy decisions will not change outcomes. Nurses must become convinced that they do have something valuable to contribute, that they have the ability and the time to do it, and that advocacy in the policy arena is not an option but a non-negotiable professional responsibility.

▶ Discussion Points

1. Watch the HBO movie Iron Jawed Angels. Which political considerations were at play in efforts to win voting rights for women?

a. To what extent have Americans today become complacent with respect to the importance of voting?

b. Describe the similarity of the fight waged by suffragettes and the one nurses have waged to gain recognition of advanced practice.

c. Discuss with colleagues how complacency imperils future professional advances for nursing.

2. Respond to the following statement in the context of the Patient Protection and Affordable Care Act (ACA), taking into consideration the results of the 2016 election and its immediate aftermath as the Republican majority jockeyed to enhance its power and promote its philosophical beliefs.

The suppliers of legislative benefits are legislators, and their primary goal is to be re-elected. Thus, legislators need to maximize their chances for re-election, which requires political support. Legislators are assumed to be rational and to make cost–benefit calculations when faced with demands for legislation. However, the legislator’s cost–benefit calculations are not the cost–benefits to society of enacting particular legislation. Instead, the benefits are the additional political support the legislator would receive from supporting legislation and the lost political support they would incur as a result of their action. When the benefit to legislators (positive political support) exceeds their costs (negative political support) they will support the legislation. ( Feldstein, 2006, p. 10 )

a. Consider how the cost–benefit analysis depicted in the statement affected efforts to repeal/replace the ACA.

b. Discuss how the cost–benefit analysis depicted in the statement did or did not affect decisions made by states about whether to expand Medicaid eligibility as allowed by the ACA but put in jeopardy by Republican control of both the legislative and the executive branches of the federal government.

c. Discuss how the cost–benefit analysis depicted in the statement did or did not affect decisions made by Congress to maintain or modify the Medicare and Medicaid programs.

3. The mission of state boards of nursing is the protection of the public by the regulation of nursing practice.

a. Compare the regulations in your state with those of at least one other state to determine the extent that APRNs have legal authorization to practice within the full scope of their education and experience.

b. Develop a proposal to change at least one regulation in your state’s nurse practice act. Which tactics would you use to persuade board members that your plan will positively affect nurses and the public?

c. Identify groups that might oppose your proposal and create responses that defend your position.

4. Create a worksheet that requires use of the state and federal government websites to identify one’s own elected officials, party affiliation, committee appointments, and other relevant background information. Use this worksheet to plan your involvement in the political arena.

References

1. American Nurses Association (ANA). (2010). Nursing’s social policy statement. Washington, DC: Author.

2. American Nurses Association (ANA). (2015). Code of ethics for nurses. Washington, DC: Author.

3. Brill, S. (2010). On sale: Your government. Time, 176(2), 28–33.

4. Center for Responsive Politics. (2016a). Health sector: PAC contributions to federal candidates. Retrieved from http://www.opensecrets.org/pacs/sector.php?txt=H01&cycle=2016

5. Center for Responsive Politics. (2016b). Influence & lobbying. Retrieved from http://www.opensecrets.org/influence

6. Chaffee, M. (2014). Science, policy, and politics. In D. Mason, J. Leavitt, & M. Chaffee (Eds.), Policy and politics in nursing and health care (6th ed., pp. 307–315). St. Louis, MO: Elsevier Saunders.

7. Citizens United v. Federal Elections Commission. (2010). 130 S. Ct. 876.

8. deVries, C. M., & Vanderbilt, M. (1992). The grassroots lobbying handbook. Washington, DC: American Nurses Association.

9. Feldstein, P. (2006). The politics of health legislation: An economic perspective (3rd ed., pp. 27–84). Chicago, IL: Health Administration Press.

10. Ferris, S., & Wong, S. (2016, December 2). Republicans raise red flags about speedy Obamacare repeal. Retrieved from http://www.thehill.com./policy/healthcare/308490-republicans-raise-red-flags-about-speedy-obamacare-repeal

11. Goldman, J. (2000). Webster’s new world dictionary. Cleveland, OH: Wiley.

12. Haylock, P. (2014). Professional nursing associations: Meeting the needs of nurses and the profession. In D. Mason, J. Leavitt, & M. Chaffee (Eds.), Policy and politics in nursing and health care (6th ed., pp. 609–617). St. Louis, MO: Elsevier Saunders.

13. Institute of Medicine. (2010). Future of nursing report: Leading change, advancing health. Washington, DC: National Academies Press.

14. Muchmore, S. (2016, December 5). Add-ons ensure Cures Act easy lame-duck passage. Modern Healthcare, 46(49), 10.

15. Nurses on Boards Coalition. (2016). Improving the health of communities and the nation. Retrieved from http://nursesonboardscoalition.org/

16. Zakaria, F. (2013, August 4). Washington is failing everyone except lobbyists. Columbus Dispatch, p. E8.

CHAPTER 10 READING FROM PG 180 TO 183

▶ Finance: Healthcare Entitlement Programs

Medicare and Medicaid are publicly funded social entitlement programs and are the “third rail” of healthcare politics. Anyone meeting the eligibility requirements for Medicare (Part A) or Medicaid is entitled to all the promised benefits, no matter the condition of the government’s (state or federal) finances. As an analogy, think of your personal budget: You plan for rent, transportation expenses, utilities, clothing, entertainment, gifts, and the like in your budget, and you balance these amounts against your anticipated income to assure that your income covers your expenses. Expenses for Medicare and Medicaid are projected every year, but unlike your clothing allowance, if the government runs short of revenue (e.g., fewer taxes are collected during an economic downturn), there is no legal option to cut back on entitlement programs. Likewise, if expenses for Medicare and Medicaid are higher than projected (e.g., perhaps more seniors are seriously ill), the government cannot choose not to provide payment for the overage in services. If the government fails to meet its obligation, beneficiaries are entitled to sue.

FIGURE 10-4 “Time to Hit the Road”

Courtesy of Kevin KAL Kallaugher, Kaltoons.com

By law, state governments must balance their budgets; the federal government may run deficits up to a ceiling set by Congress. This important concept explains many of the policies at the state and federal levels. In simple terms, Medicare is a federally funded program, and Medicaid is funded by federal and state funds along with some local funds. The full reality is more complex, but these generalities suffice for our discussion. Funding for Medicare comes primarily from general revenues (40%) and payroll taxes (38%), followed by premiums paid by beneficiaries (12%).

In 2015, the Kaiser Family Foundation reported that Medicare provided insurance coverage to 55.5 million people, including those age 65 and older (if they or their spouse made payroll tax contributions for 10 or more years) and younger people with permanent disabilities (after 24 months of receiving Social Security Disability Insurance payments), end-stage renal disease, and amyotrophic lateral sclerosis (Lou Gehrig’s disease). Medicare covers most healthcare services but does not cover long-term care services such as nursing home care ( Kaiser Family Foundation, 2017b ).

· Medicare Part A (hospital insurance program) helps pay for inpatient hospitalizations, skilled nursing home care (up to 100 days), home health (limited post-hospital care), and hospice care. The beneficiary must pay a deductible.

· Medicare Part B (supplementary medical insurance) is voluntary and covers 95% of all Part A beneficiaries. Part B helps pay for physician visits, outpatient hospital services, preventive services, mental health services, durable medical equipment, and home health. Beneficiaries pay a monthly premium plus some copayments.

· Medicare Part C is also called Medicare Advantage. It includes private health plans that receive payments from Medicare to provide Medicare-covered benefits to enrollees. Plans provide benefits covered under Parts A and B and often Part D.

· Medicare Part D is a voluntary program that helps pay for outpatient prescription drugs and is administered exclusively through private plans. Premiums and cost sharing vary according to the plan purchased. The Affordable Care Act improves coverage by gradually closing the “doughnut hole”—an unusual gap in coverage in which 100% of costs become out-of-pocket expenses. The cost of Part D is increasing at a faster rate than costs for the rest of Medicare.

Prior to the implementation of the Affordable Care Act, Medicare served all eligible beneficiaries without regard to income or medical history. As health reform rolled out, means testing was applied to those with very high incomes. In 2017, Medicare beneficiaries with incomes greater than $85,000 for individuals and $170,000 for couples paid premiums ranging from $170.50 to $389.80 per month, depending on the level of income, compared with the standard premium of $121.80. Extra Part D premiums range from $12.70 to $72.90 per month. Beginning in 2018, beneficiaries with incomes greater than $133,500 pay a higher premium subsidy than the current amount due to a provision in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 . Increasing means testing reaches far down into the middle class. The income thresholds for income-related premiums are frozen under current law until 2019, when it is estimated that the number of Medicare beneficiaries subjected to higher premiums will increase from 5% to 10% of Part B enrollees. Some members of Congress and administration officials have proposed increasing means testing until 25% of beneficiaries are subject to higher premiums.

Note: Maryland has a 36-year-old waiver from the federal government to operationalize Medicare in a unique manner. The details are beyond the scope of this chapter; however, some economists believe that Maryland’s reimbursement system may become the model for the rest of the nation.

Medicaid was enacted under the Social Security Act in 1965 as a companion to Medicare. It entitles participating states to federal matching funds on an open-ended basis, entitles eligible individuals to a set of specific benefits, is means tested, and allows states to provide broader coverage. In addition to providing health insurance coverage, Medicaid provides assistance to low-income Medicare beneficiaries (dual-eligible), long-term care assistance (nursing home and in-home community-based services), and support for the safety-net system of health care. The largest source of federal funding to the states, Medicaid is the largest health insurance program in the United States.

Medicaid fills large gaps in the U.S. health insurance market, finances the lion’s share of long-term care, and provides core support for the health centers and safety-net hospitals that serve the nation’s uninsured population and millions of others. Within broad federal guidelines, states design their own Medicaid programs. Medicaid reimburses private providers to provide services to beneficiaries. In 2017, 20% of the U.S. population received health insurance from Medicaid. Disabled and elderly adults make up only 25% of enrollees, but they account for approximately 70% of Medicaid expenditures. Of the 12 million Americans in long-term care, 87% are covered by Medicaid, making Medicaid the major program paying for long-term care ( Kaiser Family Foundation, 2017a ).

FIGURE 10-5 National health expenditures in the United States by source of payment, 2015.

Data from Centers for Medicare & Medicaid Services. (2016). National health expenditure data. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html

In those 18 states that opted out of the ACA Medicaid expansion plan, Medicaid coverage requires that beneficiaries have low incomes (defined by each state using the federal poverty guidelines) and meet one of these categories of need:

· Pregnant or recent postpartum

· Younger than age 18 years

· Older than age 65 years and blind or disabled

These restrictions were in place across all Medicaid programs prior to the implementation of the ACA.

Medically needy persons whose incomes are too high to be eligible for Medicaid may also be covered. (Each state determines eligibility.) In addition, states may define optional eligibility groups. In 2014, the federal poverty level for a family of four was $23,850 in the continental United States and a little higher in Alaska and Hawaii ( U.S. Department of Health and Human Services, 2014 ). As of April 2017, 32 states had expanded Medicaid by eliminating medical need categories and providing coverage to those with incomes at or below 138% of the FPL.

One of the arguments against expanding Medicaid is a fear of increasing the overall health expenditures for the United States ( Rosenbaum, Rothenburg, Gunsalus, & Schmucker, 2017 ). FIGURE 10-5 indicates the percentage paid by each type of payer in the U.S. healthcare system.

▶ Finance: Payment Models

The long-term goal of the federal government is to move providers (physicians, advanced practice registered nurses [APRNs], hospitals, all other health professionals who are reimbursed by federal programs) from a payment system rewarding volume of care to a model based on the quality of management of the health of populations. The term population management can translate into examples such as a ZIP code as defining a population, or a population of patients with diabetes being treated within a specific practice, or the population of patients undergoing hip replacement in a hospital. Since 2016, selected hospitals and providers have acted as “laboratories” to demonstrate the efficacy of various organizational formats and payment models to advance the goal of stabilizing and lowering healthcare costs while maintaining or increasing quality and safety.

Medicare Access and CHIP Reauthorization (MACRA) of 2015 is a complex federal law that ended the prior physician and APRN reimbursement model known as the sustainable growth rate (SGR). Payment for quality of outcomes is at the heart of the changes instituted by MACRA, which took effect in 2017: Providers must choose one program for reimbursement from Medicare. The options under the Quality Payment Program consist of the Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS). Principles of the Alternative Payment Models are:

1. Changing providers’ financial incentives is not sufficient to achieve person-centered care, so it will be essential to empower patients to be partners in healthcare transformation.

2. The goal for payment reform is to shift U.S. healthcare spending significantly toward population-based (and more person-focused) payments.

3. Value-based incentives ideally should reach the providers who deliver care.

4. Payment models that do not take quality into account are not considered APMs in the APM framework and do not count as progress toward payment reform.

5. Value-based incentives should be intense enough to motivate providers to invest in and adopt new approaches to care delivery.

6. APMs are classified according to the dominant form of payment when more than one type of payment is used.

7. Centers of excellence, accountable care organizations, and patient-centered medical homes are examples, rather than categories, in the APM framework because they are delivery systems that can be applied to and supported by a variety of payment models.

Types of payment models include fee-for-service, bundled care, accountable care, shared decision making, and the direct decision support model. Physician and APRN providers must choose whether to participate in APMs or in the MIPS. Both the APM and MIPS programs are beyond the scope of this chapter. FIGURE 10-6 depicts the overall trajectory of the payment framework models.