Chapter 8 - Public Health Policy

Legislation and Regulation

Legislation is law that comes from the legislative branches of federal, state, or local government. This is referred to as Statute Law because it becomes coded in the statutes of a government (Birkland, 2010). Much legislation has an effect on nursing. Regulations are specific statements of law related to defining or implanting individual pieces of legislation or statute law. For example, state legislatures enact laws (statutes) establishing boards of nursing and defining terms such as registered nurse and nursing practice. Every state has a board of nursing. Created by legislation known as a state nurse practice act, the board of nursing is made up of nurses and consumers.

Three Branches of Government

Legislative, Executive, Judicial

State and Local Health Departments

Many state and local health officials report that employees in public health agencies lack skills in the core sciences of public health, and that this has hindered their effectiveness. The lack of specialized education and skill is a significant barrier to population-based preventive care and the delivery of quality health care to the public. Public health workforce specialists report that the number of retirees expected in this decade will result in a major shortage of public health workers, including nurses

Legislative Action

Nurses can be involved in the legislative process at any point. Many professional nursing associations have legislative committees made up of volunteers, governmental relations staff professionals, and sometimes political action committees (PACs), all engaged in efforts to monitor, analyze, and shape health policy. Common methods of influencing health policy outcomes include face-to-face encounters, personal letters, mailgrams, electronic mail, telephone calls, testimony, petitions, reports, position papers, fact sheets, letters to the editor, news releases, speeches, coalition building, demonstrations, and lawsuits How does a bill become a law?

School and Family Health

Nurses employed by health departments or boards of education may deliver school and family health nursing. School health legislation establishes a minimum of services that must be provided to children in public and private schools. For example, most states require that children be immunized against certain communicable diseases before entering school.

The Public Health Threats and Emergencies Act"

"addresses emerging threats to the public's health and authorizes the Secretary of HHS to take appropriate response actions during a public health emergency, including investigations, treatment, and prevention". This legislation is said to have signaled the beginning of renewed interest in public health as the protector for entire communities.

Department of Labor

The Department of Labor houses OSHA, which imposes workplace requirements on industries. These requirements shape the functions of nurses and the types of health services provided to workers in the workplace. A record-keeping system required by OSHA greatly affects health records in the workplace. Each state has an agency similar to OSHA that also monitors and inspects industries, as well as the health services delivered to them by nurses. Ex: needle stick injuries

HIPPA

The Health Insurance Portability and Accountability Act (HIPAA) allows working persons to keep their employee group health insurance for up to 16 months after they leave a job (U.S. Law 107-105, 1996).

SCHIP

The State Child Health Improvement Act (SCHIP) of 1997 provides insurance for children and families who cannot otherwise afford health insurance (U.S. Law, 1997).

Public Protection

The U.S. Constitution gives the federal government the authority to provide for the protection of the public's health. This function is carried out in numerous venues, such as by regulating air and water quality and protecting the borders from the influx of diseases by controlling food, drugs, and animal transportation, to name a few.

Most legal bases for the actions of Congress in health care are found in Article I, Section 8 of the U.S. Constitution, including the following:

1. Provide for the general welfare. 2. Regulate commerce among the states. 3. Raise funds to support the military. 4. Provide spending power.

Impact of Government Health Functions and Structures on Nursing

The designation of money for specific needs, or categorical funding, has led to special and more narrowly focused nursing roles. Examples are in emergency preparedness, school nursing, and family planning. Funds assigned to antibioterrorism cannot be used to support unrelated communicable disease programs or family planning. The events of September 11, 2001, have had the public and the profession of nursing concerned about the ability of the present public health system and its workforce to deal with bioterrorism, especially outbreaks of deadly and serious communicable diseases.

Executive Branch

The executive branch is composed of the president (or state governor or local mayor) along with the staff and cabinet appointed by this executive, various administrative and regulatory departments, and agencies such as the U.S. Department of Health and Human Services. The executive branch suggests, administers, and regulates policy

Scope of Practice

The issue of scope of practice involves defining nursing, setting its credentials, and then distinguishing between the practices of nurses, physicians, and other health care providers. The issue is especially important to nurses in community settings, who have traditionally practiced with much autonomy. Health care practitioners are subject to the laws of the state in which they practice, and they can practice only with a license. The usual and customary practice of nursing can be determined through a variety of sources, including the following: • Content of nursing educational programs, both general and special • Experience of other practicing nurses (peers) • Statements and standards of nursing professional organizations • Policies and procedures of agencies employing nurses • Needs and interests of the community • Updated literature, including research, books, texts, and journals • Internet sites if it can be determined that the site is a professional source of information

Judicial Branch

The judicial branch is composed of a system of federal, state, and local courts guided by the opinions of the Supreme Court. Each of these branches is established by the Constitution, and each plays an important role in the development and implementation of health law and public policy. The judicial branch interprets laws and their meaning, as in its ongoing interpretation of states' rights to define access to reproductive health services to citizens of the states.

Legislative Branch

The legislative branch (i.e., Congress at the federal level) is made up of two bodies: the Senate and the House of Representatives, whose members are elected by the citizens of particular geographic areas. There is a federal Division of Nursing, a section within the Health Resources and Services Agency (HRSA) of the USDHHS, that refines criteria for nursing education programs as funded by Congress and affirmed by the President. The role of the legislative branch is to identify problems and to propose, debate, pass, and modify laws to address those problems.

State power concerning health care is called police power

This power allows states to act to protect the health, safety, and welfare of their citizens. Such police power must be used fairly, and the state must show that it has a compelling interest in taking actions, especially actions that might infringe on individual rights. Examples of a state using its police powers include requiring immunization of children before being admitted to school and requiring case finding, reporting, treating, and follow-up care of persons with tuberculosis. These activities protect the health, safety, and welfare of state citizens.

1948

Congress created the National Institutes of Health (NIH), and in 1965 it passed very important health legislation creating Medicare and Medicaid to provide health care service payments for older adults, the disabled, and the categorically poor.

Correctional Health

Correctional health nursing practice is significantly shaped by federal and state laws and regulations and by recent Supreme Court decisions. The laws and decisions primarily relate to the type and amount of services that must be provided for incarcerated individuals. For example, physical examinations are required for all prisoners after they are sentenced. Regulations specify basic levels of care that must be provided for prisoners, and access to care during illness is a particular focus.

Financing

Governments pay for some health care services; the 2011 percentage of the bill paid by the government was about 46.3%, and this is projected to increase to 47.6% by the year 2015. The government also pays for training some health personnel and for biomedical and health care research (NCHS, 2014). Support in these areas has greatly affected both consumers and health care providers. Federal governments finance the direct care of clients through the Medicare, Medicaid, Social Security, and SCHIP programs. State governments contribute to the costs of Medicaid and SCHIP programs.

The Nurse's Role in the Policy Process

Health policy is developed on the three-legged stool of access, cost, and quality. The policy process, which is very familiar to professional nurses, includes the following: • Statement of a health care problem • Statement of policy options to address the health problem • Adoption of a particular policy option • Implementation of the policy product (e.g., a service) • Evaluation of the policy's intended and unintended consequences in solving the original health problem

Department of Justice

Health services to federal prisoners are administered within the Department of Justice. The Federal Bureau of Prisons is responsible for the custody and care of approximately 214,000 federal offenders (Bureau of Federal Prisons, 2014). The Medical and Services Division of the Bureau of Prisons includes medical, psychiatric, dental, and health support services with community standards in a correctional environment.

Healthy People 2020: an Example of National Health Policy Guidance

In 1979 the surgeon general issued a report that began a 30-year focus on promoting health and preventing disease for all Americans. In 1989, Healthy People 2000 became a national effort with many stakeholders representing the perspectives of government, state, and local agencies; advocacy groups; academia; and health organizations

International organizations

In June 1945, following World War II, many national governments joined together to create the United Nations (UN). By charter, the aims and goals of the UN deal with human rights, world peace, international security, and the promotion of economic and social advancement of all the world's peoples. The UN, headquartered in New York City, is made up of six principal divisions, several subgroups, and many specialized agencies and autonomous organizations. At these conferences, the health of women and children and their rights to personal, educational, and economic security as well as initiatives to achieve these goals at the country level were debated and explored, and policies were formulated. Established W.H.O

Healthy People 2010

Increase quality and years of healthy life Eliminate health disparities

Healthy People 2000

Increase the years of healthy life for Americans Reduce health disparities among Americans Achieve access to preventive services for all Americans

Organizations and Agencies That Influence Health

International Organizations Federal Health Agencies Federal Non-health Agencies State and Local Health Departments

Federal Health Agency

Laws passed by Congress may be assigned to any administrative agency within the executive branch of government for implementing, supervising, regulating, and enforcing. USDHHS, EPA

Law

is a system of privileges and processes by which people solve problems based on a set of established rules; it is intended to minimize the use of force. Laws govern the relationships of individuals and organizations to other individuals and to government. Through political action, a policy may become a law, a regulation, a judicial ruling, a decision, or an order.

Public Policy

is described as all governmental activities, direct or indirect, that influence the lives of all citizens

The role of the government in health care

is shaped both by the needs and demands of its citizens and by the citizens' beliefs and values about personal responsibility and self-sufficiency. These beliefs and values often clash with society's sense of responsibility and need for equality for all citizens.

One of the first constitutional challenges to a federal law passed by Congress

was in the area of health and welfare in 1937, after the 74th Congress had established unemployment compensation and old-age benefits for U.S. citizens. Although Congress had created other health programs previously, its legal basis for doing so had never been challenged.

The Social Security Act of 1935

was passed to provide assistance to older adults and the unemployed, and it offered survivors' insurance for widows and children. It also provided for child welfare, health department grants, and maternal and child health projects.

Public Health Security and Bioterrorism Preparedness and Response Act, June 2002

with $3 billion appropriated by Congress, to implement the following antibioterrorism activities: • Improving public health capacity • Upgrading of health professionals' ability to recognize and treat diseases caused by bioterrorism • Speeding the development of new vaccines and other countermeasures • Improving water and food supply protection • Tracking and regulating the use of dangerous pathogens within the United States

Agency for Healthcare Research and Quality

is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As one of 12 agencies within the USDHHS, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision making. AHRQ is committed to improving care safety and quality by developing successful partnerships and generating the knowledge and tools required for long-term improvement. The goal of AHRQ research is to promote measurable improvements in health care in America.

Politics

plays a role in the development of such policies. Politics is found in families, professional and employing agencies, and governments. Politics determines who gets what and when and how they get it. Politics is the art of influencing others to accept a specific course of action. Therefore, political activities are used to arrive at a course of action

Home Care and Hospice

services rendered by nurses are shaped through state statutes and have specific nursing requirements for licensure and certification. Compliance with these laws is directly linked to the method of payment for the services. For example, a service must be licensed and certified to obtain payment for services through Medicare. Federal regulations implementing Medicare/Medicaid have an enormous effect on much of nursing practice, including how nurses record details of their visits, record time spent in care activities, and document client care and the client's status and progress.

USDHHS

the agency most heavily involved with the health and welfare of U.S. citizens. It touches more lives than any other federal agency.

2010

the most recent legislation passed and signed by President Obama to improve the health of the nation and access to care was the health reform law, the Patient Protection and Affordable Care Act

Information

All branches and levels of government collect, analyze, and disseminate data about health care and health status of the citizens. An example is the annual report Health: United States, 2013, compiled each year by the USDHHS. Collecting vital statistics, including mortality and morbidity data, gathering of census data, and conducting health care status surveys are all government activities.

Regulatory Action

At each level of government, the executive branch can and, in most cases, must prepare regulations for implementing policy for new laws and new programs. These regulations are detailed, and they establish, fix, and control standards and criteria for carrying out certain laws. Figure 8-3 pg 182

Healthy People 2020

Attaining high quality, longer lives free of preventable disease, disability, injury, and premature death Achieving health equity, eliminating disparities, and improving the health of all groups Creating social and physical environments that promote good health for all Promoting quality of life, healthy development, and healthy behaviors across all life stages

Nursing Advocacy

Advocacy begins with the art of influencing others (politics) to adopt a specific course of action (policy) to solve a societal problem. This is accomplished by building relationships with the appropriate policy makers—the individuals or groups that determine a specific course of action to be followed by a government or institution to achieve a desired end (policy outcome). Relationships for effective advocacy can be built in a number of ways. The American Association of Colleges of Nursing (AACN) remained concerned about the shortage of RNs and worked with schools, policy makers, other organizations, and the media to bring attention to this health care crisis. AACN worked to enact legislation, identify strategies, and form collaborations to address the nursing shortage (AACN, 2010). However, in June 2011 it was reported that employers and staffing agencies posted more than 121,000 new job ads for Registered Nurses in May, up 46% from May 2010 (AACN, 2014). Advocacy by expert and committed health professionals can bring about positive change for the profession, the community, and the clients that nurses serve.

The Process of Regulation

After a law is passed, the appropriate executive department begins the process of regulation by studying the topic or issue. Advisory groups or special task forces are sometimes formed to provide the content for the regulations. Nurses can influence these regulations by writing letters to the regulatory agency in charge or by speaking at open public hearings. After rewriting, the proposed regulations are put into final draft form and printed in the legally required publication Revisions made to proposed regulations are based on public comment and public hearing. Final regulations, published in a Code of Regulations (both federal and state), usually lead to changes in practice.

Shift of government from health care to national security after:

After the terrorist attacks on the United States in September (World Trade Center attack) and October (anthrax outbreak) of 2001

Judicial and Common Law

Both judicial law and common law have great impact on nursing. Judicial law is based on court or jury decisions. The opinions of the courts are referred to as case law (Birkland, 2010). The court uses other types of laws to make its decisions, including previous court decisions or cases. Precedent is one principle of common law. This means that judges are bound by previous decisions unless they are convinced that the older law is no longer relevant or valid. This process is called distinguishing, and it usually involves a demonstration of how the current situation in dispute differs from the previously decided situation

Federal Non-Health Agencies

Department of Defense Department of Labor Department of agriculture Department of Justice

W.H.O

Established in 1946, WHO relates to the UN through the Economic and Social Council to achieve its goal to attain the highest possible level of health for all persons. "Health for All" is the creed of the WHO. Headquartered in Geneva, Switzerland, the WHO has six regional offices. The office for the Americas is located in Washington, DC, and is known as the Pan American Health Organization (PAHO). The WHO provides services worldwide to promote health, it cooperates with member countries in promoting their health efforts, and it coordinates the collaborating efforts between countries and the disseminating of biomedical research. Its services, which benefit all countries, include a day-to-day information service on the occurrence of internationally important diseases; the publishing of the international list of causes of disease, injury, and death; monitoring of adverse reactions to drugs; and establishing of world standards for antibiotics and vaccines.

Government Health Care Functions

Federal, state, and local governments carry out five health care functions, which fall into the general categories of direct services, financing, information, policy setting, and public protection.

Direct Services

Federal, state, and local governments provide direct health services to certain individuals and groups. For example, the federal government provides health care to members and dependents of the military, certain veterans, and federal prisoners. State and local governments employ nurses to deliver a variety of services to individuals and families, frequently on the basis of factors such as financial need or the need for a particular service, such as hypertension or tuberculosis screening, immunizations for children and older adults, and primary care for inmates in local jails or state prisons.

National Institutes of Health

Founded in 1887, NIH today is one of the world's foremost biomedical research centers, and the federal focus point for biomedical research in the United States. The goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. The NIH mission is to uncover new knowledge that will lead to better health for everyone.

The LAW and Health Care

Government and its laws are the ultimate authority in society and are designed to enforce official policy whether it is related to health, education, economics, social welfare, or any other society issue. The number and types of laws influencing health care are ever increasing. Definitions of law (Catholic University of America, 2010) include the following: • A rule established by authority, society, or custom • The body of rules governing the affairs of people, communities, states, corporations, and nations • A set of rules or customs governing a discrete field or activity (e.g., criminal law, contract law) Constitutional Law Legislation and Regulation Judicial and Common Law

Policy Setting

Policy setting is a chief governmental function. Governments at all levels and within all branches make policy decisions about health care. These health policy decisions have broad implications for financial expenses, resource use, delivery system change, and innovation in the health care field. One law that has played a very important role in the development of public health policy, public health nursing, and social welfare policy in the United States is the Sheppard-Towner Act of 1921

Professional negligence

Professional negligence, or malpractice, is defined as an act (or a failure to act) that leads to injury of a client. To recover money damages in a malpractice action, the client must prove all of the following: 1. That the nurse owed a duty to the client or was responsible for the client's care 2. That the duty to act the way a reasonable, prudent nurse would act in the same circumstances was not fulfilled 3. That the failure to act reasonably under the circumstances led to the alleged injuries 4. That the injuries provided the basis for a monetary claim from the nurse as compensation for the injury An integral part of all negligence actions is the question of who should be sued. When a nurse is employed and functioning within the scope of employment, the employer is responsible for the nurse's negligent actions. This is referred to as the doctrine of respondeat superior.

Legal Issues Affecting Health Care Practices

School and Family Health Home Care and Hospice Correctional Health

Laws Specific to Nursing Practice

Scope of Practice Professional Negligence

Department of Defense

The Department of Defense delivers health care to members of the military, to their dependents and survivors, to National Guard and reserve members, and to retired members and their families

1934

Senator Wagner of New York initiated the first national health insurance bill.

Center for Disease Control

The Centers for Disease Control and Prevention (CDC) serve as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. The mission of the CDC is to protect America from health, safety and security threats, both foreign and in the United States.

A federal example of this ideological debate occurred in the 1990s over health care reform.

The Democratic agenda called for a health care system that was universally accessible, with a focus on primary care and prevention. The Republican agenda supported more modest changes within the medical model of the delivery system. This agenda also supported reducing the federal government's role in health care delivery through cuts in Medicare and Medicaid benefits.

Department of Agriculture

The Department of Agriculture houses the Food and Nutrition Service, which oversees a variety of food assistance activities. This service collaborates with state and local government welfare agencies to provide food stamps to needy persons to increase their food purchasing power. Other programs include school breakfast and lunch programs, WIC, and grants to states for nutrition education and training

Centers for Medicare and Medicaid Services.

administers Medicare and Medicaid accounts and guided payment policy and delivery rules for services for 100 million people in 2014 In addition to providing health insurance, CMS also performs a number of quality-focused health care or health-related activities, including regulating of laboratory testing, developing coverage policies, and improving quality of care

Health Policy

is a set course of action to obtain a desired health outcome for an individual, family, group, community, or society Policies are made not only by governments, but also by such institutions as a health department or other health care agency, a family, a community, or a professional organization.

first major federal governmental action relating to health

creation in 1798 of the Public Health Service (PHS).

Policy

is a settled course of action to be followed by a government or institution to obtain a desired end

Constitutional law

derives from federal and state constitutions. It provides overall guidance for selected practice situations. For example, on what basis can the state require quarantine or isolation of individuals with tuberculosis? The state can isolate an individual even though it infringes on individual rights (such as freedom and autonomy), under the following conditions (Lee et al, 2012): • There is a compelling state interest in preventing an epidemic. • The isolation is necessary to protect the health, safety, and welfare of individuals in the community or the public as a whole. • The isolation is done in a reasonable manner.

The Democrats proposed the Health Security Act of 1993

failed to gain Congress's approval. In an effort to make some incremental health care changes, both the Democrats and the Republicans in Congress passed two new laws. HIPPA and SCHIP

1890

federal laws were passed to promote the public health of merchant seamen and Native Americans

The World Health Report

first published in 1995, is WHO's leading publication. Each year the report combines an expert assessment of global health, including statistics relating to all countries, with a focus on a specific subject. The main purpose of the report is to provide countries, donor agencies, international organizations, and others with the information they need to help them make policy and funding decisions. The report builds on new research and lessons learned from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low-income countries to achieve universal coverage and improve health outcome

Health Resources and Services Administration

has been a long-standing contributor to the improved health status of Americans through the programs of services and health professions education that it funds. The HRSA contains the Bureau of Health Professions (BHPr), which includes the Division of Nursing as well as the Divisions of Medicine, Dentistry, and Allied Health Professions.

Office of Homeland Secruity

have provided funds to address this serious threat to the people of the United States. One of the first things being done is the rebuilding of the crumbling public health infrastructures of each state to provide surveillance, intervention, and communication in the face of future bioterrorism events and natural disasters.

How To Be an Effective Communicator

• Use simple communications that will be readily understood. • Choose language that clearly conveys information to individuals of diverse cultures, different ages, and different educational backgrounds. • Target oral or written communication to the issue and omit jargon unique to medicine and nursing. • State your expertise on the issue first. • Briefly describe your education and experience. • Identify the relevance of the issue beyond nursing. • Provide information regarding the impact of the issue on the legislator's constituents. • Present accurate, credible data. • Do not oversell or give inaccurate information about the problem. • Present information in an organized, thorough, concise form that is based on factual data (when available). • Give examples.