WEEK 6
Complete this week’s assigned readings, chapters 39-43. After completing the readings, post a short reflection, approximately 1 paragraph in length, discussing your thoughts, opinions, questions or concerns about one or several of the specific topics covered in the textbook readings. Identify which one MSN Essential most relates to your selected topic in your discussion.
As a reminder, no scholarly sources are required and students do not have to reply to a classmate’s original post. This post does not have an end date but please make an effort to complete your post before next week’s discussion post is posted and/or due in order to avoid falling behind.
CHAPTER 39
The United States Military and Veterans Administration Health Systems
Contemporary Overview and Policy Challenges
John S. Murray
“No one who fights for this country should ever have to fight for a job, or a roof over their head, or the care that they have earned.”
President Barack Obama
The U.S. Military Health System (MHS) provides a number of important health care services to as many as 8.3 million service members, military retirees, and their families (Murray & Chaffee, 2011; The Kaiser Foundation, 2012). Military health care is provided by approximately 140,000 military, civilian, and contract personnel working around the globe at 59 military treatment facilities (MTFs) capable of providing diagnostic, therapeutic, and inpatient care. Additionally, care is delivered at hundreds of military outpatient clinics and by private sector civilian providers (Government Accountability Office [GAO], 2012; Murray & Chaffee, 2011).
Military nursing consists of several components: active duty, reserve, National Guard, enlisted medical technicians, and federal civilian registered nurses. The Army Nurse Corps is comprised of 40,000 nursing team members, whereas the Air Force has 18,000 and the Navy approximately 5,800 (U.S. Senate Committee on Appropriations, 2012). Active duty military nurses in all armed forces must have a bachelor’s degree in nursing (BSN) from an accredited school to serve in the military.
The MHS has two missions (Figure 39-1):
• A military readiness mission: supporting wartime and other deployments (GAO, 2012; Murray & Chaffee, 2011).
• A health care benefits mission: providing medical services and support to members of the armed forces, retirees, and their dependents (GAO, 2012; Murray & Chaffee, 2011).
The Veterans Health Administration (VHA) is home to the United States’ largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers, and residential homes for disabled veterans. More than 239,000 staff, including 53,000 licensed health care clinicians, work to provide comprehensive care to more than 8.3 million veterans each year at these facilities. The VHA nursing team consists of 77,000 personnel nationwide composed of registered nurses, licensed practical/vocational nurses, and nursing assistants. Of these, approximately 5440 are advanced practice nurses (Certified Registered Nurse Anesthetists, Nurse Practitioners, and Clinical Nurse Specialists). A BSN degree is not a requirement to work for the VHA (U.S. Department of Veterans Affairs Office of Nursing Services, 2010). The VHA’s primary mission is to honor America’s veterans by providing exceptional comprehensive care that improves their health and well-being. It accomplishes this benchmark of excellence by
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providing exemplary services that are both patient centered and evidence based (U.S. Department of Veterans Affairs, 2013a).
FIGURE 39-1 The Military Health System Mission.
The MHS and VHA Budgets
The National Defense Authorization Act (NDAA) is passed by Congress annually and specifies the overall budget for the Department of Defense (DoD), which includes funding for the MHS. Funding supports the delivery of health care to service members and their families as well as supporting education and training of military medical personnel, research, and purchasing medical equipment and supplies for MTFs and clinics (Murray & Chaffee, 2011). Each year, senior military nursing leaders speak before Congress regarding accomplishments and challenges over the previous year as well as identifying what new programs and policies are needed. In 2012 the Chief of the Army Nurse Corps presented information to support the need for a new trauma-training program for nurses. This program would allow the nurses to continue to develop their full capability to manage critical trauma patients across the battlefield. In response, Congress provided funding to support the development of the Army’s first Trauma Nurse Course that prepares nurses for the ever-changing traumatic injuries treated on the battlefield (U.S. Senate Committee on Appropriations, 2012). Patient outcomes from advanced treatment of traumatic injuries on the battlefield that have resulted from this training will inform policy regarding what nurses need to know to provide this specialty care.
As with U.S. health care costs over the past decade, expenses for the MHS have also significantly increased, more than doubling from $19 billion dollars in 2001 to a projected budget of $49.4 billion in 2014, equivalent to approximately 9.5% of the entire DoD budget. Although reasons for this large increase are many, two in particular receive great attention from Congress. There currently exists a vast amount of duplication and redundancy within the current three service medical departments (Air Force, Army, and Navy). This includes personnel, processes, and equipment, which add to growing defense health care costs. Additionally, wartime requirements have led to increased expenditures. When military health care personnel are deployed, patient care is often shifted to civilian care, which is more expensive (Beasley, 2012). To be fiscally responsible, the DoD has completed a comprehensive analysis of military health care spending. Strategic planning is aimed at eliminating duplication and redundancy as well as controlling costs, while continuing to provide optimal care (Office of the Under Secretary of Defense, 2013). Since 2007, military nurses have taken the lead role in standardizing health care policies and procedures related to education, training, and research for the DoD (Murray, 2009; Murray & Chaffee, 2011). For example, instead of creating new simulation programs to meet training needs in the National Capital Region, nurses brought together the three military services and civilian academic and health care institutions to create a robust platform reducing duplication of services. This initiative met the directive set forward by the Deputy Secretary of Defense for the three branches of the military to partner on education and training initiatives to reduce defense health care costs (Murray, 2010).
Historically, the VHA has been underfunded. However, for 2014, the VHA requested and received $64 billion dollars to provide reliable and timely
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resources to support the delivery of accessible and high-quality medical services to veterans. This is a 4.5% increase over the 2012 budget and approximately 40% of the total Department of Veterans Affairs budget (Merlis, 2012). One reason for escalating costs is the financial outlay required to cover the increased number of veterans seeking care from the VHA as a result of physical and mental injuries to personnel who have been deployed multiple times in Iraq and Afghanistan. Funding will support acute hospital, rehabilitative, psychiatric, nursing home, noninstitutional extended state home domiciliary, and outpatient care. The budget also supports upgrading of treatment facilities as well as the purchase of equipment and supplies. In addition, the VHA is the United States’ largest provider of graduate medical and nursing education as well as a major contributor to medical research which is supported by the annual budget (U.S. Department of Veterans Affairs, 2013b; 2013c).
Like the MHS, the VHA is expected to provide exceptional care while controlling costs, and has implemented a number of performance measures aimed at continually monitoring the provision of high-quality care, access to care, revenue cycle improvement to improve efficiency and accuracy, as well as partnering with the MHS to improve collaboration and sharing of resources. In fact, for many years the VHA was considered an industry leader because of its safety and quality measures (U.S. Department of Veterans Affairs, 2013c).
Advanced Nursing Education and Career Progression
The MHS places great importance on advanced nursing education. During war, health care continues to evolve based on the nature of combat as well as the challenges posed by working in the austere environments characteristic of the battlefield (Spencer & Favand, 2006). Military nurses must possess the advanced practice specialty skills needed during conflict. Additionally, master’s degrees are required to be obtained before being promoted to more senior military ranks. Professional growth and development is continuously provided throughout a nurse’s career in the MHS by way of leadership experiences, on-the-job training, and continuing education. A variety of educational programs, including postgraduate opportunities, are available. Full funding, in addition to continuing to receive full salary and benefits, is provided for nurses earning advanced practice degrees as well as those pursuing doctoral studies. The armed services are committed to advancing military nursing science to optimize the health of military members and their families. Graduate education in civilian programs is available for selected promising nurse researchers. Additionally, to further advance the nursing research needs of the MHS, in 1992 Congress established the TriService Nursing Research Program (TSNRP), which is the only program funding and supporting rigorous scientific research in the field of military nursing (Duong et al., 2005).
TSNRP funds a wide range of studies to advance military nursing science. For example, in 2011 a pilot study was conducted to determine the sensitivity and specificity of small animal positron emission tomography-computed tomography (PET-CT) in identifying metabolic changes in muscle tissue surrounding simulated shrapnel injuries, and comparing this imaging with traditional x-ray images. Results showed the PET-CT to be more sensitive in identifying tissue changes. Military nurses now have a unique opportunity to educate patients and military health care providers, as well as to inform policy changes, about the possibility of early tissue changes around embedded shrapnel fragments and the use of PET-CT imaging as a possible surveillance tool. Another study supported by TSNRP in 2010 sought to understand how posttraumatic stress symptoms (PTSS) affect couple functioning in Army soldiers returning from combat. Findings included that almost 50% of couples had at least one person in the relationship with a high level of PTSS. Based on these results, development of interventions and policies designed to mitigate, or even prevent, negative outcomes such as divorce, violence, and suicide for military couples facing combat deployment are under way (TSNRP, 2013).
The VHA, like the MHS, also places great emphasis on the role of advanced practice nurses and currently employs approximately 5300 (4267 NPs, 533
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CNSs, and 500 CRNAs) (U.S. Department of Veterans Affairs Office of Nursing Services, 2010; United States Government Accountability Office, 2008) to deliver care. The VHA also recognizes the importance of providing educational benefits for nurses, thus permitting them to participate in graduate education. Additionally, VHA facilities provide some of the best platforms for clinical education and experience which many nurses use in their advanced studies (Caroselli, 2011). For example, VHA health care facilities provide a broad spectrum of primary, medical, surgical, behavioral health and rehabilitative care, and diagnostic services that serve as excellent clinical training sites. The VHA has also established the VHA Nursing Academy to address the growing national shortage of nurses. Although not a nursing school, the Academy establishes partnerships with academic institutions to expand the number of nursing faculty, enhance the professional and scholarly development of nurses, and increase student enrollment in nursing programs. For instance, advanced practice nurses and nurse researchers from the VHA serve as clinical instructors and faculty. The Academy provides excellent experiences for nurses and thus serves as a recruitment source. Following graduation, many nurses seek employment at VHA hospitals to focus on the health care needs of veterans (Caroselli, 2011; U.S. Department of Veterans Affairs, 2012).
Contemporary Policy Issues Involving MHS and VHA Nurses
Posttraumatic Stress Disorder
The problem of posttraumatic stress disorders in veterans has existed for centuries; however, the condition is attracting high levels of current attention caused by the conflicts in Iraq and Afghanistan and the disorder now impacts up to 22% of veterans (Johnson et al., 2013; Murray & Garbutt, 2012; Sabella, 2012). VHA and MHS nurses, along with their behavioral health counterparts, have collaboratively developed evidence-based guidelines on assessment and effective treatments which include multiple treatment modalities such as trauma-focused psychotherapies (e.g., exposure therapy), anxiety management, stress reduction, guided imagery, relaxation techniques, cognitive processing and behavioral therapy, and social support (Johnson et al., 2013; Murray & Garbutt, 2012; Murray & Smith, 2013; Sabella, 2012).
Current policies highlight requirements related to the timely assessment, treatment, and follow-up care of PTSD in both DoD and VHA clinical settings (U.S. Department of Veterans Affairs & Department of Defense, 2010). However, most military service members and veterans do not seek treatment for PTSD because of stigma, barriers to care, and negative perceptions associated with receiving mental health care (Hoge, 2011; Murray & Garbutt, 2012; U.S. Department of Veterans Affairs & Department of Defense, 2010). Policy issues requiring high priority include better understanding of the barriers to low mental health service use in the MHS and VHA (Hoge, 2011). Nurses are highly instrumental in understanding obstacles to care as well as working to develop and implement collaborative care models to increase outreach to veterans in need of mental health services.
Sexual Assault
Although the DoD and VHA continue to address military sexual trauma (MST; sexual assault or repeated, threatening sexual harassment that occurs during military service) and to describe what is being done to tackle this issue, many members of Congress believe there is an epidemic in the armed forces. It is estimated that 6.1% of women and 1.2% of men serving in the armed forces experienced and reported unwanted sexual contact in 2012. These numbers are believed to be much higher given that incidents go unreported as a result of fear of retaliation which could impact careers and the lack of trust that appropriate action will be taken against the offender (Johnson et al., 2013). Most experiences (67%) happened at work on military installations (Department of Defense, 2012). This is not a new issue for the military. For over two decades senior military officials and members of Congress have proposed recommendations to address sexual assault and harassment. Despite these efforts, the
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incidence of such events continues to increase annually. This creates substantial financial and emotional cost that affects several generations of veterans and lasts long after a victim leaves the military. At this point, the VHA picks up the costs associated with a variety of physical and mental health problems (primarily posttraumatic stress disorder and depression), which sexual assault and harassment can trigger.
In 2013, Congress required a response to this ongoing problem. NDAA 2013 mandated immediate policy changes to include investigation of all occurrences of sexual misconduct, requiring an independent review of all legal proceedings and investigations surrounding MST, and improving victim protections and reporting policies (U.S. Department of Defense, 2013). VHA mental health providers, including nurses, are developing and evaluating therapies specific to MST. Furthermore, nurses are using telehealth technology to reach out to veterans in remote areas of the country.
Suicide
Veteran suicide in the United States continues to remain an underreported epidemic and the most critical health issue facing the MHS and VHA. It is estimated that approximately one service veteran dies by suicide every hour (Murray & Smith, 2013). Veteran suicide rates have been reported to be as high as 20 per 100,000 people, or almost twice that of the United States in general (Murray & Smith, 2013; U.S. Department of Veterans Affairs, 2012). Several factors are associated with these alarming numbers. For example, many veterans suffer from comorbid mental health disorders such as PTSD, depression, impulsive behaviors, and substance abuse (Sher, Braquehais, & Casas, 2012). Suicide risk is also greater in veterans experiencing relationship problems, social isolation, difficulty reintegrating into the civilian community, and financial difficulties related to unemployment (Murray & Smith, 2013).
Efforts must be expanded to connect more veterans to the mental health resources needed to combat any suicidal tendencies. Concerns about confidentiality, stigma associated with mental illness, and limited availability of mental health services in some locations continue to be the major barriers to veterans seeking appropriate mental health care (Merlis, 2012). Another problem is delayed access to care. It is VHA policy that veterans seeking mental health care are seen within 14 days. The reality is that the wait for many is closer to 50 days on average before treatment is received. Although backlog has been identified as an issue, a greater problem is scheduling procedures not being followed. Instead of veterans receiving an appointment within 14 days, they are oftentimes given the next available appointment, which could be months away, placing a veteran’s well-being at risk (Office of the Inspector General, 2012).
The MHS and VHA continually strive to improve upon suicide prevention programs. Current priorities include a national suicide prevention hotline with free access to trained counselors 24 hours a day, 7 days a week, 365 days a year (Figure 39-2). Since 2007, response has been provided to more than 825,000 callers with more than 28,000 life-saving rescues. In 2009, the VHA initiated an anonymous on-line chat service. To date, this service has provided help to more than 94,000 individuals (U.S. Department of Veterans Affairs, 2013d). The hotline and online chat system are just two approaches within a more comprehensive plan developed by the VHA to prevent suicide but are not enough to tackle the problem since not all veterans are aware of the hotline, on-line chat, and other available mental health services (U.S. Department of Veterans Affairs, 2013d). VHA nurses are working to provide outreach programs to educate
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veterans and their families about the Veterans Crisis Line and online chat as well as collaborating with communities and partner groups nationwide (e.g., community-based organizations, Veteran Service Organizations, and local health care providers) to spread the word about the mental health services available through the VHA (Johnson et al., 2013; Mason & Schwartz, 2014).
FIGURE 39-2 Veterans Crisis Line.
Treatment plans for veterans who have suicidal thoughts and behaviors include somatic therapies (e.g., medications) as well as psychosocial and psychotherapies (e.g., cognitive behavioral processing). Equally important is addressing the spectrum of challenges confronting veterans. Although many are related to mental health, others include difficulties with reintegrating into family and community life as well as finding employment (Murray & Smith, 2013).
Access to Care
More recently, it has come to light that access to care for veterans is worse than previously thought. In May 2014, the Veterans Affairs (VA) Inspector General began to investigate patient wait times and scheduling practices on the basis of concerns that veterans were not receiving timely care. Preliminary findings showed that systemic patient safety issues and possible wrongful deaths occurred as a result of gross mismanagement of resources, unethical behavior, and possible criminal misconduct by VHA senior hospital leadership. Before the 2014 investigation, a 2013 U.S. Government Accountability Office (GAO) report determined that at least 50 veterans experienced delayed gastroenterology consultations for colon cancer, some of whom later died of the disease. Findings such as this provided evidence that delayed access to health care is associated with negative health outcomes (Chokshi, 2014), and these scheduling practices are not in compliance with VHA policy (U.S Department of Veteran Affairs Office of the Inspector General, 2014). Kizer and Jha (2014) noted that almost 20 years ago the VHA had to implement sweeping reforms to increase both quality and accountability. The reforms of the 1990s improved quality and increased access and efficiency (Kizer & Jha, 2014). The successes of the past reforms in the VHA provide clear evidence that the problems are fixable (Kizer & Jha, 2014) and new reforms are again needed to fix current challenges. One such attempt at reform is the VA Management Accountability Act of 2014, which has passed the U.S. House of Representatives and gives the Secretary of the VA greater authority to fire senior administrators. In addition, Senator Bernie Sanders (I-VT) along with John McCain (R-AZ) introduced a bipartisan comprehensive bill that supports veterans having access to community as well a federal health care providers. The bill also provides emergency funding for the VHA to hire more physicians, nurses, and other health care workers.
Post-Deployment Health-Related Needs
During World War II, the likelihood of surviving battlefield injuries was approximately 70%; during the Vietnam War survivability improved to 76%; and survival of service members wounded in the wars in Iraq and Afghanistan has increased to over 90%. Greater survivability is related in part to advances in medical care, improved protective gear (e.g., Kevlar vests), new medications (e.g., clotting agents), and significantly improved medical evacuation transport systems so that the wounded receive emergency surgeries within 30 to 90 minutes of injury. Despite these good survivability statistics, injured service members have significant physical, emotional, and cognitive injuries requiring attention for decades afterward (Manring et al., 2009; Tanielian & Jaycox, 2008).
Posttraumatic stress disorder, depression, and traumatic brain injury continue to be high-level policy interests for the MHS and VHA because these health-related issues often go unrecognized (Merlis, 2012). Additionally, a gap remains in the state of the science related to traumatic brain injury and the most effective way to address this problem (Murray & Chaffee, 2011; Tanielian & Jaycox, 2008). Each of these conditions has wide-ranging and harmful consequences if untreated. Employment, family relationships, social functioning, and parenting are severely impacted. Additionally, recurring problems such as substance abuse,
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homelessness, and suicide can occur. These invisible wounds of war will continue to require high priority to ensure they are appropriately recognized. Effort is needed to ensure policies and programs are consistent across the military services, within the VHA, and in collaboration with the civilian sector if they are to realize care-seeking behaviors and result in improvements in the delivery of high quality care for veterans (Tanielian & Jaycox, 2008). Policy discussions at the national congressional level are essential to determine if the MHS and VHA have the capacity to address the needs of the veteran population and how non-VHA health care settings can help address the rapidly growing needs of America’s veterans (Johnson et al., 2013).
Additionally, the American Academy of Nursing has created an awareness campaign as another avenue to improve health care for veterans. Have You Ever Served? encourages all health care providers to identify veterans in their patient population to ensure they receive the appropriate type and level of care for military-related conditions (Collins, Wilmoth, & Schwartz, 2013). See Box 39-1 for more information on Have Your Ever Served?.
Box 39-1
Have You Ever Served?
byDiana J. Mason
Despite the crisis that occurred in the spring of 2014 over excessive wait times for veterans seeking care in the VHA system, and cover-ups by administrators at some VHA health care facilities (Veterans Health Administration, 2014), VHA clinicians are nonetheless experts in assessing and managing health conditions that arise from service-related exposures and injuries. These exposures vary by service period, location, and role the veteran played.
The 2014 crisis resulted in calls for increasing veterans’ access to care in the private sector. Only about one fourth of veterans receive their care in the VHA health system with the remainder either not accessing any care or getting it from the private sector. A 2011 survey of community mental health and primary care providers revealed that only about 44% ask their patients whether they are veterans (Kilpatrick et al., 2011). Linda Schwartz, PhD, RN, FAAN, U.S. Assistant Secretary of Veteran Affairs for Policy and Planning, has noted that veterans may present to clinicians in the private sector with symptoms that clinicians may not recognize as service-related. As a result, veterans can live in chronic pain or be misdiagnosed for years.
As part of First Lady Michelle Obama’s Joining Forces initiative ( www.whitehouse.gov/joiningforces ), the American Academy of Nursing developed an initiative to increase clinicians’ awareness of the importance of assessing every patient’s veteran status, including whether the patient is a child of a veteran, since some exposures during war can cause genetic changes for offspring and some families have been exposed to toxins on military bases. The initiative is called “Have You Ever Served in the Military?” and aims to have all clinicians ask patients, “Have you ever served? If so, when and where did you serve and what did you do?” In addition, the initiative aims to embed in the electronic health record an algorithm that begins with this question and then links the responses to potential exposures, symptoms, and health problems.
The initiative was endorsed by the National Association of State Directors for Veteran Affairs. More information about the initiative can be found at www.haveyoueverserved.com .
References
Kilpatrick DG, Best CL, Smith DW, Kudler H, Cornelison-Grant V. Educational needs of health care providers working with military members, veterans and their families. Medical University of South Carolina Department of Psychiatry: Charleston, SC; 2011.
Veterans Health Administration. [Interim report: review of patient wait times, scheduling practices, and alleged patient deaths at the Phoenix Health Care System. Retrieved from] www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf; 2014.
Seamless Transition
Although major strides have been made in tertiary care, little progress has been made with reentry of veterans into the civilian world. The lack of seamless transition and continuity of care from MHS to VHA care continues to be an ongoing challenge faced by veterans and has received considerable
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congressional attention. In fact, it is estimated that only 52% of service members transitioning their care successfully make their way into the VHA system (Merlis, 2012). Many of these veterans wait for almost 1 year to gain access to the VHA because of backlog related to the vast number of claims for care, changing policies to cover a broader type of claims, and the continuing need to digitize paper health records (Bresnick, 2013). Even more troublesome, many veterans are not even being placed on wait lists. Compliance with VHA policy is needed to mitigate further access delays to health care services, which veterans have earned and deserve (U.S Department of Veteran Affairs Office of the Inspector General, 2014).
In 2008, Congress mandated that the DoD and VHA jointly develop a comprehensive management and transition policy to ensure service members received seamless behavioral health care. In response DoD and the VHA collaboratively developed an inTransition program. In this program service members are assigned a support coach, an experienced, licensed behavioral health provider, who is responsible for providing individual assistance with mental health support during the transition process. The support coach serves as a bridge to provide help between behavioral health care systems and providers. InTransition is not case management. The program is designed to assist the service member during the transition period only by encouraging the individual to continue their behavioral health care. The VHA provides a case manager who monitors the veteran over time. The program serves as an added resource to care delivered by health care providers and case managers (Office of the Assistant Secretary of Defense, 2010).
Finally, DoD and the VHA were charged with developing an integrated, interoperable electronic health record (EHR) which could be used by both agencies (Merlis, 2012). The VHA and MHS currently keep entirely different records, making it difficult for health care information to be shared and transferred when a service member transitions to the VHA. However, efforts to develop a mutually agreed upon interoperable, integrated EHR have come to a standstill because of disagreements regarding how to merge systems (Bresnick, 2013).
Conclusion
As our nation faces an increasing need to provide health care to military service members, policymakers will need to provide continuous support to strengthen the MHS and VHA. Although both health care systems function in parallel and in conjunction with each other, greater attention needs to focus on ensuring that service members transitioning from the MHS to the VHA do so in a seamless manner.
Discussion Questions
1. Are current MHS and VHA policies effective in addressing the needs of military service members and veterans?
2. What major policy issues do the MHS and VHA most need to address to improve health care services for veterans?
3. What major reforms are needed within the VHA to improve health care for veterans?
References
Beasley K. Innovative solutions will reduce DOD health care costs. [Retrieved from] www.moaa.org/uploadedFiles/MOAA_Main/Main_Menu/Take_Action/Top_Issues/Innovative%20Solutions.pdf; 2012.
Bresnick J. VA contractor digitizes benefits backlog, talks joint HER. [Retrieved from] ehrintelligence.com/2013/07/10/va-contractor-digitizes-benefits-backlog-talks-joint-ehr/; 2013.
Caroselli C. The Veterans Administration Health System: An overview of major policy issues. Mason DJ, Leavitt JK, Chaffee MW. Policy & politics in nursing and health care. Elsevier: St. Louis, MO; 2011.
Chokshi DA. Improving health care for veterans—A watershed moment for the VHA. [Retrieved from] www.nejm.org/doi/full/10.1056/NEJMp1406868; 2014.
Collins E, Wilmoth M, Schwartz W. “Have You Ever Served in the Military?” Campaign in partnership with the Joining Forces Initiative. Nursing Outlook. 2013;61(5):375–376; 10.1016/j.outlook.2013.07.004.
Department of Defense. Department of Defense annual report on sexual assault in the military. [Retrieved from] www.ncdsv.org/images/DOD_Annual-report-on-sexual-assault-in-the-military-FY2012_ExecSumm_5-7-2013.pdf; 2012.
Duong DN, Schempp C, Barker E, Cupples S, Pierce P, Ryan-Wenger N, et al. Developing military nursing research priorities. Military Medicine. 2005;170(5):362–365.
Government Accountability Office [GAO]. Defense health care: Applying key management practices should help achieve efficiencies within the military health system. [Retrieved from] www.gao.gov/assets/600/590090.pdf; 2012.
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Hoge CW. Interventions for war-related post-traumatic stress disorder: Meeting veterans where they are. Journal of the American Medical Association. 2011;306(5):549–551; 10.1001/jama.2011.1096.
Johnson BS, Boudiab LD, Freundl M, Anthony M, Gmerek GB, Carter J. Enhancing veteran-centered care: A guide for nurses in non-VHA settings. American Journal of Nursing. 2013;113(7):24–39.
The Kaiser Foundation. Military and veterans’ health care. [Retrieved from] www.kaiseredu.org/Issue-Modules/Military-and-Veterans-Health-Care/Background-Brief.aspx; 2012; 10.1097/01.NAJ.0000431913.50226.83.
Kizer KW, Jha AK. Restoring trust in VHA health care. [Retrieved from] www.nejm.org/doi/full/10.1056/NEJMp1406852; 2014.
Manring MM, Hawk A, Calhoun JH, Andersen RC. Treatment of war wounds: A historical review. Clinical Orthopaedics and Related Research. 2009;467(8):2168–2191; 10.1007/s11999-009-0738-5.
Mason DJ, Schwartz L. To the Editor New York Times: Veterans’ health care, under scrutiny. [Retrieved from] www.nytimes.com/2014/05/23/opinion/veterans-health-care-under-scrutiny.html?ref=todayspaper&_r=1; 2014.
Merlis M. The future of health care for military personnel and veterans. [Retrieved from] www.academyhealth.org/files/publications/AHMilitaryVetBrief2012.pdf; 2012.
Murray JS. Joint task force national capital region medical: Integration of education, training & research. Military Medicine. 2009;174(5):448–454.
Murray JS. Walter Reed National Military Medical Center: Simulation on the cutting edge. Military Medicine. 2010;175(9):659–663.
Murray JS, Chaffee MW. The U.S. Military Health System: Policy challenges in wartime and peacetime. Mason DJ, Leavitt JK, Chaffee MW. Policy & politics in nursing and health care. Elsevier: St. Louis, MO; 2011.
Murray JS, Garbutt S. Meeting the health care needs of America’s military veterans. [Retrieved from] ce.nurse.com/; 2012.
Murray JS, Smith D. Veteran suicide: Addressing the intensifying battle. [Retrieved from] ce.nurse.com/content/ce695/veteran-suicide/; 2013.
Office of the Assistant Secretary of Defense. HA Policy: 10-001: Department of Defense inTransition Program. [Retrieved from] www.health.mil/libraries/HA_Policies_and_Guidelines/10-001.pdf; 2010.
Office of the Inspector General. Veterans Health Administration: Review of veterans’ access to mental health care. [Retrieved from] www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf; 2012.
Office of the Under Secretary of Defense. Overview: United States Department of Defense fiscal year 2014 budget request. [Retrieved from] comptroller.defense.gov/budget.html; 2013.
Sabella D. PTSD among our returning veterans: How to recognize and assist veterans with this increasingly common mental health disorder. American Journal of Nursing. 2012;112(11):48–52; 10.1097/01.NAJ.0000422255.95706.40.
Sher L, Braquehais MD, Casas M. Post-traumatic stress disorder, depression, and suicide in veterans. Cleveland Clinic Journal of Medicine. 2012;79(2):92–97.
Spencer B, Favand L. Nursing care on the battlefield. [Retrieved from] www.americannursetoday.com/article.aspx?id=5138; 2006.
Tanielian T, Jaycox LH. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. [Retrieved from] www.rand.org/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf; 2008.
TriService Nursing Research Program [TSNRP]. Funded studies. [Retrieved from] www.usuhs.mil/tsnrp/FundedStudies/funded.php; 2013.
U.S. Department of Defense. Department of Defense annual report on sexual assault in the military. [Retrieved from] www.sapr.mil/media/pdf/reports/FY12_DoD_SAPRO_Annual_Report_on_Sexual_Assault-volume_two.pdf; 2013.
U.S. Department of Defense. Sexual Assault Prevention and Response (SAPR) Program. [Retrieved from] www.sapr.mil/public/docs/directives/649501p.pdf; 2013.
U.S. Department of Veterans Affairs & Department of Defense. VHA/DoD clinical practice guideline for the management of post-traumatic stress. [Retrieved from] www.healthquality.va.gov/ptsd/CPGSummaryFINALMgmtofPTSDfinal021413.pdf; 2010.
U.S. Department of Veterans Affairs Office of Nursing Services. About the office of nursing services. [Retrieved from] www.va.gov/NURSING/About_ONS.asp; 2010.
U.S. Department of Veterans Affairs. VA Nursing Academy. [Retrieved from] www.va.gov/oaa/vana/; 2012.
U.S. Department of Veterans Affairs. About the VHA. [Retrieved from] www.va.gov/health/aboutVHA.asp; 2013.
U.S. Department of Veterans Affairs. Funding highlights: The budget for fiscal year 2013. [Retrieved from] www.whitehouse.gov/sites/default/files/omb/budget/fy2013/assets/veterans.pdf; 2013.
U.S. Department of Veterans Affairs. Veterans Health Administration: Federal funds for medical services. [Retrieved from] www.whitehouse.gov/sites/default/files/omb/budget/fy2013/assets/vet.pdf; 2013.
U.S. Department of Veterans Affairs. Veterans crisis line. [Retrieved from] www.mentalhealth.va.gov/suicide_prevention/; 2013.
U.S. Department of Veterans Affairs Office of the Inspector General. Review of patient wait times, scheduling practices, and alleged patient deaths at the Phoenix health care system. [Retrieved from] www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf; 2014.
United States Government Accountability Office. Recruitment and retention challenges and efforts to make salaries competitive for nurse anesthetists. [Retrieved from] www.gao.gov/assets/120/119575.pdf; 2008.
U.S. Senate Committee on Appropriations. Hearing on Defense Department Health Programs. [Retrieved from] www.appropriations.senate.gov/ht-defense.cfm?method=hearings.view&id=de73767a-6390-484e-9281-ef68d4fd1343; 2012.
Online Resources
American Academy of Nursing “Have You Ever Served in the Military?” campaign.
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
www.dcoe.health.mil.
Military Health System.
National Center for PTSD.
Veterans Health Administration.
inTransitions Program.
.
CHAPTER 40
Contemporary Issues in Government
Deborah B. Gardner
“At every stage, and under all circumstances, the essence of the struggle is to equalize opportunity, destroy privilege, and give to the life and citizenship of every individual the highest possible value both to himself and to the commonwealth. That is nothing new.”
Teddy Roosevelt
Contemporary Issues in Government
Tremendous pressures face our government at national, state, and local levels. We have entered an age where the gap between rich and poor is rapidly widening. Prospects for federal legislative remedies to most political issues appear slim. Political dysfunction in Washington, DC has pushed responsibility for hard choices down to the states, both red and blue, exacerbating the differences between them (Holland, 2014). The public has taken notice of these trends and their opinion of Washington leadership is at an all-time low (Gallup, 2014). Almost two thirds of the public believe their government is controlled by a handful of powerful interests. Confidence in the Courts as a check on abuses of power and defender of the public interest is divided (Pew Research Center, 2013).
Against this backdrop, the story of the United States’ historic health care reform is still unfolding. Predictably, implementation of the Affordable Care Act (ACA) has sparked numerous controversies. This chapter highlights how the economics of health care legislation are interrelated with many federal and state issues. The interconnected policy issues presented include fiscal policy or budgetary spending and debt management, demographic shifts, immigration reform, economic inequality, and climate change. The simple nature of media sound bites and Twitter feeds fails to adequately capture or educate the public regarding the complexity of the issues facing U.S. policymakers and citizens. To help close this knowledge gap for nurses and other health care providers, it is critical to examine how the current political climate impacts decision making on these complex national policy issues and undermines public trust in the democratic process.
The Central Budget Story
Politicians and the media often focus on the U.S. annual budget as the key issue regarding the fiscal health of our country. This focus obscures many of the underlying issues and masks the fact that politicians are avoiding hard choices about what programs to cut or taxes to levy. At present, while government spending increases, many programs are experiencing deep funding cuts. Why? The basic reason is that costs for entitlement programs are
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increasing leaving less money for discretionary spending. Projections suggest that over the next decade growth in government spending will be directed at caring for an increasingly large and politically powerful older adult population (Figure 40-1). As baby boomers age, retire, and live longer, the number of Social Security, Medicare, and Medicaid beneficiaries continue to grow. This growth will place increasing pressure on the federal budget. In conjunction with these factors, the ratio of U.S. workers supporting every Social Security recipient diminished from the 1940s ratio of 159 workers for every recipient to fewer than three workers in 2014 (Social Security Online, 2014). Between 2014 and 2024, the number of Social Security beneficiaries is projected to increase three times as fast as the number of workers paying taxes to support the program (Congressional Budget Office [CBO], 2014b).
FIGURE 40-1 The aging of the baby boom generation will boost the number of Americans age 65 or older. The highlighted period represents the timespan between the oldest and the youngest of the baby boom generation reaching 65. (From U.S. Census Bureau. Historical national intercensal estimates and 2012 national population projections. Compiled as part of the Peter G. Peterson Foundation analysis, “CBO’s New Budget Projection Shows More Action Needed to Tame Debt and Deficits,” released February 2014. Retrieved from pgpf.org/Chart-Archive/0181_aging_baby_boom .)
Despite the ACA showing initial cost savings, Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) costs are expected to rise (CBO, 2014b). By 2024, spending on Social Security, health care, and interest payments on the national debt will leave less than 8% of the national income available to pay for all other discretionary needs: defense, education, medical research, and transportation (CBO, 2014a) (Figure 40-2). As a result, the government’s ability to respond to other national problems and priorities is increasingly being compromised. This reality has been called the central budget story (Samuelson, 2014).
FIGURE 40-2 Health and Social Security are the major drivers of non-interest spending. Health programs include Medicare (net of offsetting receipts), Medicaid, Children’s Health Insurance Program, and health insurance subsidies for the exchanges. (From Congressional Budget Office. [2014, February]. The budget and economic outlook: Fiscal years 2014 to 2024; Office of Management and Budget. [2013, April]. Budget of the United States government, fiscal year 2014; and Bureau of Economic Analysis. [2014, January]. National income and product accounts tables. Compiled by PGPF.)
The impact of such cost-cutting decisions is felt strongly at both state and local levels. This will be a hard trend to reverse as the constituencies for mandatory benefits, led by Social Security’s 57 million, are more numerous and powerful than other interest groups needing federal support. Politicians from both parties are loath to take on reforming Social Security and Medicare, in particular, because of their stakeholders. In his testimony before Congress in 2014, Douglas Elmendorf, the director of the nonpartisan CBO, noted there are various ways to proceed (Elmendorf, 2014):
So we have a choice as a society to either scale back those programs relative to what is promised under current law; or to raise tax revenue above its historical average to pay for the expansion of those programs; or to cut back on all other spending even more sharply than we already are. … They tend to be unpleasant in one way or another, and we have not, as a society, decided how much of that sort of unpleasantness to inflict on whom. But some combination of those three choices will be needed. (Jones, 2014)
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Fiscal Policy and Political Extremism
One of the key responsibilities of Congress is to pass an annual budget that funds the government. Budgets are the linchpin of economic policy because decisions on how revenues are spent to meet the country’s competing needs, such as providing a strong defense, funding education, and improving the health care system, validate political commitments (International Budget Partnership, 2014). As with all budgets, deficits and debt are of key importance to this decision making (Box 40-1).
Box 40-1
Budget Basics
• Mandatory Spending is federal spending based on existing laws rather than the budgeting process. For instance, spending for Social Security and Medicare is based on the eligibility rules for that program. Mandatory spending or entitlement programs are not part of the annual appropriations process.
• Discretionary Spending is the portion of the budget that the President requests and Congress appropriates every year. Examples include education, defense, and the Environmental Protection Agency.
• The fiscal year is the accounting period of the federal government. It begins on October 1 and ends on September 30 of the next calendar year. For example, FY 2014 began October 1, 2013 and ends September 30, 2014.
• Revenues, also known as receipts, are the funds collected from the public. Most of the federal government’s revenues consists of receipts from individual income taxes, social insurance (payroll) taxes, and corporate income taxes.
• The Federal or Budget Deficit is the amount of spending (outlays) that exceeds total revenues (income) in 1 fiscal year. (From Congressional Research Service 7-5700 [ www.crs.gov 98-410].)
• The National Debt is the total amount of money the federal government owes and the result of accumulated budget deficits over the years. The link between the budget deficit and national debt is that a large part of deficit bills is incurred through previous tax and spending policies that created deficits and long-term debts in the first place.
• The Debt Limit, also known as the debt ceiling, is how much total debt the government can accumulate or owe. Raising the debt limit enables the government to pay for things it has legally committed to funding in the past. Raising the debt limit does not authorize new spending commitments.
Sources: Amadeo, K. (n.d.). Discretionary fiscal policy: Budget, taxation and how it differs from monetary policy. Retrieved from useconomy.about.com/od/glossary/g/discretionary.htm ; Amadeo, K. (n.d.). U.S. debt ceiling. What it is, and what happens if it’s not raised? Retrieved from useconomy.about.com/od/glossary/g/discretionary.htm
Since the Great Recession of 2008, budget debates have dominated congressional activity. Conflicts over the powers to tax, spend, and borrow have always been at the heart of American politics. However, since 2009, rigid posturing, caustic rhetoric, and costly political actions taken regarding the federal deficit and national debt have made a compromise over the annual budget unachievable. This has resulted in Continuing Resolutions (CRs), bills that simply continue preexisting appropriations, becoming the norm.
Political tensions over the budget rose to a new level in 2011. The Republican-led House (with strong Tea Party influence) threatened to vote against raising the debt ceiling and to shut down the government if a long-term plan was not developed to further reduce the budget deficit. Legislative agreement was reached in a last-minute deal, but the delay in voting to raise the debt ceiling led to a downgrade in the credit rating of the United States for the first time in history (Kogan, 2012).
It is important to note some facts regarding this fiscal battle. There is a significant difference between a government shutdown and not increasing the debt ceiling. In a government shutdown, day-to-day operations are frozen. Government agencies are forced to stop or reduce functioning; for example, federal workers are furloughed, losing productivity and tax dollars (Klein, 2013a). However, failing to raise the debt ceiling is even more devastating. In this situation, the federal government can no longer pay any of its employees’ salaries or benefits. Those receiving Social Security, Medicare, and Medicaid payments would go without. Federal services would grind to a halt. Failing to increase the debt ceiling could result in the Treasury either defaulting on
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U.S. debt or paying it late. The dollar value would plummet and a destabilization of financial markets felt across the world. Either scenario undermines the trust that the American people, other nations, banks, and businesses place in the U.S. government honoring its financial obligations (U.S. Department of the Treasury, 2013). This may be at least one reason why no other major industrialized nation sets a total debt limit on its central government (Ruffing & Stone, 2013).
2013 Debt Ceiling Crisis: Continued Political Dysfunction
Although a legislative agreement was reached to avert the 2011 debt ceiling crisis (The Budget Control Act of 2011, Public Law 112-25, S.365, 125 Stat. 240), it was far from congenial. The legislation included a package of automatic spending cuts (known as sequestration) that would begin in 2013 if an annual budget compromise could not be reached. While the intent of the Act was to force Congress to compromise on budget funding choices, this was not the outcome. In 2013, both a debt ceiling crisis and a shutdown were on the table once again (Khimm, 2012).
Known as the United States Fiscal Cliff, the controversy over defunding the ACA resulted in a 16-day federal shutdown. Standard & Poor’s, a national financial rating agency, estimated the cost of this shutdown at $24 billion (Johnson, 2013). A CR for fiscal year (FY) 2014 was passed in December of 2013. Then, in January, after a bipartisan compromise was reached, a budget was finally approved. This agreement ended the last-minute, crisis-driven budget battles that had consumed Congress for much of the previous 3 years (Krasney, 2013). Historically, the debt ceiling has been raised with little controversy between Congress and the President (Amadeo, n.d.a). Thus, what may sound like politics as usual to those who do not closely follow national policy actually represents a new type of challenge for policy agreement and implementation.
The Current Budget Deficit
The year 2014 was the fifth consecutive year in which the deficit has declined as a share of gross
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domestic product (GDP) since peaking at 9.8% in 2009; it is projected to decline further in 2015. The Congressional Budget Office (CBO) estimates that the 2014 deficit will equal 3% of the nation’s economic output, or GDP—close to the average seen during the past 40 years (CBO, 2014a).
Although the budget deficit is decreasing, there is concern that deficits will start to rise again after 2015. Should deficits grow, either additional debt or hotly disputed spending cuts and tax hikes will be required. Timely action will need to be taken. Thus work must be done to put fiscal policy on a sustainable course. According to former Senator Alan Simpson (R-WY), co-chair of the presidential debt commission created in 2010, “The tragic part of it is, all the anguish we’re going through isn’t dealing with two-thirds of the American budget” (Kuhnhenn, 2014). Barring reform, these programs will be forced to reduce benefits.
Health professionals need to understand that in such an adversarial political climate important issues including health care reform are being marginalized rather than debated for success. In the past, the government has successfully controlled growing deficits with collaboratively developed strategies. Legislation was developed through both debate and compromise. Unfortunately, compromise has become a negative term. According to Mann and Ornstein (2012), authors of It’s Even Worse Than It Looks, the budget battles are a symptom of the United States’ larger problem, that of a dysfunctional political climate. Is it any surprise that the public is apathetic and discouraged?
How Will the Nation’s Economic Health be Addressed?
While Republicans voice alarm over large deficits and the national debt, partisan opinions remain strongly divided regarding the most effective approach to balancing the federal budget to reduce budget deficits and debt. Democrats take a traditionalist approach, which proposes a mix of spending cuts as well as increasing revenue by raising taxes and reducing tax loopholes. However, the majority of congressional Republicans have strongly rejected the idea of raising taxes and have focused on discretionary spending cuts and reforming the large entitlement programs, such as Social Security and Medicare (Amadeo, n.d.b).
Unfortunately, both sides are guilty of having talked about these issues for more than 20 years without significantly addressing them in terms of policy change. Historically, our country has frequently operated with heavy deficits. Deficits often occur during times of war or economic downturns and, in the past, decreased military spending and stimulus packages have spurred economic recovery. But the current situation is different. The government is no longer spending to grow the economy. Instead, increased spending will be the result of rising mandatory expenses or entitlements, such as Medicare and Social Security. This spending, when combined with tax cuts and the impact of the Great Recession, makes the situation unsustainable. Can congressional leaders strike a smart compromise? As partisan posturing is being placed ahead of cooperative problem solving, the majority of U.S. citizens are not holding their breath (McCarthy, 2014).
The Impact of Political Dysfunction
Unprecedented gridlock in Congress is preventing the government from getting business done, having a destructive effect on domestic and foreign policy (Hass, 2013). The Pew Research Center reported the passage of only 55 substantive bills by the 113th (2013 to 2014) Congress. That is fewer than any Congress in the 20 years since the institution began keeping such records. Substantive legislation excludes bills that are purely ceremonial legislation (e.g., post-office renamings). There is speculation that the 114th Congress could be even less productive (DeSilver, 2013). Given the negative impact on legislation, it is important to review the forces creating this power struggle.
Polarization
The gridlock in Congress is often attributed to political polarization. Polarization is the idea that
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Republicans and Democrats represent such disparate worldviews that the gaps between them rule out the possibility of finding a common ground. Much of the tension may lie in answering the proverbial question: What is the role of government in protecting the rights of all of its citizens? This is a question both political parties take seriously and view differently. It can certainly be found at the heart of the health care reform battle. However, political scientist Gregory Koger (2012) argues that partisanship, not polarization, is the primary cause of gridlock. He asserts that while the Republican and Democratic parties tend to nominate candidates with different views on major issues, partisan conflict in Congress is largely a strategic choice. He reframes polarization as teamwork within parties. Legislators work to restrain their internal party differences to compete with the opposing party. According to Koger (2012), rather than actually striving to make the United States a stronger nation, posturing in Congress (seeking to improve the reputation of one party at the expense of the other party) reigns supreme. This congressional partisanship has negative consequences for public policy efforts.
Loss of Congressional Moderates
Building on Koger’s argument that partisanship has become stronger, there are data that reflect a large decrease in congressional moderates. Sometimes referred to as bridge builders, moderates tend to transcend partisan politics, voting on an issue regardless of affiliation. The National Journal’s 2013 vote ratings report reflects a Congress more partisan in voting than ever before (Kraushaar, 2014):
For the fourth straight year, no Senate Democrat was more conservative than a Senate Republican—and no Senate Republican was more liberal than a Senate Democrat. In the House, only two Democrats were more conservative than a Republican—and only two Republicans were more liberal than a Democrat. Contrast this lack of ideological overlap with 1994, when 34 senators and 252 House members voting records put them between the most liberal Republican and the most conservative Democrat. (Kraushaar, 2014)
Outside conservative groups, such as the Club for Growth and the Senate Conservatives Fund, are enforcing ideologic purity among members as well as primary candidates. The move to the extreme right is clearly seen as House Speaker John Boehner faces constant revolt from a growing number of Tea Party–affiliated members. In the 2014 elections some of the most conservative senators had primary challengers from the right (Kraushaar, 2014).
Gerrymandering
The U.S. Constitution specifies that seats in Congress be apportioned according to the U.S. Census. Individual states create congressional districts, which then elect members of the U.S. House of Representatives. Each decade, as new census numbers are presented, redistricting occurs at the federal, state, and local levels. Gerrymandering is a negative label for redistricting. It is a process historically riddled with political finagling as politicians redraw the boundaries of electoral districts so as to create an unfair advantage for a particular political party or faction (McNamara, 2014). Both parties have participated in this practice since the process began, but the influence of gerrymandering on election outcomes over the past decade has renewed concern. For instance, despite the Democratic support that brought President Barack Obama to a second term in 2012, Republicans achieved a 33-seat majority in the House. This was a significant achievement given that Republican candidates, as a group, received 1.4 million fewer votes than their Democratic opponents. It is only the second time since World War II that the party receiving the most votes failed to win a majority of House seats (Ohlemacher, 2014).
It is also argued that representatives from sharply gerrymandered districts feel less compelled to pay attention to broad-based public opinion, because what they are really concerned about is the opinions of their specific constituencies. While some assert that gerrymandering is a red herring (Cohn, 2013),
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the current focus and money spent by both parties to dominate in the redistricting progress suggest otherwise.
Congressional Gridlock: Where is the President’s Power?
So wherever and whenever I can take steps without legislation to expand opportunity for more American families, that’s what I’m going to do. (Excerpt from 2014 State of the Union Address)
Throughout history, Presidents have exercised their authority by using executive orders, proclamations, and memorandums. Reasons for Presidential executive orders are: to direct government officials and agencies to take a specified action; to clarify or further existing law; to respond to an emergency, such as a natural disaster; or to bypass congressional gridlock.
In his 2014 State of the Union Address, President Obama unveiled his plan to sign an executive order raising the minimum wage of federal contractors to $10.10 per hour. He also pledged to move forward on implementing his Climate Action Plan via executive order. Republican members of Congress responded by announcing plans to challenge the legality of these executive orders (Weatherford, 2014).
The President’s recess appointments have also come under fire. The Supreme Court is expected to rule on the constitutional provision that allows the President to make recess appointments of high-level government officials when the Senate is not in session (Barnes, 2014). Representative Tom Rice (R-SC) has also proposed a resolution, entitled Stop This Overreaching Presidency (STOP), directing the House of Representatives to file a civil suit to challenging the President’s directive to the U.S. Department of Health and Human Services to extend health coverage that would have been terminated or cancelled as a result of provisions in the ACA (Weatherford, 2014).
The outrage voiced by conservative members of Congress at President Obama about his misuse of the executive power may be more strategic than substantive. President Obama, to date, has issued 170 executive orders since taking office in January 2009. This is fewer than most Presidents holding office in the past 100 years (Weatherford, 2014). Since the Courts have rarely invalidated an executive order, Congress is unlikely to win a legal challenge (Barnes, 2014). While the President has been targeted for his use of executive powers, nothing he has undertaken has met with more opposition that his health reform efforts.
Beleaguered Health Care Reform
The Affordable Care Act (ACA) was signed into law in 2010. Yet this contentious and long-awaited legislation continues to be the focus of endless news stories. By 2014, the Republican-majority House had voted more than 54 times without success to have the ACA repealed (O’Keefe, 2014). Supreme Court challenges continue. The health reform debate has large overtones symbolic of what some have called a culture war between proponents of different visions for America’s future. Leflar (2013, p. 1) aptly describes it as a “saga of polarized ideology, vicious politics, perverse economics, and a high-level legal battle against the background of a health care system in disarray.” As the complex and poorly understood ACA initiatives are implemented, the ongoing criticism of the legislation has affected public perceptions. A 2014 Kaiser Family Foundation poll found that 46% of the public still holds a negative view of the law and only 38% view it favorably. However, when asked about repealing the ACA, 59% of Americans wanted to see the program improved, not repealed (Hamel, Firth, & Brodie, 2014).
Although the full impact of this legislation on the U.S. health care system is not known, the conversation regarding health care has fundamentally changed since its passage. As a highly visible national and local conversation, new expectations are being placed on a deeply entrenched health care system. Stakeholders, from patients to providers to politicians, are seeing access to care in new ways, clarifying true costs and identifying incentives to sustain successful systemic changes. The role of the federal and state governments in partnering with private
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partners to implement health care reform is likely to be an ongoing discussion as health care will be in a constant state of reform and modification for years to come.
Implementation Challenges
Policy implementation involves complex regulations issued by federal agencies, such as the U.S. Departments of Health and Human Services, Labor, and the Treasury. Implementation also involves policy choices by the 50 states, with a majority of Republican governors (30) and Republican-controlled legislatures (27) (Sullivan, 2013). Among the major implementation issues are: the expansion of the Medicaid program to cover more low-income people, the formation of state exchanges (health insurance marketplaces), the establishment of an Independent Payment Advisory Board for Medicare tasked with reducing Medicare costs while retaining quality of care, the adoption of new payment models, the coverage of contraceptives as part of the essential benefits package, and the founding of the Patient-Centered Outcomes Research Institute (Leflar, 2013). These new programs at the federal and state levels are designed to improve research dissemination to enhance patient outcomes and control costs through the development of new payment models that incentivize better care coordination. They are also broadly designed to enhance access to health care and improve population health. (See Chapter 19.)
Increasing Access
The ACA, despite a rocky rollout and determined opposition from critics, has spurred the largest expansion in health coverage in America in half a century (Levey, 2014). Exclusion of patients with preexisting conditions is now a thing of the past. Curbs have been placed on insurance industry profit levels and, for the first time, millions of low-income Americans can afford to seek treatment for chronic illnesses such as cancer and diabetes. As the first deadline for coverage in 2014 passed, it was estimated that 8 million people signed up for private insurance nationally (Morgan, 2014). Three million young people remain on their parent’s health care plans (U.S. Department of Health and Human Services, 2012). More than 8 million uninsured people are eligible for Medicaid and more than 71 million additional Americans are receiving preventive services coverage (e.g., colonoscopy, flu shots) without cost sharing (Skopec & Sommers, 2013).
These gains have been achieved amid intense political resistance. Although the opposition seems unprecedented, when Medicare and Medicaid became law in 1965, President Lyndon Johnson faced the hostility of the insurance industry and the American Medical Association. Both groups declared the programs to be the start of socialized medicine. The media argued that hospitals faced unbearable burdens and predicted that older adults would flood the facilities in great numbers. Such predictions did not come to pass. Medicare, providing health insurance for all Americans over 65 years, proved popular almost immediately. After the rollout, about 19 million people signed up (Kliff, 2013b). Medicaid was harder to implement. Financed jointly by the federal government and the states, Medicaid provides medical assistance for certain individuals and families with low incomes and resources. In its first year, only 26 states agreed to participate in Medicaid. The program did not include all 50 states until 1982 (Kaiser Family Foundation, 2009).
Medicaid Expansion: State-Driven Adoption
Aimed at creating greater health care equity, the expansion of the Medicaid program to cover more low-income adults is one of the ACA’s most notable measures. However, the number of Americans who will gain this health insurance depends on the number of states that agree to expand Medicaid coverage. Twenty-five states, the same number that originally resisted Medicaid in 1965, have chosen to opt out and refused their share of the funds (Kaiser Family Foundation, 2014). As the ACA begins to take effect, the ramifications of the Supreme Court’s Medicaid ruling are becoming clearer. In states that chose to opt out of the Medicaid expansion, a coverage gap is developing. It is estimated that 5.8 million American adults living in opt-out states will
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not be able to obtain health insurance because they earn too little to qualify for federal exchange subsidies but too much to qualify for Medicaid (Urban Institute, 2014). The Urban Institute also found that the rate of uninsured is almost 50% higher in states that refused the expansion than in those that embraced the policy (Holland, 2014).
As reasons for opting out, states cite ideological opposition or concern that paying for even part of the expanded program will burden future state finances. “Ironically, taxpayers in states refusing to implement the Medicaid expansion (such as Texas) will be subsidizing the expansions in other states (such as Arkansas), through a portion of their federal income taxes” (Leflar, 2013, p. 8.) In fact, the state of Arkansas took a unique approach that other states may model (e.g., Iowa). Led by a Democratic governor and a Republican legislature, they expanded coverage by gaining an exemption to use federal funding to purchase insurance for new recipients from private insurance firms, rather than through a publicly run program. This hybrid Medicaid approach is appealing to many states facing similar ideologic conflicts (Kliff, 2013a). Unfortunately, this is only a partial Medicaid expansion program and federal funding will decline each year for Arkansas and likely to generate further budget battles. (See Chapter 19.)
Federal Insurance Exchange: Crashing Debut
The debut of the federal exchange website, a centerpiece of the law, was riddled with problems. Labeled a debacle in the headlines, millions of Americans were left frustrated and justifiably suspicious when they tried to sign up for coverage online. The Healthcare.gov rollout was a political disaster for the President. Dr. Ezekiel Emanuel, former advisor to the White House on health care reform, diagnosed three mistakes that led to this implementation fiasco. First, that the Obama administration waited too long to release specific regulations and guidance on how the exchange would work and got a late start in building the physical website. Second, the Centers for Medicare and Medicaid Services (CMS), responsible for coordinating the project, had little expertise in creating a complex e-commerce website. No one senior person in the agency was tasked with running the exchange rollout. Finally, CMS did not review best practice models. Massachusetts had years of experience with its exchange. States such as California, Connecticut, and Kentucky spent several years building their exchanges, gaining experience, and providing a good consumer experience (Emanuel, 2013).
Former U.S. Health and Human Services Secretary Kathleen Sebelius took responsibility for the initial failure of the Healthcare.gov website. She became the administration’s point person for taking questions from Congress during October 2013 hearings. The White House called in a team of management and technology experts to fix the site. By December 2013, they had it working more or less smoothly. Secretary Sebelius officially resigned in April of 2014 and was replaced by President Obama’s former budget director, Sylvia Mathews Burwell, who was confirmed without controversy (Rampton, 2014). (See Chapter 20.)
Affordable Care Act Costs and Savings
While the ACA continues to spark diverse views regarding its effectiveness, everyone agrees that we have to find ways to get more health care for our health care dollars. There is reason for optimism. Recent studies suggest that Medicaid expansions are resulting in health and financial gains (Baicker et al., 2013; Sommers, Baicker, & Epstein, 2012). These studies also document an increase in the use of most health care services. The industry appears to be moving, albeit slowly, toward a system that rewards outcomes and quality, not just volume.
New estimates show that the ACA’s coverage provisions will result in lower net costs to the federal government. The Congressional Budget Office and the staff of the Joint Committee on Taxation released estimates in April of 2014 on the budgetary effects of the provisions of the ACA that relate to health insurance coverage. The agencies currently project a net cost of $36 billion for 2014, $5 billion less than the previous projection for the year. They also project a cost reduction of $104 billion for the 2015 to 2024 period. Considering all
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of the provisions, including coverage, the most recent comprehensive estimates by the Congressional Budget Office and the Joint Committee on Taxation indicate that the ACA will reduce federal deficits (Congressional Budget Office, 2014b).
Legal Challenges to the ACA
The Supreme Court’s decisions are impacting health care reform and the tenor of debate that surrounds it. The first challenge came in 2012 when the Supreme Court ruled that states could opt out of the Medicaid expansion. A second major challenge focused on the ACA contraception mandate. Two cases, Sebelius v Hobby Lobby Stores, Inc. and Conestoga Wood Specialties Corp. v Sebelius, dealt with the ACA, religious freedom, and women’s access to contraception by for-profit business owners (The Economist, 2014). A closely divided Supreme Court ruled in favor of family-owned for-profit businesses being treated as individuals and therefore could not be required to pay for insurance coverage of contraception (Richy, 2014). (See Chapters 19 and 53.)
Finally, the newest challenge under review by the Supreme Court is the case of King v Burwell. The plaintiffs point to a passage in the ACA that suggests the federal government can only offer premium subsidies to the state exchanges. Only 16 states and the District of Columbia have state-based exchanges; the other states have an exchange run by the federal government. If the Court rules in favor of the plaintiff, it would mean about 8 million people could no longer afford health insurance, and as the number of people enrolled drops, insurance premiums would go up for all. The Court is expected to rule in the summer of 2015 (Ydstie, 2015).
Immigration Reform: Will Health Care be Included?
Generations of immigrants have been and continue to be essential to the U.S. economy and cultural diversity. In 2011, the Hispanic Pew Center estimated that over 11 million undocumented immigrants were living in the United States including 1 million children (Passel and Cohn, 2012). Conservative estimates identify at least 5100 children in U.S. foster care, their parents having been detained or deported (Wessler, 2011). We are at a point in time when the need for immigration reform has never been more pressing and our country more ready. Amid growing bipartisan and public support for comprehensive immigration reform, how immigration reform will connect to health care reform has been a very divisive issue.
A confluence of factors, from the role of the Latino vote in the 2012 Presidential election to a broad coalition of immigrant rights activists, galvanized debate in Congress and culminated in the Senate’s passage of large-scale comprehensive bipartisan immigration reform legislation: The Border Security, Economic Opportunity and Immigration Modernization Act of 2013 S.744 (National Immigration Law Center, 2013). The proposal falls short, denying immigrants access to affordable health care for up to 15 years. With a polarized Congress current immigration reform legislation remains in limbo.
Current Health Care Access
Living as an undocumented immigrant in the United States provides limited options for health care. If injured, sick, or chronically ill an undocumented immigrant can experience days, weeks, or even months of pain, with the emergency room usually the only available remedy. Lack of progress on immigration reform over the past two decades has placed financial pressures on safety-net health care organizations and created ethical challenges for health care professionals seeking to provide quality care to all patients. Undocumented immigrants are currently ineligible for the major federally funded public insurance programs: Medicaid, Medicare, and CHIP. The publicly funded health care safety net provides some access for undocumented immigrants. State-level Emergency Medicaid covers hospitalization for emergency medical treatment and Federally Qualified Health Centers provide some primary care. Health care professionals must often resort to using emergency treatment
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provisions to help undocumented patients manage health problems. This is recognized as the most expensive and medically problematic way to treat chronic disease (Fitz, Wolgin, & Oakford, 2013).
The Ethics and Economics of Access
The Hastings Center (Berlinger & Gussmano, 2013) provides an indepth overview of the ethical issues that are key to guiding legislative development. Their report notes that excluding the undocumented while health care reform is being implemented undermines the health-related rights of citizen children whose access to health care depends on their parents, and it works against the goals of reducing health disparities affecting vulnerable populations (Berlinger & Gussmano, 2013). How to integrate undocumented immigrants and other new immigrants into the country’s comprehensive efforts to improve the health care system is a challenging problem.
Immigrant advocacy groups strongly support allowing undocumented immigrants access to basic affordable health care. The purpose of the ACA is to eliminate the need for the poor and uninsured to seek uncompensated health care from emergency rooms. Advocacy groups argue that the health of future citizens or the ability to control health care costs should not be compromised. “Ensuring that every person in this country has access to high-quality preventive care enhances public health, improves individuals’ lives, curbs health costs and reduces uncompensated care for doctors and hospitals” (Rome, 2013).
More conservative advocacy groups argue they are not being anti-immigrant. Instead, they claim that it is about following the rules and not rewarding those who break them. They argue that we cannot afford to include this population in the ACA plan and that taxpayers should not have to foot the bill for health care to anyone who manages to establish illegal residence (Camarota, 2011; Longmire, 2013; Rector, 2007). With sequestration cuts, shrinking budgets, and smaller incomes this has been an effective message.
However, the Center for American Progress (Fitz Wolgin, & Oakford, 2013) challenges the stereotype of immigrants as takers and presents an array of strong research findings that demonstrate immigrants are a net positive for the economy and pay more into the system than they take out. The Social Security Administration released projections regarding the impact of unauthorized immigrants’ contributions and also found they have played a key role in prolonging the solvency of the Social Security Trust Fund (Goss et al., 2013). Other findings emphasize that the gains to legalizing the nation’s undocumented immigrant population and reforming our legal immigration system would add a cumulative $1.5 trillion to U.S. GDP over a decade (Hinojosa-Ojeda, 2010). A study by the Institute on Taxation and Economic Policy (2013) found that undocumented immigrants pay a significant amount of money in taxes each year. This data challenges the perception that immigrants are a drain on the U.S. economy.
Immigration Health Care Reform Options
The main sources of health coverage for illegal or non-qualified immigrants are through an employer or the private, individual coverage market. However, immigrants often work in jobs that do not offer coverage or are unable to afford coverage on the individual market without access to tax credits. Currently, eight states (CA, FL, IL, MA, NJ, NY, WA, WI) and the District of Columbia have fully funded programs that provide coverage to immigrants regardless of their citizenship status. However, programs for illegal immigrants are limited to specific groups (such as children or pregnant women) or provide limited services (The Kaiser Family Foundation, 2013a). The Kaiser Family Foundation (2013b) suggests several policy options for increasing access to affordable coverage for immigrants. The options include expanding access to Medicaid by either eliminating or reducing the five-year waiting period for adults who are in a lawful status. The other option is to consider granting all immigrants on the pathway to citizenship, including those in provisional status, the same access as
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citizens to affordable health coverage options (e.g., Medicaid, CHIP, and exchanges).
Although there are increased costs associated with expanding coverage to individuals with provisional status, there are also offsetting savings. For one, reductions in the number of uninsured contribute to savings in programs and services for this population. As with other populations, access to affordable health coverage enables individuals to obtain medical care when needed. Waiting for care can both exacerbate the problem(s) and raise costs through greater emergency room use. Access to health care, including prevention, can facilitate earlier diagnosis and treatment of conditions as well as improve care management. Additionally, because immigrants tend to be younger and healthier, they help spread the risk in an insurance pool, which lowers overall premium costs. Lastly, by supporting an individual’s ability to focus on employment and providing for their family, health coverage also contributes to long-term economic benefits (Kaiser Family Foundation, 2013b).
As immigration reform awaits legislative action, it will be important for nurses and other health professionals to communicate the importance of including access to health care in immigration reform. An immigration bill that makes people wait so many years for guaranteed affordable insurance and care just makes no sense.
Rising Economic Inequality
Extreme economic inequality not only limits economic growth in the communities and in the nation as a whole, it impairs family well-being (Shapiro, Meschede, & Osoro, 2013). Economic inequality is the financial disparity between entities (e.g., individuals, groups, countries). Two primary measures are used to evaluate economic inequality. One is wealth, a measure of the money and material possessions or assets people own, and the other is income (Bernstein, 2013). Wealth and income disparities affect peoples’ access to basic items and services that should be available to everyone, such as food, housing, and health care. Individual and population health disparities are highly associated with economic inequality in this country.
Recent research from Thomas Piketty (2014) and Emmanuel Saez (2013), two highly regarded economists, provides strong evidence of growing inequality in the United States from 2009 to 2012. While income for the top 1% rose by 31.4%, the bottom 99% saw income growth of just 0.4% (Saez, 2013). The gap between rich and poor also rose in emerging economies, for example, India and China (The Economist, 2011). President Obama as well as other world leaders cite rising economic inequality as a threat to social mobility and economic stability. In his 2013 State of the Union Address, President Obama called “economic inequality the defining challenge of our time” (The White House, 2013). The Pew Research Center summarizes current facts regarding economic inequality in the United States (Table 40-1).
TABLE 40-1
Economic Inequality Facts
| Fact #1 | U.S. income inequality is the highest it has been since 1928. |
| Fact #2 | The collective earnings of the top 1% increased from 10% of total earnings in 1980 to 20% today. In contrast, the bottom 90% received 65% of the earnings in 1980. Today the share is less than 50%. |
| Fact #3 | The black/white income gap in the U.S. has persisted. In 2011, median black household income was 59% of median white household income. |
| Fact #4 | Wealth inequality is even greater than income inequality. The highest-earning fifth of U.S. families earned 59.1% of all income; the richest fifth held 88.9% of all wealth. |
Source: DeSilver, D. (2014). 5 facts about income inequality. Pew Research Center. Retrieved from www.pewresearch.org/fact-tank/2014/01/07/5-facts-about-economic-inequality/ .
Measuring Wealth
Economic inequality has been rising in similar ways around the world since 1980 (Galbraith, 2012). This trend appears to be strongly driven by the financial markets of a global economy. As stated earlier, as a standard measure of economic inequality, income provides an easy gauge for comparing the gains of the very wealthy with those of the middle class and
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the poor (Bernstein, 2013). However, wealth is more encompassing than income because assets and debts can modify the impact of income on economic outcomes. Wealth allows families to be more upwardly mobile by supporting them to move into better and safer neighborhoods, investing in businesses, saving for retirement, and supporting their children’s college aspirations. Having a financial cushion also provides a measure of security when a job loss or other crisis strikes. Some people have little or no accumulated wealth (what one owns minus what one owes) because they have little or no income. Some people may have a substantial income, but be in debt because of student loans or health care expenses and therefore have little wealth.
Sadly, another factor impacting contemporary wealth outcomes is historical wealth accumulation. Policies and taxation preferences from previous eras in our country’s history continue to unfairly impact wealth along lines of race and favor the already affluent. Notably, there is an enormous and long-standing wealth gap between white households and households of color. The Institute on Assets and Public Policy reports the number of years families owned their homes was the largest predictor of the gap in wealth growth by race (Shapiro Meschede, & Osoro, 2013). Including wealth-assets and debt is key because even small amounts of wealth can ensure some economic security and opportunity. The unprecedented wealth destruction during the 2008 financial crises and recession that followed, accompanied by long-term high unemployment, underscores the critical importance wealth plays in weathering emergencies and helping families achieve long-term financial security.
The Great Recession Reshaped the Economy
Inequality highlights distribution patterns and reveals who actually benefits from economic growth (Reich, 2014). Recent events have borne this out and made growing economic inequality part of the debate over whether our nation is on a sustainable economic path. Just before the 2008 financial crisis, Congress was cutting taxes for the highest earners in an effort to stave off a depression. In the wake of the financial crisis that created the Great Recession of 2008, the credibility of such free market and trickle-down economic ideologies is increasingly being challenged (Piketty, 2014; Stiglitz, 2012). Leading economists guided fiscal policy responses to the crises, including the highly controversial bank bailouts and economic stimulus package.
However, since the recovery began, the richest have rebounded the fastest and median incomes have dropped (Fox, 2014). Beginning with the 2011 Occupy Wall Street protests that voiced the plight of the bottom 99% of income and wealth holders, inequality has quickly moved to the top of the political agenda. One of the richest businessmen in America, Warren Buffet, is even crusading for a higher inheritance tax. He argues that the United States risks becoming a plutocracy as inherited wealth is making heredity, rather than merit, determine one’s ability to command resources (Roche, 2011). Many perceive the impact of recent economic shifts in wealth disparities as having an unprecedented impact on both economic security and political equality.
Costs of Economic Inequality
New research is challenging the traditional economic view that inequality is a necessary evil for an efficient capitalist society (Galbraith, 2012; Piketty, 2014). Nobel Prize winner Joseph E. Stiglitz (2012) argues that unequal societies are not only inefficient but also tend to have unstable and unsustainable economies. Technological change and globalized markets are identified as key reasons for the problem of growing global and U.S. economic inequity. Google Chairman Eric Schmidt notes that companies, in their drive to compete with one another on a global level, are focused on cutting wages and replacing workers with technology. As a result, wages as a percentage of the economy are near an all-time low. In his perspective, this has led to the stagnation in middle-class wages and slow global economic growth (Blodget, 2014).
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Economic inequality is not only bad for the economy and the pocket book but also negatively influences economic mobility and opportunities to improve one’s life (Schmitt, 2014). The American Dream of being able to succeed regardless of the economic circumstances in which one was born is increasingly untenable. The United States is not as socially mobile as was once thought. A study of 22 countries found that the United States ranked 15th in social mobility. In countries such as the United States, where income inequality is high, it was also found that intergenerational income gains are very low (Corak, 2013). Other studies support these findings. For instance, a report from the Center for American Progress found that income inequality diminishes economic mobility between generations (Bernstein, 2013).
Finally, research suggests that as the rich accumulate more of the country’s total income and wealth, they also gain political power (Reich, 2014; The Economist, 2012). This results in a cycle of greater political influence and increased inequality. The cycle can be described as: (1) increased inequality yields greater resources for the rich that (2) the rich can then apply resources to political contributions, which (3) leads parties to move their platforms to favor the positions of wealthier individuals, and (4) increases the wealth divide; then back to (1) (O’Neil, 2012; Schmitt, 2014). However, many conservatives argue there are little data to support these concerns (Nichols & McChesney, 2013). They assert that candidates cannot buy campaigns, no matter how much money they garner (e.g., Ross Perot, Steve Forbes, and Mitt Romney). Angus Deaton, a Princeton economist, does not agree: “The political equality that is required of a democracy is always under the threat from economic inequality, and the more extreme the inequality, the greater the threat to democracy” (Reich, 2014).
Impact of Economic Inequality on Health Equity
In considering the social determinants of health, nurses know that employment and working conditions, which provide income, have powerful effects on health and health equity. We also know that quality of life is determined by more than income, such as health, housing, the environment, financial security, and social connectedness. Highly unequal societies do worse overall on such quality of life indicators. High levels of inequality are strongly associated with poor social and human development outcomes (Edsall, 2012; Wilkinson & Pickett, 2009).
Recent studies are deepening our understanding of what drives economic and health inequality (Chettyet et al., 2014; Piketty, 2014). Chetty and colleagues (2014) found that geography is a significant factor in upward mobility in the United States. For example, the odds of increasing income (upward mobility) were considerably lower in Atlanta and Memphis and higher in northeastern cities such as New York and Boston. The study also found that fairly poor children in Seattle (bottom 25th percentile of income) do as well financially as middle-class children (50th percentile of income) who grew up in Atlanta. However, the influence of geography on mobility varies by where one starts on the social class ladder. Geography was less of a significant influence on children born to high-income families than for middle-class and poor children.
Effectively Addressing Economic Inequality
A recent Pew Research Center survey found that the majority of Democrats (68%) and Republicans (61%) believe economic inequality in the United States has grown, but they disagree about its causes and solutions (Pew Research Center, 2014). Only 45% of Republicans say that the government should do something about it, compared with 90% of Democrats (Wade, 2014). Republicans tend to endorse an individualist explanation for poverty (e.g., people are poor because they do not work hard), whereas Democrats tend to support a more structural explanation (e.g., where you start on the social class ladder). Many Republicans strongly believe that government aid to the poor does more harm than good. Notably, the answers to these questions on the Pew survey diverged much more by political affiliation than social class (Wade, 2014). For example, responders who identified as having low incomes and Republican affiliation did
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not support government intervention on the issue. Such is the power of ideology inherent in political affiliation.
Economists are also divided about what to do about economic inequality. Two ideological frames seem to underlie the policy approaches recommended by economists. Those with a more conservative view argue that the policy response needs to focus on removing government regulation to enable a more free market. Lawson Bader, president of the Competitive Enterprise Institute, a nonprofit libertarian think tank, agrees that the U.S. economy is performing at a subpar level. However, he argues that government attempts to fix the problems in some mechanistic way are not the answer (Reich, 2014).
The second frame is more Keynesian, or regulatory, in its approach. Joseph Stiglitz and New York University Professor of Economics Nouriel Roubini, among others, argue that legislative action is needed. They suggest that higher taxes, particularly for the upper-middle class and top 1%, would help with the redistribution issue and release the U.S. economy’s growth potential in a sustainable way. Stiglitz and Roubini also agree that the government should limit the tax breaks, subsidies, and loopholes allowed to the major energy, agribusiness, pharmaceutical, and financial companies (Fischl, 2013). Some argue that we should focus on the poor and poverty (Schmitt, 2014), while others point to joblessness (Klein, 2013b).
Proposed Policy Strategies
In his 2013 State of the Union Address, President Obama proposed increasing the minimum wage as a way to decrease income inequality (White House, 2013). The majority of Americans agree with this strategy (Drake, 2014). He also stressed the need to create economic mobility opportunities through funding better education, job opportunities, and new retirement plans (White House, 2013). The Republican response to his message was twofold: the real problem is the inequality of opportunity caused by President Obama’s administrative policies, yet they do not want to be seen as undermining the American working population (Vanic, 2014).
Republicans have introduced bills in the House and the Senate proposing the formation of a Monetary Commission to evaluate the core issues of income inequality and to make policy recommendations (Benko, 2014). These policy actions align with the Republican belief that regulation and redistribution work against America’s economic system of free market capitalism. More specifically, they argue that redistribution undermines economic growth opportunities as the rich have fewer incentives to start new businesses or hire new employees (Debate.org, 2014).
There does appear to be one consensus strategy seen as viable to reducing economic inequality: investing in education reform. Both conservatives and liberals agree that to make the United States more competitive in the future, education reform is needed. It is also well understood that allocating more resources does not automatically lead to better results (Fischl, 2013).
To date, the congressional response to the current economic disparities and the budget situation has been to implement austerity measures, such as decreasing spending in the budget for social programs. Many other countries have followed a similar path of austerity with few positive results. While there is overwhelming evidence that severe inequality makes our country more vulnerable to economic stagnation and volatility, there is no agreement on the causes or the solutions. Like all complex problems, real solutions will be multifaceted and require bipartisan effort. Inequality is shaped by the rules of the current system and those rules can be remade.
Climate Change: Impacting Global Health
Another contemporary issue that is impacting the health and economy of our nation is climate change. Although climate change is one of the most serious public health threats, few people are aware of how it can directly affect them. This may be the reason why few Americans are concerned about environmental issues. A 2014 Gallup poll indicates that only 24% of Americans worry a great deal about this issue (Riffkin, 2014). This puts climate change, along with the quality of the environment, near the
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bottom of a list of 15 top issues. Not surprisingly, Americans from the two major political parties express different levels of worry about climate change and the environment. Many more Democrats (45%) said they worry a great deal about the quality of the environment compared with Republicans (16%).
The factors of climate and local environment intersect with health status. This makes improving the health of populations a thorny problem because of the interacting influence of social, environmental, and economic systems. Research indicates that social and economic conditions are stronger determinates of health and sickness than access to medical care or genetic endowment (Galea et al., 2011). Additional evidence suggests that the greatest public health challenges of today include air quality; climate change; the safe management of chemicals; and adequate, safe sources of water, food, and energy. These are the multifaceted conditions that create the “social determinants of health” (Koh et al., 2010). As public health is a core component of the nurse’s role, it is morally imperative that nurses cultivate a professional understanding of climate change as well as a personal commitment to acting on environmental issues.
Climate Change: It’s Happening
Many scientists argue that current human activity, specifically the production of greenhouse gases, is a key factor in global warming and, thus, climate change (Hansen, Sato, & Ruedy, 2014). This human-induced warming and the overuse of fossil fuels are closely linked to climate change (National Oceanic and Atmosphere Association, 2014). Two reports on climate change have received a great deal of public notice. The 2014 United Nations report completed by the Intergovernmental Panel on Climate Change (IPCC WGII AR5; Intergovernmental Panel on Climate Change, 2014) and The National Climate Assessment report (Melillo, Richmond, & Yohe, 2014) offer strong evidence that climate change is here and now. The United Nations report warns that the impacts of global warming are likely to be “severe, pervasive and irreversible.” The controversial report states that natural systems are currently bearing the bulk of the burden of climatic changes (Watts, 2014). As changes continue, there will be a stronger negative impact on humans.
The negative impacts of climate change are especially visible in relation to the water supply. On one hand, there is a higher risk of flooding in lowland areas. On the other hand, as drought expands in other areas, water availability is compromised and crop yields decrease. The report emphasizes that no one on the planet will be untouched by the impacts of climate change. It further cautions that humans may be able to adapt to some but not all of these changes and only within limits (Intergovernmental Panel on Climate Change, 2014).
Although climate change has the potential to harm everyone, children, older adults, and communities living in poverty are among the most vulnerable. The poor will likely be hit the hardest. Food shortages, flooding, the destruction of property, and malnutrition are some of the many ways climate change can mean disaster for the poor. As temperatures rise, so will health risks. As access to food and water become inconsistent, a host of chronic health issues will be exacerbated. Climate change-related injury and illness will increase the demand for and cost of health care, meaning even less access for many impoverished people (Goldenburg, 2014).
The poor in less developed countries are not the only populations threatened by rising sea levels. While sea levels worldwide are expected to rise an average of two to three feet by 2100, they could surge more than six feet along the Atlantic seaboard. A recent study named Boston, New York, and Norfolk, VA the three most vulnerable metropolitan areas (Davenport, 2014). “Another study found that just a one point five-foot rise in sea level would expose about six trillion dollars worth of property to coastal flooding in the Baltimore, Boston, New York, Philadelphia, and Providence, RI areas” (Gillis, 2014).
Mitigation Versus Adaptation
While the predictions for climate change are dire, the United Nations 2014 report offers a great deal
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of information on managing climate change. Historically, the climate-policy community has debated about whether to focus on reducing emissions (mitigation) or managing climate change (adaptation). The report reflects a shift in this debate by focusing on both. Further, it places a sense of control and responsibility into the hands of the many instead of the few. The authors recommend that local businesses and communities lead the way rather than waiting for the international community to agree on policies. The report also notes that many collective efforts are already under way to adapt to climate changes. There are people who will never accept the science of climate change, but responding to current disasters by developing community resources to prepare for the worst just makes good sense. Key risks and adaptation prospects are presented for public-private partnerships to consider (Friedman and Narula, 2014).
International Progress
As climate change is a global problem, the need for mitigation is critical. To date, nation-state policies have been focused on reducing carbon dioxide and other greenhouse gas emissions. The Global Legislators Organization (GLOBE) completed a recent study tracking climate legislation across the 66 countries (accounting for almost 90% of global emissions). The study finds that 64 countries have put in place or are putting in place strong legislation to reduce fossil fuel use. In addition, 61 countries have laws to promote clean energy sources within their borders and 54 have mandated strengthened energy efficiency standards (Biron, 2014). The number of national climate laws around the world has increased from 40 in 1997 to nearly 500 (Friedman and Narula, 2014).
Unfortunately, the United States is lagging far behind other nations in these legislative efforts. None of the bills currently in Congress includes targets for reducing greenhouse gas emissions. Aside from modest legislation aimed at increasing clean energy sources, the United States does not have a comprehensive climate change law (Lefton, 2014).
Adaptation is Local
What does adapting to climate change look like in practice? Communities have long practiced climate-change adaptation, such as inner city rooftop gardens, planting trees to combat urban heat, and planting drought-tolerant crops. In many of these cases, people are not even thinking that they are adapting to climate change; they are just doing what needs to be done to make the environment healthier and to improve their quality of life. But people must do more.
Policy choices in local communities, such as those at the state and national levels, are shaped by the distribution of money, power, and resources. Nurses need to advocate with public health professionals, environmentalists, and other diverse stakeholders to promote healthy communities where they live. One way to do this is to engage in legislation that promotes what is called Health in All Policies (HiAP). HiAP ( www.apha.org/hiap ) uses a collaborative approach to improve population health by embedding health considerations into many areas of local and state government decision making. Policy decisions that affect the social determinants of health are often made outside of the local health department by other government agencies and by the private sector. Decisions made in a range of areas, such as education, workplace practices, transportation, and criminal justice procedures, all contribute to the social determinants of health. HiAP seeks to ensure that decision makers are informed about the health equity and sustainability consequences of various policy options, and to integrate these considerations of health with other areas throughout the policy process (National Association of County and City Health Officials [NACCHO], 2012).
Examples of Health in All Policies
What are the questions policymakers need to ask (applying a HiAP lens) regarding how a policy might affect children, food, water, land, and air? For example, what will be the impact on the levels of
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toxins in the environment by placing a power plant in the community? What are the associated health outcomes? Another illustration might be related to the environmental impact of a proposal to develop a new light rail service versus expansion of a current state highway. Questions regarding the impact of these options on air pollution, associated asthma rates, and so on would be considered as part of the policy discussion (NACCHO, 2012).
Several best practice initiatives have been implemented recently. California has been an early adopter of HiAP at the state level. Local community initiatives that exemplify best practices in HiAP include King County’s Equity and Social Justice Ordinance in Washington, DC and Denver’s Environmental Public Policy in Colorado (NACCHO, 2012).
Nursing Action Oriented Leadership
At the community level nurses can lead efforts to ensure the health facilities they work in are prepared. In addition to preparing for disasters, staff can also be educated about local climate risks and how they could impact patient and community health. Nurses can promote green initiatives reducing the carbon footprint in communities and within hospitals and clinics. Serving on environmental health task forces, ensuring the use of recyclable products, and making purchasing decisions are examples of effective professional activities (Sayre et al., 2010).
Beyond the collective efforts noted, nurses can make a difference at the individual level. For one, we can use our knowledge of climate change and environmental health to make wiser choices in our daily lives. In mitigating the effects of climate change, nurses might want to consider reducing their personal carbon footprint. There are simple things people can do to reduce their carbon footprint. Examples include reducing energy use by turning down the heat, economizing on electricity use, eating locally sourced produce, and using a reusable water bottle instead of a plastic disposable one (Goodman, 2013). Nurses need to join forces with other health care professionals to help with mitigation, adaptation, and policy surrounding this issue.
Conclusion
The issues we face are increasingly complex and the political power within our country at the national, state, and local levels has become more decentralized and polarized. The ongoing tensions regarding the appropriate role of the government in the lives of its citizens continues to play out not only in determining the size of the government’s budget but also what services it provides and to whom it provides services.
As the gap between rich and poor widens and climate change continues, the quality of life (and health) of the middle class and the poor will be disproportionately impacted. Political leaders must be held accountable through transparency in decision making and holding conversations that provide substance, not sound bites. Extreme political rhetoric and partisanship must be condemned, not condoned, on both sides.
As America’s historic health care reform continues to unfold, nurses will be on the front lines. This makes us responsible for advocating quality health care for all, demanding action to address pervasive social problems, and using knowledge of issues impacting the health of our communities to engage effectively in the political and policy process for the betterment of all.
Discussion Questions
1. What makes the Affordable Care Act such a divisive issue both politically and economically?
2. With the increase in the number of baby boomers reaching retirement age and holding strong political power, what are the economic issues that both federal and state governments will need to address?
3. Identify some of the social, ethical, and economic reasons for addressing immigration policy reform.
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References
Amadeo, K. (n.d.a). U.S. debt ceiling. What it is, and what happens if it’s not raised? Retrieved from useconomy.about.com/od/glossary/g/National-Debt-Ceiling.htm.
Amadeo, K. (n.d.b). What was Obama’s stimulus package? Retrieved from useconomy.about.com/od/candidatesandtheeconomy/a/Obama_Stimulus.htm.
Baicker K, Taubman S, Allen H, Bernstein M, Gruber J, Newhouse J, et al. The Oregon experiment—Effects of Medicaid on clinical outcomes for the Oregon Health Study Group. New England Journal of Medicine. 2013;368:1713–1722.
Barnes R. Upcoming Supreme Court cases are weighty if not numerous. The Washington Post. 2014 [Retrieved from] www.washingtonpost.com/politics/upcoming-supreme-court-cases-are-weighty-if-not-numerous/2014/01/12/0fa0ad0c-79f1-11e3-af7f-13bf0e9965f6_story.html.
Benko R. How the GOP can win the upcoming battle over income inequality. Forbes. 2014 [Retrieved from] www.forbes.com/sites/ralphbenko/2014/01/20/how-the-gop-can-win-the-upcoming-battle-over-income-inequality/print/.
Berlinger N, Gusmano M. Undocumented patients: Undocumented immigrants and access to health care. The Hastings Center: Garrison, NY; 2013 [Retrieved from] www.undocumentedpatients.org/wp-content/uploads/2013/03/Undocumented-Patients-Executive-Summary.pdf.
Bernstein D. The impact of inequality on growth. Center for American Progress: Washington, DC; 2013 [Retrieved from] www.americanprogress.org/wpcontent/Uploads/2013/12/BerensteinInequality.pdf.
Biron C. Global study finds “impressive” wave of climate legislation. Inter Press Service: Rome; 2014 [Retrieved from] www.ipsnews.net/2014/02/global-study-finds-impressive-wave-climate-legislation/.
Blodget H. Eric Schmidt just revealed a key truth about the economy that very few rich investors and executives want to admit. [Retrieved from] www.businessinsider.com/eric-schmidt-on-inequality-2014-1; 2014.
Camarota S. Welfare use by immigrant households with children: A look at cash, Medicaid, housing, and food programs. [Retrieved from] cis.org/immigrant-welfare-use-2011; 2011.
Chetty R, Hendren N, Kline P, Saez E. Where is the land of opportunity? The geography of intergenerational mobility in the United States. [Retrieved from] obs.rc.fas.harvard.edu/chetty/mobility_geo.pdf; 2014.
Cohn N. Obama is wrong: Gerrymandering is not to blame for the GOP fever. New Republic. 2013 [Retrieved from] www.newrepublic.com/article/112410/obama-blames-gerrymandering-gop-fever-hes-wrong.
Congressional Budget Office. Updated estimates of the effects of the insurance coverage provisions of the Affordable Care Act. Congressional Budget Office: Washington, DC; 2014 [Retrieved from] www.cbo.gov/publication/45231.
Congressional Budget Office. The budget and economic outlook: 2014 to 2024. Congressional Budget Office: Washington, DC; 2014 [Retrieved from] www.cbo.gov/sites/default/files/cbofiles/attachments/45010-Outlook2014_Feb.pdf.
Corak M. Income inequality, equality of opportunity, and intergenerational mobility. DP No. 7520. University of Ottawa and Bonn: Ontario, Canada; 2013 [Germany: IZA. Retrieved from] ftp.iza.org/dp7520.pdf.
Davenport C. Rising seas. New York Times. 2014 [Retrieved from] www.nytimes.com/interactive/2014/03/27/world/climate-rising-seas.html.
Debate.org. History and debate of redistribution. [Retrieved from] www.debate.org/redistribution/; 2014.
DeSilver D. Congress ends least-productive year in recent history. Pew Research Center: Washington, DC; 2013 [Retrieved from] www.pewresearch.org/facttank/2013/12/23/congress-endsleast-productive-year-in-recent-history/.
Drake B. Polls show strong support for minimum wage hike. Pew Research Center: Washington, DC; 2014 [Retrieved from] www.pewresearch.org/fact-tank/2014/03/04/polls-show-strong-support-for-minimum-wage-hike/.
The Economist. The rich and the rest: What to do (and not do) about inequality. [Retrieved from] www.economist.com/node/17959590; 2011.
The Economist. For richer or poorer. [Retrieved from] www.economist.com/node/21564414; 2012.
The Economist. The Hobby Lobby hubbub. The Supreme Court ponders the contraceptive mandate. [Retrieved from] www.economist.com/news/united-states/21599789-supreme-court-ponders-contraceptive-mandate-hobby-lobby-hubbub; 2014.
Edsall T. Separate and unequal. New York Times. 2012 [Retrieved from] www.nytimes.com/2012/08/05/books/review/the-price-of-inequality-by-joseph-e-stiglitz.html?pagewanted=all&_r=0.
Elmendorf D. Testimony on the budget and economic outlook: 2014 to 2024. Congressional Budget Office: Washington, DC; 2014 [Retrieved from] www.cbo.gov/publication/45087.
Emanuel E. Op-ed; How to fix the glitches. New York Times. 2013 [Retrieved from] www.nytimes.com/2013/10/23/opinion/emanuel-how-to-fix-the-glitches.html?pagewanted=2.
Fischl J. Income inequality in America: What we should be doing about it? Policy.Mic. 2013 [Retrieved from] www.policymic.com/articles/26805/income-inequality-in-america-what-we-should-be-doing-about-it.
Fitz M, Wolgin P, Oakford P. Immigrants are makers, not takers. Center for American Progress: Washington, DC; 2013 [Retrieved from] www.americanprogress.org/issues/immigration/news/2013/02/08/52377/immigrants-are-makers-not-takers/.
Fox A. Inequality: The defining challenge of our time. The Huffington Post. 2014 [Retrieved from] www.huffingtonpost.com/arthur-fox/income-inequality-the-defining-c_b_4604230.html.
Friedman U, Narula SK. The UN’s new focus: Surviving, not stopping, climate change. The Atlantic. 2014 [Retrieved from] www.theatlantic.com/international/archive/2014/04/the-uns-new-focus-surviving-not-stopping-climate-change/359929/.
Galbraith J. Inequality and instability: A study of the world economy just before the great crisis. Oxford University Press: New York; 2012.
Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati A. Estimated deaths attributable to social factors in the United States. American Journal of Public Health. 2011;101(8):1456–1465.
Gallup. Trust in government. [Retrieved from] www.gallup.com/poll/5392/trust-government.aspx; 2014.
Gillis J. Climate change study finds U.S. is already widely affected. New York Times. 2014 [Retrieved from] www.nytimes.com/2014/05/07/science/earth/climate-change-report.html?hp.
Goldenburg S. Climate change: The poor will suffer most. The Guardian. 2014 [Retrieved from] www.theguardian.com/environment/2014/mar/31/climate-change-poor-suffer-most-un-report.
Goodman B. Role of the nurse in addressing the health effects of climate change. Nursing Standard. 2013;27(35):49–56.
Goss S, Wade A, Skirvin P, Morris M, Mark Bye K, Huston D. Effects of unauthorized immigration on the actuarial status of the social security trust funds. Actuarial note. Number 151. Social Security Administration: Baltimore, MD; 2013 [Retrieved from] www.socialsecurity.gov/oact/NOTES/pdf_notes/note151.pdf.
Hamel L, Firth J, Brodie M. Kaiser health tracking poll: March 2014. Kaiser Family Foundation: Menlo Park, CA; 2014 [Retrieved from] kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-march-2014/.
Hansen J, Sato M, Ruedy R. Global temperature update through 2013. National Aeronautics and Space Administration: Washington, DC; 2014 [Retrieved from] www.columbia.edu/~jeh1/mailings/2014/20140121_Temperature2013.pdf.
354
Hass RN. What is the effect of U.S. domestic political gridlock on international relations? Council on Foreign Relations. [Retrieved from] www.cfr.org/united-states/effect-uzsz-domestic-political-gridlock-international-relations/p30725; 2013.
Hinojosa-Ojeda R. Raising the floor for American workers—The economic benefits of comprehensive immigration reform. [Retrieved from] americanprogress.org/issues/immigration/report/2010/01/07/7187/raising-the-floor-for-american-workers/; 2010.
Holland J. Obamacare is widening the gap between “red” and “blue” America. BillMoyers.com. 2014 [Retrieved from] billmoyers.com/2014/04/07/obamacare-is-widening-the-gap-between-red-and-blue-am.
Institute on Taxation and Economic Policy. Undocumented immigrants’ state and local tax contributions. [Retrieved from] www.itep.org/pdf/undocumentedtaxes.pdf; 2013.
Intergovernmental Panel on Climate Change (IPCC WGII AR5). Climate change 2014: Impacts, adaptation, and vulnerability. Summary for policymakers. [Retrieved from] ipcc-wg2.gov/AR5/images/uploads/IPCC_WG2AR5_SPM_Approved.pdf; 2014.
International Budget Partnership. Why are budgets important?. [Retrieved from] internationalbudget.org/getting-started/why-are-budgets-important/; 2014.
Johnson L. Government shutdown cost $24 billion, Standard & Poor’s says. The Huffington Post. 2013 [Retrieved from] www.huffingtonpost.com/2013/10/16/government-shutdown-cost_n_4110818.html.
Jones S. CBO director: Important to give advance warning about coming changes to social security. CNSNews.com. 2014 [Retrieved from] www.cnsnews.com/news/article/susan-jones/cbo-director-important-give-advance-warning-about-coming-changes-social.
Kaiser Family Foundation. Medicaid: Timeline of key developments. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2008/04/5-02-13-medicaid-timeline.pdf; 2009.
Kaiser Family Foundation. Key facts on health coverage for low-income today and under the Affordable Care Act. Kaiser Commission on key facts. Medicaid and the uninsured. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2013/03/8279-02.pdf; 2013.
Kaiser Family Foundation. Immigration reform and access to health coverage: Key issues to consider. Kaiser Commission on key facts. Medicaid and the uninsured. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2013/02/8420.pdf; 2013.
Kaiser Family Foundation. Status of state action on the Medicaid expansion decision, 2014. [Retrieved from] kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/; 2014.
Khimm S. The sequester explained. Washington Post Wonkblog. 2012 [Retrieved from] www.washingtonpost.com/blogs/wonkblog/wp/2012/09/14/the-sequester-explained/.
Klein E. This is what would happen if we breach the debt ceiling. Washington Post Wonkblog. 2013 [Retrieved from] www.washingtonpost.com/blogs/wonkblog/wp/2013/01/07/this-is-what-would-happen-if-we-breach-the-debt-ceiling/.
Klein E. Inequality isn’t “the defining challenge of our time”. Washington Post Wonkblog. 2013 [Retrieved from] www.washingtonpost.com/blogs/wonkblog/wp/2013/12/13/inequality-isnt-the-defining-challenge-of-our-time/.
Kliff S. Arkansas’s unusual plan to expand Medicaid. Washington Post Wonkblog. 2013 [Retrieved from] www.washingtonpost.com/blogs/wonkblog/wp/2013/02/28/arkansass-different-plan-to-expand-medicaid/.
Kliff S. When Medicare launched, nobody had any clue whether it would work. Washington Post Wonkblog. 2013 [Retrieved from] www.washingtonpost.com/blogs/wonkblog/wp/2013/05/17/when-medicare-launched-nobody-had-any-clue-whether-it-would-work/.
Kogan R. How the across-the-board cuts in the Budget Control Act will work. Budget and policy priorities. [Retrieved from] www.cbpp.org/cms/?fa=view&id=3635; 2012.
Koger G. Congress: Partisan, not polarized. Blog posting. [Retrieved from] www.transportationissuesdaily.com/four-explanations-for-congressional-gridlock-you-may-not-know-about/; 2012.
Koh H, Oppenhheimer S, Massain-Short S, Emmons K, Geller A, Viswanath K. Translating research evidence into practice to reduce health disparities: A social determinants approach. American Journal of Public Health. 2010;100(S1):S72–S80.
Krasney R. Obama signs bipartisan budget deal, annual defense bill. Reuters.com. 2013 [Retrieved from] www.reuters.com/article/2013/12/26/us-usa-obama-idUSBRE9BP0HK20131226.
Kraushaar J. The most divided Congress ever, at least until next year. 2013 vote ratings. National Journal. 2014 [Retrieved from] www.nationaljournal.com/2013-vote-ratings/the-most-divided-congress-ever-at-least-until-next-year-20140206.
