Last issue’s health policy column highlighted nursing’s increased engagement in the public policy arena. To continue this conversation, this column highlights a registered nurse running for Congress to help champion access to affordable health care. Yes, Lauren Underwood, MSN/MPH, RN, of Naperville, Illinois is running for Congress to represent the 14th Congressional District of Illinois.
Her Journey to Pursuing an Elected Position
Underwood is steadfast and fiercely committed to helping shape policies and programs focused on ensuring that everyone has access to affordable health care. She is a registered nurse who received her BSN from the University of Michigan and her MSN/MPH from Johns Hopkins University. Her nursing experiences include service as a health policy advisor, research fellow, senior director, and research nurse at the National Institutes of Health Clinical Center. Her passion for public policy was heightened while serving as a health policy advisor in the Office of the Secretary at the Health and Human Services in Washington, DC initially under the leadership of Secretary Kathleen Sebelius followed by the leadership of Secretary Sylvia Burwell. In this capacity, Underwood worked on private insurance reform, summary of insurance benefits, health care quality in the Medicare program, the Agency for Health care Research and Quality, and preventive services (free screenings, immunizations, and contraceptive coverage) for four and a half years from 2010-2014.
Lauren Underwood, MSN/MPH, RN
Democratic Candidate for Congress, 14th Congressional District of Illinois
Tell us about working for the Obama administration.
Got a call the week that Mr. [Thomas Eric] Duncan was in the hospital in Dallas with Ebola asking if I would be willing to join the President’s team to help with disaster response, so I transferred over to ASPR, the Assistant Secretary for Preparedness and Response, at HHS. We worked on emerging infectious diseases (e.g., Ebola, Zika Virus, Middle East Respiratory Syndrome virus, or MERS), we also did national disasters (e.g., wildfires, hurricanes, floods) and then bioterror (small pox, anthrax) and worked with drug companies to develop vaccines, treatments, and diagnostics. I stayed in the administration until the very end, the last day. And so, when the election happened in 2016 we were working on the water crisis in Flint. I was surprised, and I thought that Hillary Clinton’s team was going to win and that we were going to hand off our work on health reform and on Flint to people who cared and wanted to continue the process. And then we got the Trump team who made it very clear they wanted to do away with health care coverage. And that’s not why I went into nursing or why I did this work. So, I knew I could stay in government and help them do that. I wanted to continue the work and so I came back home to Illinois because Illinois is a state that expanded Medicaid. I got a job working for a Medicaid managed care company in Chicago as the Senior Director for Strategy and Regulatory Affairs for a company called Next Level Health.
Are you still there?
I left my job about six weeks ago. The primary campaign was about eight months. I worked full time six and a half months; you know you have to do that. I am a young person, not someone of particular means or whatever, so it was necessary. And then it was like “Lauren, you could really win if you put your time and energy into the campaign.” And so that was an easy choice to transfer to full time.
So, you are now devoting full time to the campaign?
This reflects your journey. Describe in a few words what really made you run for an elected position.
I am going to tell you a story. Last spring when I returned home, I went to congressman Randy Hultgren’s one and only public event. It was a moderated event hosted by the League of Women Voters. And during that evening, he made a promise and said that he was only going to support a version of Obamacare repeal that allowed people with preexisting conditions to keep their coverage. That’s important to me as a nurse. I also know how critical it is for people with chronic illness to have access to medications and procedures that they need. Obviously, I worked to implement the Affordable Care Act so I read the law and I know that it works. I know that we can fix what does not work. We do not have to throw the whole thing away. Like so many Americans, I have a preexisting condition myself. I have a heart condition, SVT (supraventricular tachycardia), and it is well controlled. As you know, it is a preexisting condition, so I would not be able to get coverage under these repeal scenarios. And so, when the congressman made that promise I believed him.
And then a week to ten days later he went and voted for the American Health Care Act, which is a version of repeal that did the opposite. It made it cost prohibitive for people like me to get coverage. And so, I was upset not at the vote itself, but because he did not have the integrity to be honest the one time he stood before our community. That’s not what a representative is supposed to do. A representative is supposed to be transparent, accessible, and honest. And we deserve better. I said, “you know what, it’s on! I’m running” and launched my campaign in August and just won the primary on March 20th. I was in a field of seven—the only woman running against six men—and I won 57% of the vote.
Were you the only African American?
I know you are concerned about overall access to care and have a deep commitment to utilizing your expertise and experience while working in the Obama administration.
I believe that health care is the number one issue in this election across the country and in our district, and we need a solution to make health care more affordable for American families. It is not enough for families to rake together money for their premiums and have an insurance card in their pockets and cannot afford the coverage.
I believe that a lot of the conversation in the last several years has been political in nature and undoing President Obama’s legacy and not on at all focused on trying to lower costs and make health care accessible for American families. That’s my objective! I want to work on drug prices. I want to work on this opioid drug crisis so that loved ones can get the treatment that they so desperately need. And so, I believe there is a lot of value in having a nurse at the negotiation tables when we are making these decisions and passing policies that will transform our health care system. I am excited about the opportunity to be a leading voice on Capitol Hill on these important issues.
What do you think are the most pressing issues impacting nursing and health care?
Affordability. Any program that is starved of resources will fail. The ACA has been intentionally sabotaged and as a result, we see extraordinary high premiums that are unaffordable for most families. That is not how the program was designed to work and so I think there are technical fixes we can do to make the program more affordable. We can do things like negotiate drug prices, it can be done, we need to take a strong position on this opioid drug addiction crisis. We need to implement reforms like how we pay for rehab and how we award funds to municipalities in order to create a pathway for lasting change. And then there are opportunities to expand coverage so we will have fewer uninsured Americans. What we are seeing now in order to resuscitate it takes 2-3 doses of Narcan because the drugs are so strong. Municipalities who have received Narcan grants are running out of Narcan. A Narcan only solution is not a solution. Law enforcement only solution is not a solution. Addiction is an illness and we need to treat it as such. We need to send people to treatment so they can have a shot at recovery. We could have an evidence-based policy solution. We know treatment can be effective.
What do you think is the most pressing issue affecting nursing today?
I think there are a few things. The high cost of our education. We have not really seen increases in funding. What we have seen are marginal increases or flat funding. I think that this is unacceptable, in particular in the context of what we are seeing in higher education more broadly. And not just at the federal level. In higher education, many states have reduced putting money into public education, shifting the responsibility to families and individuals and with that coupled with flat funding for nursing education we are seeing a generation of nursing students with significant debt. And that is going to be a barrier, I believe, to our profession being able to grow. Right now, we have an economic situation where we are not seeing the shortage that we saw ten years ago. But it’s very easy to get back to that point if the economics of going into nursing shifts when you graduate from a BSN program with $100,000 in debt and are limited in your initial salary. Loan repayment programs are not that plentiful as they used to be. The economics of it makes it tough. Because we are talking about middle class folks who are not able to take on that debt. And when it is becoming increasingly attractive to become an APRN, that is all debt to be able to get the master’s to become a nurse practitioner or a nurse midwife. We are going to need some serious advocacy and a plan to deal with the cost of our education.
What are your thoughts about safe staffing?
It is so interesting. Safe staffing has been a legislative priority for decades. We have not been able to pass these bills. I think the approach needs to be more balanced with safe staffing committees in these hospitals. Moving away from these ratios and having hospitals have safe staffing committees that would take into consideration the circumstances that facilities and the region when staffing levels. On these committees, nurses would serve so a legislative body is not dictating it. I think that this is an appropriate approach coupled with compelling Medicare participating facilities to set staffing levels and monitor outcomes.
When elected, what would you do to go about helping to ensure equitable access to health care?
That’s like the question! For me, equitable access to health care allows everyone to get health care. Health care is a human right. Human rights have been fundamental to my nursing practice. It is written in our Code of Ethics—this idea that everyone should have health care—and I think our policies should reflect that. For me, that includes fixing the Affordable Care Act to ensure affordable coverage; and making sure we have clinics, hospitals, and facilities in communities so that the burden is not on low-income people or people with transportation challenges or resource limitations so that people are able to get the care and services they need. We have so much innovation, technology, and so many improvements now in a way we are able to provide care whether it’s telemedicine or individualized health care. It is a shame if all of that innovation and all of those improvements are seen in resource communities. We need to be focused in these conversations about reform and transforming our system to ensure that it is serving everyone—rural, urban, low income, and elderly.
What advice would you give to aspiring policy advocates who may be considering a run for public office?
Your country needs you! There are too few nurses in policy positions. Seek a County Board position. The County Board supervises the local Department of Health. Run for state legislator, they address scope of practice issues. Run for Congress! There are many opportunities to serve and lead. Step forward!
A nursing career in public policy was considered unique decades ago. However, increasingly nurses have developed the skill and expertise needed to inform the policy-making process through their professional and voluntary endeavors. Nurses now serve in numerous leadership roles where they use their health policy expertise to shape the policy discourse, monitor the impact of legislation, and oversee regulatory processes.
In addition to the increased numbers of nurses working in governmental and nongovernmental agencies, nurses serve as elected officials and work as health policy consultants or health care lobbyists. Regardless of role or setting, nurses working in the policy arena are required to use their public policy acumen to inform legislation, oversee regulations, or advocate for policies that are of benefit to consumers, patients, and the profession.
Nurses serving as elected/appointed officials or health care lobbyists are immersed in the policy-making process and have a front row seat in influencing the public policy agenda. Both opportunities require a comprehensive knowledge of the complexities associated with lawmaking and a willingness to listen and assess varying perspectives. The ability to communicate well and build partnerships while working with diverse stakeholders cannot be overemphasized.
Noteworthy, three nurses are serving as elected officials during the 115th Congress. Representative Karen Bass, APRN, represents California’s 37th congressional district and is in her fourth term. Congresswoman Bass serves as a ranking member of the Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations.
Representative Diane Black, BSN, has represented Tennessee’s sixth congressional district since 2010. She serves on the House Ways and Means Committee.
Representative Eddie Bernice Johnson, BSN, is the first nurse elected to the U.S. Congress and is now in her thirteenth term representing the 30th congressional district of Texas. Representative Johnson serves on the House Committee on Science, Space and Technology; House Transportation and Infrastructure Committee; the Aviation Subcommittee; the Highways and Transit Subcommittee; and Water Resources and Environment Subcommittee.
Many nurses are familiar with former representative, Lois Capps. Capps represented California’s 24th congressional district after winning the seat in 1998 after her husband died in office. She championed numerous nursing and health care issues and started the Congressional Nursing Caucus.
No doubt, other nurses are well poised to follow suit bringing their expertise to an elected office. For example, Lauren Underwood launched her campaign last fall to represent the fourteenth congressional district in Illinois. Underwood brings a wealth of nursing and government expertise and is passionate about ensuring access to high-quality health care for all.
Nurses are also well suited to serve as health care lobbyists because of their vast knowledge of nursing, health, and health care. An extensive knowledge of these and other areas is critical to advocating for legislation aimed at improving access to health care, enhancing health outcomes, and transforming our health care delivery system. Additional competencies needed for such a role include strong interpersonal communication skills, research/analytical skills, detail orientation, knowledge of political, legislative, and regulatory processes, and the ability to create and deliver messages to a wide array of diverse stakeholders including legislative officials. Health lobbyists are responsible for conducting policy analyses and summarizing information that is suitable for a variety of audiences. Nurse lobbyists may work as a consultant employed by a professional/specialty nursing or non-nursing organization, health care facility, insurance company, or pharmaceutical company, to name a few.
The current push to increase the number of nurses serving on boards provides yet another opportunity for nurses to become more engaged in aspects of the policy-making process. Depending on the mission of the organization, board members may be responsible for shaping a legislative or advocacy agenda on behalf of the constituents they serve. To illustrate, I acquired some of my health policy skills while serving as the Chair of Public Policy for my local Susan G. Komen Affiliate. In this capacity, I along with board members advocated for breast cancer funding for underserved women and helped to shape and monitor the organization’s legislative agenda. This experience provided a unique opportunity for me to serve as a lead spokesperson providing testimony before my state legislature regarding the “Reducing Breast Cancer Disparities bill.” This bill includes significant provisions designed to reduce breast cancer disparities among underserved and underinsured women across the entire state.
In addition to some of the previously mentioned career opportunities in the health policy arena, nurses in the following roles utilize their policy knowledge and expertise to advance the nursing profession and transform today’s health care delivery system:
- Dean/Associate Dean of a School or College of Nursing
- Director of Government and/or Regulatory Affairs
- Office of Government Relations
- Director/CEO of a Government Agency
- CEO or Executive Director of a Nonprofit Health Care Organization
- CEO of a Professional Nursing Organization
- Chief Nursing Officer
- Surgeon General/Assistant Surgeon General
- Chair of Health Policy Committee for a Professional or Specialty Organization
- Health Commissioner
- Board Member for a Health Department, Hospital, or Community-Based Health Care Organization
- Chair of a Health Policy Committee for a Voluntary Organization
- Nurse Attorney
- Hospital Administrator
- Executive Director of a State Board of Nursing
- Health Policy Analyst
- Nurse Regulator
Nurses wishing to pursue a career in health policy can begin by first identifying what is most important to them. Nurses who do not have a background in political science or law may need to invest in professional development through formal/informal education. Taking health policy courses is a good step as such course work provides an overview of the policy-making process and may provide some exposure to in-person or virtual lobbying.
Getting involved with the advocacy/legislative arm of one’s professional or specialty organization is yet another great way to gain exposure and experience related to the policy-making process. Many nursing organizations have a policy agenda and work to ensure that their voices are heard on things of importance to the profession and those they serve. Serving as an intern in a legislative office for an elected official may also provide some beginning exposure to the policy and legislative process. These types of experiences can enhance one’s credibility when launching a career in public policy.
Participating in health policy fellowships, internships, or other structured immersion activities can go a long way in laying the foundation for future engagement in the policy arena. I cannot overestimate the value of talking with those already in the field. Elected officials, nurse/health care lobbyists, and individuals currently running for office as well as other nurse leaders can provide valuable insights regarding the expectations for this type of role. Attending a state board of nursing meeting is another excellent way to become acquainted with the regulatory aspects of the policy-making process. Finally, staying abreast of current and emerging issues in health care and nursing provides a critical foundation for future advocacy and political activism in the health policy arena.
Increasingly, nursing students are being introduced to health policy and are encouraged to play an active role in some aspects of the policymaking process. Yes, I know, so much to do and so little time! However, opportunities to enhance one’s level of awareness and engagement regarding the policymaking process have never been greater. Planting the health policy seed has become important to professional nursing organizations, nurse educators, and even nursing students who applaud the push for integrating health policy and advocacy content in today’s nursing curricula.
Today’s nursing students must acquaint themselves with a number of policy issues that may impact their practice, the delivery of health care, and the profession of nursing. Nursing students are encouraged to develop increasing levels of knowledge, skills, and competencies related to health policy and advocacy commensurate with their advancing levels of nursing education. The American Association of Colleges of Nursing (AACN) has identified key health policy competencies to include in nursing curricula starting at the baccalaureate through the doctoral level. Nurse educators are encouraged to incorporate these competencies when designing and implementing health policy courses for nursing students across all levels of nursing.
Starting at the baccalaureate level, nursing students are introduced to aspects of health care policy, finance, and regulatory environments. Students at the master’s level are engaged in analyzing health policies and their impact on health care financing, practice, and health outcomes. Nurses at this level are expected to help interpret research findings as well as advocate for policies that will improve the health of the public and advance the profession of nursing. Building on these skills and competencies, students at the doctoral level are expected to acquire the necessary skills to demonstrate a higher level of involvement of leadership in developing policies, influencing policymakers, and assuming influential leadership responsibilities at the local, state, national, and/or international level.
Early on during nursing education, one should begin thinking about how legislation informs nursing practice and how public policies influence the health outcomes of the patients and communities that one serves. For example, funding for nursing education and research is an ongoing issue for the profession. This need requires ongoing and persuasive advocacy and communication with state and federal legislative officials. Each year, numerous organizations lobby at our nation’s capital to make the case for funding to support nursing education and research. In fact, increased funding levels for nursing education and research are, in part, attributed to the diligent advocacy by the nursing community and other stakeholders.
Opportunities for Policy Development
Recognizing the need to introduce nursing students to the policymaking process, the AACN hosts an annual Student Policy Summit. This three-day summit is open to nursing students enrolled at AACN member institutions and is designed to familiarize students with the policymaking process and nurses’ role in professional advocacy. Students journey to Washington, DC, to take a glimpse at the policymaking process at the federal level. Speak with your school and/or faculty to ensure that there is representation and support from your academic institution during the call for applications. For information about future offerings, I encourage you to visit the AACN’s website.
Recognizing the need to foster the policy development of its members, the National Black Nurses Association offers an annual Health Policy Institute at their annual meeting. Speakers with expertise and experience in the health policy arena have presented on topics, including health equity, prescription drug abuse, reproductive rights, and mental health, to name a few. Another example is the Oncology Nursing Society, which provides an online tutorial on the policymaking process and ways to become an effective patient advocate. Many nursing organizations hold virtual and in-person annual lobby days empowering its members to advocate on behalf of patients, communities, and the profession.
Be sure to check with your student, professional, and specialty organizations to see what opportunities they have to help supplement your classroom education. Volunteerism is yet another way to develop familiarity with the policymaking process and gain experience in advocacy. For me, I volunteered for a long time with the American Cancer Society and the Susan G. Komen for the Cure. These experiences enabled me to establish the linkage among practice, research, and patience advocacy. This in turn fueled my passion for learning more about the policymaking process and the various legislative initiatives informing the health and well-being of communities of color.
Although numerous bills are introduced each year, only a small percentage will make it through the entire process, culminating in action at the executive level and signed by the President for passage. Similarly, numerous bills may be introduced or reauthorized that will have some implications for patients (e.g., reimbursement for care, increased access to care, support for clinical trials) or the profession of nursing (e.g., funding for nursing education and research). One bill that has implications for patients and the profession is the Nurse and Health Care Worker Protection Act of 2015 [H.R. 4266/S. 2408]. This piece of legislation was introduced by Representative John Conyers, Jr. (D-MI) and Senator Al Franken (D-MN) on December 16, 2015, during the 114th Congressional Session. This is the only national legislation that improves the quality of patient care and protects nurses and health care workers by addressing the safe handling of patients. To track the progression of this legislation, visit www.congress.gov.
During your nursing education or even in the workplace, stimulate some discussion and support around legislation and health policy issues and topics that have implications for nursing. Nursing in the 21st century demands that we take our rightful place at the table and advocate for patients and the profession. Developing the wherewithal to do so at the student level is an important first step.