Recollections of the Flint water crisis are still vivid in the minds of many Americans. Responses to this crisis in the winter of 2014 needed to be swift and comprehensive. And while it may be hard to believe that access to clean, adequate, and equitable water in America remains at risk, advocates for environmental justice call for continued vigilance in ensuring access to safe and clean water. In this column, we discuss the need to ensure equitable access to this life sustaining resource through advocacy and legislative action with Katie Huffling, RN, MS, CNM, who is the executive director of the Alliance of Nurses for Healthy Environments.
Katie Huffling, RN, MS, CNM
Ms. Huffling, tell me a bit about yourself and how you became involved in addressing environmental health issues?
I trained as a nurse-midwife at the University of Maryland School of Nursing. While there, I had the great fortune to meet Barbara Sattler and Brenda Afzal. They were leading the only environmental health center at a school of nursing in the country. Through their mentorship, I learned about the many ways that environmental toxicants could affect reproductive health and the health of the growing fetus. It is an area that many of us received little or no content on in nursing school, yet they can have significant negative health impacts across the lifespan. I became very passionate about environmental health issues and when the opportunity arose to work on this full time with the Alliance of Nurses for Healthy Environments, I jumped at the chance! We are the only national nursing organization focusing solely on the intersection of health and the environment. I now work with nurses and nursing organizations around the country on a number of environmental health issues such as climate change, clean air and water, toxic chemicals, and inclusion of environmental health into nursing curriculum.
Can you give me an example of an environmental health issue that is affecting health right now?
Clean water is one of the greatest public health advancements of the 20th century. As nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. Nurses rely on water to wash their hands, give newborns their first baths, and is essential for the clean linens utilized throughout health care.
Here in the United States we have an expectation that when we turn on the tap clean, healthy water is going to come out. Unfortunately, for many throughout the country this is not the case. Every year, millions of Americans experience waterborne illnesses. Waterborne illnesses are caused by a variety of sources, including waterborne pathogens such as viruses or bacteria, human or animal waste, heavy metals such as lead or arsenic, or industrial pollutants. Certain populations may also be more likely to be exposed to unsafe drinking water, including low-income populations and some communities of color.
I know you have been a champion for environmental justice for some time now. What are some key legislative priorities with regard to clean and safe water?
To address a number of urgent clean water issues, the U.S. Environmental Protection Agency (EPA) proposed an update to the Clean Water Act, originally passed in 1972. The Clean Water Act needed to be updated due to the great expansion of knowledge regarding upstream sources of pollution. Researchers now understand how important protecting headwaters and other upstream water sources are to clean water downstream. There was also confusion concerning which waters were protected by the Clean Water Act. This followed two Supreme Court Decisions in 2001 and 2006, directly impacting the drinking water for 1 in 3 Americans.
In 2015, the EPA and the Army Corps of Engineers finalized the Clean Water Rule (CWR). This rule was only finalized after an intensive stakeholder process in which they held over 400 meetings and received over 1 million comments, 87% of which were in favor of the rule. The Clean Water Rule clarifies which “waters of the US” will be regulated under the Clean Water Act. These include traditional navigable waters, tributaries, a small number of waters that have a significant nexus to traditional navigable waters, interstate waters, or territorial seas, and also exempts certain waters such as puddles, ornamental ponds and rain gardens, and continues certain farm exemptions.
After the rule was finalized, a number of plaintiffs sued the EPA. The rule was suspended by the Sixth Circuit court until the outcome of these suits. This stay was overruled in February 2018. During this time the Trump Administration announced they were going to suspend the rule until 2020. This suspension was overruled by the courts in August and the CWR must now be enforced in 26 states.
The issues that the CWR addresses are very important to environmental justice communities. If the rule is repealed, low-income communities and communities of color—who already face disproportionate exposures from other environmental hazards—may be most impacted. These communities, along with rural communities, are more likely to have poor infrastructure that is not able to handle contaminants in the water. These communities also may not have the resources to upgrade their water systems. They may also be more likely to rely on well water that can be more susceptible to pollution from upstream sources.
Turning to implications for nursing, why and how can nurses get involved in addressing this issue?
The EPA has announced they plan to permanently repeal the CWR; however, this repeal has not been finalized yet. If they repeal this rule, the drinking water for over 117 million Americans could be negatively impacted. Once this official announcement occurs, the nursing voicing will be crucial to protecting this vital public health regulation. There are many ways nurses can be active in this policy arena:
- Watch the new webinar from the Alliance of Nurses for Healthy Environments for one-hour free CE that reviews the CWR and provides opportunities for action (https://envirn.org/the-clean-water-rule).
- Sign this petition to Acting Administrator Wheeler asking to him to keep the CWR in place.
- Call your Senators and Congress people and ask them to support the CWR.
- Engage your professional nursing organizations—write a newsletter article and ask them to write a letter to Acting Administrator Wheeler or to Congress. As the most trusted profession, when our nursing organizations actively engage on issues such as clean water, Congress listens.
The most vulnerable among us are harmed by dirty water. By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health.
Are there additional resources we should be aware of?
The American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (which is available online here).
The Alliance frequently offers webinars (many with free CE) on a variety of environmental health topics. We’re free to join and if you sign up for our newsletter you will be notified of upcoming webinars and opportunities for action. To learn more, visit https://envirn.org.
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.