Presidential candidates are gearing up for the 2020 presidential election and are sharing their platforms and agendas for creating a stronger and more prosperous nation. Presidential hopefuls have identified a number of proposals focused on ensuring access to health care. Some candidates vow to ensure access to health care by recommending universal health care coverage through a single payer national government health care program referred to as the Medicare- for-all proposal. Other candidates are in favor of some version of this proposal by lowering the Medicare eligibility age to 50 but also retaining the private insurance option. Still, some presidential hopefuls aim to ensure health care coverage by providing a public option for people under age 65 or by strengthening health care coverage by building on the Affordable Care Act. Regardless of a candidate’s position, the debate on how to achieve universal coverage will continue to evolve overtime leading up to the election and way beyond.
Findings from a Kaiser Family Foundation’s survey found that the majority of people who voted on a regular basis are not familiar with or clear on the Medicare-for-all proposal. Survey respondents are seeking solutions to everyday problems such as paying for care, eliminating red tape, and navigating the health care system.
While there are many proposals that are under consideration, the Medicare-for-all proposal is one of the most frequently cited proposals designed to ensure universal health care coverage. There are several versions of this approach to health care coverage, such as the proposed version introduced by Senator Bernie Sanders in 2017. Here we discuss the Medicare for All Act of 2019 (M4A), one of the most recently introduced iterations of the Medicare-for-all approach to health care coverage.
National news media such as CNN, The New York Times, and The Washington Post traditionally have provided an in-depth discussion and analysis on presidential campaign issues, including health care.
The following are a few resources that can assist nurses in staying abreast of some of the campaign health care related discussions and other issues relevant to health reform:
This proposed legislation is similar to the legislation introduced by Senator Sanders in 2017 and other single payer legislation proposed by members of Congress. While there are some similarities, there are also some differences. For the most part, Medicare-for-all proposals will constitute a major shift in health care financing and will move from the traditional focus on providing health care coverage exclusively for those age 65 and older to more widespread care coverage for those under age 65.
Here is a brief snapshot of some of the basic components of the M4A introduced by Rep. Pramila Jayapal (D-WA) on February 27, 2019:
Single federal government administered program to cover all U.S. residents (including immigrants and possibly undocumented individuals)
Open enrollment to those age 19 and under as well as those 55 and older one year after enactment
Abolishes traditional benefits covered through traditional Medicaid/Medicare program, Children’s Health Insurance (CHIP), the Federal Employees Health Benefits Program, or TRICARE (health care for active and retired military)
Recommends a ban on cost sharing (e.g., copays, deductibles)
In addition to the 10 categories of the essential benefits in the Affordable Care Act, proposed additional covered benefits and services include hospitals services; ambulatory patient services; primary and preventive services; prescription drugs and medical devices; mental and substance abuse treatment services; laboratory and diagnostic services, comprehensive services across childbearing cycle; newborn and pediatric services; emergency services and transportation, early and periodic screening as outlined in Medicaid; transportation to health care services particularly for low income and persons with disabilities; and long-term care services and support.
As the nation’s largest group of health care workers, nurses must possess a fundamental awareness of the various proposals devoted to ensuring access to health care. This will be particularly important for the many individuals, families, and communities who continue to lack access to care and suffer disproportionately from a number of health conditions and illnesses. As the most trusted profession, we are well suited to lend our voices to advocate for better access to care for all and are encouraged to do so. Our role in educating our policy makers has never been greater as we have firsthand knowledge of how the lack of access to quality health care coverage impacts the health and well-being and even life expectancy of those residing in the United States.
Be sure to stay informed of the various debates and proposals on universal health care coverage. Efforts to revise our current approach to health care financing and access to health care is complex and will require that we stay abreast of the discussions surrounding this issue. The American Nurses Association, the Kaiser Family Foundation, TheWashington Post, and Health Affairs, to name a few, traditionally provide a synopsis on where candidates stand on health care issues and universal coverage. In addition to watching the presidential debates, nurses are encouraged to visit the web sites of the various presidential candidates to become more familiar with their position on health care ( e.g., access, universal coverage, health care reform) along with a myriad of other health care issues (e.g., prescription drug coverage, supplemental coverage). As we continue to support access to health care as a human right, our awareness of the issues and advocacy for access to quality health care for all will remain an important factor in the upcoming presidential campaign.
Nurses, like other health care professionals, have been hearing the buzz about mindfulness. Technology corporations, like Google, are instituting mindfulness programs, as are health care and wellness-related workplaces. Lifestyle magazines like Oprah and Yoga Journal are covering the topic, but surprisingly, so are Harvard Business Review and other business publications.
Perhaps you’re wondering what the term actually means, and whether it’s been proven effective in treating patients and those who want to be proactive in warding off illness and disease.
In this article, nurses and mindfulness experts will explain their unique approaches and how they help patients with health challenges. You’ll learn about the evidence behind the practice, so you can comfortably introduce it to your patients. You might even want to incorporate it into your own work and personal life.
What is Mindfulness?
Simply, mindfulness means that you direct your mind to the present versus having it wander aimlessly. You practice an awareness of your thoughts, and a focus on the here and now, not the past or future.
The opposite state, “mindlessness,” is what happens when you drive home at the end of a 10-hour shift, suddenly arrive at your front door, and can’t remember how you get there.
Are You Interested in Trying Mindfulness for Yourself?
The mindfulness and health site,DrJud.com, offers a free online course for health care professionals. The seven-module video course answers common questions about the practice and the evidence supporting it.
Continuing medical education (CME) credits are available through Brown University.
Though mindfulness meditation is thousands of years old, with its roots in Buddhism, today’s mindfulness practices are often not spiritually centered. Scientifically-based mindfulness programs are meant to be used by patients of all faiths (or none).
That awareness may help boost patient emotional well-being and help strengthen their immune system. One example of the benefits of mindfulness, the Cleveland Clinic reports that 20 randomized trials reviewed in 2011 show improvement in overall mental health.
Mindfulness is a drug-free tool that can help optimize neural processing, boost immune system function, address the epidemic-level of chronic pain, reduce insomnia, and even caregiver burnout.
In new research, mindfulness shows promise in reducing the incidence of physical diseases or managing existing conditions. Examples are diabetes and hypertension. Mindfulness can also be an aid in breaking unhealthy habits, such as smoking, and averting the associated risk of disease.
One Nurse’s Research on Mindfulness and Hypertension
Eunjoo An, MSN, RN, a PhD candidate in nursing at UCLA, studied ways to reduce hypertension, which is the number one risk for stroke, she says. As a nurse, An knew that simply telling people what to do—eat right, exercise, etc.—wasn’t enough. She suspected that mindfulness training along with a health promotion program could have beneficial results.
Earlier research showed that mindfulness has a calming effect on the fight or flight response, leading to blood pressure and heart rate reduction, An says. “The difference in my research is that it’s looking at not only blood pressure but habits; most patients have difficulty changing diet and exercise,” she explains. “Mindfulness brings focused attention to body. During those times you’re more likely to say to yourself: ‘I should eat better,’ and then that translates to that behavior. No study has taken that to the next step.”
An used the UCLA mindful awareness program beginner’s course, which is not as extensive as some approaches, but more approachable than others, she says. The mindfulness group was told to practice at home. She hoped that the training would help calm patients and that reduced stress would translate to behavior change.
Her research was applied to hypertension in an independent living facility that is primarily African American. She was the instructor for the health promotion group, using the six-week program modules on a government website. Both groups received information about healthy diet and the importance of exercise.
The results? “The mindfulness group, with stage 1 hypertension, reduced their systemic blood pressure to normal range at the end of the 12-week study,” she says. While blood pressure did go down in both groups, “in the mindfulness group it dropped into the normal range whereas in the health promotion group it stayed in the high range.” Mindfulness practice was beneficial in helping patients to eat and exercise in such a way that their blood pressure dropped 40%.
To learn more, watch An’s three-minute presentation about her research on the benefits of mindfulness available on YouTube.
Beyond Mindfulness for In-Patient Care
Menna Olvera Feder
The Urban Zen Integrative Therapy (UZIT) program brings mindfulness plus yoga, Reiki, essential oil therapy, and contemplative end-of-life care to patients and providers. Started in 2009 by fashion designer Donna Karan in New York, it soon expanded nationwide with the launch of the UZIT teacher training program.
“UZIT-trained therapists provide a variety of care, in a wide range of settings, to patients, staff, and caregivers, plus the community,” explains Menna Olvera Feder, UZIT acting program director.
Services can be accessed through a number of hospitals, rehab centers, senior-care and hospice facilities, as well as yoga studios offering drop-in stress-management class.
Research has been conducted at multiple facilities, including Beth Israel Medical Center in New York City and Wexner Heritage Village in Columbus, Ohio, showing significant health benefits. Patients experienced fewer symptoms of pain, anxiety, nausea, insomnia, constipation, and didn’t require as much medication for relief from those conditions.
When a UZIT-trained nurse “sees a patient isn’t breathing well, or is in pain, or is exhausted, they have what they need in their toolbox to address it,” says Olvera Feder. The UZIT protocol “adds a level of care to nursing that drew the nurse to be a nurse to begin with.”
The holistic program is used in health care environments with a diversity of patient populations. “We want to attract people of different cultures and those who are bilingual. We’re always looking for nurses who are Spanish-speaking or who speak Chinese,” says Olvera Feder.
Simple, clear terms are used to introduce the care modalities to patients and their families. For instance, “yoga,” is explained as “mindful movement to address respiration, digestion, and circulation,” Olvera Feder says. “Because when you’re in bed, you’re not doing downward dog.” Mindful movement in that case may mean that pillows aren’t stacked too high, and the patient is positioned in simple supported postures to bring them into a more comfortable state.
The UCLA Health has a number of UZIT trained health care professionals, among them is Anna Dermenchyan, RN, MSN, CCRN-K. An Armenian American, Dermenchyan was an ICU nurse before transitioning to a quality role in 2013, with the aim of improving patient care. She is also pursuing her PhD in nursing at UCLA School of Nursing.
“Urban Zen is meant for patients who feel pain and anxiety—that’s pretty much any patient in a hospital—they feel so much better after,” she says. One of the moving examples of UZIT’s effectiveness was when Dermenchyan sought to help a family say their final farewells to a brain-dead patient. “We provided Reiki and essential oils to them and a sad experience was made less painful,” she recalls.
Though always aware of stress in the health care workplace and how it affects nurses and patients, “I realize now how stressed everyone is, including physicians and administrators, and how vulnerable they are to fatigue and burnout,” she adds.
Mindfulness Class in Your Pocket
Not every organization has a mindfulness program available for patients, and not every patient has the money or time to attend formal training sessions. That’s where digital mindfulness apps come into play.
“We consider ourselves the leader in evidence-based, digital therapeutics for mental health,” says Mark Mitchnick, MD, CEO of MindSciences, Inc. “It’s pretty easy to put an app out in the health care space, especially in mental health, but do they have evidence behind them? We get grouped with some very scientific, rigorously researched” companies, and some that are not.
Currently the company offers three apps: Eat Right Now to address emotional eating, Unwinding Anxiety to relieve anxiety and stress, and Craving to Quit for smoking cessation. They are based on the work of Judson Brewer, MD, PhD, a leading mindfulness researcher, $11 million in funding from the National Institutes of Health (NIH), and input from thousands of users in clinical trials, and later as subscribers.
Many users first learn about this brand of apps because their health care provider recommends them. “It’s offered to individuals through organizations and insurance providers, such as Humana,” he explains. “We wanted to offer [mindfulness] as something scalable and very affordable—and today that’s an app.”
For example, MindSciences is “working with coal miners in Appalachia, using our smoking app in a pulmonary clinic,” says Mitchnick. “Folks are enrolled in a clinic but still smoke.” Using a hybrid model of delivery—digital app plus the participation of health care professionals—they aim to help patients kick the smoking habit.
Similarly, they’ve started working with bariatric surgery clinics to help patients avoid regaining weight lost after surgery. “We’re not a willpower-based system,” he says. “In the case of eating, you have to separate out ‘I’m feeling hungry’ from ‘I’m feeling anxiety,’ and find a more appropriate behavior for that.”
Interested individuals can independently download the app, try it out free for three days, and later subscribe. In the case of Craving to Quit, the program is $24.99 a month, which includes the mobile app training modules, an online support community, and weekly live expert video group coaching sessions. The program has been shown to be twice as effective as a leading smoking cessation treatment, and it’s backed by a limited money-back guarantee.
Mindful Yoga-Inspired Tools for Patients
Oregon Health & Science University (OHSU) in Portland, Oregon, offers a number of mindfulness programs to its patients and staff members. Kimberly Carson, MPH, C-IAYT, E-RYT, is a mindfulness educator and yoga therapist. She is considered a leader in the therapeutic use of mindful yoga for people with medical challenges.
Carson offers an ongoing drop-in class, Breath by Breath, as an introduction to mindfulness-based stress reduction methods. The class is free of charge to OHSU patients and any interested members of the community.
“Breath by Breath is a combination of mindfulness practices and yogic tools,” she explains, for cardiac, oncology, chronic pain, and other patients, plus their caregivers. “Sometimes people come once, sometimes a few times, or sometimes for years.” The class is held twice a week, for hour-long sessions, in conference rooms offered by participating departments.
Along with instruction in a variety of relaxation and mindfulness practices, Breath by Breath incorporates yoga-inspired adaptive movement, “We don’t take people to the floor,” explains Carson, “these movements are appropriate for most people—the postures are skillful to a medical or aging physiology.”
Group discussions and sharing make up an important component of the session. “At the beginning of the class, “I use what I call the ‘quickening question,’ which is totally spontaneous, such as ‘What inspired you today?’” she says. “The question helps give voice to people’s experience.”
She also facilitates Mindful Yoga for Chronic Pain, a five-week, drop-in series, “which is more asana heavy,” she explains. Gentle postures help patients develop mindful awareness of bodily sensations, thoughts, and emotions in this evidence-based intervention.
Beyond classes, Carson offers “bedside mindfulness” in the Bone Marrow Transplant Unit to address pain, agitation, insomnia, and existential distress. “I go in and lead patients through a mindfulness process,” she explains. “It quiets the nervous system, so they get relief right then. We do a body scan and breath awareness exercise. That’s the face-to-face introduction to the skill, to give them a taste of what’s available.” Later, patients can access more training modules on “the mindfulness channel” via OHSU’s digital education platform.
Mindfulness for Minority Communities
Jeffrey Proulx, PhD, is a Native American who has been studying mindfulness as a way to reduce psychological stress and improve physical health in underserved communities. A K99/R00 award from the NIH National Center for Complementary and Integrative Health is currently funding his contemplative-based program to reduce diabetes in Native communities. He has also done culturally based mindfulness research with other ethnic minority communities.
Proulx believes that psychological stress needs to be viewed in a wider context that includes historical oppression. “They wanted to wipe Native Americans off the face of the earth, and African Americans were enslaved,” he explains. “So, for these populations, daily stress is compounded by historical stressors.” But instead of focusing on cultural trauma and the associated poor health behaviors, he works with communities to explore their resiliency and strength.
Mindfulness-Based Stress Reduction [MBSR] is the landmark evidence-based program developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center in 1979. Many health care mindfulness programs and health apps are based on this intensive, eight-week training series. Proulx has facilitated these classes for patients and health care providers at OHSU, as has Carson.
“But MBSR isn’t really geared to address cultural trauma, intergenerational trauma, people getting sicker from generation to generation,” he explains. “I’m approaching it from another way. The bigger, overall issue is how people carry on.”
One way Proulx makes sure his offering is culturally competent is by using the term “stress reduction” rather than “mindfulness.” That only goes so far, he warns: “You can call it different things to sand down the edges,” but it doesn’t change the basic shape, and what he’s trying to create “is a program to get at stress in your community, not just the upper class white community.”
The development process is long for his years-long studies in these communities who may be suspicious of him or medical professionals generally. To head off prejudice, he enlists the endorsement of community leaders (e.g., the tribal council or church pastor) and forms a small advisory group for guidance and assistance.
Proulx aims to create a safe, open, and accepting environment among community members. “You do that by learning about the history of the community, the culture, and becoming part of the neighborhood,” he says. “It’s an effort to develop trust, show trustworthiness, and embody trustworthiness.”
Their own culture then informs how these involved community members experience his mindfulness and stress reduction training. “‘Oh, it’s like Proverbs,’ I often hear,” says Proulx. “Or ‘It’s like Christian charity and compassion.’”
Underserved populations can also be a source of future trainers and greater diversity in the mindfulness field. “I encourage people in those communities to become teachers,” he explains. “Brown University is paying for that training.”