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!
Have you ever heard the phrase, “Two heads are better than one”? Well, it’s now a proven fact that working with others to resolve an issue is more productive than trying to figure it out on your own.
Professional fields, such as public health, value intradisciplinary teamwork as well as interdisciplinary teamwork. Through collaboration, innovation often emerges to address complex health issues.
But why does this matter for public health as compared to other fields? Let’s take a step back to understand what health actually is.
WHO’s Definition of Health Goes beyond Mere Physical Health
One of the first things we learn in the field of public health is the definition of health. In its 1948 constitution, the World Health Organization (WHO) defined health in its broader sense as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
This definition takes a holistic view of health, not just the absence of bodily diseases. It implies that health encompasses multiple layers, such as one’s social well-being.
The Relationship of Health and Multiple Influences on Health
How does this definition of health align with the influences on health as described in the socio-ecological framework? The socio-ecological framework illustrates that there are multiple levels of influences on our health, ranging from:
Intrapersonal/individual factors (genetics)
Interpersonal factors (culture, family and values)
Organizational factors (faith-based organizations, schools and community organizations)
Community influences (neighborhood and healthcare)
Public policy (laws, media and the food industry)
These influences extend beyond the core public health disciplines of behavioral science/health education, biostatistics, environmental health, epidemiology and health services administration. As public health practitioners, our need to learn and collaborate with other disciplines is paramount.
For instance, interprofessional education and practice can work together to address a specific public health issue like obesity.
Parents and other family members can influence a child’s dietary habits and physical activity. A public health practitioner can consider these collaborations as opportunities.
How can we work with social workers to understand family dynamics and intervene to promote healthy habits?
What is the role of sociologists, psychologists or anthropologists in understanding culture and values contributing to healthy habits?
Access to fresh fruits and vegetables can influence one’s ability to eat healthy and prevent obesity. A public health practitioner interested in addressing obesity trends in a particular community ought to consider the following:
How can we work with local schools to incorporate a school garden, so that children learn how to grow healthy fruits and vegetables?
“Place” matters as the PBS series “Unnatural Causes” eloquently shows. Where an individual lives, works or plays either limits or promotes opportunities for healthy habits (e.g. safety of neighborhoods or easy access to healthy food options).
How do public health practitioners work with local/city officials and law enforcement to address security issues or other matters affecting healthy activities, like walking or running?
What is the role of parks and recreation services in ensuring amenities for healthy lifestyles?
Easy access to health care services is a well-known contributor to healthy behaviors. Access to health and health insurance is aligned with socio-economic status. Lower socio-economic status also correlates with obesity trends (for example, cheaper food products are often high in calories and less nutritious).
How does a public health practitioner work with policy makers to address access to healthy foods for lower socio-economic groups?
How can we work with the food industry to address childhood obesity?
Even if you are not a public health practitioner, I encourage you to think about how what you do can affect the health and well-being of individuals, communities, nations and the world. Consider also what you can do to support public health initiatives to promote wellness and prevent diseases at all levels of influence, according to the socio-ecological framework.
In the United States, race once defined an individual’s level of freedom, including where they could enter, sit, and eat. Today, with African Americans at a higher risk than White Americans for obesity, high blood pressure, stroke, and heart disease, race also defines the quality of healthcare, making health disparities in African Americans the true silent killer.
Statistics from the American Heart Association and Center for Disease Control and Prevention acknowledges the prevalence of cardiovascular diseases in African Americans. However, the link between race and health are obscured, and there is not much conversation dedicated to eliminating the socioeconomic and cultural barriers that make African Americans a target for death by disease.
So the question is what should we as healthcare professionals implement to address socioeconomic and cultural barriers that contribute to the healthcare disparities in African Americans and other minority populations? Should we continue to research different treatment regimens that can improve the overall health of African Americans and other minority groups? Or should we continue to educate these populations through traditional patient education? The Answer is No! In order for us to get something that we have never had, that means we have to do something that we have never done. The solution to this issue must extend beyond medicine, and instead be addressed by community leaders, community health providers, and minority healthcare professionals so race can be a category and not a barrier to quality healthcare.
There is undoubtedly a necessity to increase the level of cultural sensitivity among physicians, nurses, & other healthcare personnel; recognize unfavorable socioeconomic and cultural barriers as a preexisting condition; improve the community surrounding African Americans & other minority patients; and increase the number of minority healthcare workers. Implementing these actions will begin the process of closing the gap of socioeconomic and cultural barriers that contribute to the healthcare disparities in African Americans and other minority populations.
The current health care crisis is multifaceted, ongoing, and incredibly significant to those within the profession. The reform the country is currently experiencing came as a result of several factors: high cost of treatment, ineffective payment methods, and millions of uninsured Americans in need. Though these problems have begun to enter the national conversation, there are still many issues that need to be addressed and fixed.
Nurses are often referred to as the front line of the health care system—meaning that the changes occurring on a national level will affect them directly, perhaps even first. With the coming reform, health care facilities and their nursing staff must account for slashed budgets, reduced personnel, and political pressure. Moreover, President Obama recently set aside more than $36 billion to create a nationwide network of electronic health records—a massive undertaking that will require a combination of proven communication skills and strategic management to implement, use, and manage.
In addition to these changes, the population is aging, Medicare funding is in jeopardy, and the nursing shortage is projected to grow to one million by 2020. As the public gains access to health care, the lack of nurses will be felt even more acutely.
Nurses must equip themselves with the skills necessary to manage and help solve these crises.
The next generation of nursing leaders will be charged with placing an emphasis on interpersonal and interdepartmental communication—translating and acting as a diplomat between the clinical and business sides of health care institutions. Nursing leaders must have a strong working knowledge of clinical practice and the business of health care, all within an everchanging political arena. Nurses holding both a Master of Science in Nursing (M.S.N.) and a Master of Business Administration (M.B.A.) will be better equipped to understand both sides of the equation.
This may be unfamiliar territory for the nursing profession. Executives must be able to identify key health care trends, watch regulatory rules and legislation—and be able to implement changes within their own organization based on these findings.
Dual degrees in nursing and business help nurses manage these responsibilities in more ways than one could count. Registered nurses are not generally educated in the business side of health care, and while a Bachelor of Science in Nursing is excellent preparation for nursing clinical practice, patient care is far removed from the fiscal responsibility of bringing consumption and cost to sustainable levels. A business-trained leader, such as an M.B.A.-prepared executive, may be able to provide financial analysis of factors associated with treatment, providing the cost in real dollars and highlighting areas of strength or problematic gaps. Yet, while that training may prove invaluable in discovering economic stopgaps, understanding financial problems is not effective in providing a cost benefit unless a clinical solution can be found as well. Therein lies the primary benefits of obtaining dual M.S.N./M.B.A. degrees—understanding and linking both sides of health care.
M.S.N./M.B.A. programs aim to prepare students for mid- to upper-level management roles in health care organizations, including chief nursing executives, nursing managers, nursing supervisors, nursing educators, nursing informaticists, nurse practitioners, clinical nurse specialists, and more. According to the Centers for Medicare and Medicaid Services, by 2015 health care costs will hit $4 trillion and account for 20% of the U.S. economy. By 2012, the number of nursing executives is expected to increase faster than most health care professions. Still, in today’s diffi cult economic environment, being as educationally competitive as possible is key to securing a position as a nursing executive.
Employers will be looking for nursing executive candidates skilled in communication and conflict resolution, leaders who have the ability to cultivate an ongoing conversation between patients, staff, and administration. M.S.N./ M.B.A. degree programs also generally provide more targeted business preparation, training students in areas such as relationship management, organizational leadership, business relations, and change management—skills which are more crucial now than ever.
Where to Obtain a Dual M.S.N./M.B.A.
Just a few options of many… Anderson University
Chamberlain College of Nursing
Johns Hopkins University
Loyola University Chicago
Sacred Heart University
Saint Joseph’s College of Maine
Saint Xavier University
Seton Hall University
University of Indiana
University of Iowa
University of Pennsylvania
University of Texas, Arlington
University of the Incarnate Word
University of Virginia School of Nursing
Class work, prerequisites, clinical requirements, and other details of these dual degree programs vary widely. Students may obtain their dual degree at one school or through articulation agreements between two distinct schools of nursing and business. Accelerated programs often combine these studies even further, saving students both time and money. At Chamberlain College of Nursing, courses such as Leadership Role Development, Health Policy, and Informatics prepare graduates to serve as effective nursing leaders, able to understand the politics and decisions inherent in health care leadership. Business studies, including Managerial Accounting, Marketing Management, and Business Economics help students develop strong analytical abilities, understand health care economics, learn to resolve organization and business issues, execute health care strategies, and foster communication and interpersonal skills.
In order for the health care field to flourish in the face of a continuing recession and monumental policy changes, the profession must seek out and support individuals prepared for both the monetary and clinical challenges. The time for aspiring health care leaders to gather the knowledge and credentials they need is now. The industry’s success depends just as much on cost savings as on the finite resources vital to maintaining crucial care—namely, the people and practices that allow health care to function. Future nursing leaders must further prepare themselves to manage every facet of the coming changes to the industry, including attaining knowledge of both the business and the science of health care.
During the 2011 National Nurses Week, a week the American Nurses Association honors every year from National Nurses Day, May 6, to Florence Nightingale’s birthday, May 11, four nursing students were given the opportunity to travel to Sierra Leone to work on a field mission for Mercy Ships.
Since 1978, Mercy Ships has delivered free health care and services to more than 70 countries in the developing world—taking their facilities and staff with them across the oceans on ships. The field mission welcomed four nursing students from Northwest University to prepare in Sierra Leone for the arrival of the largest non-government hospital ship in the world, with a crew of 450, the Africa Mercy.
From their campus near Seattle, Washington, the four students and their professor joined a team of 350 nurses from more than 40 countries who volunteer with Mercy Ships every year. Because Mercy Ships requires volunteer nurses to be registered nurses with at least two years of professional experience, the nursing students prepared on land for the ship’s arrival by gathering medical records for patients and testing day-workers from the local community, who volunteer on the ship, for tuberculosis. One future nurse says she left with an appreciation for the availability of health care in the United States; many of the people they helped in Sierra Leone do not have any hospitals nearby.
Mercy Ships has over 1,200 volunteers every year from a variety of professions, such as surgeons, dentists, cooks, and teachers. While surgical nurses volunteer for two weeks, patient care nurses can volunteer for eight weeks or longer. Students gained perspectives not normally absorbed from classroom lectures or even technical training.