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Frameworks for Action in Policy and Politics
Eileen T. O’Grady, Diana J. Mason, Freida Hopkins Outlaw, Deborah B. Gardner
“The most common way people give up their power is by thinking they don’t have any.”
March 31, 2013 marked an important deadline in the implementation of landmark legislation, the Affordable Care Act (ACA)1, also known as Obamacare. By that date those eligible to enroll for insurance coverage through the marketplace had to purchase a plan if they were to avoid a 2015 tax penalty of $95 or 1% of their annual income (whichever was higher). Amid a frenzy of media attention, an estimated 8 million people signed on for coverage during open enrollment—the period between October 2012 and the deadline—exceeding the revised target of 6.5 million (Kennedy, 2014). And the numbers kept increasing, as millions more enrolled in Medicaid or the Children’s Health Insurance Program (known as CHIP) (Centers for Medicare and Medicaid Services [CMS], 2014).
Nurses were essential to these enrollments. For example, Adriana Perez, PhD, ANP, RN, an assistant professor at Arizona State University College of Nursing, used her role as president of the Phoenix Chapter of the National Association of Hispanic Nurses to organize town hall meetings with Spanish-speaking state residents to explain the ACA and encourage enrollment among those with a high rate of un- or under-insurance. She also developed a training model in partnership with AARP-Arizona and used it to empower Arizona nurses to educate multicultural communities on the basic provisions of the ACA. Through many such initiatives, the United States reduced the number of uninsured people by over 10 million in 2014; the number is projected to be 20 million by 2016 (Congressional Budget Office [CBO], 2014).
However, access to coverage does not necessarily mean access to care, nor does it ensure a healthy population. Health care access means having the ability to receive the right type of care when needed at an affordable price. The U.S. health care system is grounded in expensive, high-tech acute care that does not produce the desired outcomes we ought to have and too often damages instead of heals (National Research Council, 2013). Despite spending more per person on health care than any other nation, a comparative report on health indicators by the Organisation for Economic Co-operation and Development (2013) shows that the United States performs worse than other nations on life 2expectancy at birth for both men and women, infant mortality rate, mortality rates for suicide and cardiovascular disease, the prevalence of diabetes and obesity in children, and other indicators.
In 1999, the Institute of Medicine (IOM) issued a report, To Err is Human: Building a Safer Health System, which estimated that health care errors in hospitals were the fifth leading cause of death in the U.S. (IOM, 1999). By 2011, preventable health care errors were estimated to be the third-leading cause of death (Allen, 2013; James, 2013). The ACA includes elements that can begin to create a high-performing health care system, one accountable for the provision of safe care, as well as improved clinical and financial outcomes. It aims to move the health care system in the direction of keeping people out of hospitals, in their own homes and communities, with an emphasis on wellness, health promotion, and better management of chronic illnesses.
For example, the ACA uses financial penalties to prod hospitals to reduce 30-day readmission rates. It also provides funding for demonstration projects that improve “transitional care,” services that help patients and their family caregivers to make a smoother transition from hospital or nursing home to their own homes to help reduce preventable hospital readmissions. Based, in part, on research by Mary Naylor, PhD, RN, FAAN, professor of nursing at the University of Pennsylvania School of Nursing, these demonstrations are stimulating creative methods of accountability across health care settings, with most using nurses for care coordination and transitional care providers (CMS, n.d.; Coalition for Evidence-Based Policy, n.d.; Naylor et al., 2011).
Promoting health requires more than a high-performing health care system. First and foremost, health is created where people live, work, and play. It is becoming clear that one’s health status may be more dependent on one’s zip code than on one’s genetic code (Marks, 2009). Geographic analyses of race and ethnicity, income, and health status repeatedly show that financial, racial, and ethnic disparities persist (Braveman et al., 2010). Individual health and family health are severely compromised in communities where good education, nutritious foods, safe places to exercise, and well-paying jobs are scarce (Halpin, Morales-Suárez-Varela, & Martin-Moreno, 2010). Creating a healthier nation requires that we address “upstream factors”; the broad range of issues, other than health care, that can undermine or promote health (also known as “social determinants of health” or “core determinants of health”) (World Health Organization [WHO], n.d.). Upstream factors promoting health include safe environments, adequate housing, and economically thriving communities with employment opportunities, access to affordable and healthful foods, and models for addressing conflict through dialogue rather than violence. According to Williams and colleagues (2008), the key to reducing and eliminating health disparities, which disproportionately affect racial and ethnic minorities, is to provide effective interventions that address upstream factors both in and outside of health care systems. Upstream factors have a large influence on the development and progression of illnesses (Williams et al., 2008). The core determinants of health will be used to further elucidate and make concrete the wider, more comprehensive set of upstream factors that can improve the health of the nation by reducing disparities. Figure 1-1 depicts the core determinants of health developed by the Canadian Forces Health Services Group.
FIGURE 1-1 Surgeon General’s Mental Health Strategy: Canadian Forces Health Services Group—An Evolution of Excellence. (From www.forces.gc.ca/en/about-reports-pubs-health/surg-gen-mental-health-strategy-ch-2.page.)
A focus on such factors is essential for economic and moral reasons. Even in the most affluent nations, those living in poverty have substantially shorter life expectancies and experience more illness than those who are wealthy, with high costs in human and financial terms (Wilkinson & Marmot, 2003). To date however, most of the focus on reducing disparities has been on health policy that addresses access, coverage, cost, and quality of care once the individual has entered the health care system–despite the fact that for more than a decade research has established that most health care problems begin long before people seek medical care (Williams et al., 2008). Thus, changing the paradigm requires knowledge about the political aspects of the social determinates of health and the broader 3core determinants. Political aspects of the social determinants of health appear in Box 1-1.
Political Aspects of the Social Determinants of Health
• The health of individuals and populations is determined significantly by social factors.
• The social determinants of health produce great inequities in health within and between societies.
• The poor and disadvantaged experience worse health than the rich, have less access to care, and die younger in all societies.
• The social determinants of health can be measured and described.
• The measurement of the social determinants provides evidence that can serve as the basis for political action.
• Evidence is generated and used in a continuous cycle of evidence production, policy development, implementation, and evaluation.
• Evidence of the effects of policies and programs on inequities can be measured and can provide data on the effectiveness of interventions.
• Evidence regarding the social determinants of health is insufficient to bring about change on its own; political will combined with evidence offers the most powerful strategy to address the negative effects of the social determinants.
Adapted from National Institute for Health and Clinical Excellence. (2007). The Social Determinants of Health: Developing an Evidence Base for Political Action. Final report to the World Health Organization Commission on the Social Determinants of Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan, L. Myer, T. Houweling, L. Jadue, and F. Florenza.
The ACA begins to carve out a role for the health care system in addressing upstream factors. For example, the law requires that nonprofit hospitals demonstrate a “community benefit” to receive federal tax breaks. Hospitals must conduct a community health assessment, develop a community health improvement plan, and partner with others to implement it. This aligns with a growing emphasis on population health: the health of a group, whether defined by a common disease or health problem or by geographic or demographic characteristics (Felt-Lisk & Higgins, 2011).
Consider the 11th Street Family Health Services. Located in an underserved neighborhood in North Philadelphia, this federally qualified, nurse-managed health center (NMHC) was the brainchild of public health nurse Patricia Gerrity, PhD, RN, FAAN, a faculty member at Drexel University School of Nursing. She recognized that the leading health problems in the community were diabetes, obesity, heart failure, and depression. Working with a community advisory group, Gerrity realized that the health center had to address nutrition as an “upstream factor” that could improve the health of those living in the community. With no supermarket in the neighborhood until 2011, she invited area farmers to come to the neighborhood as part of a farmers’ market. She also created a community vegetable garden maintained by the local youth. And area residents were invited to attend nutrition classes on culturally relevant, healthful cooking. 11th Street Family Health Services is one of over 200 NMHCs in the United States that have improved clinical and financial outcomes by addressing the needs of individuals, families, and communities 4(American Academy of Nursing, n.d., b). The ACA authorizes continued support for these centers, although the law does not mandate they be funded. Congress would have to appropriate funding for NMHCs but has not done so. (See Chapter 34 for a more detailed discussion of NMHCs.)
The ACA may not go far enough in shifting attention to the health of communities and populations. One approach gaining notice is that of “health in all policies,” the idea that policymakers consider the health implications of social and economic policies that focus on other sectors, such as education, community development, tax codes, and housing (Leppo et al., 2013; Rudolph et al., 2013). As health professionals who focus on the family and community context of the patients they serve, nurses can help to raise questions about the potential health impact of public policies.
Nursing and Health Policy
Health policy affects every nurse’s daily practice. Indeed, health policy determines who gets what type of health care, when, how, from whom, and at what cost. The study of health policy is an indispensable component of professional development in nursing, whether it is undertaken to advance a healthier society, promote a safer health care system, or support nursing’s ability to care for people with equity and skill. Just as Florence Nightingale understood that health policy held the key to improving the health of poor Londoners and the British military, so are today’s nurses needed to create compelling cases and actively influence better health policies at every level of governance. With national attention focused on how to transform health care in ways that produce better outcomes and reduce health care costs, nursing has an unprecedented opportunity to provide proactive and visionary leadership. Indeed, the Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health (2011), calls for nurses to be leaders in redesigning health care. But will nurses rise to this occasion?
Health care opinion leaders in a 2010 poll identified two reasons nurses would fall short of influencing health care reform: too many nurses do not want to lead, and with over 120 national organizations, nursing often fails to present a united front (Gallup, 2010). As the largest health care profession, nursing has great potential power. Yet, similar to many professions, it has struggled to collaborate within its ranks or with other groups on pressing issues of health policy. The IOM report has provided a rallying point for nursing organizations to work together and engage other stakeholders to advance its recommendations.
Reforming Health Care
The Triple Aim
In 2008, Don Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI) first described the Triple Aim of a value-based health care system (Berwick, Nolan, & Whittington, 2008): (1) improving population health, (2) improving the patient experience of care, and (3) reducing per capita costs. This framework aligns with the aims of the Affordable Care Act.
The Triple Aim represents a balanced approach: by examining a health care delivery problem from all three dimensions, health care organizations and society can identify system problems and direct resources to activities that can have the greatest impact. Looking at each of these dimensions in isolation prevents organizations from discovering how a new objective, decreasing readmission rates to improve quality and reduce costs, for instance, could negatively impact the third goal of population health, as scarce community resources are directed to acute care transitions and unintentionally shifted away from prevention activities. Solutions must also be evaluated from these three interdependent dimensions. The Triple Aim compels delivery systems and payors to broaden their focus on acute and highly specialized care toward more integrated care, including primary and preventive care (McCarthy & Klein, 2010).
The IHI (n.d.) identified these components of any approach seeking to achieve the Triple Aim:
• A focus on individuals and families
• A redesign of primary care services
• Population health management
• A cost-control platform
• System integration and execution
Note that these possess the goal of creating a high-performing health care system but do not focus on geographic communities or social determinants per se. However, these two concepts can be incorporated into the Triple Aim of improving the health of populations and reducing health care costs.
The Triple Aim is easy to understand but challenging to implement because it requires all providers, including nurses, to broaden their focus from individuals to populations. The success of the nursing profession’s continued evolution will hinge on its ability to take on new roles, more cogently and creatively engaging with patients and stepping into executive and leadership roles in every sector of heath care. But it must do so within an interprofessional context, leading efforts to break down health professions’ silos and hierarchies and keeping the patient and family at the center of care.
The ACA and Nursing
The ACA is arguably the most significant piece of social legislation passed in the United States since the enactment of Medicare and Medicaid in 1965. Implementation continues to be a vexing process and a political flashpoint. It has defined the ideologies of U.S. political parties, and yet the public remains largely uninformed and misinformed about the legislation; 3 years after its passage, 4 out of 10 Americans were still unaware of many of its provisions and unsure that the ACA had become law (The Henry J. Kaiser Family Foundation, 2013). (Chapter 19 provides a thorough description of the ACA.) The ACA is over 2000 pages long, which reflects the complexity of creating a new health care infrastructure that addresses a wide array of issues including patient protections, health insurance industry reforms, and workforce development, to name a few. Newer systems of care are emphasized in the ACA that link patient outcomes to costs incurred in treatment and to high-value health systems. The legislation can be categorized into four main cornerstones (Figure 1-2).
FIGURE 1-2 Four cornerstones of reform. (From O’Grady, E. T., & Johnson, J. . Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.)
The ACA was born out of national macroeconomic concerns. The United States spent $2.7 trillion in 2011, or $8680 per person, on health care; a rate higher than inflation that is expected to consume nearly 20% of the gross domestic product by 2020 (CMS, 2013). With businesses having to spend such large amounts on health care for employees, the United States cannot compete in the global economy. Furthermore, such high health care expenses divert funds away from addressing the upstream factors that could prevent the need for costly acute care. Although previous presidents in the past 50 years tried unsuccessfully to pass health care reform legislation, President Obama was elected at a time when many Americans agreed that the United States could no longer afford to maintain a health care system that had neither spending controls nor accountability for improving clinical outcomes. The ACA was an outgrowth, in part, to “bend the cost curve,” or reduce the rate of increase in health care spending (Cutler, 2010).
To improve the health of the public and reduce health care costs, health promotion and wellness, disease prevention, and chronic care management must be built into the foundation of the health care system (Katz, 2009; Wagner, 1998; Woolf, 2009). At 6the same time, acute care must use fewer resources, be made safer, and produce better outcomes (Conway, Mostashari, & Clancy, 2013).
Nurses are important players in shifting the focus of health care to one that prevents illnesses, promotes health, and coordinates care. Nurses have been performing in such roles without naming or measuring their activities for decades. But there are exceptions. The American Academy of Nursing’s Raise the Voice Campaign (American Academy of Nursing, n.d., a) has identified nurses who have developed innovative models of care for which there are good clinical and financial outcome data. Known as “Edge Runners,” these nurses have demonstrated that nursing’s emphasis on care coordination, health promotion, patient- and family-centeredness, and the community context of care provides evidence-based models that can help to transform the health care system.
The ACA presents many opportunities for nurses to test new models of care that have already shown promise for improving health outcomes and the experience of health care, while lowering costs. The Center for Medicare and Medicaid Innovation (CMMI) was authorized to spend $10 billion over a decade to pilot-test programs that may improve the safety and quality of care. For example, under the Bundled Payments for Care Improvement Initiative, health systems will enter into payment arrangements that include financial and performance accountability for episodes of care. Currently being studied, an episode of care includes the inpatient stay and all related services during the episode up to 90 days after hospital discharge. These models may lead to higher quality, more coordinated care at a lower cost to Medicare. If the program is successful in achieving these outcomes, they are authorized to launch the program nation-wide.
If these can be shown to achieve the Triple Aim, the ACA authorizes the Secretary of the U.S. Department of Health and Human Services to put these programs in place permanently. The CMMI provides opportunities for nurse leaders and nurse researchers to demonstrate new methods of improving care in cost-effective ways. In addition, the ACA created the Patient-Centered Outcomes Research Institute (PCORI) with $3.5 billion to support comparative-effectiveness research that examines the outcomes that matter to consumers. Nurses serve on the governing board and review panels of PCORI. It provides nurses with opportunities to compare nursing interventions, head-to-head or with medications or other treatments that have sufficient evidence.
The following examples illustrate how nursing is embedded in the four cornerstones of reform. Some of these examples address only one cornerstone; others address all four.
- Create Value.
NMHCs are operated by advanced practice registered nurses (APRNs), primarily nurse practitioners (NPs). These clinics are often associated with a school, college, university, department of nursing, federally qualified health center, or an independent nonprofit health care agency. Managed by APRNs, NMHCs are staffed by an interprofessional team that may include physicians, social workers, public health nurses, psychiatric mental health nurses at the generic and advanced levels, and behavioral therapists. Barkauskas and colleagues (2011) found that quality measures for NMHCs compared positively with national benchmarks, particularly in chronic disease management. The founders of several NMHCs have been designated Edge Runners, including Patricia Gerrity of the 11th Street Family Health Service, as described earlier. NMHCs serve as critical access points for keeping patients out of the emergency room and hospitals, saving millions of dollars annually (Hansen-Turton et al., 2010).
- Coordinate Care.
The patient-centered “medical home” or “health home”2 (PCMH) model was designed to satisfy patients’ needs and to improve care access (e.g., through extended office hours and increased communication between providers and patients via e-mail and telephone), 7increase care coordination, and enhance overall quality, while simultaneously reducing costs. The medical home relies on a one-stop-shopping approach by a team of providers, such as physicians, nurses, nutritionists, pharmacists, and social workers, to meet a patient’s health care needs. Peikes and colleagues (2012) found that the PCMH model’s attention to the whole person across care settings (such as from hospital to home) may improve physical and behavioral health, access to community-based social services, and management of chronic conditions. A number of NMHCs have achieved PCMH designation by the National Committee on Quality Assurance.
- Payment Reform.
Bundling payments and paying for care coordination, including through “accountable care organizations” (ACOs), are examples of payment reform. ACOs are similar to integrated delivery systems that combine services across health care settings and focus on ways to improve care delivery and outcomes under a bundled payment plan. Bundling payments allows for reimbursement of multiple services provided during an episode of care, rather than the traditional fee-for-service payments for each service or procedure for a single illness. ACOs differ from health maintenance organizations (HMOs) in that they are not incentivized to cut services but rather to keep people healthy. Indeed, one of the major differences between HMOs in the 1990s and ACOs today is that the latter are held to a higher standard of measuring, reporting, and making transparent the process and outcome indicators of quality. Each ACO has to have a minimum of 5000 Medicare patients (population health); if the ACO demonstrates that it keeps people healthy and saves Medicare money, those savings are “shared” with the ACO. Nurses are central to preventing complications in hospitalized patients, ensuring smooth transitions to home, and coaching the patient and family caregivers in self-care and health-promoting behavioral changes. As such, they are a vital component of ACO success.
But payment reform is proving to be challenging. The CMMI, authorized under the ACA, initially funded 31 “pioneer” ACOs. By mid-2014, only 22 remained, mostly because of difficulty in managing payment to the various entities in the ACO’s network. Nonetheless, there is some consensus that the fee-for-service payment system encourages overtreatment (unnecessary and costly care) and must be replaced (Cutler, 2010; Gibson & Singh, 2012).
- Improve Access to Coverage.
The ACA does not guarantee health insurance coverage for all, including undocumented immigrants, but, by 2017, it will cover up to 30 million of the 45 million who were uninsured when the bill was signed in 2010 (89% of the total nonolder adult population; 92% of nonolder adult American citizens) (Congressional Budget Office [CBO], 2014). It makes it illegal for insurance companies to deny coverage to people with preexisting conditions, to drop people once they acquire a costly illness, or to apply annual and lifetime caps on coverage. As the demand for health care surges, it is expected that APRNs will be positioned to provide much of the needed primary care, creating the need for APRNs to practice to the full extent of their education and training. Barriers preventing such practice include mandated physician supervision or collaboration in two thirds of states, insurers refusing to credential or impanel APRNs, Medicare requirements for physicians—rather than NPs—to order referrals to home care and hospice, and other local, state, and national policies that limit APRN practice.
Access to coverage does not ensure that people will have access to care. There is a lack of primary care physicians (PCPs) serving the poor, in both rural and urban regions; approximately 210,000 PCPs currently practice, and it has been estimated that another 52,000 will be needed by 2025 (Petterson et al., 2012). This shortfall has led to the development of the APRN role. A workforce analysis center at the Health Resources and Services Administration reported that if primary care NPs and physician assistants (PAs) are fully integrated into a health care delivery system that emphasizes team-based care, the projected shortage of PCPs would be “somewhat alleviated” by 2020 (U.S. Department of Health and Human Services, 2013).
Community-based health care centers will be expanded in areas where there are health care 8provider shortages. Expansion of the National Health Service Corps is expected to ensure that providers, including registered nurses (RNs) and APRNs, will be available to staff these centers. An emphasis on primary care will increase the demand for NPs and RNs, and the ACA authorizes additional support for primary care workforce development (loans, scholarships, new educational program development, and expansion of existing programs). (See Chapter 60 for more on the nursing workforce.)
Nurses as Leaders in Health Care Reform
Coinciding with the passage of the ACA was the timely publication of The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). It makes four recommendations, one of which is “Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States” (Figure 1-3).
FIGURE 1-3 Four key messages: The IOM report. (From Institute of Medicine. . The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from www.iom.edu/nursing.)
This presents a challenge to nurses: to identify opportunities to participate in policy decision making at all levels of society, the health care system, and health care organizations. Although nursing is well positioned to contribute to a reformed health care system, we cannot assume that those making the decisions about reform will automatically seek nurses’ input. And, if invited to policy tables, will nurses show up and participate fully? The IOM report calls for the profession to develop its leadership capacity, while encouraging policymakers and others to appreciate nurses’ perspectives on policy. Whether developing new models of care, sharing ideas for regulations with policymakers, developing demonstration projects that the new health care law seeks to test, or advocating new legislation to amend and improve upon the law (or preventing it from being dismantled), nurses must strengthen their social covenant with the public and more forcefully engage in shaping policy at all levels within government, workplaces, health-related organizations, and communities.
Policy and the Policy Process
What do we mean by policy? Policy has been defined as the authoritative decisions made in the legislative, executive, or judicial branches of government intended to influence the actions, behaviors, or decisions of citizens (Longest, 2010). But that definition limits its application to sectors outside of government. For example, health care organizations set policy that affects employees, patients, and even surrounding communities (for example, by closing a neighborhood clinic or buying property for hospital expansion). Thus, a broader definition of policy is “a relatively stable, purposive course of action or inaction followed by an actor or set of actors in dealing with a problem or matter of concern” (Anderson, 2015, p. 6).
Public policy is policy crafted by governments. When the intent of a public policy is to influence health or health care, it is a health policy. Social policies identify courses of action to deal with social problems. All are made within a dynamic environment and a complex policymaking process. Private policies are those made by nongovernmental entities, whether health care organizations, insurers, or 9others. Indeed, there is growing recognition that policies set by health care organizations and insurers, for example, can limit APRN practice even in states that have removed laws requiring physician supervision or collaboration. A hospital can limit what APRNs do as long as the organization does not call for APRNs to practice beyond the state’s scope-of-practice policy.
Policies are crafted everywhere, from small towns to Capitol Hill. States use policies to specify requirements for health professions’ licensure, to set criteria for Medicaid eligibility, and to require immunization for public university students, for example. Hospitals use policies to direct when visitors may visit patients, to manage staffing, and to respond to disasters. Public schools employ state policies to specify who may administer medications to schoolchildren and what may be sold from a school vending machine. Towns, cities, and other municipalities use policies to manage public water, to define who may run for office, and to decide if residents may keep exotic pets.
In a capitalist economy such as that of the United States, private markets can control the production and consumption of goods and services, including health care. The government often “intervenes” with policies when private markets have failed to achieve desired public objectives. But when is it necessary for the government to intercede? Broadly speaking, in the current U.S. political system, the divide between liberal and conservative political parties is a fundamental disagreement about the degree to which government can and should solve problems (Kelly, 2004) in education, national security, the environment, and nearly every other aspect of public life. The American political landscape is continuously shifting, as public mood shifts with new Representatives being elected and senior Representatives desiring to stay in office.
Longest (2010) describes two types of public policies the government develops:
• Allocative policies provide benefits to a distinct group of individuals or organizations, at the expense of others, to achieve a public objective (this is also referred to as the redistribution of wealth). The enactment of Medicare in 1965 was an allocative policy that provided health benefits to older adults using federal funds (largely from middle- and high-income taxpayers).
• Regulatory policies influence the actions, behavior, and decisions of individuals or groups to ensure that a public objective is met. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulates how individually identifiable health information is managed by users, as well as other aspects of health records.
Policymaking is an often unpredictable dance that requires a high degree of political competence. Our system is based on continuous policy modification—incremental change is exceedingly more likely than revolutionary change. But there are exceptions; once in a generation a large social program is passed such as Medicare and Medicaid in the 1960s and the ACA in 2010.
Forces That Shape Health Policy
Some of the most prominent forces that shape health policy appear in Figure 1-4.
FIGURE 1-4 The forces that shape policy.
Values undergird proposed and adopted policies and influence all political and policymaking activities. Public policies reflect a society’s values and also its conflicts in values. A policy reflects which values are given priority in a specific decision (Kraft & Furlong, 2010). Once framed, a policy reveals the underlying values that shaped it. Different people value different things, and when resources are finite, policy choices ultimately bring a disadvantage to some groups; some will gain something from the policy, and some will lose (Bankowski, 1996). To support or oppose a policy requires value judgments (Majone, 1989). Conflicts between values were apparent throughout the debates on the ACA; for example, despite a strong contingent of advocates for a government-run, nonprofit insurance option that would compete with private insurers, the insurance industry opposed it, as did others who saw it as an increase in government control, and it was not included in the law.