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NTI2008 Policy Politics And You

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NTI2008 Policy Politics And You

  1. 1. Policy, Politics and You: You too can be a voice Todd M. Grivetti, BSN, RN, CCRN Poudre Valley Hospital Ft. Collins, CO Class Code: 220 Category B
  2. 2. House Keeping Please turn cell phones and pagers to vibrate .
  3. 3. Disclosure Statement As a member of AACN’s Speaker’s bureau I have received an honorarium from AACN for this presentation. I have no other vested interest(s) from any other organization.
  4. 4. Learning Outcomes <ul><li>At the end this session participants will be able to: </li></ul><ul><ul><li>Identify issues which they have a passion to write about and do it. </li></ul></ul><ul><ul><li>Identify resources for searching for issues. </li></ul></ul><ul><ul><li>Describe writing techniques that get heard. </li></ul></ul><ul><ul><li>Discuss the need for public policy and change. </li></ul></ul><ul><ul><li>Identify political resources and how to contact them. </li></ul></ul>
  5. 5. Identify Your Passions or Values <ul><li>Child Health Care in the U.S. </li></ul><ul><ul><li>SCHIPS </li></ul></ul><ul><ul><li>Legislation </li></ul></ul><ul><li>Health Insurance in America </li></ul><ul><ul><li>Cost to sustain adequate coverage </li></ul></ul><ul><ul><li>National system (Benefit or not) </li></ul></ul><ul><li>Patient Safety Issues & Access to Quality Health Care </li></ul><ul><ul><li>Vulnerable populations </li></ul></ul><ul><ul><li>Patient’s Rights </li></ul></ul><ul><ul><li>Medication errors </li></ul></ul><ul><li>Public Policy and Community safety </li></ul><ul><ul><li>Nursing shortage </li></ul></ul><ul><ul><ul><li>American for Nursing Shortage Relief </li></ul></ul></ul><ul><ul><li>Violence in the workplace and environment. </li></ul></ul>
  6. 6. Identify your Resources
  7. 7. Children’s Health Care SCHIP’s <ul><ul><li>SCHIP’s </li></ul></ul><ul><ul><ul><li>Created to provide health insurance coverage to children whose families who made too much money to qualify for Medicaid but too poor to afford private health insurance. </li></ul></ul></ul><ul><ul><ul><li>2007 – Reauthorization for 5 years failed and was vetoed by President Bush on Oct. 3 rd , 2007. </li></ul></ul></ul><ul><ul><ul><ul><li>Democratic leaders drafted a second bill, but unable to pass with less than 2/3 majority required to override the veto. </li></ul></ul></ul></ul><ul><li>Source:'s_Health_Insurance_Plan </li></ul>
  8. 8. Children’s Health Care <ul><li>SCHIP’s currently in all states. </li></ul><ul><ul><li>Resources include: </li></ul></ul><ul><ul><ul><li>State government websites </li></ul></ul></ul><ul><ul><ul><li>Political action committees </li></ul></ul></ul><ul><ul><ul><li>AACN’s Public Policy page: </li></ul></ul></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul><ul><ul><ul><li>Kaiser Family foundation </li></ul></ul></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul>
  9. 9. Kaiser Family Foundation Kaiser Family Foundation 5/1/08
  10. 10. SCHIPS (CO & IL) Comparison Source: Kaiser Family Foundation –
  11. 11. Massachusetts
  12. 12. Children’s Health Care <ul><li>Currently 9.4 million children 18 and under are uninsured in the U.S.* </li></ul><ul><ul><li>Millions more lack adequate coverage. </li></ul></ul><ul><li>Campaign for Children’s Health Care </li></ul><ul><ul><li>held a petition drive to call on Congress and the President to begin legislation that will provide comprehensible, affordable and high-quality health coverage for all children. </li></ul></ul>, 2007; Campaign for Children’s Health Care, 2007
  13. 13. Children’s Health Care
  14. 14. Health Insurance in America <ul><li>47 million Americans without adequate health insurance. * </li></ul><ul><li>The type of insurance held by most Americans and favored by public policy ** </li></ul><ul><ul><li>Employment based </li></ul></ul><ul><ul><ul><li>Tax subsidy in excess of $100 billion annually </li></ul></ul></ul><ul><ul><li>Individual insurance </li></ul></ul><ul><ul><ul><li>Held by 7% of Americans. </li></ul></ul></ul>* Kaiser Family Foundation, 2007; ** Knowledge@Wharton, 2000.
  15. 15. A National Health Plan <ul><li>Hacker’s Plan – 3 Principles </li></ul><ul><ul><ul><li>No one loses what they currently have. Unless, employer’s “kick” you out. </li></ul></ul></ul><ul><ul><ul><li>Creation of Health Care for American market (HCA) </li></ul></ul></ul><ul><ul><ul><ul><li>Insurers compete for business of individuals and employers. </li></ul></ul></ul></ul><ul><ul><ul><li>Group market contains strong public insurer modeled on Medicare creating competition between private companies and the public market. </li></ul></ul></ul><ul><ul><li>Kline, 2008 </li></ul></ul>
  16. 16. A National Health Plan <ul><li>Wyden’s Plan: Senator Ron Wyden (OR) and Senator Robert Bennett (UT): </li></ul><ul><ul><li>Lacks public insurer – no public-private competition . </li></ul></ul><ul><ul><li>Does away with employer health coverage almost entirely. </li></ul></ul><ul><ul><li>Create “Health Help Agencies” in each state. </li></ul></ul><ul><ul><ul><li>No “cherry-picking”, no high premiums, or denials of coverage for pre-existing conditions. </li></ul></ul></ul><ul><ul><li>Everyone pays the same price, but everyone has to buy insurance that’s at least comprehensive as the current Blue Cross-Blue Shield Standard Plan </li></ul></ul><ul><ul><li>Subsidies for low income </li></ul></ul><ul><ul><li>Penalties for those who do not buy </li></ul></ul><ul><ul><li>Medicare still exists for the elderly. </li></ul></ul>Kline, 2008
  17. 17. A National Health Plan <ul><li>Lewin Group – “ Gold Standard ” Healthcare consulting. </li></ul><ul><ul><ul><li>Estimates Hacker’s plan will save $1.04 Trillion over 10 years. </li></ul></ul></ul><ul><ul><ul><ul><li>Basic Efficiencies: Administrative and technological. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If it works, it will have two effects: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Money savings by mandating the HCA to spend less money. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Caps spending and induces providers to utilize available funds more cost effectively. </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Estimates Wyden’s plan will save $1.48 trillion over 10 years. </li></ul></ul></ul><ul><ul><ul><ul><li>Not from explicit spending caps as Hacker’s plan, but from consumers who see how much they are spending on health care and then become more price-sensitive and choose cheaper options. </li></ul></ul></ul></ul>
  18. 18. Public Policy <ul><li>Nursing Legislative issues </li></ul><ul><ul><li>Shortage, education, workplace issues </li></ul></ul><ul><ul><li>Resources? </li></ul></ul><ul><ul><ul><li>Professional Organizations (AACN, ANA, AONE) </li></ul></ul></ul><ul><li>Patient safety goals – 98,000 Americans die annually due to medical mistakes in hospital’s alone. </li></ul><ul><ul><li>Medication errors </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>New CMS guidelines </li></ul></ul><ul><ul><li>Resources? </li></ul></ul><ul><ul><ul><li>Joint Commission </li></ul></ul></ul><ul><ul><ul><li>Organizational policies </li></ul></ul></ul><ul><ul><ul><li>Centers for Medicare and Medicaid Services (CMS) </li></ul></ul></ul>
  19. 19. Policy Development: <ul><li>Scope: Who the policy is intended for: </li></ul><ul><ul><li>Example: Identify the range for the organization – (i.e., All PVHS Hospitals). </li></ul></ul><ul><li>Strategies for development: </li></ul><ul><ul><li>Criteria for a good policy </li></ul></ul><ul><ul><ul><li>Useful for intended users. </li></ul></ul></ul><ul><ul><ul><li>Includes policies on all levels and meets relevant criteria for accreditation and legislative requirements. </li></ul></ul></ul><ul><ul><ul><li>Will it improve quality service. </li></ul></ul></ul><ul><ul><ul><li>Evidence Based practice. </li></ul></ul></ul>
  20. 20. Policy Development <ul><li>Positioning nurses in strategic positions is one way to move these recommendations forward. We need to get nurse leaders at policy tables, decisions boards, leadership/CEO positions, and government positions. The Robert Wood Johnson Foundation will soon launch its Pipeline to Placement: Getting Nurses on Boards , a program that will match health and health care boards and commissions with an adequate number of nursing leaders who could fill those roles. </li></ul>Unruh, 2007
  21. 21. Tips for Writing Good Policies <ul><li>Devote time at least once per month to brainstorm issues pertaining to one area of the policy and review draft versions as required. </li></ul><ul><li>Be aware of the need to actually tailor policies to your own organization. </li></ul><ul><li>Be aware that borrowing other policies may result in approaches and styles of policy which are not compatible to others. </li></ul>
  22. 22. Tips for Writing good Policies <ul><li>Keep it Simple </li></ul><ul><li>Ensure Drafts have a number and date for ease of tracking. </li></ul><ul><li>Endorsed policies should include who authorized the policy and when. </li></ul><ul><li>Ensure there is someone in the organization who is responsible for maintaining control of policies and production of policy manual. </li></ul>
  23. 23. Public Policy & Political Competency Guidelines <ul><li>Be aware of the impact of the state board of nursing, Center’s on Medicare/Medicaid services, and the department of health services within your state on the practice of nursing </li></ul><ul><li>Participate in organizations that impact the practice of nursing. </li></ul><ul><li>Expect colleagues to actively participate in nursing and health-care policy organizations. </li></ul><ul><li>Meet with your state legislator at least every three months. </li></ul><ul><li>Invite legislator to your organization and chapter meetings to share ideas and influence policy </li></ul>Malloch, 2005
  24. 24. Professional Organizations
  25. 25. AACN’s Public Policy Agenda <ul><li>Framework established in January 1996 by the Board of Directors. </li></ul><ul><ul><li>1980’s – Health Policy and Legislative Committee continued to develop </li></ul></ul><ul><ul><ul><li>AACN – developed relationship with ANA by writing letters of support and providing testimony for legislative and regulatory issues. </li></ul></ul></ul><ul><ul><li>1990 – 1996 continued to develop and introduce a legislative fellowship. </li></ul></ul><ul><ul><li>April 1996 – Public Policy Work Group reviewed and clarified the framework. </li></ul></ul>
  26. 26. AACN’s Public Policy <ul><li>August 1996 – Developed three global public policy priority issues: </li></ul><ul><ul><li>Vulnerable populations </li></ul></ul><ul><ul><li>Public and community safety </li></ul></ul><ul><ul><li>Humane and ethical care. </li></ul></ul><ul><li>October 1996 – </li></ul><ul><ul><li>Resource kits developed for </li></ul></ul><ul><ul><ul><li>Organ donation </li></ul></ul></ul><ul><ul><ul><li>Tobacco-free kids </li></ul></ul></ul><ul><ul><ul><li>Domestic Violence </li></ul></ul></ul><ul><ul><ul><li>Bicycle helmet safety </li></ul></ul></ul><ul><ul><li>Introduced at NTI in May 1997 </li></ul></ul>
  27. 27. AACN Public Policy Priority Issues <ul><li>AACN ensures that vulnerable populations have access to quality health care. </li></ul><ul><li>AACN works to ensure public and community safety. </li></ul><ul><li>AACN works to ensure the provision of humane and ethical care. </li></ul><ul><li>Value of Nursing – 1999-Present </li></ul><ul><ul><li>Creating public awareness of nursing’s value to health care. </li></ul></ul><ul><ul><li>Advocating for solutions to the nursing shortages. </li></ul></ul><ul><ul><li>Addressing workplace issues which pose barriers to providing safe quality care. </li></ul></ul>
  28. 28. AACN’s Health Policy Restrictions <ul><li>Chapter’s may not participate in or contribute to political campaigns. </li></ul><ul><li>Chapters may not lobby on behalf of AACN. </li></ul><ul><li>AACN is a 501(c)3 organization which must comply with restrictions placed on lobbying and political activities. </li></ul><ul><li>Chapter members are prohibited from using their membership for any electioneering. </li></ul><ul><li>Chapter members are prohibited from contributing to political action committees. </li></ul><ul><li>Chapter members are prohibited from speaking on behalf of AACN unless they have been designated as an AACN spokesperson. </li></ul><ul><li>Chapter members are prohibited from endorsing, supporting or opposing issues on behalf of AACN unless they have been asked to do so by AACN. </li></ul>
  29. 29. AACN’s Advocacy Tool Kit <ul><li>12 Rules for working with public officials: </li></ul><ul><ul><li>Don’t underestimate public officials. </li></ul></ul><ul><ul><li>Don’t look down on government and politics. </li></ul></ul><ul><ul><li>Be understanding. </li></ul></ul><ul><ul><li>Forge Relationships. </li></ul></ul><ul><ul><li>Be Reasonable. </li></ul></ul><ul><ul><li>Be Thoughtful. </li></ul></ul><ul><ul><li>Don’t blame public officials for “Failing” to do what you wanted. </li></ul></ul><ul><ul><li>Be Cooperative. </li></ul></ul><ul><ul><li>Be Realistic. </li></ul></ul><ul><ul><li>Be Practical. </li></ul></ul><ul><ul><li>Be a good Proponent. </li></ul></ul><ul><ul><li>Be Informed </li></ul></ul><ul><li>AACN-Advocacy Tool Kit </li></ul>
  30. 30. Capwiz Home Page - AACN
  31. 31. Capwiz Elected Officials
  32. 32. Issues and Legislation
  33. 33. Nursing Legislation <ul><li>Current Legislation : </li></ul><ul><ul><li>H.R.4001 To amend title VIII of the Public Health Service Act to expand the nurse student loan program, to establish grant programs to address the nursing shortage, to amend title VII of the Higher Education Act of 1965 to provide for a nurse faculty pilot project, and for other purposes. </li></ul></ul><ul><ul><li>H.R.2572 To amend the Higher Education Act of 1965 to establish a student loan forgiveness program for nurses. </li></ul></ul><ul><ul><li>H.R.2123 To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes. </li></ul></ul><ul><ul><li>H.R.2122 To amend title XVIII of the Social Security Act to provide for patient protection by limiting the number of mandatory overtime hours a nurse may be required to work in certain providers of services to which payments are made under the Medicare Program. </li></ul></ul>
  34. 34. Nursing Legislation <ul><ul><li>H.R.2066 To amend title XIX of the Social Security Act to improve access to advanced practice nurses and physician assistants under the Medicaid Program. </li></ul></ul><ul><ul><li>H.R.1567 Stop TB Now Act of 2007 </li></ul></ul><ul><ul><li>H.R.772 To amend the Public Health Service Act to authorize capitation grants to increase the number of nursing faculty and students, and for other purposes. H.R.677 To provide for a study by the Institute of Medicine of the National Academy of Sciences to identify constraints encountered by schools of nursing in admitting and graduating the number of nurses sufficient to meet the health care needs of the United States, and for other purposes </li></ul></ul>
  35. 35. Communicating with Legislators
  36. 36. Telephone Communication <ul><li>Telephone: 202-224-3121 </li></ul><ul><ul><li>Ask for your Senator’s or Representative’s office. </li></ul></ul><ul><ul><li>Search the Congressional database for your representative. </li></ul></ul>
  37. 37. Telephone Communication <ul><li>Phone calls are not generally handled by the member of Congress. They have assigned staff aides which do this. </li></ul><ul><ul><li>Identify yourself and ask to leave a brief message for Senator/Representative (_____) that you either support or oppose (S.____/H.R.___). </li></ul></ul><ul><ul><ul><li>“Good Morning, My name is Todd Grivetti and I am a Critical Care Registered Nurse. I would like to leave a message for Representative Musgrave in opposition of HR 2123.” </li></ul></ul></ul>
  38. 38. Telephone Communication <ul><li>You may also want to state your reason for your support or opposition. </li></ul><ul><li>Ask for the senator’s or representative’s position on the bill. Also request a written response to your telephone call. </li></ul><ul><li>Write down the name of the staff member you spoke with for future reference. Utilize them as your point of contact. </li></ul><ul><li>AACN – </li></ul>
  39. 39. Pitfalls to Telephone communications <ul><li>No written documentation – no visual proof you actually made the phone call. </li></ul><ul><li>No way of guaranteeing that your message or your name, telephone number or address is recorded correctly. </li></ul><ul><li>Generally not ideal for introducing yourself to a legislative assistant. </li></ul><ul><li>Mason, 2007 </li></ul>
  40. 40. Letter Writing tips <ul><li>The saying “The pen is mightier than the sword” is prolific in nursing’s political action arena. As nurses we know what happens on a daily basis and WE have the power to facilitate change in daily practice. </li></ul><ul><li>The nurse with political competency knows what the rules are or policies are for the profession and the industry, knows who or what organization created them, the rationale for their existence, and how they impact the provision of health-care services. </li></ul><ul><li>(Malloch, 2005) </li></ul>
  41. 41. Three “rights” of letter writing: <ul><li>Right Letter. </li></ul><ul><li>Right elected official. </li></ul><ul><li>Right time. </li></ul>
  42. 42. Writing guidelines <ul><li>When writing to members of congress or a state or local official there are general guidelines: </li></ul><ul><ul><li>Direct your letter according to the legislator’s responsibility. </li></ul></ul><ul><ul><li>Only write to the elected officials that represent you. </li></ul></ul><ul><ul><li>Clarify your issue. You may write to the chair of a specific committee if your representative does not sit on that particular committee. </li></ul></ul><ul><ul><li>Time your letter(s) to allow staff to address issues prior to pressing any legislation. </li></ul></ul><ul><ul><li>Your purpose for writing should be stated in the first paragraph of the letter. If the letter pertains to a specific legislative bill, identify it accordingly, e.g., House bill: H.R. ____, Senate bill: S.___. </li></ul></ul><ul><ul><li>Be courteous, to the point and include key information, using specific examples to support your position. </li></ul></ul><ul><ul><li>Address only one issue per letter. Keep the letter to a minimum of one page. </li></ul></ul>Mason, 2007; AACN Legislation Center
  43. 43. Letter to Senator <ul><li>Address: </li></ul><ul><ul><li>The Honorable (Full Name), (Rm #), (name of) Senate Office Building. United States Senate, Washington, D.C. 20510 </li></ul></ul><ul><ul><ul><li>The Honorable Ken Salazar, 702 Hart Senate Office Building, Washington, D.C. 20510-0605. </li></ul></ul></ul><ul><ul><ul><li>Salutation: Dear Senator Salazar </li></ul></ul></ul><ul><li>Source: (AACN Legislative Center, 2008; Mason, 2007). </li></ul>
  44. 44. Letter to Representatives <ul><li>Address: </li></ul><ul><ul><li>The Honorable (Full Name), (Rm#), Name of House Office Building. United States House of Representatives, Washington, D.C. 20515 </li></ul></ul><ul><ul><ul><li>The Honorable Marilyn Musgrave, 1507 Longworth House Office Building, Washington, D.C. 20515-0604 </li></ul></ul></ul><ul><ul><ul><li>Salutation: Dear Representative Musgrave, </li></ul></ul></ul><ul><li>Source: AACN Legislative Center. </li></ul>
  45. 45. Full address Salutation Purpose for writing the letter
  46. 46. E-Mailing Tips <ul><li>Generally, same guidelines as with letter writing. </li></ul><ul><ul><li>Most legislators have e-mail addresses embedding on their websites. </li></ul></ul>
  47. 47. American Nurses Association
  48. 48. American Nurses Association <ul><li>Current Health Care policy agenda’s </li></ul><ul><ul><li>Nursing’s agenda for the future </li></ul></ul><ul><ul><li>ANA’s Health Care Agenda 2005 </li></ul></ul><ul><ul><li>Workforce trends among U.S. Registered Nurses. </li></ul></ul><ul><ul><ul><li>Position Statements: </li></ul></ul></ul><ul><ul><ul><ul><li>Stem Cell Research 1/10/2007 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Privacy and Confidentiality 12/8/2006 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Assuring Patient Safety: Registered Nurses’ Responsibility in All Roles and Settings to Guard against Working when Fatigued 12/8/2006. </li></ul></ul></ul></ul>Source: American Nurses Association, 2008.
  49. 49. ANA’s Election 2008 Action Center <ul><li>Created to be a one-stop resource to help find information about the 2008 elections. </li></ul><ul><ul><li>Provides information on election processes </li></ul></ul><ul><ul><li>Candidate information both Democrat and Republican. </li></ul></ul><ul><ul><li>Publish </li></ul></ul><ul><ul><ul><li>Capitol update 10 times annually. </li></ul></ul></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul>
  50. 50. State and Local Issues <ul><li>Utilize Kaiser Family Foundation </li></ul><ul><li>Utilize your state nursing association </li></ul><ul><li>Utilize your state hospital association to find out any upcoming or pending legislation issues. </li></ul><ul><li>Utilize your state legislative web sites. </li></ul>
  51. 51. Conclusion <ul><li>As critical care nurses, we have a unique opportunity to make a difference in legislative issues. </li></ul><ul><li>Identify your passion and write in either support or opposition </li></ul><ul><li>Get involved in organizational, local, state and national policies </li></ul><ul><li>Contact your state legislator’s when you get home. </li></ul>
  52. 52. References <ul><li>Alliance for Health Reform (2007). Massachusetts Health Reform Tool Kit. Retrieved November 25, 2007, from </li></ul><ul><li>Alliance for Health Reform (January 1, 2006). The Uninsured and Rising Health Care Costs. Retrieved November 25, 2007, from </li></ul><ul><li>American Association of Critical Care Nurses (2007, November.) Legislative Action Center. Retrieved November 30, 2007, from </li></ul><ul><li>Dickinson, L., (2007). Meeting the Dilemma of Health Care Access: Extend Insurance coverage while controlling costs . Brookings Institute. Retrieved July 5, 2007, from </li></ul><ul><li>Federation of American Hospitals and Families (2007). Presidential Candidate Forums . Retrieved November 27, 2007, from </li></ul>
  53. 53. References <ul><li>Kaiser Family Foundation (2007). State Health Facts. Health Coverage and Uninsured . Retrieved November 25, 2007, from </li></ul><ul><li>Kaiser Family Foundation (September 14, 2007). Establishing Universal Health Insurance System Would Help to Address Racial Health Disparities . Retrieved September 14, 2007, from </li></ul><ul><li>Kline, E., (2008). The Elusive Politics of Reform. Prospect Liberal Intelligence. Retrieved April 28, 2008, from </li></ul><ul><li>Malloch, K., Porter-O’Grady, T. (2005). The Quantum Leader: Applications for the new world of work. Boston. Jones and Bartlett Publishing. </li></ul><ul><li>Mason, D., Leavitt, J., Chaffee, M. (2007). Policy & Politics in Nursing and Health Care (5th Ed.). Philadelphia. Elsevier Saunders. </li></ul><ul><li>Unruh, L., Hassmiller, S. (2007). Legislative: Economics of nursing invitational conference addresses quality and payment issues in nursing care. Retrieved April 15, 2008, from </li></ul>
  54. 54. References <ul><li>What Policy Makers Don’t Know About Health Insurance. Knowledge@Wharton, (2000). Retrieved April 14, 2008, from http:// =185 </li></ul><ul><li>Yacuk, M., (2007). Health Care coverage in America: Understanding the issues and Proposed Solutions. Alliance for Health Care Reform . Retrieved April 10, 2007, From </li></ul>
  55. 55. Web References <ul><li>American Association of Critical Care Nurses Legislative Action Center – </li></ul><ul><li>American Hospital Association – </li></ul><ul><li>American Nurses Association – </li></ul><ul><li>Campaign for Children’s Health Care. </li></ul><ul><li>Hastings Center – </li></ul><ul><li>Institute for Healthcare Improvement – </li></ul><ul><li>Institute of Medicine (IOM) – </li></ul><ul><li>Kaiser Family Foundation – </li></ul><ul><li>Library of Congress – </li></ul><ul><li>Source Watch Encyclopedia – </li></ul>
  56. 56. ? Questions ? U R Y
  57. 57. Estes Park, CO E-mail [email_address]

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