Eileen Sullivan-Marx: Journal readers are a wide range of nurses. Policy, Politics, and Nursing Practice has been something that I’ve been involved with for most of my career because it intersects the things that matter to me most—policy, politics, and practice. The readers often are graduate students and faculty. Faculty use the articles for undergraduate students as well.
You’ve done so much for nursing. In fact, that is one of the things that I think is unique about you. From the get go, you have been out there as a nurse who’s running for Congress. A number of people who are nurses have been in Congress over generations. But to me, you took it on as you’re running for Congress and you’re getting involved in politics and policy, because you are a nurse and use nursing as your framework for who you are. You’ve just been marching forward with a new banner and a new wind under your sails for nursing. I think that’s what excites so many nurses about your career. We want to know a little bit about how you came to that.
First, as maybe a student thinking about nursing. Then, you’re a nursing student and then at what point did you see the way to blend policy and politics and nursing?
Lauren Underwood: When I was in elementary school, I was diagnosed with a heart condition, and it was that early experience with my pediatric cardiologist and team that inspired me to go into health care. I just knew that I wanted to help people and help other young kids like me who were going through scary kind of isolating times. I didn’t know anybody else who had an experience like I had. There were these really compassionate adults and it’s the care that I received that put me on this path.
I picked nursing in high school because it was really important to me to stay in the health care field. I had discovered public health, and I knew that that’s what I wanted to do. Community and population level interventions that’s how I would phrase it now. In high school, I wouldn’t have quite said it the same way, but I knew I was going to need a master’s degree in order to really have the kind of impact that I wanted, and so I was looking for an option for an undergrad major that would enable me to always have a job. That was so important to me just given what was going on economically in our country and within my family. It was important for me to always be able to work, and that was what was so attractive about nursing. I could move anywhere in the country. I could always work and I would have this great foundation to be able to build upon if and when I might be fortunate enough to be able to continue my education. At the same time, my family was always politically aware. They were not politically active, so we were not active in campaigns. My parents were not active, even with advocacy groups. But we watched the news every night. I read the newspaper—the physical newspaper—every day and I was aggressive about it, I had to be the first person to read that newspaper, because I did not want to see it crumpled-up or see any section missing. I wanted to be first reading the newspaper.
In high school, the Mayor of my town set up this program for the first time that high school students could get appointed to local boards and commissions. When I was 16, I got a one-year appointment to our town’s Fair Housing Commission. This was during the time that the courts were deciding whether Section Eight Vouchers [government assistance program to help families obtain and retain a home] were legal sources of income. If there were then any apartment complexes that were discriminating against people because they had the Section Eight Vouchers were in violation of civil rights law. Our community had this reputation of being very open, welcoming, and diverse. What I found in serving on this Commission was that everybody didn’t have that same experience. I loved it. I was young. I was curious. I was opinionated. I was the student Commissioner.
I was learning about a new field in my community but really having impact. I got reappointed my senior year. Then went to the University of Michigan to study nursing. I knew about public health. I was interested in public health. I was interested in politics broadly, and I had this experience in local government. I didn’t know what I was going to do with all of those things. Then, second semester freshman year at 8 a.m. on a Monday, there was an honors seminar that I had to take. It was mandatory for 10 of us. I was the only person excited because it was policy and politics in nursing and health care. We used that iconic textbook [edited by Diana Mason].
Dean Ada Sue Hinshaw, the legend, was our faculty along with Dr. Barbara Guthrie. They guided us through this introduction to health care policy and nursing policy and what we could do and the impact we could have. My mind was blown. I had never heard that phrase health policy before. And when I found out about it, I was like that’s exactly what I want to do. So, I was blessed and fortunate to be introduced so early in my curriculum, so early in my career. Then, I made every decision from that point in order to get the experience that I would need to be impactful. The summer after my sophomore year I interned for Senator Obama in DC. The summer after my junior year I interned for the Centers for Disease Control and Prevention in Atlanta. Then, the summer after my senior year I was enrolled in my Master of Public Health (MPH) program. I was focused once I found out which pathway I wanted to follow.
Eileen Sullivan-Marx: That’s terrific. You know so many of us have had that experience of being active. For me, it was in the 60s in high school and in my town. My parents were not active but very aware of politics. My mother was always an Election Board Judge of Elections. We ran a small business in town, so you knew a lot of people. I had an uncle who owned a small-town newspaper. It was always that kind of exposure. I think you were able, in your generation to jump right in—the fact that you were exposed to Ada Sue Hinshaw and Barbara Guthrie at that point. Because for so many of us it was this thing over there on the side. Chris Kovner can identify. We would join a nursing organization. But it’s the directness I think that you were able to do and that hasn’t been easy, because I think some people say how real are you. Because in our day you had to do two years of med-surg. In fact, if you wanted to do Community health, you had to go round robin to get there. I think that’s a great advantage for you. Can you say something about some of that? Comments you might have had where people are saying wow how is this nursing health policy? How is it practice?
Lauren Underwood: What’s interesting is that my alma mater, University Michigan, was very clear that they were training us to be exceptional nurses and exceptional nurse leaders. And that was always the foundation. They fully expected us to go on and be an APRN [advanced practice registered nurse] and they expected us to go on and be faculty. They expected us to be innovators and leaders and that’s why I think that they’re not entirely shocked that I ended up in Congress. Because there was this expectation that we were going to go on and do these great things for our profession, to push the profession forward, and I just happened to be in school at that time.
In the late 2000s, we had a nursing shortage. The profession was innovating in terms of how we were going to meet the needs for the future of our profession. There was an openness to have the accelerated degree programs and accelerated PhD programs, to have impact, looking at the demographics of our profession, looking at the growth that we were seeing across the country and the need for people to lead in order to take care of our communities. For me, I felt really comfortable expressing my ambition and I felt supported within my institution that they were going to find clinical opportunities for me to meet the qualifications, yet still explore my unique interests and I felt supported in my ambition. That’s just unique, I would say in general, and that’s not just for nursing. I think it’s something that’s unique for young women. I think it’s unique for people of color to be not only yes that’s great, go for it, but what can we do to help you? Here are some people that you should talk to, connecting me with mentors and friends during this crucial time when I was exploring what a career in health policy could mean and, as you know, there are so few policy nurses. It is an incredibly small community. And so, as a result, we all know each other and to be introduced to that community as a student and then be connected and supported in that way, I never felt limited.
Eileen Sullivan-Marx: That’s great. That’s important to note for this article that Representative Underwood never felt limited. Even recently into my PhD program writing my essays, it was you’re not going to do that policy stuff. You’re going to do X, but I kept doing the policy stuff on the side, but yet it is what I became most known for. I had to do this other thing, which was good work, but anybody could have done it, I wanted to drive unique things.
Lauren Underwood: When I was looking for graduate programs that was part of my assessment. Could I find a place that would be equally or even more supportive and more creative in terms of the ways that I could get these competencies and what it meant to be a public health nurse and be the best public health nurse. Then, also, to be able to grow and learn and contribute and that’s why I went to Hopkins and also the proximity to DC. What I wanted to do was clear from the beginning. I think that’s something really special and I hope that more and more schools of nursing have the courage to embrace students who may express some nontraditional goals.
Eileen Sullivan-Marx: I know that you’ve been supportive of recommendations we’ve made to Congress for funding nursing education. Tell us a little bit about that inflection point when you decided to run for Congress.
Lauren Underwood: I had spent seven and a half years working at the U.S. Department of Health and Human Services (HHS). I was first a career employee working on the affordable care act [ACA], private insurance reform, health care quality and Medicare, preventive services, and basically anything the Obama administration was getting sued on related to the ACA was in my portfolio and I loved it. I spent my early 20s doing this work to connect 23 million Americans with coverage. And then I joined the administration [in an appointed position] to work on public health emergencies and disasters. I joined the Obama administration the week that Mr. Duncan had Ebola in Dallas. We did Zika, the water crisis in Flint and all sorts of natural disasters and emergencies. I stayed until the last day [of the Obama administration]. The Trump transition made it really clear that they wanted to take away health care coverage from people, which was not what I was about. I knew I couldn’t stay in government to help them. I had a choice about staying in or leaving because I had been a career person first at HHS.
I left the executive branch and returned home to Illinois. I was working for a Medicaid Managed Care Plan in Chicago living my best life and I just happened to go to my Congressman’s town hall.
This was during the time of Obamacare repeal during the spring of 2017. There were all these versions of Obamacare repeal that were up for consideration. And the Congressman said that he was only going to support a version of repeal that let people with preexisting conditions keep their health care coverage. I was a nurse that worked on the ACA and I have this health care condition. And when he made that promise I believed him. That was his line in the sand. Literally two weeks later he voted for the American Health Care Act, which was the version of repeal the did the opposite and made health insurance cost prohibitive for people like me to get care. I got really upset. I was just furious and I said, you know what – I’m running. This is too important. You can’t be cavalier with people’s health care.
And so, I did all the things: you reach out to the party and start talking to folks. But what was really key is I went to lunch with one of my girlfriends and told her I had this crazy idea to run for Congress. She pulled out her notebook at lunch and started writing things down and she was my partner in that first primary campaign and we figured it out. When I said I was the most unlikely person, people were like oh wow that’s so sweet that you’re running. They didn’t even think I had a chance, but I beat six guys in that primary. And beat that incumbent Congressman in November 2018.
Eileen Sullivan-Marx: Besides the fact that you were enthusiastic, passionate, well informed, what was one of the drivers as to why you kept leaping forward beyond the usual kind of a candidate?
Lauren Underwood: Two things. The number one issue in the election was health care and I brought expertise as a nurse. Someone who worked on the ACA. I was working for a provider-a private company. I’ve been a patient and I understood the law as it was, and I had a greater understanding of the ACA than my opponent, the Congressman, and then all my primary opponents—these six guys –they’re great guys—they just did not have the expertise. When I walked into a room, even with people who didn’t share my political point of view, they knew that I was very clear on what was going on in our health care system. I had many solutions. They knew that I understood the problem and I understood what was going on with their families and that I had been fighting for years to try to solve it. They knew that there was alignment between the key issue and my background. Health care was number one across all demographics including our farmers who had been searching for health care solution for their families for years, and had not found anything that would work. That enabled us to walk into every room and be taken seriously, even if we didn’t agree on anything. People knew that on this issue, which was important to them, that I had credibility. The second thing is that we were willing to show up everywhere in person to engage people and build connections.
I remember that first clinical skills course that I took in school and we were taught how to build rapport with our patients—to have that connection in a few short moments because you don’t have a lot of time when you walk in. You introduce yourself. You have to look into their eyes and say “hi I’m Lauren. I’m your nurse, how are you today?” And if they’re nonverbal you’re doing that with a family member or someone else that’s there with them, because if you don’t have that trust and that therapeutic relationship it’s not going to go well during your shift and you really could set that patient back. It’s up to us to be skilled at building that connection. I do that every day in my job and I was stunned when I identified that it feels the same way in the campaign at it did walking into that patient’s room.
Eileen Sullivan-Marx: That’s a great point. I think that we start to so internalize nursing that we take ourselves for granted. Do you think that? So that you say this is nurse power and nurse skill.
Lauren Underwood: It’s the same skill sets and I think that you know the nursing process, the way that we solve problems, the analytical abilities that we have. That you don’t jump to the intervention before doing an assessment. And that you do a complete assessment before jumping to an intervention. That process has guided me through Congress and it has offered a lot of clarity, because a lot of my colleagues have no idea what problem they’re trying to solve. And there’s this superficial understanding. No one is an expert on everything. But I do think that, for the things that we’re going to call ourselves (I focus my time and energy on X), we have got to take the time to do the assessment. And that is something that was just ingrained throughout my education and that I’ve applied as a Congresswoman. I say that I am a data-driven evidence-based policy maker. We take our cues from the literature. We try to embrace solutions that have some suggestion that they would work as intended. If the evidence is not robust then I’ll write a bill asking for more information. Can the General Accountability Office (GAO) do the study? Can we find somebody to get us this information so that we can make an informed decision?
Eileen Sullivan-Marx: One of the things that I noticed too is if I’m alone, as the only nurse and I’m doing this that once I start getting a few more nurses engaged in something—in a board or in a process—then we’re all doing it together. It’s the lift for nursing to really make a profound difference. It starts to surprise everyone. I’ve certainly done that—at NYU and I’ve done it elsewhere. How do you connect to other representatives? We don’t have a senator at this point who’s a nurse. How is that network and what is your vision? Would it be to have 20 nurses in Congress?
Lauren Underwood: Right now there are three of us. There is Chairwoman Eddie Bernice Johnson. She’s the Chair of the Science, Space and Technology Committee, which is just incredible to have someone with her expertise. I have a new colleague, Cori Bush from St Louis. It’s been so great, because all three of us are Democrats and we’re all Black women. We’re from different generations and from different regions of the country. Our approach to the job is different and yet we share, I think, this common recognition of the importance of health care and people’s health—social-emotional wellbeing. In terms of an embrace and a recognition of the roles social determinants of health play and a willingness to speak out regardless of the policy issue on the impact that those can have on the communities that we serve. We talk about issues differently. We do the work differently. I would love it if we had a nurse colleague on the other side of the aisle. I think it would create a richer dialogue about these important issues like health care, economic security and right now we have so much food insecurity in this country. Because of the pandemic and people lost their jobs and it’s just such a volatile environment, you do not have to be on one side of the aisle or another to acknowledge how important it is to have access to healthy, nutritious foods and, unfortunately, when the conversation ends up being dominated by people from one part of the country or one political persuasion or one gender or one race other folks tune it out and they think that it’s radical or that there’s something extreme about it. When, in reality, what we’re talking about is our values. I think that as nurses, we share a lot of values.
I taught for a number of years at Georgetown. It was required course in the master’s program and my students at the beginning would always come in and they’d say “Why do I have to take this class? This is so ridiculous. I’m not political. I don’t care if my husband makes the political decisions for our family.” And then, by the end of the term they would say, “I see.” You have this experience most likely. There’s this tension between who supports nursing, who supports us, who supports our profession, and who is crafting policies that will help our patients. And who, as the nurses, people are more aligned to vote for and then, when they start digging in, some folks start to see that their favorite candidates are not always aligned with their professional values or their personal values or who they are, there’s a tension there. And having to coach folks that it’s okay to be supportive and to lobby and to advocate and to champion someone who is doing the work on behalf of your colleagues and your community and still not want to vote for that person. It’s okay to have that kind of point of view. It was so powerful for our profession for people to see what it means to be a nurse grounded in these values that say that people should have health care. People shouldn’t be going hungry. Folks should be able to afford their prescription drugs. Seniors should be treated with dignity and have end of life care, compassionate comprehensive end of life, care and not come from a Democrat’s mouth.
Eileen Sullivan-Marx: But imagine if we had 20, 30, or 40 nurses [in Congress]. It would be huge because that’s how we move forward. One of the things that when you’re talking to an undergraduate student and they’re in that course that they don’t want to take what advice do you have to faculty who teach that course? What kind of tricks do you have? Do you assign projects?
Lauren Underwood: I always was very clear about what was fact and what was opinion. Is it politics? We all have these beliefs and convictions and mine would obviously creep out as I was teaching. I always tried to be very clear to give alternate sources and use nonpartisan sources to maintain credibility. I would also encourage folks to pick projects that aren’t necessarily the most straightforward hospital clinical projects. We used to do a lot around sidewalks. If you are advocating for sidewalks in your community is that a public resource that the taxpayers should be funding? It’s not a partisan issue like Medicare and payment policy but a public good for public benefit in terms of injury prevention. It is much is easier to teach students individual skills than to teach them how to articulate their point of view using the evidence. There’s robust evidence around injury prevention and helmet use and whatever without a partisan point of view. They were getting confused as to that tension point I was talking about.
Eileen Sullivan-Marx: Like Wi-Fi access in neighborhoods, whether it be for small businesses or individuals.
Lauren Underwood: Things like that.
Eileen Sullivan-Marx: You can move that forward. That’s certainly one of the things that can be helpful. What’s your typical day like? You have talked a little bit about your committee responsibilities.
Lauren Underwood: In this Congress, I am assigned to two committees—the House Committee on Veterans’ Affairs (VA). I’m on the Health Subcommittee. The VA is an incredible health care system that has its challenges. I focus pretty exclusively on suicide prevention, mental health, and women’s health care. The VA has this unbelievable responsibility for caring for women veterans across the lifespan. I think folks forget that there are still cadet nurse corps members from World War II that are alive and they’re active and they’re getting care in the VA that has been inconsistent at best. I also serve on a House Committee on Appropriations. The Congress has three core functions: we create programs and we call that authorizing to solve problems. We fund the federal government appropriations, including funding those programs, and then we do Congressional oversight over the executive branch. Within the appropriations committee I am assigned to the Agriculture Subcommittee, which also has jurisdiction over the Food and Drug Administration. That’s how we fund COVID and tobacco. Trying to make sure that we are curbing the tobacco usage epidemic. And then I serve on the Homeland Security Subcommittee. There we have ICE [U.S. Custom and Immigration Enforcement], immigration, Federal Emergecy Management Agency (FEMA), cyber security, and the US–Mexico border and the Canadian border. It’s fascinating and then obviously I still do health care work, too.
Eileen Sullivan-Marx: I remember when I was involved in my fellowship for policy that it is agriculture that has a lot to do with senior centers because it really is a lunch program. What kind of assistance would be great for nursing to give you? We have enthusiastic students, we have enthusiastic graduate students, and we have retired faculty. How can we be helpful to you?
Lauren Underwood: In addition to that, I also cofounded and am cochair of the Black Maternal Health Conference to improve our nation’s the maternal mortality crisis and we’ve had such incredible support from the nursing community in that work, which has just been extraordinary. We’ve already made significant change. The American Rescue Plan, which is the latest COVID package, included our Medicaid expansion. For the first time, we’re extending Medicaid coverage to folks for the full year long postpartum period, instead of their coverage cutting off 60 days, which we know is just completely inadequate. Nurses have been so helpful for us in terms of gathering and presenting evidence. Many of these problems have a local focus and for us in Congress it is very difficult to get that kind of local data. Evaluation type data demonstrating that an intervention is effective. We can build relationships with nurses, either in our communities or folks who’ve been impacted by these problems. Site visits and testimonial stories are very powerful. I think that nurses take for granted that every elected official knows a nurse or has interacted with nurses. We assume that they know about the work that we do. In my experience that is completely false. They have no clue what happens at schools of nursing. They have no idea the level of expertise that a BSN graduate brings. They have no idea what APRNs do. They have no idea what practicing to the full extent of our education and training means. We [nurses] have got to do better about inviting them [members of Congress] in. My colleagues are very familiar with physician education. Their whole advocacy strategy is completely different than how nursing engages members of Congress and we’ve got to step it up.
Eileen Sullivan-Marx: Absolutely that’s a great point well, I know that we had about 30 minutes to cover this interview.
Lauren Underwood: Thank you. I’m honored to be able to help lead us forward. Let me know what ideas you have. I mean we really love when people come to us with ideas. The first time I heard that we are going to be proposing a billion dollars for nursing education, I wasn’t sure, and then I thought is that enough?
Eileen Sullivan-Marx: Thanks for this interview. Thanks for everything that you do. You’re such an inspiration to all of us and, of course, anything we can do let us know. Call us and you can call them the Academy [American Academy of Nursing]. Thank you.
