Access to affordable healthcare remains a major policy concern in the United States, particularly for individuals living in low-income households, rural communities, and medically underserved areas. Although programs such as Medicaid have improved access to healthcare services, differences in state eligibility requirements, financial barriers, and shortages of healthcare professionals continue to affect vulnerable populations. Addressing these concerns requires more than identifying healthcare disparities. Policymakers and healthcare advocates must understand how an issue receives political attention and how proposed solutions become legislative priorities.
Kingdon’s Multiple Streams Framework (MSF) provides a useful approach to understanding this process. The framework explains how policy problems, available solutions, and political conditions interact to create opportunities for policy change (Hoefer, 2022). This assessment examines the major components of MSF, explains why the framework is appropriate for advocating expanded healthcare access, and discusses its application to Medicaid expansion and community-based healthcare programs. It also considers the role of nursing professionals in influencing healthcare policy decisions.
Kingdon’s Multiple Streams Framework is a policy analysis model that explains how certain public concerns gain the attention of government decision-makers while others remain unresolved. The framework identifies three streams that influence the policymaking process: the problem stream, the policy stream, and the politics stream. These streams generally operate independently, but their convergence can create an opportunity for meaningful policy action (Bolukbasi & Yıldırım, 2022).
The problem stream concerns situations that policymakers and the public recognize as requiring government intervention. In healthcare, these problems may include inadequate insurance coverage, increasing treatment expenses, preventable hospitalizations, and unequal access to primary care. Evidence from public health reports, healthcare organizations, and community assessments can help establish the seriousness of these concerns. However, the existence of a problem does not automatically guarantee that policymakers will address it.
The policy stream involves developing and evaluating possible solutions. For healthcare access, proposed interventions may include expanding Medicaid eligibility, increasing financial support for community health centers, and improving access to preventive services. Policy proposals must be financially realistic, technically feasible, and acceptable to relevant stakeholders to gain serious consideration (Hoefer, 2022).
The politics stream reflects the political environment in which decisions occur. Changes in government leadership, legislative priorities, public attitudes, and interest-group activities can influence whether a proposal receives support. When favorable political circumstances coincide with a recognized problem and an available solution, a policy window may emerge.
According to Bolukbasi and Yıldırım (2022), institutional arrangements influence how political actors participate in the policy process. This observation is particularly relevant to American healthcare policy because federal and state governments exercise different responsibilities over Medicaid. Understanding these institutional relationships helps advocates identify where and when policy change may be possible.
The Multiple Streams Framework is appropriate for the healthcare access advocacy agenda because it connects evidence-based problem identification with practical policy development and political decision-making. Healthcare disparities are influenced by several interconnected factors, including insurance eligibility, household income, geographic location, and the availability of healthcare providers. Consequently, addressing these disparities requires a framework that considers both healthcare needs and the political conditions affecting reform.
One advantage of MSF is its emphasis on agenda-setting. Healthcare advocates may have strong evidence demonstrating a need for expanded coverage, but their recommendations may receive limited attention when political priorities are focused elsewhere. MSF encourages advocates to recognize circumstances that could increase support for healthcare reform, including changes in legislative leadership, public concern about healthcare affordability, and discussions about state healthcare budgets (Hoefer, 2022).
Another advantage is the framework’s recognition of policy entrepreneurs. These individuals or organizations invest their expertise, relationships, and resources in promoting policy proposals. Nurses, professional associations, community organizations, and healthcare administrators can serve in this capacity by communicating patient experiences, presenting research findings, and encouraging policymakers to consider practical solutions.
Sykes et al. (2023) discuss the skills and professional development needs of public health practitioners who participate in policy advocacy. Their work supports the importance of preparing healthcare professionals to engage with policymakers rather than limiting their responsibilities to direct patient care.
MSF is therefore particularly relevant to nursing advocacy because it provides a structured way to connect clinical concerns with the political activities necessary to influence healthcare policy.
The first step in applying MSF involves establishing limited healthcare access as a public policy problem. Individuals without affordable insurance coverage may postpone medical appointments, avoid preventive screenings, or experience difficulty obtaining treatment for chronic conditions. These barriers can increase the likelihood of complications and place additional pressure on emergency departments and other healthcare services.
Healthcare advocates can strengthen the problem stream by collecting evidence about insurance gaps, unmet healthcare needs, and differences in service availability across communities. For example, nurses working in rural health facilities may identify recurring difficulties among patients who must travel long distances to receive specialized care. Such observations can help define policy concerns when supported by reliable community health data.
The importance of presenting evidence clearly is consistent with the broader role of empirical research in informing health interventions. Leresche et al. (2023) examined how the implementation of empirical research findings is documented in conflict-affected settings. Although their study does not directly evaluate Medicaid expansion, it illustrates the importance of connecting research findings with implementation processes.
For healthcare access advocacy, presenting understandable evidence about the consequences of limited coverage can help policymakers recognize the need for intervention.
The policy stream focuses on identifying interventions capable of addressing the recognized healthcare problem. Medicaid expansion represents one possible approach because it can extend insurance eligibility to additional low-income adults in participating states. However, insurance coverage alone does not guarantee that patients can obtain timely services. Provider availability, transportation difficulties, and administrative requirements may continue to create barriers.
A comprehensive policy proposal should therefore combine coverage expansion with investments in community-based healthcare services. Increased support for community health centers, telehealth infrastructure, and preventive care programs could improve access for populations facing geographic or financial limitations.
Policy development also requires careful consideration of implementation costs and administrative feasibility. Legislators may be more receptive to proposals that clearly describe expected benefits, funding arrangements, and responsibilities among healthcare organizations.
The Multiple Streams Framework helps advocates prepare these proposals before favorable political opportunities arise. Instead of waiting until an issue becomes politically prominent, advocacy groups can develop evidence-based recommendations that are ready for legislative consideration (Hoefer, 2022).
Political circumstances strongly influence whether healthcare access proposals progress through the legislative process. State elections, leadership transitions, budget negotiations, and changes in public attitudes may create opportunities for policy discussions. However, these circumstances can also introduce resistance when policymakers disagree about government spending or the appropriate role of public insurance programs.
Within MSF, advocates must understand the political environment and adjust their strategies accordingly. For example, a state legislature considering changes to healthcare funding may provide an opportunity to introduce proposals supporting Medicaid eligibility or community health services.
Advocacy organizations can respond by meeting with legislators, providing policy briefs, and presenting evidence about the needs of underserved populations. Partnerships between nursing associations, patient representatives, healthcare organizations, and community leaders may also strengthen support for proposed reforms.
Sykes et al. (2023) emphasize the relevance of advocacy capabilities among public health professionals. These capabilities include communicating policy concerns and participating in activities intended to influence decisions affecting population health.
The central strength of MSF becomes apparent when the three streams converge. A recognized healthcare access problem may attract political attention at the same time that a practical policy proposal becomes available and government leaders demonstrate an interest in reform.
For example, consider a state where evidence reveals substantial gaps in healthcare coverage among low-income adults. Healthcare organizations have already developed a Medicaid expansion proposal, and newly elected policymakers identify healthcare affordability as a legislative priority. These circumstances could create a policy window for advancing the proposal.
This example is an illustrative policy scenario rather than a documented legislative event. It demonstrates how the framework can guide advocacy by identifying the relationship between public problems, proposed solutions, and political conditions.
Policy entrepreneurs are particularly important during these periods because opportunities for reform may be temporary. Effective advocacy requires timely communication, stakeholder coordination, and a clear understanding of legislative procedures.
Nurses have an important role in healthcare policy because their clinical responsibilities provide direct exposure to the barriers patients experience when seeking treatment. They may observe how inadequate insurance coverage, transportation limitations, or difficulties obtaining follow-up appointments affect patient outcomes. These experiences can inform policy discussions when combined with credible research and population health evidence.
Within the Multiple Streams Framework, nurses can contribute to each stream. In the problem stream, they can identify healthcare access concerns through patient assessments, quality improvement findings, and community health observations. In the policy stream, they can collaborate with administrators, researchers, and professional associations to recommend interventions. In the politics stream, they can communicate with elected representatives, participate in professional advocacy initiatives, and support public education.
Nursing leadership is also essential for ensuring that proposed policies consider health equity. Policy recommendations should account for populations experiencing disproportionate barriers to care, including rural residents, individuals with disabilities, and economically disadvantaged communities.
Ethical nursing advocacy requires accurate communication of evidence, respect for different stakeholder perspectives, and attention to the potential consequences of policy decisions. Nurses should avoid presenting assumptions as established findings and should recognize that proposed reforms may involve financial and administrative trade-offs.
Through these activities, nursing professionals can contribute to a policymaking process that considers both legislative feasibility and the practical needs of patients.
Applying MSF to healthcare access expansion requires a coordinated advocacy strategy. The first recommendation is to establish a clear evidence base describing the extent of healthcare access disparities. Nursing organizations and community healthcare providers should use reliable data to identify affected populations and explain how coverage limitations influence access to necessary services.
The second recommendation is to develop policy proposals that address both insurance coverage and service availability. Medicaid expansion should be considered alongside improvements in community healthcare capacity, particularly in underserved areas. Proposals should include realistic implementation plans, potential funding considerations, and methods for evaluating outcomes.
The third recommendation is to strengthen partnerships among healthcare professionals, patient advocates, community organizations, and policymakers. Collaboration can help communicate healthcare needs from different perspectives and improve the credibility of proposed interventions.
The fourth recommendation is to provide policy advocacy education for nurses. Training in legislative processes, evidence communication, stakeholder engagement, and policy evaluation can prepare nursing professionals to participate more effectively in public decision-making. This recommendation is consistent with the professional development concerns discussed by Sykes et al. (2023).
Finally, advocacy groups should continuously assess political conditions to identify opportunities for introducing or advancing policy proposals. Recognizing a policy window does not ensure legislative success, but it can improve the timing and relevance of advocacy activities.
Although MSF provides a useful explanation of agenda-setting, it has limitations. The framework does not guarantee that the convergence of the three streams will result in policy adoption. Political disagreements, competing legislative priorities, and institutional restrictions may prevent proposals from advancing even when a policy window appears favorable.
Another limitation is that MSF focuses primarily on how issues gain attention and reach the decision-making agenda. It provides less detailed guidance for managing implementation challenges after legislation has been approved. Healthcare reforms may require additional frameworks to address workforce capacity, organizational readiness, financing, and program evaluation.
Furthermore, political opportunities can be difficult to predict. Advocates may invest substantial resources in developing proposals without knowing when policymakers will be prepared to consider them.
Bolukbasi and Yıldırım (2022) highlight the importance of institutions in shaping participation and policy change within the multiple streams process. Their analysis suggests that advocates must consider institutional structures rather than assuming that political momentum alone will produce reform.
For these reasons, MSF should be used alongside implementation planning and ongoing evaluation when developing healthcare access initiatives.
Kingdon’s Multiple Streams Framework offers a valuable approach to understanding how healthcare access concerns can become legislative priorities. Its emphasis on the problem, policy, and politics streams helps advocates recognize the conditions necessary to advance proposals such as Medicaid expansion and increased support for community health programs. The framework is especially relevant to nursing because it connects evidence from healthcare practice with the broader political process.
Effective advocacy requires clear identification of healthcare disparities, practical policy recommendations, stakeholder collaboration, and timely engagement with policymakers. Nurses can contribute to these activities by using clinical knowledge and research evidence to communicate the needs of vulnerable populations. Although MSF does not guarantee policy adoption or successful implementation, it provides a structured foundation for advancing healthcare access initiatives. Its application can support more informed policy discussions and encourage reforms intended to improve equitable access to healthcare services.
Bolukbasi, H. T., & Yıldırım, D. (2022). Institutions in the politics of policy change: Who can play, how they play in multiple streams. Journal of Public Policy, 42(3), 1–20. https://doi.org/10.1017/S0143814X2100026X
Hoefer, R. (2022). The multiple streams framework: Understanding and applying the problems, policies, and politics approach. Journal of Policy Practice and Research, 3(1), 1–5. https://doi.org/10.1007/s42972-022-00049-2
Leresche, E., Hossain, M., Livia, M., Hermans, V., Burtscher, D., Rossi, R., Lonsdale, C., & Singh, N. S. (2023). How is the implementation of empirical research results documented in conflict-affected settings? Findings from a scoping review of peer-reviewed literature. Conflict and Health, 17(1). https://doi.org/10.1186/s13031-023-00534-9
Sykes, S., Watkins, M., & Wills, J. (2023). Public health practitioners as policy advocates: Skills, attributes and development needs. Health Promotion International, 38(5), 1–11. https://doi.org/10.1093/heapro/daad102
