Iowa, however, isn’t a state with a high percentage of people living with HIV, the virus that causes AIDS. Prosecutions related to this particular law are often highly publicized as much for their uniqueness as for a public’s need to know. In addition, of the statute’s 24 convictions since its inception, three have been appealed and subsequently affirmed by the Iowa Supreme Court.

Ed Fallon, a member of the Iowa legislature during the 1998 session when the HIV transmission law was nearly unanimously passed, said he voted in favor despite having some reservations at the time. Because more than a decade has passed, he can’t remember specific items of contention that may have been brought up during legislative debate, but he has a general sense of the federal government requiring such a law if the state wanted to access monies for HIV- and AIDS-related care and education.

Fallon also isn’t sure if often spirited debate surrounding the ban on same-sex marriage, passed earlier that same session, influenced debate of the criminal transmission law.

Opening a door to unintended consequences

Bob Rigg, an academic member of a legislative study committee charged with reorganizing the criminal code, believes members of the group are likely be willing to address issues surrounding this statute and others during the course of their research. That being said, he also wants advocates to understand that “once the flood gate is opened, it can’t be closed.”

“There is often this notion of ‘Boy, we are going to change it and we are going to make it all better,’ but sometimes when you open that door [you don't get the results you intended],” said Rigg, who worked as a public defender in Polk County until 1995 when he became director of a criminal defense program he developed at Drake University.

“Keep in mind that when you are talking about a legislature, a lot of them are from rural areas. They are conservative. They have notions about how things work and how they don’t work. Their understanding may be absolutely perfect, but their clarity on some other things might not be. And, you are asking these members to weigh in on a criminal act that you’re going to turn into a crime and punish someone for doing. To me, that is a very dangerous thing to do unless you know exactly where you are going with it and exactly what’s going to happen with it. … There’s no way to stop it, and there is no way to stop the amendments that would come from either one political party or the other.”

Rigg’s personal preference, because the political process can be so unpredictable, is to be extremely thoughtful when considering criminal code changes.

“When people start playing around with the criminal code or they start saying that we should amend our Constitution, I’m like, ‘No, we shouldn’t.’ I err on the side of caution,” he said. “If you think what you’ve got is bad, be careful. You just might end up with something even worse.”

Although he is familiar with and has written about Iowa’s criminal transmission of HIV law, he says he still doesn’t know enough about it to determine if it is effective policy.

“The worst policy in the world is made on an anecdotal basis,” he said. “That is, when you don’t like the result of one case out of 1,000, and you attempt to change policy to fix that one result. What happens is that you end up making the other 999 worse. That’s the worst way to make policy, and the worst way to get legislation through.”

A thorough evaluation of the transmission law, according to Rigg, would be an analysis of each case that has been prosecuted.

“You have to look at the Department of Corrections because although people have been sentence, you want to know exactly how much time they’ve served,” he said. “Just because a defendant is sentenced to 25 [years], doesn’t mean he or she is going to serve 25. Some of these individuals could be paroled in as little as two.”

While state intervention to reduce prison sentences may not be an intended consequence of the initial legislation, Rigg argues that it can have “a moderating effect” on an otherwise extreme sentence.

“It is the judge’s job to sentence them. It is the DOC’s job to evaluate them for release,” he said.

Because he hasn’t done an extensive study on the practical impacts of this particular statute, which is not currently on the committee’s radar, Rigg indicated he didn’t feel comfortable voicing an opinion as to its effectiveness.

“Is this statute something that should be discussed? Yes,” he said. “I think all laws should be evaluated periodically to see if they are accomplishing the intended goals of the legislature. Matter-of-fact, now that you called me I might bring this statute up within the subcommittee and ask what is going on with it.”

Yet even if Rigg and the rest of the committee decide to research this or other criminal statutes, such review is not likely to be quick. The last major revision of the criminal code took place in 1978, a process that began, according to Rigg, during the 1960s.

EARLIER: HIV-positive man’s prison sentence shines light on Iowa law; Iowa courts stand firm on HIV transmission law

With all the added scrutiny and few practical solutions to show for it, most signs point to a nursing crisis that continues to get worse, and Iowa is likely to bear the brunt of it.

The American Health Care Association estimated in July that 116,000 nursing positions in hospitals and more than 19,000 positions in long-term care facilities were vacant. The problem is projected to skyrocket by 2010 to an estimated shortage of 275,000 nurses. By 2020, the U.S. Department of Health and Human Services anticipates a shortage of 1 million nurses.

A significant cause of the problem is a lack of qualified educators to train new nurses. Nearly 2,000 otherwise qualified applicants to Iowa nursing programs were not able to attend in 2008 due to educator shortages.

“It is the single largest contributor to the shortage,” explained Dr. Rita A. Frantz, professor and dean of the University of Iowa College of Nursing. “We have a national shortage of nurse faculty as well as a shortage of practicing nurses. The two are intricately intertwined. That is, without the appropriate number of nurse faculty, we can’t admit all the qualified applicants to our nursing programs.”

And new nurses are not only needed to fill existing vacancies but to replace a rapidly aging nursing workforce.

In December 2007, the Iowa Board of Nursing stated that 41 percent of the state’s active licensed practical nurses (LPNs) were age 47 and up. In addition, 51 percent of the active registered nurses (RNs) in the state were age 47 and above.

“Here at the University of Iowa, the average age of a faculty member is 56,” Frantz said. “If you look at them by rank, with the most senior rank being a full professor, the average age is 59. Those are your more senior, experienced researchers and teachers. We’re going to have large numbers of them leaving the academic environment to retire in a fairly short period of time.”

Demographic shifts, worsening economy exacerbate Iowa’s nursing crisis

The Iowa Nursing Task Force, which presented a written report in March 2008, predicted that by 2020, the state would experience a shortfall of about 9,000 RNs, or one-fourth of the current workforce.

This is dire news for the Hawkeye State, whose aging population places increasing demands on health care services, especially on long-term facilities. An older population, combined with trends of younger families vacating rural counties, could result in a magnified problem in Iowa’s rural areas and smaller hospitals.

“Because rural hospitals have a primary population of older patients, their primary revenue stream is from Medicare,” Frantz said. “Those reimbursement rates for acute care hospitalization are in many cases not sufficient to cover the costs of delivering care to that patient population. … Hospitals in larger areas draw from a larger cross-section of the general population and have more sources for their revenue stream.”

As more of the population is impacted by the economic downturn, more people will likely turn to public health care coverage like Medicare/Medicaid as their primary coverage. This forces even mid-sized, urban hospitals in Iowa to tighten their belts, implementing hiring freezes to control costs. That can have the effect of masking the underlying nursing shortage.

“Hiring freezes are the case in some pockets of the country,” said Frantz. “I worry that might be misinterpreted by the public to mean that the nursing shortage is over. That is not the case. It is a blip on the economic radar screen.”

Frantz believes that once the economy improves and unemployed or underemployed people return to work, many will once again begin full use of health care benefits.

“There is a projection that once the economy turns around again, we will have a huge upswing in the demand for health care services,” she said. “Along with that will come a major upswing for nursing services. At that same time, we have these factors that we know are contributing to the shortage. Those will be more evident and place further stress on health care facilities at the same time."

More Educators Could Stem Crisis

Though reforming the U.S. health care system will likely produce controversial answers to a long list of complicated questions, one proposed solution to the nation’s worsening nurse shortage is alluringly simple.

Each year, nursing schools turn away thousands of qualified applicants for lack of the instructors and resources to accommodate them. If only schools could admit more students, the looming nursing crisis might be reversed.

“If I can put it in anatomical terms, there’s not enough red blood cells flowing through the blood stream. We need to make more red blood cells,” said Dr. Rita A. Frantz, professor and dean at the University of Iowa’s College of Nursing. “It’s not that we don’t have the students. We definitely have the applicant pool — way more than we can accommodate. And this isn’t a problem unique to our school. It’s happening throughout the country.”

U.S. Rep. Tom Latham (R-Ames), who has been an active participant in policy discussions related to nursing for years, thinks the federal government can help give schools like Frantz’s the resources they need to attract more nurse educators. Together with U.S. Rep. Tammy Baldwin, a Wisconsin Democrat, Latham introduced a bill that would establish a federal student loan repayment program for nurses who agree to teach full-time at an accredited school of nursing.

Programs already exist to help nursing school graduates pay student loans, but none specifically target prospective instructors. In 2004, Iowa began a new Nursing Education Loan Repayment Program that took aim at alleviating the shortage of nurse educators and registered nurses (RNs), especially those who work in long-term care facilities or in rural communities. The program, administered by the Iowa College Student Aid Commission, does not eliminate required payments to student loans, but supplements the payments. Depending on the nurse’s chosen place of employment, the supplements can range from $5,000 to $20,000, spread over a four-year commitment.

The bill proposed by Baldwin and Latham would specifically target individuals who are interested in pursuing advanced degrees to become nurse educators.

Frantz is all for it. “It gives individuals an option of working off their loan by being a faculty member,” she explained. “If the legislation passes as it is currently written, these educators could work off as much as 80 percent of their total loan debt — which is just amazing.”

Among other benefits, the bill might do a better job keeping nursing school graduates in Iowa than efforts targeted at other types of nurses. Students who hope to become nursing instructors “have family and other ties to the state that will keep them here, which is not necessarily the case with our undergraduate students,” Frantz said.

A few interest groups have already come out in support of the Latham-Baldwin bill. Dr. Polly Bednash, executive director of the American Association of Colleges of Nursing, applauded it.

“A significant barrier to addressing the nurse faculty shortage is enticing nurses with advanced degrees to pursue careers in academia when salaries in the practice setting are much higher,” Bednash said. “One way to compensate for these lower salaries and attract younger nurses into teaching roles is to relieve their educational debt.”

The Service Employees International Union, which counts 80,000 nurses among its 2 million members nationwide, has also endorsed the measure.

When free market incentives go wrong, government help may be needed

Recognizing that its own nursing instructors were growing older and that few replacements were coming in to fill the void, the University of Iowa launched a multi-faceted program in 2007 that shifted more emphasis toward the preparation of new nursing instructors.

The program has achieved some success. Forty-five students are expected to graduate at the end of this summer with an advanced degree that will have prepared them to teach in Iowa’s community college system. An additional 70 students were admitted to that program this spring and are scheduled to graduate next summer.

Despite the university’s efforts to train more nurse educators, once students graduate with advanced degrees, it is often in their financial interests to work in clinical practice instead. The average annual salary for nurse educators is about 20 percent less than nurses with higher degrees can earn in clinical practice. (This despite the fact that nurse salaries are low industry-wide.)

Latham and Baldwin hope their bill will correct the disparity, making it less of a sacrifice to teach.

“I believe this would go a long way toward addressing the nursing shortage,” Latham said. “There are plenty of qualified applicants who want to become nurses that are shut out each year.”

Latham says he is not opposed to the bill being grouped into a larger health care reform package. He understands that either way it would require a new appropriation, but he says the cost is necessary to avert a health care disaster.

“Nurses really are the face of health care,” he said. “If left unaddressed, this shortage is going to undermine access and quality of care in Iowa and throughout the nation.”

Local sexual assault and domestic violence programs rely on a combination of state, federal and private funds to maintain operation. Although the state provided funding for these programs as early as 1979, a number of changes and tight state budget years have dramatically eroded available state funding.

In 2002 the state budget to support these programs was eliminated, and nine programs were forced to close or merge. Subsequently money was taken from the Iowa Attorney General’s Victim Compensation Fund as a  stop-gap measure that would allow the remaining programs to continue operating. But the Victim Compensation Fund can no longer support the domestic violence and sexual assault victim assistance programs.

Realizing that the Victim Compensation Fund would not be able to serve its intended purpose — providing assistance to victims of violent crime — and continue to fund the domestic and sexual assault assistance programs, the Iowa attorney general’s office, the Iowa Coalition Against Domestic Violence and the Iowa Coalition Against Sexual Assault began pressing state officials several years ago for an independent budget line item.

While mindful of the current budget crunch, the dependent agencies also know that fiscal year 2009 will be the last year that Iowa’s domestic violence and sexual assault programs will receive $4 million via the Victim Assistance Grant line item.

“Something has to give,” said Iowa Attorney General Tom Miller. “We have advised the Legislature for several years that the Compensation Fund, which comes from various fines and penalties paid by criminals, would not always be able to fully fund both programs. Now we’ve hit that crunch time. We need the Legislature’s direct appropriation of funds again — as it did in years past — for the crucial network of local programs all over Iowa.”

Miller, who led a news conference Wednesday at the State Capitol, said the 31 programs are located in 27 counties, but they serve the entire state. Despite the budget crunch, Miller said the current funding levels must be maintained.

“It is difficult for me to ask for this funding in these hard financial times, but I believe this is a matter of justice and a matter of safety,” he said. “It’s a matter of justice because Iowa has a long record of assisting victims of crime, and not just punishing and rehabilitating criminals. And it’s a matter of safety and security and recovery for victims.”

The programs, according to Miller, provide “indispensable, life-saving services” that include helping victims with safety plans, finding safe houses for women and children, guiding people through the criminal justice system and helping those who fall prey to violent crime cope with the unforeseen costs of being a victim.

Budget requests, filed by the attorney general’s office in October, include a $3.2 million direct appropriation to the programs, ending the mandated link to the Victims Compensation Fund. The attorney general’s office would retain the legal authority to transfer money from the fund to the local programs, but only if such transfers were fiscally possible.

“This would put the Compensation Fund on a more solid footing and would permit the Office to pay victims their full benefits on a prompt basis,” wrote Miller in his October request letter.

Miller also requested an additional $850,000 for local crime victim service programs. This would provide $850,000 for fiscal year 2010 that was moved in fiscal year 2009 from the Forfeited Property Fund to the grant program fund to replace lost federal support.

According to Beth Barnhill, executive director of the Iowa Coalition Against Sexual Assault, rural Iowans will likely feel the brunt of any program cuts first.

“The programs most at risk are the rural programs that are heavily reliant on state funding,” she said. “They are unlikely to have local resources to make up the shortfall.”

Last year the Crime Victim Compensation Program served 5,249 Iowa victims of crime and paid $7.2 million of their out-of-pocket expenses.  The expenses included things such as victim counseling, medical care, funeral and burial expenses, child care required for court proceedings or medical treatment, and compensation of wages lost due to crime-related injuries or court appearances.

During that same time frame Iowa’s local domestic abuse and sexual abuse programs served 26,934 victims — 20,042 women, 5,294 children and 1,058 men. The programs provided 100,814 nights of safe shelter to 4,416 victims and children.

Local programs provide emergency shelters, counseling, medical advocacy, crisis hotlines, guidance for victims going through criminal justice proceedings and many other individualized services. Most of the local programs serve large geographical regions — some up to six or eight counties — with small, low-paid staffs of dedicated professionals.

On Sept. 27, 2007, the Iowa programs participated in a 24-hour “snapshot” or requested services in the state. The count from that day showed that services were provided to 813 individuals. But there were an additional 114 requests for services that could not be met because of a lack of resources.