The Structural and Historical Aspects of Healthcare Delivery in Japan and the United States After reading Chapters 4 and 6 of the textbook by Lovett-Scott and Prather (2014), write a 300-word paper by

INTRODUCTION The United States of America (USA) covers 3,717,727 square miles and is made up of 50 states (Infoplease, 2010). The USA’s population in 2004 was 293,027,571 (U.S. Census, 2004). In 2010 the population reached over 307 million. The proportion of the population that is under 15 years old in the United States (U.S.) is 21%, and the over-60 population proportion is 16% (UNO, 2004). Slightly more than 12.4% of the population were 65 years and older of which 1,557,800 (4.5%) were living in nursing homes (U.S. Census, 2010). The primary languages spoken in the United States are English and Spanish. The largest ethnic groups are European American (75%). African American and Latino groups each constitute approximately one-eighth of the population. The largest religious groups are Protestant (over 50%) and Roman Catholic (25%). The United States is the largest, most powerful nation in the industrialized (developed) world, and it has a high literacy rate. However, in 2006, while it led the world in healthcare spending per capita, it ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th in life expectancy, earning an overall ranking of 37th in the industrialized world in healthcare performance (Murray & Frenk, 2010, p. 1). Life expectancy in the United States is 80 years of age for European American women, 75.9 for African American women, 75.3 for European American men, and 68.9 for African American men. The life expectancy rate for the United States is among the lowest for the industrialized world, and infant mortality is among the highest. Americans consider quality, affordable health care a birthright, an expectation. Yet, unlike other world powers, the U.S. government plays a small role in ensuring that everyone has equal access to quality health care and services. Although the United States is envied for its wealth, high technological capabilities, and research savvy, historically it has not kept pace with other industrialized nations in the area of healthcare delivery. This is reflected by its poor outcomes in infant mortality and life expectancy. The healthcare system is also overwhelmed by disparities and inequities in care and lack of access (except for the most affluent and informed), and cost that has outpaced care. Despite an international reputation as an advocator for human rights, a nation which has openly shown intolerance of non-Western countries charged with violating the human rights of their citizenry, the United States is a system plagued with its own injustices. Though a commodity to some, many believe health care is a birthright. Primary care is of major importance to maximizing health outcomes. The Institute of Medicine (Starfield, 1994) describes primary care as care on first contact, comprehensive care, coordinated or integrated care, and care that is longitudinal rather than episodic. Three decades ago many in the United States overutilized emergency departments for routine, non-acute care. To reverse this trend, the healthcare system began focusing more on primary care and prevention. By allowing patients to see the same provider on each wellness and illness visit, many individuals stopped seeking routine care in emergency rooms. Rather, they began utilizing physician’s offices and community and migrant health centers (C/MHCs) where the focus was, and still is, on maintaining health and wellness. Health providers enrolled patients to their maximum capacity in these centers and private offices. Years later, as providers stopped taking new patients and began denying services to those on Medicaid (a government funded insurance plan for the poor and disabled funded under Title XIX of the Social Security Act), there was a cyclical trend of consumers migrating back to emergency departments for primary care, in numbers not seen for more than thirty years. Many attribute this to the downturn in the U.S. economy resulting in a historically high unemployment rate. Today the only primary care (preventive and illness care provided by the same health provider) that many people receive is in the emergency departments. Some of the barriers that limit access to care are financial, structural, and personal. Financial barriers include not having health insurance, not having enough health insurance to cover needed services, or not having the financial capacity to cover services not paid for by a specific health plan or insurance. Structural barriers include the lack of primary care providers, medical specialists, or other healthcare professionals to meet special needs, or the lack of healthcare facilities (USDHHS, Healthy People 2010). HISTORICAL The first operation performed in the United States was an excision of a tumor from a patient’s neck. During an address before the American Medical Association, John Collins Warren confirmed that he performed the world’s first surgical procedure on October 16, 1846 in a Boston, Massachusetts hospital, using sulphuric ether anesthesia (Cincinnati, Ohio, May 8, 1850). Over 20 years later, the United States is the only country in the industrialized world that does not have a National Health Care program. In the decades leading up to the seventies, health care was provided almost exclusively in outpatient clinics or general practice/family practice offices. The 1970s witnessed the emergence of primary care as we know it. Approximately 30 years ago the United States healthcare system was medically dominated. Physicians ruled. The diagnostic tests, procedures, and referrals made, and length of hospital stays of patients were based on physician’s unscrutinized decisions. During the past twenty-five years the United States has moved from physician dominance, where physicians were autonomous decision-makers, to insurance companies and business dominance. Other systems, such as the United Kingdom and Ghana, still place physicians in powerful autonomous roles. In the early 1990s, President Clinton proposed healthcare reform to provide universal coverage but this effort failed and the current system, though widely criticized, prevails. In 2009, President Barack Obama proposed an “Insurance Mandate Plan,” called the Affordable Care Act, designed to ensure that everyone with the ability to do so, purchases insurance coverage. The Affordable Care Act The status of health care in the United States has posed critical problems for individuals, families, older adults, state budgets, and the U.S. economy. Prior attempts at healthcare reform in the United States have failed. In 2007, the United States spent approximately $2.2 trillion ($7,421 per person) or 16.2% of the GDP on health care (Office of the Actuary, 2007). By 2009, healthcare spending escalated to $2.5 trillion (an increase of $134 million) and reached a record estimate of 17.3% of the U.S. economy (OECD, 2008; Orszag, 2008). Long-term projections suggest that aging will play a critical role in healthcare spending with Medicare and Medicaid taking up a significant proportion of the healthcare budget. If the projections hold true, healthcare spending could rise to 25% of the federal budget by 2025 and, more ominously, to nearly half (49%) of the budget by 2082 (Orszag, 2008). In the wake of the economic crisis of 2007, increasing numbers of Americans are uninsured or they have inadequate health coverage. According to the U.S. Census Bureau, the number of uninsured increased from 46.3 million in 2008 to 50.7 million in 2009 (DeNovas-Walt, Proctor, & Smith, 2010). “Because uninsured persons often postpone seeking care, have difficulty obtaining care when they ultimately seek it, and must bear the full brunt of healthcare costs, prolonged periods of uninsurance (no insurance coverage for over a year) can have a particularly serious impact on a person’s health and stability. Over time, the cumulative consequences of being uninsured compound, resulting in a population at particular risk for suboptimal health care and health status” (Agency for Healthcare Research and Quality (AHRQ), 2007, p. 118). The 2008 National Scorecard on U.S. Health System Performance observed that the quality of health care in the United States is “uneven” and falls short of what is expected given its resources. Across 37 indicators, the United States achieved an overall score of 65 out of a possible 100. “Performance measures of health system efficiency remain especially low, with the United States scoring 53 out of 100 on measures gauging inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Lowering administrative costs alone could save up to $100 billion a year at the lowest country rates” (The Commonwealth Fund Commission, 2008, p. 10). Eight in ten Americans are dissatisfied with the prohibitive costs of health care (Gallup Poll, 2007); and many are likely to forgo healthcare services altogether (Healthreform.gov, 2011). Ideas and strategies to improve health care in the United States have been enmeshed in heated political debates for over two decades. However, the country has taken more definitive steps to build a comprehensive healthcare plan. On March 23, 2010, the Patient Protection and Affordable Care Act (PPAC), more commonly referred to as the Affordable Care Act, was signed into law by President Barack Obama. The new health reform intends to ensure that all Americans have access to quality, affordable health care. “A major goal of the Affordable Care Act is to put American consumers back in charge of their health coverage and care” (Healthcare.gov, 2010, Provisions: Patient’s bill of rights). The PPAC is particularly aimed at low- to moderate-income groups, and vulnerable populations including children and low-income childless adults. A statement by the U.S. Secretary of Labor captures the essential expectations of the legislation. A new day is finally dawning for every American family that has seen its wages and dreams eroded by a healthcare system that has worked only for insurance companies—and at the expense of regular people. Last night’s historic vote in the U.S. House of Representative clears the path for Americans to gain coverage and financial stability that they both need and deserve. More than 32 million people now will be covered by health insurance and pre-existing conditions cannot be the basis to deny aid to those who need it most (U.S. Secretary of Labor Hilda L. Solis, March 22, 2010). In order to achieve the goal of affordable health care, the PPAC has created a number of provisions to hold the insurance industry accountable, especially in terms of driving down costly premiums, limiting out-of-pocket expenses, and preventing discriminatory practices such as denying coverage to people with pre-existing conditions. Under the new law, it is illegal for insurance companies to rescind coverage due to a mistake in paperwork. The new regulations also prohibit the use of lifetime limits on coverage as well as annual dollar limits, i.e., what the insurance company will pay (Healthcare.gov, 2010, Provisions: Patient’s bill of rights). The Affordable Care Act extends coverage up to age 26 and requires coverage of preventive services and immunizations. The new regulations protect consumers’ rights to choose their physicians, or keep the ones they have. This is based on the premise that, “people who have a regular primary care provider are more than twice as likely to receive recommended preventive care; are less likely to be hospitalized; are more satisfied with the healthcare system, and have lower costs. Yet, insurance companies do not always make it easy to see the provider you choose” (Healthcare.gov, 2010, Provisions: Patient’s bill of rights). This protection extends to emergency care and protects the consumer from being charged higher co-payments. As part of its strategy to lower costs and make coverage more accessible, the PPAC calls for building a more competitive private health insurance market through American Health Benefit Exchanges, sometimes referred to as State Exchanges. Exchanges offer a choice of health plans that meet certain benefits and cost standards. Health benefits offered through an Exchange must include a uniform package of essential health benefits. There are federal government-sponsored grants available to states to facilitate the implementation of health benefit packages. Table 4-1 provides information on the health benefits offered through a State Exchange. The Exchanges will provide a “One-Stop Shop” for comparing benefits, pricing, and quality (Healthcare.gov 2010, Provisions: Patient’s bill of rights). American citizens and legal immigrants who do not have coverage can obtain it directly through an affordable insurance Exchange. The Exchange is available to small businesses (fewer than 100 employees) who wish to obtain coverage for their employees (Taylor, 2010). Consumers and small businesses that use the Exchanges may qualify for tax credits. Table 4-1 Health benefits offered through the Exchange. Levels of Coverage: In general, qualified health plans must offer various plans based on the portion of the healthcare costs that would be covered by the plan. • Bronze: 60% of actuarial value • Silver: 70% of actuarial value • Gold: 80% of actuarial value • Platinum: 90% of actuarial value Catastrophic Plan: A plan covering all of the essential benefits and a minimum of three primary care visits for individuals under the age of 30 (as well as establishing certain individuals exempt from the individual mandate) once a certain level of cost sharing is reached. Child-Only Plan: Any qualified health plan offered under the Exchange must also be available as a plan only to individuals who have not attained the age of 21. Annual Cap: May not exceed the cost sharing for high-deductible health plans in the individual market in 2014 (currently $5,950 per individual/$11,900 per family). The limitation on cost-sharing is indexed to the rate of average premium growth. Deductibles: For plans in the small group market deductibles are limited to $2,000 for individual/$4,000 for a family, indexed to average premium growth. Uniform Benefits Package: Qualified health plans are required to offer a uniform benefits package as defined by the secretary of the federal Department of Health and Human Services. At a minimum, the package must include the following “essential health benefits”: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health benefits • Substance use disorder services • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory devices • Preventive and wellness services • Chronic disease management • Pediatric services, including oral and vision care Source: Taylor, M. (2010) LAO: The Patient Protection and Affordable Care Act: An Overview of its Potential Impact on State Health Programs, May 13, 2010, p. 8. As part of the plan to make health care more accessible, the Affordable Care Act includes an individual mandate that requires U.S. citizens and legal residents to obtain coverage or pay a penalty. Several components of the new health reform focus on the needs of the older adults including free preventive care (e.g., annual wellness visits); a community care transitions program designed to avoid unnecessary readmissions; and 50% drug discounts for seniors who reach the “donut hole” or coverage gap when buying Medicare Part D brand name or generic drugs. The Affordable Care Act is a massive reform and may take as long as ten years to become fully implemented. Proponents of the new healthcare reform anticipate several positive outcomes including a more stable economy with a reduction in government overspending by more than $100 billion over the next decade (Healthcare.gov, 2010, Provisions: About the law); enhanced work productivity, better informed consumers, an increased sense of responsibility for personal health, and the development of a more efficient, coordinated system of health care. Although a far cry from universal health care as proposed under the Clinton plan, and considered by many as a step in the right direction, it is currently being argued in the courts for repeal. Those opposing reform reportedly fear too much government involvement, cost escalation, and tampering with Medicare benefits in order to fund reform. The country’s healthcare flaws have become such an embarrassing legacy that the government feels compelled to take action to improve health delivery. Hence, many continue to rally for the country to pass healthcare reform. STRUCTURE Healthcare delivery in the United States is highly fragmented and decentralized with much collaboration among local clinics, C/MHCs, and hospitals. Many hospitals in and near large metropolitan cities are highly specialized, such as hospitals for women and children; orthopedics; eye, ear, nose and throat; spinal cord injuries; and special surgeries. Specialty care within hospitals is prescribed by the complexity of the services required. According to the American Hospital Association (AHA, 2010), there are a total of 5,795 hospitals in the United States. The majority (3,011) are urban community hospitals, and 1,997 are rural community hospitals. Of these, 2,918 are not-for-profit; 1,092 are state and local government owned; 211 are federal government owned, 998 are investor-owned, for-profit hospitals, and 117 are non-federal, long-term care hospitals. Community hospitals are defined as all non-federal, short-term general, and other special hospitals (AHA, 2010). Acute care hospitals are highly technological and specialized. They are well staffed and include specializations in burns; brain and other trauma; hemodialysis; neonatal, and pediatric intensive care; high risk maternity; and palliative care. The United States relies on physicians and other clinical specialists to routinely care for patients, even those experiencing complications. Most of the care delivery in the United States is hospital-based with an upward trend toward community-based, primary care that encourages patients to access their primary care provider practices (private physician offices, community health centers, and clinics) before seeking care in more costly emergency departments. Private, for-profit hospitals must operate in what Americans refer to as the “black” (making a profit) in order to fully function. As smaller, more financially vulnerable hospitals’ financial statements approach the “red” as a result of low cash flow from accumulating more debt than profit, they seek creative ways to remain afloat. The most recent approach to addressing financial fluidity for many smaller hospitals across the country is to merge with larger, more financially stable ones, and, upon merger, create an integrated delivery system. This provides them with the financial cushion needed to remain viable. Many well-educated healthcare professionals make up the healthcare workforce in the United States. In regard to interdisciplinary roles, responsibilities, and outcomes, there is a tremendously large demand for healthcare services in the United States. During the last two decades, the shortage of healthcare professionals, especially registered nurses, has become a national crisis. Numerous reports by organizations such as the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), and the New York State Labor-Health Industry Task Force on Health Personnel have reported that this shortage will become more pronounced as the effects of declining enrollments and increased retirements are felt by the healthcare community. The shortage of minority nurses (those of African, Latino, Asian, and Native/Alaskan descents) is most noticeable. Prior to the downturn in the United States economy in 2008, vacant budgeted nursing positions in hospitals more than doubled. In 2008, vacancy rates in hospitals nationally were at an all-time high. The AACN reported that the downturn in the economy resulted in a short-term stabilizing of the nursing workforce in some parts of the country (AACN, 2009). Despite the current shortage of registered nurses in the United States, Buerhaus, Staiger, and Auerbach (2009) suggest that the United States should brace itself for a worsening of the shortage, and predict that the RN shortage could reach as high as 500,000 by 2025. This is partly attributed to the large number of baby boomer nurses (born between 1944 and 1960) expected to retire in the next five to ten years. The latest projections from the U.S Bureau of Labor Statistics (BLS), predict more than one million new and replacement nurses will be needed by 2016, creating more than 587,000 new nursing positions, making nursing the nation’s top profession in terms of projected growth (United States Department of Labor, 2007). The majority of the nurses entering the profession in the United States do so by completing a two year Associate’s Degree in Nursing rather than a four year baccalaureate degree in nursing (BSN). Although hospital-based diploma programs still exist is in the United States, there are relatively few. Also, there is extensive documented evidence that patient outcomes are better with BSN-prepared nurses at the bedside (AACN, 2009; Tourangeau, et al., 2007; Aiken, et al., 2008; Aiken, et al., 2002; Smedley, et al., 2003; Needleman, et al., 2002; American Nurses Association, 2000) resulting in an American Nurses Association (ANA) initiative to increase educational requirements for entry level into professional practice to the baccalaureate level. Called “BSN in 10,” the legislation further standardized the nursing profession. In 2008 there were 3,063,163 licensed registered nurses (RNs) living in the United States. Of this number, 2,596,599 (84.8%) were employed in various settings; however, hospitals were the largest employers of RNs, employing 62.2%. Of the total, 5.6% of RNs practicing in the United States received their initial education in another country or a U.S. territory. The majority of these nurses, approximately 48.7%, are from the Philippines, 11.5% are Canadians, and 9.3% are from India. During the past fifty years, the United States has regularly imported nurses to ease the nursing shortage. This demand-driven U.S. nurse shortage is referred to by Brush, Sochalski, and Berger (2004) as the migratory push and pull factor. Nurses throughout the world feel pushed out of their home countries because of low pay and poor employment conditions, and pulled into industrialized countries because of better pay, and other perks. This factor is credited with stimulating the growth of for-profit organizations that serve as brokers to ease the way for nurses to emigrate (Brush et al., 2004). The major push and pull factors associated with international nursing recruitment are listed in Table 4-2. In 2001, Filipino nurses represented more than half of the foreign graduates taking the licensing examination. Nurses from Canada, the United Kingdom, India, Korea, and Nigeria collectively accounted for an additional 25% (NCSBN, 2004). Nurses are enticed to leave their home countries by promises of better pay and working conditions; improved learning and practice opportunities; and free travel, licensure, and room and board (Buchan, Parkin, & Sochalski, 2003). For example, in 2004 the U.S. Department of Labor reported the median annual earnings for RNs as $48,090. Average earnings for RNs working in hospitals were $49,190, and those working in nursing homes were $43,850 (USDL, BLS 2004–2005). These wages contrast sharply with the annual wages of $2,000–$2,400 earned during the same year in the Philippines (Sison, 2002). Table 4-3 presents destination countries of many of the foreign nurses recruited to practice in countries other than their home countries. Although the percentage of foreign nurses working in hospitals has steadily declined in the past ten years, their numbers in public/community health and ambulatory settings have grown (Brush et al., 2004). Foreign nurse representation in nursing homes has risen from 7.4% to 9.3% (National Sample Survey of Registered Nurses, 2000). Table 4-2 Main push and pull factors in international nursing recruitment. Push Factors Pull Factors Low pay (absolute and relative) Higher pay and opportunities for remittance Poor working conditions Better working conditions Lack of resources to work effectively Better resourced health systems Limited career opportunities Career opportunities Limited educational opportunities Provisions of post-basic education Impact HIV/AIDS Political stability Unstable/dangerous work environment Travel opportunities Economic instability Aid work Source: Buchan, Parkin, & Sochalski, WHO, 2003. International nurse mobility: Trends and role implications; WHO_eip_osd_2003.3pdf Table 4-3 Destination countries: total number of nurses and main source of international recruitment. Country Number of Nurses Main Source of International Recruitment Australia 149,202 UK and New Zealand Ireland 61,629 UK, Philippines, So. Africa Norway 45,133 Other Scandinavian countries, Germany, Philippines United Kingdom (UK) 640,000 (580,000) Philippines, So. Africa, Australia United States (US) 2,238,800 Philippines, Canada, Africa (mainly So. Africa & Nigeria) Note: Data from OECD Health Data (CD-ROM, 2001b), reported as full time equivalent (FTE) practicing nurses in some countries. This figure appears to be the number of nurses on the registry, some of whom are inactive. OECD data for the United Kingdom (UK) is incorrect so bracketed figure is the actual number of registrants in the UK. Source: Buchan, Parkin, & Sochalski, 2003, WHO, 2003. International nurse mobility: Trends and role implications, WHO_eip_osd_2003.3.pdf There is a two-step process for obtaining an RN license in the United States. This process is separate from the process necessary for obtaining a work visa. Foreign nurses wishing to practice in the United States are prescreened by the Commission on Graduates of Foreign Nursing Schools (CGFNS). This commission reviews the educational background, licensure in the home country, English language proficiency testing, and a predictor exam that provides an indication of the nurse’s ability to pass the U.S. nursing licensing examination (NCLEX). In many cases, foreign educated nurses, other than those from Canada, must successfully pass the NCLEX licensing exam in the United States before being permitted to practice. However, because each state has its own board of nursing and operates independently, some states may have additional requirements, and a few states may directly endorse foreign educated nurses who have not taken the NCLEX (Buchan et al., 2003). The scope of a nurse’s practice in the United States is governed by the nurse’s educational preparation and experience. Currently, a nurse who is newly graduated can enter general practice and work in various settings in the United States by two methods—by earning a two year associate’s degree (ADN) or a four year baccalaureate degree (BSN). Hospital-based diploma programs that were very popular during the fifties and sixties are almost non-existent today. Nurses can earn national certification in a number of specialty areas through highly recognized professional nursing organizations such as the American Nurses Association’s (ANA’s) American Nursing Credentialing Center (ANCC). Advanced practice nurses (APN) have expanded scopes of practice. The scope of practice, and practice privilege parameters, for advanced practice nurses such as nurse practitioners (NPs) and clinical nurse specialists (CNS) are defined by each state. APNs are nurses who have earned a master’s degree. These nurses have successfully completed advanced course work in pathophysiology, pharmacology, health assessment, research, and case management. Furthermore, they have gained expertise in particular specialty careers such as clinical nurse specialist, nurse practitioner, nurse midwife, and nurse anesthetist. Most recently, nurses have become experts in nurse informatics, integrating nursing information and technology to develop structures needed to build systems that better document and support nurses’ actions and clinical decisions; and forensics nursing that addresses sexual assault, abuse, domestic violence and death investigations (see www.nursecredentialing.org). Some states require NPs to have a collaborating agreement with an approved physician in order to practice. NPs have, for many years, rallied for states to expand their scopes of practice. In 2008, 22 states had expanded scopes of practice for NPs in all specialty areas. Despite the critical need for more community-based mental health providers, some physicians in psychiatric mental health practice object to the autonomy given nurse practitioners, arguing that only psychiatrists, not NPs, are qualified to practice independently (Ginsberg, Taylor, & Barr, 2009). The RN workforce is aging. The average age of RNs practicing in the United States is 46.8 years. Additionally, 16.2% of RNs in the U.S. workforce are between 50 and 54 years old. This raises significant concerns among individuals who fear that the aging trends and future retirements could substantially reduce the size of the U.S. nursing workforce. Further, because the general population and the proportion of older adults in the population is growing, there will be an even greater future need for healthcare and nursing services across the nation (USDHHS, HRSA, 2004). The average annual earnings for RNs in 2008 were $57,785. Nurses with master’s or doctorate degrees rose to 376,901, an increase of 37% from the year 2000 (USDHHS, HRSA, 2004). Advanced practice nurses have met educational and clinical practice requirements beyond their initial nursing education, and are educated at minimally the master’s level. Most advanced practice nurses have advanced credentialing and certification by each state and a nationally recognized accrediting body. In 2008 there were approximately 250,527 advanced practice nurses, of which nurse practitioners were the majority (63.2%). The median nurse practitioner’s salary was $89,845. Like physicians, nurses certified as anesthetists and those in specialty care make considerably more. New APN guidelines by the American Association for Colleges of Nursing (AACN) recommend that new masters programs be developed in order to prepare clinical nurse leaders who are clinicians with evidenced-based application expertise, and practice doctorates (DNP) a new terminal degree for clinical experts similar to doctorates in medicine (MD), doctorates in dentistry (DDS and DMD), doctorates in pharmacy (PharmD), and doctorates in physical therapy (DPT). The AACN believes that such advanced degrees are particularly needed in complex healthcare areas in order to strengthen overall healthcare delivery and practice (AACN, n.d.). Many of the most recent initiatives in planning to improve the nursing profession grew out of the Institute of Medicine’s (IOM) initiated research that revealed that an enormous number of patients (44,000 to 98,000) die annually due to preventable medical errors. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) responded with its National Patient Safety Goals. Approximately four years after reporting their initial findings, the IOM followed up by commissioning a task force to examine the educational preparation of healthcare professionals specifically in an attempt to determine if new graduates were adequately prepared to practice. The task force recommended that the curricula in all programs be revised, giving rise to a greater focus on increasing the entry level into nursing and advanced practice. In addition to RNs there were 596,355 Licensed Practical/Vocational Nurses in the U.S. workforce. Licensed Practical/Vocational Nurses complete an approved program in 10–12 months. LPNs/LVNs are slightly older on average than the RN workforce, fewer are foreign born, they work in long-term care, C/MHCs, clinics, primary care offices, and males make up a relatively small percentage of both RN and LPN/LVN workforces (USDHHS, HRSA, 2004). Well-trained patient care technicians and nurse assistants work closely together in hospitals, nursing homes, and primary care settings assisting with care delivery. In many areas in the United States there is no longer a shortage of nurses. When the economy declined during 2008, many retired nurses returned to work and those approaching retirement continued to work. For the first time in decades new graduates were having difficulty landing their first graduate nursing position. According to the Health Policy Institute, in 15 years the United States will have a physician shortage of 200,000. A shortage of physicians, and until recently, also nurses, resulted in the demand for care exceeding the supply, triggering the growth of what is called mid-level providers. To compensate for the shortage of physicians in the United States, professionals such as advanced practice nurses who are mostly certified nurse practitioners and clinical nurse specialists have tremendously helped to bridge the physician gap. Both are typically educated at, minimally, the Masters level. These nurse experts are employed by hospitals, C/MHCs, clinics, urgent care centers, and independent practices. Physician’s assistants, also considered mid-level providers, are employed directly by physicians or hospitals. In addition to advanced practice nurses, registered professional nurses manage and supervise the overall care of patients in a variety of roles and settings, including hospitals and nursing homes. Physicians in the United States are well educated. After completing four years of pre-professional baccalaureate education, they complete four years of medical school, and four to seven years residency in their chosen specialty, such as family medicine, obstetrics/gynecology, orthopedics, or pediatrics. After the residency, the physician is eligible to become board certified in their selected specialty. According to the American Medical Association (nd) physicians who attended medical school outside the United States or Canada must first be certified to practice by the Educational Commission for Foreign Medical Graduates (ECFMG). All international medical graduates (IMGs) must complete residency training in the United States before they can obtain a license to practice medicine even if they were fully trained, licensed, and practicing in another country. Most physicians in the United States are board certified. It is relatively easy for employers to utilize government sponsored waivers to sponsor foreign born students who complete medical residency or fellowship programs in the United States. Siskind and Siskind (nd) describe three basic visa categories: J-1, requiring physicians to return to their home country for at least two years after their medical training before being eligible to apply for a work visa or green card; H-1B, that does not require the physician to work in underserved communities; and IGA, or interested government agency, where a government entity or state health department writes a letter of sponsorship stating that it is in the best interest of the public for the physician to remain in the United States. Professional licensing is administered through each state’s Education Department, Division of Professional Licensing. The number of employed providers per 100,000 persons in the population is data used to measure the rate of growth of the provider workforce relative to the growth of the overall U.S. population. The USDHHS, HRSA (2001) reports that in 2000, the physician workforce in the United States included 737,504 actively practicing physicians, equating to 263.8 practicing physicians per 100,000 persons in the population. Of this number, 238,734 were primary care physicians (85.4/100,000 population), 154,300 had surgical specialties (55.2/100,000 population) 101,353 (36.3/100,000) were in internal medicine, 86,315 (30.9/100,000) were general/family practice physicians, 51,066 (18.3/100,000) were in pediatrics, and 40,241 (14.4/100,000) were in obstetrics and gynecology. With the exception of endocrinologists, there are considerably more medical specialists than general practice (primary care) physicians. There are few endocrinologists, demonstrating the need for primary care physicians to play an active role in the management of diabetes care and other endocrine problems. The average net annual income for all physicians was $205,700. Surgeons had the highest average income at $274,700, obstetrics/gynecologist earned $227,000, internal medicine at $196,000, general/family practice physicians at $144,700, and pediatricians at $137,800 (American Medical Association, 2004–2005). Physicians in specialty practices, such as cardiology, oncology, orthopedics, and anesthesiology tend to earn considerably higher salaries. FINANCING The United States spends 19.3 percent of its budget for health care ($6,714) per capita, considerably higher than Canada, France, and the United Kingdom (OECD, 2008). Sources of funding for healthcare services in the United States include direct pay by the individual using the services where the consumer privately pays out-of-pocket, sometimes according to a sliding fee scale; charity/welfare which is written off; Medicare and Medicaid for which the government pays; and insurance, which is almost exclusively through Health Maintenance Organizations (HMOs), managed care in an attempt to lower costs. Under the HMO plan patients choose a primary care physician (PCP) within a network. That physician takes care of all their medical needs including referrals to specialists. The Preferred Provider Organization (PPO) is similar to the HMO but patients choose a provider or specialist from a network, and if they are seen by anyone other than a PPO provider, payment for services provided by the non-PPO provider are typically lower, and may even be withheld. In 1996, Medicap surfaced in an attempt to contain costs by capping payments made to hospitals and health providers at a preset fixed rate for services. This was replaced by managed care. The direct-out-of-pocket payment, direct reimbursement models include “Contract” models, such as Independent Preferred Provider, Integrated models, and HMOs. Modes of payment to providers include hospital reimbursements using diagnostic related groupings (DRGs), setting fees by grouping similar health problems, a negotiated fee-for-service, per diem, and capitation, a set limit on the amount that providers are reimbursed for services. Physicians are paid a standard fee for services. This fee is set by a HMO and paid directly to the physician. Consumers are responsible for a co-payment when they visit their providers or specialists. The co-payment is an out-of pocket payment that is a fraction of the actual cost of care. The rigors of cost controls are many. Financing of health care overall has always been within the realm of insurance companies. Shi and Singh (2004) describe the healthcare system in America as characteristically in disarray, plagued with a multiplicity of social and economic constraints that have resulted in a severely compromised three tier system relegated to Medicare for older adults, Medicaid for those lacking the ability to pay, and private insurance for everyone else. These authors paint a rather grim picture of the United States healthcare system fraught with a malady of problems. Although major improvements have been made in regard to professional standards of practice and quality in-hospital indices evidenced by many hospitals reaching magnet status during the past decade, the financing and the institutional core is still missing, that is, many hospitals lack well-coordinated, integrated systems of care, and their technology is outdated. The cost of health care in the United States escalated out of control during the last twenty years. Managed care and Health Maintenance Organizations (HMOs) have not been the answer. This is partly because there must be better solutions to the healthcare problem that preserves the health and quality of lives without pitting one important initiative against another. Many were disappointed that the Clinton Health Care Reform Bill could not garner enough support to work out a legitimate compromise. The pharmaceutical companies were blamed for paying off key players that squashed any hopes of survival for the bill. In examining the role of government in financing health care it is important to discuss its reliance on Medicare for those 65 and older, and Medicaid, health coverage for the poor, which is covered by the Federal Social Security Act, 1966, and is funded through taxes. Management of both is decentralized to the state and local governments. The Federal Social Security Act was later amended to fund Social Security disability, providing health care for those who have conditions that prevent them from being employed. The United States also provides health care to American Indians and Alaskan Natives through the Indian Health Services (IHS) and comprehensive medical and psychiatric care to veterans through its federal-government-operated Veterans Administration. According to the most current Department of Health and Human Services (2012) publication of “Medicare and You,” Medicare provides coverage in four different parts, Parts A, B, C and D. Medicare is health insurance for people 65 and over, people under 65 with certain disabilities, and people of any age with end-stage renal disease which is permanent kidney failure that requires either dialysis or kidney transplant to live. It does not cover long-term care or custodial care. Also, individuals are often responsible for co-payments, deductibles, and coinsurance. A co-payment is the person’s share of the cost for services such as $10.00–$40.00; a deductible is the amount the person pays before Medicare, the prescription drug plan, or other insurance begins to pay; and coinsurance is a preset percentage of the cost of the service such as 20% after deductibles. The 2012 Medicare & You Handbook further describes what is covered by Parts A through D. Part A is generally referred to as hospital insurance. However, hospitalization helps cover a skilled nursing facility, such as rehabilitation, hospice, and home health care. Part B is known as medical insurance. It helps cover provider services such as physicians, outpatient care, durable medical equipment such as wheelchairs, walkers, and hospital beds, and it covers home health care and some home preventive services to help maintain health and prevent complications. When persons retire they become eligible for Medicare Part B. The health plan they were previously under while working requires them to enroll in Medicare Part B within an eight month window that begins one month after employment ends. Those failing to do so will probably pay a penalty and will be forced to wait until the next annual, general enrollment period to sign up, which is usually between the months of October and December. If they need Part B services during this waiting period, they must pay for the services out-of-pocket. These services include such things as diagnostic laboratory tests and procedures such as CT scans, MRIs, colorectal cancer screenings, immunizations, kidney dialysis, ambulatory surgical center procedures, and a variety of other services such as what is considered to be medically necessary transportation by ambulance to a hospital or skilled nursing facility. Part C, also referred to as Medicare Advantage, is a supplemental plan for retirees for which the individual pays extra. This plan covers any gaps in coverage and provides the individual with service upgrades. For example, individuals who have Part C would qualify for a higher quality placement in a rehabilitation facility after surgery than individuals without a supplemental advantage plan. Some popular Medicare Advantage plans include Medicare Blue, MVP Gold, Humana, and the American Association of Retired People (AARP)-recommended advantage plan through United Health Care. Part C is similar to an HMO or PPO. Medicare Part D covers prescription drugs. Part D is run by a Medicare-approved private insurance company. When a person turns age 65, if that person is already receiving social security or railroad retirement benefits, he or she will, in most cases, automatically get Part A and B effective the first day of the month in which they turn 65. Persons who are under 65 but disabled, and receiving social security disability benefits, also automatically get Medicare Part A and B. If a person is not receiving social security or railroad retirement board benefits, as would be the case if the person was still working, the person can sign up for both A and B but if they are not eligible for free premiums they will have to pay out-of-pocket for Part A and B. The IHS, located on or near reservations, provides acute and chronic care to American Indians. Veteran services (outpatient and inpatient) are totally paid for by the government. The U.S. healthcare insurance plan covering active duty and retired military service workers is called TRICARE. This plan covers outpatient visits, hospitalization, preventive services, maternity care, immunizations, mental/behavioral health for active and retired service members and their families. There is also dental coverage. The basic TRICARE health plans are Prime, Standard, and Extra. TRICARE Standard and Extra provide the most flexibility in regard to visiting authorized providers in or outside the network, scheduling appointments, the need for referrals, and the percentage paid of the total cost, known as a cost-shares. TRICARE Prime is only available to members on active duty and command-sponsored family members. Referrals are required by all three plans for approval to see specialists. Table 4-4 provides an overview of TRICARE health plan options. The struggle to provide affordable, equitable quality health care in this country resulted in an out-of-control national debate about the feasibility of a government led fixable plan. Many question the ability of the government to offer a fiscally sound plan, arguably doubting that the government is in a position to effectively manage health care using management problems of Medicaid and Medicare as examples of irresponsibility. Medicare, a health insurance for individuals 65 and older, disabled individuals who are entitled to Social Security benefits, and those with end stage renal disease has long been criticized as falling short of its goal. Care of the older adult is funded through Medicare and coinsurance called Medigap to cover gaps between what Medicare covers after a person reaches 65, is chronically ill, or is disabled. Despite Medigap, Americans still are often bankrupted because of the extremely high cost of medical care either because they have insufficient Medigap coverage or no coverage at all beyond Medicare. Long-term care in the United States is definitely an area in need of serious consideration. With the exception of Medicaid, long-term care coverage, such as for nursing home stays, is not covered by U.S. government financing. People sometimes become so desperate for solutions that they resort to uncustomary methods of meeting their chronic care needs. Paying for long-term care out of pocket costs approximately $70,000 per year. Unless the individual has considerable financial resources this is not a feasible option. Medicaid rather than Medicare pays most nursing home costs for people with limited income and assets. The best option, for most middle-income earners, is to purchase long-term care insurance for approximately $2,000 per year, well in advance of needing it. If purchased later in life, premiums can be considerably higher. Table 4-4 TRICARE: an overview of beneficiary costs. Active duty service members •  No enrollment fees or co-payments for any plan •  $0 at military treatment facilities Active duty family members •  No enrollment fees or co-payments when enrolled in TRICARE Prime •  Low cost-shares when using TRICARE Standard and Extra •  $0 at military treatment facilities Retired service members and families •  Low annual enrollment fees for TRICARE Prime ($260/individual or $520/family) •  Minimal network co-payments (ranges from $12–$30) •  Low cost shares when using TRICARE Standard and Extra Source: TRICARE: military health insurance at: www.tricare.mil/mybenefit/profilefilter;do.sessionid=PrKXmx8Xl58,56n0pQzLKDKvg1YFlwyTOBgGcw1PvhfmRFQGfTyw!-1368627664? Last updated March 6, 2012. Medicaid will cover the nursing home care for those without means to pay, but their nursing home choices are limited, waiting times are lengthy, the facilities and care are less than optimal, and outcomes are poorer. To be eligible for Medicaid, the person has to first spend all their savings, including retirement assets, leaving no opportunity to leave their assets to their heirs. Under these circumstances, a long-term illness can be financially devastating. The United States healthcare system has an extremely high reliance on technology, resulting in more money being spent at the tertiary level of care. Funding priorities are acute hospital care which is more draining on the healthcare budget. The role of payers in the United States system is threefold. It includes government, employers, and individuals, whereas employers have little or no role in most other healthcare systems worldwide. The role of insurers in the United States system is extensive and involves, in part, Health Maintenance Organizations (HMO) open enrollment, and fees based on individual experience ratings, based on how often a person utilizes the system and the complexity of their health problems. An individual hospitalized with an acute illness who has several comorbidities, for example, will be more costly to treat with each hospital or primary care encounter than an individual who is relatively healthy. This person’s individual insurance rate will be higher than a healthy individual. Group insurance ratings that are based on an overall healthier aggregate are considerably lower. There is little or no centralization of health care in the United States system. INTERVENTIONAL Interventions in the U.S. system are highly scrutinized by insurance companies, a practice that is considered by many Americans to be extremely controlling and restrictive. Referrals for diagnostic testing are often denied even when an experienced physician deems the test or referral is necessary. The following scenario depicting the problems primary providers experience when attempting to manage a traumatic injury effectively and expediently, exemplifies the problem: X-Rays have ruled out a fracture but Mr. Jey, a 52-year-old male is still complaining of severe pain on weight bearing. His physician highly suspects a soft tissue injury which cannot be detected by a CT scan. Despite the fact that the gold standard test is an MRI, his insurance company insisted that a CT scan be done first, and only if negative would they then approve the MRI. Although a CT scan will not reveal the highly suspected soft tissue injury which, if untreated, can cause impingement on nerves, unrelieved pain, and serious damage to surrounding organs, an MRI cannot be ordered first. The patient was reluctantly sent for a CT scan which was negative; he then had the MRI which, as suspected, revealed severe contusions and a tendon tear that required surgical repair. This apparently insensitive, and fiscally unsound, insurance company practice slowed the diagnostic process and disregarded the patient and the physician’s knowledge. The time spent with the problem unresolved was significantly longer, and ultimately the insurance company paid for both diagnostic tests. In this case where were the cost savings? To their credit, some physicians send patients for MRIs despite insurance company directives and fight with them later for payment. Americans often voice concerns that insurance companies should not interfere in the practice of medicine. Rather they should develop institutional processes and execute claims more efficiently and effectively. This would, in the minds of many, allow physicians to practice medicine. Also, politicians are criticized for pitting one program against another for their own political gains rather than making decisions that are in the best interest of the American people. PREVENTIVE Government regulation of practice licensure, food, and drugs is evidence of its attempt to ensure the quality and safety of patients in the United States. In fact, the U.S. government is often accused of overlegislating and overregulating medications. Preventive measures must consider, among other things, the culture and traditional practices of its people. It also considers how well the country handles such environmental problems as tobacco use and substance use and abuse; which may include funding for programs to address health and safety programs. It is a particular challenge for the United States to address these problems when smoking and drinking alcohol are socially accepted, and using illicit mood-altering drugs is common. Prevention is very much evidenced in care received in community/migrant health centers (C/MHCs) although it is severely underfunded. The mission of these health centers has always been to provide comprehensive primary care services to community residents regardless of the individual’s ability to pay (Plaska & Vieth, 1995). Centers located in health professional shortage areas are partially funded by a grant from the Department of Health and Human Services, United States Public Services Section 329/330. The focus of the C/MHC’s care is to promote health and prevent illness, keeping people out of the hospital. In the mid-60s, C/MHCs served an estimated 7 million people, and in 2010, they served more than 20 million of the nation’s most vulnerable residents, including a large number of migrant/seasonal farm workers, and one million homeless patients, at over 8,000 sites (Whelan, 2010). Yet, C/MHCs continually face financial challenges because of the nationwide movement toward managed care. A major goal of managed care is to decrease cost by paying greater attention to productivity, and better management of human and fiscal resources. Culture is a major consideration when planning for, and implementing, patient care in and out of the hospital. Health seeking beliefs and practices emanate from an individual’s culture. How patients perceive, or accept, the care being provided them is contingent on their culture, for it reflects who they are. Experienced medical and nursing providers with cultural competence, that is, those who strive to incorporate treatment and care plans embracing of the person’s culture, will model behaviors that underscore the importance of providing culturally congruent care. These providers are more likely than incompetent providers to influence the practices of novice providers by modeling and coaching the right behaviors. Despite the diverse culture of the people it serves, the United States’ standard of health and medical deliveries are generally Eurocentric. Family, culture, religion, and social health, the very elements of importance to preventing illness are often disregarded when a person enters the healthcare system. Preventing illness and maintaining healthy lifestyles are imperative to longevity. This is especially important because in the United States, life expectancy is lower than other industrialized nations and infant mortality is among the highest. Just as no two persons are the same, no two cultural groups respond the same way to a provider’s recommended treatment. A clear example of this is the way in which the significance of food for some cultures is overlooked when health providers make attempts to convince patients to modify their diets in order to improve their health. Although it is relatively easy for providers to inform their patients that they must absolutely reduce their fat or salt intake, this advice is ineffective if culture is not addressed. Patients’ cultural backgrounds may be deeply rooted in not only the food they eat but the specifics on how the food is prepared. If the approach taken does not include culturally acceptable alternatives, patients’ eating habits are not likely to change, their blood pressures are not likely to decrease, and as a consequence, the heart attack or stroke the provider may have been attempting to prevent may not be successfully averted. There are many barriers to healthcare access in the United States resulting in health disparities (see Chapter 14). This further illustrates the magnitude of the problem of addressing disease prevention. When there is a widened gap between health and culture, and the poor and wealthy maintaining health and preventing illness is a great challenge. RESOURCES Community support is very important as the strength or weakness of an individual’s immediate community often reflects the strength of individuals and families residing in it. The safety of the environment might determine how often children are allowed to play and exercise outdoors, get fresh air, or even if environmental hazards and contaminants keep them confined to their homes. When residents share a sense of community and belonging this could contribute to a sense of comfort and well-being. Family support provided to the ill spans generations and cultural groups. Family traditions and values often influence how an individual defines health, and the specific health seeking beliefs and practices. Grandparents and godparents often share in the upbringing of children. Family, in America, is defined as nuclear or extended, depending on the cultural group. European Americans tend to be more nuclear in their family orientation than other cultural groups in the United States (Purnell & Paulanka, 2004). Many men and women are raising families as single parents and depend on the support of family and friends to succeed. Some cultural groups rely on women to care for children, parents, even in-laws when ill. During the past 25 years there has been a major trend toward eldercare in America, pressuring many to balance multiple roles of job/career, immediate family, care of their parents, and, during especially tough economic times, supplementing their parents’ fixed incomes. Spirituality and religion is a source of strength for many living in America. Religious freedom and choice, with the exception of a few extremists, is embraced in the United States. People are permitted to formally and informally openly practice their religion peacefully. Numerous cultural groups wear religious symbols without fear of discrimination. Immigrants often come to America in search of religious freedom. Religion and spirituality also play a major role in death and dying across cultures. Many health providers consider a good death as spending the end-of-life in a hospital, hospice, or nursing home surrounded by experts who are needed to guide everyone through the process and loved ones for additional support (Long, 2003). Americans consider death as a natural process when it occurs during old age, or when the person is chronically ill. Funerals and memorial activities are ways of validating the lives of the deceased but often strengthen the lives of those left behind (Walsh and Burke, 2006). During times of loss and grief, financial, physical, and emotional comfort and support are often critical in assisting families through some of their most challenging times. MAJOR HEALTH ISSUES Historically, America as a nation has been accused of being a country where, with the exception of exercise, everything is done in excess. Americans eat, drink, and smoke too much, and many Americans drive wherever they go, even when traveling a few blocks. This accounts for heart-related diseases leading the list of health problems affecting the United States. There are multiple barriers to individuals seeking health care in the United States. Personal barriers include cultural or spiritual differences and language, particularly for non-English speaking immigrants. It also includes not knowing what to do or when to seek care, and includes concerns about confidentiality or discrimination (USDHHS, Healthy People 2010). Strengthening C/MHCs might be the way to go in addressing access and decreasing some of the barriers discussed in Healthy People 2010. Expanding funding to these centers may be a good way to compensate for the underfunded preventive care in the United States. Wilensky and Roby (2005) suggest that C/MHCs play a vital role regardless of the type of insurance system in place because they reduce barriers to care and provide quality, culturally competent care to vulnerable populations. The current private employer-based U.S. healthcare system does not create incentives for providers to care for low-income and vulnerable populations. Even in countries with universal health coverage, health centers increase access to care and improve health outcomes. The Top Ten Leading Causes of Death in the United States The ten leading causes of death in the United States for all ages, races, and genders disproportionately affect some groups as compared to others, and are among some of the most fiscally and pathologically challenging problems to combat. These problems, ranked from the cause affecting the greatest number of people to the least number of people, are listed in Table 4-5. Table 4-5 Top 10 causes of death (all ages) in the United States, 2002, with the number and percent of years of life lost by disease. Data From: Death and DALY estimates by cause, 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls DISPARITIES Globally, countries are in a quest for healthcare systems that provide quality, and are not costly but efficient. In 1997, approximately 37 million persons in America were without health insurance (Clinton, 2003). Healthy People 2010 indicates that health insurance provides access to health care; persons with health insurance are more likely to have a primary care provider, receive appropriate preventive care such as Pap tests, immunizations, or early prenatal care. Additionally, adults with health insurance are twice as likely to receive routine check-ups than adults without health insurance. Further, about one-third of adults under age 65 years who were below the poverty level were uninsured. Approximately one in three persons of Latino descent was without health insurance coverage in 1997. Mexican Americans had one of the highest uninsured rates, at 40%. Today, approximately 40 million persons in the United States are uninsured (USDHHS, Healthy People, 2010). In the United States, heart disease leads the way for mortality followed by cancer and stroke. These top three diseases, heart disease, cancer, and stroke, account for the overwhelming majority of deaths in the United States. However, people of African and Latino descents are more likely to die than individuals of European descent. Women in general, and those 65 and older, are more likely to die than men (National Institutes of Health, 2006). Malignant neoplasms, with which, again, the over 65 year old group is more affected and cerebrovascular disease (stroke) have devastatingly poorer outcomes. Unintentional injury ranks as the number one cause of death in the United States for the 1–44 age group, third for ages 45–54, and fifth for ages 55–64. Prevention is key to improving outcomes. For example, educating individuals in safeproofing their homes is of paramount importance if there are older adults and small children in the home. Basic measures such as the use of seat belts when in automobiles, smoke detectors, and carbon monoxide detectors can also be lifesaving. Nine of the ten leading causes of death are preventable. Table 4-5 lists the top ten causes of death in the United States. Despite these alarming statistics, a relatively small portion of the nation’s healthcare budget is appropriated to promotion of health and prevention of disease. During the decade of the 1990s, the Clinton administration, under the leadership of first lady Hillary Clinton, introduced a Health Care Reform bill called, Clinton: American Health Choices Plan. Clinton writes, There were compelling reasons to push ahead. By the time Bill became President, 37 million Americans, most of them working people and their children, were uninsured. They weren’t getting access to care until they were in a medical crisis. Even for common medical concerns they wound up in an emergency room, where care was most expensive, or they went broke trying to pay for medical emergencies on their own. In the early 1990s, one hundred thousand Americans were losing coverage each month, and two million were without coverage temporarily as they changed jobs. Small businesses were unable to offer coverage for their employees because of the exploding cost of healthcare premiums. And the quality of medical care was suffering, too. In an effort to control costs, ins

nce companies often denied or delayed treatment prescribed by doctors in deference to their corporate bottom lines. Rising healthcare costs were sapping the nation’s economy, undermining American competitiveness, eroding workers’ wages, increasing personal bankruptcies and inflating the national deficit (Clinton, 2003, p. 144). The Clinton plan would have allowed people to keep their existing insurance if they were satisfied. If they were not, they had an option to choose a plan similar to the plan afforded to Congress or to choose a government option similar to Medicare (Clinton HC Plan). Tactics by those in opposition to the bill and pharmaceutical companies that paid off key supporters of this bill are credited with the demise of a plan that could have proven to be what the country needed. The healthcare system is currently out of sync with anything that even remotely resembles fairness and reason. Ironically, of all the industrialized nations in the world, the United States is the only one without a national health insurance plan. Also, prescription medications around the world are a fraction of the cost of the same medications in America. Insurance companies are out of control and people are dying every day while awaiting approval for a lifesaving treatment, surgery, or diagnostic procedure that requires prior authorization. Others are outright denied coverage due to preexisting problems, and are illegally unenrolled. For some patients, the co-payment for an essential medication is so high that they do without it. Eventually they need a much more expensive intervention for a complication that may have been prevented had they been able to afford the medication. Still others die while awaiting treatment approval or after having been denied treatment. If individuals lose their jobs in this country, most can continue their healthcare insurance for eighteen months by paying out-of-pocket to the tune of $800 or $900 a month, for what is called the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA is available for workers and their dependent children if they lose their jobs, only if they were employed in a workforce with at least 20 employees. They are entitled to continue their coverage under their former employer for 18 months, and, if disabled, for up to 29 months (Consumer Reports, p. 85). When persons are out of work and paying premiums this high there is little left over for rent or mortgage, utilities, food, and medication; that is, if they are fortunate enough to be receiving unemployment benefits in the first place. Immediately upon reaching the 18-month COBRA deadline, individuals have to pay 2 or 3 times the COBRA amount to continue insurance coverage, which very few have the means to do. Some breathe a sigh of relief when they reach age 65 because they qualify for Medicare. However, even if individuals make it to Medicare age they are likely to be required to pay for additional health insurance, such as Medigap or HMO Medicare coverage, for services not covered by Medicare. A final disparity perspective comes from guest essayist Penelope Frontuto, who relates her personal experience with the healthcare system and the need for reform: After being laid off from my job at the Visiting Nurse Service of Rochester and Monroe County, I continued family coverage under COBRA for $900 per month. When COBRA ran out I paid $2,200 a month. As I reached Medicare eligibility, my husband and I qualified for an HMO-based Advantage Plan which went from an initial monthly $94.50, to $165.00 in addition to co-pays for medications all totaling over $400 a month. However, my daughter became uninsured. While one senator in the spotlight for writing healthcare reform was reported to have received $1.5 million in re-election funds from the pharmaceutical industry … We have to fix this … We have to stop politicizing healthcare reform (Frontuto, 2009, p. 21A). Almost overnight individuals are relegated to second-class citizenry; at a time when they should be retiring and living the good life, they lose their health, their homes, and their dignity almost simultaneously. As a nurse practitioner, this is a common scenario I have observed repeatedly, and feel powerless to change. Very little can be done apart from giving samples whenever possible, encouraging patients to appeal insurance company decisions, and to not give up hope. Insurance company tactics such as instituting a physician grading system based on the number of referrals made and diagnostic tests ordered often dissuade health providers from making referrals to specialists, or ordering expensive diagnostic procedures. If not for the highly publicized actions of a few who deliberately disrupted town hall meetings throughout the country, healthcare reform would, without question, be much further along. However, ready or not, much needed healthcare reform is on the horizon. The system will eventually get the long awaited overhaul that is needed. SUMMARY Approximately 25 years ago, the United States healthcare system was medical dominated and physicians ruled. The diagnostic tests, procedures, referrals, and length of hospital stays were based on physician’s unscrutinized decisions. For the last twenty-five years however, health care has been moving from physician dominance to business dominance. In effect, insurance companies now rule. More focus must be placed on cost containment and achieving clear measurable outcomes. By tracing over two decades of health care in the United States, this chapter has provided insight on how health care is financed, the role of the health centers in providing affordable, comprehensive care, and practice challenges experienced by providers and consumers. This has all led to health reform. Healthcare reform, a response to controlling escalating healthcare costs, preserving a patient’s right to choose their health provider, and assuring that all Americans have access to affordable, high quality care will likely be further debated and challenged before finalized. With a particular focus on patient safety, quality of care, preserving wellness, preventing insurance companies from unenrolling patients and cancelling their coverage when they become ill, health outcomes will probably be improved. Those in opposition to changing the healthcare system reportedly fear too much government involvement, cost escalation, and tampering with Medicare benefits in order to fund reform. This chapter has also presented some convincing arguments in support of healthcare reform. In the words of guest essayist Frontuto, “the United States healthcare problem is fixable and must be fixed now!” Discussion Questions 1.  Where are people most likely to receive primary care today, and why? 2.  Describe the changes in specializations over the past 30 years. How have these changes affected the primary provider and the consumer? 3.  Explain why Managed Care and HMOs are not “the answer” to healthcare issues in the United States. 4.  Explain why Community and Migrant Health Centers are viable alternatives to emergency care. 5.  Identify arguments for and against healthcare reform. 6.  Describe three strengths or barriers that facilitate or limit access to health care and give examples of each. Case Scenario for the United States Mr. Samuels’ Long-Term Care Service Options Mr. Samuels, a 93-year-old severely hard of hearing male, slipped on theùice, suffered severe contusions and sprains of his left lower leg, and was hospitalized for three days before being transferred to a nearby nursing home for rehabilitation. His hearing aid was misplaced somewhere between the hospital and the nursing home; however, no one ever claimed responsibility for it. Prior to being hospitalized, Mr. Samuels lived independently in his own home in the New York City area. He never complained about his care at the nursing home where he spent most of his time in bed or sitting for extended periods in a chair, but he repeatedly begged his niece, who lived almost 600 miles away, to take him out of the nursing home. Once assured by Medicare that, with the exception of a wheelchair, her uncle would receive full home care services, the niece had him discharged after five months in the nursing home, and he was to continue rehabbing at her home in upstate NY. Upon discharge, Mr. Samuels had lower extremity weakness, could not take more than a few steps without his knees buckling, and he needed to be bathed. Despite a home care referral being submitted by his new primary care physician, for the first six weeks no one visited from the local home care agency. When services did begin around the 7th week, physical therapy and occupational therapy services abruptly ended after 4 visits, and the home health aide services provided two hours a day, ended after 40 hours. Although the niece made several appeals for continuation of services, no one from Medicare contacted her to clarify the numerous questions she had about the change in services or to explain why the services were halted. DISCUSSION POINTS There are several quality of life issues for Mr. Samuels as he moves through various stages of care. Let’s address his situation at each phase. 1.  Mr. Samuels lived on his own for a long time. Identify the qualities it takes for an older adult to do that. 2.  Recognizing these characteristics, what could have been done to make sure Mr. Samuels’ time in the nursing home involved more than staying in bed or sitting around? What could have been done immediately? What could have been done over his five month stay? 3.  Instead of getting better, Mr. Samuels’ health steadily declined in the nursing home. How does this happen? As an administrator or as a health practitioner, what could have been done to ensure that Mr. Samuels was healing properly? 4.  Imagine life for the niece the first six weeks without healthcare assistance for her uncle. How do you think she felt? How do you think she managed Mr. Samuels’ care? 5.  Mr. Samuels is aware of the problems surrounding support for his health care. How do you think he feels about depending on his niece? 6.  In view of the problems and confusion with Medicare, where does the niece go from here? 7.  What can the niece do to obtain uninterrupted healthcare services from Medicare? Are there steps she missed? How can health practitioners assist families through the maze of Medicare? REFERENCES Agency for Healthcare Research and Quality (AHRQ). 2007 National Healthcare Disparities Report. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, February 2008. AHRQ Pub No. 08-0041. Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, T. L., & Cheney, T. (2008). The effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223–229. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. 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