The U.S. Health Care System

A well-functioning healthcare system is characterized by coordinated, efficient, cost-effective, and quality healthcare. Although the U.S. passed the  2010 Patient Protection and Affordable Care Act (PPACA), universal health care is lacking. Healthcare is provided through public and private insurance plans and unconnected federal, state, and local governments and individual providers.

The Cost of U.S Health Care

Healthcare services in the U.S. are costly, whereby the cost of healthcare per person is double the cost spent in other developed countries. Gaynor’s (2018) research shows that the U.S. spends 18% of its Gross Domestic Product (GDP) on health care. The high healthcare cost is associated with high payments to healthcare providers and institutions. Research shows that in 2018, the U.S. spent $10, 637almost twice as much on health per person, which is $5,527 on average in other developed countries (Kurani and Cox, 2020). Further, Americans spent $6,624 per person on inpatient and outpatient care compared to $2,718 per person in other developed countries. U.S. patients stay in hospitals for short periods, and most medical procedures are performed at high prices. The healthcare costs increased by 9.9% in 2020, increasing the healthcare cost to $12,530 per person (OECD, 2021). The U.S. spent $ 11,100 per person on healthcare in 2019, the highest cost per capita across the OECD (OECD, 2021). These findings indicate high healthcare costs in the United States. Americans incur high out-of-pocket costs to pay for health care services. The comparative value of the U.S. healthcare costs is disproportionate, undermining economic growth and Americans’ economic well-being. 

Payment for U.S. Healthcare

Healthcare in the U.S. is funded by the government, private health insurers, and consumers. The government comprises the public sources of healthcare funding and includes federal programs such as Medicare, Medicaid, and Veterans Administration (Gaynor, 2018). The federal government pays for the national Medicare programs for adults aged 65 years and above, people with disabilities, veteran organizations, and low-income people. The Medicare program also includes Medicaid and the children’s Health Insurance program. The State government pays for local coverage and safety net. Medicare pays for hospital and physician visits and prescription drugs. Employer-sponsored plans and direct purchase exchanges provide private insurance. Private payment models include Health Maintenance Organization (HMO) and High Deductible Health Plans (HDHPs). Consumer payments include direct out-of-pocket payments paid for every healthcare service accessed. Patients pay these costs to reimburse providers for every unit of care provided. Americans incur out-of-pocket costs in excess, subjecting them to negative health chock and high hospital bills.

Healthcare is a Human Right

Healthcare is a basic human right and not a privilege. According to Article 25 of the United Nations Universal Declaration of Human Rights, medical care is a right. States must grant this right by enhancing access to health care, health institutions, and essential medicines. Access to health as a human right entitles people to disease prevention, treatment, and control. The right to access health also includes health determinants such as access to health education, favorable work conditions, and gender equality (Bauchner, 2017). All people should access essential health services without incurring high costs or financial hardships. Health as a human right also implies that humans are entitled to take control over their health by accessing health promotion education without discrimination. The provision of people-centered care embodies health as a human right in the practice of healthcare. Humans should be active participants in their own care to ensure their human rights are respected, achieve better health outcomes, and ensure the efficiency of healthcare systems.

Shortfalls in the Design of the U.S. Healthcare System

The major problem in the design of the U.S. healthcare system is the lack of universal coverage, which has led to rising health costs and widening the inequity gap. According to Baggio et al. (2018), the lack of universal health in the U.S. disproportionately affects low and middle-income families, increasing social and economic discrimination in healthcare services. Patients face financial difficulties and difficulties paying for high medical bills and related expenditures. The government outsources funding from private firms to meet its administrative needs. Another shortfall in the U.S. healthcare system is the lack of insurance coverage. Rising insurance premiums and decreasing insurance policies’ quality exclude people from insurance coverage (Sacks et al., 2020). The increased number of uninsured Americans threatens the U.S. economy, increasing spending on disease control and prevention. U.S. healthcare system can be redesigned by consolidating healthcare services to lower costs and improve quality. Instead of having public and private hospitals offering the same services at different costs, they can be consolidated to offer the same services at standardized prices. Another strategy is to eliminate the fee-for-service payment system that reimburses care providers based on the volume of services offered instead of quality. The Centers for Medicaid and Medicare Services (CMS) and policymakers are responsible for redesigning the healthcare system.

Patient Protection and Affordable Care Act

            The Patient Protection and Affordable Care Act (PPACA)  is a healthcare reform aimed at enhancing access to healthcare insurance, reducing healthcare costs, and improving the quality of care. A major ACA provision is to expand health insurance coverage to uninsured Americans by expanding private and public insurance schemes (Feder, Tormohlen, and Crum, 2017). Under this provision, employers must cover their workers, and individuals should have insurance coverage. Another provision is to improve health quality and system performance through comparative research of various medical treatments, investing in health information technology, and enhancing care coordination between Medicare and Medicaid for eligible patients. ACA also intends to lower health care costs by reducing health insurance premiums, reducing uncompensated care and implementing Medicate payment reforms. PPACA will increase coverage of uninsured Americans, reduce health care costs, and enhance access to care. Reduced health care costs will lead to the growth of the U.S. economy (Rudowitz and Antonisse, 2018). ACA will reduce the high payments made to medical providers, curb the growth of insurance premiums paid to employers, lower long-term economic deficits, and increase national savings.

Accountable Care Organizations

Accountable Care Organizations (ACOs) are created to solve the problems of high health care costs, coordinate patient care and population health. ACOs comprise a team of doctors and healthcare providers united to provide coordinated, high-quality care (Blackstone and Fuhr, 2016). ACO assign patients to physicians to primary care providers whose expertise aligns with patients’ needs. Medicare patients can also access healthcare services from any provider that accepts Medicare. ACOs provide physicians and hospitals with incentives to reduce costs through sharing the cost savings. Cost-savings techniques such as bundling payments shift financial risks to health care providers, enhancing efficient care delivery. ACOs are not the best choice because they can lead to monopolistic practices and increase healthcare prices. ACOs are also difficult to implement because they are designed around sharing information. Organizations without Electronic Medical records (EMRs) could incur financial and resource costs to implement ACOs. It is difficult for these organizations to know which patients are registered in their ACO.

Role of Registered Nurses in the U.S. Health Care System

The advent of patient-centered care and the revolution of primary care in the U.S. have enhanced multidisciplinary care approaches. All care providers are engaged in activities that enable them to practice their knowledge and skills. Registered Nurses (RNs) can exercise their clinical skills and training to contribute to healthcare decisions. RNs’ major role in U.S. healthcare is to drive change and improve health. According to Flinter et al. (2017), nurses are involved in change as advocates for safe, quality, accessible, affordable, and patient-centered care. RNs are in immediate contact with patients and on the frontlines of healthcare and are the first to notice changes in health care quality and negative patient outcomes. Nurses also serve as primary care providers by promoting behaviour change and managing chronic conditions. RNs also lead health care management teams to enhance patient care and reduce the cost of care for patients. Nurses also coordinate patient care by ensuring transitions to hospital, primary care settings, and home. RNs should play the role of advocating for patients’ needs and patient-centered care. RN is an effective profession for enhancing patient care. Nurses in the U.S have a common voice for advocating for patients and influencing positive change in the nursing profession.

Institute of Medicine Themes

Given the current challenges in the U.S. healthcare system, various stakeholders, including the Institute of Medicine (IOM), have emphasized the need to transform the healthcare system to improve care quality and enhance access to healthcare services. The main themes in the IOM’s Report on the future of nursing primary care and prevention, interprofessional collaboration and coordination, and payment for healthcare services (National Academies of Sciences, Engineering, and Medicine, 2016). Nurses should practice the knowledge, skills, and training in providing primary care and preventing diseases. Patient-centered and coordinated care can be attained through interprofessional collaboration. Nurses can collaborate with other professionals to ensure coordinated care. Nursing care should prioritize wellness and prevention to mitigate the cause of preventable disease conditions and health care problems. Nurses should focus beyond patients’ current conditions and consider how to enhance patients’ wellness. These themes are viable because nurses are prepared to assume new roles to improve care, advance health and increase care value. Moving forward in the nursing practice requires new thinking and practices. Nurses need to focus on promoting health and collaborating with patients and their families to engage in care that meets patients’ needs. Nursing is at the core of patient care, and it is the practice needed to revolutionize healthcare to increase focus on patient-centered and high-quality care.

References

Baggio, S., Dupuis, M., Wolff, H., & Bodenmann, P. (2018). Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage. PLoS One, 13(10), e0204666.

Bauchner, H. (2017). Health care in the United States: a right or a privilege. JAMA, 317(1), 29-29.

Blackstone, E. A., & Fuhr Jr, J. P. (2016). The economics of Medicare accountable care organizations. American health & drug benefits, 9(1), 11.

Feder, K. A., Mojtabai, R., Krawczyk, N., Young, A. S., Kealhofer, M., Tormohlen, K. N., & Crum, R. M. (2017). Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act. Drug and alcohol dependence, 179, 271-274.