Nursing
Topic: The Affordable Care Act
Paper details:
These discussion questions (DQ) DOES NOT need an APA format (Please there is no need for Student’s Name, Institutional Affiliation name, Course Number and Name, Instructor’s Name or Due Date). Research ( resources in the attachment) and answers the questions in the sequence. Please answer all the parts/segments of the question. Please add in-text citation and reference
The Affordable Care Act was signed into law by President Barack Obama in March 2010. Many of the provisions of the law directly affect health care providers. Review the following topic materials:
1. “About the Affordable Care Act”
2. “Health Care Transformation: The Affordable Care Act and More”
What are the most important elements of the Affordable Care Act in relation to community and public health? What is the role of the nurse in implementing this law?
The above discussion questions (DQ) DOES NOT need an APA format (Please there is no need for Student’s Name, Institutional Affiliation name, Course Number and Name, Instructor’s Name or Due Date). Research ( resources in the attachment) and answers the questions in the sequence. Please answer all the parts/segments of the question. Please add in-text citation and reference.
Resource
s: Study “About the Affordable Care Act,” from the U.S. Department of Health & Human Services website.
URL:
https://monkessays.com/write-my-essay/hhs.gov/healthcare/facts/timeline/index.html
Explore the Topics and Issues page of the American Public Health Association (APHA) website.
URL:
https://www.apha.org/topics-and-issues
Read “Health Care Transformation: The Affordable Care Act and More” (2014), located on the American Nurse Association website.
URL:
https://www.nursingworld.org/~4afc9b/globalassets/practiceandpolicy/health-policy/healthcare-reform-document.pdf
Read “EPHO1: Surveillance of Population Health and Wellbeing,” by the World Health Organization (WHO), located on the WHO website.
URL:
https://monkessays.com/write-my-essay/euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations/epho1-surveillance-of-population-health-and-wellbeing
The Environment, Policy, and Health EffectivenessBy Sue Z. Green
‘Saving our planet, lifting people out of poverty, advancing economic growth … these are one and the same fight. We must connect the dots between climate change, water scarcity, energy shortages, global health, food security, and women’s empowerment. Solutions to one problem must be solutions for all.” —Ban Ki-moon, former United Nations Secretary-General (2011, paras. 23-24).
Essential Questions
• What are the environmental influences on populations?
• How do environmental influences affect nursing practice?
• What oversight organizations guide regulations and policies?
• What are the interrelationships among health policy, social justice, and nursing practice?
Introduction
Health care’s rapid transformation during this century centers on the environment, health care policies, and effectiveness of the health care system. When entering nursing, the focus is often on bedside skills, an individual’s immediate needs, and the closest health care setting. Advancement in nursing practice now demands that nurses look beyond the proximate and seek to understand the larger world that encompasses health care. Health disparities, inequities of care, and the need to advocate for social justice become integral to new nursing roles for this century. An understanding of environmental health and the components of the U.S. health care system provide a foundation for care of populations.
Environmental Health
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Environmental health is the broad science focused on how the environment influences human health, injury, and disease. According to the World Health Organization (WHO) (2018a), environmental health is “all the physical, chemical, and biological factors external to a person and all the related behaviors.” The science includes the assessment and control of these factors affecting health with the goal of disease prevention and healthy environments (World Health Organization [WHO], 2018a). Environmental health science does not include human behaviors resulting from genetics or from the psychosocial/cultural environment (WHO, 2018a). The American Public Health Association (APHA) denotes environmental health as a critical component of public health systems (American Public Health Association [APHA], 2018). The public health focus is on relationships between people and their environment for health promotion and safe, healthy communities (APHA, 2018). In 2012 alone, unhealthy environments resulted in a global mortality rate of 1 in 4, accounting for approximately 12.6 million deaths (WHO, 2016a).
Environmental Threats to Health
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Risk factors for more than 100 injuries and diseases are environmental, including air, water and soil pollution, chemical exposures, climate change, and ultraviolet radiation (WHO, 2016a). The largest share of environment-related deaths results from noncommunicable diseases (NCDs), such as cardiovascular disease, stroke, cancers, and chronic respiratory disease (WHO, 2017b). Healthy People 2020’s overview of environmental health includes natural and technological disasters as part of the concerns (HealthyPeople.gov, n.d.a), such as injuries sustained from a tornado, a disease outbreak due to flooding, or a nuclear leak resulting from a breakdown in technological surveillance. Environmental health is connected to the social determinants of health (SDOH). SDOH are conditions of living, such as housing, socioeconomics, transportation needs, and quality of education that directly impact health and access to health care needs. Environmental health concerns related to the SDOH center on working conditions, housing, water, sanitation, and healthy lifestyles (Prüss-Üstün, Corvalán, Bos, & Neira, 2016). In other words, a healthy environment contains healthy living conditions or SDOH. Environmental barriers to healthy living conditions become detrimental to health. For example, lack of adequate shelter to protect an individual from temperature extremes can cause harm, as can a lack of access to healthy and ample nutrition. The poor physical conditions of housing and high household energy costs negatively affect the health of low-income families’ economic, physical, and behavioral health and security (Hernández, 2016). Because some form of energy is required for basic cooking, lighting, and heating, those with low incomes may face hardships if household energy expenditures exceed 10% of their income (Hernández, 2016). Expenditures on heating or cooling may increase due to poor housing physical conditions, such as air leaks, broken windows, or lack of insulation. The economic situation may cause families to consider whether they can afford to both heat and eat (Hernández, 2016). The prioritization of resources and trade-off decisions affect physical and behavioral health through stress and deprivation.
Higher risks of cardiovascular diseases, stroke, and diabetes result from an unhealthy diet (Micha et al., 2017; WHO, 2017b). Recent studies find that exposure to violent crimes, household-noise levels, proximity to traffic noise, and air pollution affect the development of cardiovascular diseases (Chum & O’Campo, 2015). These neighborhood factors are thought to reduce physical activity, sleep, and rest and increase stress, depression, and anxiety, all of which negatively impact cardiovascular health (Chum & O’Campo, 2015). Reduced access to grocery stores, parks, and recreation and easy access to fast food in neighborhoods also increases cardiovascular health risks (Chum & O’Campo, 2015). Poor air quality at home or work correlates with development of lung disorders, such as chronic bronchi or alveolar disorders. Cancer, asthma, and chronic obstructive pulmonary diseases result from exposure to radon, smoke, lead, toxic gases and particulates, coal dust, or asbestos, with smoking being the highest risk of death (WHO, 2017b). Thus, a poor environment increases the burden of disease regarding NCDs. The burden of disease reflects the morbidity, mortality, financial costs, and health disparities resulting from disease, affecting human longevity and the well-being of countries socially and economically.
Exposure to poor environments results in poor health. Poor health results in vulnerability to communicable disease. Proximity and specific types of behavior can lead to spread of disease. Poor sanitation and water pollution can lead to an outbreak of cholera or other gastrointestinal-related infectious diseases. Growth of molds, bacteria, mycotoxins in damp housing increases respiratory infectious disease occurrence (Prüss-Üstün et al., 2016). Uncontrolled populations of mosquitoes, ticks, fleas, lice, and sandflies increase the risk of vector-borne diseases, such as malaria, Chagas, dengue fever, yellow fever, Zika virus, West Nile virus, Lyme disease, typhus, and plague (WHO, 2017d). Tuberculosis, hepatitis B and C, parasitic diseases, and sexually transmitted diseases (STDs) increase in unsafe, unhealthy environments (Prüss-Üstün et al., 2016). A growing concern is the world’s reliance on antibiotics to control infections and the increased development of antimicrobial-resistant pathogens. Poor hand hygiene and contact precautions increases the transmission risk of antimicrobial-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) (Seibert, Speroni, Oh, DeVoe, & Jacobsen, 2014). Antimicrobial resistance reduces the range of effective antibiotics available, lengthens illness and hospital stays, and increases the risk of death (Duckworth, 2017). Crowding, skin-to-skin contact, and shared equipment, supplies, or personal items spread MRSA in the community. Spread of MRSA within a community can occur to the point of forcing the shutdown of public areas to decontaminate equipment and surfaces, especially schools, day care centers, and athletic venues (Centers for Disease Control and Prevention [CDC], 2016b). According to the National Academy of Sciences, Engineering, and Medicine (NASEM) (2017a), the antimicrobial resistance has become an emerging and global health condition, resulting in a number of deaths. The WHO (2017a) considers antimicrobial resistance to be “one of the biggest threats to global health, food security, and development today” (para. 1). The commonly resistant organisms are Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus (MRSA), Mycobacterium tuberculosis, Streptococcus pneumoniae, Enterococci faecium (Vancomycin-resistant Enterococci or VRE) and Salmonella (National Academy of Sciences, Engineering, and Medicine [NASEM], 2017a; WHO, 2018c). In addition, Clostridium difficile (C. diff) is an urgent concern in U.S. health care environments (NASEM, 2017a).
Reducing the Health Impacts of Global Climate and Environmental Changes
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The current environment has modifiable health risks. For example, better environmental conditions reduce transmission of diseases from the animal world. Animals have diseases considered zoonotic, meaning they are transmissible to humans. Modern day communicable disease epidemics often originate from animal transmissions. Such is the case for Ebola, salmonellosis, severe acute respiratory syndrome (SARS), and influenzas. The WHO notes that 61% of human disease-causing microorganisms are from animal transmissions and represent 75% of emerging infectious diseases in the past decade (WHO, 2018d). The following topics are prominent means for health promotion and disease prevention when confronting climate and environmental changes.
One Health
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One approach to combating climate and environmental issues is collaboration among multiple professions and/or multiple nations. The Centers for Disease Control and Prevention (CDC), WHO, and professional organizations use this approach. The One Health initiative uses the concept of global interdisciplinary collaboration among physicians, “A One Health approach is important because 6 out of every 10 infectious diseases in humans are spread from animals.” (CDC, 2018c, para. 2)veterinarians, and other health and environmental professionals to address all aspects of health care for humans, animals, and the environment (One Health Initiative, n.d.b). Joint efforts among these professionals currently conduct public health surveillance of cross-species diseases, including treatment and preventative measures. The initiative seeks to advance health care by “accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving medical education and clinical care” (One Health Initiative, n.d.a, para. 1). Efforts include multiple collaborations among professional and educational settings for medical, veterinary, public health, and the environment sciences. Goals include a better understanding of cross-species disease transmission and environmental research. The initiative’s objectives aim to provide and improve diagnostics, vaccines, prevention and control measures, and education for political leaders and the public. The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) notes that people live “in an interconnected world where an outbreak of infectious disease is just a plane ride away” (CDC, 2018b, para. 1). The CDC has experts working on a One Health Zoonotic Disease Prioritization to focus and mitigate impact of endemic and emerging zoonotic disease threats to the public. The One Health approach is an ecosystem approach, keeping the links between humans, animals, and the environment (Gyles, 2016; Van Helden, Van Helden, & Hoal, 2013; Shrestha, Acharya, & Shrestha, 2018).
Sustainable Development Goals
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Risk factors for transmission of communicable disease directly link with poor environments. The Sustainable Development Goals (SDGs), which are holistic, people-centered global health initiatives for the year 2030, were developed by the United Nations (UN) and the WHO. These goals align with the concept of social justice as well as the idea that health is a right that is to be equitably available to all. The SDGs include:
1. No poverty
2. Zero hunger
3. Good health and well-being
4. Quality education
5. Gender equality
6. Clean water and sanitation
7. Affordable and clean energy
8. Decent work and economic growth
9. Industry, innovation, and infrastructure
10. Reduced inequalities
11. Sustainable cities and communities
12. Responsible consumption and production
13. Climate action
14. Life below water
15. Life on land
16. Peace, justice, and strong institutions
17. Partnerships for the goals (United Nations, n.d.)
The various initiatives and other SDGs interact to meet SDG 3—ensure healthy lives and promote well-being for all ages and address environmental factors (WHO, 2018f). For example, promoting sustainable agriculture (SDG 2) helps achieve food security and reduces malnutrition, which will promote health and well-being. Clean water and sanitation (SDG 6) targets water shortages, poor water quality, and sanitation issues, which will reduce transmission of disease. SDG 7’s aim for affordable clean energy addresses food production, climate change, and economic livelihoods, thereby improving the environment and health. SDG 13 tackles actions combating climate change.
Recent estimates hold that 92% of the global population is living in areas where the air pollution levels exceed the WHO limits (WHO, 2016b). The BreatheLife campaign is a global collaborative effort to increase awareness of health risks of even short-lived climate pollutants. Poor air quality increases the global burden of disease and increases mortality. Air pollution is a leading risk factor for the development of NCDs. Air pollution-related deaths have been linked to the following NCDs: 36% of lung cancer, 35% of pulmonary disease, 34% of stroke, and 27% of heart disease deaths (BreatheLife, n.d.; WHO, 2018b). Counteractive measures include promoting green spaces and alternatives to burning waste and fuels for transportation, heating, and cooking (WHO 2016b). Such measures are expected to help reduce climate changes as well.
A joint effort between the WHO and the United Nations International Children’s Fund (UNICEF) (WHO & United Nations International Children’s Fund [UNICEF]) seeks global prevention measures for provision of safe water, sanitation, and hygiene (WASH). WASH can improve nutritional statuses, reduce diarrheal diseases, intestinal parasite infections, and environmental enteropathy, thereby reducing the global burden of disease and deaths (WHO & UNICEF, 2017). Billions lack safe water at home and/or have no toilets (see Figure 4.1 and Figure 4.2). SGD 6 incorporates measures to combat this issue and the lack of soap and water for handwashing (see Figure 4.3). These measures overlap with goals from One Health. In addition, the measures create overall improvements in maternal, newborn, and child health. Recently, the UN Secretary-General called for global action for WASH in all health-care facilities noting that a survey of 100,000 facilities revealed that “more than half lacked the simple necessities, such as running water and soap” (WHO, 2018e, para 10).
Figure 4.1
Access to Safe Water for All by 2030
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Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the World Health Organization.
Figure 4.2
Access to Safe Sanitation for All by 2030
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Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the World Health Organization.
Figure 4.3
Access to Soap and Water for Handwashing
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Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the World Health Organization.
Healthy People 2020 and Environmental Quality
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Healthy People 2020 objectives focus on objectives in six categories that direct actions toward environmental health issues involving outdoor air quality, surface and ground water, toxic substances and hazardous waste, homes and communities, infrastructure and surveillance (such as public health departments), and global environmental health (HealthyPeople.gov, n.d.a). These objectives are congruent with the mission, goals, and objectives of the Environmental Protection Agency (EPA), another U.S. government agency. The EPA’s mission “is to protect human health and the environment” (Environmental Protection Agency [EPA], n.d.b, para. 1). Goals and objectives of the EPA’s strategic plan include clean air, land, and water by enforcing federal laws to protect human health and the environment and requiring the safe use of chemicals (EPA, n.d.a). The significant emerging environmental issues involve climate change, disaster preparedness, and nanotechnology. Nanotechnology at the EPA involves researching how to measure the nanomaterial concentrations and seek to determine how minute chemicals and materials in products pose risks to human health and the environment (EPA, n.d.c). Air quality improvement measures from the EPA and Healthy People are aimed toward the use of alternative modes of transportation, such as bicycling, walking, mass transit, or telecommuting. Measures are in place to reduce adverse health effects resulting from toxic emissions from manufacturing and other sources. The water quality objectives address methods for meeting federal regulations for safe drinking water, such as the Safe Drinking Water Act of 2008; reducing waterborne disease outbreaks; conserving water; and sustaining coastal waters safe for swimming (HealthyPeople.gov, n.d.a). Evidence of progress in the area of toxic substances and hazardous wastes is verified through the increase in recycling efforts as well as the reduction in hazardous waste sites, pesticide exposure, and serum lead levels in toddlers and preschoolers (HealthyPeople.gov, n.d.a). Residents of healthy homes seek to reduce indoor household allergen levels from cockroaches, mice, and dust; radon exposure risk; and lead-based paint as well as dust- and soil-lead hazards (HealthyPeople.gov, n.d.a). In addition, the initiatives monitor the health of community educational systems to provide healthy school environments with indoor air quality management; a reduced amount of molds; proper use, storage, and disposal of hazardous materials; safe drinking water; and prudent use of pesticides. Healthy People 2020 initiatives measure the body burden of toxins or the amount of a radioactive element or toxic material in a body, especially lead. Routes of entry include oral, integumentary, and respiratory. Storage sometimes occurs in human or animal fat tissue.
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Since Florence Nightingale, nurses are accountable for managing the environment to promote health (Jackman-Murphy, 2015). In 2007, the American Nurses Association (ANA) published ANA’s Principles of Environmental Health for Nursing Practice with Implementation Strategies. These principles incorporated nursing’s heritage of disease prevention and social justice, ongoing global climate changes, and increasing burdens of individual exposures (American Nurses Association [ANA], 2007). The ANA’s Scope and Standards of Practice guides all nurses to practice in a safe and environmentally healthy manner (ANA, 2010). Nurses work to counteract the direct and indirect health implications of climate changes that result in temperature extremes, air pollution, toxic exposures, food shortages, and water scarcity. Climate changes have health repercussions, especially in the very young, older adults, those with preexisting chronic health conditions, immigrants, and the poor (Allen, 2015). Extreme weather events pose risks of drowning, physical injuries, heat exhaustion, postdisaster infections, mental health consequences, and risks of fires. In a study of weather-related mortality among U.S. residents from 2006 to 2010, “about 31% of these deaths were attributed to exposure to excessive natural heat, heat stroke, sun stroke, or all” (Berko, Ingram, Saha, & Parker, 2014, p. 1). Because of extreme heat, there are about 618 preventable human deaths each year in the United States (CDC, 2017b). The world experienced 15 of its warmest years on record since 2000 (CDC, 2016a). The rise in the annual temperature correlates with climate changes. The EPA (2016) monitors key indicators related to causes and effects of climate changes as noted in the report Climate Change Indicators in the United States. The report discusses the multiple indicators and the effects of climate on health. Nurses are in the position of sharing this evidence-based research and increasing awareness within the nursing practice. Nurses can subscribe to professional publications and attend workshops to foster their own development. For example, NASEM, formerly the Institute of Medicine (IOM), sponsored a workshop in 2017 called “Protecting Health and Well-Being of Communities in a Changing Climate” and published on its website a brief summary of the workshop proceedings with results from four regions of the United States (NASEM, 2017b). The Alliance of Nurses for Healthy Environments (ANHE, pronounced Annie) recognizes nursing’s pivotal role in health promotion and environmental health through nursing education and professional leadership, research, evidence-based practice, and policy advocacy (Alliance of Nurses for Healthy Environments [ANHE], 2017). All nurses have the responsibility to practice in an environmentally safe manner and to provide evidence-based information about environmental health to the nursing field, the patients, the public, and policy makers.
Healthy Work Environments
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Healthy work environments are the primary focus of two U.S. federal agencies: National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OHSA). NIOSH is a research agency, under the auspices of the CDC, established by the Occupational Safety and Health Act of 1970 (CDC, 2018a). NIOSH researches workplace environments and makes recommendations for prevention of work-related injury and illness. NIOSH maintains a list of antineoplastic and other hazardous drugs in health care settings. OHSA is structured under the U.S. Department of Labor with the mission of assuring safe and healthy work conditions through writing and enforcing regulatory standards (Occupational Safety and Health Administration [OSHA], n.d.a). OSHA has links for filing safety and health complaints, reports of death or severe injury, and whistleblower information regarding employee protections from retaliation when reporting injuries, safety concerns, and similar activities. OSHA maintains eTools with information on hazards present in health care, such as blood-borne pathogens, mercury, and workplace violence (OSHA, n.d.c). Both NIOSH and OSHA link the public and health care professionals to topical resources for workplace safety and health. For example, both sites have links to information regarding ergonomics, and the agencies jointly published a hospital respiratory protection program toolkit (CDC, 2015a).
Both agencies target prevention of harm to the human body, particularly the musculoskeletal system through the ergonomic design and arrangement of the workplace environment, including equipment and the persons. Nurses, for example, study body mechanics to determine the best use of workplace equipment to make beds, move persons, and transport equipment. Lifting, carrying, pushing, and pulling all use musculoskeletal functions. Poorly designed equipment can be harmful. Today’s technology may have a person performing one function or movement over long periods each day, and this repetition can be injurious to the body. The stressors to the body often result in musculoskeletal disorders (MSD), which trigger one-third of lost work days or workday cases. The U.S. Bureau of Labor Statistics (2017) uses the days away from work as a measure of severity of injuries and illnesses. Specifically, health care workers have a high rate on nonfatal occupational illness and injury (U.S. Bureau of Labor Statistics, 2017). The ANA surveyed nurses regarding work-related injuries, and of the respondents, 62% of the nurses reported concerns of suffering a disabling musculoskeletal injury as one of the top three workplace safety concerns; 80% reported working despite frequent musculoskeletal pain (ANA, 2011). Therefore, nurses need to keep informed of the dangers of MSD risks in the workplace. In 2014, the ANA published Safe Patient Handling and Mobility: Interprofessional National Standards and Implementation Guide to Safe Patient Handling and Mobility: Interprofessional National Standards. OHSA recommends minimization of manual lifting of patients and the elimination of lifting when possible (OHSA, n.d.b). The nurse should monitor coworkers for risks and educate others about ways to counteract the risks.
Hazardous waste is another area of concern in workplace safety and the environment. Hazardous waste includes, but is not limited to, regulated medical waste (RMW) and other hazardous substances such as chemicals, cleaning solutions, corrosives, heavy metals, and radioactive materials. RMW must be disposed of separately, usually incinerated, from other waste to avoid spreading communicable disease from blood, body secretions, or otherwise potentially infectious materials. Hazardous waste and RMW has to be tracked with manifests and signatures throughout the disposal chain of custody.
To identify hazardous waste consistently around the world, the United Nations Economic Commission for Europe (UNECE) created an international system of chemical classifications by types of hazard, called the Globally Harmonized System of Classification (United Nations Economic Commission for Europe [UNECE], 2013). The Globally Harmonized System (GHS) categorizes chemicals into classes according to either physical, health, or environmental hazards. This system standardized these chemical classifications, labeling requirements, and information sheet requirements, known as Safety Data Sheets (SDS). In the United States, OSHA requires an SDS for each hazardous item in the workplace (OSHA, n.d.b). Product labels and the SDS communicate the hazardous nature of the chemical through the hazard statements, signal words of “Warning” and “Danger,” and pictograms. For example, a pictogram of skull and crossbones indicates danger of severe toxicity, and a flame indicates highly flammable chemicals (see Figure 4.4).
Figure 4.4
Severe Toxicity and Highly Flammable GHS Symbols
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Every worker should have access to the SDS for reference. Nurses need to know the location of hazardous chemicals and the SDS. Organizations have policies and procedures in place to meet OSHA standards. In addition, the nurse must protect and educate coworkers of these risks, proper containment, and disposal methods according to OHSA and organizational standards.
Check for Understanding
1. Which global environmental threats are encountered in your nursing practice?
2. How can the nurse incorporate concepts of social justice to promote environmental health?
3. What additional environmental hazards could be removed from the workplace?
U.S. Health Care System
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According to a recent report, the U.S. health care system ranks last in overall performance among 11 countries examined (Schneider, Sarnak, Squires, Shah, & Doty, 2017). The United States pays the highest cost per person, yet has poor health care outcomes (Schneider et al., 2017, The Commonwealth Fund, 2017). The bottom line is that the U.S. system is not working as well as others (The Commonwealth Fund, 2017), which is due, in part, to the complexity of the U.S. health care system. To advocate for health care system improvements, the nurse needs an understanding of the current system.
Organizational Structure
Health care in the U.S. is decentralized with a variety of public and private access points. The public health system includes government entities and collaborative efforts with community nonprofit organizations and faith-based organizations (see Figure 4.5). Government entities include health agencies at the federal, state, and local levels, public safety agencies, and environmental agencies. Government agencies include state and local health departments, providing care such as laboratory services, health screenings, treatment of disease, and epidemiology surveillance. Private health care is delivered in inpatient, outpatient, or ambulatory care; long-term or residential; mental health; home care; wellness center; and alternative medicine settings. Private institutions are either for-profit private facilities or nonprofit private facilities, with the latter being the largest component. According to the American Hospital Association (AHA), there are more than 5,500 private, short-term care hospitals in the United States (American Hospital Association [AHA], 2018). Both private and public health care is offered by professionals known as providers, who include physicians, nurse practitioners, nurses, and other ancillary professionals who deliver health care directly to their clients or patients (Kahn, 2011). A trained workforce Helps providers in care provision and are considered resources. Other resources include technology, equipment, and supplies. The vulnerable aspect of the system is the consumer who is at risk of harm if the health care system does not function efficiently and safely when delivering care.
Figure 4.5
The Public Health System
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Note. Adapted from “The Public Health System & the 10 Essential Public Health Services,” by the Centers for Disease Control and Prevention, 2017.
Agencies Associated With Health Care
No matter the setting or organizational formation, the facilities have the overarching governmental regulatory mechanisms of the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA), the CDC, and OSHA (Healthcare Triage, 2014). Other federal agencies involved in health care include the:
• Center for Global Health;
• Office of Noncommunicable Diseases Injury and Environmental;
• Office of Infectious Diseases;
• Office of Public Health Preparedness and Response;
• Office of Public Health and Science (OPHS);
• Office for State, Tribal, Local, and Territorial Support; and
• Office of Surveillance, Epidemiology, and Laboratory Services.
Other federal agencies with a relationship to health care entities include the
• Office of Veterans Affairs (VA),
• EPA,
• Department of Justice,
• Department of Labor,
• Department of Defense,
• Department of Agriculture, and
• National Science Foundation.
This large collection of agencies reveals the complexity and sometimes fragmentation of U.S. health care. Agencies at state and local levels center on state and local public health care agencies, such as state and local health boards and state, county, or city departments of health. Multiple volunteer organizations complete the final aspect of health care services. Not all areas have government fire, police, and emergency services. Volunteer emergency medical technicians and paramedics provide emergency care in some locales. Other volunteer agencies may have a national outreach. For example, Volunteers of America (VOA) (n.d.) offers Helpance for senior living and care services. The National Association of Free and Charitable Clinics (NAFC) (n.d.), a network of volunteer agencies, provides medical services for the underinsured.
Financing Mechanism for U.S. Health Care
Financing Costs for Individual Care
Paying for health care is a major concern in the United States. Although individuals may have freely accessible health care at a variety of settings, the health providers and organizations expect payment for services rendered in order to remain operational; however, transportation, restrictions on eligibility for certain services, and ability to pay are barriers for some. The cost of services and has risen to new heights in this century. One means of paying for health care is through out-of-pocket payment or self-payment of services. Most Americans have neither the income nor savings to cover the full cost of health services when faced with more than a minor illness or condition. Ability to pay for services often comes in the form of health insurance coverage. Health insurance is an arrangement with the government or a private company to guarantee payment for health care services, generally for illnesses, injuries, and health conditions.
Federal and state governmental resources for health care are available for some (see Figure 4.6). Active duty military service members, veterans, their families as well as members of the National Guard and military reserves have eligibility for federally government-funded health insurance coverage through a health care program called Tricare (Tricare, n.d.). People who are 65 or older, those younger than 65 with certain disabilities, and those of any age with end-stage renal disease are commonly eligible for Medicare, a federal health insurance program (Centers for Medicare & Medicaid Services [CMS], 2014). Currently, more than 18% of the U.S. population, or 57 million people, depend on Medicare (Dean, Noel-Miller, & Lind, 2017). Medicare consists of multiple parts and eligibility stipulations, which confuses some about whether they are eligible for these benefits. The individual must apply for Medicare enrollment during specified times of the year, usually during the fall. The Medicare health and medications plans change yearly, requiring the person to review and choose coverage annually. Medicare Part A is hospitalization insurance for stays in acute care hospitals, short-term skilled nursing facilities, and some hospice and home care (CMS, 2014). Typically, the person pays a deductible before Medicare begins to provide compensation. Deductibles are out-of-pocket expenses. Medicare Part B provides coverage for practitioner services, outpatient care, and durable medical equipment, such as oxygen and wheelchairs. Medicare Part B coverage requires user enrollment and the payment of a monthly government premium. Medicare Part B generally provides 80% compensation for the cost of services, and the person must pay the remaining 20% as a copayment, plus any deductible. Medicare Part C, better known as Medicare Advantage, is not a separate Medicare benefit, but allows for Medicare coverage for those who wish to enroll in some private insurance plans (CMS, n.d.). Medicare Part D coverage requires user enrollment and the payment of a monthly government premium for lower cost prescription medications.
Figure 4.6
Financing Structure of the U.S. Health Care System
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Note. Adapted from United States of America: Health System Review, by T. Rice, P. Rosenau, L. Y. Unruh, A. J. Barnes, & R. B. Saltman, 2013, Health Systems in Transition, 15, p. 27. Copyright 2013 by Health Systems in Transition.
Medicaid is a health insurance program for certain families with low incomes, which is jointly funded by the federal government and the state where the family resides. Note that Medicaid is for families, not low-income adults without children, but it does provide for eligible blind or disabled persons. Since 2014, in accordance with provisions of the Affordable Care Act (ACA), states have the authority to expand eligibility for Medicaid to persons under the age of 65 if the family income is below 133% of the federal poverty level (FPL) for that family’s size (Medicaid.gov, n.d.b). The states, the U.S. territories, and the District of Columbia vary in Medicaid coverage. Some persons receiving Medicaid are also eligible for Medicare, known as dual eligibility.
Oversight of federal program policies and procedures for Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP) is through the Center for Medicaid and CHIP services (CMCS) (Medicaid.gov, n.d.b). The CHIP program provides states with federal matching funds for provision of health coverage to children of eligible families (Medicaid.gov, n.d.b). To be eligible for CHIP coverage, the family income must be too high to qualify for Medicaid and yet still too low to afford private coverage (Medicaid.gov, n.d.b). Most states allow coverage for children of families at 200% or greater of FPL (Medicaid.gov, n.d.b). More than 74 million adults and children are covered by Medicaid or the CHIP program (Medicaid.gov, n.d.a). The BHP is a health insurance coverage option, which is another provision of the ACA, allowing state health benefits for low-income adults, who have eligibility to purchase private insurance coverage through a health insurance exchange or marketplace (Medicaid.gov, n.d.b).
The majority of the U.S. population finances health care costs through private health insurance (Kahn, 2011). The individual pays a premium to the private insurance company. If employed, people can often enroll in their companies’ group health plan, for which the employer typically pays a significant portion of the premium, reducing the cost to employees. In the past century, especially the 1960s, individuals could chose whatever health care facility and provider they wished, and the private insurance company would compensate the services (Kahn, 2011). Because of the rising cost of health care, insurance companies placed restrictions on choice. Now, private health insurance companies negotiate contracts with providers and facilities for acceptance of prearranged cost of services. Health maintenance organizations (HMOs) provide tighter management of funds with enrollees paying a premium and predetermined fee for services from a preset list of providers and facilities (Kahn, 2011). Ordinarily, care delivered by those not on the preset list results in no compensation, and the individual is then responsible for the cost, unless a preapproved referral is in place. Preferred provider organizations (PPOs) provide a more flexible list of providers and facilities, but with higher fees (Kahn, 2011).
The ACA provided an expectation that every American have health care insurance. One of the concepts was to provide health insurance options for those who were unemployed or uninsured in the United States. The population had no centralized means of surveying options, leaving many unsure of how to find a health insurance plan that was best suited for themselves or their families. With the advent of the ACA, health insurance exchanges or marketplaces emerged. Some exchanges are ACA government-regulated, standardized health care plans. Others are private non-ACA exchanges, generally for small businesses. Both provide central sites for browsing health care plans competitively offered by the private insurance companies choosing to participate. The ACA concepts of transparency and accountability aid in the sharing of expenses across larger groups of people, more like a group plan. Moreover, marketplace and insurance companies share plan information through electronic data interchanges (EDIs) when an individual enrolls. Most states use the federal marketplace, Healthcare.gov.
Public Health Financing for Populations
Population health programs cannot operate without facilities, personnel, equipment, and supplies, all of which require funding. The most common sources of monies come from federal grants, state and local funds, and city or county revenues (CDC, 2013). Funding also comes from private organizations. Funding varies according to the current government’s health budget and legislative policy making (CDC, 2013). Grants provide funds to accomplish specific public purposes, and contracts or purchase orders with vendors normally acquire the equipment, supplies, and other services (CDC, 2017a). The Prevention and Public Health Fund (PPHF or The Fund), established under the ACA, is the compulsory annual funding of federal monies directed to the improvement of the U.S. public health system for prevention, wellness, and public health initiatives (EveryCRSReport, 2017; CDC, 2017c). For example, public health initiatives for smoking cessation used funds from PPHF to develop the mass media campaign, Tips from Former Smokers (American Lung Association, n.d.).
One Family
The following is an example of how one family structure can encounter multiple methods of financing their health care.
Mary, a retired, 65-year-old woman, now has a Medicare Part A card for health care. John, her 64-year-old husband, maintains insurance through his employer. Their daughter, Sarah, and granddaughter, Grace, are on Medicaid, but their son, Bob, has an income too high for Medicaid. Bob’s family is covered by CHIP.
Check for Understanding
1. How do One Health collaborations aid epidemiological surveillance?
2. How could access to health care be improved in the United States?
3. What aspects of the public health system have improved in the past decade?
4. How does an understanding of health care financing provide a foundation for advocacy related to population health nursing practice?
Public Health Delivery and Institute of Medicine Reports
Two major nonprofit organizations greatly influence the direction of public health care: the Robert Wood Johnson Foundation (RWJF) and NASEM. Sometimes, the influence comes through RWJF campaigns for action or sometimes through research reports. For example, in 2009, the RWJF requested that the IOM examine measurement, law, and funding within public health (Institute of Medicine [IOM], 2011a). This study followed the IOM’s report, The Future of Public Health (IOM, 1988), which scrutinized public health.
The Future of Public Health
With the advent of sanitation, safe water, protection against epidemics, and lower infant mortality rate than in the 1900s, there has been difficulty maintaining an appreciation of the critical nature of providing public health (IOM, 1988). The Future of Public Health was a landmark report that revealed that the public health infrastructure was poorly focused and inadequate (IOM, 1988). Recommendations were to regain dedication to the mission of public health with the government playing a vital role in policy development toward its mission at federal, state, and local levels (IOM, 1988). Government support emphasized environmental health, mental health, social services, and medical care for impoverished people (IOM, 1988). Shortly after The Future of Public Health was published, the IOM followed up with To Err is Human, (IOM, 2000), which resulted in national outcry over medical errors. The RWJF and the American Association of Retired Persons (AARP) began campaigns to correct these issues, now reflected in the initiatives described in Culture of Health and the Future of Nursing: Campaign for Action (American Association of Retired Persons [AARP], n.d.; Reinhard, 2018, Robert Wood Johnson Foundation [RWJF], n.d.a; RWJF, n.d.b).
Crossing the Quality Chasm: A New Health System for the 21st Century
Subsequent to the publication of To Err is Human, the IOM scrutinized the overall U.S. health care system for ways to improve the quality of care in light of a new century. The report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), triggered reactions still felt today. The publication documented that inadequate funding, insufficient accountability, and lack of partnerships with other health care service providers continued to plague the health care system (IOM, 2001). The IOM recommended six aims for improvement, shifting health care’s focus to safe, effective, timely, efficient, equitable, and patient-centered provision of care (IOM, 2001). Thus, the focus changed from errors and safety to a focus on quality as a means of error prevention and creation of safety. Strategies incorporate customization of care based on an individual’s needs, continuous healing care, patient control over health care decisions, evidence-based practice, free flow of clinical information, and transparency (IOM, 2001). In light of public health nursing, the emphasis on equitable care aligns with the concept of social justice and reduction of health care disparities.
The Future of the Public’s Health in the 21st Century
The IOM conducted further analysis of the public health system in The Future of the Public’s Health in the 21st Century (IOM, 2003). This report showed that there was still inadequate funding, insufficient accountability, and lack of coordination to collaborate with other health care services (IOM, 2003). The report distinguished three core functions of public health, which continue in the present: assessment, policy development, and assurance of the public (IOM, 2003). Furthermore, 10 essential public health services were determined (IOM, 2003). These core functions and essential services are now national public health performance standards (see Figure 4.7).
Figure 4.7
The 10 Essential Public Health Services
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Advocacy for Improvement of Population Health
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Universal Health Coverage (UHC)
As of June 2017, the number of uninsured Americans dropped to 9% of the population, down from 16% in 2010 (Clarke, Schiller, & Norris, 2017). This means that 28.8 million Americans are still uninsured (Clarke et al., 2017). In addition, almost 4.6% of the U.S. population, or 15 million people, failed to seek medical care during the previous 12 months because of cost of care (Clarke et al., 2017). An American may have health insurance, yet fail to seek medical care because of the out-of-pocket cost of the deductible (Chin, 2017; Olen, 2017). Some insured Americans must make the difficult choice of whether to seek needed care and pay a medical bill or pay for food and housing (Chin, 2017; Olen, 2017). Americans are in poorer health than other high-income countries globally, which disputes beliefs that U.S. has the best health care (Schneider & Squires, 2017). Many believe that the ACA is the closest to universal health coverage (UHC) that the United States can achieve.
During the last century, the WHO declared health as a fundamental human right (WHO, 2018g). UHC is in alignment with the SDG 3 of promoting good health and well-being for all people and all ages (WHO, 2018d). One of the WHO’s global goals is that all people have access to needed health promotion and prevention, curative rehabilitation, and palliative health services with sufficient, effective quality and without financial hardship (WHO, 2018g). As of 2017, over half the global population still does not have access to necessary health services (WHO, 2017c). The WHO advocates equitable access to all health services, quality health services, and protection against financial hardship when needing health care (WHO, 2018g). Out-of-pocket expenses are minimal under UHC (Schneider & Squires, 2017). The challenge in the United States is the hodgepodge financing, high health care costs, and accessibility to health care (Robinson, 2016; Schneider & Squires, 2017).
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A crucial position of the nursing profession, nationally and globally, is the provision of equitable health care and the reduction of health disparities. As nurses know well, the perception that a nurse merely carries out physician orders is incorrect; nurses are change agents. Since Nightingale, nurses have acted as advocates for policy and system advancements that improve health for every human (Thurman & Pfitzinger-Lippe, 2017). Through lifelong learning and an understanding of change theory, nurses are engaged in transforming care for vulnerable and at-risk populations, reducing health disparities and social injustices, and improving the global perception of health care (Edmonson, McCarthy, Trent-Adams, McCain & Marshall, 2017; Paquin, 2011; Walter, 2017). Nurses demonstrate this engagement when they identify stakeholders who have a vested interest to support change or maintain the status quo, determine sources of power to enable the change process, and examine their own professional perspective of inequitable conditions (Walter, 2017). Evidence-based practice and mentoring by those already involved in advocacy for social justice provide powerful knowledge and skills for social policy change (Paquin, 2011). Nurses recognize that social equity comprises all basic human needs, such as food, clothing, shelter, education, and employment, extending beyond access to health care (Walter, 2017).
Health in All Policies (HiAP)
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A framework for governmental collaboration and decision making resulted in the Health in All Policies (HiAP) guidelines. HiAP is a collaborative approach that “You cannot get through a single day without having an impact on the world around you. What you do makes a difference, and you have to decide what kind of difference you want to make.” —Dr. Jane Goodall (The Jane Goodall Institute, n.d., para. 1)incorporates public health considerations into government decisions and policy making, ensuring a neutral or positive influence on the SDOH (SurgeonGeneral.gov, n.d.). The process uses collaboration with public and private stakeholders, creating a prevention-focused strategy that values health for the individuals, families, and public that explores the array of possible outcomes of a new decision or policy before it is made and the sequelae has unintended effects on health. HiAP originated as an approach through the WHO. The guidelines have a prominent focus for the U.S. National Prevention Strategy and Healthy People initiatives (CDC, 2016c).
As prominent problem solvers, nurses make a difference and can advocate for approaches that reduce health inequities that a policy or decision could create. Nurses sometimes hesitate to become active in the political arena, but they are a needed voice (Webb, 2017). The CDC maintains a site for HiAP resources (CDC, 2015b).
Figure 4.8
HiAP Wheel
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Note. Adapted from “Health in All Policies,” by the Centers for Disease Control and Prevention, 2016. Copyright 2016 by the Centers for Disease Control and Prevention.
Advanced Nursing Leadership, the IOM, and the ACA
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The reports by the IOM and the passage of the ACA expanded the role of nursing leadership for the 21st century. While nursing is already the largest workforce in U.S. health care, the IOM report, The Future of Nursing: Leading Change, Advancing Health, has created even more opportunities for advance practice nursing (IOM, 2011b). Now with the focus of health care moving from traditional illness to preventative care, nursing roles also are transforming (Berg & Dickow, 2014). The new roles create leaders who seek health equity and the advancement of the SDOH. The IOM report indicates that, with the passage of the ACA, nurses are in prime position to now practice as fully as possible, reducing barriers to advanced practice nursing. This has meant including nurse practitioners in Medicare compensation, just as physicians already were. The report urged states to revise their Nurse Practice Acts to remove barriers to advance practice (IOM, 2011b). Among the recommendations was the reduction of barriers to furthering nursing education such as expansion of scholarships, loans, and grants, as well as recommendations for an increase in baccalaureate-prepared nurses and development of nurse residency programs (IOM, 2011b). The advancement of nursing leadership includes meeting the recommendation of doubling the number of nurses with a doctorate, along with the expectation of all nurses to incorporate theory, research, clinical competency, and leadership development to meet the changing needs of health care (IOM, 2011b). An endorsement for placing nurses in policy and other decision-making capacities incorporated nurses on various public and private boards for health advancement (IOM, 2011b). The number of nurses encouraged to take the reins of change makes for an impressive influence (Berg & Dickow, 2014). The health promotion and preventative care aspects of the ACA are well within the leadership roles of nursing. The United States is capable of having the best health care in the world, and nursing is on the forefront for this change (Schneider & Squires, 2017).
Healthy People 2030
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Every 10 years, new national goals are set for Healthy People initiatives, and, as such, the Healthy People 2030 program is being developed. The proposed framework was open to public comment, which the HHS reviews before making final revisions. When the time occurs for formulation of the 2030 objectives, additional public comment is a possibility. Meanwhile, the proposed framework for Healthy People 2030 is available on the HealthyPeople.gov website (HealthyPeople.gov, n.d.b). Currently, the proposed framework equates health and wellness with attaining health literacy, eliminating health disparities, and achieving health equity. Nurses monitoring the site and health news are aware as the plans progress.
Check for Understanding
1. How does the WHO goal of universal health coverage align with U.S. goals for health care?
2. What aspects of HiAP improve quality of population health care?
3. Which aspects of public health quality monitoring have improved as a result of the IOM reports?
Reflective Summary
Public health nursing began with a focus on disease prevention and wellness by providing safe water and sanitation. The health of the environment expanded from a focus on a neighborhood to one of the whole world. Nurses now advocate for ongoing legislative reform, safe and supportive communities, and environmental sustainability. The U.S. health care system’s fragmented financing system has led to millions of Americans who are uninsured or lack access to health care because of costs. The conditions of this century’s current health care demand that nurses become knowledgeable about policies affecting health and health care. Nurses, as advocates with leadership abilities, are in a position to turn health care in the United States from being 11th to Number 1 in the world.
Key Terms
Affordable Care Act (ACA): Health care reform legislation with multiple provisions signed into law by U.S. President Barack Obama and became known as Obamacare; among the provisions include health insurance coverage to uninsured, measures to lower costs and improve health care system efficiency, preventative care, extension of care to dependents under the age of 26, and prohibited insurance claim denial or higher premiums for preexisting conditions.
