While this question may seem rhetorical, perceptions of and experiences with the United States healthcare system can create the belief that to care about or try to understand federal policies on health care is fruitless. At least three issues contribute to this perspective. One prominent issue is the long-standing and interconnected problems the current system is unable to address: the rising costs of health care, the reduction in employer-based health care, the growing ranks of uninsured, and an inadequate supply of health providers. A second issue is that the U.S. healthcare system is a large and multipart healthcare complex that is rigidly hierarchical and not well coordinated or unified in purpose, scope, or values. And third, but interdependent with the previous issues, is that the politics and policies that shape the relationship between these inputs and outputs can seem extremely remote and hard to address. This chapter attempts to demonstrate that the linkages among these problems can be understood and that this knowledge is imperative for influencing and practicing public health nursing.

In the healthcare reform debate, much has been said or written about whether or not the healthcare reform will work, what it might
cost, and the impact it would have on each one of us as individuals. It has also been suggested from those who have great faith in our current system that it should be left alone. It may work well for some people, but on the whole our healthcare system ranks 37th out of 191 world health systems in the World Health Report 2000 (World Health Organization, 2010), and our nation has the highest rate of preventable deaths among 19 industrialized nations (Cohen, 2009). In 2010, the number of nonelderly uninsured Americans reached 49.1 million, an increase reflecting a slow economy and a decline in employer-sponsored coverage. Increases in the uninsured largely reflect adults who have lost employer-based coverage and do not qualify for public coverage. This means that despite popular images of the uninsured, the majority of uninsured are working families. Low-income workers are at the greatest risk to be uninsured because job-based coverage is often not offered; even when it is, these workers are less able to afford the premiums. The lack of health insurance affects access to health care as well as increases costs. The uninsured delay or forgo needed care, making them more likely to be hospitalized for avoidable conditions. Overall, the uninsured are less likely to receive preventive care. Cost barriers to health care have been growing in the past decade, making the uninsured more likely than the insured to be unable pay for basic necessities because of their medical bills (The Henry J. Kaiser Family Foundation, 2011).

Arguably, one of the great strengths of the American healthcare system has been its strong private sector orientation, which facilitates ready access to all manner of services for those with stable coverage and strongly encourages ongoing medical innovation by product manufacturers. Our healthcare system has some of the finest medical facilities, technologies, innovations, treatments, and human talent. Many of the world’s best medical practitioners are here. Health care generates more new job opportunities than any other sector of our economy. The rapid advance of medical technology over the past 50 years has unquestionably improved the health status of millions of American citizens. Employer-sponsored insurance has played a crucial role in retaining this strong private sector presence in the U.S. health sector. However, employer-based coverage is also the Achilles’ heel of American health care. One main failing is that it is not portable or owned by the worker. Moreover, because many millions of workers must change jobs and insurance frequently, there is little incentive for prevention. As employer-based health insurance costs continue to rise, those increases are being passed on to the employee through increased insurance premiums. Finally, today’s open-ended federal tax exemption for some employer-paid premiums encourages expansive coverage, which further escalates cost (Capretta, 2009).

Despite its significant strengths, the U.S. healthcare system has long suffered from unequal access, disorganization, and waste (e.g., the value it provides does not match its enormous cost). Research conducted over many decades documents large disparities in the use of health care and in its cost from one location to another. These differences cannot be explained by contrasting rates or varying severity of illness among population groups. Furthermore, it is increasingly apparent that higher rates of healthcare use do not necessarily lead to better care; in fact, they sometimes lead to worse outcomes (Mechanic, 2011). Former White House advisor and bioethicist on health care, Ezekial Emanuel, notes that both political parties do agree that that our economy and our nation will not succeed if healthcare
costs continue to rise. The fact that few people understand how much is spent on health care versus how much needs to be spent to provide quality care, and the difference between the two undermines the importance for needing to implement healthcare reform. He points out factually, that in 2010, the United States spent $2.6 trillion on health care, averaging over $8,000 per American, according to the Centers for Medicare & Medicaid. In comparing these costs to France, which has roughly a total gross domestic product of $2.6 trillion, the United States spent on health care what the 65 million people of France spent on everything including health care. The other important problem is growth. If healthcare costs continue to grow faster than the economy (present rate of 2% a year), it will be roughly one third of the entire economy by 2035 (Emmanuel, 2011).

On March 23, 2010, President Barack Obama signed into law H.R. 3590, the Patient Protection and Affordable Care Act (P.L. 111-148) and seven days later signed H.R. 4872, the Health Care and Education Reconciliation Act of 2010 (P.L. 1101-152). The goals of this healthcare reform are to create a system that can provide healthcare coverage for all and no longer create personal bankruptcy. In other words, it was designed to help avoid economic disaster for employers and to hold all parties— doctors, nurses, hospitals, drug companies, and insurers—collectively responsible for making health care better, safer, and less costly (Gawande, 2009). The ACA was passed in an attempt to get policy aligned with these goals. The ACA puts in place comprehensive health insurance reforms to increase access, guarantee more healthcare choices, invest in creating a new infrastructure that holds the potential to improve care quality, and contain costs for all Americans. Indeed, the sheer scope and complexity of the nation’s healthcare system, as part of a larger political and global economic context, make the implementation of this new healthcare legislation a most formidable endeavor; this was the rationale for incremental implementation, with most changes taking place by 2014. But for the infrastructure to succeed, the tools developed by the ACA must be applied (Orszag, 2011).