1 Running head: NATIONAL INSURANCE 1 National Health Insurance Marijo Johnson Ferris State University
2 NATIONAL INSURANCE 2 Abstract National insurance is a controversial alternative to health care coverage to end health disparities in the United States as well as resolve the healthcare economic crisis. This analysis aims to identify the current U.S. healthcare reimbursement practices as well as identify healthcare disparities in the U.S. Other industrialized nations with universal health plans will be reviewed and compared with healthcare outcomes in the U.S. to determine if a national insurance plan may be beneficial to resolve healthcare disparities in the U.S. In addition, research will be analyzed to identify potential effects on nursing practice.
3 NATIONAL INSURANCE 3 National Insurance There are multiple emerging concerns about healthcare quality, reimbursement and access to care. The United States is in a state of healthcare dilemma with questions about allocation of resources, reimbursement strategies and quality improvement. Although Healthcare Reform is in progress, it is prudent to continue to assess other avenues which may present positive solutions to the current state of turmoil. This research presents information to assist in answering the question: Would a National Health Insurance plan in the United States decrease the health disparities seen today as opposed to continuation of the current U.S. healthcare reimbursement programs? Due to a variety of potential barriers, Americans are often not receiving the medical care needed or receiving care late in the cycle of illnesses or disease processes (U.S. Department of Health and Human Services, para. 2). When patients delay treatment, it likely causes the healthcare system increased costs related to increases in nursing time, more intense medical services and longer lengths of stay. This can quickly drain the healthcare system of financial resources causing organizations to make budget cuts which may include staffing, supplies, new technology and other areas. Budget cuts often cause a decrease in staff satisfaction which inadvertently affects quality patient care. It is essential nurses increase knowledge about current healthcare reimbursement practices as well as future proposals which may affect the quality care nurses deliver. The social mandate of nursing is to contribute to the good of society by knowledge-based practice related to contemporary and emerging health needs in the changing social and healthcare context of the future (Roy, 2011, p. 345). With the current issues in healthcare reimbursement and allocation of resources, change is necessary and inevitable. It is imperative nurses become involved to ensure integrity of nursing practice in all current and future healthcare systems (American Nurses Association, 2004, p. 9).
4 NATIONAL INSURANCE 4 Environmental Assessment Currently many Americans are without insurance or with insufficient income to pay for medical insurance, copayments or services. Cohen & Martinez (2011) conducted a study which revealed between January March 2011, 46.5 million Americans were without insurance at the current time of survey and 60.5 million people were uninsured for at least part of the previous year (para. 1). Without the means to pay for healthcare, many may delay treatment and avoid preventative care. Delays in treatment lead to prolonged, worsening illness which therefore requires an increase in healthcare resources to alleviate symptoms and regain optimal wellness. Quality outcomes are the measurement of the effectiveness of any healthcare system. The Agency for National Healthcare Research and Quality (AHRQ) reveals health care quality and access are suboptimal, especially for minority and low-income groups (U.S. Health and Human Services, 2010a, para. 8). Current deficits in healthcare include: cancer screening and management of diabetes; deficits in quality in states in the central part of the country; deficits in inner-cities and rural areas and disparities in preventative services and access to care (U.S. Health and Human Services, 2010a, para. 8). With these disparities noted, it is the call of all professional healthcare workers, including nurses, to become knowledgeable and active in alleviating barriers and assisting in the development of a healthcare system for the good of all. Theory The nursing profession is one guided by theory and research. Theory and research not only leads the professional nurse to evidenced based practice, but also assists in ensuring ethical and universal care is provided for the good of all. Research and theory must continue to develop and address current healthcare trends to guide the professional nurse in practice. Leadership,
5 NATIONAL INSURANCE 5 management and organizational theories are still evolving as the complexity of healthcare organizations grow and variables that influence care delivery increase and become more apparent (Yoder-Wise, 2011, p. 7). Nurses need to rely on theory to guide practice and the delivery of quality services. Castilla Roy s Adaptation Theory is one nurses can use to assist through the changing healthcare times. Roy (2011) reflects the social context of the 21st century requires new knowledge with key issues including changing demographics such as increasing racial and ethnic diversity and increasing variances in ages (p. 345). Simultaneously, the 21st century healthcare has changed to include population-based care, increasing complexity of care, evidence of unsafe care in institutions, need for care for increasing numbers of people with chronic conditions, and persistent health disparities within countries (p. 345). Nursing based on this model, aims to enhance system relationships through acceptance, protection, fostering of interdependence and promoting personal and environmental transformations (Roy, 2011, p. 346). It is within this context, Roy (2011) sets the criteria for good according to the Adaptation Model by promoting adaptation of populations and transforming a society to one that promotes dignity (p. 346). Promoting dignity includes enabling all persons to access healthcare to attain and maintain optimal wellness with appropriate resources for patients and families. Resources may include access to physicians, medications, preventative care and necessary procedures to maintain quality of life. Currently, with the disparities evident in the U.S. all people do not have the same access to medical services to promote optimal wellness. The Prospects Theory is a healthcare economics theory which compares the consumer s ability to have choices in healthcare to outcomes and measures outcomes by financial gains and losses (Abellan-Perpi nan, Bleichrodt, and Pinto-Prades, 2009, p. 1040). In a study completed
6 NATIONAL INSURANCE 6 by Abellan-Perpi nan, Bleichrodt, and Pinto-Prades (2009), it was determined the Prospect theory offered better health outcomes than the comparison theory (p. 1046). Given the health disparities in access to care, it becomes difficult for all populations to have equal choices in health services and obtain optimal outcomes. Current U.S. Healthcare Reimbursement Current healthcare reimbursement consists of mixed payer sources including Medicaid, Medicare, private employer based insurance plans and individual payers. Medicare is a federally funded health insurance program that provides coverage for certain services for those who are 65 years and older and some disabled (Yoder-Wise, 201, p. 231). Although the plan aims to provide medical coverage for participants, gaps remain in the lack of coverage for dental and vision services (Yoder-Wise, 2011, p. 231). In addition, although there is a Medicare Part D plan for medication coverage, the plan is complicated and there are costs for premiums as well as copayments for medications (Yoder-Wise, 2011, p. 231). Despite this government coverage, there continue to be access concerns and disparities related to the elderly and disabled living and limited income and experiencing potentially large deductibles or medication co-payments. Other federal insurance plans include those for military personnel, veterans and American Indians (Yoder-Wise, 2011, p. 231). An additional government funded program is the Medicaid insurance program. The Medicaid program is funded by a combination of federal and state monies and covers medical services for the indigent, blind, disabled and children with disabilities (Yoder-Wise, 2001, p. 231). Services included are physician care, hospital services, diagnostic testing, prenatal care, nursing home and home health services (Yoder-Wise, 2011, p. 231). Gaps in medical care with those receiving Medicaid may be related to economic status. Access to care
7 NATIONAL INSURANCE 7 may be threatened as the indigent or disable population may have difficulty finding transportation to appointments and therefore delay treatment until the illness is critical and inevitable. In addition, educational barriers may affect the understanding of the importance of preventative care as well as routine physician visits. Private insurance can be purchased by individuals and generally provided by employers as a group policy (Yoder-Wise, 2011, p. 231). Private insurance may have high premiums, may not be affordable by small businesses and may not be available or affordable to part time employees (Yoder-Wise, 2011, p. 231). Due to the high cost for part time employees, this leaves potential gaps in coverage of the employed population whose earnings are too high to qualify for a government funded insurance plan. Premiums, copayments and high deductibles may deter healthcare recipients from receiving preventative and routine healthcare services. Individuals may also purchase healthcare coverage or pay for medical services independently. For individuals to purchase health insurance plans, the rates are typically high and provide minimal coverage (Yoder-Wise, 2011, p. 231). Gaps are likely to occur due to lack of financial resources to cover care. Again, healthcare recipients are likely to delay treatment until a medical emergency arises. Delays may require emergency services which are costly and consume large amounts of health resources to return the healthcare recipient to homeostasis and optimal wellness. The U.S. has multiple opportunities for insurance and payment for medical services. With the current U.S. healthcare system, healthcare recipients are less likely to wait for tests and receive superior amenities in physician offices, clinics and hospitals (Fuchs, 2010, p. 2181). Nonetheless, it is evident the U.S. healthcare system is in crisis with multiple healthcare disparities and sparse resources secondary to elevated costs.
8 NATIONAL INSURANCE 8 Case Studies and Comparisons to National Insurance Kennedy & Morgan (2008) conducted a study between Canada and U.S. related to cost related prescription non-adherence. In this study, cost related prescription non-adherence was noted as a widespread clinical problem. Both Canada and the U.S. treat prescription coverage separately from medical coverage. This study recognized people over 65 years old, women and adults with multiple co-morbidities and limited income are at the highest risk for cost related medication non-adherence. It was further noted that Quebec has a mandatory prescription insurance program and shows the best resource to removing barriers associated with cost related medication non-adherence. Shcoen and Doty (2004) completed a comparison study in healthcare disparities related to income in relation to cost factors, access and perceived quality of care between the United States, United Kingdom, Australia, New Zealand and Canada. Healthcare access was measured related to: ability to see a see a specialist; ability to obtain care on the weekends; access to care in the area one lives; timeliness of sick visit appointment and timeliness of non-emergent surgery. This study revealed the United States was noted to have the most significant differences related to income and the ability to see a specialist, access care on the weekends and receive care in the area the resident lives. The United Kingdom had the least income related disparities in these areas. Canada and Australia also showed small disparities. New Zealand showed a significant disparity in the ability to see a specialist but little disparity in receiving care in the area one lives and receiving care on the weekend. All five countries show very minimal disparity between income levels in relation to wait times for a sick visit with the physician. Wait times for nonemergent surgery had less variance between income levels within the U.S. than the other
9 NATIONAL INSURANCE 9 countries. In addition, the U.S. typically had shorter wait times for non-emergent surgery with only 1-3% of respondents waiting over 6 months in the U.S. compared to 25-29% in the United Kingdom. The U.S. had a significant increase in respondents not following up with recommended treatment, filling prescription and seeing the physician for medical problems based on income. Minimal disparity was noted in the United Kingdom and Australia with a slightly higher increase noted in New Zealand and Canada. All five counties showed positive perceptions in quality of care provided by physicians. The U.S. had the highest discrepancy related to income with increased perceived quality related to above average income. Interestingly enough, respondents with below average income in Australia and the United Kingdom perceived a higher quality of care than those with an above average income. U.S. Healthcare Reform Currently the U.S. does not have a universal health insurance proposal or plan in progress. Healthcare reform is the proposal to decrease healthcare disparities and improve quality of care. According the U.S. Department of Health and Human Services (2010), the current healthcare reform act offers many incentives to assist with bridging healthcare access and affordability gaps. Although the Affordable Healthcare Act in not a universal healthcare plan, it does have some similarities with government funding as well as government oversight of private insurance plans. Plan components include small business tax credits to small businesses offering affordable healthcare to employees, increased federal funding to state Medicaid programs, assistance for insurance benefits through new medical exchanges, extending coverage to young adults by allowing them to stay on parents insurance plans, ensuring new insurance plans offer preventative services free of
10 NATIONAL INSURANCE 10 copayments or deductibles, eliminating annual lifetime coverage laws and eliminating denial of coverage based on pre-existing conditions (U.S. Department of Health and human Services, 2010). The Affordable Healthcare Act s many components will occur over a time period of 2010 through This plan is placed to decrease disparities and bridge the gap for quality healthcare services for all. Questions remain if the program will be the answer to America s current healthcare dilemma. The effect of the Affordable Healthcare Act on the nursing profession is unknown. Provisions exist to increase and improve education for nursing professionals and encourage others to enter the field. Nurses regularly evaluate safety, effectiveness and cost in healthcare with the understanding that resources are limited and unequally distributed (ANA, 2004, p. 11). The ANA (2004) reflects as members of a profession, registered nurses must work toward more equitable distribution and availability of healthcare services throughout the nations (ANA, 2004, p. 11). Nursing Standards of Practice Professional nurses need to become involved in healthcare reform and consider the implications of a national insurance plan. Becoming involved in eliminating healthcare disparities ensures the standards of nursing practice can be maintained through ethics, quality and collaboration. The above case studies will be reflected upon with evaluation of the nursing scopes and standards of practice involving quality, collaboration and ethics. Nurses strive in practice to provide quality care to patients. They used evidence based knowledge related to previous research, studies and experiences to guide practice and achieve quality care. Quality and Safety Education for Nurses (QSEN) (2012) defines quality as the "use of data to monitor the outcomes of care processes and improvement methods to design and test
11 NATIONAL INSURANCE 11 changes to continuously improve the quality and safety of health care systems." ANA (2004) states Standard seven is quality of practice and includes the registered nurse systemically enhancing quality and effectiveness of nursing practice (p. 33). The study completed by Schoen & Doty (2004) reflects that quality care is perceived as optimal in countries with universal coverage as well as in the U.S. healthcare system. One could conclude that increased access and availability of health services to all would only improve the perception of quality care in the U.S. ANA (2004) Standard seven further reflects the professional nurse is responsible to minimize costs and unnecessary duplication as well as analyze and implement systems to remove or decrease barriers within systems (p. 33). This standard directs the professional nurse to identify the healthcare environment and recognize the current disparities effecting healthcare recipients access to appropriate services which limits the attainment of optimal wellness. Consideration of a national health plan can be beneficial as evidence by the positive benefits other industrialized nations have observed. To achieve true quality of care, collaboration is necessary. Collaboration requires health teams to work together to determine and provide the best services to clients to achieve the goal of optimal wellness and quality of life. Members of the healthcare team include patients, families, significant others, communities, medical suppliers and medical service payers. Providers and healthcare workers must collaborate to avoid duplicate services and provide cost effective quality care. QSEN (2012) directs the profession nurse to recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs." Needs may include special circumstances related to healthcare disparities involving lack of access to care due to limited insurance or financial barriers. ANA (2004) presents standard eleven as collaboration with patient families and others in the conduct of nursing practice (p. 38).
12 NATIONAL INSURANCE 12 This standard consists of the nurse partnering with others, including healthcare payers to ensure the patient can obtain services needed in the most cost effective, comfortable and dignified manner available to provide quality outcomes (p. 38). With a universal healthcare plan, it is presumed every individual would have access to care in respect to payment for services, thus decreasing income based disparities. Although cost of services is a consideration that nurses must consider when collaborating care, ethics remain of utmost importance. The adage is healthcare a right or a privilege becomes irrelevant in the nurse patient relationship and practice of delivering quality healthcare services to people in need. QSEN (2012) defines safety related to nursing practice as "minimizing risk of harm to patients and providers through both system effectiveness and individual performance." System effectiveness includes identifying disparities that cause barriers to receiving adequate healthcare services. ANA (2004) standard twelve states the registered nurse integrates ethical provisions in all areas of practice (p. 39). The registered nurse serves as a patient advocate assisting patients in developing skills for self advocacy (ANA, 2004, p. 39). Ethical practice entails the nurse being aware of healthcare barriers to care and advocating for appropriate services as needed despite the ability to pay for services rendered. This may place healthcare organizations at risk for financial turmoil, leading to budget cuts which affect nurse staffing levels as well as availability of technological services. With this noted, it is prudent for professional nurses to be a proactive advocate to eliminate healthcare barriers and disparities to enable populations to obtain services, including preventative care. While a national insurance plan may place limits on certain services or procedures, it is suspected with a national insurance plan, allocation of resources would promote justice and beneficence.
13 NATIONAL INSURANCE 13 Implications and Inferences Concerns related to universal healthcare continue among American s with fears related to governmental restrictions to services, long wait times for services and quality of care. It is necessary for nurses to become involved in healthcare reform and evaluate the benefits of a national insurance plan to determine if improved access and quality can be maintained. Based on the above studies, it can be surmised that countries with partial or complete government funded insurance plans have decreased healthcare disparities based on income as opposed to the U.S. healthcare system. With a national insurance plan, it can be presumed all citizens would have access to medical insurance thus elimination the disparities based on income. However, many national insurance plans do not accommodate national insurance for illegal immigrants. Without addressing this factor, disparities among populations would continue to exist in the U.S. A national healthcare plan may assist nurses in providing increased quality care by providing preventative and routine services early on during illnesses and disease processes. A national insurance plan may increase the collaboration between healthcare providers and payers with both entities committed to quality and cost effective care. Concerns have been noted related to the increase in demands on healthcare workers if a national insurance plan were to evolve. The natural effect maybe an increase in healthcare recipients receiving care with the number of providers insufficient to provide adequate and efficient services. Although this may be inevitable, the end result could be improved healthcare with less emergent services and decreased lengths of hospital and critical care stays. This would allow for more services to be provided at the forefront of the illness and disease versus on the emergent situations due to delayed treatment.
14 NATIONAL INSURANCE 14 Conclusion Disparities are evident with the current U.S. healthcare reimbursement system. Disparities include access to care, quality of care, cost related medication non-adherence and disparities related to income and race. Countries with universal healthcare plans tend to have a decrease in health disparities related to income and access to services. The U.S. pay more for healthcare than any other country in the world; however, among twelve countries studies, including the U.S., Canada, Australia and several Western European countries, the U.S. system is consistently among the worst performers (Campbell & Campbell, 2006, p. 17). U.S. healthcare recipients and providers need to ban together to assess the current U.S. system and become active participants in making a change that will decrease disparities and improve quality. Nurses are committed to quality and ethical care regardless of the individual s ability to pay, race or religious affiliation. Registered nurses have been social and political leaders and advocates, addressing many societal issues including, universal healthcare, social security, Medicare, Medicaid, the financing and reimbursement of healthcare, healthcare reform, ethics and patient rights (ANA, 2004, p. 9). Evaluation of a national health insurance plan for U.S. healthcare reform could be the answer to many of the healthcare disparities currently occurring today.
15 NATIONAL INSURANCE 15 References Abellan-Perpiñan, J. M., Bleichrodt, H. & Pinto-Prades, J. L. (2009). The predictive validity of prospect theory versus expected utility in health utility measurement. Journal of Healthcare Economic. 28(6), Retrieved from: American Nurses Association. (2004). Nursing scope and standards of practice. Silver Springs, MD: Nursesbooks.org Campbell, T. C. & Campbell, T. M. (2006). The China study. Dallas, TX: BenBella Books. Fuchs, V. (2010). Government payment for healthcare: Causes and consequences. New England Journal of Medicine. 363, Retrieved from: Kennedy, J. & Morgan, S. (2009). Cost-related prescription nonadherence in the United States and Canada: A system-level comparison using the 2007 international health policy survey in seven countries. Clinical Therapeutics, 31(1), doi: /j.clinthera Quality and Safety Education for Nurses. (2012). Quality and safety competencies. Retrieved from: Roy, C. (2011). Extending the Roy Adaptation Model to meet the global changing needs. Nursing Science Quarterly. 24(4), p doi: / Schoen, C. & Doty, M. (2004). Inequities in access to medical care in five countries: Findings from the 2001 commonwealth fund international health policy survey. Health Policy
16 NATIONAL INSURANCE 16 U.S. Department of Health and Human Services. (2010). National healthcare disparities report, Retrieved from: U.S. Department of Health and Human Services. (2010). Provisions of the Affordable Health Care Act by year. Healthcare. Gov. Retrieved from: Yoder-Wise, P. (2011). Leading and managing in nursing (5 th ed.). St. Louis, MO: Elsevier Mosby.
17 NATIONAL INSURANCE 17 GRADING CRITERIA FOR SENIOR ISSUE ANALYSIS PAPER STUDENT: TOPIC Points Grade and Comments A. INTRODUCTION: This should include the issue and its relevance to the nursing profession. Clearly focused and well written introductory statement on an appropriate topic. The question at issue should be made clear. Discuss the importance and the purpose of the topic. How widespread is the issue? What are the various points of view that must be considered? What does it mean? What difference does it make for nurses to become involved? B. THEORY BASE: There should be relevant theoretical support (concepts) provided from nursing. Theory (concepts) from other disciplines should also be incorporated to demonstrate how this issue can be looked at from an interdisciplinary and collaborative perspective. C. ASSESSMENT OF THE HEALTHCARE ENVIRONMENT: Use a systems framework to consider what policies, resources, or quality and safety issues may be related to this issue. What are the challenges and who or what entities are involved? Also include underlying foundational assumptions that may be pertinent Great identification with adaptations theory, needed more on Prospect Theory-the research studymore relevant than what other theory? How does the Prospect Theory influence nursing? 20 well done, gaps of each choice addressed, nice to have case study approach D. INFERENCE/IMPLICATIONS/CONSEQUENCES: What is the logical interpretation of the data about this issue? What are the likely outcomes of the various positions on this issue? Nice work! E. RECOMMENDATIONS FOR QUALITY AND SAFETY IMPROVEMENTS: Discuss realistic intervention strategies Well aligned!
18 NATIONAL INSURANCE 18 that could be used by nurses in different settings and discuss these interventions as they relate to a minimum of 3 ANA standards of professional practice. This section should be discussed from the perspective of how quality and safety will be improved by incorporation of the recommended strategies. QSEN competencies will be important to review or consider in writing this section. (Support your identified interventions with relevant research). F. Appropriate References and Structure (professional references and journals, minimum of 5 sources, incorporates original nursing research, adheres to assigned length of pages not including title page, abstract or refs) Total Points % FINAL GRADE less Deductions: DEDUCTION OF UP TO 30 points will be made for APA/writing/grammatical/punctuation errors. Minor APA, mostly in references -2 96