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The current debate over healthcare in the United States pits those who advocate a more nationalized healthcare system against those who want to build on the current liberal healthcare system. President Obama has supported moving toward a national healthcare system but now may be backing away from that sweeping change to gain support for smaller reforms. The implementation of a national healthcare system in the United States would be a dramatic departure from the current liberal healthcare system.
Competing Models
The liberal healthcare system in the United States has a structure of primary, secondary and tertiary levels of care. Access to the system is primarily employer based.1
With pharmacologic, technologic and scientific advances, the United States has excelled in tertiary care, while the focus on primary care and, at times, secondary care has dwindled. A major reason for this focus on tertiary care is related to finances. Research development for medications, machines (technology) and procedures is costly, and the stakeholders -- drug companies, technology companies, hospitals and physicians -- want to be paid accordingly to reclaim these costs.
As an alternative, a national healthcare system can be structured in a variety of ways, ranging from more centralized government control of all aspects of healthcare, such as in Great Britain, to a less centralized model where more decisions are made on a local or jurisdictional level, such as in Canada. Regardless of the degree of government involvement, all versions of national healthcare systems focus on primary care as essential to overall health, with specialty and hospital-based care deemed less important.
Fixing the System
While U.S. residents continue to need the excellent tertiary care currently provided, we also need more access to primary and secondary care services. In fact, a growing population of older adults is making some in the medical community suggest that we need an increase in the physician workforce as large as 30% to meet primary care needs.2
This approach seems a bit simplistic for addressing a complex problem. The percentage of the Gross Domestic Product (GDP) that the U.S. government and employers and individuals pay for healthcare is the highest in the world. And yet, the United States scores lower on major health indicators, such as infant mortality or longer life expectancy, than other less costly health systems.3
Plus, a large percentage of physicians are entering into specialty medicine rather than primary care for both professional and financial reasons. Specialties are valued more than general practice in terms of prestige and salaries. These larger salaries are especially enticing to medical students and residents with significant school loans to pay back.
Trying to correct our current system with simplistic measures such as increasing the number of physicians completely misses an opportunity at correcting the system's real problems. These real problems include a lack of focus on and funding for primary care and prevention, which could ultimately decrease our healthcare spending by decreasing the number of patients requiring tertiary level care.
Many people in the healthcare community believe that one way to fix these problems is by strengthening interprofessional models of healthcare instead of relying on a physician-only model.4 Healthcare providers such as nurse practitioners and other advanced practice nurses can play an integral role in primary care and in shifting the focus of our healthcare from the tertiary model to one that values prevention and management.5
NPs in the U.S. Health System
The United States is one of the first countries to use NPs. Nurse practitioners entered the healthcare system in 1967.6 While the role began as a hospital-based certificate program, it has evolved into a master's-prepared postgraduate certification. In fact, as of 2015, the baseline requirement to practice as an NP will be a clinical doctorate degree.
Nurse practitioners have prescriptive authority and are trained to provide close to 90% of services typically offered by a primary care provider.6 Some of the advantages of NPs are that training typically focuses on a special population (for example, pediatrics, geriatrics or women's health) and is not as extensive as medical school. Also, NP education is based on a nursing model that takes a holistic approach to patient care by including the patient's emotional, physical, and socioeconomic status into clinical decision making.
The care an NP provides is designed to be uniquely health focused rather than illness focused, which is different from the traditional medical model of treating the illness. Further, the nurse practitioner role was designed to serve the underserved, meaning that NPs tend to more willingly seek out positions in rural areas or with vulnerable populations since they can make the biggest impact in those communities.
When a health problem is outside of the scope of an NP's practice, she or he then collaborates or consults with another provider. NPs typically do not have the same reporting structure as physicians, and they are not certified by the same licensing bodies as physicians.
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