The U.S. health care system has undergone a huge shift recently. These changes have and will continue to require the advanced practice registered nurse (APRN) not only to be clinically competent but also to have an understanding of the organizations in which care is presently being delivered. The APRN must have knowledge of and the ability to create the systems of care that will ensure the high-quality and cost-effective care needed in the future.

The economics of health care have become increasingly complex. In an attempt to achieve cost efficiencies, merging health care organizations have given birth to giant health care corporations. However, the goal of cost savings has not necessarily been consistently achieved. This is evidenced by ever-increasing health care costs and the percentage of the national budget being spent on health care today, with less than-ideal-outcomes for all citizens (Levit et al., 2003; National Center for Health Statistics, 2013).


Health care delivery systems in the United States are unlike those of any other country in the world. Most other developed countries have national health insurance programs run by governments and financed through general taxes, so almost all citizens are entitled to receive health care. The United States has recently take steps toward a national health insurance program. The Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010. As all laws do, it takes time to put processes in place and see the effects and outcomes of the new legislation. The initial year for individuals and families to sign up for health insurance as mandated by the ACA was 2014.

There are varying opinions regarding the health care reform law. For many, this law enables insurance coverage regardless of preexisting conditions or the ability to pay the insurance premiums. Other benefits of the new law include tax credits for small businesses to offer employee health coverage and the mandate that all coverage must include preventive services. There are some perceived drawbacks to the new health care legislation. Every individual is mandated to have some form of health insurance or will have to pay a fine. Also, the increasing costs of premiums needs to be considered, because insurance companies can no longer deny coverage and companies will need to raise rates to ensure coverage for everyone. Unfortunately, despite the increased premium costs, insurance reimbursement to health care providers has also decreased. This has created an environment of strategic health care implementation.

There is traditionally strong evidence that health insurance coverage improves access and quality of health and medical care, contributing to the overall health of individuals and their families. According to 2010 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2010a, 2010b):

• In emergency departments, the percentage of visits by patients who had some form of insurance coverage was 5 times higher that of uninsured visits.

• The number of patient visits to physician's offices was more than 20 times higher for individuals with private health insurance or Medicaid/Children's Health Insurance Program (CHIP) compared with those with no insurance.

An increasing number of Americans are gaining access to insurance coverage with the implementation of the ACA. In 2012, 45.5 million Americans, or 14.7% of the U.S. population, were underinsured or uninsured, including working-age adults (those aged 18-64; Cohen & Martinez, 2012; Kaiser Commission on Medicaid and the Uninsured, 2012). A Gallup poll in May 2014 revealed the rate of the uninsured had been reduced to 13.4% (Levy, 2014). These reports also show a narrowing in the inequity of coverage based on race and ethnicity, gender, and age. Uninsured persons are defined as persons without private health insurance, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP) coverage, a state-sponsored or other government-sponsored health plan, or a military plan. Also included among the underinsured and uninsured are persons who have only Indian Health Service coverage or a private plan that pays for only one type of service, such as accidents or dental care (National Health Interview Survey, 2012).

The complexities of the various systems of care—which include nonprofit and proprietary organizations; large and small corporations; local, regional, and worldwide conglomerates; small and multisystem plans; multistate health care systems and payment mechanisms; and regulatory requirements—can be overwhelming to the new APRN. Few nurses have a strong background or experience in the organizational influences of health care. Content on the complexity of health care coverage has historically been minimal in nursing undergraduate education. This knowledge deficit is compounded by the fact that most nurses have limited experience with the organizational dimensions of health care coverage while they are employed as staff nurses (Ladden, Bednash, Stevens, & Moore, 2006).

What remains to be seen is the impact of increasing access on the health care system. Many believe this will cause a huge influx of patients needing care, thus overburdening an already short supply of primary care providers. Rationing of care has been discussed as a potential and negative outcome of this increased patient load (Robinson, Williams, Dickinson, Freeman, & Rumbold, 2012). This could mean long waits for nonemergent care and nonexistent elective services. A formal priority-setting approach has yet to be implemented on a large scale. Preventive care will become the focus, and nontraditional forms of health care delivery will need to be implemented (Cornelissen et al., 2014). The shortage of primary care physicians and the emphasis on preventive services create an opportunity for APRNs to have an impact on the health care delivery systems.

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