This paper examines the crisis of uninsured Americans — estimated at 40–45 million as of the early 2000s — and the unique position nurses occupy in responding to it. Because nurses deliver approximately 80% of direct patient care, they face difficult ethical and practical decisions when treating patients who cannot afford coverage or preventative services. The paper argues that nurses and nursing organizations should actively lobby for systemic change, beginning with community health profiling to identify local demographic needs and poverty levels. It outlines a four-part profiling framework and proposes practical steps such as shared staffing arrangements with underserved clinics, ultimately positioning individual nurses as legitimate and powerful advocates for equitable health care reform.
One of the most frequently cited cultural, social, and economic problems of our day is the millions of Americans who live without health insurance. The staggering numbers appear as a side note in nearly every program, article, or research document addressing the evolution of health care in modern American culture.
In terms of access to health care, the lack of a publicly funded system — except for the very poor — has left 40 million Americans uninsured, with the system itself controlled by private insurance companies whose central aim is profit rather than high-quality patient care (Lumby, 2001, p. 69). Since 2001, that statistic steadily grew; by 2003, the number had risen to 45 million (McCabe & Burman, 2006, p. 3). With these staggering numbers, combined with the exponential growth in medical technology and its associated costs, the problem becomes even more acute. Nursing is particularly challenged by this reality, as is the health care system as a whole, since even the simplest care is barred from so many people. Prevention, for all its advances, frequently goes on the back burner until a patient's situation becomes grave.
Nurses are the first line of contact with patients, regardless of insurance status. As noted in the literature, "around 80% of direct patient care is provided by nurses, midwives and health visitors, with nursing services forming close to a quarter of the NHS budget" (Thomas, 1999, p. 66). Nurses are therefore frequently placed in a position of managing economic issues that are unrelated to the overall health of the patient — and this often occurs under dire circumstances. Patients without insurance tend to be unable to afford preventative or early care, and they often present with conditions of serious health concern.
Nurses and physicians are left facing a painful dilemma: consenting to treatment may financially devastate a patient who has no means to pay, yet withholding or delaying care could result in death or a severely diminished quality of life. Compounding this tension, nurses are also members of health care teams that are regularly reminded of the need to contain costs and act as responsible financial stewards. The question, amid all these conflicting loyalties, is what nurses should do — both to advocate for broader systemic change and to make sound clinical decisions while a patient is in immediate need. As the following observation about advanced practice nurses illustrates, the same challenge applies to any nurse at a front-line point of care, such as a family clinic or an emergency room:
"Nicely demarcated documents and policy papers discuss discrete scopes of practice for APNs, but in front of you sits the live embodiment of a holistic person who does not fit in those discrete categories, and asks for a full array of health care." (McCabe & Burman, 2006, p. 3)
Patients frequently need far more than a narrow, specialized type of care. When they finally gain access to the health care system, the nurse must respond to a full spectrum of needs, which necessarily expands the practical scope of nursing practice and delivery.
To change such a situation, nursing organizations need to lobby for change. But what, exactly, should nurses lobby for? Does the profession need to advocate for universal health care within a system that has long conditioned its workforce against such a move? For instance, nurses are frequently told by the for-profit and nonprofit organizations that employ them that universalizing care would reduce patient quality while also decreasing nurses' own pay and benefits (Boaz, 1994, p. 27).
One possible way that nurses — both in practice and as patient advocates and members of a professional industry — can push for change is to demonstrate an understanding of, and demand accountability for, demographic access to health care within their organizations. Health profiling in the region and agency where a nurse works can serve as a point of understanding between providers and the community, making clear the specific needs of the population they are called to serve.
Social models of health practice may be designed by health care professionals at the local level to address particular issues within an area. As Thomas (1999, p. 66) notes, "health profiling can be seen as the first step towards incorporating a social model into nursing practice. A health profile compiled for a specific population can be placed within the care environment, such as the general practice, a school, or an accident and emergency department, or it can be focused on a cultural or geographical population."
The four aspects of community health profiling are: (1) collecting and analyzing information; (2) selecting priorities for action; (3) choosing nursing activities, including methods of working, for selected priorities; and (4) evaluating nursing practice. Information should be gathered based on regional demographics of disease, including incidence of illness, disability, and trauma, as well as on the existing health system — what it provides and does not provide — relative to the community's defined and identified needs.
Once information has been gathered, it can be analyzed to identify and select priorities. Priorities can be aimed at individuals, at a group or community level, or at a national and/or local campaign level. Appropriate nursing activities can then be chosen to pursue action. Thomas (1999, p. 66) presents the following key activities as a summary of suggestions:
1. Assess the health needs of local populations through the compilation of health profiles. 2. Support people in participating in the life of their community to influence factors that affect their health. 3. Build healthy alliances and a supportive infrastructure to provide information, resources, and practical help for community initiatives. 4. Increase health resources in communities by establishing local networks. 5. Engage with local statutory and voluntary groups to work toward health-related policies and actions. 6. Increase uptake of health services by ensuring they are accessible, appropriately offered, and effectively targeted.
"Integrating poverty measures into community health profiles"
"Individual nurses driving meaningful systemic change"
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