Health Policy, Politics, and Nursing Power in the US

Introduction

This paper outlines several high-level issues in the American healthcare system. At this level, the discussion centers on questions such as the political environment, the influence of key stakeholders, and existing power structures. By analyzing the healthcare system through these lenses, observers can better understand why good ideas are — or are not — successfully implemented. Five central questions are addressed, beginning with the impact of socioeconomic and sociopolitical factors on US health policy.

Socioeconomic and Sociopolitical Factors

One of the most critical issues in the US healthcare system is the socioeconomic disparity in health outcomes, which is typically driven by differential access to care. Lantz, House, and Lepkowski (1998) found that mortality risk was a function of income, with the lowest-income groups in their study bearing the highest mortality risk. While there are numerous potential causal factors — each worthy of its own study — the fundamental link is clear: socioeconomic status affects health outcomes. Braveman and Gottlieb (2014) noted that wealth provides better access not only to healthcare, but also to healthy lifestyles, since affluent areas typically have more parks, recreation facilities, and greater access to healthy food choices.

This reality should, in theory, lead poor and middle-class Americans to strongly favor political action that expands healthcare access — but that has not proven to be the case. This is where the sociopolitical dimension becomes critical. Healthcare access has become highly politicized in recent years. Many Americans who would otherwise benefit from policies that expand healthcare access are aligned with the Republican Party, which has routinely sought to limit such expansions. This creates an unusual sociopolitical environment in which there is strong political will to maintain the status quo, even though most Americans, in principle, favor better access to healthcare.

This is not to suggest that universal healthcare would otherwise be a straightforward policy outcome in the US. A strong capitalist worldview prevails in American society — one in which even health is treated as a commodity to be bought and sold. This outlook is widespread across the population and is sufficiently entrenched that arguments in favor of alternative healthcare models often fail to gain meaningful traction. This sociopolitical environment is largely absent in most other OECD countries, the majority of which have instituted far greater healthcare access than currently exists in the United States.

The Impact of Healthcare Politics

Recent healthcare politics have been characterized by the expansion of access under the Affordable Care Act (ACA), multiple attempts to undermine key provisions of that law, and sustained uncertainty — as key stakeholders struggle to anticipate a political environment that shifts with changes in power in Washington.

Patients are a critical stakeholder group that is often affected negatively by this volatility. Uncertainty helps no one: coverage levels fluctuate with the political climate, and so do cost controls. Because cost and access are closely related, the constant changes in the political environment have a significant impact on patients and their families.

Governments are similarly affected, in the sense that an enormous amount of governmental energy is directed toward shaping the course of healthcare in the United States — not always with much success. Furthermore, the constantly shifting policy landscape, combined with the central importance of healthcare to voters, means that politicians devote substantial time and effort to the issue, even when they fail to produce meaningful change (Patel & Rushefsky, 2014).

The nursing profession can sometimes seem caught in the middle. Nurses work directly with patients and frequently encounter individuals who struggle with healthcare access. Beyond that, nurses must contend with budget constraints that can lead to reduced hours, inadequate supplies, or understaffing. While nursing remains a growth profession, the total funding available in the healthcare system — relative to overall demand — directly affects what nurses do, the conditions under which they work, and the overall attractiveness of nursing as a career.

Healthcare is one of the most heavily regulated industries in the United States. This may seem counterintuitive to some, but the government is the largest single payer, and both the insurance industry and healthcare service delivery are subject to extensive regulation — as are pharmaceuticals and medical equipment. Each individual regulation can affect the nursing profession, and the overall volume, tone, and enforcement of regulation all influence how nurses perform their jobs and whether they find satisfaction in their roles.

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