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Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The U.S. spent $9,364 per person on health care in 2016, compared to $4,094 in the U.K., which ranked first on performance overall (Commonwealth Fund, 2017). An overall score of 64% was recently given to the United States for its achievement across 42 core health indicators related to long, healthy, and productive lives; quality; access; efficiency; and equity of health care (Commonwealth Fund, 2012) (see Figure 2.2).

FIGURE 2.2 U.S. scorecard on health system performance.

      Source: The Commonwealth Fund. (2012, January 15). Scores Dimensions of a High Performance Health System. Retrieved from https://www.commonwealthfund.org/chart/scores‐dimensions‐high‐performance‐health‐system.

      Some major findings from the U.S. Scorecard include the following (Radley, Hayes, & Collins, 2019):

       Rising death rates, high levels of obesity, and gaps in care are pressing challenges for states

       The rise in deaths from suicide, alcohol, and drug overdose is a national crisis

       Regional differences in performance persist, as do within‐state disparities

       Many states are not getting good value for their health care dollars

       States made progress in areas that were the target of efforts to improve

       Per capita spending growth in employer plans is outpacing that in Medicare

Access to Health Care for All

      The United States is one of only a few large countries in the world without a universal system of health care. The U.S. has higher prices for most health care services and prescription drugs, according to available internationally comparable data. Meanwhile, utilization of several services, including physician consultations and hospital stays, is lower than in many comparable countries. Use of some services, such as C‐sections and knee replacements, is higher in the U.S. than in similar countries (Sawyer, McDermott, & Kaiser, 2019). In the US we have fewer office visits and shorter average hospital stays, yet the U.S. overall spends twice as much per person on health care than do comparable countries (Sawyer et al., 2019).

Health Care Payment in Other Countries

      Note that some countries, such as Britain, New Zealand, and Cuba, provide health care in government hospitals, with the government paying the bills. Others (e.g., Canada and Taiwan) rely on private‐sector providers, paid for by government‐run insurance. Many other wealthy countries (e.g., Germany, the Netherlands, Japan, and Switzerland) provide universal coverage using private doctors, private hospitals, and private insurance plans. In some ways, health care is less socialized overseas than in the United States, where almost all Americans sign up for government Medicare insurance at age 65. In Germany, Switzerland, and the Netherlands, seniors stick with private insurance plans for life. Meanwhile, the U.S. Department of Veterans Affairs is one of the world's purest examples of government‐run health care (Reid, 2009).

Hospital Care

The number of acute care hospital beds in the United States is 6,210 and in 2016, there were about 35.7 million hospital stays with a mean length of stay of 4.6 days and a mean cost of $11,700 per stay (AHA, 2019). From 1980 to 2015, the overall mortality rate in the United States fell by 29%, compared to a 54% decline in comparable countries. Disability adjusted life years (DALYs) are a measure of disease burden and the rate per 100,000 shows the total number of years lost to disability and premature death. Though DALYs have declined in the U.S. and comparable countries since 2000, the U.S. continues to have higher age‐adjusted rates than those of comparable countries. In 2017, the DALYs rate was 31% higher in the U.S. than the comparable country average (Sawyer et al., 2019).

      Critical Thinking 2.1

      Think about how you could improve the delivery of health care delivery with limited funding and clinicians. Why are people in the United States not as healthy as they are in other countries? Health care that focuses on more delivery of prevention and primary care would increase health and decrease disease throughout the U.S. How can you work individually and with your community to begin to accomplish this?

      Real World Interview

      As a nurse practitioner, there are many things about the American health care system that I really value. There are minimal wait times and there are lots of specialties.

      I like that a patient whom I refer with a serious diagnosis can be seen by a specialist within 2 weeks. We develop and make top‐notch technology available and we have great health care standards. For all of these reasons, we keep the world on track and it follows our lead. I'm also aware every day of the shortcomings of the health care system. It's far too expensive, there are too many special interest groups, and it's all going to collapse under its own weight, a classic example of capitalism gone amuck. For example, health insurance companies have too much power, and I hate how all the insurance hoops prevent me and my colleagues from giving the best care to our patients. We need a national health policy, and if the American people make enough noise, politicians will get behind it, too. I'm in favor of a national health plan, one that will ensure that all Americans have access to care. It needs to be one that incorporates what we already do best with what's useful from other countries such as Japan and Canada. We have a lot to learn from what they do well that we don't do.

       Nadine Lamoreau, RN, MSN, FNP, APRN‐C

      Fort Fairfield, Maine

      When you look at a group of 1,000 people, it is estimated that 800 of them will experience symptoms of some disease or condition. Of this group of 800, 265 people will be seen in a practitioner's office or hospital outpatient department or emergency department, or they will use home health care. Only eight will eventually be hospitalized. The majority of the people don't need hospitalization and would benefit from more resources available for primary health care delivery outside the hospital (Green, Gryer, Yawn, Lanier, & Dovery, 2000). This finding seems odd when considering where the research dollars are targeted and where the majority of health care dollars are devoted, that is, acute care settings in hospitals. Note that a consistent focus on illness and injury, often referred to as a downstream focus, means fewer dollars are invested in upstream efforts. A focus on upstream efforts would be directed at keeping the population well through health promotion and illness prevention strategies and would be less costly.

Need for Primary Health Care

      The majority of patient care and health care occurs in communities outside acute care settings. Primary care “which provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996, p. 1), should be better understood and appreciated for the role it has in improving patient's health status and health outcomes. The key foundations of primary care (Starfield, 1998) can be applied across the health care continuum and across organizational settings, because primary care emphasizes seven important features: care that is continuous, comprehensive, coordinated, community oriented, family centered, culturally competent, and begun at first contact with the patient. According to Starfield (1998), patients and clinicians need to work together to appropriately utilize services, based on the following four foundations of primary care:

       First Contact: Conduct the initial

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