The ability of the United States to deliver health care is dependent on both public and private sources so that citizens can access cost effective quality care. This chapter focuses on how American health care is organized, funded, and accredited.

There are three types of health care service delivery: primary – emphasizes health promotion and prevention of illness and disability, secondary – emphasizes detection and early intervention to prevent further illness and disability, and tertiary – emphasizes restorative care or rehabilitation for those with chronic or irreversible conditions. Within each category there are a variety of public and private stakeholders that influence service delivery.

Health care is funded by Medicare (the largest purchaser of health care), Medicaid, insurance companies, and managed care companies. It is estimated that 16.3 % of the U. S. population is not insured by any of the above. Americans not covered by health insurance pay for health care out-of-pocket.

Medicare and Medicaid were created as a result of the Social Security Act Amendments in 1965. Health care costs began to rise after the passage of these amendments. Research has indicated much variation in health care and clinical practice which contributed to increased cost and affected quality.

National organizations have been established to assure health care organizations (e.g., hospitals, ambulatory care, home care facilities) provide quality care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is one such organization that accredits hospitals. Accreditation is important because it is one of the main ways hospitals become certified to receive federal Medicare and Medicaid reimbursement.

There are multiple organizations and agencies that have become influential in quantifying and defining quality health care. Sample professionals are cited who have developed a framework for the quality of competencies. Over 60 agencies, such as the Agency for Healthcare Research and Quality, have developed practice guidelines and support research regarding the effectiveness of medical practice based on clinical outcomes. Recently, the Centers for Medicaid & Medicare (CMS) has ranked and publicized how well all states within the U. S. have complied with adhering to clinical best practices.

Forces and trends that influence health care are also reviewed in this chapter as the nursing profession positions for the future.