Nursing is a major component of the health care delivery system in the United States. Health care delivery systems are mechanisms designed to provide health care services. Health care delivery systems continually change. Therefore, nurses need to understand the levels of health care, the settings in which health care is delivered, and the professionals who are part of the health care team.

Health care is delivered through three basic levels: primary, secondary, and tertiary. Primary health care includes health promotion and illness prevention provided to decrease the risk of an illness. Some common primary health care activities are lifestyle modification, immunization against specific diseases, and improving the environment. Secondary health care includes early detection through screening, and interventions for specific diseases. Tertiary health care includes activities to minimize the effects of a disease and prevent permanent disability. The purpose of these activities is to restore functioning through education, retraining, and environmental modification.

Health care is delivered in many settings, both public and private. Governmental, voluntary, and nonprofit institutions, on the federal, state, or local levels, fund public sector agencies. The United States Department of Health and Human Services is responsible for federal services, which includes health education, programming to care for people with specific health problems; protection of the public from unsafe drugs, food, and cosmetics; the prevention of communicable diseases; the conduct of medical research; the provision of health care for Native Americans; and research on quality health care.

The private sector of health care includes independent providers who are paid on a fee-for-service basis in which the recipient of care pays for his or her own health care. Common settings are outpatient clinics, hospitals, extended care facilities, industrial clinics, and home health care agencies.

The health care system is staffed by many providers: Nurses, physicians, physician assistants, advanced practice registered nurses, pharmacists, dentists, dental hygienists, dietitians, social workers, respiratory therapists, physical therapists, occupational therapists, chaplains, and unlicensed assistive personnel. Nurses work in hospitals, community health agencies, home health care environments, and ambulatory care services. The proportion working in hospitals has declined because clients are discharged from the hospital sooner than in the past and because expanded opportunities are available outside of the hospital. Nurses assume any or all of the roles of caregiver, teacher, advocate, manager, expert, case manager, and team member.

Health care delivery is strongly influenced by economics. Health care services were formerly funded on a fee-for-service basis, with little incentive to deliver cost-effective care. Most are now funded at a preset amount, based on the client’s diagnostic related group (DRG), or medical diagnosis. In contrast to countries such as Canada, which has a single-payer system with the government paying for health care, the United States has both private and public funding. Expenditures for health care have been higher in the United States than in any other country and cost containment measures have had mixed success.

Employers typically provide private insurance at some cost to employees. Employees are paying increasing premiums and deductibles for their insurance. The unemployed and underemployed cannot afford private insurance. Managed care is one way that private health insurance companies attempt to control costs. Managed care is a system of providing and monitoring care in which access, cost, and quality are controlled before or during delivery of services. Managed care plans provide health care services at a preset flat fee and are administered through health maintenance organizations (HMOs). HMOs also may offer service through preferred provider organizations (PPOs) or through exclusive provider organizations (EPOs), in which members have no choice of providers. HMOs must approve the primary health care provided members and are thus known as a single point of entry into the system.

The federal government provides public insurance through Medicare and Medicaid. Medicare provides funding for health care for the elderly, for the permanently disabled, and for people with end-stage renal disease. Medicaid provides health care for the indigent and is administered through state governments. Canada uses a national health care insurance plan, paid for through taxes, to fund health care for all citizens.

Costs, access issues, and quality have all influenced health care. Health care costs have risen dramatically in the last few decades, fueled by an oversupply of medical specialists, a surplus of hospital beds, third-party payment for health care, inequitable health care financing, and the use of high-technology equipment. The federal response has been to fund care at a preset amount for diagnostic related groups (DRGs).

Additionally, access to health care is limited for several reasons. Fewer employers are offering health insurance. Care is crisis-oriented and fragmented for the uninsured and underinsured. As costs rise and access declines, quality has declined due to cost containment measures and poor continuity of care. Quality has also been adversely affected by a shortage of nurses.

Several factors have fueled the shortage of nurses. Alternative career opportunities are available for young women now, and members of the present cohort of nurses will retire within 15 to 20 years. At the same time, the general population is aging and technological advances have led to increased demand for nursing care in hospital and in outpatient settings.

Consumers are faced with many other health care challenges. They fear losing their health insurance and are faced with fewer choices of provider physicians and hospitals. Access to care has decreased, particularly for the aged, chronically ill, children, impoverished, and those living in rural areas.

There is an oversupply of hospital beds, fueled by federal funding for hospital building after World War II. Cost and quality initiatives have led to standardization of care, shorter lengths of stay, and increased need for self care. Many medical services have moved into outpatient clinics, public health agencies, community health programs, school clinics, and long-term care facilities.

Numerous trends indicate a positive outlook for the nursing profession. The American Nurses Association plan, Nursing’s Agenda for the Future, provides goals for nursing’s future by 2010 in several areas: leadership and planning, delivery systems, legislation/regulation/policy, professional/nursing culture, recruitment/retention, economic value, work environment, public relations/communication, education, and diversity. Nursing Sensitive Quality Indicators have been developed to measure the cost/quality impact of nursing care.

The evolution of advanced practice nursing has been advantageous for consumers as well as for the profession. Most advanced practice nurses work independently, facilitating access to care, continuity of care, and high quality. Medicare directly reimburses advanced practice nursing, despite medical association efforts to limit practice. The public’s perception of nurses remains positive.