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Idea: Treat America as a Patient

How do you fix the health system? We can start by taking a nurse’s perspective on the body politic.

Nurses comprise America’s most trusted profession. With that trust comes the moral responsibility to speak to America as a patient. I’m talking about more than a metaphor. Framing the nation from the perspective of a nurse can literally make America, and its citizens, healthier. Let’s see how.


1. Nurses know that the best outcome of health care is better health.

As a nurse, I know that if a treatment is not producing as much health as it needs to, then I should do something. When we’re talking about all of America, my intervention has to be policy, to heal the system. As nurses, we need to help shape the system to produce more health.

I feel qualified to do that not just because I worked on health care policy in Washington, but also because I’m a nurse. I’m used to figuring out what works and what doesn’t to produce the most health in a patient. It’s critical that the nations health care policies are responsible and efficacious; and, most of all, constantly focused on producing better health.


2. We know that health requires a partnership with the best professionals, and with patients themselves.

When I came back to the government after working in clinical practice and academia, I realized how dependent agencies are on the resources of people on the ground. If you’re a payer or a federal official, you’re sitting there and just hoping the system works; because all you’re doing, essentially, is paying for it. The best health comes from all the players having a say in health outcomes. Not just nurses and physicians but also social workers and other mental health professionals, housing authorities, nutritionists, community health workers, local pharmacies, or dentists.


3. We seek health, we pay for care. More should go to health.

You have heard that America pays more for health care per capita than just about any nation on earth. We use high tech to treat patients’ symptoms, driving up health care expenses even while America falls behind most other rich nations in measures of actual health.

But look at the system from a nurse’s perspective—that is, a broad perspective that goes beyond a clinic or a hospital room—and the amount of money America spends on health care in total puts us just about in the middle of the pack. As Betsy Bradley points out in her book, The American Health care Paradox, we over-finance health care and under-finance social services. Add up the two budgets for health care and social services, and America’s total health expenses per capita aren’t that different from those in other developed countries. But we’re terrible at the outcomes.

While other nations treat the broad causes of ill health, we’re still stuck treating the symptoms.

We see these complications every day: transportation affects our patient’s health, determining whether they can sleep eight hours a night without wasting time on an inadequate bus system or, worse, realizing they can’t get to their job. Having a roof over their head, getting good food support, income support, job training, and the list goes on. When people get jammed up in life, they tend to get sick. We nurses see that one sick family member can imperil the health of the rest of the family. Sometimes we don’t need someone to help us monitor blood pressure; we need someone to manage the stress that’s causing blood pressure to go up.

Nurses are ideally suited to understanding those broader causes. I was talking recently with a group of clinicians about the difficulty of managing patients with diabetes. Many patients clearly know what they’re supposed to do. If they’re not actually doing it, maybe we don’t need to educate them more, or just focus on managing their blood sugar. Maybe what they need is a social worker to help figure out why compliance is so difficult for them.


4. We need to realign payment structures to focus on outcome.

Current payment structures don’t work. It’s not for lack of money. This nation spends more than $3 trillion a year on health care. The problem is a lack of focus on delivering better health. When people are healthy, they engage in daily commerce. They can work their jobs. The data are clear on this: a healthier country is a wealthier country.

Therefore we have to decide as citizens if we want a purely free marketplace, or one that we have influenced somewhat through policy. For one thing, we should determine a floor: a minimum of health care and services that everyone gets. Once we’ve defined that floor, we can use the marketplace to design services and incentives for people to consume those services. Mental health care should be a part of that. When I worked in the U.S. Senate, we visited a family in New Jersey that once had been very well to do. They had stripped all their finances for a son with schizophrenia. If that can happen to a family of means, think of what a mental health crisis can do to the families of the rest of America. That doesn’t do any of us any good.


5. Nurses know it’s not just the patient, it’s the population.

A patient is not just plugged into an IV; she’s plugged into a family and a community, a social and political and physical infrastructure that goes way beyond us providers. Is this a left-wing perspective? A right-wing one? I don’t think it’s either L or R. It’s P: population. As nurses, we have the responsibility of knowing how to get the best health out of health care. And we know that a broad perspective is essential.

Meanwhile, the political dialogue in our nation is terribly destructive. It’s pulling apart the bonds that hold us together. Part of our responsibility as a profession is to bring Americans back into working for the nation’s overall health—not just the health of individuals but of us all. Besides, we nurses know: If you want to stay healthy, it’s best to be surrounded by healthy people.

What can you do? Join a national nursing organization as well as a community organization. Focus on a particular field appropriate to your work, such as disabilities or Alzheimer’s or diabetes. Become an advocate for health with your state representative.

This may sound a little too idealistic, but I saw early on, with my own eyes, what we nurses can do when we join forces. When I was a master’s student at the University of Michigan, Congress threatened to cut the budget for the Nurse Training Act. A bunch of us got together in the school’s gym, and we called every nursing school in the country. We told them to show up on Capitol Hill. We printed booklets on how to lobby and did training on the buses. Local nurses in the DC area put us up.

By the time we arrived, the bill to cut the funding had already been through committee. “Don’t get your hopes up,” a committee staffer said. But, even though we didn’t really have a clue what we were doing, we turned that tsunami around. The bill got shot down. We nurses won. And, I believe, so did our patient, America.

Julie Sochalski, PhD, FAAN, RN


Julie Sochalski, PhD, FAAN, RNJulie Sochalski, PhD, FAAN, RNAs the United States’ former chief nurse, Julie Sochalski, PhD, FAAN, RN, has one patient: the U.S. health care system. Her intervention: evidence-based reform to heal that system. From 2010 to 2013, Dr. Sochalski oversaw a multi-million-dollar budget, directing the U.S. Department of Health & Human Services Division of Nursing and serving as its principal advisor for health workforce policy. These days, Penn Nursing’s Associate Dean for Academic Programs studies gaps in the U.S. health care system and looks for policy solutions. She also studies the side effects of health policy decisions. The biggest question: How can nurses and other health care professionals be best deployed to achieve optimal population health? This article is based on an interview with Dr. Sochalski during the summer, when she was juggling research and teaching with her duties as a residential-hall Faculty Director; she now advises some 500 firstyear Penn students at Hill College House. “I love it,” she said of her living arrangement. “The students are the best part of it.”