Characteristics of the Health Care System

The current health care environment is complex. Scarce resources combined with increasing health care costs make access to health care difficult for a variety of persons. While there are many factors implicated in what Richmond & Fein (1995) term "the health care mess", being elderly appears to be a significant one.

Factors that contribute to constraints on access to care for the elderly are both personal and system-related (the latter are indicated by bold print) and include:

• Diminished physical capacity such as declining mobility, sensory loss, or inability to drive oneself due to vision impairment. These lead to increasing difficulty getting to physician appointments or clinics. Since under managed care there may be a shortage of specialists who serve patients on Medicaid or Medicare, access may be further impaired.
  
  
• Diminished financial resources, limiting access to care by rendering prescriptions too expensive, or by restricting the numbers of available providers or clinics. Additionally, home care support services have been cut.
  
  
• Lack of knowledge about available resources or lack of information about how to access resources. Pressures from managed care and insurance companies for health care providers to see more patients, while providing less time for educating patients and advocating for them.

Advocating for patients in a health care system, where the elderly are NOT a priority but cutting costs IS a priority, is very difficult for nurses who have responsibilities to meet the health needs of patients. Nurses can perceive themselves to be caught in a "dirty hands dilemma" (Mohr & Mahon, 1996). That is, clinicians can find themselves stuck in a situation where any action possible is either unethical or inadequate to meet crucial needs of the elderly. When patients take second place to profit motives or cost control measures, the nurse may feel as if he/she can do nothing to change the system or meet the elderly patient's needs.

It is essential that in advocating for their patients, nurses have a basic understanding of the nature and structure of contemporary U.S. health care arrangements and how these may impede or facilitate care.