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An Analysis of the Health Care of the United States and Colombia

Diana Carolina Pulido
Hawaii Pacific University
NUR 6015
Fall 2016

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Table of Contests
Page

I Data Collection.........3
II Health Care Delivery Model....3
A. The United States ....3
B. Colombia .....6
III Finance8
A. The United States.....8
B. Colombia......................................9
IV Role of the Advance Practice Registered Nurse.....9
A. The United States.....9
B. Colombia.10
V Analysis.......11
VI References .13

An Analysis of the Health Care the United States and Colombia

Data Collection

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This assessment provides an overall view of the health system of two developed
countries, the United States and Colombia. Addressing certain strengths and weakness allows
identifying areas that are working appropriately and those that need attention from formal leaders
to consider a reform. To get started, a healthcare expenditure statistic was reviewed for both
countries, according to The World factbook, in 2014 the U.S. expend a total estimate of $ 9,403
dollars on health per capita, but in contrast, Colombia seems to be expending less on health; a
total of $962 dollars per capita was identified. Expenditure on health for 2014 was also reviewed
in percentile, with a 17.1% for the U.S. and a 7.2% for the country of Colombia (WHO, 2016).
For an overall view, Infant mortality rate and life expectancy factors are added. Recently in 2015,
The World factbook reported six infant deaths out of 1,000 live births, opposed to Colombia
which has more infant deaths, had a rate of 14 out of 1000 live births. Regarding life expectancy,
females seem to live longer such as 82.1 years and males 77.5 years. The overall total estimate of
years expected to live is 79.8 years. Contrary to Colombia, they seem to live less yet, women still
have longer life, male is 72.6 years and female 79 years. The total population usually live up to
75.7 years (2016).
Health Care Delivery Method
The United States
Before health insurance existed, citizens of the U.S had more freedom in choosing the
appropriate care based on their health needs as health care cost was low priced due to the poor
requirements of the study. During this time, the hospital was owned by the doctors and its only
customer were the poor population (JBPUB). However, as the field of medicine started to
innovate in its study requirements (addition of training and licensure) providers became honored
and hospitals became accepted in wealthy individuals. As result, health care cost started to rise,
depriving the poor population of receiving health care services. This change in medicine placed

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the American people in the need for a health care system. After the 1930s, hospitals were no
longer owned by doctors but became part of church organizations and the government (JBPUB).
In 1965 the government created two health programs; Medicaid a health insurance that provides
coverage for poor population and Medicare a health insurance that provides coverage for
disabling and the elderly (Mason, 152). To aid reduce healthcare cost, in 1980, hospitals started
to expand its services by developing outpatient and ambulatory surgeries sites which currently
continues to grow. In order to ensure all Americans were able to receive emergency medical
treatment, in 1985, a law is known as the Emergency Medical Treatment and Active Labor Act
was passed. Hospitals, considered The Foundation and and integral part of health care
system, created health insurances and Hospitalist positions (a provider who cares for patients
admitted to hospitals) (JBPUB). In the 1900s, after obtaining report analysis from discovered
link between environmental conditions and disease, the U.S government implemented measures
such as the development of Public Health Departments who focus on public health care
education, illness prevention, disease outbreaks analysis and control. Educational organizations
such as John Hopkins University also aid by developing Public health schools. National
programs such as Healthy People were then created to maintain the U.S. health care system
focus in finding and implement a measure that can increase life expectancy, increase health care
access and the reduction of health inequality (JPUB). Due to unaffordable health care service and
possible financial instability of providers, the American Medical Association influenced the need
for private health insurances, which finally these were started to be seen after 1929. In order to
aid health care cost, Former President Nixon signed The Health Maintenance Organization
(HMO) (private health insurance with limited providers and referrals), then the Diagnostic
Related Group DRG was created (JPUB). The DRG is a payment mechanism for reimbursing

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hospitals for inpatient health care services in which a predetermined rate is set for treatment of
specific illnesses (prospective payment, n.d.).
Three major strengths were identified from the U.S. health care system. The first one is
having different health insurances, plans, and modes of payment that can fit a person's current
financial status. This allows the individual to obtain the necessary medical treatment to expand
life expectancy (Jiaquan, 2014). Another identified strength is how the U.S. approaches health
care to reduce early mortality. The U.S. health system changed its focus from treating current
disease into health disease prevention via clinical research studies, health promotion volunteer
foundations, new school programs requirement, advancement of medicine (Welcome to, 2014).
The last strength found is how advanced the healthcare profession is becoming. Having advanced
practical nurses in primary care areas allows physicians to specialize in areas of shortage, this
change increases access to health care delivery and aids maintain health care system cost
("Policymakers", 2016). On the other hand, three major weakness were also found; the ability of
certain insurances in denying coverage to any individuals with preexisting medical conditions,
the U.S. healthcare cost is considered one of the fastest in growing and the highest per person in
the world industry, and lastly the ongoing dilemma of inadequate health care access. Part of this
dilemma is the lack of primary care providers and physicians are leaving this practice to
specialize. This problem, often seen in rural and low-income areas, is highly contributing to poor
health lifestyles and noncompliance of care, especially because of lengthening of wait time for a
patient's to be seen. (Brubaker, 2011). A fact found in Medical News Today reported that the U.S.
health system is still considered one with the highest rate of disease out of all developed
countries due to the high healthcare rates (not everyone can afford medical treatment). Uninsured

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patients rates continue to decrease, to prove this, in 2015 the U.S. experienced a remarkable
drop from 15.9% in 2009 to 9.8% (Nordvist, 2016).
A change was proposed and enacted on March 23, 2010, known as The Affordable Care
Act or also known as Obamacare. The purpose of this act was to protect all Americans by
allowing them to receive healthcare treatment regardless of their general status. This established
health insurance for patients with pre-existing conditions at an affordable premium cost, it also
changed the requirements for medical reimbursement from quantity into quality care. It supports
preventive care by providing free health screening such as mammograms, colonoscopy to certain
population (Nordvist, 2016). It allows health insurance companies to excuse honest mistakes
when filling a health coverage application. This act also increased healthcare access by allowing
Americans to seek out of network care during emergency situations and provided the freedom to
choose a primary care provider of those who participates (Improving health, n.d.). In 2014
Obamacare expanded horizons with the addition of new beneficial features in Medicaid and
Medicare coverage such as 50% discount for Medicare part D participants (Nordvist, 2016).
Colombia
For decades, Colombia has mandated all population to have healthcare insurance. The
healthcare system is represented by three subsystems: the public (hospitals, outpatient clinics,
and surgery sites), the insurance and the private (private insurance or out-of-pocket). The
insurance subsystem works as a single payer system. Agencies known as Entidades Promotoras
de Salud EPS are in charge of all healthcare finances and health promotion. These agencies allow
all Colombians to have healthcare coverage. EPS are divided into two regimens; Regimen
Contribution (contributive), obtained from employer and employees deductible to cover
beneficiary and dependents and Regimen Subzidiado (subsidized), obtained from the state to
cover poor and unemployed population. EPS offers Plan Obligatorio de Salud (mandated

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coverage plans) which are chosen based on the filled application. These agencies have
Instituciones Prestadoras de Servicios (health providing institutions) such as Comeva,
Comfenalco, or Colsalud which are the clinic that provides healthcare service to those who are
covered ("Como funciona, 2013). Three major strengths of Colombia health system is how its
coverage extends to 97% of the population (Suizo, 2015). Its advantage relates to the ability to
afford health care cost. Another strong point is the consideration of Colombias healthcare as one
of the world's class health according to Live and Invest Overseas article. This healthcare system
exceeds many developed countries and currently, is considered to be "the best in Latin America
and respected internationally. Several hospitals and clinics are currently accredited by the Joint
Commission International and also by U.S. organizations (2016). Another identified strength was
the presence of five top-notch hospitals, which are ranked among best 35 in Latin America,
this country offers some of the continents best medical facilities and most highly skilled
doctors. Medical tourism (to include complicated surgeries) has increased due to the high
quality of care and affordability (2016). Three disadvantage noted in the Colombian health
system is the decreasing role of health care professionals during governmental health reforms.
The majority of hospitals and Nursing homes in Colombia work as independent commercial
agencies taking the overall health care autonomy. Privatizing these agencies cause inability to
regulate and track performance, allowing private negotiators to manipulate its system (Suatzo,
2015). Another block is the lack of health care promotion. The shortage in certified
administrative personnel and community representation reduces the opportunity for preventive
care. Also, lack of hospitals (1.2 acute care hospitals per 1,000 people), home health services and
providers in rural areas increases mortality rate. Lastly is the provision of power finance to the
EPS agencies. Unethical practices such as creating bureaucratic barriers for treatments,

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withholding payments and investing funds in areas not related to health care and lack of health
promotion (Cohen, 2013).
Currently, the senate approved the bill Salud Mia in January of 2016. This bill consist of
taking away the finances rights from the EPS (which will receive the new name Health
Managers) and providing state funds only if the treatment needed is approved by EPS (EPS
sometimes denies specific treatment to their associates even though is under the plan) and the
quality care provided based on a sliding scale. The goal is to preserve these agencies as this are
an aid in keeping health care cost affordable, yet allowing the state to monitor for any negligence
or malpractice in the population. Currently, this bill is pending the house approval. However, the
administration of President Juan Manuel Santos proposed a legislation in which claims to
completely "eliminate the EPS". This has caused controversy in the population and is currently in
the senate for approval (Cohen 2013).
Finance
The United States
Healthcare is paid in several ways, it can be directly on the patient on the same day of
received care, others may use their employment health insurance, or active duty and their
dependents and veterans can use Tricare (a federal government health insurance). Also, lowincome mothers, elderly and disable patients can use Medicaid or Medicare (Health
economics, 2016). There are other private pay options that can be used, known as private
insurers. These offer premiums that can be paid to commercial carriers such as Blue Cross/Blue
Shield by employee and employer contribution, managed care plans such as Health Maintenance
Organization (HMO) or Preferred Provider Organization (PPO) or Point of Service Plan (POS).
For mothers who cannot qualify for Medicaid due to income and are not able to afford private
health insurance, they can do so through the State Childrens Health Insurance Program (SCHIP)

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(Health economics, 2016). Citizens share expenses by performing direct and indirect payments
such as co-pays or premiums, contribution to payroll reduction, taxes, and out-of-pocket
expenditure (when health insurance does not cover). The government also share expenses via
single payers programs for certain population (Health economics, 2016).
Colombia
Health care in Colombia is paid from the payroll deductible contribution obtained from
the employee and the employer, also from local and the nation revenues. Citizens share expenses
by contributing with the EPS deductible. Usually, those with low minimum wage starts at
$72.200 ($30.00 dollars) but can run up to $14 million ($6,000 dollars) for those with high
income. The government share expenses by providing the EPS with funds for the subsidized
population (Como funciona, 2013). There are purely private pay options in Colombia very
similar to the U.S. known as Medicina Prepagada or Prepay Medicine. Its affiliation is
voluntary, and offer several of plans and agencies. Currently on 2% of the population uses this
method, is often purchased by high-income families as the rest of the population prefer to only
have EPS coverage. The downfall of these agencies are the restrictions it carries for certain care
and also medications (Como funciona, 2016).
Role of the Advanced Practice Registered Nurse
The United States
Advance Practice Registered Nurses APRNs have developed a major role in the health
care system. These are registered nurses who obtained their Master or Post Master degree and
were granted a certification that allows them to practice with a specific population. These nurses
have received the appropriate education that allows them to assess, order labs, diagnose,
prescribe medications and manage illness without the supervision of a physician depending on
the location. There are four areas APRNs can specialize their practice: Certified Nurse

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Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Certified Nurse
Midwife. Recently, After the annotation of the Affordable Care Act, the U.S health care system
have recognized the need for a change in health care delivery, and as result, it has stimulated the
development and the continuation of nurses organizations to advocate in hospitals and at the
government level for the purpose of advancing nursing practice and to meet the populations
needs. The U.S. government has granted each state regulatory authorities to determine the
autonomy and scope of practice of APRNs. Having each state decide the requirement and future
practice of these professionals have created uniform regulations across the U.S. as an exchange,
APRNs are not been utilized to the full extent of their abilities. Some of those limitations APRNs
face according to American Nurses Association include State practice and licensure (varies by
each state), physician-related issues (physicians believe nurses are incapable of providing
quality care), payer policies (sometimes these are linked to state regulations which prevent
APRNs from practicing independently), continuity of care (due to the variety of state
regulations, APRNs are unable to follow their patients care) (Hain, 2014).
Colombia
In Colombia, APRN profession is not recognized. However, nurses can advance into the
clinical specialist, anesthesia, and practice authority. Currently, APRN role has not been
recognized as part of the health care system, in fact, medical professionals are not considered as
part of health care reforms (Advance practice, 2013). However, nurses who chose to advance
in education known as Enfermero Jefe have the capacity to diagnose, treat, and monitor patients
with minimal supervision of physicians depending on the facility that is been practiced
(Profesion enfermero, 2016). Due to the nation surplus of health care providers, APRN
profession continues to be underestimated (Advance practice, 2013). Some of the limitations
these advance nurses face include: lack of recognition of nursing as an autonomous profession

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(Nursing continues to be viewed as skill tradition rather than research for better outcomes), lack
of incentives for evidence-based nursing" (due to its underestimated value, institutions do not
offer time off, grants or the appropriate compensation to graduate professional), The limited
availability and usefulness of nursing evidence(language and statistical analysis was a barrier
when accessing certain international literature), the separate worlds of academia and clinical
practice(the lack of agreement between the researcher and nurses during research studies and
the lack of initiative from clinical nurses to promote a change) (DeBruyn, 2014).
Analysis of Both Countries
Every country in the world is unique and has something to learn from each other. Even
though the U.S. and Colombia are developed countries, there are still issues these countries must
readdress for the welfare of its people. The U.S. health care has been well recognized in other
countries due to the way advance in medicine is approached, however, due to the system's
function, prices have increased, maintaining life expectancy at average. In order to reduce its
cost, it is suggested for the U.S. to stop using the current system and innovate based on other
countries systems, perhaps analyzing the single payer system Colombia currently uses (EPS). It
is understandable that certain population disagree and are uncertain of socialized systems,
nonetheless, health care professionals and citizens should be well explained with evidence and
data analysis of the cost reduction this may bring, this change could increase life-expectancy
along with quality care. On the other hand, Colombia needs to stop making decision without
having suggestions from healthcare professionals during healthcare reforms as the U.S. currently
does. Not having the opinion from healthcare providers prevents the identification of the location
where the system is malfunctioning, stagnating the system as routines. Colombia should also
start to recognize advance nurses as a profession, recognizing these professionals will allow to

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gain respect and trust from population, perform as healthcare providers and ultimately aid reduce
or maintain health care cost. This change may increase governmental revenue which can be used
for research studies and to promote health as the U.S. Furthermore, Colombia should continue to
use the EPS system as this is what has been maintaining healthcare accessible contrarily to the
U.S. Now, The U.S. should stop developing healthcare reforms that only benefit certain
populations, because this inequality is what block the population from accessing the health care
and also it promotes noncompliance with the nations regulation. In addition, the U.S. should
continue to support the approval of APRNs ability to continue care across the states, besides
decreasing mortality rate, this will aid healthcare access in areas they are not allowed to
independently practice (physicians are now moving into specialty areas).
In conclusion, as the world evolves, it is essential to periodically examine healthcare laws
and regulations. As benefit, all government in the world should consider healthcare providers
suggestions as guidance for healthcare reforms because as frontline, they be able to appoint the
areas that need improvement that at times formal leaders may omit. All countries should focus
more in disease prevention and promotion rather than advancing in technology as this is only a
temporary measure to relief symptoms. All healthcare professionals such as APRNs should be
accepted and warrant to practice across the states, this change will demonstrate care towards the
population as the main goal in healthcare is safety and in return, it will aid the second goal which
is cost.

References

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