Health policy and the private sector. New vistas for nursing.

During the past two decades, the drive to rein in rising health care costs has shifted some of the power in health care policy making from professional groups, government agencies, and not-for-profit health care organizations to large for-profit corporations (1-4). This has been a world-wide phenomenon, as the provision and financing of health care services is shifted from governments to private health care organizations (5,6). In the United States, the shift in power is manifested in profound ways. Market competition and bottom-line economics have permeated the health care system, creating powerful new incentives for mergers, other corporate restructuring, and the shift to for-profit status by formerly not-for-profit insurance companies and providers. Private sector health care is now increasingly influenced by for-profit organizations (3). Moreover, the health insurance industry has been transformed as traditional indemnity insurance is replaced by versions of managed care. The role of government, or the public sector, in setting parameters for health care financing and standards for the delivery of health care services is increasingly outpaced in cost cutting by organizations that directly face the bottom line. In addition, private foundations, many of which are under the auspices of managed care organizations, now fund a large proportion of health care research and demonstration projects, a task once largely within the realm of the government. Through education and experience, nurses have developed political sophistication and understanding of policy making in the public sector (7). The challenge now is to educate nurses to adapt their political and policy strategies to the new health care milieu. This challenge is particularly crucial for advanced practice nurses, who must survive in a managed care environment.