Grit, in a word, is stamina. But it's not just stamina in your effort. It's also stamina in your direction, stamina in your interests.—Angela Duckworth

Recently, I was shaken to my core by the fractured nature of healthcare and the degree of health inequity in the US. I practice in a primary care clinic that serves a population of uninsured and underrepresented individuals. The vast majority of patients in the practice migrated to the US to make a better life for themselves and their children, just as my grandparents did. This week, I was caring for a 25-year-old woman, who when arriving in the US along with her 10-year-old daughter 2 months ago was involved in a motor vehicle collision in the van that transported them across the border. She and her daughter were severely injured and received top-notch, life-saving care at a Texas hospital. However, after life-saving care was performed and the patients were discharged, they were not able to receive the surgical care and follow-up required to restore physical function and performance.

Universal healthcare, also known as universal health coverage, is a healthcare system in which all individuals have access to healthcare and financial protection, regardless of their ability to pay. In a universal healthcare system, the government and/or some other entity is responsible for ensuring that all individuals, regardless of their≈socioeconomic status or health conditions, have access to healthcare services, such as preventive care, primary care, emergency care, and hospitalization. Essentially, universal healthcare has two major components: provision of high-quality healthcare to all and protection from personal financial hardship and bankruptcy.

Healthcare costs

Affordability and access to healthcare are two of the most significant issues expressed by the US public today, and what currently seems unattainable will eventually become inevitable. In the US, healthcare is a for-profit industry, although nonprofit and government-sponsored healthcare also exists within it to create a hybrid system. In 2021, US national health expenditures grew to $4.3 trillion ($12,914 per person), with healthcare spending accounting for 18.3% of the US gross domestic product. In comparison with the US, other wealthy countries spend about 50% less per capita on healthcare and report improved health outcomes in many key areas, such as life expectancy. In the US, policies supporting universal healthcare have been proposed since 1934, when President Franklin D. Roosevelt called for health insurance coverage as part of Social Security; however, these policies were removed from the final bill that became law. The road to universal access to healthcare is not insurmountable; other countries, including Germany, Canada, and the United Kingdom (among others), fought universal healthcare implementation early on and eventually established universal coverage. Many moved toward public funding versus private insurance in an effort to ensure equity and increase efficiencies. The US can learn much about the roadmap to universal healthcare from other countries.

Transforming healthcare

What does the path forward to universal access to healthcare look like? And what steps are necessary to move from a low-functioning healthcare delivery model to an integrated person-centered healthcare system with universal access? In the book Why We Revolt: A Patient Revolution for Careful and Kind Care, Dr. Victor Montori calls for a national dialogue among clinicians and patients to reengineer and reclaim healthcare, moving from the industrialization of healthcare toward a culture that will create a genuine healthcare system that values both patients and the healthcare workforce.1 NPs have a history of partnering with patients to transform healthcare delivery. As the NP workforce continues to grow, so do opportunities and professional responsibility to lead efforts at the organizational, state, and federal levels and to advocate for policies that seek to achieve universal access in a system that equitably supports whole-person, team-based, person-centered care.

The NP role was established almost 60 years ago to improve access to and quality of care for children and adolescents, seeking to expand care to underserved communities and disrupt the status quo.2 That goal continues today as the public battles the healthcare industry's greed and unyielding power against disruptive innovations and evidence-informed policies to improve access and ensure equity in the journey to enact universal healthcare.3

NP advocacy and change

Over the last nearly 60 years, NPs have fought tirelessly to eliminate clinical practice barriers, claim payment parity, and attain full-practice authority in the majority of states. These advocacy and leadership efforts have improved access to and efficiencies in care; however, we as a nation have a long way to go to fully meet the needs of the population by addressing the growing chronic disease crisis as well as optimizing and fully resourcing primary care. NPs' passion and grit have informed and modified organizational, state, and federal policies leading to improved health equity for and healthcare access to underserved and uninsured populations. It is that same grit, defined as turning passion, perseverance, drive, and wisdom into performance, that will propel NPs to lead efforts to expedite the transformation of a fragmented and fractured model of care delivery to an integrated and coordinated healthcare system grounded by universal access and team-based care.4

Carving out a path to universal healthcare will require not only the political will of the public and decision-makers but also a clear understanding of short- and long-term projected costs. Proponents of universal healthcare argue that it can improve health outcomes, reduce healthcare disparities, and promote social and economic equality. However, opponents argue that it can be expensive to implement and that the demand for healthcare may lead to long wait times for certain procedures or services. In a highly competitive marketplace, NPs must be prepared to deliver care in a value-informed team-based practice model, since the implementation of universal healthcare will likely entail significant economic costs.5,6 Moreover, since NPs are experts in delivering evidence-based preventive healthcare services in diverse settings, the upfront costs will be partially offset by a healthier population, which is posited to reduce costs in the long term.

Since their inception, NPs have been known for providing pragmatic solutions at the front lines of patient care delivery to address complex healthcare challenges. These frontline and advocacy efforts have improved access to patient care and have pushed the boundaries over time, demonstrating tenacity and grit. With grit and by being fully determined, I pushed the boundaries of a broken health system to negotiate a way to get the necessary care for the mother and daughter who migrated to the US. Although it may be a temporary win, it is not nearly enough. Together, in solidarity, I call all NPs to move forward with grit, tenacity, and persistence to fight the good fight to ensure healthcare for all.

REFERENCES 1. Montori V. Why We Revolt: A Patient Revolution for Careful and Kind Care. Rochester, MN: The Patient Revolution; 2017. 2. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care. Harv Bus Rev. 2000;78(5):102–112. 3. Berwick DM. Salve lucrum: the existential threat of greed in US health care. JAMA. 2023;329(8):629–630. 4. Lee TH, Duckworth AL. Organizational grit. Harv Bus Rev. 2018;96(5):98–105. 5. Yakusheva O, Rambur B, Buerhaus PI. Value-informed nursing practice: what is it and how to make it a reality. Nurs Outlook. 2022;70(2):211–214. 6. Zieff G, Kerr ZY, Moore JB, Stoner L. Universal healthcare in the United States of America: a healthy debate. Medicina (Kaunas). 2020;56(11).