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The U.S. health care system is a complex and ever-evolving machine. It is the culmination of various health care policies stemming from numerous special interests, political expedience, economic considerations, and theoretical perspectives. Because the U.S. health care system fluctuates along with current political climates, any account of it is subject to change within the next 3–5 years. While currency can be challenging, understanding the elements in the cur- rent health care system is crucial to understanding how public health affects and is affected by it. Appendix A focuses on the basics of the health care workforce, agencies, financing, insurance, dimensions within the public health system, and the overall connection between health care and public health.

A special section is devoted to health care funding in the United States and includes an out- line of the Affordable Care Act. How these systems of funding function and how public health supports these efforts also is explored. Lastly, Appendix A details the responsibilities and accountability of the U.S. public health system, especially those of the seven specific agencies that function as part of the health care realm and public health.

A.1 Linking Public Health to the U.S. Health Care System The link between the U.S. health care system and the public health realm can be understood by examining how the system first started.

A Tradition of Giving The U.S. method of caring for the sick, poor, aged, and mentally ill historically was grounded in churches and religious orders and was later expanded on by charitable organizations such as the Catholic sisters’ work during war times and epidemics (Stepsis & Liptak, 1989). The con- cept that people need to take care of people became rooted in a system of giving, and it was through this system that social services assistance such as Medicare and Medicaid developed.

Indeed, federal and state laws were born from the idea that health is a partnership between those who can provide services and those who need them. After the passage of An Act for the Relief of Sick and Disabled Seamen in 1798, the nation began to view health care as a right and a necessary part of human existence. It became part of the public realm and thus forged the link between health care and public health. Table A.1 shows the progression of the U.S. health care system.

Appendix A The Health Care System in the United States

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Section A.1 Linking Public Health to the U.S. Health Care System

Table A.1: Transition and growth of the U.S. health care system

Year Event/landmark

1798 Passage of An Act for the Relief of Sick and Disabled Seamen

1800–1910 Sick insurance offered by the Massachusetts Health Insurance Company of Boston

1862 Bureau of Chemistry established (forerunner of the Food and Drug Administration)

1870 Marine hospitals organized into a centrally controlled Marine Hospital Service

1887 One-room laboratory that eventually would become the National Institutes of Health opened

1890 Public Health Service Commissioned Corps legislation

1902 Marine Hospital Service renamed, becomes Public Health and Marine Hospital Service

1906 Pure Food and Drugs Act passed (eventually became part of the FDA)

1912 Public Health and Marine Hospital Service shortened to Public Health Service

1921 Bureau of Indian Affairs Health Division created (forerunner of the Indian Health Service)

1929 Baylor University began to offer a “sickness” insurance plan for teachers that would become the model for Blue Cross plans The Great Depression began; few people covered by health insurance

1932 Blue Cross established

1935 President Roosevelt signed into law the landmark Social Security Act of 1935, a major turning point in American history; initiated a system of elderly benefits for workers, workers’ benefits resulting from industrial accidents, unemployment insurance, aid for dependent mothers and children, and benefits for the blind and the disabled supported by taxes on individual and employer payrolls

1939 The Federal Security Agency created, merging fields of health, education, and social insurance

1942 Rise of unions and economic downturn during World War II, resulting in the passage of the National War Labor Board, which set a cap on wages but allowed labor unions to offer fringe benefits, such as health insurance, as tax-exempt deductible income

1944 Public Health Service Act of 1944 made the United States Public Health Services (PPS) the primary division of the Department of Health, Education, and Welfare (HEW)

1946 Communicable Disease Center established (forerunner of the Centers for Disease Control and Prevention)

1940–1950 Freezing of wages; employers offered health insurance not subject to income tax as a benefit alternative

1950 Forty-year increase in personal health care expenditures rose from $82 in 1950 to $2,511 in 1990

1953 The Cabinet-level Department of Health, Education, and Welfare (HEW) created

(continued)

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Section A.1 Linking Public Health to the U.S. Health Care System

Forces Shaping the Current System World wars, the Great Depression, economic issues, social and health policy, and the gradual acceptance of the concept of “sickness” and health insurance further shaped the nature of the U.S. health care system. These transitional factors eventually pushed the responsibility of health care from the individual to the employer, diminishing the role of individual responsi- bility and lifestyle choices. See A Closer Look for more details on the beginnings of employer- based health insurance.

Year Event/landmark

1965 Medicare and Medicaid passed; federal government became the largest single purchaser of health care

1970 National Health Service Corps created

1973 Health Maintenance Organizations (HMO) Act addressed rising health care costs

1979 Department of Education Organization Act removed the education duties from the HEW

1980 HEW became the Department of Health and Human Services

1983 Prospective payment system (PPS) legislation assigned diagnostic-related groups (DRGs) for hospital payment, directed to control inflationary hospital costs

1988 McKinney Act passed to provide health care to the homeless

1992 Resource-Based Relative Value Scale (RBRVS) created a relative value affecting reimbursement for physicians in family practice, internal medicine, and obstetrics and lower fees for surgeons and radiologists; resulted in a shortage of physicians in some areas of medical practice

1995 Social Security Administration became an independent agency

1996 Welfare reform passed under the Personal Responsibility and Work Opportunity Reconciliation Act Health Insurance Portability and Accountability Act passed

1997 State Children’s Health Insurance Program (SCHIP) created

2002 Landmark study by the Institute of Medicine: The Future of the Public’s Health in the Twenty-First Century Office of Public Health Emergency Preparedness created

2003 Medicare Prescription Drug Improvement and Modernization Act enacted, the most significant expansion of Medicare with a prescription drug benefit

2010 Affordable Care Act passed

2016 Affordable Care Act under scrutiny; threats to repeal it

Sources: Klees, Wolfe, & Curtis, 2011; U.S. Department of Health and Human Services, 2017; U.S. Public Health Service Commissioned Corps, n.d.-b

Table A.1: Transition and growth of the U.S. health care system (continued)

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A Closer Look: How Did Insurance Become an Employer Responsibility?

Payment for health care services started out as a cash-only affair when a physician’s services were needed. For those who had little or no money, trades of food or other commodities were given in return for health care services. Sickness insurance was essentially catastrophic coverage in the event that the breadwinner of a family, usually the man, could no longer provide for his family due to sickness or injury. While such insurance was not mandatory in the United States, it was exceptionally popular in Europe, where industries were required to provide it. Requiring businesses to offer sickness insurance was considered an intrusion of government into the practices of businesses, which was against the democratic system developed in the United States (Roberts, 2009). The progressive movement in the early 20th century, a period of widespread activism and political reform, sought to make health insurance a national priority, arguing that it would “stabilize the income of workers, relieving poverty caused by sickness, and healthier workers would be more efficient” (Roberts, 2009, p. 8). However, the demands of World War I halted the push to create compulsory health insurance.

During the industrial and technological growth of the 1920s, newly available diagnostic tools and treatments were expensive, and they increased the costs of health care to the point where most people simply could not afford it. Because of this, the notion of national health insurance again became a focal point. Most people in the medical community did not want government interference into their work and considered the possibility radical. In fact, President Franklin D. Roosevelt had originally planned to include voluntary health insurance in his New Deal reforms, but the concept was removed due to negative reactions from the medical community.

During the Great Depression, Baylor Hospital in Dallas, Texas, was facing the dilemma of choosing between empty beds or patients who could not pay their bills. To combat this, the hospital developed a plan where schoolteachers could pay 50 cents per month to the hospital and receive up to 20 days of care. The first claim under this “insurance” occurred in 1929, when one teacher broke her ankle over Christmas break.

Baylor’s health care plan, which utilized the blue cross symbol, was eventually developed nationwide into Blue Cross health insurance plans. Hospitals across the nation began adopting this type of insurance, and within 10 years, almost 3 million people had Blue Cross plans.

Over time, employers began to offer such health insurance plans as incentives for employment. Considering that the Great Depression caused significant financial damage to both individuals and the nation, health plans were a great opportunity for families to receive health care without high out-of-pocket expenses at hospital or doctor visits. This was the beginning of what is currently the most common scenario: Health insurance is obtained through employment.

Sources: Morrisey, M. A. (2013). Chapter 1: History of the health insurance in the United States. In Health insurance (2nd ed.). Chicago, IL: Health Administration Press. Retrieved from https://www.ache.org/pubs/Morrisey2253_Chapter_1.pdf Roberts, J. A. (2009). A history of health insurance in the U.S. and Colorado. University of Denver. Center for Colorado’s Economic Future. Retrieved from http://www.du.edu/economic future/documents/HistoryOfHealthInsurance_CCEF.pdf

https://www.ache.org/pubs/Morrisey2253_Chapter_1.pdf

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As the industrial revolution struck the United States, so did the need for health care. But for- malized health care could not keep up with the growing demand for health care services, so the American health system implemented quick and temporary solutions often called “stop- gap measures.” Unfortunately, these multiple stopgap measures resulted in a complex, redun- dant, and fragmented health care system. Broad forces shaping the evolving system included

• economic incentives fueled by government-enacted programs; • political expediency; • compromises on a Cadillac tax (a 40% excise tax on employer plans that exceed

$10,200 per year for individuals and $27,500 for families) in exchange for conces- sions to limit its scope;

• development of diagnostic tools and technology-driven interventions; • escalation of increasing efficacy of pharmaceutical interventions; • increases in hospital beds and medical manpower linked with the further enhance-

ment of the need to be able to pay for these services; and • multiple funding sources from governmental entitlements, grants, and categorical

programs for similar or the same services.

The appetite of the American consumer for health care services in conjunction with limited consumer economic consequences meant that as more people used health care, the more expensive it became. Most Americans didn’t realize that the cost of these consumer-driven consumption patterns would trigger major economic issues in the future (National Acade- mies of Sciences, Engineering, and Medicine, 2017a).

Public Health and Health Care Working Together The realization that public health services and the U.S. health care system are inextricably linked is an unfolding perspective. By examining the overall health status in the United States and the perfor- mance of these two interlocking systems, it is clear that U.S. spending for health care services is high and will likely continue to rise (Darzi et al., 2012).

The Public Health Service is responsible for guid- ing health care in the United States. According to the Institute of Medicine (IOM), which conducts an ongoing analysis of public health services and the U.S. health care system, the first critical step

to a fully functional system is to set a national target for the health system performance on two key measures: longevity and per capita health, which is the amount of money the nation spends on health care per person (National Committee on Public Health Strategies, 2012). Numerous individuals and organizations, including the Robert Wood Johnson Foundation, have researched and reviewed both measures for years.

monkeybusinessimages/iStock/Thinkstock The public health and health care systems are linked. Spending more effort on preventing illness and promoting wellness could help reduce health care costs.

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Following the passage of the Affordable Care Act, the Robert Wood Johnson Foundation charged the Institute of Medicine with examining three public health issues: measurement, the law, and funding (National Committee on Public Health Strategies, 2012). The IOM’s initial report indicated that there was not enough funding for effective public health. In addition, the current funding structure of public health was deemed dysfunctional and ill equipped. The IOM strongly suggested that the nation implement population-based prevention and wellness initiatives to help reduce costs. That is, rather than sinking millions of dollars into treatment and illness, the national focus should be on wellness and prevention (National Committee on Public Health Strategies, 2012).

While it may seem obvious that the national health care system should be linked to pub- lic health, there are other models that are structured differently. The next section outlines the different health care models and describes the elements that pertain to the existing U.S. model.

A.2 Health Care Systems The successful provision of health care services requires strong collaboration among pro- viders, services, institutions, and resources in a goal-focused model. Three basic models for health care systems have evolved based upon the funding mechanism of private, public, blended, and limitation of services. All of the models have coverage for those with limited resources, but access to this support has many barriers, including limitations as to what can be covered. None of the publicly nationalized health system models, other than that of the private–public United States model, offers the scientific, medical diagnostics, and interven- tion technology developed by the private sector component of the U.S. health care system. Table A.2 compares the three major health system models, representative countries, funding, and providers.

Table A.2: Basic health system models

Model Representative countries Funding/providers

Bismarck France, Germany, Austria, Switzerland, Belgium, Holland, Japan

Premium funded Mandated insurance Public/private providers

Beveridge United Kingdom, Italy, Sweden, Spain, New Zealand, Norway, Finland, Canada, Hong Kong*, Denmark, Cuba

National health service Taxation Limited coverage Government/public Tight control of costs

National insurance United States, Taiwan Public Private providers

*Hong Kong is a special administrative region of the People’s Republic of China but maintains a large degree of autonomy after being under British rule for decades.

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Health care is an economic function providing health care services. The model for the U.S. health care system is market driven. It is a complex system with multiple funding resources and navigation issues. The major stakeholders in the U.S. health care system model include consumers (insured and uninsured), providers, employers, government agencies, insurance companies, managed care organizations, manufacturers of pharmaceuticals, medical suppli- ers, and professional organizations—essentially the consumers and suppliers of direct and indirect patient/client services.

National Insurance Model The U.S. health care system primarily aligns with the national insurance model. Taiwan’s health care system is also based on the national insurance model. However, the U.S. system is quite different, as it is a blend of the fragmented public–private partnership model. In fact, the current health care system in the United States is made up of small elements from vari- ous national health care systems fused into a larger system. This blending of private–public resources results in a health care system with a unique structure and funding mechanisms. Further complicating this organizational structure is the movement of individuals into and out of both the private model and the public model. The public model is considered categori- cal health care for the poor, elderly, disabled, and mentally ill. But individuals can fall between the two systems and fail to receive services.

The number of Americans under 65 years of age covered by employer-sponsored health insurance declined slightly from 58.6% in 2010 to 58.3% in 2011; this is attributable to the impact of unemployment during the most recent recession (Gould, 2012). Individuals with- out employer-sponsored insurance can purchase insurance from a private insurance com- pany, pay out of pocket, or access public funds. These public funds are usually distributed categorically by age and other criteria. This type of additional insurance purchase is known as a “safety net” system. All Americans can access the public sector for health services as long as they meet the service’s qualifying guidelines. The public component provides health care services for the vulnerable populations of the elderly, the disabled, the poor, and children through programs such as Medicare, Medicaid, Title V Maternal and Child Health Services, the Children’s Health Insurance Program (CHIP), State Health Insurance Programs (SHIPs), school health programs, supplemental food programs for children and the elderly, public health immunization and health services, federally qualified health care providers, and Indian Health Services (U.S. Department of Health and Human Services, 2017).

The U.S. health care system attempts to link services between providers such as hospitals to skilled long-term care facilities, residential services, rehabilitation, in-home services, and mental health facilities. Within the larger hospitals and facilities, there may be specialized services targeting specific patient care needs such as mental health care, intensive care, pedi- atrics, obstetrics, burn units, cancer, and cardiovascular services. Hospital-owned or con- tracted services within a facility may include imaging, laboratory, specialized surgical centers, radiation therapy, emergency services, in-home, hospice, ambulatory care, and outpatient services. These types of services can be provided by private practitioners, medical groups, not-for-profit or for-profit organizations, physician-owned or public health services, the mili- tary, or Indian Health Services. In addition, hospitals may have specific designations, such as critical access, tertiary, primary, or academic health care center, with varying reimbursement

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patterns. Coordination of health care services can be offered by physicians but happens pri- marily through social assistive services, like a public health agency or family services office for complex and case-managed patients.

Health services for the patient or client are in part organized by the personal physician who directs client health needs by weeding through a multitude of potential institutional and provider services. In some instances, coordination happens through case management ser- vices and social assistance organizations, driven initially by insurance companies and public entities. Social Services, in collaboration with physicians, provide a gatekeeping function for publicly funded programs and insurance companies. Case management is a system of man- aging integrated health and human services for a defined group of patients or clients. The patients or clients may be high risk for hospitalization or special care needs, or they may be clients with various publicly funded community-home waivers for Medicaid and long-term care, mental health, and rehabilitation services. Case management services are organized to support the patient or client with wraparound services, community-based interventions that provide a multitude of needs for children and their families that typically involve some level of mental health needs, and to enhance independence. Some insurance plans/providers have case management services and health maintenance organizations to manage access and costs.

State public health agencies have oversight responsibility for safe practices of health care service using a system of licensure/credentialing requirements, inspections, and specific monitoring for health care and human service providers and institutions. While licensed practitioners have state and professional organizations overseeing the practice guidelines and standards, the state department of public health or one of its branches is generally the licensing body.

Health Care Workforce The United States Labor Occupational Handbook identifies 41 categories of health care work- ers (U.S. Bureau of Labor Statistics, 2018b). The health care workforce is diverse, drawn from fields such as the life sciences, social science, and information technology (financial, eco- nomic, and educational areas). Professional schools provide the skills and knowledge needed to fulfill these roles. According to the Bureau of Labor Statistics (2018a), there will be 2.4 million new health care jobs by 2026, a projected expansion rate of 18%.

• Physicians provide diagnostic and treatment interventions as well as a first point of contact into the health care system for patients. From selected national stud- ies concerning physician resources, Young, Chaudhry, Rhyne, and Dugan (2010) reported that there were 850,085 physicians in 2010 with an active license to prac- tice medicine in the United States. By studying the complexity of physician supply and demand and referencing multiple government and professional organizations’ research studies, Dill and Salsberg (2008) projected that by the year 2025, there may be a physician shortage as high as 130,000 physicians.

• Registered nurses (RNs) make up the bulk of the health care occupation workforce. RNs provide and coordinate patient care, educate patients and the public, and pro- vide case management and emotional support to patients and their family members. Practicing requires an associate, bachelor’s, and/or master’s degree in nursing.

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• In response to the projected health care services demands, there has been an accelerated expansion of advanced nurse practitioners. Advanced nurse practitio- ners (ANPs) have advanced academic nursing degrees with specialty areas and/or general practice areas. They are licensed to practice at an advanced level and cre- dentialed to diagnose and provide treatment options for acute, episodic, or chronic illnesses, independently or as part of a health care team (O-NET Online, 2018).

• Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) provide nurs- ing care in nursing homes, physician offices, hospitals, and private homes under the supervision of a registered nurse or physician. LPNs/LVNs must complete a state- approved academic program and be licensed to practice.

• Physical therapists are in above-average demand, extending into 2020. Physical therapists assist people with illnesses and/or injuries limiting mobility. A physical therapist may also supervise a physical therapy technician or assistant. Academic preparation is advancing from the master’s degree to doctorial preparation. Physical therapists are licensed.

• Occupational therapists treat patients with injuries, illnesses, and/or disabilities facilitating the resumption of activities of daily living. Occupational therapists supervise occupational technicians and occupational assistants; entry into the field requires a master’s degree licensure.

• Medical and clinical laboratory technologists and technicians vary in occupational preparation based upon future practice area. Academic preparation also varies and may include certification and associate’s, bachelor’s, and/or graduate degrees. Licensure and/or certification consistent with legislated practice standards is required in each state.

• Health care managerial/administration occupations are another health care job area projected to expand. As Americans are experiencing an increased incidence of chronic conditions combined with lon- ger lives, the demand for health care will require additional workers to provide health care services and access into the system for recipients of categorical pro- grams such as Medicaid and other sources of welfare funding. Integration of these health and social services will be increas- ingly managed by a case manager sys- tem. Case management is “a collaborative process of assessment, planning, facilita- tion, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes” (Case Manage- ment Society of America, 2017, para. 1).

Demand will also expand for those in the health education and health promotion fields, par- ticularly in light of the Affordable Care Act now covering prevention services. Many individu- als are unaware of how to become healthier; hence, the need for health educators alongside health promoters is expected to grow.

XiXinXing/iStock/Thinkstock Demand in the health care workforce goes beyond doctors and nurses. As longevity increases in the United States, health care administrators become more and more integral to the system.

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Other health care personnel positions expected to experience increases include the following ancillary personnel (U.S. Bureau of Labor Statistics, 2018a):

• emergency medical technicians • paramedics • medical sonographers • medical records personnel • medical transcriptionists • health information technologists • nursing assistants and medical assistants

Health Institutions and Agencies There are many institutional health care organizations. They include inpatient care facilities such as hospitals, long-term care facilities such as nursing homes and assisted living, and out- patient clinics. Classification is based upon function and type, such as government (federal, state, community, city, military), specialty service focused, community organizations, and fis- cal profiles. In this section, health care institutions are profiled and categorized as inpatient, outpatient, or community providers.

• Inpatient health care facilities employ the largest number of health care providers. The CDC discovered that in 2014 (the most recent data available), hospitals were about 63% full with an average length of stay being 5.5 days (CDC, 2016d). Any facil- ity allowing for overnight stays is considered an inpatient facility; however, most hospitals allow for a stay of no more than 25 nights (Medicare.gov, 2017).

• Long-term care focuses on patient stays of longer than 25 days. Long-term care hospitals (LTCHs) are certified as acute-care facilities for those who need critical or intensive care. In addition, this category includes nursing homes, assisted living, and any other health care facility that becomes a home for individuals (Medicare.gov, 2017). In some cases, certified group home environments that provide special care for disabled persons are also considered long-term care facilities.

• Outpatient care and community providers include doctor’s offices, clinics, and other one-time visit facilities. There are no beds for any overnight stays. Community pro- viders and clinics handle most patient needs in the United States.

Financing and Reimbursement Insurance and/or public programs finance health care services that provide the client or patient coverage. The consumer can also privately purchase supplemental insurance to cover copays, deductibles, and other out-of-pocket expenses not covered by insurance. Major sources of financing and reimbursement for health care services are provided primarily by the government, out of pocket, and by private insurance. Table A.3 outlines of a few of these major funding sources.

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The U.S. health care system is financed through a complex private–public system. Health care consumes a large part of the gross domestic product (GDP) and is growing faster than the national income—which is a source of significant concern. The GDP is a measurement of the economic health of a nation. It consists of the monetary value of all goods and services pro- duced within a nation (Investopedia, 2018). Both the private and the public sectors are reel- ing under the increased costs of funding employee health benefits and retirement health ben- efits. States concerned with the increasing costs of Medicaid and other federal programs are changing guidelines to limit coverage. The private sector has sought to control bottom-line costs by limiting dependent coverage and by implementing larger copays and deductibles. Thus, both the public and private sectors are passing along the growing costs of health care to the beneficiaries.

The Debate Over Health Care Financing Several major viewpoints drive the health care financing debate, such as the role of per- sonal responsibility for health, social justice, utilitarian concepts, and economic and political theories.

• Philosophical: From a social justice perspective, the question is basic: Is health care a right or a privilege? Is it the responsibility of citizens to pay for the health services of others, even though they can afford to purchase health insurance, and even for individuals maintaining unhealthy lifestyle choices?

• Economic: Does health care enhance a utilitarian function such as “healthy” status, in which an individual is able to work and purchase economic goods? Or is it an economic incentive? This viewpoint can be observed in the historical economies in which merchant seamen were provided with health services to ensure the transport of trade goods.

• Political: More recently, the view has turned political, where funding can be a means of gaining favor with selected population groups or causes.

Table A.3: Major funding sources for health care services

Capitation A system whereby the funder reimburses the provider based upon a set cost for a population. Capitation is used in some grant-funded programs, in experimental projects such as Medicaid, in health care management organizations, and in grant funding with a designated population/sample. Capitation minimizes risk to the funder.

Managed care A program/service providing coordination, utilization, and cost containment for a group of designated clients or patients

Health care management organization An organization that manages a system of integrated health care for a designated group of clients or patients

Health care insurance An agreement or contract protecting the patient or client from a health care cost

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These are typical questions and dilemmas that arise in discussions of the entitlement pro- grams and the Affordable Care Act of 2010. The philosophical conflict about who should have insurance, who should pay for it, how much individuals should pay, and how much should be paid for by others is part of the conundrum of conflicting economic, political, and philo- sophical perspectives. The debate remains active today, and some believe it has moved the nation away from viewing health care as a charitable and humanitarian service for the sick and disabled toward one of varying personal agendas: gaining notoriety, improving a political position, or pushing for social justice.

Two Approaches to Financing Health Care Regardless of the ongoing debate, the financing of health care is still an issue and can be divided into two major approaches: a market-based approach and a government-driven approach.

In the market-based approach, private entities fund health care, and the government may cover designated vulnerable populations. In the market-based model, consumer demands fuel the second driver of increased health care costs, which is the health care industry itself. Innovative technologies, treatments, and pharmaceuticals supporting interventions that were not possible in previous times (such as heart transplants or knee replacement surgery) also feed this cycle.

Private enterprises have implemented various cost management strategies, including man- aged care, provider networks, and health care management services. These actions tend to decrease how often people use higher-cost services such as emergency department visits and hospitalization. Private financing insurance funding generally includes some deductibles, copays, and waiting periods to reduce costs to the insurance agency and to discourage unnec- essary use. Some individuals elect to pay out of pocket for health care services, and that puts them at risk for exorbitant health care expenses.

In the government-driven approach, or the public system approach, the government finances health care expenses through funds allocated by taxes. Examples of this are Medicaid, Medicare, military health care (Veterans Administration), and specific funding for targeted populations.

The private market-based model is quite flexible in providing health care services, especially innovations in the medical field. For example, individuals in the market-based model tend to have earlier and easier access to the newest diagnostic testing or surgical techniques. This often translates into earlier diagnoses and treatments for illnesses (Thorp, Howard, & Glac- tionnova, 2007). With the government model, it is difficult to control abuse or unnecessary use of the benefits, and there are fewer incentives for change and access to early diagnostic tests and emerging treatment innovations (Thorp et al., 2007).

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As the overall costs of health care spending have provoked a national debate, one question remains: How much will be spent on health care? Despite the cost, the Centers for Medicare and Medicaid Services (2012) noted that the major coverage expansions from the Affordable Care Act would result in 22 million fewer uninsured people, from the 46 million who were uninsured before the passage of the act. While more people did gain insurance from the ACA, it was also predicted that the 10 years that followed would see the fastest increases of most health-related expenditures, which include prescription drugs, out-of-pocket expenses, clini- cal services, and physician services. Hospital usage was also projected to increase over the next decade, but at a much slower rate than other services.

Dimensions of the U.S. Public Health System The National Academies of Sciences, Engineering, and Medicine (NASEM) (2017a) reported that if the United States is to achieve a higher level of quality of prevention and treatment ser- vices, then the fundamental concepts that have molded the system will need to be assessed, evaluated, and developed into reliable affordable health care services. Citing administrative waste, inadequate funding for public health, and failure to utilize public health in reforming U.S. health care, NASEM (2017b) sent a strong message to the secretary of the Department of Health and Human Services recognizing the enormity of the lack of emphasis on prevention and declaring that the system needed to be fundamentally assessed and reevaluated.

While health care costs will continue to expand, so will the role of the public health system within the realm of health services. The current public health model was shaped through the integrated patterns of population growth, global economics, wars, depressions, and sci- entific technology-fueled revolutionary growth in medical science, disease prevention, and intervention.

Continued growth in scientific knowledge about health and disease and the importance of health resulted in the merging of the U.S. Department of Health, Education, and Welfare (DEW) and the U.S. Public Health Service (PHS) into the Department of Health and Human Services (U.S. Department of Health and Human Services, 2017).

The United States Department of Health and Human Services is a large organization that provides monitoring, coordination, and health policy formation. (Refer to Chapter 1 for the organizational structure.) Within each region, state, county, and city, public health services directly implement the core public health functions: assessment, policy development, and assurance. Figure A.1 displays the location of the 10 U.S. regional health offices.

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Each state department of public health coordinates communication, funding, and policy among the state’s county and city public health organizations. The state and local public health departments touch many community agencies. They monitor food vendors, agricul- ture, waste disposal, recreational sites, lead exposure, immunizations, childcare and residen- tial facilities such as nursing homes, and licensing of nursing home administrators. Coordina- tion of policy and program activities is found at both the local and state levels.

State health departments’ activities are administrated by a public health official along with a medical officer. The same structure is applied to smaller populations at the local, county, or city public health organizations, generally termed boards of health. Duties of the state and local boards of health include implementing public health programs, monitoring and assessing health status, and coordinating fiduciary concerns, including funding allocations. The state and local boards funnel federal funds into state and local health programs. These programs include Title V Maternal and Child Health Services and administrative needs for implementing the Department of Agriculture’s Women, Infants, and Children (WIC) program. Also, size and characteristics of a population determine the extent of public health activities.

Figure A.1: The 10 regional health offices

Each regional office is responsible for assessment, policy development, and assurance for the states within its region.

Source: Adapted from “Regional Offices,” by U.S. Department of Health and Human Services, 2014 (https://www.hhs.gov/about/agencies /iea/regional-offices/index.html).

Boston

Regions

NYC

Chicago

Kansas City

Atlanta

Dallas

Denver

Seattle

San Francisco

5 9

https://www.hhs.gov/about/agencies/iea/regional-offices/index.html

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Section A.3 Funding the U.S. Health System

For example, some public health agencies may provide in-home health care services for aging adults and the disabled, while others may pass the funds through to a contracted agency. Finally, state and local boards of health are responsible for the implementation and evalua- tion of the Healthy People 2020 goals and action plans.

The Connection to Community Health With the Healthy People goals driving public health efforts nationwide, it is important to rec- ognize the connection to the community. Community health is part of the public health sys- tem when it comes to assessing, evaluating, and implementing activities that improve the health of a target population. It could be considered the smaller segment of public health in a specific community. As one example, public health would emphasize population well-being within the state of Nebraska, while community health efforts would focus on the population of Omaha—one community within the state. To break that down further, the city of Omaha could be segmented by municipalities, each one having its own community health focus.

Regardless of the size of the community, community health services monitor the health status/ characteristics of the people residing within specified geographical areas. Community health professionals perform their functions best—to assess, evaluate, and implement actions to improve the health of a specific population—in an environment fostering collaboration. They work with local agencies, professional organizations, and nongovernment organizations to implement and monitor the Healthy People 2020 goals and action plans (CDC, n.d.-c). The Healthy People initiative just began its third decade of providing goals and objectives focused on improving the nation’s health. It is a collaborative effort among the United States Depart- ment of Health and Human Services, the Centers for Disease Control and Prevention, and the National Center for Health Statistics (CDC, n.d.-c). Within the publication, the leading health indicators are stipulated under 42 focus areas and 1,200 objectives. Public health agencies, in collaboration with federal, state, and local organizations, develop strategies for realizing the Healthy People 2020 objectives and goals.

The provision of health care services requires strong collaboration among providers, ser- vices, institutions, and resources in an informal framework. The U.S. health care system is unlike any other in the world. The Department of Health and Human Services is the large agency in which the Public Health Service is embedded. Public health, in cooperation with the private health care system, has the responsibility of overseeing the health of the nation; however, accountability is grounded in the Public Health Service.

A.3 Funding the U.S. Health System The U.S. health care system is composed of a vast group of legislative funding streams and programs, the most recent being the Affordable Care Act (ACA) of 2010. To understand how the ACA is funded, it is important to first understand what it accomplishes.

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The Affordable Care Act Attempting to address cost, quality, and access concerns in the U.S. health care system, and taking inspiration from the successes of health care plans of other countries, the United States passed the Affordable Care Act of 2010. Also known as the Patient Protection and Afford- able Care Act, it combined the concepts of cost, quality, and access to health care for the Ameri- can people. This landmark legislation focused on providing health coverage for every citizen in the United States. It is not national health care—which provides free health care—but it is a step toward a national health care plan. This particular act brought in two very different perspectives that were not originally part of health insurance pro- grams in the past: Prevention services were now fully covered, and every individual was mandated to purchase some type of health insurance.

Under the Affordable Care Act, new guidelines for access to care, financial resources, and access to health care insurance were enhanced. Limits on cost sharing for covered benefits and new rules for private health insurance, health care exchanges, a decrease in reimbursement for health care providers, rationing, and review panels were some of the primary factors initiating the prominent Congressional discussions. These discussions included additional issues such as the extent to which the legislation would reduce the cost for low-income consumers, addressing the shortage of critical health provid- ers and reducing reimbursement of providers and the total cost of the legislation (Kaiser Family Foundation, 2012). A major argument in favor of the health care act was the access to preventive care with no additional costs.

The Affordable Care Act was passed with limited vetting by the legislators. The fiscal and eco- nomic case for the pending legislative agenda was based on the assumption that the continu- ing fiscal shortfall in the U.S. economy was due to excessive health care cost inflation—and that comprehensive health care reform would fix the fiscal issue. This continues to be a major subject of debate.

Prior to the ACA’s passage, critics suggested that the law would eventually betray the nation’s commitment to care for its vulnerable populations, meaning these individuals would not be able to receive the same standards of care as other consumers (Aaron, 2009).

The Affordable Care Act is a complex piece of legislation. The passage of this act has differing pros and cons, depending on the evaluator. The law has three main goals:

1. Make affordable health insurance available to more people 2. Expand the Medicaid program to cover all adults with income levels below 138% of

the federal poverty level 3. Support innovative medical care delivery methods designed to lower all health care

costs (Healthcare.gov, n.d.-a)

monkeybusinessimages/iStock/Thinkstock Prevention services, such as annual physicals, are now fully covered services under the Affordable Care Act of 2010.

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Section A.3 Funding the U.S. Health System

One of the benefits of the ACA for the public health realm was the addition of the Prevention and Public Health Fund, which was created by section 4002 of the ACA. It is the nation’s first mandatory funding stream dedicated to improving the nation’s public health. See Spotlight on Public Health Figures to learn about a prior attempt to pass a national health plan, during Franklin D. Roosevelt’s presidency.

Spotlight on Public Health Figures: Franklin D. Roosevelt (1882–1945)

Who is Franklin D. Roosevelt? Franklin Delano Roosevelt was born in 1882 in New York. He was the only child born into a wealthy family, so his upbringing was very different from that of most of the nation during that time. He attended Harvard University and later went to law school at Columbia University, passing the bar exam in 1907. He married his fifth cousin, Eleanor Roosevelt, and entered the political arena shortly afterward. He was the 32nd president of the United States, serving the country during one of the most difficult periods in American history. His passion for reform and improvements won over the hearts of the nation. He was diagnosed with polio, for which there was no cure or vaccine. He died in 1945 of a cerebral hemorrhage, just before World War II ended.

What was the political climate at the time? Roosevelt’s tenure in office occurred during what many historians consider one of the most difficult periods in American history. Roosevelt served as president during the Great Depression, built a new nation through his New Deal program, and saw the nation through World War II. His leadership, including his reforms and public programs, helped shape the nation into a stronger world power.

What was his contribution to public health? While the New Deal was a significant contribution to the nation’s overall well-being, Roosevelt’s main contribution to public health was the development of a national health care plan. Roosevelt proposed within the Social Security Bill of 1935 his first draft of a national health insurance plan. Due to significant opposition, especially from the American Medical Association, the health insurance plan was left out of the bill. The second and last attempt at national health care in the United States occurred only 4 years later. The Wagner Bill included the National Health Act of 1939. Sen. Robert Wagner introduced the bill, which granted states the right to establish compulsory health insurance. Roosevelt was in full

Circa Images/Glasshouse Images/SuperStock President Franklin D. Roosevelt developed a national health care plan as part of the Social Security Bill of 1935, but strong opposition from the medical community forced him to remove it from the bill.

(continued)

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Section A.3 Funding the U.S. Health System

Other System Funders Other significant players in the health care arena include a blend of private pay and employer- based insurance companies, Medicare, Medicaid, specific entitlements (such as Title V, WIC, SHIP, and CHIP), state/county and local government expenditures, and grants. An entitlement refers to rights to services for certain populations or groups. In the case of Medicare, people age 65 and older are entitled to receive those funds. This differs from a benefit, which is not automatically awarded to someone because of membership in a population. For example, even if a person is age 65, the individual is not entitled to additional health care benefits through a private insurer. Purchasing additional health care is a benefit provided through the purchase agreement or through an employer if the individual is still working. There are also programs funded directly through public health and other government agencies.

Medicare A federal health insurance program for people age 65 and older, Medicare has been in exis- tence since 1965. It also provides health insurance for some younger people with disabilities and those with permanent kidney failure. It contains four parts: A, B, C, and D.

Spotlight on Public Health Figures: Franklin D. Roosevelt (1882–1945) (continued)

support of such legislation, which would have been funded by federal grants given to the states for the establishment of health insurance programs. Strong opposition from the American Medical Association again forced the bill to die in committee. Although Roosevelt’s efforts seemed to die with him, President Barack Obama’s administration passed the Affordable Care Act in 2010—an act that gave the nation exactly what Roosevelt had envisioned in 1935.

What motivated him? Roosevelt was a peacemaker who believed that nations should be able to cohabitate without fighting. He devoted a significant amount of his time to planning the United Nations, a coalition that he thought would help build international relationships and create a safer and peaceful world. That belief in a more peaceful world, along with his own failing health due to polio, motivated him to seek better health outcomes for the people of the United States.

Sources: Biography.com. (2018b). Franklin D. Roosevelt biography. Retrieved from https://www.biography.com/people/franklin-d -roosevelt-9463381 Freidel, F., & Sidey, H. (2006). Franklin D. Roosevelt. Retrieved from https://www.whitehouse.gov/about-the-white-house/presidents /franklin-d-roosevelt/ Physicians for a National Health Program. (2016). A brief history: Universal health care efforts in the US. Retrieved from http://www .pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-the-us Rorabaugh, A. (n.d.). Wagner bills: Wagner National Health Act of 1939. The American Government’s Responsibility in Health Care: The Chronic Debate. Retrieved from http://76478895.weebly.com/wagner-bills.html

https://www.biography.com/people/franklin-d-roosevelt-9463381

https://www.whitehouse.gov/about-the-white-house/presidents/franklin-d-roosevelt/

http://www.pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-the-us

http://76478895.weebly.com/wagner-bills.html

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• Medicare Part A covers hospitalizations, nursing home care, hospice, and some home health care services.

• Medicare Part B is the medical insurance section, which covers prevention services, screenings, doctor visits, and medical supplies such as insulin for diabetes.

• Medicare Part C is an advantage plan, which consists of Medicare parts A and B together under one policy. This plan is mainly offered through private companies under Medicare contracts and may include health maintenance organizations (HMOs), preferred provider organizations (PPOs), private fee-for-service plans, special needs plans, and savings account plans. In addition, most Part C plans cover prescriptions.

• Medicare Part D is more commonly referred to as the Prescription Drug Plan. It cov- ers medications that might be prescribed by physicians, hospitals, or other health care providers (Centers for Medicare and Medicaid Services, n.d.).

Medicaid Medicaid is a state-run operation that provides health care coverage for low-income people of any age. Eligibility varies from state to state, but most offer coverage for a base income rate near the poverty level. Beginning in 2014, all people under age 65 with incomes up to $15,000 per year became eligible for Medicaid. Those age 65 and over qualify for Medicare (Healthcare.gov, n.d.-b).

Title V Title V is a portion of the Maternal and Child Health (MCH) Services Block Grant, which pro- vides services for mothers and their children. Title V was created in 1935 as part of the Social Security Act and provides programs for mothers, infants, and children, including those with congenital disabilities. Today, Title V is the only federal program that focuses solely on the health of mothers and children. It makes a special effort to help communities deliver various services such as care coordination, transportation, home visits, and nutrition counseling. It provides prenatal services for more than 2 million women and primary prevention services to more than 17 million children, 1 million of whom have special needs. Title V receives nearly 85% of the MCH funding, which is allocated to the states. From there, the states distribute the funds to the various local and county programs (Health Resource and Services Administra- tion, n.d.).

WIC WIC (Women, Infants, and Children) is a supplemental food and nutrition program that serves low-income pregnant, postpartum, and breastfeeding women, as well as infants and children up through age 5. The program is offered in all 50 states, along with 34 Indian tribal organi- zations; Samoa; Washington, DC; Guam; the Northern Mariana Islands; Puerto Rico; and the Virgin Islands. Operating under the auspices of the United States Department of Agriculture, the program provides foods and nutritional counseling to those who are eligible (U.S. Depart- ment of Agriculture, n.d.).

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Section A.4 Responsibility and Accountability of the U.S. Public Health System

SHIP The State Health Insurance Assistance Program (SHIP) is a national counseling and assis- tance program that provides educational services to those with Medicare. Every state has a SHIP, which offers assistance via telephone or in person. Elements included in this counseling are the provision of educational materials and offers of referrals for services (Administration for Community Living, 2017).

CHIP All 50 states operate a Children’s Health Insurance Program (CHIP), which is a public offer- ing of free or low-cost health insurance for those under age 18 (Healthcare.gov, n.d.-c). This coverage pays for pediatrician visits, medications, hospitalizations, and other needed health care. The program is similar to Medicaid but is jointly funded by both federal and state gov- ernments. In 2009, Congress passed the Children’s Health Insurance Program Reauthoriza- tion Act (CHIPRA), which provided additional funds for CHIP, some of which were to be used for a new program to reach eligible children who were not enrolled.

A.4 Responsibility and Accountability of the U.S. Public Health System

The United States Public Health Service is a large department of the United States Department of Health and Human Services. It has far-reaching responsibilities. This vast array of respon- sibilities and accountabilities is communicated downward through the state and county or city levels of public health. These functional entities include approximately 3,000 county and city health departments and local boards of health; 59 state, territorial, and island nation health departments; more than 160,000 public and private laboratories, hospitals, and other private-sector health care providers; and volunteer organizations such as the American Red Cross and American Diabetes Association (Lister, 2005).

These social services offer vulnerable populations of low-income individuals, mothers and children, the mentally ill, patients with addiction problems, and patients lacking access to health care a wrap- around public health safety net. However, there are some populations that fall through the system, such as the working poor. Public health officials at the local, state, and federal levels continue to work to address these system holes. Regardless, public health entities at all levels collaborate to ensure the quality of the health care services throughout the nation. Furthermore, public health’s three core functions (policy development, assessment, and assurance) can truly be found within all commu- nity and governmental entities in order to provide much-needed services to all, but especially these vulnerable populations.

John Rowley/Photodisc/Thinkstock Public health entities can help ensure that health services are accessible for vulnerable populations, such as low- income persons, women, children, and the disabled.

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Section A.4 Responsibility and Accountability of the U.S. Public Health System

Seven Key Agencies and Their Responsibilities Seven primary agencies deliver public health services. Given this broad array of responsibil- ity, the United States Department of Public Health’s overall charge was set forth in a landmark study by the Institute of Medicine (1988), which named the core functions of the national public health service: assessment, policy development, and service assurance. These three core functions have been used to organize and adapt the department to meet the challenges of emerging threats and environmental hazards, allocation of resources, and service provi- sion to meet the population’s needs. Table A.4 outlines the responsibilities and accountabili- ties of these seven agencies. More details on each agency can be found in Chapter 1.

Table A.4: U.S. public health system organizational chart

Agency Primary services Extended services

National Institutes of Health (NIH)

Medical research Includes 27 separate health institutes and centers

Food and Drug Administration (FDA)

Ensures safety of food and cosmetics and safety and efficacy of pharmaceuticals, biological products, and medical devices

Products represent 24 cents out of every U.S. consumer dollar spent

Centers for Disease Control and Prevention (CDC)

Health surveillance; monitors and prevents disease outbreaks; implements disease prevention strategies and maintains national health statistics; immunization services, workplace safety and environmental disease prevention; includes the Agency for Toxic Substances and Disease Registry

Maintains personnel in more than 25 foreign countries, guarding against international disease transmission; prevents exposure to hazardous substances from waste sites on the EPA’s national priorities list

Indian Health Service (IHS)

Works to provide health services 46 hospitals, 324 health centers, 309 health stations, and 34 urban Indian health programs

Health Resources and Services Administration (HRSA)

Provides access to essential health care services for low-income people, the uninsured, or those who live in rural areas or urban areas where health care is scarce; maintains the National Health Service Corps

Provided medical care to nearly 17 million patients and more than 4,000 sites nationwide in fiscal year 2009; helps to build the health care workforce, administers programs to improve the health of mothers and children (Title V, WIC Program), serves people living with HIV/AIDS through the Ryan White CARE Act, and oversees the nation’s organ transplantation system

Substance Abuse and Mental Health Services Administration (SAMHSA)

Ensures quality and availability of education, prevention, and treatment for addiction services and mental health services

Monitors prevalence and incidence of substance abuse and provides funding through block grants to states to support substance abuse and mental health services

Agency for Health Care Research and Quality (AHRQ)

Supports research on health care systems and quality, cost, access, and effectiveness of medical treatments

Provides evidence-based information on health care outcomes and quality of care

Source: From “HHS Agencies and Offices,” by U.S. Department of Health and Human Services, 2015 (https://www.hhs.gov/about /agencies/hhs-agencies-and-offices/index.html).

https://www.hhs.gov/about/agencies/hhs-agencies-and-offices/index.html

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Section A.4 Responsibility and Accountability of the U.S. Public Health System

Ethics and Legal Implications of the U.S. Public Health System Ethics in government operations, including lawmaking, are overseen by the Office of Gov- ernment Ethics (OGE), which was established by the Ethics in Government Act of 1978. It provides direction, oversight, and accountability of executive branch policies (U.S. Office of Government Ethics, n.d.).

According to the Office of Government Ethics (n.d.), the OGE is responsible for six key elements:

1. Maintaining enforceable standards of ethical conduct 2. Overseeing a financial disclosure system 3. Ensuring that executive branch ethics programs are in compliance with laws and

regulations 4. Providing education and training to the more than 5,700 ethics officials, as well as

executive branch employees 5. Conducting outreach to the general public 6. Sharing good practices with, and providing technical assistance to, state, local, and

foreign governments and international organizations

The OGE has no jurisdiction within state or local governments, nor does it conduct investiga- tions of individuals. It is meant solely for the executive branch of government.

Ethics are applied and enforced through the laws that have had an impact on the nation’s health. Table A.5 is a brief synopsis of health care laws that have undergone significant ethical considerations prior to approval.

Table A.5: Laws with strong ties to ethical concerns Law/act Explanation

General public policies These are principles that state laws should not be made to injure the public or go against the public good.

Sherman Trust Act of 1890 Conspiracy to restrain trade among certain states is illegal, including such health issues as market competition, price fixing, and preferred provider agreements. In other words, it limits the creation of monopolies.

Civil Rights Act of 1964 All individuals, regardless of race, color, or national origin, living in the United States will have equal rights, including admission to a medical facility for treatment.

Privacy Act of 1974 All individual privacies are protected from the misuse of federal records, which includes those under Medicare, Medicaid, and other government health care services.

Emergency Medical Treatment and Active Labor Act of 1986

Any individual seeking medical treatment in the event of an emergency will receive it regardless of the ability to pay or means of payment.

Ethics in Patient Referrals Act of 1989

Doctors are prohibited from requiring the use of specific laboratories for testing based upon a prior financial arrangement.

Patient Self-Determination Act of 1990

Patients should be informed of their rights before receiving care. This law extends to end-of-life decisions as well as routine examinations.

Health Insurance Portability and Accountability Act of 1996

The privacy of all medical health records in all forms (electronic, paper, verbal) should be maintained.

Sarbanes–Oxley Act of 2002 Top executives from public corporations must account for the corporation’s financial statements. It was passed as a result of the Enron scandal.

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Section A.5 Issues and Trends in the U.S. Health Care System

A.5 Issues and Trends in the U.S. Health Care System The U.S. health care system is in a state of escalating costs and access issues. The same inge- nuity, creative forces, and political dynamics that set the foundation for the emergence of the modern health care system after World War II also produced today’s struggling health care system. Changes in population dynamics and personal responsibility will continue to present a challenge.

Social Changes and Personal Responsibility Social changes affect how the people of a nation view health. The World Health Organization has defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Grad, 2002, p. 984). With Americans participat- ing in fewer physical activities, the nation has become overweight and obese—issues that have been linked to chronic diseases such as heart disease, diabetes, and stroke. As a whole, the people of this nation do not believe that their poor habits (sedentary lifestyle and over- eating) are unhealthy. This has become a new culture that will likely strain the health care system if the trend isn’t reversed. Unless each individual takes responsibility for his or her own health, chronic diseases will become the norm, draining the resources of the existing health care system.

Organizational Issues Considering that some health researchers believe that the health care system is fragmented, duplicated, and lacking in the coordination of services, it likely will not be able to handle the potential increase in health needs (Bipartisan Policy Center, 2012). Others complain that the system is rife with administrative cost, waste, and fraud, which could become another con- cern in the future (Bipartisan Policy Center, 2012). To combat this, public health professionals are focusing their attention on prevention to reverse the trend of rising chronic diseases so that the health care system won’t have to suffer.

Quality and Access Questions While some believe the health care system lacks quality, others ask, in response, why people from other nations come to the United States for health care services. The issue cited is that other nations’ health care systems provide mediocre care because of their lower costs. However, that may not mean the care is poor. The definition of “quality” is dependent in some part on the perceptions of the consumer. While it has its flaws, the U.S. health care system is still an innovative one, providing services for a large multicultural population. While some argue that the number of uninsured remains a major issue in the United States, there is a safety net within the public

monkeybusinessimages/iStock/Thinkstock Cost, quality, and access issues contribute to the U.S. health care system’s constant changes. Developing collaboration between the public and private domains could help improve care efficiency and access.

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Section A.5 Issues and Trends in the U.S. Health Care System

health system to provide for various groups, including women and children, the elderly, low- income citizens, and the disabled. The U.S. public health system, through encompassing ser- vice outreach programs, targets at-risk populations in an approach that is not significantly different from that of socialized medical systems. With a private–public partnership such as the one that now exists, the United States’ model does not differ significantly in opera- tional aspects from other national models. The differentiating factor is the emphasis on the employer-sponsored health care function.

The U.S. health care system is in constant flux, partly predicated on the cost, quality, and access issues and the implementation of the Affordable Care Act. From a health care system perspective (private and public), major challenges appear to reside in supply and demand in caring for vulnerable populations, such as the uninsured, the poor, the chronically diseased, the aging, and the mentally ill. The problem involves high demand with limited supply (i.e., availability) of health care workers. Perhaps, the answer could lie in developing a collabora- tion of health care services between both public and private domains to provide seamless and easy access to health care services.

Controlling Costs In its report What Is Driving U.S. Health Care Spending?, the Bipartisan Policy Center (2012) reported four factors driving the growth in health care costs:

1. Prices 2. Population 3. Use 4. Intensity

The key areas that will drive spending further are the following:

• fee-for-service reimbursement • fragmentation in care delivery • administrative burden on providers, payers, and patients • populations aging, rising rates of chronic disease and comorbidities, as well as life-

style factors and personal health choices • advances in medical technology • tax treatment of health insurance • insurance benefit design • lack of transparency about cost and quality, compounded by limited data, to inform

consumer choice • cultural biases that influence care utilization • changing trends in health care market consolidation and competition for providers

and insurers • high unit prices of medical services • the health care legal and regulatory environment, including current medical mal-

practice and fraud and abuse laws • structure and supply of the health professional workforce, including scope of prac-

tice restrictions, trends in clinical specialization, and patient access to providers (Bipartisan Policy Center, 2012, pp. 6–7)

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Summary & Resources

A review of the current health care spending levels suggests that spending would reach nearly $5 trillion, or 20% of the gross domestic product (GDP) by 2021 (Ginsburg et al., 2012). It is critical for policymakers to take heed of what is happening and focus on mitigating this situ- ation before it becomes far too expensive to live in the United States.

Frankly, there is no single entity driving up costs. In addition to the aforementioned list, tech- nology will also contribute to health care cost increases, including the following factors:

1. Mobile health smartphones, tablets, computers, and phone applications 2. Comparative effectiveness research 3. Personal medical records 4. Telemedicine 5. Enhanced medical technology providers

Besides these ever-increasing costs, many politicians are currently seeking to repeal the ACA. A repeal of such a large piece of legislation is a difficult task; however, if the political climate is ripe for such actions, it is possible. That would undo much of the success the nation has experienced in expanding access to health care through lower-cost insurance and eliminate the public health fund.

Summary & Resources

Chapter Summary A health care system did not exist for many years in the United States, but it eventually became a nation of health insurance holders—most of whom received such insurance through their place of employment. The current public health system was shaped through the integrated patterns of population growth, global economics, wars, depressions, and scientific technology- fueled revolutionary growth in medicine, disease prevention, and interventions. There are different models of health care throughout the world, including Bismarck (premium funded and mandated), Beveridge (universal health coverage), and national insurance (public and privately funded).

There are several key funding areas for the nation’s people—especially those who do not have employer-sponsored health insurance plans. This includes the expansions made through the ACA as well as Medicaid and Medicare. Title V, WIC, SHIP, and CHIP also provide a vast array of health services to vulnerable populations such as children and senior citizens.

The overarching body that handles public health aspects is the U.S. Department of Health and Human Services. While the structure of public health was outlined in depth in Chapter 1, this appendix focused on seven key organizations that interact with the health care system for both access to care and prevention services. Within the system is an important set of ethical and legal responsibilities, all of which are managed and coordinated under the Office of Gov- ernment Ethics.

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Summary & Resources

The largest national concern currently on the table is the potential repeal of the Affordable Care Act. While the ACA is not a perfect piece of legislation, it certainly has brought some relief to people who did not have access to health care prior to its passage. Repealing may undo such successes. The political climate often guides decisions on legislation, which means that as the political parties come and go from leadership, so will threats to and benefits for the public health system.

Additional Resources

Henry Kaiser Family Foundation

http://www.kff.org/medicare/medicare-timeline2.cfm http://www.kff.org/medicaid/ Visit the first site to watch the Medicare video for additional information about the history and goals of Medicare. Visit the second site to learn more about Medicaid.

The Affordable Care Act

https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf The Affordable Care Act is an official public law. The certified full-text version of the law can be found here.

United States Department of Labor, Bureau of Labor Statistics

http://www.bls.gov/ooh/health care/ Visit this site for additional information about the different occupations in the field of health care.

http://www.kff.org/medicare/medicare-timeline2.cfm

http://www.kff.org/medicaid/

https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

http://www.bls.gov/ooh/health care/