Discussion and Assignment due in 36 hours
combs
ResourcesForWeek3.docxThe following resources have been provided to help you learn more about important concepts covered this week. Look for ways to apply these resources to this week’s activities and assignments. Ensure you:
· Read “ Price Transparency Needed From All Stakeholders, HFMA Task Force Says ” from Modern Healthcare.
CHAPTER 3 Current Operations of the Healthcare System
|
LEARNING OBJECTIVES |
|
The student will be able to: ■ Identify the stakeholders of the U.S. healthcare system and their relationships with each other. ■ Discuss the importance of healthcare statistics. ■ Compare the United States to five other countries using different health statistics. ■ List at least five current statistics regarding the U.S. healthcare system. ■ Discuss complementary and alternative medicine and its role in health care. ■ Define OECD and its importance to international health care. |
|
DID YOU KNOW THAT? |
|
■ According to the Bureau of Labor Statistics, the projection for job growth in the healthcare industry over a 10-year period is 9.8 million jobs by 2024. ■ Most healthcare workers have jobs that do not require a four-year college degree but health diagnostic and treatment providers are the most educated workers in the United States. ■ Healthcare employment is found predominantly in large states such as California, New York, Texas, and Florida. ■ Approximately 40% of U.S. adults use some form of nontraditional medicine. ■ The healthcare industry and social assistance industry reported more work-related injuries than any other private industry. ■ Life expectancy and infant mortality rates are an indication of the health of a population. |
▶ Introduction
The one commonality with all of the world’s healthcare systems is that they all have consumers or users of their systems. Systems were developed to provide a service to their citizens. However, the U.S. healthcare system, unlike other systems in the world, does not provide healthcare access to all of its citizens. It is a very complex system that is comprised of many public and private components. Healthcare expenditures comprise approximately 17.5% of the gross domestic product (GDP) . Health care is very expensive and most citizens do not have the money to pay for health care themselves. Individuals rely on health insurance to pay a large portion of their healthcare costs. Health insurance is predominantly offered by employers. The uninsured rate remains at an all-time low with 9.1% of under 65 uninsured as of the end of 2015 according to CDC.Gov data. Generally, 2016 saw a rough increase of all the 2015 numbers. (Obamacare enrollment, 2016). The government believes this is the result of the universal mandate for individual health insurance coverage.
In the United States, in order to provide healthcare services, there are several stakeholders or interested entities that participate in the industry. There are providers, of course, that consist of trained professionals such as physicians, nurses, dentists, and chiropractors. There are also inpatient and outpatient facilities; the payers such as the insurance companies, the government, and self-pay individuals; and the suppliers of products, such as pharmaceutical companies, medical equipment companies, and research and educational facilities (Sultz & Young, 2006). Each component plays an integral role in the healthcare industry. These different components further emphasize the complexity of the U.S. system. The current operations of the delivery system and utilization statistics will be discussed in depth in this chapter. An international comparison of the U.S. healthcare system and select country systems will also be discussed in this chapter, which provides another aspect of analyzing the U.S. healthcare system.
▶ Overview of the Current System Update
It is projected that between 2014 and 2024, nearly 10 million jobs will be added in the U.S. healthcare industry (Bureau of Labor Statistics [BLS], 2016a). The United States spends the highest proportion of GDP on healthcare expenditures of any country. The system is a combination of private and public resources. Since World War II, the United States has had a private fee-for-service system that has produced generous incomes for physicians and has been profitable for many participants in the healthcare industry (Jonas, 2003). The healthcare industry operates like traditional business industries. Organizations designated as for profit need to make money in order to operate. The main goal of entities that are designated nonprofit is based on a particular social goal, but they also have to make money in order to continue their operations.
There are several major stakeholders that participate or have an interest in the industry. The stakeholders identified as participants in the healthcare industry include consumers, employers, healthcare and non-healthcare employers, healthcare providers, healthcare facilities, governments (federal, state, and local), insurance companies, educational and training institutions, professional associations that represent the different stakeholders, pharmaceutical companies, and research institutions. It is also important to mention the increasing prominence of alternative therapy medicine. Each role will be discussed briefly.
▶ Major Stakeholders in the Healthcare Industry
Consumers
The main group of consumers is patients who need healthcare services from a physician, a hospital, or an outpatient facility. From an organizational perspective, the consumer is the most important stakeholder for an organization. The healthcare industry operates like a business. If a consumer has the means to pay out of pocket, from governmental sources, or from health insurance, the services will be provided. If an individual does not have the means to pay from any of these sources of funding, a service may not be provided. There is a principle of the U.S. healthcare system, duty to treat , which means that any person deserves basic care (Pointer et al., 2007). In some instances, healthcare providers will give care to someone who has no funding source and designate the care provided as a charitable care or bad debt , which means either the provider does not expect payment after the person’s inability to pay has been determined or the efforts to secure the payment have failed (Smith, 2008). Businesses also take the same action. Many of them provide a community service or donate funds to a charitable cause, yet both traditional businesses and healthcare organizations need to charge for their services in order to continue their operations.
FIGURE 3-1 Healthcare Industry Stakeholders
There are also other consumer relationships in the healthcare industry. Consumers purchase drugs either from their provider or over the counter from pharmacies. The pharmaceutical companies market their products to physicians who in turn prescribe their products to their patients. The pharmaceutical companies also market their products to hospitals and outpatient facilities to encourage the use of their drugs in these facilities. Medical equipment companies also sell their products to facilities and individual providers.
Employers
Employers consist of both private and public employers. The healthcare industry is the largest U.S. employer. According to the Bureau of Labor Statistics (BLS) , there are several segments of the healthcare industry, including ambulatory healthcare services, hospitals, and nursing and residential care facilities . Ambulatory healthcare services are comprised of physicians, dentists, other health practitioners, outpatient care centers, medical and diagnostic laboratories, home healthcare services, and other ambulatory care. The hospital segment provides inpatient services primarily with outpatient as a secondary source. It provides general and surgical care, psychiatric substance-abuse hospitals, and other specialty hospitals. Residential care facilities include nursing care, mental health, substance abuse and mental disabilities, community care for the elderly, and other residential care facilities (BLS, 2016b). Healthcare employment opportunities can be more easily found in large states such as California, New York, Texas, and Florida (BLS, 2016c). Employers outside the healthcare industry are also stakeholders because they provide a large percentage of health insurance coverage to individuals nationwide.
Hospitals
There are approximately 11,000 hospitals in the United States. Hospitals provide total medical care that ranges from diagnostic services to surgery and continuous nursing care. They traditionally provide inpatient care, although more hospital systems are also providing outpatient care. Some hospitals specialize in treatments for cancer, children’s health, or mental health. It is important to note that hospitals are an integral component of the healthcare system. Many uninsured and underinsured individuals present themselves at emergency departments (EDs) across the country and use EDs as their primary care provider. In 2013, more than 136 million individuals presented themselves to the ED as their entry into health care. During times of public health crises, hospitals are the backbone of providing care. In 2015, hospitals provided $46.4 billion in uncompensated care, an increase of $7.1 billion from 2010 (American Hospital Association, 2016).
Nursing and Residential Care Facilities
These types of facilities provide nursing, rehabilitation, and health-related personal care to people who need ongoing care. There are 76,000 facilities nationwide. Nursing aides provide the majority of care. Residential care facilities provide around-the-clock social and personal care to the elderly, children, and others who cannot take care of themselves. Examples of residential care facilities are drug rehabilitation centers, group homes, and assisted-living facilities (BLS, 2016d).
Physicians and Other Healthcare Practitioners
In 2014, there were nearly 700,000 U.S. physicians and surgeons. In the past, physicians traditionally practiced solo, but more often physicians are practicing in a group practice to reduce administrative costs. In 2014, there were 151,000 dentists. The job outlook for both physicians and dentists is very positive due to the aging of the U.S. population. Other healthcare practitioners include chiropractors, optometrists, psychologists, therapists, and alternative medicine practitioners (BLS, 2016e).
Alternative health or complementary and alternative medicine (CAM) practitioners, who practice unconventional health therapies such as yoga, vitamin therapy, and spiritual healing, are being sought out by consumers, who have to pay out of pocket for these services because they are currently not covered by health insurance companies. However, chiropractors and acupuncturists who are also considered alternative medicine practitioners are more likely to be covered by health insurance companies. Recognizing consumer interest in this type of medicine, in 1998, the National Center for Complementary and Alternative Medicine (NCCAM) was established within the National Institutes of Health. Its purpose is to explore these types of practices in the context of rigorous science, train complementary and alternative researchers, and disseminate information. More medical schools are now offering some courses in alternative medicine.
According to the NCHS, an estimated 59 million persons aged 4 years and over had at least one expenditure for some type of complementary health approach, resulting in total out-of-pocket expenditures of $30.2 billion. More was spent on visits to complementary practitioners ($14.7 billion) than for purchases of natural product supplements ($12.8 billion) or self-care approaches ($2.7 billion) (National Center for Health Statistics, 2016).
Home Healthcare Services
Home healthcare services , which offer medical care in the home, are provided primarily to elderly, chronically ill, or mentally impaired individuals. Mobile medical technology allows for more home health care for medical problems. Home health care is one of the fastest growing components of the industry as a form of employment because of consumer preference and the cost effectiveness of home medical care (BLS, 2016f).
Outpatient Care Centers and Ambulatory Healthcare Services
Outpatient care centers include kidney dialysis centers, mental health and substance abuse clinics, and surgical and emergency centers. Ambulatory healthcare services include transport services, blood and organ banks, and smoking cessation programs (BLS, 2016g).
Laboratories
Medical and diagnostic laboratories provide support services to the medical profession. Workers may draw blood, take scans or X-rays, or perform other medical tests. This segment provides the fewest number of jobs in the industry (BLS, 2016h).
Government
As a result of the Medicare and Medicaid programs, the federal and state governments are the largest stakeholders in the U.S. healthcare system. The government at both levels is responsible for financing health care through these programs as well as playing the public provider role through state and local health departments. U.S. Department of Veterans Affairs medical facilities also provide services to those in the armed forces (Sultz & Young, 2006).
Insurance Companies
The insurance industry is also a major stakeholder in the healthcare industry. It is often blamed for the problems with the healthcare system because of the millions of underinsured and uninsured individuals. There have been many news reports highlighting the number of medical procedures that have been disproved for insurance coverage, the cost of health insurance coverage, etc. There are traditional indemnity plans such as Blue Cross and Blue Shield , but managed care, which is also considered an insurance plan, has become more popular for cost control. The Affordable Care Act has placed restrictions on what health insurance companies can do regarding reimbursement restrictions.
Educational and Training Organizations
Educational and training facilities such as medical schools, nursing schools, public health schools, and allied health programs play an important role in the U.S. healthcare industry because they are responsible for the education and training of healthcare employees. These institutions help formulate behaviors of the healthcare workforce.
Research Organizations
Governmental research organizations such as the National Institutes of Health (NIH) and the CDC not only provide regulatory guidance but also perform research activities to improve health care. However, there are also private research organizations, such as the Robert Wood Johnson Foundation , the Pew Charitable Trusts , and the Commonwealth Fund , that support research efforts through grants.
Professional Associations
Professional associations play an important role in healthcare policy. There are associations that represent physicians, nurses, hospitals, long-term care facilities, and so on. Most healthcare stakeholders are represented by a professional organization that guides them regarding their role in the healthcare industry. They also play a large role in governmental regulations because they often lobby at all governmental levels to protect their constituents. The following are examples of professional associations that represent some of the major stakeholder organizations in this industry.
■ American Hospital Association (AHA) : The AHA is the most prominent association for all types of hospitals and healthcare networks. Founded in 1898, the AHA, which is a membership organization, provides education and lobbies for hospital representation in the political process at all governmental levels (AHA, 2016).
■ American Health Care Association (AHCA) : Founded in 1949, the AHCA is a membership organization that represents nonprofit and for-profit nursing and assisted-living facilities, subacute-care providers, and facilities for developmentally disabled individuals. Their focus is to monitor and improve standards of nursing home facilities (AHCA, 2016).
■ American Association of Homes and Services for the Aging (AAHSA) : The AAHSA, which is a membership organization, represents nonprofit adult day care services, home healthcare services, community services, senior housing, assisted-living facilities, continuing-care retirement communities, and nursing homes. It lobbies at all governmental levels regarding legislation that can impact the industry and provides technical assistance for these organizations (AAHSA, 2016).
Pharmaceutical Companies
A functioning healthcare system needs medications that are prescribed by a provider or purchased as an over-the-counter medicine from a pharmacy. The pharmaceutical industry is integral to the success of a healthcare system. Innovative drugs have improved people’s quality of life. There has been an internal division within the pharmaceutical industry between the manufacturing of brand name drugs and generic or “me too” drugs. A generic drug , which does not have name recognition, is a less costly alternative to a brand name drug. The generic drug manufacturer must provide the same active ingredients as the brand name drugs; however, the manufacturing process is less costly to makers of generic drugs because they do not have to file for a patent. A generic drug has no patent protection and is sold at discounted prices (Zhong, 2012).
Brand name drugs such as Lipitor and Viagra are typically more expensive than generic drugs because such drugs might cost a pharmaceutical company more than $1 billion and take several years to develop. The Food and Drug Administration, which is responsible for approving drugs for human use, has traditionally upheld a very strict and lengthy approval process. However, recently, the FDA is removing red tape and speeding up the process for drugs that can help serious diseases. When a patent is awarded, a pharmaceutical company typically has 20 years’ patent protection to develop a drug. However, because of the length of time it takes to determine the safety and effectiveness of a drug, once the drug is available for the public, the patent may be reduced several years (Mandal, 2014). Once that patent protection has ended, there are more opportunities for generic drug companies to control the market (Herper, 2013).
Like health insurance companies, the pharmaceutical industry is often vilified because of the cost of some prescribed medicines, which often precludes any consumers from purchasing these medications themselves without health insurance assistance. The industry’s response is that it takes millions of dollars and years of research to develop an effective medicine and that is a major reason why some medicines cost so much. The pharmaceutical industry is represented by the Pharmaceutical Research and Manufacturers of America (PhRMA) (PhRMA, 2016).
▶ Stakeholders’ Environment
Working Conditions
Healthcare workers have many varied opportunities for workplace settings. Hospitals are a typical work environment, as are physician offices. As outpatient services have become more popular, healthcare professionals can work from their homes. Healthcare professionals can work in outpatient facilities, schools, laboratories, corporations, and other unconventional settings. They are exposed to serious health hazards, including contaminated blood, chemicals, drugs, and X-ray hazards. Depending on the job, there may be ergonomic issues due to lifting of patients and heavy equipment. This industry has one of the highest injury and illness rates. U.S. hospitals recorded nearly 58,000 work-related injuries and illnesses in 2013, amounting to 6.4 work-related injuries and illnesses for every 100 full-time employees: almost twice as high as the overall rate for private industry. In 2013, healthcare personnel reported seven times the national rate of musculoskeletal disorders compared with all other private sector workers. Nurse assistants and nurses have the highest injury rates of all occupations (OSHA, 2015).
Projected Outlook for Employment
The healthcare industry’s employment outlook is positive. By 2024, there is a projection of an additional 22 million jobs. Growth will most likely be outside the inpatient hospital centers because cost containment is the major priority for health care. Health care will continue to grow for three major reasons: the aging of the U.S. population, advances in medical technology, and the increased focus on outpatient care.
▶ Healthcare Statistics
U.S. Healthcare Utilization Statistics
The National Center for Health Statistics (NCHS) , which is part of the CDC, produces an annual reports on the health status of the United States. This publication, Health, United States, provides an overview of current data on healthcare utilization, resources, and expenditures. This publication examines all different aspects of the U.S. healthcare delivery system as well as assessing the health status of U.S. citizens. The following information is summarized from the 2015 publication.
U.S. Demographics and Healthcare
Life expectancy rates are an indication of the health of a designated population. Between 2004 and 2014, life expectancy at birth increased for females (1.1 years) to 81.4 years, white males (1.4 years) to 76.7 years, black females (2.3 years) to 78.4 years, and black males (3.1 years) to 72.5 years. Racial disparities exist in life expectancy at birth rates although they have narrowed. In 2014, the rate of white male life expectancy at birth was 4.2 years longer than that for black males, and the rate for white females was 3.0 years longer than that for black females. In 2014, Hispanic males (79.2 years) and females (84 years) had longer life expectancy rates than non-Hispanic white or non-Hispanic black males and females (CDC, 2016a).
Health Care Payers
Statistics from 2014 indicate that over 34% of personal health care expenses was paid by private health insurance, 23% was paid by Medicare, 17.4% by Medicaid, and nearly 1% was paid by consumers. The other 30% was paid by other types of programs and insurance. In 2014, the Medicare program had over 54 million enrollees with expenditures of nearly $613 billion an increase of $30 billion from 2013. The Medicare Part D drug program accounted for $78 billion up $8 billion from the previous year CDC (2016b).
U.S. and International Comparison of Health Statistics
Established in 1961, the Organisation for Economic Cooperation and Development (OECD) is a membership organization that provides comparable statistics of economic and social data worldwide and monitors trends of economic development. Currently 34 countries, including the United States, are members of this organization. Their budget is derived from the member countries; the United States contributes 25% of the budget. The OECD produces, on a continual basis, a health data set of the 34 member countries as well as candidate and key partner countries when possible (Brazil, China, Colombia, Costa Rica, India, Indonesia, Latvia, Lithuania, the Russian Federation, and South Africa) (Organisation for Economic Cooperation and Development [OECD], 2016). The following are highlights from the OECD health data (OECD, 2015).
Health indicators such as infant mortality rates , average life expectancy, and health risk behaviors are used to evaluate the health status of a population. Because the United States spends the highest per capita on health care in the world, it is expected that U.S. health indicators would rank superior to all other countries’ healthcare indicators.
|
TABLE 3-1 OECD Country ISO Codes |
|||
|
Australia |
AUS |
Japan |
JPN |
|
Austria |
AUT |
Korea |
KOR |
|
Belgium |
BEL |
Luxembourg |
LUX |
|
Canada |
CAN |
Mexico |
MEX |
|
Chile |
CHL |
Netherlands |
NLD |
|
Czech Republic |
CZE |
New Zealand |
NZL |
|
Denmark |
DNK |
Norway |
NOR |
|
Estonia |
EST |
Poland |
POL |
|
Finland |
FIN |
Portugal |
PRT |
|
France |
FRA |
Slovak Republic |
SVK |
|
Germany |
DEU |
Slovenia |
SVN |
|
Greece |
GRC |
Spain |
ESP |
|
Hungary |
HUN |
Sweden |
SWE |
|
Iceland |
ISL |
Switzerland |
CHE |
|
Ireland |
IRL |
Turkey |
TUR |
|
Israel |
ISR |
United Kingdom |
GBR |
|
Italy |
ITA |
United States |
USA |
|
Partner country ISO codes |
|||
|
Brazil |
BRA |
Indonesia |
IDN |
|
China |
CHN |
Latvia |
LVA |
|
Colombia |
COL |
Lithuania |
LTU |
|
Costa Rica |
CRI |
Russian Federation |
RUS |
|
India |
IND |
South Africa |
ZAF |
|
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center |
Demographic Trends
The percentage of people in the United States over age 65 increased from 9% in 1960 to 15% in 2010 and is expected to double to 27% in 2050. The proportions will be large in Japan, Korea, and Spain, where, it is predicted, 40% of the population will be over 65 years old by 2050. The increase in the over-80 population share will increase dramatically. In 2010, the average in OECD countries was 4%, which will increase to 10% by 2050. These trends will place large strains on healthcare systems, particularly the long-term care sector (OECD, 2015).
Life Expectancy Rates
Current data trends indicated that OECD-country life expectancy rates are increasing, which can be attributed to improving health care services, lifestyle changes, and increased public health education. The 2013 average life expectancy in the OECD countries is 80.5 years. The U.S. average is 78.8 years. Spain and Switzerland have the highest life expectancy, more than 80 years. The lowest life expectancy rate is Mexico’s, below 75 years. The gains in life expectancy in the United States have been less than in other OECD countries. For example, in 1970, the U.S. life expectancy was one year above the average of OECD countries; it is now more than one year below the OECD average. Possible reasons are the rates of uninsured individuals across the country, high obesity rates, and adverse living conditions due to poverty. Considering the high levels of U.S. healthcare spending, the life expectancy rates should be higher (OECD, 2015).
Life Expectancy at age 65
Life expectancy rates at age 65 have increased for both genders over the past 20 years in all OECD countries: an increase of 5.5 years since 1970. Medical care advances and lifestyle changes have contributed to the age increase. In 2013, people over age 65 in OECD countries could expect to live 19.5 more years—21 years for women and 18 years for men. In the United States, the average life expectancy was slightly lower at 19.2 years. Life expectancy for women at age 80 was highest in France and Japan (11.5 years); for men at age 80, life expectancy was highest in Japan and Spain (9 years). In general, people with higher education tend to live longer and are healthier. It is also important to mention that even though people tend to live nearly 20 years longer post 65, those years may be issues with their health (OECD, 2015).
Figure 3-2 Share of the Population Aged over 65 and 80 Years, 2010 and 2050
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
Figure 3-3 Trends in the Share of the Population Ages
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
Figure 3-4 Life Expectancy at Age 65, 1970 and 2013 (or Nearest Years)
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
Figure 3-5 Life Expectancy at Age 65 by Sex, 2013 (or Nearest Year)
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
Life Expectancy by Gender and Educational Level
In all OECD countries, women’s life expectancy rates are much higher than those of men. The 2013 average OECD life expectancy rate for women is 83.1 years, compared to men’s 77.8 years.
Figure 3-6 Healthy Life Years at Age 65, European Countries, 2013
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
Figure 3-7 Life Expectancy at Birth by Sex, 2013 (or Latest Year)
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
In the United States, the life expectancy is less than the average of the OECD countries with a widening gap with the leading countries. In 2013, the U.S. mens’ life expectancy was 4.3 years less than that of the leader, Switzerland (up from less than 3 years in 1970). In 2013, the U.S. women’s life expectancy rate was 5.4 years shorter than that of the leader, Japan (there was no gap in 1970). This gap may be due in part to our high obesity rates which are a significant risk factor for diseases (OECD, 2015).
Figure 3-8 Gap in Life Expectancy at Age 30 by Sex and Educational Level, 2012 (or Latest Year)
Health at a Glance 2015: OECD Indicators by OECD Publishing. Reproduced with permission of OECD Publishing via Copyright Clearance Center
According to OECD data, those individuals with the highest level of education live 6 years longer than those with the lowest level of education. There was an average gap of 8 years in educational levels in the men’s life expectancy (OECD, 2015).
Infant Mortality
Infant mortality rates are measures of the number of children less than one year of age who die. The average 2013 OECD rate is 3.8. In 2013, there was little difference in infant mortality rates among most OECD countries, with the average less than 4 deaths per 1,000 live births. The lowest rates are found in Iceland, Slovenia, and Finland, at 1.3 and 1.7, respectively, for Slovenia and Finland. The highest rates are much higher than the OECD average of 3.8: Indonesia (24.5), South Africa (32.8), and India (41.4). The United States’ reduction in infant mortality rate has been slower than that of other OECD countries. The U.S. rate, 5.0, is now higher than the OECD average. In the United States, there are large differences in infant mortality rates among racial groups. Black women are more likely to give birth to low-birth-weight infants, and black infants’ mortality rate is double that of white infants (NCHS, 2014).
Tobacco Use
According to the World Health Organization, tobacco use kills 6 million people annually, of whom 600,000 are killed from involuntary smoking or second-hand smoking (Tobacco, 2016). It is the largest preventable risk factor. In OECD countries, smoking rates vary widely. In the 34 OECD countries, 20% of the adult population smoked in 2013, although smoking rates in men are higher than women’s rates in all OECD countries except Sweden and Iceland. The rates in Sweden, Iceland, Mexico, and Australia are less than 13% of the adult population. Smoking rates remain high in Greece for both males and females, and one in two men in Latvia and Indonesia smoke daily. However, smoking rates have declined in most OECD countries due to public health campaigns, smoke-free-environment policies, and increased taxation on tobacco products. The U.S. ranks 5th of the 34 countries rated regarding tobacco use which illustrates our national focus on tobacco free work environment and aggressive educational campaigns (OECD, 2015).
CHAPTER 4 Government’s Role in U.S. Health Care
|
LEARNING OBJECTIVES |
|
The student will be able to: ■ Describe five U.S. governmental organizations and their roles in health care. ■ Discuss the role of the Administration for Children and Families regarding children and families. ■ Analyze the integration of the collaboration of the Department of Homeland Security and the Federal Emergency Management Agency and its importance to disaster management. ■ Describe the role of the National Institutes of Health in healthcare research. ■ Discuss the U.S. Food and Drug Administration’s regulatory responsibility in health care. ■ Evaluate the role of the Centers for Medicare and Medicaid Services in health care. |
|
DID YOU KNOW THAT? |
|
■ Social regulation focuses on actions such as those in the healthcare industry that impact an individual’s safety or well-being. ■ The U.S. Surgeon General is the chief health educator in the United States. ■ The Food and Drug Administration is responsible for accrediting and inspecting mammography facilities. ■ The Department of Homeland Security is responsible for ensuring that all governmental levels have an emergency preparedness plan for catastrophic events. ■ The Affordable Care Act created the Center for Medicare and Medicaid Services. Innovation Center for the purpose of testing “innovative payment and service delivery models to reduce program expenditures and improve the quality of health care.” |
▶ Introduction
During the Depression and World War II the United States had no funds to start a universal healthcare program—an issue that had been discussed for years. As a result, a private-sector system was developed that did not provide healthcare services to all citizens. However, the government’s role in providing healthcare coverage evolved to being a regulatory body to ensure that the elderly and poor were able to receive health care. The passage of the Social Security Act of 1935 and the establishment of the Medicaid and Medicare programs in 1965 mandated the government’s increased role in providing healthcare coverage. Also, the State Children’s Health Insurance Program (SCHIP), now the Children’s Health Insurance Program, established in 1997 and reauthorized by the Affordable Care Act (ACA) through 2019, continues to expand the government’s role in children’s health care. The laws require states, upon enactment, to maintain current income eligibility levels for CHIP through September 30, 2019 ( CHIP, 2016 ). In addition to the reauthorization of the CHIP program, the ACA increased governmental interaction with the healthcare system by developing several of the governmental initiatives that focus on increasing the ability of individuals to make informed decisions about their health care.
In these instances, the government increased accessibility to health care as well as provided financing for health care to certain targeted populations. This chapter will focus on the different roles the federal, state, and local governments play in the U.S. healthcare system. This chapter will also highlight different governmental programs and regulations that focus on monitoring how health care is provided.
▶ History of the Role of Government in Health Care
Social regulation focuses on organizations’ actions, such as those in the healthcare industry, that impact an individual’s safety. Social regulations focus on protecting individuals as employees and consumers ( Carroll & Buchholtz, 2015 ). These types of regulations are common in the U.S. healthcare system. The healthcare industry claims it is the most regulated industry in the world. It is important to mention that in addition to governmental regulations, there are nongovernmental regulations of U.S. health care by accrediting bodies such as the Joint Commission, which began over 80 years ago and accredits nearly 21,000 healthcare organizations and programs ( The Joint Commission, 2016 ). However, regulatory oversight is mainly handled at the federal, state, and local governmental levels.
▶ U.S. Government Agencies
Regulatory healthcare power is shared among federal and state governments. State governments have a dominant role of regulating constituents in their jurisdiction. To ensure success in this regulatory process, state governments also developed local government levels to provide direct services to constituents and regulate their geographic region. Legislatures establish the legal framework for state and local governmental authority ( Jonas, 2003 ).
Important Federal Government Agencies
Many federal agencies are responsible for a sector of healthcare. The U.S. Department of Health and Human Services (HHS) is the most important federal agency. It is a cabinet-level department of the executive branch of the federal government. The Secretary of the HHS provides advice to the President of the United States regarding health and human services policy ( Pozgar, 2014 ). HHS collaborates with state and local governments because many HHS services are provided at those levels. There are 11 operating divisions: the Centers for Disease Control and Prevention (CDC) , the Administration for Community Living (ACL) , the National Institutes of Health (NIH) , the Agency for Toxic Substances and Disease Registry (ATSDR) , the Indian Health Service (IHS) , the Health Resources and Services Administration (HRSA) , the Agency for Healthcare Research and Quality (AHRQ) , the Substance Abuse and Mental Health Services Administration (SAMHSA) , the U.S. Food and Drug Administration (FDA) , the Administration for Children and Families (ACF) , and the Centers for Medicare and Medicaid Services (CMS) . Each of these agencies will be discussed individually ( HHS, 2016 ).
Centers for Disease Control and Prevention (CDC)
The CDC was established in 1946 and is headquartered in Atlanta, Georgia, with 10 additional U.S. locations. Its mission is saving and protecting the health of Americans. The CDC is available 24/7 to respond to any manmade or natural event. By connecting state and local health departments across the United States, the CDC can discover patterns of disease and respond when needed. The CDC has created four health goals, which focus on (1) healthy people in healthy places, (2) preparing people for emerging health threats, (3) positive international health, and (4) healthy people at all stages of their life. To achieve these goals, the CDC focuses on six areas: health impact, customer focus, public health research, leadership, globalization, and accountability. The CDC website provides information on disease, healthy living, emergency preparedness, injury prevention, environmental health, workplace safety, data and statistics, and global health. The CDC also provides specific information for travelers, infants and children, pregnancies, and state and tribal associations. It is the lead U.S. agency for disease outbreaks, such as Ebola and Zika ( CDC, 2016 ).
Administration for Community Living (ACL)
All Americans—including people with disabilities and older adults—should be able to live at home with the supports they need, participating in communities that value their contributions. To help meet these needs, the HHS created a new organization, the ACL.
Established in 2012, the ACL brings together the efforts and achievements of the Administration on Aging, the Administration on Intellectual and Developmental Disabilities, and the HHS Office on Disability to serve as the federal agency responsible for increasing access to community supports, while focusing attention and resources on the unique needs of older Americans and people with disabilities across the lifespan.
The ACL mission is to maximize the independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers. Since its inception, it has developed elderly housing initiatives, new models of community care for the elderly and people with disabilities, a partnership with the Veterans’ Administration to counsel veterans on their ongoing service needs, and a national network of increased transportation access for the elderly and people with disabilities ( ACL, 2016 ).
Agency for Toxic Substances and Disease Registry (ATSDR)
The ATSDR, headquartered in Atlanta, Georgia, and administered organizationally with the CDC, was established in 1985 and is authorized by the Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA; more commonly known as the Superfund law). The ATSDR is responsible for finding and cleaning the most dangerous hazardous waste sites in the country. Specific functions include public health assessments of waste sites, health consultations concerning specific hazardous substances, health surveillance and registries, response to emergency releases of hazardous substances, applied research in support of public health assessments, information development and dissemination, and education and training concerning hazardous substances. The ATSDR’s mission is to protect the public against harmful exposures and disease-related exposures to toxic substances. The ATSDR is the lead federal public health agency responsible for determining human health effects associated with toxic exposures, preventing continued exposures, and mitigating associated human health risks. ATSDR is administered organizationally with the CDC. The ATSDR has 10 regional offices within the Environmental Protection Agency (EPA) across the country ( ATSDR, 2016 ).
National Institutes of Health (NIH)
Established in 1930 and headquartered in Bethesda, Maryland, the NIH is the primary federal agency for research toward preventing and curing disease worldwide. Its mission is the pursuit of knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability. The NIH is comprised of 27 institutes and centers that focus on different diseases and conditions, including cancer, ophthalmology, heart, lung, and blood disorders, genes, aging, alcoholism and drug abuse, infectious diseases, chronic diseases, children’s diseases, and mental health. Although the NIH has sponsored external research, it also has a large internal research program. Nearly 150 Nobel Prize winners have received NIH funding, which has led to the development of the MRI, how viruses can cause cancer, insights into cholesterol control, and other important advances in medicine ( NIH, 2016 ).
Health Resources and Services Administration (HRSA)
Created in 1982 and headquartered in Rockville, Maryland, the HRSA is the primary federal agency for improving access to healthcare services for people in every state who are uninsured, isolated, or medically vulnerable. The five organizational goals are improving access to quality healthcare, strengthening the health care workforce, building healthy communities, improving health equity, and strengthening HRSA management and operations. The HRSA has six bureaus: primary health care, health professions, healthcare systems, maternal and child health, the HIV/AIDS bureau, and the Bureau of Clinician Recruitment and Service. The HRSA provides funding to grantees that provide health care to those vulnerable populations. It also oversees organ, bone marrow, and cord blood donation; supports programs against bioterrorism; and maintains databases that protect against healthcare malpractice and healthcare waste, fraud, and abuse. Tens of millions of Americans get affordable health care and other help through the HRSA’s 100-plus programs and more than 3,000 grantees ( HRSA, 2016 ).
Agency for Healthcare Research and Quality (AHRQ)
Created in 1989 and headquartered in Rockville, Maryland, the agency’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all U.S. citizens. The AHRQ’s cutting-edge research helps people make more informed decisions and improve the quality of healthcare services. AHRQ focuses on the following areas of research: healthcare costs and utilization, information technology, disaster preparedness, medication safety, healthcare consumerism, prevention of illness, and special-needs populations. The AHRQ has a National Partnership Network, which includes over 600 federal, state, and local health agencies, health professional groups, patient and caregiver advocacy groups, health systems, and businesses committed to improving the quality of health care through informed decision making. These organizations support the AHRQ’s efforts to share evidence-based resources with patients and caregivers, health professionals, and others in their communities ( AHRQ, 2016 ).
Indian Health Service (IHS)
Established in 1921 and headquartered in Rockville, Maryland, the mission of IHS is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. Also part of its mission is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people. It also is responsible for promoting American Indian and Alaska Native communities and cultures and for honoring and protecting the inherent sovereign rights of these people. The IHS provides a comprehensive health-service-delivery system for approximately 1.9 million American Indians and Alaska Natives who belong to 566 federally recognized tribes. Twelve area IHS sites provide services to constituents ( IHS, 2016 ).
Substance Abuse and Mental Health Services Administration (SAMHSA)
Established in 1992, the SAMHSA is the main federal agency for improving access to quality substance abuse and mental health services in the United States by working with state, community, and private organizations. The Administrator of the Substance Abuse and Mental Health Services Administration co-chairs the HHS Behavioral Health Coordinating Council (BHCC), which is a coordinating body within the HHS established in 2010 by the HHS Secretary. The BHCC’s chief goals are to share information and identify and facilitate collaborative, action-oriented approaches to address the HHS behavioral health agenda without duplication of effort across the HHS. The SAMHSA is the umbrella agency for mental health and substance abuse services, which includes the Center for Mental Health Services (CMHS) , the Center for Substance Abuse Prevention (CSAP) , and the Center for Substance Abuse Treatment (CSAT) . The Center for Behavioral Health Statistics and Quality (CBHSQ) is responsible for data collection, analysis, and dissemination of critical health data to assist policymakers, providers, and the public for use in making informed decisions regarding the prevention and treatment of mental and substance use disorders ( SAMHSA, 2016 ).
U.S. Food and Drug Administration (FDA)
Established in 1906 as a result of the Federal Food, Drug, and Cosmetic Act , the FDA is responsible for ensuring that the following products are safe: food, human and veterinary products, biologic products, medical devices, cosmetics, and electronic products. The FDA is also responsible for ensuring that product information is accurate. The following is a summary of FDA responsibility for each category:
1. Food: The FDA ensures that food labeling contains accurate information. Also, the FDA regulates the safety of all food except poultry and meat and oversees bottled water, dietary supplements, infant formulas, and food additives.
2. Veterinary products: The FDA has oversight of the production of livestock feed, pet food, and veterinary drugs and devices.
3. Human drugs: The FDA has regulatory oversight of both prescription and over-the-counter (OTC) drug development and labeling, which includes the manufacturing standards for these drug products.
4. Biologics: The FDA has oversight of vaccines, blood and blood products, cellular and gene therapy products, tissue and tissue products, and allergenics.
5. Medical devices: The FDA has authority for premarket approval for any new devices, as well as developing standards for their manufacturing and performance, and also must track reports of any malfunction of these devices. The FDA has oversight of dental devices.
6. Cosmetics: The FDA oversees both the safety and labeling of cosmetic products.
7. Electronic products: The FDA develops and regulate standards for microwaves, television receivers, and diagnostic equipment such as X-ray equipment, laser products, ultrasonic therapy equipment, and sunlamps. It also must accredit and inspect any mammography facilities.
8. Tobacco products: Cigarettes, cigarette tobacco, roll your own tobacco, and smokeless tobacco. The FDA regulates the manufacture, distribution and marketing of all tobacco products. Starting in August 2016, the FDA will begin to apply and enforce key provisions of the Family Smoking Prevention and Tobacco Control Act as it relates to the sale, marketing, and manufacturing of e-cigarettes.
The FDA is also responsible for advancing public health by speeding up innovations to make medicine and food more effective, safer, and more affordable. It is also responsible for ensuring that the public receives accurate information to be able to make informed decisions about using medicine and food products. The FDA also plays a significant role in the nation’s counterterrorism capability. The FDA fulfills this responsibility by ensuring the security of the food supply and by fostering development of medical products to respond to deliberate and naturally emerging public health threats ( USFDA, 2016 ).
Administration for Children and Families (ACF)
The ACF, which has 10 regional offices, is responsible for federal programs that promote the economic and social well-being of families, children, individuals, and communities. Their mission is to empower people to increase their own economic well-being, support communities that have a positive impact on the quality of life of their residents, partner with other organizations to support Native American tribes, improve needed access to services, and work with special-needs populations. The ACF also has programs that target human trafficking and refugees ( ACF, 2016 ).
Centers for Medicare and Medicaid Services (CMS)
The CMS was established when the Medicare and Medicaid programs were signed into law in 1965 by President Lyndon B. Johnson as a result of the Social Security Act. At that time, only half of those 65 years or older had health insurance. Medicaid was established for low-income children, the elderly, the blind, and the disabled and was linked with the Supplemental Security Income program (SSI). In 1972, Medicare was extended to cover people under the age of 65 with permanent disabilities. The CMS also has oversight of SCHIP, Title XXI of the Social Security Act, which is financed by both federal and state funding and is administered at the state level.
Headquartered in Baltimore, Maryland, the CMS has over 20 offices that oversee different aspects of programs. The primary responsibility of CMS is to provide policy, funding, and oversight to healthcare programs for elderly and poor individuals. For many years, the CMS was a geographically based structure with 10 field offices. In 2007, it was reorganized to a consortia structure based on the priorities of Medicare health plans and financial management, Medicare fee for service, Medicaid and children’s health, surveys and certification, and quality assurance and improvement. The consortia are responsible for oversight of the 10 regional offices for each priority. In 2010, the Center for Program Integrity was developed as part of the CMS; it focuses on best practices for program implementation (CMS, 2016a). As part of the Affordable Care Act, the Innovation Center was established. Congress created the Innovation Center for the purpose of testing “innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits. The CMS also oversees the ACA Health Insurance Marketplace (CMS, 2016b).
Occupational Safety and Health Administration (OSHA)
Established on December 29, 1970, and part of the U.S. Department of Labor, the Occupational Safety and Health Administration (OSHA) was established to govern workplace environments to ensure that employees have a safe and healthy environment. The Act covers most private sector employees. OSHA requires states to develop their own job safety and health programs, which can be approved by OSHA. States can apply for approval for their plans and receive up to 50% funding for their programs. There are currently 22 states that have programs that protect both private and public sector employees ( OSHA, 2016 ).
Under OSHA enforcement, the following legislation ensures that healthcare workers are protected.
The Hazard Communication Standard (HCS) ensures that all hazardous chemicals are properly labeled and that companies are informed of these risks ( Hazard Communication, 2016 ). The Medical Waste Tracking Act requires companies to have medical waste disposal procedures so that there is no risk to employees and the environment (Environmental Protection Agency, 2016 ). The Occupational Exposure to Blood-borne Pathogen Standard developed behavioral standards for employees who deal with blood products, such as wearing gloves and other equipment and disposal of blood collection materials ( OSHA Quicktakes, 2016 ).
Surgeon General and U.S. Public Health Service
The Surgeon General is the U.S. chief health educator who provides information on how to improve the health of the U.S. population. The Surgeon General, who is appointed by the President of the United States, and the Office of the Surgeon General oversee the operations of the commissioned U.S. Public Health Service Corps , which provides support to the Surgeon General. The U.S. Public Health Service Commissioned Corps consists of 6,700 public health professionals who are stationed within federal agencies and programs. These commissioned employees include various professionals such as dentists, nurses, physicians, mental health specialists, environmental health specialists, veterinarians, and therapists. The Surgeon General serves a four-year term and reports to the Secretary of HHS. The Surgeon General focuses on certain health priorities for the United States and publishes reports on these issues. In 2010, the Affordable Care Act designated the Surgeon General as the chair of the National Prevention Council, which provides coordination and leadership among 20 executive departments with respect to prevention, wellness, and health promotion activities ( Office of the Surgeon General, 2016 ).
Department of Homeland Security (DHS)
The Department of Homeland Security (DHS) was established in 2002 as a result of the 2001 terrorist attack on the United States. It consists of 22 different federal departments with over 240,000 employees and focuses on protecting the United States. The Federal Emergency Management Agency (FEMA) , which is responsible for managing catastrophic events, was integrated into the DHS in 2003. Together, they are responsible for coordinating efforts at all governmental levels to ensure emergency preparedness for any catastrophic events such as bioterrorism; chemical and radiation emergencies; mass casualties as a result of explosions, natural disasters, and severe weather; and disease outbreaks. They coordinate with the CDC to ensure there are plans in place to quickly resolve these events. In conjunction with FEMA, the DHS has also developed a National Incident Management System (NIMS) , which provides a systematic, proactive approach to all levels of government and private sector agencies to collaborate and ensure there is a seamless plan to manage any major incidents. It is the essential foundation to the National Preparedness System (NPS) , which outlines an organized process for an integrated preparedness system for any disaster ( DHS, 2016 ).
Office of the Assistant Secretary for Preparedness and Response (ASPR)
The Office of the Assistant Secretary for Preparedness and Response (ASPR) was created under the Pandemic and All Hazards Preparedness Act in the wake of Hurricane Katrina to prevent, prepare, and respond to the adverse health effects of public health emergencies and disasters. ASPR focuses on preparedness planning and response; building federal emergency medical operational capabilities; countermeasures research, advance development, and procurement; and grants to strengthen the capabilities of hospitals and healthcare systems in public health emergencies and medical disasters. The office provides federal support, including medical professionals through the ASPR’s National Disaster Medical System , to augment state and local capabilities during an emergency or disaster. The Office of Emergency Management provides support and coordination of federal, state, and local activities during times of emergency. The Secretary of HHS delegates to the ASPR the leadership role for all health and medical services support function in a health emergency or public health event (PHE, 2016).
State Health Departments’ Role in Health Care
The U.S. Constitution gives state governments the primary role in providing health care for their citizens. Most states have several different agencies that are responsible for specific public health services. There is usually a lead state agency with approximately 20 agencies that target health issues like aging, living, and working environments, as well as alcoholism and substance abuse. Many state agencies are responsible for implementing certain federal acts, such as the Clean Water Act, the Clean Air Act, the Food, Drug, and Cosmetic Act, and the Safe Drinking Water Act ( Turnock, 2007 ). State health departments monitor communities to identify health problems. Additionally, they diagnose and investigate health problems and provide education about health issues. They also develop policies to support community health. They must enforce laws and regulations to promote health and safety. Most state agencies are responsible for or share responsibility for federal programs related to maternal and infant health services and cancer prevention. They are responsible for providing population-based services for the CDC’s health priorities, which include motor vehicle injuries, HIV, obesity, food safety, tobacco use, teen pregnancy, and nutrition. Vital statistics collected include deaths, births, marriages, and health and disease statuses of the population. These statistics are important to collect because they serve as a basis for funding. The Council of State and Territorial Epidemiologists (CSTE) decides which diseases should be considered reportable to the CDC, which then produces the Morbidity and Mortality Weekly Report (MMWR) . The MMWR is an estimate of the prevalence of disease throughout the country ( Association of State and Territorial Health Officials, 2016 ).
State health departments also license health professionals such as physicians, dentists, chiropractors, nurses, pharmacists, optometrists, and veterinarians who practice within the state. Further, they inspect and license healthcare facilities such as hospitals and nursing homes. Most state agencies provide technical assistance to their local health departments in the following areas: (1) quality improvement, (2) data management, (3) public health law, (4) human resource management, and (5) policy development. It is important to emphasize that the state health department provides oversight to local health departments, which are directly responsible for providing public health activities for their community ( Mays, 2008 ). State agencies are funded primarily by federal sources, state resources, and Medicaid and Medicare, with the remaining sources supplied by fines and fees, indirect federal funding, and other minor sources ( Association of State and Territorial Health Officials Profile, 2016 ).
Local Health Departments’ Role in Health Care
Local health departments are the governmental organizations that provide most of the direct services to the population. There are 2,800 local health departments across the United States. Although their organizational structures may differ, their basic role is to provide direct public health services to their designated areas. It is difficult to generalize as to the types of services offered by local health departments because they do vary according to geographic location, but most are involved in communicable disease control. The following are highlights of the types of direct services offered by local health departments:
■ Over 90% of local health departments provide adult and children immunizations.
■ Over 90% offer communicable/infectious disease surveillance.
■ Over 80% offer tuberculosis screening and 75% offer tuberculosis treatment.
■ Over 75% offer environmental surveillance.
■ Approximately 70% offer population nutrition services.
■ Nearly 75% provide school/day care center inspection.
■ Nearly 85% provide activities to address health disparities.
■ Approximately 75% provide food safety education ( NACCHO, 2016 ).
Local health departments receive funding from their state government and the federal government, direct funding such as from the CDC, reimbursement for services from Medicaid and Medicare, private health insurance, and fees for services. Because of population size and coverage, local health department funding varies from state to state. Local sources are the greatest contributor to funding local health departments, followed by state allocations, Medicare and Medicaid, fees, and other federal funding ( NACCHO, 2016 ). However, the ACA has strengthened the position of the local health departments by providing funding opportunities for educating the public health workforce and increasing the focus on preventive services that are traditionally performed by the local health departments (Historic Health Reform Legislation, 2013).
▶ Conclusion
The government plays an important role in the quality of the U.S. healthcare system. The federal government provides funding for state and local governmental programs. Federal healthcare regulations are implemented and enforced at the state and local levels. Funding is primarily distributed from the federal government to the state government, which then allocates funding to local health departments. Local health departments provide the majority of services for their constituents. More local health departments are working with local organizations such as schools and physicians to increase their ability to provide education and prevention services.
The DHS and FEMA now play an integral role in the management and oversight of catastrophic events, such as natural disasters, earthquakes, floods, pandemic diseases, and bioterrorism. The DHS and FEMA collaborate closely with the CDC to ensure that both the state and local health departments have a crisis management plan in place for these events. These attacks are often horrific and frightening with a tremendous loss of life, and as a result, the state and local health departments need to be more prepared to deal with catastrophic events. They are required to develop plans and be trained to deal effectively with many of these catastrophic issues. Finally, the Affordable Care Act has increased government involvement in the healthcare industry to promote access to a quality healthcare system.
▶ Wrap-Up
Vocabulary
· Administration for Children and Families (ACF)
· Administration for Community Living (ACL)
· Agency for Healthcare Research and Quality (AHRQ)
· Agency for Toxic Substances and Disease Registry (ATSDR)
· Center for Behavioral Health Statistics and Quality (CBHSQ)
· Center for Mental Health Services (CMHS)
· Center for Substance Abuse Prevention (CSAP)
· Center for Substance Abuse Treatment (CSAT)
· Centers for Disease Control and Prevention (CDC)
· Centers for Medicare and Medicaid Services (CMS)
· Council of State and Territorial Epidemiologists (CSTE)
· Department of Homeland Security (DHS)
· Federal Emergency Management Agency (FEMA)
· Federal Food, Drug, and Cosmetic Act (FDCA)
· Hazard Communication Standard (HCS)
· Health Resources and Services Administration (HRSA)
· Indian Health Service (IHS)
· Morbidity and Mortality Weekly Report (MMWR)
· National Disaster Medical System
· National Incident Management System (NIMS)
· National Institutes of Health (NIH)
· National Preparedness System
· Occupational Exposure to Blood-borne Pathogen Standard
· Occupational Safety and Health Administration (OSHA)
· Office of Emergency Management
· Office of the Assistant Secretary for Preparedness and Response (ASPR)
