Introduction to Health Care

and Public Health in the U.S.

Introduction to and History of
Modern Health Care in the U.S.
Lecture a
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 Introduction to and History of
Modern Health Care in the U.S.
Learning Objectives - 1

• Define key terms in health care and public

health (Lectures a, b, c, d)
• Describe components of health care
delivery and health care systems
(Lecture a)
• Discuss examples of improvements in
public health (Lecture b)
2
 Introduction to and History of
Modern Health Care in the U.S.
Learning Objectives - 2

• Define core values and paradigm shifts in

U.S. health care (Lecture c)
• Describe the technology used in the
delivery and administration of health care
(Lecture d)

3
 Some Definitions: Health

• Often thought of as the absence of

disease
• World Health Organization (WHO)
– “…state of complete physical, mental and
social well-being and not merely the absence
of disease or infirmity”
• “Illness” is a state of poor health

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 Health Care

• The prevention and treatment of illness

• Delivered by people from varied disciplines
– Medicine – Laboratory Science
– Dentistry – Pharmacy
– Nursing – Other allied health
professions

• Work together as interdisciplinary teams to

deliver care
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 Health Care Delivery

• Delivered in different places

• Inpatient facilities
– Hospitals
o Institutions for treating sick or injured people
o Historically places for shelter, almshouses
o Hospital Survey and Construction Act (also known
as the Hill-Burton Act) passed in 1946
– Nursing and residential care
• Outpatient facilities
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 Health Care Delivery - Hospitals

• Types of hospitals:
o General medical and surgical
o Specialty (orthopedic, pediatrics, women’s
services)
o Psychiatric

• Publicly or privately owned

• Patients can be admitted:
– Via emergency department
– Directly from physician’s office

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 Health Care Delivery – Nursing
and Residential Care Facilities - 1
• Short-term or long-term facilities
• Long-term care classified by level of care
• Skilled nursing facilities (nursing homes)
– Proliferated after amendment of the Social
Security Act
– Originally part of the welfare system
– Now part of the health care system

8
 Health Care Delivery – Nursing
and Residential Care Facilities - 2
• 1969 - Medicare drastically reduced
coverage for nursing homes
• 1970 - Miller Amendment established a new
standard, “intermediate care”
• 1990s - “Sub-acute care”
Provided care for patients discharged
from hospitals who briefly need a
higher level of care “than is provided to
the majority of patients in a skilled
nursing facility.”
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 Health Care Delivery –
Outpatient Facilities – 1
• Physicians offices • Dental offices
– Primary care – General dentists
– Specialty care – Specialists
– Single specialty or o Orthodontists

multispecialty o Endodontist
o Oral Surgeons

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 Health Care Delivery –
Outpatient Facilities – 2
• Medical and diagnostic laboratories
– X-rays
– CT Scans and MRIs
– Biologic Specimens
• Other ambulatory health services
– Ambulance services
– Home health care
– Hospice
– Visiting Nurse Services
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 The Health Care Industry

• One of the largest industries in the U.S. and

rapidly growing in employment
– 2014 - 18.0 million jobs for wage and salary workers
– Estimated to grow to 21.9 million jobs by 2024
• Top four fastest growing job categories
– Home health care services
– Outpatient care centers
– Offices of other health practitioners
– Other ambulatory health care services

12
Overviews of Health Care Systems

• Askin (2014)
– Started by two medical students who are now
physicians
– Overview of U.S. health care system, now in
second edition,
https://healthcarehandbook.wustl.edu
• Reid (2010)
– Comparative overview of different models of
health care around world assessed by
Washington Post journalist
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 Reid’s Four Systems and
Their U.S. Analogs (2010)
Name Description Countries U.S. Analog
Beveridge Provided and financed Great Britain, Veterans
by government Hong Kong, Administration
Cuba (VA)
Bismarck Regulated private Germany, Employer-
insurance – must cover France, provided health
all Switzerland insurance
National Private system with Canada, Medicare,
health government-run Taiwan, South Medicaid
insurance insurance Korea
Out-of-pocket Pay as you go Most poor U.S. uninsured
countries

Reid, 2010

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 Some Definitions of Care

• Primary care: Initial and ongoing care,

typically provided in an office or clinic
• Secondary care: Specialty care provided
in the community
• Tertiary care: Highly specialized care
usually provided by referral in a large,
typically academic, medical center

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Health Care System Stakeholders
(the “p”s)
• Patient: The one who gets health care, often
called a consumer or citizen when they are well
• Provider: Those who provide health care, e.g.,
physicians, nurses, allied health
• Purchaser: Those who buy health care, usually
employers or the government
• Payor: Those who pay the health care system,
i.e., the insurance companies and government
• Public health: Protectors of the public’s health

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 How Health Care is Financed - 1

• No matter who pays the cost (patient,

employer, or government), most health
care is financed on the notion of insurance
– Everyone pays some, those who need it use it
– Although modern system may be better
described as “pre-paid” health care than
insurance

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 How Health Care is Financed - 2

• Payment methods
– Private fee-for-service
– Private managed care, a.k.a., HMOs
– Government-financed, a.k.a., single-payor
– Government-provided

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 Insurance –
Some Use More Than Others

http://www.nihcm.org/concentration-of-health-ca
re-spending-chart-story

http://www.nihcm.org/concentration-of-health-ca
re-spending-chart-story
19
 Brief History of
Health Care Finance - 1
• Mid-20th century
– Introduction of health insurance
– Growth of “open-ended” spending
• Late 20th century
– Efforts to control costs, culminating in
managed care
– Empowerment of patients/consumers and
growth of Internet

20
 Brief History of
Health Care Finance - 2
• 21st century
– Costs continued to rise well above inflation
but have leveled off in recent years
– Still, are we on a collision course with
increasing costs, aging baby boomers, more
costly technology, etc.?

21
 Major Health Care
Payors in U.S. - 1
• Private health insurance: For most
employed citizens and their dependents,
except those in lower-paying jobs
• Medicare: Government insurance for
elderly and disabled
• Medicaid: Government insurance for
indigent

22
 Major Health Care
Payors in U.S. - 2
• State Children’s Health Insurance
Program (S-CHIP): Government insurance
for uninsured low-income children
• Other expenses due to out-of-pocket,
public health, and other expenditures

23
 Organization of the
Health Care Industry

1.1 Table: Percent distribution of employment and establishments in health services by detailed industry
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sector, 2008.
 Introduction to and History of
Modern Health Care in the U.S.
Summary – Lecture a
• Important definitions
– Health
– Health care
– Health care systems
• Different types of health care delivery
– Inpatient
– Outpatient
• Different models that range from private to
public funding – most are combination
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 Introduction to and History of
Modern Health Care in the U.S.
References – 1 – Lecture a
References
Askin, E and Moore, N (2014). The Health Care Handbook - A Clear and Concise Guide
to the United States Health Care System, Second Edition. St. Louis, MO, Washington
University in St. Louis.
Definition of Healthcare. Preamble to the Constitution of the World Health Organization
as adopted by the International Health Conference, New York, 19 June - 22 July
1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of
the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
A. (n.d.). Health Care Careers Directory 2012-2013. American Medical Association.
ISBN#: 978-1-60359-770-8.
Health Care and Social Assistance: NAICS 62, US Bureau of Labor Statistics, http
://www.bls.gov/iag/tgs/iag62.htm.

26
 Introduction to and History of
Modern Health Care in the U.S.
References – 2 – Lecture a
References
Henderson, R (2015). Industry employment and output projections to 2024. Monthly
Labor Review, , Retrieved January 17, 2017,
http://www.bls.gov/opub/mlr/2015/article/industry-employment-and-output-projections-
to-2024.htm
Reid, TR (2010). The Healing of America: A Global Quest for Better, Cheaper, and Fairer
Health Care. New York, NY, Penguin Books.
World Health Report 2000 - Health systems: improving performance. (2000). Retrieved
January 20, 2017, from WHO website: http://www.who.int/whr/2000/en/ .

Charts, Tables, Figures

1.1 Table: BLS Quarterly Census of Employment and Wages, 2008. (2008). Retrieved January 20,
2017, from US Bureau of Labor Statistics website: http://www.bls.gov/cew/.

27
 Introduction to Health Care and
Public Health in the U.S.
Introduction to and History of
Modern Health Care in the U.S.
Lecture a
This material was developed by Oregon
Health & Science University, funded by the
Department of Health and Human Services,
Office of the National Coordinator for Health
Information Technology under Award
Number 90WT0001.
28