Health Care Delivery in the United States

James R. Knickman
Brian Elbel
Jonas & Kovner’s
Health Care
in the
United States
12th Edition
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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CHAPTER 1 The Challenge of Health Care Delivery and Health Policy 3
CHAPTER 2 Organization of Care 15
CHAPTER 3 The Politics of Health Care in the United States 51
CHAPTER 4 Comparative Health Systems 73
CHAPTER 5 Population Health 101
CHAPTER 6 Public Health: A Transformation in the 21st Century 123
CHAPTER 7 Health and Behavior 151
CHAPTER 8 Vulnerable Populations: Meeting the Health Needs of Populations
Facing Health Inequities 183


CHAPTER 9 The Health Workforce 231
CHAPTER 10 Health Care Financing 257
CHAPTER 11 Health Care Costs and Value 277
CHAPTER 12 High-Quality Health Care 311
CHAPTER 13 Health Care Management 343
CHAPTER 14 Health Information Technology 357

The Future of Health Care Delivery and Health Policy 381
U.S. Government Public Health Agencies 397

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Jonas & Kovner’s
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James R. Knickman, PhD, is the Robert Derzon Chair in Public and Health A!airs
at New York University with joint appointments at the NYU Wagner School of
Public Service and at NYU Langone Medical School’s Department of Population
Health. He has spent four decades splitting his time between academe and the
philanthropic sector. His work focuses on health policy and he has played many
roles both as a researcher and a leader in philanthropy to advance the use of public policy to improve the American health care system. He was a Vice President
at the Robert Wood Johnson Foundation and President of the New York State
Health Foundation. He has a PhD in Public Policy Analysis from the University of
Pennsylvania and did his undergraduate work at Fordham University. He serves
on the Board of Directors at three non-pro”t organizations, including chairing
the National Council on Aging.
Brian Elbel, PhD, MPH, is an associate professor of Population Health and Health
Policy at the New York University School of Medicine, where he heads the Section
on Health Choice, Policy and Evaluation within the Department of Population
Health, and at the NYU Wagner Graduate School of Public Service. He is the
Assistant Dean for Strategic Initiatives in the O#ce of Science and Research of
NYU Langone Health and the Director of the NYU Langone Comprehensive
Program on Obesity. He studies how individuals make decisions that in$uence
their health, with a particular emphasis on evaluation, obesity, and food choice.
His work uses behavioral economics to understand health decision-making
among vulnerable groups, and the role and in$uence of public policy on these
decisions. His research has been funded by the National Institutes of Health,
Centers for Disease Control and Prevention, the National Science Foundation
and the Robert Wood Johnson Foundation and has been featured in national television, radio, and print media. Dr. Elbel earned his bachelor’s degree from %e
University of Texas at Austin and his master’s and doctorate in Health Policy/
Health Economics from Yale University.
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Jonas & Kovner’s
12th Edition
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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List of Features xiii
Foreword by Anthony R. Kovner, PhD xvii
Acknowledgments xix
Organization of This Book xxi
Contributors xxiii
Chapter 1 The Challenge of Health Care Delivery and Health Policy 3
Brian Elbel and James R. Knickman
Introduction 4
!e Importance of Good Health to American Life 5
De”ning Characteristics of the U.S. Health System 6
Major Issues and Concerns 8
Key Stakeholders In#uencing the Health System 9
Organization of !is Book 12
Conclusion 13
Case Exercise—Health Care Delivery Plan 13
Discussion Questions 13
Reference 14
Chapter 2 Organization of Care 15
Amy Yarbrough Landry and Cathleen O. Erwin
Introduction 17
Description of the Current Care Delivery System 17
!e Future of the Delivery System 39
Best Practices 45
Conclusion 46
Case Exercise—Innovative Ideas 47
Discussion Questions 47
References 48
Chapter 3 The Politics of Health Care in the United States 51
Rogan Kersh and James Morone
Introduction 52
Health Care Infrastructure and Spending: Many Dollars, to What E$ect? 53
Who Pays? !e Politics of Medicare, Medicaid, and Much More 60
!e Politics of Providing Equitable Health Services 65
How Personal Health Decisions Become Public: !e Case of Obesity 67
Conclusion: Better National Health Ahead? 69
Case Exercise—Insurance Plans 70
Discussion Questions 70
References 70
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viii Contents
Chapter 4 Comparative Health Systems 73
Michael K. Gusmano and Victor G. Rodwin
Introduction 74
Health System Models 75
NHS and NHI Systems Compared With the United States 78
!e Health Systems in England, Canada, France, and China 79
Lessons 93
Case Exercise—European Lessons Learned 94
Discussion Questions 94
References 95
Chapter 5 Population Health 101
Pamela G. Russo and Marc N. Gourevitch
Introduction 102
!e Population Health Model 103
!e Medical Model 104
Comparing the Medical and Population Health Models 106
!e In”uence of Social Determinants on Health Behavior and Outcomes 108
Leading Determinants of Health: Weighting the Di#erent Domains 112
Health Policy and Returns on Investment 115
Conclusion 118
Case Exercise—Sodium and its E#ects on Our Health 120
Discussion Questions 120
References 121
Chapter 6 Public Health: A Transformation in the 21st Century 123
Laura C. Leviton, Paul L. Kuehnert, and Kathryn E. Wehr
Overview of a Complex Infrastructure 124
Public Health Requires a Collective Response from Society 128
Public Health is Di#erent from Individual Health Care 130
!e Core Functions of Public Health De$ne Essential Public Health Activities 132
Governmental Agencies Have Legal Authority for the Core Functions 135
Social, Economic, and Political Forces are Transforming Public Health 140
Conclusion 146
Case Exercise—Cure For Birth Defects Policy Options 146
Discussion Questions 146
References 147
Chapter 7 Health and Behavior 151
Brian Elbel, Elaine F. Cassidy, Matthew D. Trujillo, and C. Tracy Orleans
Introduction 152
Behavioral Risk Factors: Overview and National Goals 153
Changing Health Behavior: Closing the Gap Between Recommended and Actual Health
Lifestyle Practices 159
!e Role and Impact of Primary Care Interventions 163
Multilevel Models For Population-Based Health Behavior Change 166
Changing Provider Behavior: Closing the Gap Between Best Practice and Usual Care 171
Conclusion 177
Case Exercise—Comprehensive Plan for Addressing Risk Factors 178
Discussion Questions 178
References 179
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Contents ix
Chapter 8 Vulnerable Populations: Meeting the Health Needs of Populations Facing
Health Inequities 183
Monique J. Vasquez, Jacqueline Martinez Garcel, Elizabeth A. Ward, and
Lourdes J. Rodríguez
Introduction 184
Understanding Factors and Systems that Impact People Disproportionately A!ected by
Health Inequities 186
“e Growing Number of Health Inequities 192
Uneven Footing After the Great Recession and a Strained Social Service Sector 198
Organization and Financing of Health Care, Population/Public Health/Prevention, and
Other Services for Populations Experiencing Health Inequities 199
Rural Health Clinics and Rural Health Networks 201
Social Service Needs 203
Federal and State Financing of Care for Vulnerable Populations 206
Challenges for Service Delivery and Payment 208
Emerging and Tested Ideas for Better Health Delivery 210
Case Exercise 8.1—Patient Engagement: Bronx-Lebanon Hospital Department of Family
Medicine’s Patient-Centered Medical Home 213
Case Exercise 8.2—Integrated Care: Camden Coalition of Health Care Providers 213
Opportunities in the ACA to Meet Health Care Needs of Vulnerable Populations 214
Conclusion 219
Case Exercise 8.3—Plan for Refugees 220
Discussion Questions 220
References 221


Chapter 9 The Health Workforce 231
Joanne Spetz and Susan A. Chapman
Introduction 232
Who Is Part of the Health Workforce? 232
Traditional Approaches to Health Workforce Planning 234
Health Workforce Education 235
Critical Issues for the Health Workforce 240
Conclusion: Building the Future Health Care Workforce 248
Case Exercise—Workforce Recruitment Plan 248
Discussion Questions 248
References 249
Chapter 10 Health Care Financing 257
James R. Knickman
Introduction 258
General Overview of Health Care Financing 259
What the Money Buys and Where It Comes From 262
How Health Insurance Works 262
How Providers are Paid for the Health Services “ey Deliver 267
Specialized Payment Approaches Used by Payers 269
Conclusion 273
Case Exercise—Becoming an Accountable Care Organization Versus Not Becoming an
Accountable Care Organization 274
Discussion Questions 274
References 274
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x Contents
Chapter 11 Health Care Costs and Value 277
David C. Radley and John Marchica
Introduction 278
Spending Levels and Cost Growth 278
De!ning and Measuring Value in Health Care 284
Cost Drivers and Barriers to Value 286
Initiatives to Address Expenditure/Value Tradeo”s 294
Delivery System Reform 298
State-Driven Value-Based Initiatives 303
Conclusion 304
Case Exercise—Monitoring of Value 305
Discussion Questions 305
References 306
Chapter 12 High-Quality Health Care 311
Carolyn M. Clancy and Irene Fraser
Introduction 312
De!ning Quality 312
How are We Doing? 313
How Do We Improve Quality? 314
How Do We Incentivize Quality Care? 322
What are Major Recent Developments A”ecting Quality? 332
Core Competencies for Health Administrators 336
Conclusion 338
Case Exercise—Using Data to Support Sustainability 338
Discussion Questions 339
References 340
Chapter 13 Health Care Management 343
Anthony R. Kovner and Christy Harris Lemak
Introduction 344
Governance, Performance and Accountability 344
#e Complex Tasks of Leadership and Management 348
Evidence-Based Management 351
Challenges Managers Face 352
Conclusion 354
Case Exercise—Strategic Plan Report 355
Discussion Questions 355
References 355
Chapter 14 Health Information Technology 357
Karen B. DeSalvo and Y. Claire Wang
Introduction 358
Health Data Needs and IT Use Cases 359
Case Exercise 14.1—
NYC Macroscope 364
HIT Interoperability 365
Standards 367
Driving Forces Shaping the Use of Data and HIT 367
Case Exercise 14.2—Avera Health 370
Challenges to More E”ective Use of Information and Data 370
Privacy and Security 371
Current Marketplace and Emerging Opportunities 372
Conclusion 374
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Contents xi
Case Exercise 14.3—Electronic Health Records 374
Discussion Questions 374
References 375
Chapter 15 The Future of Health Care Delivery and Health Policy 381
James R. Knickman and Brian Elbel
Introduction 382
Forces Shaping Change in the Health System 383
Key Challenges that Will Receive Attention in Upcoming Years 388
Future Prospects for Di!erent Stakeholders in the Health Enterprise 391
Conclusion 393
Case Exercise—Payments and Budget Caps in Medicare 394
Discussion Questions 394
References 394
Appendix U.S. Government Public Health Agencies 397
Glossary 403
Index 423
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The Challenge of
Health Care Delivery
and Health Policy
Brian Elbel and James R. Knickman
Understand the importance of health and health care to American life
Describe defining characteristics of U.S. health care delivery
Discuss major issues and concerns
Identify key interest groups (stakeholders)
Explain the importance of engaging a new generation of health leaders
access to health care
customer friendly
fee-for-service system
health care delivery
health maintenance
health system
Patient Protection and Affordable Care Act
population health
© Springer Publishing Company DOI: 10.1891/9780826172730.0001
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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4 Part I. Health Policy
Why health is so important to Americans
Defining characteristics of the U.S. health care delivery system
Factors that shape the structure of the delivery system
Seven key challenges facing the health system
Stakeholders who shape and are affected by how the health system is
organized and how it functions
The organization of the book
Our goal in editing this book is to provide a vibrant introduction to the U.S. health
care system in a way that helps new students understand the wonders of health
and health care. !e book lays out the complexities of organizing a large sector of our economy
to keep Americans healthy and to help people
get better when they become ill. In addition,
the book provides a framework to help professors engage students, with room for each
professor to bring his or her perspective to
the materials covered.
To introduce students to the many parts of
the health system in the United States, we have
engaged some of the leading thinkers and “doers” in the health sector to explain the
parts of the system in which they are expert. Each author brings a di”erent perspective, and it is not our aim to present one voice on this topic. Rather, we have asked
each author to lay out the facts about a given topic and to o”er ideas about what he
or she thinks must happen to improve a speci#c aspect of the health system.
In many ways, the text lays out a serious “to do” list facing our health system and o”ers individuals beginning a health-related career a guide to the types
of challenges that could engage them. !e authors explain how the health system works, its challenge, and how individuals can contribute to the process of
strengthening our system to ensure it works e$ciently and e”ectively at the task
of keeping all of us healthy.
In this #rst chapter, we explain the importance of the health system, provide
an overview of how the system is organized, sketch out some of the challenges
facing the overall system addressed in the book, and discuss the roles of #ve types
of key stakeholders involved in the health enterprise. We also provide the logic
behind the topics the book addresses and explain the book’s organization.
Most of us are consumers
of health care, and some
are both consumers
providers, employers, or policy
makers. This means
all of us
have a stake in improving the
performance and delivery of
U.S. health care.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 1. The Challenge of Health Care Delivery and Health Policy 5
Our nation is built on the idea that society should ensure an opportunity for “life,
liberty, and the pursuit of happiness.” !ese words, of course, are from the second
sentence of our Declaration of Independence. !e aspiration of ensuring “life”
is the core goal of the health system. It is obvious that nothing is possible for an
individual without life, and most of us would agree that health is among the core
needs to live a vibrant, viable life. Good health is essential to participate in the
political and social system, to work to support ourselves and our families, and to
pursue happiness and a good life.
Our nation has invested a tremendous amount to learn how to keep people
healthy and how to restore health when disease, injury, or illness occurs. In the
19th century, researchers and public health experts from the United States and
other countries began to understand the role of germs in communicating disease
and the importance of basic public health practices, such as ensuring clean water
and safe sanitation to maintain health. In the 20th century, the science and art
of medicine exploded, creating amazing know-how to treat people who have
diseases, injuries, and illnesses.
In response to the emerging know-how for delivering medical care, a large
and complex health enterprise developed throughout the 20th century and continues to evolve. !e pipeline of new ideas for better treating illnesses is quite full
and promises to lead to ever-expanding methods to restore health when Americans have life-threatening medical problems. We are now faced with “personalized medicine” or the promise or hope that big data can solve many problems
related to health or health systems.
We use the word
enterprise deliberately because the health system is a blend
of an altruistic-oriented set of providers and activities mixed with a huge industry that accounts for a sizable portion of all economic activity in our society.
value we put on health has led us to devote just under 20% of our economic
resources to medical care and health promotion (see Chapter 10, Figure 10.1).
Fully 11% of all jobs in America are in the health sector (Altarum, 2018). Each of
us spends a sizable share of our income on the health care we need. We spend
this money through taxes, which support a good share of the health enterprise;
through foregone wages used by our employers to pay for health insurance; and
by sizable out-of-pocket health care expenses for which each of us is responsible.
!us, the pursuit of life, listed as a core principle in the Declaration of Independence, not only has resulted in a set of social and political norms about the
importance of good health to everyone in America but also has spurred a huge
industry that a#ects and is a#ected by society’s economic activity and economic
decisions. To understand the health system, we need to understand not only the
art and practice of medicine and public health but also the economic, organizational, and management issues that must be addressed to keep the health system
e#ective, e$cient, and a#ordable in our overall economic life. How we go about
organizing and managing the health system and changing it over time can hurt or
help both our health status and our economic status.
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6 Part I. Health Policy
It is ironic that most health professionals think of themselves as working within
health system when in truth one of the !rst de!ning features of what we
call a system is that health-related activities are not ordered or organized as a
single enterprise. Rather, e”orts to improve health and health care involve many
types of actors and organizations working independently and with little coordination to make contributions to improving health status. In particular, our current approach to delivering medical care has evolved and keeps evolving in a
haphazard way shaped more by economic incentives and opportunities than by
a central or logical design. Equally importantly, this is not just about medical
care, but social services and other systems in place that could have an even larger
impact on health.
In recent years, we also have begun to recognize the clear di”erence between
health maintenance and restoring health to a person who has a medical
problem. #e medical care system clearly takes charge of restoring health when
people are ill. Often the medical care system takes charge of caring for people
even if restoring health is impossible; the goal may be to limit the spread of a
medical problem, to alleviate the symptoms of a medical problem, or to help a
person cope with the pain and su”ering and loss of function when major medical
problems emerge. Doctors, nurses, technicians of various types, hospitals, nursing homes, rehabilitation centers, pharmaceutical companies, and medical device
companies are among the actors who engage in e”orts to care for people when
they have medical problems.
#e goal of maintaining health also involves many actors and activities. To
some extent, medical providers help with this huge task by providing screening
and prevention services that can keep people from becoming ill and help to identify illnesses very early when they might be easier to treat. However, good health
among a population also requires a vibrant public health and social service system that works to help people avoid illness. Public health activities include preventing epidemics; making sure food, water, and sanitation are safe; monitoring
environmental toxins; and developing community-based, public awareness, and
education initiatives to help people eat healthy foods, exercise, and not engage
in unhealthy behaviors such as smoking, drinking alcohol in excess, and using
recreational drugs or abusing prescription drugs.
Increasingly, we also recognize that the health of populations is determined
by social and economic factors. Adequate family incomes, high-quality educational opportunities, and being socially connected are all key factors that predict the
health of a given person. Social issues such
as discrimination, abuse, and social respect
all are important determinants of health. To
ensure attention to these issues and others
like them requires involvement from many
Adequate family incomes, highquality educational opportunities,
and being socially connected are
all key factors that predict the
health of a given person.
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Chapter 1. The Challenge of Health Care Delivery and Health Policy 7
sectors of our society as well as political leadership to guide collective action to
ensure our society encourages pro-health norms and practices. Some people
term this a “health in all” approach to social policy. !e relatively new concept
population health has also worked its way into the health system, with such
systems increasingly taking into account the lives of patients outside the walls of
their buildings.
We have organized this book so that it addresses both types of health issue
challenges: (a) keeping the population healthy and (b) providing e”ective medical care when needed. Other key de#ning characteristics of the U.S. health care
system guide the organization of this book:
■■ !e importance of organizations in delivering care. !ese include hospitals, nursing homes, community health centers, physician practices, social services agencies,
and public health departments.
■■ !e role of professionals in running our system. !ese include physicians, nurses,
managers, policy advocates, policy makers, researchers, technicians, and those directing technology and pharmaceutical businesses.
■■ !e emergence of new medical technology, smartphones, big data, and new pharmaceuticals. New techniques in imaging, smartphone-based apps, big data, machine
learning, pharmaceuticals, surgical procedures, DNA coding, and stem-cell technology are remarkable but often expensive ways of improving health care.
■■ Tension between “the free market” and “governmental control.” !is tension
shapes America’s culture but is sharply present, among the points of debate, in the
health care sector. Relative to citizens of other countries, Americans have more diversity of opinion about whether health care, or certain health care services, are “goods”
or “rights.” How one feels about this issue often determines whether a person thinks
the delivery of health care should be done by nonpro#t or for-pro#t organizations and
whether health care should be #nanced by taxes or private payments.
■■ A dysfunctional payment system. !e traditional way we have paid health care
providers rewards them for providing more and more billable services rather than
rewarding them for being e$cient and delivering e”ective care. !is
has begun to change with more frequent use of payment approaches that
reward valued services. But, we still have a long way to go to make it economically
logical for providers to be e$cient, to be customer or patient friendly, and to focus on
the delivery of high-value services. Also, the payment approach is not transparent for
individuals who use health care. For example, patients frequently have no idea what a
service costs until after it is delivered. !is is rarely true for other goods and services
in the U.S. economy.
!ese de#ning characteristics make
health care delivery a challenging part of
U.S. politics and the economy. Addressing the
challenges of delivering health care is worth
the best e”ort and thinking of our readers,
who are tomorrow’s health care leaders.
Addressing the challenges of
delivering health care is worth
the best effort and thinking of
our readers, who are tomorrow’s
health care leaders.
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8 Part I. Health Policy
Our health system can be improved in many ways. !e chapters that follow
address a long list of speci”c concerns. Many of these issues #ow, however, from
seven overarching themes regarding challenges that each of us in the health sector can address:
■■ Improving quality. Reliable studies have indicated that between 44,000 and 98,000
Americans die each year because of medical errors. Other well-regarded studies show
that people with mental health or substance use problems, asthma, or diabetes receive
care known to be e$ective only about half the time. In addition, the health system
could do much more to improve the experience of patients receiving care. !e system
is not always
customer friendly and has not adopted many practices routinely used in
other service sectors to improve the consumer experience. We have a good knowledge
base about how to organize care so that high-quality services happen virtually all of the
time. !e challenge is spreading this knowledge into practice across the nation.
■■ Improving access and coverage. Millions of Americans still lack insurance coverage, and millions more have inadequate coverage for acute care. !e federal health
reform, the
Patient Protection and Affordable Care Act (ACA; Obamacare), has
dramatically reduced the number of people who lack insurance coverage, though gaps
in coverage persist. Many states (though a decreasing number) have chosen not to
adopt some of the expansions for low-income residents because of political opposition. Even when Americans have insurance coverage,
access to health care is not
always ensured. Many rural areas have shortages of doctors and other providers, and
many doctors refuse to see patients with certain types of insurance (generally coverage
for low-income residents, or Medicaid coverage) because of low payment rates.
■■ Slowing the growth of health care expenditures. Health care expenditures are
simply the price of services multiplied by the volume (or number) of services. Total
expenditures are growing much more rapidly than the rest of the economy because
both prices and volume of services have increased relentlessly over the past 50 years.
To keep health care a$ordable for middle-class and low-income residents—as well as
for taxpayers and employers—we need to devise ways to moderate the ever-increasing
share of our nation’s economy devoted to the health sector. !e challenge is to determine how to restructure delivery and payment so we can focus on high-value care
as we get more e%cient, with less waste. !ere has been progress in bringing costs
of care down, especially due to the dynamics put in place by the great recession that
started around 2008. Unfortunately, progress in reducing costs has helped businesses
and government payers of care much more than it has helped individuals who have to
buy health insurance in the private market place.
■■ Encouraging healthy behavior. Healthy behavior can help people avoid disease and
injury or prevent disease or injury from getting worse. For millions of Americans, leading healthy lives is not of the highest priority relative to other more pressing factors in
their lives. Changing health-related behavior is a di%cult challenge, and one that health
systems are increasingly taking on, but we need to identify e$ective prevention programs
and ways to make our social and built environments more encouraging of healthy choices.
■■ Improving the public health system. !e governmental public health infrastructure
maintains population health and regulates aspects of the health care delivery system.
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Chapter 1. The Challenge of Health Care Delivery and Health Policy 9
State and local health departments monitor the health of residents, provide a wide
range of preventive services, and regulate health care providers and businesses, such
as restaurants, that a!ect population health. “e e!ectiveness and funding of state,
municipal, and county health departments vary widely.
■■ Improving the coordination, transparency, and accountability of medical care.
Problems of quality, cost, and access are caused by fragmentation and lack of coordination at the community level. “is fragmentation exists both within and between
health care organizations. It is a!ected by a lack of integrated and electronic record
systems and by a lack of cooperative relationships among di!erent types of providers who treat the same patient. For example, primary care physicians, hospitals, and
specialty physicians often fail to work as teams or in coordinated ways. Consumers
often are not given all of the information they deserve to make adequate medical
choices. Providers often refuse to reveal the prices they will charge patients, second
opinions are still not encouraged as frequently as they should be, and patients often
do not get clear explanations of treatment options or the pros and cons of these
■■ Addressing inequalities in access and outcomes. In the United States, medical care
and its associated outcomes depend on one’s income level, race, and geographical location. In many cases, the care received by those with less income is subpar. Moreover,
studies demonstrate that access and outcomes vary by race, even for Blacks, Latinos,
and Whites who have the same incomes and education levels. Marked di!erences also
exist in access, quality, and outcomes across di!erent regions of our country. Best
practices do not spread easily or quickly. Addressing these inequalities is a major challenge facing the health sector.
A complicated enterprise like the health system includes many types of stakeholders. A stakeholder group is a set of people who have a strong interest in how
something in our society is done. In addition, stakeholders generally have some
power in shaping what happens. Finally, di!erent stakeholders may have very different goals and views about what should be done and how.
To understand the health system, one needs a good scorecard of the interests and roles of distinct stakeholder groups. Each contributor to this book
gives attention to roles of stakeholders. “e stakeholders that keep appearing as
the story of the health system unfolds include #ve key groups: (a)
(b) providers and other professionals engaged in the health system, (c) employers,
(d) insurers, and (e) public policy makers.
Individual consumers (or patients) should
be at the center of the health system. After
all, it is their needs and wants that are the
A stakeholder group is a set
of people who have a strong
interest in how something in our
society is done.
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10 Part I. Health Policy
reason for this giant enterprise. In some ways, however, individuals sometimes
seem like bystanders in health care decisions. Often, physicians and other providers assert that they know best and fail to have a patient co-manage a medical
problem or be a full partner in selecting a choice of action. Or, perhaps worse, an
insurer decides what is best or “allowed” given a speci!c health condition.
Individuals are also bystanders in issues about payments. Providers sometimes think their “customer” is an insurance company because the insurer pays
much of the bill. In addition, the same provider (unknown to many individuals)
may charge astonishingly di”erent prices to di”erent groups and individuals. #e
usual norm in our economy, unlike in health care, is that the person receiving
goods or a service is the customer, and the customer has a right to know what the
charge will be before purchasing the good or service.
Even so, individuals are in$uential stakeholders in many ways. For example,
when there is widespread dissatisfaction among them, change happens. Insurers
changed the rules of early managed care payment systems in the 1990s due to
consumer complaints. Similarly, a major federal program o”ering a new form of
catastrophic insurance to elders was repealed after sharp dissatisfaction among
Most experts argue that individuals need to be at the center of health care
choices. Additionally, individuals need to understand the crucial role their
behavioral choices play in determining their health status. Choosing to eat
healthy foods, stay physically active, drink alcohol moderately, and abstain from
tobacco products are among the most important choices they make to protect
their health.
What do individuals want as key stakeholders? Most importantly, they want
good access to health care for themselves and their families. Polls indicate that
individuals value good-quality care and a”ordable care. #ey would also like to be
treated well by providers and have a good experience when they need care.
Providers and Other Professionals Engaged in Making the
Health System Operate
Many professionals work to advance medical knowledge, medical practice, and
the business of health care. #e vast majority of this
workforce is motivated principally by the social goal of keeping people healthy. Medical providers, caregivers,
pharmaceutical and medical device companies, and researchers have created an
impressive set of interventions that can help people who are sick.
In recent years, however, many members of the broad health workforce have
faced great !nancial pressure to prevent the costs of health care from increasing
as quickly as in the past. Payment systems keep lowering the fees paid for goods
and services, and consumers and payers have been demanding better quality, better outcomes, more value, and better patient experiences. In addition, the organization of services has begun to evolve quickly.
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Chapter 1. The Challenge of Health Care Delivery and Health Policy 11
More and more physicians and other
providers are working in large practices
compared with the small ones that used to
be the norm. Hospitals are merging with
other types of medical providers, and the
approach insurers use to pay for services
is changing rapidly. A greater number of
professionals, inside and outside the health
system, are also increasingly engaged in
working to improve health.
Understanding the views and needs of the health workforce and the organizations dedicated to improving health is crucial to understanding how the system
works and how to improve the system. !e following chapters suggest that providers and professionals engaged in the health enterprise would value simpler
rules that govern how care is provided and fair opportunities to earn incomes
that re”ect their expertise and their large investments in training.
Employers are stakeholders because most businesses o#er employees private
health insurance as a key element of their compensation package. In this sense,
the cost of health insurance is a cost of doing business for employers and can
greatly a#ect the pro$tability of a business. For example, employee health care
costs add approximately $1,500 to the cost of producing every automobile manufactured in the United States.
In their role as stakeholders, employers want to see a slowdown in their
health care cost responsibility as compared with the last 50 years. In addition,
employers want healthy employees who are productive and do not have to take
time o# from work due to illness. !ese desires lead some employers to advocate
for high-quality health care and for wellness and prevention programs that help
employees stay healthy.
Insurance companies act as the intermediary among payers (often employers),
providers (who need a system for getting paid), and consumers (who need a system
to determine the kinds of health care covered by the employer’s insurance plan).
In some cases, insurers take some $nancial risk: If the payments they make
to providers exceed the premiums set for employers, the insurer loses money.
Increasingly, however, the insurer leaves the employer to bear the risk and plays
the role of a pure intermediary, setting rules to determine when a health service
is eligible for reimbursement and other rules to determine what payment is made.
Of course, an insurer must negotiate these rules with employers and providers.
Understanding the views and
needs of the health workforce
and the organizations dedicated
to improving health is crucial to
understanding how the system
works and how to improve the
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12 Part I. Health Policy
As stakeholders, insurers always face pressure. Employers, consumers, and
providers often have tense relationships with insurers, who in many ways play
the role of referees in health care. Payers often feel that the costs of running the
insurance process are too expensive.
Some approaches to payment currently exist that could compete with traditional insurance companies. Some health systems are starting their own insurance companies, and it is possible that capitated payment systems (payment of a
premium for a person/family for the year regardless of use of covered bene!ts)
could bypass traditional insurance systems and go directly from payers to providers. Insurers want to protect their role in the health sector. “ey also seek to
expand their role by o#ering analytical services that can support higher-quality
and more e$cient delivery approaches.
Public Policy Makers
“e !nal type of stakeholder we consider is policy makers; both appointed public o$cials and elected politicians are included in this category. However, policy
makers do not act as a single stakeholder group. Instead, various components of
this group set agendas, which often con%ict with one another.
Elected o$cials di#er strikingly in their views about how the health system
should work and about the role government should play in health care. At times,
di#erences in views re%ect di#erent ideologies. Sometimes, however, di#erent
views emerge about how best to manage the extensive responsibilities that have
fallen to government over the past 80 years.
Consensus does exist on some policy issues, however, within this stakeholder
group. Most elected o$cials and civil servants working on health issues would
like to see slower in%ation rates in the health sector. In addition, there is consensus that the U.S. health system should use state-of-the-art medical care and
prevention interventions. Finally, there is a common sense that quality and the
patient experience should be important concerns of health providers.
“e book is organized into four parts:
Part I: Health Policy—has chapters on the current state of health care delivery, charts depicting key statistics, a discussion of the important role of policy,
and a comparative analysis of health care delivery in other countries.
Part II: Keeping Americans Healthy—has four chapters on population health,
public health, behavioral health, and the health of vulnerable populations.
Part III: Future of Health Care Delivery and Health Policy in the United
has six chapters on organization of care, workforce, !nancing, cost and
value, quality of care, health care management and governance, and information
Part IV: Futures—summarizes key ideas addressed in the book, with a look to
the future about how change in the health system might play out.
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Chapter 1. The Challenge of Health Care Delivery and Health Policy 13
!e editors remain optimistic that pragmatism, “exibility, consensus building,
and attention to objective, high-quality evidence can bring about positive change.
We remain stimulated by the challenges we face as we work hard at the local, state,
and national levels to create and sustain a viable and e#ective health care system.
Certainly, we have observed that best practices are now used to improve
health care and health across a wide range of settings in the United States and
worldwide. How do we speed up the process of getting more for the money we
spend, and how do we engage every type of stakeholder to bring about more
e#ective services by insisting on best practices in everything we do? !is book
gives the reader the motivation and skills to get engaged.
!e future U.S. health care delivery system will see improvements if committed and informed Americans choose to enter the $eld and engage e#ectively.
Future leaders who are knowledgeable about the health sector and who know
how to implement e#ective change are needed. !e system also needs to improve
quality, get more value for cost, improve patient participation in self-care, and
encourage provider transparency and accountability.
You are an aide to the governor of State X. A billionaire has said he will give the governor $3
billion if he comes up with a satisfactory plan to improve health and medical care for the state.
Assume the state currently spends $300 billion on health care annually. The goal is ensuring
quality of health care, improving the patient experience, improving the overall health of the
state’s population, and containing the increase in health care costs. Develop the criteria for
assessing the success of the plan. Where will the major shifts in resources occur? Give a
rationale for your recommendations.
As you consider this case, you might address the following questions:
1. How might the billionaire evaluate whether the governor’s plan is satisfactory?
2. After the money is given to fund the plan, what must happen to improve health care
delivery performance substantially in State X?
1. What is the real and perceived performance of the U.S. health care system? How do
views di#er among di#erent groups of patients, providers, payers, and politicians?
2. Why do we spend so much money on health care?
3. Why isn’t the population healthier?
4. How is the ACA part of the problem or part of the solution to improving health care
delivery in the United States?
5. What are your priorities to improve the value of health care Americans get for the
money we spend? What is your rationale for these priorities?
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14 Part I. Health Policy
Altarum. (2018). Health care jobs engine propels share of total jobs to all-time high.
Retrieved from
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Organization of Care
Amy Yarbrough Landry and Cathleen O. Erwin
Describe the current care delivery system
Define and distinguish between types of health care services along the
continuum of care
Identify and discuss types of organizations in the U.S. health care delivery
Increase awareness of new mechanisms for health system performance
Understand and discuss future trends in the health delivery system
Describe innovative approaches to improving care delivery
academic health center
accountable care organizations (ACOs)
ambulatory care
average length of stay (ALOS)
centers of care
chronic care
community health improvement
continuing care retirement community
continuity of care
continuum of care
© Springer Publishing Company DOI: 10.1891/9780826172730.0002
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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AN: 1998657 ; James R. Knickman, PhD, Brian Elbel, PhD, MPH.; Jonas and Kovner’s Health Care Delivery in the United States, 12th Edition
Account: s3563253.main.ehost

16 Part I. Health Policy
corporate practice of medicine (CPOM)
emergency care
end-of-life care
health homes
horizontal integration
hospice care
instrumental activities of daily living (IADLs)
long-term care
multispecialty group practice (MSGP)
palliative care
patient-centered medical home (PCMH)
population health
prehospital care
primary care
private practice
public health agencies
quaternary care
rehabilitation clinics
same-day surgery
single specialty group practice
solo practice
specialty care
special hospitals
subacute care
tertiary care
urgent care centers
vertical integration
The current organization of the health care delivery system
Types of health care delivery organizations
Health system performance
The future of the health care delivery system
Examples of best practices in the organization of medical care
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Chapter 2. Organization of Care 17
In the United States, health care is delivered through a complex and multifaceted system of private and public institutions that operate in cooperation with,
but largely independent of, each other. Unlike
many other countries, the United States has
no central governmental agency to control
the delivery of health care, although delivery is heavily in!uenced through health
care legislation and the government’s role
as a major purchaser of health care services
through Medicare, Medicaid, and other public
programs. “e
continuum of care in the United States encompasses care from
the cradle to the grave and includes services focused on both the prevention and
the treatment of medical conditions and diseases as well as end-of-life care.
“e individuals and organizations that provide care in the United States are
faced with increasing pressure and scrutiny from the government, private insurance organizations, and the public to provide the highest quality of care while
controlling costs and increasing access to underserved populations. Consequently, health care services and organizational structures are continuously being
adapted to meet the demands and mandates of health care policy and to survive
and thrive in this dynamic health care environment.
“is chapter describes the current health care delivery system in the United
States, including services, organizations, health system performance, and new
innovations in care delivery.
“e World Health Organization (WHO) de#nes health as a “state of complete
physical, mental and social ‘wellbeing’ and not merely the absence of disease or
in#rmity” (WHO, 2017). By de#nition, the health system includes all organizations, institutions, and resources that have a primary purpose of promoting,
restoring, and/or maintaining health (WHO, 2015). From a broad, comprehensive
perspective it includes care delivered through traditional clinical and public health
settings as well as contributions to health from a variety of community organizations that have a stake in or can a$ect the health of individuals and communities.
“e following sections provide a general discussion of the types of clinical health
care services available in the United States, the types of organizations through which
these services are delivered, and how these and other organizations are involved in
the #elds of community health, community bene#t, and population health.
Health Care Services
Health care services are provided for the purpose of contributing to improved
health or to the diagnosis, treatment, or rehabilitation of sick people. Health care
The organization of the nation’s
complex and multifaceted
health care system can
evolve as patients’ needs and
government regulations and
policies change.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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18 Part I. Health Policy
services include prevention, cure, rehabilitation, and palliation e!orts oriented to either
individuals or populations.
Prevention of disease and maintenance of
general good health are the focus of health
promotion and preventive services. Health status is a!ected by a number of factors, including health policy, individual behavior, social determinants, physical
determinants, biology and genetics, and availability of health services. Services
associated with prevention may be focused on the health of an individual or the
health of a population. Although prevention services have always been available
in the United States, an even greater emphasis is placed on prevention because of
its prominence in the Patient Protection and A!ordable Care Act of 2010 (ACA)
as an essential component of health insurance bene”ts. Most health plans must
cover a set of preventive services at no cost to the bene”ciary. Additionally, a variety of new reimbursement mechanisms used by both private and governmental
payers incentivize provider organizations to keep patient populations healthy and
out of the hospital.
#e prevention “eld often distinguishes interventions delivered by a health
care provider (clinical prevention services) from those delivered by non–health
care providers (community-based prevention initiatives). According to the Institute of Medicine (IOM, 2012), a holistic view of community-based prevention
incorporates cultural, social, and environmental changes; also, community-based
prevention is often more di%cult to fund and sta! than clinical interventions.
Certain preventive services may be o!ered through a clinical–community relationship that might entail a primary care provider making a connection with a
community-based organization to provide speci”c services (such as a community-based weight-loss program) or collaboration between clinical and community-based organizations to network, coordinate, or cooperate on preventive
services delivery. Additionally, the “eld sometimes distinguishes between prevention initiatives that focus on individuals one at a time and initiatives that are
more population-based, working with larger groups of people (e.g., e!orts to
increase the availability of healthy food in low-income neighborhoods).
between the “elds of public health, community health, and
population health,
which are sometimes used interchangeably yet di!er somewhat in de”nition and
scope. Traditionally, public health has been viewed as a function of federal, state,
and local public health departments to address health concerns a!ecting the public at large, such as preventing epidemics, containing environmental hazards, and
promoting healthy living (IOM, 2003).
A more expansive view of public health is the concept of
community health
or community bene”t, which focuses on collaboration among a
wide array of organizations (e.g., public health departments, health care delivery
organizations, social service agencies, government entities) to address issues
Health care services are
provided for the purpose of
contributing to improved health
or to the diagnosis, treatment, or
rehabilitation of sick people.
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Chapter 2. Organization of Care 19
impacting the health of a particular community. !e interest in how health care
and public health activities could be coordinated to improve the health of communities was accelerated in the mid-1990s, fueled by organizations such as the
Robert Wood Johnson Foundation, Institute of Medicine, and U.S. Department of
Health and Human Services and organized hospital groups such as the Catholic
Hospitals of America and Voluntary Hospitals of America (VHA), among others.
!e Association for Community Health Improvement is an a”liate organization
of the American Hospital Association (AHA) and serves as a national association
for community health, community bene#t, and population health professionals.
!is is one avenue through which hospitals and health systems receive educational resources, tools, networking opportunities, and professional development
to assist in achieving organizational community health goals.
Although many health care organizations actively engaged in community
health needs assessment and activities prior to the passage of the ACA, the ACA
mandates that all nonpro#t hospitals complete a community health needs assessment (CHNA) process every 3 years. CHNAs are a tool that have long been used
by hospitals, public health departments, and other social service agencies (e.g.,
United Way) to identify and prioritize signi#cant health needs in the community.
Community health also encompasses a broad perspective on the various components or factors that a$ect the health of a community, such as employment,
crime, education, housing, transportation, food, and medical care.
More recently, the concept of
population health has become an important
topic and focus for health care delivery organizations and payers. It has been
de#ned as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart, 2003). In general,
population health focuses on health status indicators for a de#ned group of
people, and the goal of population health management is to improve the health
of the population and reduce inequities or disparities between population
groups. Ways that organizations approach population health management will
be described later in this chapter.
Clinical prevention services are often categorized as primary, secondary, or
tertiary, based on the stages of the disease they target.
PRIMARY PREVENTION SERVICES Primary prevention services are focused on preventing or reducing the probability of the occurrence of a disease in the future. Services are provided through public and private institutions and are often focused
on educating the public about the risks associated with individual behaviors that
can negatively a$ect their short- and long-term health.
Examples of primary prevention include immunizations for prevention of
childhood diseases, smoking cessation programs to reduce the risk of lung cancer
and heart disease, weight loss programs, prenatal and well-baby care, programs
to increase workplace safety, and the promotion of hand washing to reduce the
spread of in&uenza or other diseases. !e services are provided through a wide
variety of institutions, such as public health departments, physician o”ces,
hospitals, social service agencies, places of employment, houses of worship, and
broadcast media, among others.
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20 Part I. Health Policy
SECONDARY PREVENTION SERVICES !ese services are focused on the early detection
and treatment of disease in order to cure or control its e”ects. !e goal is to minimize the e”ects of the disease on the individual. Secondary services are largely
focused on routine examinations and tests such as blood pressure screenings,
Pap smears, routine colonoscopies, examination of suspicious moles, and mammograms. Early detection and treatment often increases the probability of a successful outcome.
TERTIARY PREVENTION SERVICES !ese services are targeted at individuals who already
have symptoms of a disease in order to prevent damage from the disease, to slow
down its progression, to prevent complications from occurring as a result of the
disease, and ultimately to restore good health to the person with the disease.
Tertiary prevention includes services such as providing diabetic patients with
education and counseling on wound care. It also includes institutional practices
such as infection control in a hospital facility to prevent illness or injury caused
in the process of providing health care.
Acute Care
Acute care is short-term, intense medical care providing diagnosis and treatment
of communicable or noncommunicable diseases, illness, or injury. !e de#nition of acute care varies across the scholarly literature and textbooks. Acute care
is sometimes de#ned as
primary, specialty, tertiary, or quaternary in nature,
centered around the care delivered by physicians and other providers in clinical
settings (such as physician o$ces and hospitals). Acute care services may be provided on an
outpatient basis (i.e., not requiring an overnight hospital or health
care facility stay) or on an
inpatient basis (i.e., requiring an overnight stay).
A more comprehensive de#nition of acute care includes not only these services
but also the emergency services provided in the community given the time-sensitive nature of the need for diagnosis and treatment. One proposed de#nition of
acute care includes the components of the health system where acute care is delivered to treat unexpected, urgent, and emergent episodes of illness and injury that
could lead to disability or death without rapid intervention (Hirshon et al., 2013).
Based on this de#nition, acute care encompasses a range of functions including
emergency care, trauma care, prehospital emergency care, acute care surgery,
critical care, urgent care, and short-term inpatient stabilization (Figure 2.1). !e
following sections outline the types of acute care based on the framework illustrated in Figure 2.1, although not all of the domains are discussed because of obvious overlaps. !e primary, specialty, tertiary, and quaternary care de#nitions are
incorporated into the framework to show where these levels of care best #t within
the acute care model and to note relationships to other forms of care.
EMERGENCY AND URGENT CARE Emergency care is designed to provide immediate
care for sudden, serious illness or injury, although it is sometimes utilized for
nonemergent care by individuals who are uninsured or underinsured. A medical
emergency is de#ned by what is known as the prudent layperson standard:
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Chapter 2. Organization of Care 21
[A] condition with acute symptoms of su!cient severity (including severe pain)
such that a prudent layperson, who possesses average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to
result in (i) placing the health of the individual (or unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any
bodily organ or part. (Social Security Act § 1867)
Emergent types of care (such as trauma) can be classi”ed by the triage level,
that is, by the emergency severity index (ESI). #e ESI is a “ve-level triage algorithm that clinically strati”es patients into groups based on immediacy of the
need to be seen, which includes the following levels:
1. Immediate (less than 1 minute)
2. Emergent (1–14 minutes)
3. Urgent (15–60 minutes)
4. Semiurgent (61–120 minutes)
5. Nonurgent (121 minutes–24 hours)
In 2015, .7% of ED visits were classi”ed as immediate, 7.4% as emergent, and
29.8 as urgent; the remaining 61.2% were either semiurgent, nonurgent, not triaged, or unknown (Centers for Disease Control and Prevention [CDC], 2017).
#e Emergency Medical Treatment & Labor Act of 1986 (EMTALA) requires
that all patients who present themselves for treatment at an ED must be screened
and evaluated, provided the necessary stabilizing treatment, and admitted to the
hospital when necessary—regardless of ability to pay.
Urgent care is used for an illness, injury, or condition that is serious enough
for a reasonable person to seek care right away but not so severe as to require
ED care. It is considered
ambulatory care, which means that the person in need
of care can walk (or ambulate) into the facility. However, a patient in need of
“ambulatory” care may need some assistance entering the facility, depending on
the nature of the illness or injury (e.g., severe ankle sprain). Services are provided
by physicians and advanced practice providers (such as nurse practitioners or
physician assistants) typically on a walk-in basis without a previously scheduled
appointment because of the immediacy of the need. Urgent care services may be
provided through a traditional physician practice or an urgent care center.
PREHOSPITAL CARE Prehospital care includes medical services provided in the community, such as stabilization by emergency services before or during transportation to a health care facility. It also includes evaluation and treatment provided
through local, community-based providers, as in a private physician practice
Primary care. Primary care is the “rst and most general source for routine
treatment of illness and disease. Primary care providers may be physicians, physician assistants, or nurse practitioners who have trained in family medicine,
internal medicine, pediatric medicine, gerontology, or other primary care “specialties,” such as obstetrics and gynecology. In the managed care environment,
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22 Part I. Health Policy
aTreatment of individuals with acute surgical needs, such as life-threatening injuries, acute appendicitis, or
strangulated hernias.
bTreatment of individuals with acute life- or limb-threatening medical and potentially surgical needs,
such as acute myocardial infarctions or acute cerebrovascular accidents, or evaluation of patients with
abdominal pain.
cAmbulatory care in a facility delivering medical care outside a hospital emergency department, usually on
an unscheduled, walk-in basis (e.g., evaluation of an injured ankle or fever in a child).
dTreatment of individuals with acute needs before delivery of de!nitive treatment (e.g., administering
intravenous “uids to a critically injured patient before transfer to an operating room).
eCare provided in the community until the patient arrives at a formal health care facility capable of giving
de!nitive care (e.g., delivery of care by ambulance personnel or evaluation of acute health problems by
local health care providers).
fSpecialized care of patients whose conditions are life-threatening and who require comprehensive care
and constant monitoring, usually in intensive care units (e.g., patients with severe respiratory problems
requiring endotracheal intubation and patients with seizures caused by cerebral malaria).
Source: Hirshon, J. M., Risko, N., Calvello, E. J. B., de Ramirez, S. S., Narayan, M., #eodosis, C., &
O’Neill, J. (2013). Health systems and services: #e role of acute care.
Bulletin of the World Health Organization, 91, 386–388. doi:10.2471/BLT.12.112664. Used with permission.
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Chapter 2. Organization of Care 23
primary care delivery plays an important role in the coordination of care to help
control costs and ensure that the appropriate level of care is sought for the health
concern. Primary care providers are involved in delivering both acute care and
preventive care.
Specialty care. Specialty care refers to care delivered through providers who
are trained as specialists or subspecialists in the !eld of medicine. “is type of care
sometimes requires a referral from a primary care physician. Specialists focus on a
particular body system or on a speci!c disease or condition; they have the knowledge and expertise to handle medical conditions beyond the realm of primary
care. For example, cardiologists diagnose and treat conditions involving the heart,
endocrinologists focus on hormone systems and may specialize in a disease such
as diabetes, and neurologists are trained to diagnose and treat disorders associated
with the nervous system—brain, spinal cord, and so on. Similarly to primary care,
specialty care may be utilized to address both acute and preventive care needs.
Chronic care. Chronic care is the continual treatment and monitoring of
conditions that can be controlled but not cured; it includes both physical and
behavioral conditions. Examples of chronic conditions include diabetes, hypertension, and depression. As the life expectancy of the population has increased, so
have the incidence and prevalence of chronic conditions. It is estimated that more
than one-fourth of all Americans and two out of three older Americans have at
least two chronic conditions, and approximately 66% of the nation’s health costs
are attributable to the treatment of people living with multiple chronic conditions (Agency for Healthcare Research and Quality, 2013).
“e management and treatment of chronic conditions may be delivered by
primary and/or specialty care providers. By de!nition, chronic care is not considered acute care; however, chronic conditions can cause or exacerbate acute
episodes of illness. Chronic care also !ts within the category of preventive services, which include services that focus on the early detection and management
of chronic conditions.
TERTIARY CARE Tertiary care typically involves hospitalization for specialty care
that requires highly specialized equipment and expertise and involves more complex therapeutic interventions, such as coronary bypass surgery, neurosurgery,
advanced neonatal intensive care, or treatments for severe burns or injuries. Some
tertiary care services may be provided on an outpatient basis, such as same-day
surgeries. Patients are admitted to a tertiary facility through a
practitioner order
from a quali!ed provider who has been granted admitting privileges by the facility.
QUATERNARY CARE Quaternary care, an extension of tertiary care, entails providing
the most complex medical and surgical care for highly specialized and unusual
cases. It may involve experimental procedures, experimental medications, or very
uncommon surgeries or procedures. Examples of quaternary care are advanced
trauma care and organ transplantation. Quaternary care is not o#ered by every
hospital or medical center; it is more likely to be found in academic medical centers.
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24 Part I. Health Policy
SUBACUTE INPATIENT CARE Subacute care is a level of inpatient care needed by a
patient immediately after or instead of hospitalization for an acute illness, injury,
or exacerbation of a disease process. !is level of care centers on providing one
or more active medical conditions or administering one or more technically complex treatments. It requires more intensive skilled nursing care than is provided
to the majority of patients in a skilled nursing facility (i.e., nursing home).
!e term “subacute care” has been applied to a broad range of medical and
rehabilitative services and settings that provide care to patients after an acute
care episode. It combines rehabilitation and convalescent services for patients
who typically need 10 to 100 days of treatment and is provided in settings other
than in acute care hospital beds. Subacute care is delivered in facilities licensed to
provide the appropriate level of care, which includes special units established by
acute care hospitals and skilled nursing facilities.
Rehabilitative Care
Rehabilitative health care services are aimed at restoring a person to his or her
original state of health (or as close as possible). Rehabilitation services help a person keep, regain, or improve skills and functioning for daily living that have been
lost or impaired because of illness or injury. Services include physical therapy,
occupational therapy, speech–language pathology, and psychiatric rehabilitation.
Rehabilitative services are o”ered in a variety of inpatient and outpatient settings.
Long-Term Care
Long-term care encompasses a range of services and support provided to meet
personal care needs on a long-term basis, most of which is not medical care. It
encompasses an array of services provided in a variety of settings for people who
have lost some independence because of a medical condition, injury, or chronic
illness. Long-term care is often used to provide assistance with
activities of daily
living (ADLs)
, such as bathing, dressing, using the toilet, transferring to or from
a bed or chair, and eating, among others. Other common services and support
assist with
instrumental activities of daily living (IADLs), which are everyday
tasks, such as housework, taking medication, preparing meals, shopping, and
responding to emergency alerts, among others.
!e duration and level of long-term care needed by individuals vary and often
change over time. Long-term care services may be provided in an individual’s
home or in a community setting or institution.
End-of-Life Care
End-of-life care is provided in the #nal hours or days of an individual’s life. !is
type of care includes physical, mental, and emotional comfort as well as social
support for people who are living with and dying of terminal illness or a condition that is advanced, progressive, and incurable. End-of-life care requires a range
of decisions. !ese decisions may include preparing advance directives to make
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Chapter 2. Organization of Care 25
end-of-life wishes clear to family and providers as well as determining the types
of treatment and care that will be utilized.
Palliative care is the treatment for discomfort, symptoms, and stress of serious illness, providing relief from pain, fatigue, nausea, shortness of breath, loss of
appetite, or problems with sleep. Palliative care can be received at any stage of an
illness but is always included in hospice care.
When the focus shifts from cure to care, a patient moves to hospice care.
Hospice care is end-of-life care utilized when a patient is expected to live 6
months or less. It is provided by a team of health care professionals and volunteers in the home, a hospice center, a hospital, or a skilled nursing facility. Hospice
programs also provide services to support a patient’s family. !e interdisciplinary
hospice team usually consists of the patient’s personal physician; hospice physician or medical director; nurses; hospice aides; social workers; bereavement
counselors; clergy or other spiritual counselors; trained volunteers; and speech,
physical, and occupational therapists, if needed.
Health Care Delivery Organizations
!is section discusses the wide range of organizations that exist to deliver health
care services, including hospitals, health systems, physician o”ces, specialty hospitals, long-term care facilities, rehabilitation hospitals, home health agencies,
and other health-related organizations.
By de#nition, a hospital (other than psychiatric) is an institution primarily engaged
in providing, by or under the supervision of physicians, to
inpatients, diagnostic
and therapeutic services for medical diagnosis, treatment, and care of injured,
disabled, or sick persons; or rehabilitation services for injured, disabled, or sick
Outpatient services are optional but have been growing in importance
over time as more and more medical interventions can be done in an outpatient
setting and as the #eld sees growing importance to integrating primary care, specialty care, and inpatient care for reasons of both quality and e”ciency.
According to the AHA (2018), the United States has approximately 5,534
registered hospitals, which include all community, federal, psychiatric, and longterm care hospitals and hospital units located in institutions (such as prison
hospitals, college in#rmaries, and so on). Hospitals can be categorized in a number
of ways, such as by purpose, size, ownership, location (urban or rural), teaching
status, or system a”liation. Most hospitals in the United States provide general
medical and surgical services on a short-term basis. !e four primary categories
for hospitals according to the AHA are (a)
community, (b) special, (c) rehabilitative and chronic disease, and (d) psychiatric.
Hospitals are subject to federal and state regulations. A hospital must be
licensed to operate; licensing is handled at the state level by the agency or entity
designated with such authority for the state. Licensure focuses on physical plant
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26 Part I. Health Policy
requirements, sanitation, personnel, and equipment. To receive reimbursement
for services provided to Medicare and Medicaid patients, hospitals must receive
certification from the federal government. Hospitals may choose to pursue
accreditation by !e Joint Commission, an independent, nonpro”t organization
that accredits hospitals and other types of health care institutions. !is voluntary
participation in accreditation is a symbol of quality that indicates the organization has met certain performance standards. !e Centers for Medicare & Medicaid Services (CMS) recognize accreditation as suitable proof that a hospital has
met the minimum requirements to receive certi”cation.
Patients are referred to the hospital for services on the authority of a member
of the medical sta# (i.e., a physician) who has been granted admitting
in accordance with state law and criteria for standards of medical care established
by the facility. Hospitals provide both
inpatient (requiring an overnight stay) and
outpatient services (not requiring an overnight stay). Outpatient services are
sometimes referred to as
ambulatory care, which means the patient is able to
walk (ambulate) into the facility to receive diagnostic or therapeutic treatment.
However, in actuality not all patients who receive outpatient services can ambulate (e.g., patients brought to the ED by ambulance).
COMMUNITY HOSPITALS By AHA de”nition, community hospitals are all nonfederal,
general, and other special hospitals accessible by the general public.
General hospitals provide patient services, diagnostic and therapeutic, for a variety of medical conditions; the
average length of stay (ALOS) is less than 25 days.
Hospitals also provide diagnostic x-ray services, clinical laboratory services, and
operating room services with facilities and sta# for a variety of procedures. Services are provided on both an
inpatient and an outpatient basis. Traditionally,
hospitals primarily have delivered care on an inpatient basis, but over the past
three decades more services have been moved to an outpatient, or
basis to contain costs. In addition to cost containment, medical practices have
advanced enabling many procedures that previously required an overnight stay
to become less invasive and therefore require a shorter recovery period that can
be achieved at a patient’s home without nursing care.
Special hospitals provide diagnostic and treatment services for patients who
have speci”ed medical conditions, both surgical and nonsurgical. !ese hospitals
must provide the services deemed appropriate for the speci”ed medical conditions for which services are provided.
Community hospitals are grouped by ownership in three categories:
■■ Voluntary, not-for-pro”t (nonpro”t)
■■ Investor-owned (for-pro”t, proprietary)
■■ Public (state or local government owned and managed)
Some community hospitals operate as free-standing single hospital entities,
whereas others are part of a health system. A system is de”ned as either amultihospital
or diversi”ed single hospital system. Community hospitals may also be classi”ed as
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Chapter 2. Organization of Care 27
participating in a network, which is de!ned as a group of hospitals, physicians, other
providers, insurers, and/or community agencies that work together to coordinate
and deliver a broad spectrum of services to the community (AHA, 2018).
Hospitals may also be classi!ed by teaching status—teaching hospitals are
a”liated with medical schools and provide clinical education, residencies, and
internships for medical and dental students. #ese teaching hospitals (along with
other hospitals not a”liated with a medical school) also provide clinical education and training for nursing and allied health professions students. Teaching
hospitals are typically voluntary, not-for-pro!t or public, government-sponsored
hospitals. Some teaching hospitals operate as part of an
academic health center, which comprises an allopathic or osteopathic medical school, one or more
health professions schools (e.g., allied health, dentistry, nursing, pharmacy, public health, veterinary medicine), and one or more owned or a”liated teaching
hospitals or health systems. Academic health centers are heavily involved in clinical research and high-level tertiary and quaternary care, in addition to providing
advanced training and education for clinicians in primary and specialty care.
REHABILITATION HOSPITALS Rehabilitation hospitals specialize in providing therapeutic interventions to help patients regain functional ability to the highest possible
level after an injury or illness that has caused some loss of ability. By Medicare
de!nition, 75% of a rehabilitation hospital’s patients must require intensive (at
least 3 hours per day) rehabilitative services to treat conditions related to stroke,
spinal cord injury, major trauma, brain injury, or other debilitating disease or
injury. Rehabilitative services provided within these facilities include physical
therapy, occupational therapy, and speech-language therapy. Other services may
also be provided to assist patients with psychological, vocational, or social needs
related to their condition.
PSYCHIATRIC HOSPITALS #e primary function of a psychiatric hospital is to provide
diagnostic and treatment services for patients who have a psychiatric-related
illness. Some facilities specialize in short-term or outpatient therapy, whereas
others may specialize in temporary or permanent care of residents who require
routine assistance, treatment, or a specialized and controlled environment as a
result of a psychological disorder. General hospitals may also operate psychiatric
units within their organizations.
Psychiatric hospitals are required to provide clinical laboratory and diagnostic x-ray services in addition to psychiatric, psychological, and social work services. Psychiatric hospitals have written agreements with general hospitals for
the transfer of patients in need of medical or surgical services not available at the
psychiatric institution (AHA, 2018).
OTHER HOSPITALS #e federal government operates approximately 209 hospitals
that are not accessible to the general public. Included among these hospitals are
those operated by the Veterans Administration (VA) for the nation’s military veterans, the Department of Defense (DOD) for active duty military personnel, and
the Indian Health Service (IHS) for American Indians and Alaska Natives.
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28 Part I. Health Policy
Physician Organizations
In the United States, physicians have traditionally been self-employed, working in
private medical practices that they own either solely or in partnership with other
physicians. Hospitals establish relationships with physicians by granting them
admitting privileges to provide inpatient and outpatient procedures and services
to their patients that cannot be delivered within the physician practice setting. In
recent years, however, there has been a trend toward the employment of physicians
by hospitals and other health care organizations and toward larger practice sizes.
!is trend has been attributed to a number of reasons, including stagnant reimbursement rates, a desire for better work-life balance for physicians, and e”orts by
hospitals to increase market share. !e results of a physician practice benchmark
survey in 2016 conducted by the AMA indicate that only 47.1% of physicians have
an ownership stake in their practices, and an equal amount (47.1%) are employees
of either a medical practice or hospital organization. !is marks the #rst year that
the majority of physicians are not practice owners, with a 6% decrease observed
from a prior study conducted in 2012. Additional trends indicate that having an
ownership stake is less common among women physicians than men and less
common among younger physicians than older physicians (Kane, 2017).
As mentioned, physicians may be employed by others (e.g., hospitals, government, medical schools) or be self-employed (i.e., in
private practice). A variety of physician practice settings are utilized in the United States, which include
solo practice, single specialty group practice, multispecialty group practice
, corporate medical practice, and urgent care centers, among others.
SOLO PRACTICES A physician practice operated by one physician is known as a solo
practice. Approximately 20% of physician practicing in the United States are in
solo practices, compared with 40.5% in 1983 (AMA, 2013). According to the
AMA (2013), a majority of physicians in solo practices own their practice.
SINGLE SPECIALTY GROUP PRACTICES !e most common type of physician practice is
the single specialty group practice: a practice with two or more physicians who
have the same medical specialty, such as internal medicine or cardiology. Fortytwo percent of the physicians in the United States are in a single specialty group
practice (Kane, 2017).
MULTISPECIALTY GROUP PRACTICES A multispecialty group practice consists of two or
more physicians who practice di”erent medical specialties. Approximately 25% of
physicians in the United States are in a multispecialty group practice (Kane, 2017).
CORPORATE MEDICAL PRACTICES Corporate medical practices are physician practices owned by business corporations or entities. !is is commonly known as
corporate practice of medicine (CPOM). CPOM is prohibited in some
states: !e types of prohibitions vary by state and may be found in various laws,
regulations, or court rulings. A typical exception allows hospitals and health
maintenance organizations (HMOs) to employ physicians because these businesses were established for the purpose of providing treatment to patients and
are licensed entities. Most states allow physicians to provide services through a
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Chapter 2. Organization of Care 29
professional service corporation (P.C.), a business entity formed for the purpose
of providing professional services, such as medical services. Some states have
CPOM laws but do not enforce them. Such laws were established in an earlier
era when concern about the commercialization of medicine led to great e!orts to
ensure that medicine would be practiced only by licensed professionals.
URGENT CARE CENTERS Urgent care centers o!er walk-in, extended-hour access to
individuals with acute illness and injuries that are not bona “de emergencies.
In addition to services found in the typical physician’s o#ce, urgent care centers usually can treat minor fractures and provide intravenous $uids as well as
perform on-site x-ray and laboratory test processing. %ese centers are typically
sta!ed by physicians and other providers and operate 7 days a week, including
holidays, from 8 or 9 a.m. until 7 or 9 p.m. %is is a growth area in the health care
delivery system, with more than 9,000 centers operating nationwide and approximately 300 new centers opening each year.
COMMUNITY HEALTH CENTERS Community health centers (CHCs) provide health care
services, focusing on primary and preventive care, to medically underserved and
indigent populations. Approximately 27 million people are served by CHCs in
10,400 communities in the United States (National Association of Community
Health Centers, n.d.). To receive care at a CHC, an individual must be a resident
of the state in which the center is located, be uninsured, and be poor as de”ned by
federal poverty guidelines. CHCs contract with the state or local health department to provide services to eligible individuals; they also help to provide linkages
to social services and government-sponsored health insurance programs, such as
Medicaid and the Children’s Health Insurance Program (CHIP). CHCs may be
organized as part of a public health department or another health service organization, or as a nonpro”t organization.
Ambulatory Surgery Centers
Ambulatory surgery centers (ASCs) are facilities that provide surgical services
for procedures that are done on an outpatient basis. %is is sometimes referred to
same-day surgery. ASCs are not physician o#ces, although physicians have
taken the lead in their development.
%e “rst ASC was established in 1970 by two physicians. Today, more than
5,400 ASCs are in operation across the United States. Physicians have some ownership in approximately 90% of the licensed ASCs in the United States. Community hospitals have also partnered with physicians to open and operate ASCs, and
a small percentage of ASCs are entirely hospital owned.
Patients treated at an ASC have already been diagnosed by a physician
and have elected to have an outpatient surgical procedure. All ASCs must
have at least one dedicated operating room and the appropriate equipment to
perform surgery safely and provide quality patient care. %e most prevalent
specialties served by ASCs are ophthalmology, orthopedics, gastrointestinal,
pain management, plastic surgery, and urology (Ambulatory Surgical Center
Association, 2018).
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30 Part I. Health Policy
Long-Term Care Organizations
Long-term care organizations operate facilities for individuals who are not able
to manage independently in the community. !e services provided in these facilities vary depending on the level of assistance needed; services may range from
custodial care and chronic care management to short-term rehabilitative services. Long-term care facilities (LTCFs) may be owned by government entities,
nonpro”t organizations (including churches), or investor-owned corporations.
LTCFs may be independent facilities that are either freestanding or operated
within a
continuing care retirement community. LTCFs may be part of a multifacility organization (that is, a chain) or may be hospital-owned as either an
attached or a freestanding facility.
INDEPENDENT LIVING FACILITIES Independent living facilities are multiunit housing
developments that may provide support services such as meals, transportation,
housekeeping, and social activities. !ese facilities are typically utilized by active
senior adults who do not require assistance with ADLs.
Independent living facilities are sometimes operated as part of a
care retirement community
, which provides a full range of LTCFs and other
services—an assisted living facility and a skilled nursing facility. !is arrangement
enables seniors to make a transition into a residence that meets their physical
needs as they begin to require more medical assistance. Independent living facilities that do not provide many services beyond a residence are sometimes referred
to as senior apartments.
ASSISTED LIVING FACILITIES Assisted living facilities are available for individuals who
are basically able to care for themselves but may need some assistance with some
daily activities. Assisted living facilities are residential facilities that provide services that may include meals, laundry, housekeeping, medication reminders, and
assistance with ADLs and IADLs.
Most states require licensure for assisted living facilities, and the exact de”nition
of what constitutes an assisted living facility varies among states. Approximately
90% of assisted living services in the United States are paid through private funds,
although a few states allow payment for assisted living through Medicaid waivers.
SKILLED NURSING FACILITIES A skilled nursing facility (or nursing home) is licensed by
the state in which it operates to provide 24-hour nursing care, room and board,
and activities for convalescent residents and residents with chronic or long-term
illnesses or conditions. Special populations served by skilled nursing facilities
include physically or mentally challenged children and adults, and children and
adults with debilitating diseases and/or conditions. Regular medical supervision
and rehabilitation services must be available. !e facilities are sta#ed by health
care professionals including a physician as medical director, registered nurses
(RNs), licensed practical nurses (LPNs), and trained nursing assistants. Skilled
nursing facilities are reimbursed through a variety of mechanisms, including private funds, long-term care insurance, Medicare (for short-term rehabilitation or
subacute care), and Medicaid. Medicaid is the source of payment for 6 out of 10
residents in skilled nursing facilities.
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Chapter 2. Organization of Care 31
Rehabilitation Organizations
Rehabilitative services are provided in a variety of inpatient and outpatient settings, including inpatient rehabilitation hospitals, rehabilitation units in acute
care hospitals, skilled nursing facilities, outpatient rehabilitation centers and
units, and other medical rehabilitation providers.
INPATIENT REHABILITATION FACILITIES An inpatient rehabilitation facility is either a
freestanding inpatient rehabilitation hospital or a unit of an acute care hospital.
Intensive acute rehabilitation services are provided and generally include at least
3 hours of therapy per day for 5 to 7 days each week. !erapy may include physical, occupational, speech, or recreation therapy.
Patients who cannot tolerate intensive therapy in an acute rehabilitation setting may be transferred to a transitional care
, long-term care, or subacute care
facility, where less intensive rehabilitation services are provided along with other
medical services (e.g., 24-hour skilled nursing care) needed for convalescence
and recovery.
OUTPATIENT REHABILITATION PROVIDERS Rehabilitation services may be provided on
an outpatient basis—that is, the patient lives at home and visits the facility for
therapy. !erapy plans are developed on an individual basis and typically include
2 to 3 days of treatment per week. Nursing services are usually not included in
the outpatient setting.
Centers of care are facilities that provide outpatient rehabilitative services for patients with a particular speci”c illness, such as multiple
sclerosis, Parkinson’s disease, or stroke.
!ree types of providers may qualify for reimbursement for outpatient rehabilitation services by Medicare:
■■ Rehabilitation agencies are organizations that provide integrated, multidisciplinary
programs designed to upgrade the physical functions of handicapped and disabled
individuals through a specialized team of rehabilitation personnel.
■■ Rehabilitation clinics are facilities established primarily to provide outpatient rehabilitative services by physicians. To meet the de”nition of a clinic, medical services
must be provided a group of three of more physicians practicing rehabilitation medicine together, and a physician must be present in the facility at all times during the
hours of operation to perform medical services.
■■ Public health agencies are o#cial agencies established by state or local government
that provide environmental health services, preventive medical services, and, sometimes, therapeutic services.
Integrated Delivery Systems
An integrated delivery system (IDS) is a collaborative network of providers who
work together in a coordinated fashion to provide a continuum of care to a particular patient population or community. Within an IDS, providers work together
through information sharing, shared responsibility, and collaborative resource
utilization (Enthoven, 2016). Many believe integrated delivery systems can help
to address some of the problems associated with the fragmented delivery system
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32 Part I. Health Policy
in the United States and move toward the goals of improving the quality and
accessibility of care while containing or reducing costs.
Integrated delivery systems have existed since the early 1900s, but interest
in the IDS concept began to spread in the 1990s when hospitals and physician
practices consolidated through mergers and acquisitions in the face of changing
reimbursement methodologies from public and private insurers. Interest in IDSs
has surged in recent years during the national health reform debate as experts
have suggested that the IDS approach to health care delivery can improve quality
and reduce costs. Research has shown that IDSs have a positive e!ect on quality,
but there is little evidence of an e!ect on costs or health care utilization (Hwang,
Chang, LaClair, & Paz, 2013).
Two types of integration—horizontal and vertical—are used to create an
Horizontal integration involves linking organizations that provide the
same level of care, such as a multispecialty group practice.
Vertical integration
involves linking organizations that provide di!erent levels of care, for example,
preventive, primary, secondary, tertiary, and long-term care. One of the goals of
an IDS is to provide
continuity of care for the patient, which includes continuity of information (e.g., shared medical records), continuity across primary and
secondary care (e.g., discharge planning from specialist to generalist care), and
provider continuity (e.g., seeing the same provider each time).
Emergency Medical Services
An emergency medical service (EMS) provides acute care for medical emergencies that take place outside the hospital setting. EMS is utilized within a community to treat those in need of urgent medical care or to stabilize and transport
patients with illness or injuries who are unable to transport themselves to the
appropriate medical facility. It is a system of coordinated response and emergency medical care involving multiple people and agencies.
EMS is regulated by federal and state governments and may be provided by
paid professionals or, in some communities, by volunteers. “e organization of
EMS varies from community to community, based on state regulation, population density, and topography, and may be provided via public institutions, private
institutions, or a public–private con#guration. Prehospital EMS can be based in a
#re department, a hospital, an independent government agency (such as a public
health agency), or a nonpro#t corporation (such as a rescue squad); EMS may
also be provided by commercial for-pro#t companies. “e essential components
of an EMS system are the same regardless of the provider.
Home Health Care Organizations
Home health agencies and organizations provide medical services in a patient’s
home. Services are typically provided for elderly or disabled patients, or for
patients who are unable to visit a hospital or physician’s o$ce because of weakness after surgery or other reasons. Care provided in the home may be acute,
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Chapter 2. Organization of Care 33
long-term, or end-of-life. Home health primarily involves the provision of skilled
nursing services and therapeutic services (e.g., physical, occupational, and/or
speech and hearing). A home health agency may be a public, nonpro!t, or proprietary agency and may be a subdivision of a larger organization. “e agency
must be licensed by the state in which it operates or receive approval that it has
met all standards and requirements to operate. “ese agencies are also subject
to certi!cation requirements by CMS and may also seek accreditation from an
independent accrediting organization. Home health agencies and organizations
must have policies established by a governing body that must include at least one
physician and one RN, and the services it provides must be overseen by a physician or a registered professional nurse.
Hospice and Palliative Care Organizations
Palliative care services are available for anyone with a serious illness as well as for
patients who are terminally ill. Palliative care may be provided in a hospital, outpatient clinic, long-term care facility, or hospice facility. It is delivered by a team
of specialists, including physicians, nurses, and social workers, and may include
other professionals, such as massage therapists, pharmacists, and nutritionists.
Each facility where palliative care is provided typically has its own palliative care
team; these professionals work in partnership with a patient’s primary physician
and others involved in treating the individual.
Hospice care is provided to terminally ill patients either in their homes (
hospice residential care) or in a health care facility (hospice inpatient care) owned and
operated by a hospice organization or health system. According to the National
Hospice and Palliative Care Organization (2018), hospice care programs were
!rst established in 1974 and have grown in number to more than 4,199 Medicare certi!ed programs, including both primary locations and satellite o#ces, as
of 2015. “e majority of hospice programs are o$ered by freestanding, independent agencies (72.2%), and the remainder are part of a hospital system (14.2%),
home health agency (12.9%), or nursing home (0.6%). Hospice programs range in
size from small organizations serving fewer than 50 patients on an annual basis
to large, corporate chains operating programs on a national basis and caring for
thousands of patients each year. In 2015, 32% of hospice programs registered with
Medicare were nonpro!t organizations, 63% were for-pro!t organizations, and
about 5% were government owned and operated.
Medication is an integral part of health care delivery, and pharmacists play a
signi!cant role in ensuring the safe and e$ective use of medication to achieve
desired health outcomes. “e role of the pharmacist has traditionally been to
dispense medication; that role is now expanding into the direct care of patients
as the use of medication has grown and new technologies are employed in the
medication dispensing and utilization processes.
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34 Part I. Health Policy
Licensed pharmacies include retail pharmacies in the community setting and
hospital or other institutional pharmacies. Community pharmacies include chain
pharmacy organizations (e.g., CVS, Walgreens); pharmacies located within other
large retail organizations (e.g., Walmart, Kroger); and independent, locally owned
and operated pharmacies. !e community pharmacy provides the public with
access to medication, including administering “u shots, and serves as a source of
advice on health issues. Approximately 6 out of 10 licensed pharmacists work in
the community setting. Institutional pharmacies control drug distribution within
a health care facility and help to ensure each patient receives the appropriate drug
and dosage. Institutional pharmacies are involved in highly specialized areas,
including nuclear medicine, intravenous therapy, and drug and poison information. A hospital or health system may also operate a retail pharmacy within its
facilities in addition to its clinical pharmacy operation.
Pharmaceutical Companies and Medical Device Manufacturers
Another integral part of the health care delivery system are the pharmaceutical companies and medical device manufacturers that develop and supply medications, medical supplies, durable medical equipment, and medical devices to
health care organizations and sometimes directly to the public. Not only do these
organizations supply materials needed for the direct care of patients, but they
also play an important role in helping ensure safe and e#ective care.
Medical device manufacturers provide essential products for modern
medical care, including devices that range from CT scanners and surgical robotic
devices to blood pressure cu#s and thermometers. !ese products also constitute a signi$cant portion of the national health expenditure. !e CMS estimates
retail spending on durable medical equipment in the amount of $51 billion and
spending for other nondurable medical products at approximately $62.2 billion
in 2016. !e biopharmaceutical industry comprises the pharmaceutical and
biotechnology industries. Biopharmaceutical companies develop, manufacture,
market, and distribute drugs and vaccines used to prevent and treat diseases. It is
made up of four sectors: pharmaceutical and medicine manufacturers, pharmacy
wholesalers, research and development services, and management of companies
and enterprises. Biopharmaceutical companies spend up to $135 billion annually on research and development, and it is estimated that it takes up to 15 years
to develop a medicine or vaccine. !e biopharmaceutical industry accounts for
nearly 20% of all research and development investment in the United States,
where new drugs must be approved by the Food and Drug Administration (FDA)
as safe and e#ective.
!e industry is sometimes referred to as “Big Pharma” because of its size,
its in”uence over health care legislation, and its e#ect on the cost of health care
delivery. !irty-six of the largest pharmaceutical companies make up the membership of the industry’s professional association, the Pharmaceutical Research
and Manufacturers of America (PhRMA), and invest more money in lobbying
than any other industry in the United States.
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Chapter 2. Organization of Care 35
Other Delivery Organizations
TELEMEDICINE Telemedicine uses electronic communications to exchange medical
information between sites to improve a patient’s clinical health status. Telemedicine services may include primary care and specialist referral services, remote
patient monitoring, consumer medical and health information, and medical
education. Hospitals, specialty clinics, home health agencies, and physicians’
o!ces all use telemedicine. “e services may be o#ered within a single health
care organization or between health care organizations.
According to the American Telemedicine Organization (2018), more than
half of U.S. hospitals are participating in some form of telemedicine, and more
than 200 telemedicine networks with 3,500 service sites exist in the United
States. Emerging models of telemedicine delivery include o#ering specialty consultation services through membership associations that match people in need
of services with providers, and independent businesses that are organized to
provide telemedicine consultation services but are not health care providers.
“ese independent businesses recruit appropriately licensed specialists to provide telemedicine services and then market these services and handle contract
negotiations and all legal and technical aspects of delivery.
Retail Clinics
Retail clinics are medical clinics located in pharmacies, grocery stores, and “big
box” stores such as Target. “ese clinics provide routine care for acute conditions (e.g., bronchitis) as well as preventive care. Retail clinics began emerging in
2000, and more than 2,000 clinics were operating in the United States by 2016.
Retail clinics are often open extended hours and on weekends, o#ering a convenient alternative for routine care, particularly when conventional physician
o!ces are closed. A study by the Rand Corporation indicated that young adults
(ages 18–44) account for 43% of patient visits, although the utilization of retail
clinics by seniors is increasing (Rand Health, 2016). In 2016, three-quarters of
the retail clinics in the United States were operated by two companies—CVS and
Walgreens (Rand Health, 2016). Retail clinics are also operated by hospital chains
and physician groups, accounting for about 11% of the market. Although some
critics of retail clinics voiced concern about the quality of care provided, research
suggests that these facilities provide equivalent quality of care to care o#ered in
other provider settings for a select group of conditions. Most commonly, patients
seek care at retail clinics for acute conditions including respiratory infections and
sore throats. However, these clinics are viewed as promising settings for vaccinations and chronic care management.
Health System Performance
Although the United States spends more money per capita on health care than
any other nation in the world, we are lagging behind other countries on a variety of quality indicators, including average life expectancy and infant mortality
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36 Part I. Health Policy
rates. !e Institute of Medicine (IOM) estimates that more Americans are killed
every year by medical errors than in automobile accidents. As a response to these
staggering statistics, the IOM released
Crossing the Quality Chasm (2001), a
landmark report that issued a mandate for improvement in U.S. health system
performance. Additionally, a portion of the ACA is dedicated to improving quality and health system performance through funding research, aligning “nancial
incentives with performance outcomes, and identifying a national quality strategy. Although marginal improvements in quality and performance have been
observed in the past decade, we still have a long way to go to achieve a highperforming health system.
Organizations such IOM, the Institute for Healthcare Improvement (IHI),
and the National Committee for Quality Assurance (NCQA) are leading the
health system improvement movement through initiatives including patient centeredness, the Triple Aim, and the
patient-centered medical home (PCMH).
!e CMS is “nancially incentivizing the “meaningful use” of electronic health
records (EHRs) by health care providers to promote quality improvement in
health care. Quality improvement e#orts of this type promote collaboration
among health care providers, payers, the government, and other stakeholders with the goal of achieving real health system change. In the next section
of this chapter, we provide an overview of some of the quality improvement
initiatives that demonstrate the most promise in improving U.S. health system
The Triple Aim
!e IHI is a not-for-pro”t organization that
is dedicated to improving health and health
care worldwide. !e IHI (2018) promotes a
learning initiative and a framework called
the Triple Aim for health care organizations and communities. !e idea behind the
Triple Aim is that to improve the delivery
of health care in the United States, organizations must simultaneously pursue three
dimensions: (a) improve the patient experience of care, (b) improve the health of populations, and (c) reduce the per-capita
cost of health care.
Achieving this triple aim is di$cult because one organization is rarely
accountable for all three dimensions. However, the IHI has identi”ed “ve system
components necessary for ful”llment of the Triple Aim:
■■ Focus on individuals and families: Care should be customized at an individual level
utilizing families and caregivers as partners.
■■ Redesign primary care services/structures: A team of professionals must be established
that can deliver the majority of necessary care.
The idea behind the Triple Aim
is that to improve the delivery
of health care in the United
States, organizations must
simultaneously pursue three
dimensions: improve the patient
experience of care, improve the
health of populations, and reduce
the per-capita cost of health care.
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Chapter 2. Organization of Care 37
■■ Population health management: Partnerships within the community are necessary to
promote prevention and wellness.
■■ Cost control platform: Cooperative relationships with provider groups must be in place
to control costs.
■■ System integration and execution: Services across the continuum of care must be
Although the Triple Aim initiative is ambitious, a few health systems have
taken on the challenge and have succeeded. A strong focus on primary care, coupled with community alignment, is necessary to achieve positive patient experiences and improvement in population health. Additionally, active physician
participation is crucial to reduce costs. A model of care utilizing a multidisciplinary approach is one way to approach the Triple Aim. Signature Healthcare
achieved success with this approach by initiating a Complex Care Clinic focused
on high-risk Medicare Managed Care patients
Signature Healthcare, located in eastern Massachusetts, provides services to
approximately 10,000 residents over the age of 65. !eir most vulnerable patient
population includes elderly with multiple chronic illnesses, social challenges, and
functional limitations. Signature decided to develop a process focused on providing quality care for this population, and they used the principles of the Triple Aim
for guidance.
1. Signature created a Complex Care Clinic led by nurse practitioners to facilitate the
management of chronic diseases among this patient population. Appointments were
lengthened from 15 minutes to 40 minutes per visit to accommodate patient needs.
Nurse practitioners, in consultation with physician partners and a care coordination
team, took over care management for these patients.
2. Signature engaged community stakeholders in patient care. For example, many
elderly patients needed assistance with transportation, “nances, and meals. Signature engaged local organizations, including the Alzheimer’s Association and the
Visiting Nurse Association, as partners in care. Additionally, they worked with
the local public transportation system to facilitate subsidized transport for these
3. Signature updated its infrastructure to best serve this patient population. Internal
roles were reassessed, guidelines speci”c to geriatric conditions were put into place,
and screening protocols to help identify seniors at risk for falls were implemented and
integrated into the health record.
Signature’s initiative aimed at managing elderly patients with complex
conditions was successful on a variety of fronts. Patients participating in the
Complex Care Clinic had decreased ED utilization and decreased hospital
admissions. Billing and coding practices improved as a result of the coordinated
approach to providing care. Finally, patient feedback on the new approach to care
was extremely positive, and approximately 98% of patients rated their care as
“very good” (IHI, 2015).
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38 Part I. Health Policy
Patient Centeredness
!e IOM identi”ed patient centeredness as one of six domains that de”ne quality
care. Patient-centered care is “care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide
all clinical decisions” (IOM, 2001). Six dimensions to patient-centered care have
been identi”ed (Gerteis, Edgman-Levitan, & Daley, 1993):
■■ Respect for patients’ values, preferences, and expressed needs
■■ Coordination and integration of care
■■ Information, communication, and education
■■ Physical comfort
■■ Emotional support
■■ Involvement of family and friends
Providing patient-centered care means giving patients the information they
need to participate actively in decision making about their care with the goal of
obtaining the most desirable outcome. If a patient is incapacitated or unable to
participate in decision making regarding his or her care, then a family member
or caregiver should be engaged. When a health care intervention cannot provide
a cure, it should aim to alleviate the patient’s su#ering. !e likelihood that an
outcome desired by a patient can be achieved is increased by actively involving
patients and family members in decision making regarding the provision of care.
Although we are making progress in this direction, research suggests that
certain patient-centered practices are still rare. Movements toward the PCMH
and patient-centered research are continuing to shift the momentum in the right
direction; however, there is still a long way to go. !e achievement of a truly
patient-centered health system will require the participation of patients, family
members, physicians, nurses, and other health care providers involved in the
provision of care.
Population Health Management
In terms of the organization of care, there is a growing interest among the payer
community (insurance companies, Medicare, etc.) for providers to engage in
population health management of de”nable patient populations for which they
provide coverage. Provider organizations are engaging in a variety of population
health management activities that involve managing a patient’s care across provider settings. First, e#ectively managing the network of providers that patients
see can help ensure they are receiving the most e$cient and e#ective care for
their conditions. Helping patients navigate physician and specialty care visits can
facilitate information sharing among providers and led to better care outcomes.
Providers are also making e#orts to manage patient transitions of care. A transition in care occurs when a patient moves from one health care delivery setting to
another. For example, a patient might be discharged from an acute care hospital
and require home health services to facilitate recovery. A hospital can manage
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Chapter 2. Organization of Care 39
this transition of care by proactively planning for the discharge with the patient,
family, and home health service.
Provider organizations are also beginning to invest in providing care within
the home for seriously ill patients. Hospitals are trying new ways to embed
resources within the homes of high-risk patients to ensure they remain compliant with medication protocols and remain healthy. Outreach may involve phone
calls, telemedicine services, or simply deploying a practitioner to the patient’s
home. Finally, provider organizations understand that chronic diseases are the
primary drivers of death and disability in the United States. Using data analytics
can help organizations identify chronically ill patients so that their conditions can
be carefully managed (Optum, 2014).
Recent years have seen the introduction of several innovative new models of care
that have potential to realign incentives and improve overall health system performance in terms of cost, quality, and access. !e ACA encouraged the adoption
of these new models, and a variety of new organizational forms have emerged
from the private sector. Renewed interest in physician employment models also
demonstrates potential for increased integration and more closely aligned clinical and “nancial incentives between physicians and other providers.
Innovative Models of Care Delivery
Patient-Centered Medical Homes
!e PCMH model of primary care emphasizes communication and care
coordination. Patient centeredness is an important goal of PCMHs. Physician
practices must meet certain standards to be designated as PCMHs. !e NCQA
released revised standards for PCMHs in
2017 focused around six concepts which
represent the overall themes for PCMH
(see Table 2.1). Evidence suggests that the
PCMH is e#ective at improving health care

quality and reducing costs.
Group Health Cooperative (GHC) in

Seattle, Washington, provides an example of a successful PCMH model. GHC
is a nonpro”t health system that consists of physician groups, medical facilities,
and health plans that serve Washington and northern Idaho. In 2006, the system
decided to pilot test a PCMH practice. GHC’s pilot practice expanded sta$ng and
emphasized the use of care teams. !e ratio of patients to primary care providers was reduced for the pilot practice, and their enhanced sta$ng model included
physicians, medical assistants, LPNs, physician assistants/nurse practitioners,
RNs, and pharmacists. !e idea behind this increased sta$ng was to facilitate
Evidence suggests that the
PCMH is effective at improving
health care quality and reducing
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40 Part I. Health Policy
patient relationships and to allow for comprehensive coordinated care. Additionally, patient encounters with clinical sta! increased from approximately 20 minutes
to 30 minutes in duration, and time was set aside each day for teams to create
coordinated care plans (Reid et al., 2010). “e pilot clinic was so successful that
HGC spread implementation of the PCMH model across 25 additional clinics. “e
clinics that implemented PCMH practices experienced better health outcomes,
increased access to care, and improved physician and sta! satisfaction (Reid, 2015).
Health Homes
Health homes were created by the ACA to give states an option for providing
patient-centered, medical home–type services to Medicaid bene#ciaries su!ering from severe or multiple chronic conditions. “e purpose of health homes is
to create a system of care that facilitates and coordinates access to primary care,
acute care, behavioral care, and long-term community-based services. Medicaid
bene#ciaries with (a) at least two chronic conditions, (b) one chronic condition
and high risk for another, or (c) a serious mental health condition are eligible for
health home services.
Health home services are o!ered by
designated providers, teams of health professionals that link to a designated provider,
or a health team. Physicians, group practices,
community health centers, home health
agencies, or any other provider deemed

Team-Based Care and Practice
Helps structure a practice’s leadership, care team responsibilities, and
how the practice partners with patients, families, and caregivers
Knowing and Managing Your
Sets standards for data collection, medication reconciliation, evidence
based clinical decision support, and other activities
Patient-Centered Access and
Guides practices to provide patients with convenient access to clinical
advice and helps ensure continuity of care
Care Management and Support Helps clinicians set up care management protocols to identify patients
who need more closely managed care
Care Coordination and Care
Ensures that primary and specialty care clinicians are effectively
sharing information and managing patient referrals to minimize cost,
confusion, and inappropriate care
Performance Measurement and
Quality Improvement
Improvement helps practices develop ways to measure performance,
set goals, and develop activities that will improve performance

Source: Adapted from National Committee for Quality Assurance. (2018). Structure of concepts, criteria, and
. Washington, DC: Author.
Promoting care for the whole
person, care that is individually
tailored to each patient and
family, is a goal of health homes.
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Chapter 2. Organization of Care 41
appropriate by the state is considered a designated provider. Health teams consist
of a physician and other health care professionals such as nurses, social workers,
and other appropriate professionals. Health homes provide care management,
care coordination, health promotion, transitional care from inpatient to other
settings, individual and family support, follow-up care, and referral to community social support services. Additionally, health homes use health information
technology (IT) to coordinate such services. Health homes must provide qualitydriven, cost-e!ective, culturally appropriate care. Promoting care for the whole
person, care that is individually tailored to each patient and family, is a goal of
health homes.
Accountable Care Organizations
Accountable care organizations (ACOs) are groups of providers that share
responsibility and “nancial accountability for providing high-quality, coordinated care to Medicare patients. #e goal of ACOs is to ensure that patients get
the right care at the right time in the most e$cient way. ACOs are organized
around primary care providers, and the high level of care coordination provided
by ACOs is particularly important for the chronically ill. If ACOs are successful at
meeting quality and cost savings targets, these organizations qualify for “nancial
incentives or shared savings from the Medicare program.
#e ACA facilitated the creation of ACOs for the Medicare program. Some
ACO models allow for sharing of “nancial risk and reward for a de”ned population of patients, while other ACOs allow for shared savings based on “nancial and quality targets Family Foundation. In 2018, more than 550 Medicare
ACOs represented approximately 12 million Medicare bene”ciaries. Additionally, provider groups are creating “ACO-like” organizations that strive to
facilitate comprehensive care coordination for patient populations beyond
Medicare bene”ciaries.
Medicare ACOs have demonstrated moderate success in reducing costs and
improving quality for patient populations. In 2016, all ACO types generated
signi”cant net savings and demonstrated lower spending on Medicare services.
In terms of quality, all ACO models had equivalent or better quality than traditional Medicare providers (Kaiser Family Foundation, 2018). Although early
indicators of success are limited, ACOs remain a promising model for improving care coordination and lowering the cost of care for particular populations
of patients.
Beth Israel Deaconess Care Organization (BIDCO) achieved success as one of
the early Medicare “Pioneer” ACOs. It is currently participating with the Medicare program as a “Next Generation” ACO, a program designed for organizations
with experience coordinating care for Medicare bene”ciaries. BIDCO includes
more than 2,500 physicians, a variety of community hospitals, and a network
of providers allowing it to function as an IDS. #ey support providers with a
robust population health program that facilitates regular provider meeting and
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42 Part I. Health Policy
information sharing among network participants. BIDCO attributes its success
as an ACO to several factors:
1. First, BIDCO created an IT infrastructure that allows information sharing among
providers. !is gives providers the information needed to make evidence-based care
2. Second, BIDCO worked with a variety of stakeholders from within and outside the
health care industry to redesign processes and “nd a fresh approach to providing care.
3. !ird, BIDCO increased transparency surrounding quality indicators and this
approach resulted in collaboration and competition among providers. !is ultimately
led to improved outcomes.
4. Fourth, BIDCO began to look at data in di#erent ways that factored in the role that
social determinants of health can play in predicting someone’s utilization of services.
5. Finally, BIDCO created an incentive model to motivate physicians to increase individual and system level performance. (Hulbert, 2017)
BIDCO is currently aligned with more than 30,000 Medicare bene”ciaries.
!e organization was able to achieve signi”cant cost savings and perform well on
quality indicators as a Pioneer ACO. After its “rst year of participation as a “Next
Generation” ACO, BIDCO again demonstrated cost savings and produced highquality outcomes (CMS, 2018).
Community-Based Solutions
Social needs of individuals play an important role in contributing to health.
These needs include issues such as housing conditions, access to healthy food,
crime in the community, and poverty. In the current health care environment,
the emphasis on population health and prevention has facilitated the interests of provider organizations in addressing social issues to keep community
members healthy and out of hospitals. Keeping patients healthy is not only
the right thing to do, it is also financially beneficial under new payment methodologies that incentivize health. Although the linkage between social factors
and health has long been recognized, more collaboration between community
resources and provider organizations to provide social services has emerged
in recent years.
One example of such a collaborative is the
Staten Island Performing Provider
System (PPS)
. In 2015, Staten Island University Hospital and Richmond Hill Hospital received funding through the state of New York to form the Staten Island PPS.
!e PPS engaged community-based organizations that provide social services for
citizens such as homeless shelters, food banks, community health centers, and
physicians serving large numbers of uninsured and Medicaid patients. !e provider organizations and social services organizations are working collaboratively
on a variety of projects aimed at improving the health status of the community
and reducing avoidable hospital admissions. Projects include e#orts to better
coordinate care and social services for people with serious conditions, improve
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Chapter 2. Organization of Care 43
health literacy, and implement substance abuse initiatives for at-risk youth
(Sparer, Muennig, & Brown, 2016). Although the PPS is still in its early stages,
this type of collaboration shows promise in improving the health of communities.
Provider organizations are also developing community-based programs
aimed at reducing avoidable hospital readmissions. According to CMS, almost
one of every !ve Medicare patients is likely to be readmitted to the hospital
within 30 days of discharge. “ese readmissions may occur because of inadequate care management resulting from a bumpy transition in care from one
setting to another. Unnecessary readmissions are extremely costly to the Medicare system, and acute care hospitals face !nancial penalties if their readmission
rates are too high. Most importantly, inappropriate readmissions are bad for
patient care. In an e#ort to better coordinate transitions of care, health care providers have found success in reducing readmission rates by seeking communitybased solutions.
Care Transition Choices (CTC) program presented by the Partners in
Care Foundation is one example of a successful community-based program
aimed at improving transitions of care for high-risk patients. “e
CTC started
as a pilot program established through CMS under the Community Care Transition Program. “e program has been so successful that private health plans
and physician groups have adopted the program and kept it in operation. “e
CTC program works by assigning care transition coaches to work with high-risk
patients on cultivating health self-management skills, review appropriate medication use, and recognize warning signs of a worsening condition. Coaches visit
patients in the hospital and in their homes. In addition to clinical monitoring,
coaches link patients with community resources, including meal delivery and
wheelchair-accessible transportation. “e program has been successful in signi!cantly reducing hospital readmissions among Medicare patients and reducing
costs (Partners in Care Foundation, 2018).
Clinical Integration
Physician–Hospital Alignment
“e alignment of physician and hospital
goals and incentives is a critical success
factor in the era of health reform. Traditionally, both types of provider have been
reimbursed based on volume or productivity. However, reimbursement mechanisms
are becoming more focused on quality and
e$ciency. Identifying ways to align the incentives of physicians and hospitals is
vitally important to maximize the clinical quality of care while minimizing costs.
Di#erent economic levels and approaches to physician–hospital alignment
involve a variety of organizational arrangements. Loosely aligned physicianhospital arrangements involve a traditional independent practice model, in which
Identifying ways to align the
incentives of physicians and
hospitals is vitally important to
maximize the clinical quality of
care while minimizing costs.
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44 Part I. Health Policy
physicians are still “volunteer” members of a hospital’s medical sta! and alignment is sought through contractual arrangements to secure medical directors and
physician administrators. In this traditional alignment model, economic integration is not achieved. Closer alignment might be achieved through more strategic
approaches, such as joint ventures or co-management agreements between physicians and hospitals with some level of shared economic interests. “e ultimate
level of physician–hospital alignment is achieved through employment relationships with full economic integration. With this level of alignment, physicians are
truly employees and are required to comply with hospital policies and share goals
(Sowers, Newman, & Langdon, 2013).
A well-regarded example of an integrated health system is Scripps Health
(, which includes acute care hospitals, outpatient centers, and
home health and hospice services in the San Diego, California, area. Scripps
employs more than 15,000 workers, and approximately 3,000 a#liated physicians
provide care at Scripps facilities. Scripps Health is a success story in the area of
physician–hospital alignment. In 1999, Scripps was losing millions of dollars a
year and physician and employee con$dence was at an all-time low. A new CEO
created an organizational turnaround by aligning physician and hospital interests
more closely through a co-management approach. Although California law makes
direct physician employment di#cult, closer alignment was achieved through an
integrated foundation model that emphasizes transparency and open communication between physician and administrative leadership. “e CEO was able to
regain physician trust and leverage close alignment with physicians to achieve
$nancial and quality improvements. Since the turnaround, Scripps Health has
been well positioned for growth, and the system has received numerous awards
and accolades, including becoming one of
Fortune magazine’s “100 Best Companies to Work For” (Scripps Health San Diego, n.d.). In 2017, Scripps announced
the implementation of a new dyad leadership model that pairs hospital administrators with physician leaders to further align mutual interests.
Physician Employment Models
More complex reimbursement systems are emerging from health reform and the
quality movement. Physician payment is moving from a primarily fee-for-service or
volume-based methodology to a model more dependent on quality and clinical outcomes. As a result of this shift, many physicians are no longer interested in private
practice models. Instead, they are seeking a#liation and employment opportunities
with health systems and hospitals. Physician employment models free up clinician
time so they can focus on providing patient care rather than the business of running
a practice. Employment can be advantageous for hospitals and health systems by
increasing their level of alignment with physician providers. Physician employment
models often tie compensation to quality and productivity metrics.
“e Mayo Clinic ( is one successful model of physician
employment. Physicians work together with other clinic sta! to care for patients,
and their work is centered on the philosophy that “the needs of the patient come
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Chapter 2. Organization of Care 45
!rst” (Mayo Clinic, n.d.). “e culture of Mayo is unique, rooted in the values of its
founders: teamwork, collegiality, professionalism, mutual respect, and commitment to progress for the organization and individuals. Care is provided by integrated teams of physicians, health care professionals, and scientists. “e Mayo
culture emphasizes team success over individual success. Although physician
employees are provided with a vast array of resources and support, they are compensated with a salary. “is salary structure eliminates any incentives to perform
tests or procedures for !nancial gain. Treatment is purely focused on what is best
for the patient (Mayo Clinic, n.d.).
Innovative Approaches to Improving Care Delivery
So far in this chapter, we have described several organizations that use innovative
approaches to deliver high-quality health care. Health care delivery organizations
must continue to innovate if they hope to deliver high-quality care while controlling costs. “is section highlights two organizations that have strong reputations
as long-term innovators.
Intermountain Healthcare—Salt Lake City, Utah
Intermountain Healthcare ( fosters a culture
of innovation. Intermountain is a nonpro!t health care system comprising 22
hospitals, more than 185 physician clinics, and an a#liated insurance company.
“e system has more than 33,000 employees who serve patients in Utah and
southeastern Idaho. “e mission of Intermountain Healthcare is “helping people
live the healthiest lives possible” (Intermountain Healthcare, n.d.). In addition to
pursuing the typical health care delivery activities of an integrated health system,
Intermountain has several programs that nurture a learning environment and
culture of innovation.
Intermountain has several initiatives centered around using technology and
innovation to provide high-quality care at a sustainable cost. Intermountain
Innovations is an e$ort to develop new revenue streams by commercializing
proven clinical and technological innovations. “e Intermountain Simulation
Center capitalizes on technology to provide training for clinicians and employees
that will help promote safety and reduce medical errors among its health team.
Intermountain hosts the Homer Warner Center, a research facility dedicated to
the discovery and implementation of technology through medical informatics.
Of particular prominence is the Intermountain Transformation Lab. “e purpose of this lab is to bring innovation and technology to the patient’s bedside at a
rapid pace. In addition to working with external technology partners, Intermountain’s Healthcare Transformation Lab also provides opportunities for Intermountain employees to develop ideas into new technology. “e lab provides a place for
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46 Part I. Health Policy
clinicians to work with technology experts in developing innovative ideas that
will improve the delivery of health care. Examples of projects targeted by the lab
include designing the patient room of the future, creating a hand-washing sensor
for providers, 3D printing of medical devices for clinical purposes, and creating a
“Life Detector” to notify caregivers of changes in vital signs of patients.
Intermountain hopes to a!ect change in the delivery of health care through
providing educational opportunities and conducting research throughout the
system. Its culture of innovation capitalizes on the knowledge of caregivers and
employees to improve quality and reduce costs (Intermountain Healthcare, n.d.).
The Cleveland Clinic—Cleveland, Ohio
“e Cleveland Clinic ( is a multispecialty academic
medical center with a focus on clinical care and research. It houses more than
1,400 hospital beds at its main campus and works with more than 3,000 physicians and scientists. “e Cleveland Clinic’s mission is “to provide better care of
the sick, investigation into their problems, and further education of those who
serve” (Cleveland Clinic, 2018). Quality and innovation are among its core values,
and the clinic is consistently named in
U.S. News and World Report’s “America’s
Best Hospitals” survey.
Cleveland Clinic is innovating care delivery by negotiating directly with selfinsured employers as part of its Program for Advanced Medical Care (PAMC).
“e idea behind PAMC programs is to allow employers to provide their employees with access to world-class health care at a reasonable price. Bundled payment programs and transparency in quality outcomes make the Cleveland Clinic
a natural choice for large employers interested in securing greater value in their
health care purchases. PAMC’s #rst agreement of this kind began with Lowe’s
Companies in 2010 to provide heart care for its more than 200,000 employees.
“e clinic recently expanded its cardiac program by contracting with Walmart
and is now focusing on marketing packages of orthopedic procedures to large
employers. Promoting this form of “domestic medical tourism” may change the
way care is delivered, or at least promote transparency among health care providers in terms of quality and pricing (Cleveland Clinic, 2018).
“e U.S. health care delivery system can look forward to many changes on the
horizon. Uncertainty surrounding the ACA continues to push providers to continually improve quality and manage costs. Innovative new forms of delivering
health care will continue to emerge to meet the demands of both patients and
purchasers of health care. Health care delivery organizations that fail to evolve
and learn will face a di$cult road. “ose organizations that focus on innovation
and knowledge creation will be well positioned for the future.
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Chapter 2. Organization of Care 47
You have just been promoted to work as the assistant to the CEO of a large, partially integrated
health care delivery system. Your first assignment is to identify several innovative ways to
improve health system quality, control costs, and maximize access to care for citizens in your
community. Opportunities exist to improve physician-hospital alignment and to provide more
integrated care across health system entities. Draft a memo to your CEO that answers the
following questions:
1. What are five innovative ideas your health system could implement to meet improvement
goals around cost, quality, and access?
2. What innovation or innovative idea is the most critical to ensure the health system
achieves its goals?
3. What innovation will be the most difficult to achieve? Why?
4. Why will the implementation of these innovative ideas improve health system
1. !e U.S. health system is shifting its focus to wellness and prevention. Give an example of the three forms of prevention. How should emphasis on prevention alter the
delivery of health services in a particular community?
2. The baby boomer generation, which represents a significant portion of the U.S.
population, is reaching an age when its utilization of health services will most
likely increase. Additionally, life expectancy continues to improve with advancements in medicine and community health. Discuss how this aging of such a large
segment of the population will affect specific health care delivery services and
3. Most health care in the United States is delivered in traditional settings such as hospitals, physician organizations, and long-term care organizations. However, access to
new delivery settings is becoming more readily available, and demand for care delivery through telemedicine and retail clinics is increasing. Give an example of an application for telemedicine. Discuss how the utilization of telemedicine might a”ect cost,
quality, and access to care in the U.S. health care system.
4. Although the United States spends more money per capita on health care than any
other country in the world, its performance has much room for improvement. How
can ideas such as the Triple Aim initiative or patient centeredness help to improve
performance in the U.S. health system?
5. Discuss why coordinated care delivery approaches, such as PCMHs or ACOs, might
improve care for patients. Discuss barriers and opportunities for implementation of
such coordinated care delivery approaches.
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48 Part I. Health Policy
Agency for Healthcare Research and Quality. (2013). Retrieved from
Ambulatory Surgical Center Association. (2018). What is an ASC? Retrieved from https://
American Hospital Association. (2018). Fast facts on U.S. hospitals, 2018. Retrieved from
Centers for Disease Control and Prevention. (2017).
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. Retrieved from https://www
Centers for Medicare & Medicaid Services. (2018). Next Generation ACO Model. Retrieved
Cleveland Clinic. (2018). Facts & !gures. Retrieved from
Enthoven, A. C. (2016). What is an integrated health care !nancing and delivery system
(IDS)? and what must would-be IDS accomplish to become competitive with them?
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Gerteis, M., Edgman-Levitan, S., & Daley, J. (1993).
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Hirshon, J. M., Risko, N., Calvello, E. J. B., de Ramirez, S. S., Narayan, M., “eodosis, C.,
& O’Neill, J. (2013). Health systems and services: “e role of acute care.
Bulletin of the
World Health Organization, 91
, 386–388. doi:10.2471/BLT.12.112664
Hulbert, J. (2017, October 30). Five ACO success tips from Beth Israel Deaconess Care
Organization CEO.
Managed Healthcare Executive. Retrieved from!ve-aco-success-tips-beth-israeldeaconess-care-organization-ceo
Hwang, W., Chang, J., LaClair, M., & Paz, H. (2013). E#ects of integrated delivery systems on
cost and quality.
American Journal of Managed Care, 19(5), e175–e184. Retrieved from
Institute for Healthcare Improvement. (2015).
Signature Healthcare: A Triple Aim improvement story. Cambridge, MA: Author. Retrieved from
Institute for Healthcare Improvement. (2018).
!e IHI triple aim initiative. Retrieved from
Institute of Medicine. (2001).
Crossing the quality chasm: A new health system for the 21st
. Washington, DC: National Academies Press.
Institute of Medicine. (2003).
!e future of the public’s health in the 21st century. Washington,
DC: National Academies Press.
Institute of Medicine. (2012).
An integrated framework for assessing the value of communitybased prevention. Washington, DC: National Academies Press.
Intermountain Healthcare. (n.d.). Transforming healthcare. Retrieved from
Kaiser Family Foundation. (2018). Medicare delivery system reform: “e evidencellink:
8 FAQs: Medicare ACO models. Retrieved from
Kane, C. K. (2017).
Policy research perspectives: Updated data on physician practice arrangements: Physician ownership drops below 50 percent. Chicago, IL: American Medical
Association. Retrieved from
Kindig, D., & Stoddart, G. (2003). What is population health?
American Journal of Public
, 93(3), 380–383. doi:10.2105/AJPH.93.3.380
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Chapter 2. Organization of Care 49
Mayo Clinic. (n.d.). Culture. Retrieved from
National Association of Community Health Centers. (n.d.). About our health centers.
Retrieved from
National Committee for Quality Assurance. (2018).
NCQA PCMH recognition: concepts
(PCMH) 2017
. Washington, DC: Author. Retrieved from
National Hospice and Palliative Care Organization. (2018). Retrieved from http://www.
Optum. (2014).
!e four steps of population health management. Retrieved from https://
Partners in Care Foundation. (2018). Avoid re-hospitalization of high-risk patients and cut
costs with Care Transition Choices. Retrieved from
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!e evolving role of retail clinics. Retrieved from
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group health medical home at year two: Cost savings, higher patient satisfaction, and
less burnout for providers.
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Social Security Act, 42 U.S.C. § 1867(e)(1)(A).
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de#ning the healthcare delivery system:
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. Newark, DE: KPMG Government Institute. Retrieved from
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The Politics of Health Care
in the United States
Rogan Kersh and James Morone
Understand the health care infrastructure
Explain the effect of spending on the health care infrastructure
Describe the politics of Medicare and Medicaid
Discuss the impact of politics on the health care delivery system
Explore how personal health decisions become public
administrative efficiency
patient outcomes
policy issue
Costs for health care infrastructure
Many dollars are spent on health care but to what effect?
The politics of Medicare and Medicaid
The role of politics in equitable health care services
Personal health decisions become public: obesity
© Springer Publishing Company DOI: 10.1891/9780826172730.0003
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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AN: 1998657 ; James R. Knickman, PhD, Brian Elbel, PhD, MPH.; Jonas and Kovner’s Health Care Delivery in the United States, 12th Edition
Account: s3563253.main.ehost

52 Part I. Health Policy
It is the best of health care systems; it is the worst of health care systems—at least
among rich nations. Health care in the United States is a point of cultural pride (“!nest in the world!”). It is the nation’s largest economic sector, at $3.5 trillion in annual costs and
approaching 20% of U.S. GDP (gross domestic
product). It is a moral issue, given low-income
Americans’ terrible health care outcomes,
dragging the national average below other rich
countries on most measures of population health,
including maternal mortality and life expectancy
at birth. It is a
policy issue because every one of these dimensions (quality, costs,
injustice) feed into heated congressional, White House, and state/local legislative
discussions. And health care is, of course, a deeply personal matter: It is about the
human condition, about wellness and su”ering, sickness and death.
#e modern American health care system was forged by political choices.
#e United States experienced furious debates about whether to cover all citizens through a government program (in the 1940s), even as most other wealthy
democracies were organizing such programs. It deployed tax policy to foster a
private, employer-sponsored health insurance coverage industry (1950s). It !lled
the gaps in coverage for some of America’s poor and almost all people over 65
with two programs, Medicare and Medicaid, legislated in 1965 (and now swallowing a quarter of the federal budget and, on average, a !fth of state budgets).
Every presidential administration in the past 80 years—Democratic and Republican, liberal and conservative—has proposed major changes in health policy. Both
the Barack Obama and the Donald Trump administrations zoomed in on health
care in their !rst months. In short, the battle over the shape of American health
care is constant (Blumenthal & Morone, 2008; Henry Kaiser Foundation, 2016).
#is chapter takes up three main dimensions of the U.S. health care system,
emphasizing throughout the central role of politics and policymaking. We
begin with the basics—America’s national health infrastructure and how medical services are !nanced. Next we zero in on health insurance, which inspires
especially heated policy debates (more technical reviews of issues related to
!nancing and health insurance are presented in Chapters 10 and 11). A third
primary theme is health disparities among Americans: Geography, a proxy
for wealth and poverty, is a major determinant of health outcomes (this topic
is covered in more detail in Chapter 8). After describing the political context
for health care, we take up a speci!c issue—obesity—and detail how political
maneuvering shapes health matters that many Americans still consider personal, not a matter of government regulation. As both history and contemporary practice show, many ostensibly private matters in the health domain have
Despite the United States’
enormous spending on health
care—the highest in the
world—patient outcomes lag
behind those of comparable
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 3. The Politics of Health Care in the United States 53
been the subject of public regulation—even in the famously individualistic,
anti-government United States.
At the core of health politics and policy
is the question of whether individuals have
a right to health care or whether it should
be treated as any other market good, like
clothes or food or cars. Most wealthy democratic countries view health care as a foundational human right and provide at least a
basic level of health services to all residents;
some, like Canada, aim for a universal right
to equal care (Chapter 4 focuses in more detail on a comparative global health
perspective). Uniquely among advanced democracies, the United States views
health care not as a right but a patchwork: an entitlement for most people over
65, a perquisite of employment in some companies and sectors, and a service to
be purchased either as insurance or at point of service for millions of others. !e
United States is among a handful of countries not to have rati”ed a UN treaty
declaring health care a fundamental human right (UN o#cial text, 2018).
Our idiosyncratic health system has always been shaped by political
debates—drawing in policymakers as well as large employers, private insurance companies, and professional medical decision makers. !is chapter
examines whether the result of all that politicking is better health outcomes
for most Americans. Our main aim in this chapter is to clarify the roles of policymaking and politics in the U.S. health system. Our discussions of “nancing,
insurance, and obesity as a behavioral health issue and comparative health care
are meant to complement other chapters in the book and to provide context
for the exploration of the dynamics of politics and policymaking in the world
of the U.S. health system. Our aim is to communicate how politics and policy
impact the health system and how political scientists approach the topic of
health care.
!e U.S. system of delivering and “nancing health care is the most complicated
among advanced countries. Some nations, like Great Britain, manage health care
through the government; others, like Switzerland, rely on the private market
(with government subsidizing care for the least well-o$). Still others—Singapore,
for example—mix government-run care for low-income residents with a private
system (Gusmano & Rodwin, this volume). !e United States includes elements
of all three. Complicating matters further, treating patients and paying for those
treatments are managed by di$erent collections of institutions. !e one-word
summary: fragmentation.
At the core of health politics and
policy is the question of whether
individuals have a right to health
care or whether it should be
treated as any other market
good, like clothes or food or cars.
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54 Part I. Health Policy
Providing Health Care
Let’s start with government-provided care. American military veterans receive
health care from more than 1,200 hospitals and clinics managed by the Veterans
Health Administration (VHA). More than 305,000 VHA health professionals and
support sta! tend to some 9 million veterans each year, making this the largest
health system in the United States. Veterans’ complaints in recent years about
long waits for care and elaborate eligibility rules have resulted in diminished
approval ratings for the VHA, even as it spends nearly $200 billion annually (VA
Health Care, 2017). Along with this federal management of veterans’ care, state
and local governments also run public clinics and hospitals, which help serve
those who can’t otherwise a!ord care. Moreover, members of the armed forces
and their families receive care through services organized by each branch of the
federal military. Overall, about a quarter of U.S. health care delivery is through
these various government-run entities.
“e remaining three-quarters of hospitals and clinics are run by private companies, which are deeply enmeshed in the U.S. health care system. Of those clinics
and hospitals that are private, about 70% are nonpro#t—managed by universities,
religious institutions, charities, or nonpro#t networks. “e remainder are forpro#t, often organized into large systems: the Hospital Corporation of America,
for example, based in Nashville, Tennessee, manages more than 175 hospitals in
the United States and the United Kingdom, with annual revenues of more than
$3 billion.
What about prescription drugs and other pharmaceuticals? “e U.S. drug
industry is almost entirely private—an economic behemoth with global reach,
approaching $500 billion in annual sales. By comparison, in most other advanced
democratic countries, the government purchases and distributes prescription
What di!erence does it make that so
much of the U.S. health infrastructure is outside government supervision? A lot: In most
advanced countries, a central government
body (like the United Kingdom’s National
Health Service, or China’s Ministry of Public
Health) provides strategic planning; determines where additional doctors, nurses,
and other health professionals are needed
(and whether there are su$cient hospitals
and clinics to house them); and pays most
of the cost of care. In the United States, privately managed care facilities are free to open or close where and when they wish.
America has no national health planning; individual states and large cities monitor their health systems, regulate providers, and collect reams of health data—but
do not wield direct in%uence on the provision of care. “e result is a hodgepodge
The U.S. drug industry is almost
entirely private—an economic
behemoth with global reach,
approaching $500 billion in
annual sales. By comparison, in
most other advanced democratic
countries, the government
purchases and distributes
prescription drugs.
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Chapter 3. The Politics of Health Care in the United States 55
of some often-superb facilities, especially in higher-income neighborhoods, and
many places (especially inner cities and rural areas) devoid of !rst-rate medical
institutions or professionals.
Although the U.S. system lags behind
almost every wealthy nation in health outcomes—more on that later—America does
lead the world in health
innovation: developing new treatments, medical instruments, and drugs for the bewildering array
of diseases and health conditions that beset
us. More than 60% of health research and
development (R&D) funding is carried
out by private industry; another quarter is
funded by the government, often as grants
to university researchers, many of whom
work closely with private companies to license their discoveries for sale. Nearly
150 U.S. universities also manage large health care systems, organized around
teaching hospitals where the next generation of medical professionals are trained.
In sum, if you get sick in the United States, are not in the military or a military veteran, and need to see a doctor, chances are high that she will be privately
employed—though likely in a nonpro!t hospital or clinic. If you are under 65,
unemployed, and uninsured, you may seek care at an emergency room or a low/
no-cost public clinic. Should you receive a prescription, you’ll probably go to a
private pharmacy like CVS or Walgreens and buy (with help from insurance,
which we talk about below) drugs or other palliative services. “ose pharmaceuticals (or insulin treatments, special bandages, etc.) were likely produced by
private companies, though the R&D may well have involved government-funded
research in university or public laboratories at places like the Centers for Disease
Control and Prevention (CDC), a government agency.
Perplexed yet? Health care provision in the United States is a tangled mixture of national, state, and local government; private companies, both forpro!t and nonpro!t; universities and nonpro!t health-advocacy organizations;
and medical professionals spread across all these groups. “is multi-layered
complexity—sitting atop an equally complicated !nancing arrangement, discussed in detail in the following—is part of the reason that Americans far outstrip the rest of the world in health care spending. Let’s take a look at where that
annual $3.5 trillion goes.
Health Care Spending
Figure 3.1 provides a summary of how American health care dollars are spent.
Note that this arrangement—nearly a third of total funds spent on hospital care, for example—is not ordained by law or medical best practices but
Although the U.S. system lags
behind almost every wealthy
nation in health outcomes,
America does lead the world in
health innovation: developing
new treatments, medical
instruments, and drugs for the
bewildering array of diseases and
health conditions that beset us.
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56 Part I. Health Policy
re!ects a mix of tradition, strategic decisions, investor choices, and political
compromises. Many other countries spend a higher percentage of their health
dollars on government administration (1.2% in the United States) because their
systems are subject to central control. Most others also spend a far lower proportion of their health dollars on prescription drugs (approaching 11% in the
United States)—mainly because their national government purchases drugs in
bulk quantities and manages their distribution. As we will see below, U.S. political debates on funding prescription drugs tend to rule out such centralized government purchases.
“e United States is also distinctive in terms of
how much it spends on health
care: by a considerable margin, the world’s most per capita. Figure 3.2 lists the top
health-spending countries per person.
With the United States considerably ahead of other wealthy nations—
spending twice as much as the average peer country—questions arise about
what lies ahead. “Bending the health cost curve” downward has been a
priority for health policymakers for decades; President Richard Nixon
warned darkly that “we face … a breakdown in our medical system,” caused
by rising costs, back in 1969 (Nixon, 1969). Fifty years later, costs continue
to rise.
5 4.2
Hospital Care Physician Services Clinical Services Long-Term Care
Home Care Other Personal Care Prescription Drugs Net Insurance Cost
Public Health
Investment Government
Source: Data from the Department of Health and Human Services (DHHS) and !e Centers for Medicare
& Medicaid Services (CMS).
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Chapter 3. The Politics of Health Care in the United States 57
Bending the Cost Curve? Health Spending
in Coming Years
Given the convoluted U.S. infrastructure, the
job of providing high-quality health services
is demanding—and becomes more di!cult
as costs soar. After a drop in annual increases
after the A”ordable Care Act (ACA)’s passage, costs have begun again to rise steadily,
with prescription drug increases leading the
way. Other drivers of the current boost in U.S. health expenses include higher
costs for out-of-pocket care, rising Medicare expenses as a swelling number of
baby boomers age into the program, and ACA premium hikes—the latter a consquence of executive branch regulatory actions designed to weaken the ACA.
In a sentence, why do Americans pay so much for health care? Because U.S.
providers charge more for the same service. Without a single regulator negotiating prices, costs are simply passed along (Cuckler et al., 2018). To understand the
United States $10,348
Switzerland $7,919
Germany $5,550
Netherlands $5,385
Austria $5,227
Country Average
Belgium $4,839
Canada $4,752
Australia $4,708
France $4,600
Japan $4,519
United Kingdom $4,192
Source: Data from Peterson-Kaiser Health System Tracker.
Given the convoluted U.S.
infrastructure, the job of providing
high-quality health services is
demanding—and becomes more
dif!cult as costs soar.
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58 Part I. Health Policy
complexities of rising health costs, and the central role of political decisions, let
us look more closely at prescription drugs.
Pharmaceutical companies raised prices well beyond in!ation with the advent
of the Trump administration: After growing by around 2% annually, drug costs
leapt upward by 4.4% during 2017–2018. As a study by Pharmacy Bene”t Consultants (PBC) shows, 40 prescription drugs had price increases of more than
100% across the 15 months since January 2017; more than 225 drugs cost at least
a third more (Pharmacy Bene”t Consultants’ comparison, 2018). Current projections are for annual drug cost increases of some 6.5% over the next decade.
Pharmaceutical company representatives argue that higher costs are driven by
increased use of specialty drugs to treat cancer and genetic disorders, but those
skyrocketing fastest on PBC’s list include drugs for bee stings, bedwetting, and
prescription skin cream.
U.S. drug costs are more than twice as
high as the average for other industrialized
countries, a gap larger than that for nearly all
other consumer goods. Public policy decisions are a major reason. In contrast to most
other countries, the American government
guarantees extended monopolies to drug
companies, with generic alternatives that would dramatically reduce prices often
held up for years by litigation. Exacerbating this political decision, Medicare’s
initial passage included a compromise, since rea#rmed many times by Congress,
that the Centers for Medicare & Medicaid Services (CMS) cannot use its immense
bulk-purchasing power to negotiate lower prices with drug manufacturers. CMS
payment plans are also required by Congress to cover nearly
all drugs, rather
than concentrating on the most frequently prescribed (and/or cheaper) medications (Kesselheim, Avorn, & Sarpatwari, 2016). Companies routinely claim that
the high costs of research and development, along with long delays in Food and
Drug Administration (FDA) approval of new drugs, keep their costs high. But academic analyses “nd at best mixed evidence of association between R&D expenses
and drug prices (Jaroslawski, Auquier, & Toumi, 2017; Kesselheim, Avorn, & Sarpatwari, 2016), and the FDA’s swifter drug approval processes in recent years has
not resulted in a commensurate price reduction for new pharmaceuticals.
A “nal reason for unusually high prescription drug prices is the fragmentation of the industry. Drug companies utilize distributors for their products, who
add a hefty premium to the price of every drug. How much do they add? Drug
companies are not permitted to list their prices before the distributor markup. It
is a fragmented system is rife with opportunities for “investment.” Budget-minded
policymakers, restricted at every turn from addressing these well-protected political decisions, can agree only that innovative policy moves are an essential part
of the solution to sharply rising prescription drug prices (Alexander et al., 2017;
Frank & Zeckhauser, 2018).
For a blend of reasons, then—manifestly including politics—U.S. health
spending is the world’s highest. What do we get for all those dollars expended?
U.S. drug costs are more than
twice as high as the average for
other industrialized countries, a
gap larger than that for nearly all
other consumer goods.
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Chapter 3. The Politics of Health Care in the United States 59
Across the !rst two-thirds of the 20th century, America was among world leaders
in terms of health outcomes, ranking near the top in areas like infant mortality
and life expectancy. In recent decades, almost every wealthy nation has surpassed
the United States on primary measures of mortality and morbidity. As we will
explore, these are
average measures; they mask enormous di”erences between
rich and poor.
Patient Outcomes and Beyond: Evaluating American Health Care
Assessing health care systems is a complex science (Gusmano & Rodwin, this
volume). A hospital that rates highly on curing patients may actually turn away
the sickest cases. Nuanced assessment measures are therefore required. Along
patient outcomes, analysts now evaluate health care systems in four additional areas: access (is health care availability timely and a”ordable?), care process (including such vital aspects as patient safety, preventive care, coordinating
care across di”erent health providers, and health professionals’ engagement with
administrative efficiency (measuring whether the immense bureaucracy required to operate health systems work smoothly and swiftly), and equity
(do all who seek care receive similar treatment?). Chapter 12 reviews the topic of
quality improvement in more detail.
Since health care systems exist to enhance people’s health and well-being,
patient outcomes top the list of evaluative criteria. Here the United States performs poorly, compared to peer nations. On an Institute of Medicine comprehensive study of 17 high-income countries, Americans scored at or near the worst on
nearly all of nine measures, including frequency of homicides, incidence of heart
and lung disease, infant mortality, obesity, disability rates, frequency of car accidents, and sexually transmitted infections among teens (Woolf & Aron, 2013).
Together, these features drive down life expectancy. According to latest Organisation for Economic Co-operation and Development (OECD) estimates, Americans born in recent years can expect to live to age 78.8 on average—a full 5.1 years
less than in Japan, and not in the world’s top 30 countries—ranking below Chile,
Slovenia, and Cuba (Kochanek, Murphy, Xu, & Arias, 2017; OECD, 2017).
On the other above-listed dimensions, from system e#ciency through
equity, the United States is also a relatively low performer. Figure 3.3 summarizes an analysis of all !ve evaluative dimensions by the Commonwealth Fund,
a global health policy research organization (Schneider et al., 2017). As you
can see, the United States scores highest—!fth overall—on care process, thanks
to preventive measures like mammography screening and provider–patient
engagement, ranging from wellness counseling on healthy behaviors to end-oflife discussions with health providers. Otherwise, American health systems perform poorly. $e United States ranks next to last in administrative e#ciency and
!nishes at the bottom in the other three areas. Add up the results and America
!nishes last overall among wealthier countries.
$e American combination of high health spending per capita—31% higher
than Switzerland, the second most expensive—and lagging patient outcomes is
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60 Part I. Health Policy
a source of concern for U.S. health providers and policymakers alike (Papanicolas, Woskie, & Jha, 2018). Figure 3.4 combines these two comparative features—
higher costs and poorer results—in a compelling juxtaposition. Among the world’s
25 largest economies, the United States outstrips all others on expense (farthest
right, along
x axis) and lags most on life expectancy (farthest down on y axis).
Part of the reason U.S. health care is so expensive—and partly why outcomes
are poor compared to other advanced countries—involves how it is !nanced.
When it comes to who
pays for insurance and delivering health care services, here
again complexity rules. And also again, political debates and deals are central to
America’s convoluted architecture of health !nancing.
Some 18% of the U.S. GDP (all goods and services a nation produces) is devoted
to health services, a percentage that continues to rise—and that is higher than
peer nations, which typically spend around 10% of GDP on health care. Financing those huge health costs involves a jumbled mixture of national, state, and
local government; private insurance companies; individual payers; and private
charities. Figure 3.5 illustrates the mix of payment sources for U.S. health care.
Look carefully at the !gure and you’re probably in for a surprise. “e largest source of health insurance in the United States is the government: Medicare
(a federal government program), Medicaid (joint federal and state), and other
Source: Retrieved from Commonwealth Fund.

Care Process + Access + Administrative
Efficiency + Equity + Outcomes + Health Care
2 9
8 3 4 4 6 6 1
2 6 9 8 4 3
7 1 5
9 2 1 7 5 6 8 3
1 6
6 9 2 4 5 8 3
7 9
6 2 8 5 3 4 1
1 9 5 8 6 7 3 2 4

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Chapter 3. The Politics of Health Care in the United States 61
0 $500 $1,000 $2,000 $3,000 $4,000
Health Expenditure
(adjusted for inflation as well as purchasing power parity [PPP] for price differences between countries)
Life Expectancy (Years)
$5,000 $6,000 $7,000 $8,000 $9,000
South Korea
New Zealand
Source: Financing Healthcare by Esteban Ortiz-Ospina and Max Roser. Retrived from !e Economist.
programs amount to 41% of insurance coverage. Together, these giant entitlement
programs (only Social Security is larger) account for approximately $1.18 trillion
in government spending, a !gure that by 2026 is expected to top $2 trillion. Private plans account for 34% of health care insurance (see Figure 3.5). “e next biggest slice: “out of pocket.” People pay at the
point of service, either to cover cost sharing
(which can run to thousands of dollars) or
because they have no insurance.
Ironically, because they have no negotiating leverage, uninsured individuals face
higher prices than the insurance companies
Ironically, because they have
no negotiating leverage,
uninsured individuals face
higher prices than the insurance
companies pay.
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62 Part I. Health Policy
Health Insurance,
Public Health
Other Third
Party Payers
Investment, 5%
Out of Pocket,2
Private Health
(Title XIX)
Medicaid Federal, 11%
(Title XIX)
State and
Local, 6%
(Titles XIX and
Title XXI), 4%
1 Includes worksite health care, other private revenues, Indian Health Service, workers’ compensation, general assistance, maternal and child
health, vocational rehabiliation, Substance Abuse and Mental Health Services Administration, school health, and other federal and state local
2 Includes copayment, deductibles, and any amounts not cover by health insurance.
Source: Retrieved from CMS.
Note: CHIP, Children’s Health Insurance Program; DOD, Department of Defense; VA, Veterans
pay. Bill Clinton starkly pointed out the problem of individual payers back in
1993: “our grandchildren will !nd it … unthinkable that there was a time in this
country when hardworking families lost their homes, their savings, their businesses, lost everything, simply because the children got sick” (Clinton, 1993).
Despite years of policy e”orts, Clinton’s lament remains true today. One study,
by the Kaiser Foundation, concluded that roughly a quarter of Americans have
trouble paying medical bills and that the bills have had “a major impact on the
family”—often including bankruptcy (Hamel, Norton, Pollitz, Levitt, Claxton, &
Brodie, 2018).
Along with soaking up a signi!cant majority of spending, health insurance
is essential to enable people to a”ord the spiraling costs of treatment, among
many other bene!ts (Sommers, Gawande, & Baicker, 2017). No American political battleground has been more !ercely contested in recent years than how health
insurance is provided and paid for.
In a majority of the world’s nations, health care is free to residents, with
insurance provided mainly by the national government. Fall ill in any of 160
countries—from Costa Rica to Zambia, Pakistan to Denmark—and you can seek
care secure in the knowledge that government-paid insurance will cover the cost
of your treatment. In a smaller group of countries, the private market is a main
source of insurance. In Switzerland, for example, the government mandates that
everyone have health coverage but does not provide it: Instead, Swiss purchase
individual plans from more than 100 private companies. (Government subsidies
are provided to people in lower income brackets, on a sliding-scale basis.)
#e U.S. system is a patchwork, the result of political compromises on Capitol
Hill, state legislatures, city councils, employers, health care institutions, health
care professionals, the White House, and more. How did we get to this tangled
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Chapter 3. The Politics of Health Care in the United States 63
and fragmented nonsystem? We turn now to a closer look at the peculiar political
history of health insurance in America.
Health Insurance Reform: A Brief Political History
President Harry S. Truman (1945–1953) ran for reelection in 1948 touting
his national health insurance plan; it was his top domestic priority. However,
Congress—dominated by conservative Southern Democrats—buried the issue.
!e powerful chair of the Senate Finance Committee declined even holding
hearings on the proposal. If the United States operated as a parliamentary
democracy, like Germany or Canada, the president would have been able
(indeed, expected) to pass the program he promised in the campaign. National
health insurance fell short—thanks to the American government of checks and
balances (Blumenthal & Morone, 2008).
Republican President Dwight D. Eisenhower (1953–1961) was eager to build
a private insurance alternative to Truman’s plan. His administration made permanent a tax deduction to encourage employers to o”er health insurance to
workers—and the private health insurance system took o”. Note that it was
#nanced by a conscious policy decision: what political economists call a tax
expenditure, one that cost the federal government $253 billion in 2018.
With John F. Kennedy’s win in 1961, Democrats resurrected the Truman plan,
reduced its scope to cover only those over 65, and renamed it Medicare. !eir
hope was that it would prove so popular that the rest of the population would
demand coverage, too. In a legislative coup, planned by President Lyndon Johnson (1963–1969) and the chair of the Ways and Means Committee, Wilbur Mills
(D-AK), Congress passed not just Medicare but two counterproposals introduced
by the Republicans and the American Medical Association. !e #nal legislation
included a federal program that paid hospital and physician costs for people over
65 (Medicare) and a federal state program, administered on the state level, that
paid for some categories of poor people, mainly families with dependent children
(Medicaid). Even with these limits, opponents denounced the Johnson/Mills program as “socialized medicine.” Only 10 House Republicans voted for it, though
most changed to “aye” votes after failing to bury the bill (Berkowitz, 2005; Blumenthal & Morone, 2008).
!ese two programs eventually came to cost a quarter of the entire U.S. federal budget. Periodic expansions of Medicare and Medicaid still left millions of
Americans without insurance, at the mercy of a frayed health care safety net. By
the early 1990s, nearly 20% of Americans under 65 (the cuto” age after which
Medicare provides insurance), or just under 40 million people, had no health
insurance. President Bill Clinton, after signing in 1993 a massive bill designed to
bring the federal budget back into balance, turned to health care reform. A multiplicity of health care changes were blended into one of the most ambitious legislative e”orts since World War II, with extension of insurance at the measure’s heart.
Opponents, again trumpeting the dangers of government-mismanaged health
care, were able to defeat the e”ort, thanks in part to widely watched television
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64 Part I. Health Policy
advertisements starring an innocuous American couple, Harry and Louise, worrying aloud about the devastating e!ects of “letting government choose: We lose.”
“e Clinton administration assisted opponents by taking a year to design
and submit its plan. As Lyndon Johnson well understood, such massive proposed
changes very rarely can navigate the American system of multiple vetoes beyond
a year after a presidential election. A more focused expansion of insurance for
around 660,000 low-income children, known as the Children’s Health Insurance
Program (CHIP), won bipartisan support and passed in the wake of the Clinton
health-reform collapse. Today an expanded CHIP serves nearly 9 million children
Barack Obama submitted his health insurance expansion within 2 months of
taking o#ce and, after a year of blistering politics in Congress and in congressional town hall meetings dominated by the rising Tea Party, managed to win passage by February 2009. “e legislation $nally squeaked through without a single
Republican vote. In marked contrast to past reforms (Social Security in 1935,
Medicare/Medicaid in 1965), Republicans did not shift their $nal votes to “aye,”
but kept right on resisting (Ho!man, 2003).
To date, “Obamacare” has extended coverage to some 20 million people, around two
$fths of those uninsured before the ACA
was enacted. It involves two major programs. First, it subsidized private insurance
and required people to purchase it. Second,
it put aside the state-by-state Medicaid
patchwork and expanded the program to
cover everyone under 138% of poverty (today, about $32,000 for a family of four).
Notably, the $rst is the kind of program once sponsored by Republicans; the latter
expands a classic big-government program legislated during the Johnson years.
Implacable Republican opposition continued. A Republican-led Congress
staged more than 100 votes between 2011 and 2018 to repeal the law and twice
advanced repeal to the U.S. Supreme Court, where it failed both times by a 5–4
margin. Donald Trump, whose 2016 presidential campaign was built in part
around a promise to eliminate the ACA, dismantled portions of the law through
executive orders and ordered sweeping cutbacks in federal advertisements
during periodic enrollment periods.
One target of Republican ire is the ACA’s individual mandate, which requires
most people to have insurance. In order to $nance care for sick people, healthy
ones must pay into the system—and they, in turn, receive a!ordable health services should they fall ill. To ensure compliance with the mandate, a $nancial
penalty is charged to those who fail to sign up for insurance (which is heavily
subsidized for the poorest Americans). President Trump issued an executive
order in 2017 ending that penalty; months afterward in summer 2018, his Justice
Department issued a ruling that the mandate itself was unconstitutional (Beech
& Lambert, 2018), despite congressional passage and two a#rmative decisions in
To date, “Obamacare” has
extended coverage to some 20
million people, around two !fths
of those uninsured before the
ACA was enacted.
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Chapter 3. The Politics of Health Care in the United States 65
the Supreme Court. In contrast, the Medicaid expansion continues to spread, as
we discuss below.
Peering in 2018 into the murky future, the nonpartisan Congressional Budget
O!ce predicted a return to rising numbers of uninsured people, given continued
peeling away of the mandate and other aspects of the ACA. What may fairly be
viewed as a moral tragedy—that millions of people in the world’s wealthiest country are unable to pay for health services—will continue for the forseeable future.
Fifty-eight countries around the globe, including nearly all U.S. peer countries
(wealthy democracies), provide universal care—every resident is guaranteed access
to the health care system by their government. Of the world’s 201 nations, 160 provide free health care: no cost to the patient.
“is does not mean that people in di#erent
income classes are all treated equally—it is
possible in some of these 160 countries to
buy private insurance, which can ensure
superior care. But a minimum level of professional care is generally guaranteed to all.
“e United States is among the small handful of countries (most of them lower income, like Liberia, Iraq, and Haiti) that
do not provide free care and do not seek to cover all residents. One result is signi$cant health disparities in the United States: “e quality of health coverage and
care varies widely, depending on where you live and how much wealth you have.
Take a look, for example, at Raleigh, North Carolina. Babies born in the 27617
zip code, generally home to wealthier households, have an average life expectancy of
88 years. Mere miles away, in the 27610 zip code on Raleigh’s southeast
side, babies born today have a life expectancy of
76 years: a shocking 12-year gap.
“at’s the di#erence between Japan (number 1 in life expectancy) and Kyrgyzstan
(number 106), or between Germany (ranked 24) and Iraq (121) (World Health
Organization, 2016).
Health outcomes are worse in almost every respect: Residents of the 27610
zip code have higher rates of obesity, diabetes, and asthma and return to hospitals
within a month of discharge far more often than their neighbors in the 27617 zip
code. “ey miss work for illness far more frequently. And a much higher proportion are uninsured, so when poorer residents seek care at a $rst-rate medical
facility like WakeMed Hospital—if available to them at all—it could break their
bank account (VCU Center on Society & Health, 2018). Figure 3.6, produced by
Virginia Commonwealth University’s Center on Health & Society and the Robert
Wood Johnson Foundation, graphically illustrates this Raleigh disparity in life
Fifty-eight countries around
the globe, including nearly all
U.S. peer countries (wealthy
democracies), provide universal
care—every resident is
guaranteed access to the health
care system by their government.
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66 Part I. Health Policy
Similarly disturbing divergences are evident across the country: from California, where two freeway exits separate neighborhoods with 9 years’ di!erence in
life expectancy, to New York City, where six subway stops also separate a 9-year
gap. “is stark illustration demonstrates what public health researchers have long
known: Health disparities are endemic in the United States (Egen, Beatty, Blackley,
Brown, & Wyko!, 2017). Health outcomes across most groupings of Americans
rise steadily as education improves, income grows, housing is safer, access to good
care exists, and public transportation services are readily available. Once again,
all these topics are indelibly colored by political choices—in America’s federalist system, decisions are variously made at the national, state, and local level, not
infrequently with disagreements and tensions across o#ce holders on each level.
Contributing to political complexity around care for America’s less well-o!,
many rural residents of “red states”—those overwhelmingly voting Republican—
both exhibit relatively poor health outcomes and staunchly oppose government
e!orts to improve their health. Versions of the sign “Keep your government
hands o! my Medicare!” regularly appeared at Tea Party rallies in the wake of
the ACA’s passage (Skinner, 2012)—the irony was noted publicly by President
Obama, among many others (CNN, 2009).
2 miles
Life expectancy at birth (years)
Shorter Longer
82 YRS
ZIP 27713
77 YRS
ZIP 27703
88 YRS
ZIP 27617
81 YRS
ZIP 27606
76 YRS
ZIP 27610
Source: VCU’s Center on Health & Society and the Robert Wood Johnson Foundation.
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Chapter 3. The Politics of Health Care in the United States 67
With little national government e!orts at present to address health disparities, some states and cities are taking action themselves. Virginia in June 2018
became the 33rd state (including the District of Columbia) to expand Medicaid
to a wider set of needy residents, a policy passed as part of the ACA but left up to
individual states. Although conservative governors tended to oppose this extension even though more than 90% of funds came from the national government,
the bene”ts continue to spread (Sommers & Epstein, 2017). Figure 3.7 demonstrates, as of June 2018, which states have opted into this Medicaid expansion—
and which have not. All 18 of the latter had Republican governors and/or large
GOP majorities in their state legislature at the time of this writing.
#e preceding discussions demonstrate that policy decisions, emerging from
political “ghts and compromises, are essential to shaping the distinctive U.S.
health care system. Certainly health providers, market forces, and patients are
also vital contributors—but none of these act absent of political context. And
Number of states
that have not yet
expanded Medicaid
Number of states,
including the District
of Columbia, that have
expanded Medicaid
Source: Data from A 50-State Look at Medicaid Expansion FamiliesUSA (2007).
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68 Part I. Health Policy
that context itself is the subject of a pitched battle among con!icting American
ideals. On one hand, the U.S. policy is often described as among the world’s most
favorable to individual freedom—prizing personal liberty foremost. On the other,
repeatedly across our national history government actors have charged freely into
private arenas, regulating in the name of public health and safety personal matters like Americans’ drinking habits, sexual practices, or tobacco use (Kersh &
Morone, 2002a; Kersh & Morone, 2002b). Understanding this push–pull between
liberty and government regulation in the name of improved public health is at the
heart of health politics in the United States (Chapter 7 focuses on how health and
behavior in!uence health status in further detail).
Alcohol provides one example of private behavior turned subject of public
health regulatory regimes, helping to illustrate present-day trends. Alcoholic
beverages were long more commonly consumed by Americans than water, given
the dangers inherent in untreated water across the United States’ “rst century.
(#e “revolutionary” “rst widespread disinfection regimen for water was not
introduced until 1881 (McGuire, 2006).) When John Chapman, known as Johnny
Appleseed, planted all those apple trees in the 1840s, their fruit was more often
used to make fermented or “hard” cider than for eating (Kerrigan, 2012). Despite
the ubiquity of cider, beer, rum, and wine on American tables, the United States
underwent “ve major rounds of liquor prohibition between the 1820s and 1919.
#e battle culminating in the 18th Amendment—outlawing the production or
sale of any alcoholic beverages—was merely the most ambitious.
Much closer to the present day, coalitions of national and state political
actors have mounted a sustained challenge to the tobacco industry, resulting in
severe restraints on what many smokers consider their personal choice. As with
alcohol, public o$cials—pressed into action by social movements, advocacy
groups, and medical professionals—moved to regulate a topic that had been
seen as purely private behavior. Note also that in areas like regulating alcohol and tobacco, other advanced democratic nations take a more laissez-faire
#e politics of obesity follow this familiar arc: Social stigma regarding overweight people tips into outright discrimination, including in the workplace (Watson, Levit, & Lavack, 2018)—and is further fueled by medical conclusions that
obesity poses a serious threat to personal health. Eventually professional interest
groups come together with concerned public health o$cials, and the policy battle
is joined (Kersh & Morone, 2010).
#ough the politics of health care can feature headlong rushes to judgment
(witness government prohibition of alcohol, or Anthony Comstock’s Victorianera e%orts to o$cially ban literature on birth control) (Morone, 2004), the obesity
case has played out more deliberately, owing especially to the food industry and
its political allies’ organized resistance to change.
Public o$cials’ concern about the growing American obesity rate surfaced
around the year 2000 and was met swiftly with a concerted e%ort to emphasize
personal responsibility, not “nanny state” government actors, in response. #e
idea that overweight and obese people had only themselves to blame—“just say
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Chapter 3. The Politics of Health Care in the United States 69
no, and push back from the table,” in the words of a widely reprinted editorial—
tapped a deep individualistic strain in U.S. politics and, especially at the national
level, sti!ed policymaking designed to address nutrition and diet. No signi”cant
policy addressing obesity passed Congress between 2000 and 2010, though dozens of bills were introduced; indeed, the only related measure that won approval
in either chamber was the “Personal Responsibility in Food Consumption Act
of 2005,” which protected the food industry against lawsuits. It passed the U.S.
House but failed in the Senate (Kersh, 2015; Kersh & Elbel, 2015).
National policy debates also play out in state and local arenas, and here more
substantive achievements have been registered. Prominent policies considered
and, in some locations, enacted include taxes on sugar-sweetened beverages and
junk foods (Pomeranz, Wilde, Huang, Micha, & Moza#arian, 2018); calorie labels
on chain and fast-food restaurant menus (Kiszko, Martinez, Abrams, & Elbel,
2014); government encouragement for “reformulation” of popular snack foods
to reduce sugar, salt, and/or fat content (Buttriss, 2013); and regulating the availability and nutritional quality of “competitive foods” served in schools (Datar &
Nicosia, 2017).
National policy action on obesity since 2010 has focused on calorie menu
labeling, passed as part of the ACA. New York, Philadelphia, Washington’s King
County, and the State of California were among jurisdictions that implemented
a calorie-labeling rule. Even with ample precedent, it took nearly 8 years (and
much lobbying on both sides) before the administrative rulemaking process
“nally yielded a formal labeling rule in May 2018. Meanwhile, U.S. obesity rates
have risen inexorably, topping 37% of adults in 2018. $irty years ago, most
U.S. states reported adult obesity rates of 10% or lower, with none higher than
15%. $e health consequences of obesity are well chronicled (Meldrum, Morris, & Gambone, 2017), but—much as with the U.S. health system as a whole—
the American policymaking system, susceptible at every turn to veto points,
interest group in!uence, and deliberately slowed action, has added layers of
complexity rather than opening a path to better health outcomes or reduced
We invited readers at the opening of this chapter to imagine whether the result
of extensive politicization of U.S. health systems has led to enhanced patient care
or greater e%ciency. Comparisons to other countries, as well as a look toward the
future—as we write, media alarms are being sounded about Medicare’s impending bankruptcy, a few years hence (Edney, 2018)—would suggest that a rosy view
is hard to apply. Much as with American society more generally, absent a strong
movement for meaningful change, the likely road ahead involves a mixture of
dazzling health care innovations, greater disparities in access to care, kneebuckling expenses, and immense investment of time and energy by political as
well as health professionals—with little concrete improvement to show for it.
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70 Part I. Health Policy
As you sit down to choose your insurance plan for the upcoming year, you have to answer
two questions: (a) what is your BMI (body mass index)? and (b) how many cigarettes do you
smoke a day? The second question is easy for you because you are not a smoker and never
have been. But the !rst one—well, you are overweight. You need to decide how to answer the
question. If you answer truthfully, your insurance rates go up. If you lie, your rates stay the
same, but you run the risk of being caught and paying a !ne.
1. How would you decide which choice to make? What factors would you consider?
2. Is it fair and equitable to be charged more for insurance if you are overweight or
a smoker? What about those who drink or are hypochondriacs—shouldn’t they be
grouped, too?
1. How is the U.S. health care system !nanced? How is that di”erent from China and
Great Britain?
2. If the government is not paying to support health care, what is it paying for?
3. What is the role of politics in Medicare and Medicaid?
4. How can average citizens use his or her in#uence on politicians to provide equitable
health services?
5. Why are personal health decisions becoming public?
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Comparative Health Systems
Michael K. Gusmano and Victor G. Rodwin
Understand the difference between national health insurance (NHI) and
national health service (NHS) systems
Highlight key features and issues in the health systems of Britain, France,
Canada, and China
View the U.S. health system from an international perspective
national health insurance (NHI)
national health service (NHS)
Looking abroad to promote self-examination at home
Health system models
NHS and NHI systems compared with the United States
The health systems in England, Canada, France, and China
Provider payment
Coordination of care
Workforce and information technology (IT)
Health system performance
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74 Part I. Health Policy
Windows can sometimes be mirrors. A look
at health systems abroad can enable us to
develop a better understanding of our health
system in the United States. An international
perspective reveals that the United States
has the most expensive health care system
in the world. Unlike other wealthy countries,
however, the United States fails to provide
universal health insurance coverage. Moreover,
in contrast to most other wealthy nations, our
population faces !agrant inequities in access
to primary and specialty care. Health care
costs are often a source of “nancial strain,
even bankruptcy, for people with serious illness
(Hacker, 2006), and Americans su#er from high rates of mortality that could have
been avoided with timely and appropriate access to a range of e#ective health care
services (Nolte & McKee, 2012). $ere is also evidence that the U.S. health care
system squanders resources and fails to address many of its population’s health care
needs. Not surprisingly, public opinion polls regularly”nd that medical professionals
and the public are dissatis”ed with the system and believe major change is necessary
(Blendon, Benson, & Hero, 2014; Hargreaves et al., 2015).
Looking Abroad to Promote Self-Examination at Home
International comparisons of health care system performance remind us that
there are workable alternatives to our current system. Examining other systems
provides “the gift of perspective” and helps us to understand our own system
“by reference to what it is like or unlike” (Marmor, Freeman, & Okma, 2005). As
Rudolf Klein (1997, p. 1270) explains:
Policy learning … is as much a process of self-examination—of re!ecting on the
characteristics of one’s own country and health care system—as of looking at the
experience of others … the experience of other countries is largely valuable insofar
as it prompts a process of critical introspection by enlarging our sense of what is
possible and adding to our repertoire of possible policy tools. For policy learning is
not about the
transfer of ideas or techniques … but about their adaptation to local
circumstances. (emphasis in original)
$is chapter attempts to provide a better understanding of the U.S. health
care system by comparing it to health systems in wealthy countries, which share
many characteristics in common, and by contrasting it to China, a more striking
contrast. Our focus on wealthy nations draws on the experience of member
nations of the Organisation for Economic Co-operation and Development
(OECD), an organization based in Paris that studies economic trends, policies,
Public opinion polls regularly !nd
that medical professionals and
the public are dissatis!ed with
the system and believe major
change is necessary.
Price, volume, and technology
diffusion are the most
important factors driving
health care costs, not an
aging population.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 4. Comparative Health Systems 75
and health data of its members. We pay special attention to England,1 which
operates a
national health service (NHS), and to Canada and France, which have
national health insurance (NHI) systems. Our focus on China is an example of
so-called BRIC nations (Brazil, Russia, India, and China) with large populations
that have bene!ted from rapid economic growth over the past two decades and
now are demanding access to state-of-the-art medical care.
Although England’s NHS is one of the most public systems in the world, it also
allows opportunities for private hospitals, private practice, and private insurance
for those who prefer such options. Canada is frequently compared with the United
States because of its physical proximity and similar political culture; until the mid-
1960s, Canada’s health care !nancing and delivery systems were nearly identical to
those in the United States (Marmor et al., 2005). France’s health system also shares
many features with the U.S. health system. Like the United States, France relies
on a multipayer system for !nancing care and o”ers a mix of public and private
providers for delivering health care services. French citizens also enjoy freedom of
choice among providers—to an even greater extent than Americans. #e French
experience (Rodwin, 2006) suggests that it is possible to achieve universal coverage
without adopting a single-payer NHI system, such as Canada’s, or an NHS, as in
England. China has proclaimed a commitment to universal health care coverage and,
given its size and progress over the past decade, represents an important case study.
Despite its rapidly growing economy, China’s national investments in public health
and medical care are still far smaller than those of OECD nations, and out-of-pocket
payments represent roughly one-third of all health care expenditures. We conclude
the chapter with some lessons of comparative experience for U.S. policy makers.
NHS systems, such as those in the United Kingdom, Sweden, Norway, Finland,
Denmark, Portugal, Spain, Italy, and Greece, may be traced back to Lord Beveridge,
who wrote the blueprint for the English NHS immediately after World War II.
Although such systems are characterized by a dominant share of !nancing derived
from general revenue taxes, this does not preclude other forms of !nancing. For
example, the relative size of private !nancing and provision is much higher in
Italy and Spain than in Sweden or Denmark. In England, 76% of NHS funding
comes from general taxation, 18% from a payroll tax, and the remainder from
private payments (#omson, Osborn, Squires, & Reed, 2012, p. 33). Historically,
NHI systems have had a more open-ended reimbursement system for health care
providers, but this distinction is blurring as NHI systems are increasingly under
pressure to operate within budget limits.
NHI systems may be traced back to Chancellor Otto von Bismarck, who established the !rst NHI program for salaried industrial workers in Germany in 1883.
With the exception of Canada, whose dominant share of !nancing is from general
1 We focus on England, the largest constituent country within the United Kingdom, because
there are important di!erences among the NHS in Scotland, Wales, and Northern Ireland.
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76 Part I. Health Policy
tax revenues, these systems are characterized by payroll tax-based !nancing. In addition to income taxes, about a quarter of Canada’s federal spending on health care
comes from corporations. “e provinces also supplement income and corporate
taxes with additional sources of funding such as sales, tobacco, and alcohol taxes. As
with NHS systems, NHI systems are characterized by signi!cant variation in their
!nancing and organizational arrangements. For example, the share of French public
health care expenditures !nanced from an income tax on all earnings, including
dividends and interest from capital, increased to 16% in 2016 (Rodwin, 2018).
Whether one’s image of a health system is private and market-based, as in the
United States and Switzerland; public and government-managed, as in the United
Kingdom and Scandinavian nations; or at some intermediary point along such a
continuum, as in France and Canada, it is possible to make some useful distinctions
with respect to the public versus private provision of health care and methods of
!nancing health services. Table 4.1 classi!es health systems along these dimensions.
Provision of Health Services
“e arrangements for providing health care in Table 4.1 distinguish whether health
services are delivered by the public, private not-for-pro!t, or private for-pro!t
sector. Within these categories, many distinctions may be added. For example, some
publicly capitalized organizations (row A) are national (e.g., the Veterans Health
Administration [VHA] in the United States), others are subnational (state mental
hospitals), and many are local (municipal hospitals). Likewise, the not-for-pro!t
category may include a variety of quasi-public organizations, such as hospital
trusts in Britain (row B). “e for-pro!t form of provision (row C) includes private
for-pro!t hospitals and a distinctive subcategory in the United States – hospitals
and managed care organizations (MCOs) that sell ownership shares to investors
on publicly traded stock markets. Indeed, the growth of large investor-owned
MCOs distinguishes the United States from most other OECD nations.

Income Taxes and
General Revenue
Payroll Taxes
Government Owned and
Private Nonpro!t/
Private For-Pro!t

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Chapter 4. Comparative Health Systems 77
!e four methods of raising revenues to pay for health services correspond to
columns 1 through 4:
■■ 1: General revenue “nancing through the “scal tax system, including personal income
■■ 2: Compulsory payroll tax “nancing through the Social Security system
■■ 3: Voluntary premiums assessed by private health insurance companies and often paid
by either employees or individuals
■■ 4: Individual out-of-pocket payments made at the time a patient receives a service
Although all countries rely on blends of these four sources of revenue to
“nance health care services, most developed countries have adopted one of two
distinct health system models for actually getting care delivered to patients. NHS
systems generally rely on the government to organize the delivery of services
directly and either employ providers directly or as private contract employees. In NHI systems, governments organize social insurance programs that
reimburse health care providers for services rather than paying for health care
directly through the government’s budget. NHI systems generally rely mostly
on payroll taxes to fund their health services. NHS systems, however, rely on
general revenue taxation such as income taxes and a broad range of other taxes
to fund the delivery system. Using income taxes and general revenues allows for
greater redistribution of resources from the wealthy to the poor. Payroll types
are generally not highly redistributive.
In contrast to England, Canada, and France, China and the United States
rely, to varying degrees, on subnational and local governments to “nance health
care. In Canada, provinces and territories administer universal health insurance
programs, and the federal government provides block grants that account for
approximately 20% of health care expenditures. To qualify for the federal funds,
provincial and territorial health insurance systems must meet “ve criteria speci-
“ed by the Canada Health Act of 1984. !ey must be (a) administered on a nonpro”t basis by a public authority; (b) comprehensive in the sense that they must
cover most health services provided by hospitals, medical practitioners, and dentists; (c) universal in that all legal Canadian residents are covered; (d) portable
so that coverage for all residents in each province or territory is transferable to
all other parts of Canada; and (e) accessible, although “reasonable access” is not
de”ned in the law.
In 2009, China adopted a reform that provided health insurance for all of
its population. Between 2000 and 2013, the share of government total health
expenditure doubled from 15.5% to 30.1% (Qian, 2015). Although China now
provides some minimal health insurance to the majority of its population, coverage remains extremely limited, and as we noted earlier, roughly one-third of
all spending on health care still comes from out-of-pocket payments (Table 4.1,
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78 Part I. Health Policy
column 4). In terms of public funding for health care, China relies—to an even
greater extent than Canada—on subnational government revenues to !nance the
country’s three NHI funds.
Below the national government, China has provincial, regional, and local governments. By the mid-1990s, these subnational government authorities !nanced
80% to 90% of total government spending on social services, including health
care (Hipgrave et al., 2012). “e adoption of health reform has increased central government contributions to health care, but local government taxes and
out-of-pocket payments from individual patients still represent the two largest
sources of revenue. “is approach has exacerbated the large economic disparities between the wealthier coastal provinces and the poorer rural provinces in
western China. “e national government has attempted to address the country’s
rural-urban disparities, but with limited success.
Table 4.1 enables one to highlight key features of NHS and NHI systems and
to adopt an international perspective on the U.S. health care system. “e most
striking di#erence between the United States and NHS or NHI systems is that
the United States—even after passage of the Patient Protection and A#ordable Care Act of 2010 (ACA)—includes large elements of !nancing based on
actuarial principles whereby private insurance premiums (column 3) are set
with respect to estimated risk. In contrast, in NHS and NHI systems, most
health care !nancing is based on ability to pay (columns 1 and 2). Ability-topay criteria lead to wealthier, younger, and healthier individuals paying disproportionately to !nance the care of poorer, older, and sicker individuals. Aside
from this important distinction, the rows and columns of Table 4.1 suggest that
most health care systems have elements of many boxes ranging from socialized medicine (box A1) to out-of-pocket payment for private practitioners and
hospitals (box C4).
“e United States has neither an NHS nor an NHI system. Instead, the
U.S. health care system relies on a patchwork of public and private insurance
with large gaps in coverage (see Chapter 3). Its enormous pluralism exhibits
components of its health system within each of the boxes in Table 4.1. It uses
a social insurance system for older people and for those with permanent disabilities (Medicare: columns 1 and 2); a social welfare system for some people
with low incomes (Medicaid, column 2); and an employer-based private health
insurance system for a large percentage of salaried employees in the private
and public sectors (column 3). Along with its public and private insurance programs, the United States also has elements of socialized medicine, such as the
military health care system, the VHA system, and the Indian Health Service
(IHS) for Native American and Alaskan Native people.
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Chapter 4. Comparative Health Systems 79
Beyond the di!erences we have noted
between NHI and NHS systems, these systems have evolved in similar directions.
After World War II, governments have gradually extended their role in the “nancing
and provision of health services. What was
once largely the responsibility of the family,
philanthropy, religious institutions, employers, and local governments has largely
been taken over by national and subnational governments—a trend that has
accompanied the rise of the welfare state (de Kervasdoué, Kimberly, & Rodwin,
1984). #is evolution has a!ected all wealthy OECD nations and, increasingly,
BRIC and less developed nations. #e U.S. reliance on employer-based private
health insurance for many Americans is an important contrast to NHI and NHS
systems. Yet even in the United States, recent decades have seen an expansion of
public insurance and a decline in employer-based coverage.
#e growth of government involvement in health systems has characterized
OECD nations during the great boom years of health sector growth (1950s and
1960s) when governments encouraged hospital construction and modernization,
workforce training, and biomedical research. It continued in the 1970s, when the
goals of OECD countries shifted more in the direction of rationalization and cost
containment (Rodwin, 1984). In the early 21st century, public and private health
insurance has become the dominant source for funding health care, and public
expenditure on health care services, along with education and Social Security,
has become one of the largest categories of social expenditures as a share of gross
domestic product (GDP).
In contrast to these trends in OECD nations, by the end of the 1970s, China
moved from a health system dominated by public “nancing to one dominated by
private, out-of-pocket payments. Between 1949 and the early 1980s, the Chinese
health system was “nanced largely by the central government and state-owned
enterprises (Valentine, 2005). In 1978, Deng Xiaoping called for market reforms.
#e central government reduced its share of national health care spending from
32% to 15% (Blumenthal & Hsiao, 2005). It slashed subsidies to public hospitals
and introduced market mechanisms in health care, resulting in rapid growth of
out-of-pocket payments and income-based inequities.
By the late 1990s, Chinese o$cials increased investment in public health to
address growing disparities between rural and urban areas. E!orts to improve
the public health and primary care systems accelerated after the outbreak of
severe acute respiratory syndrome (SARS) in late 2002. By the end of 2003, more
than 5,000 people were infected with SARS and 349 people died (Smith, 2006),
thus exposing the weaknesses of the public health system. Since 2009, China has
continued to expand the role of government through the creation of new public
After World War II, governments
have gradually extended
their role in the !nancing and
provision of health services.
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80 Part I. Health Policy
insurance schemes and the adoption of new public health regulations (Wang,
Gusmano, & Cao, 2011).
In addition to the growth of government’s role in health care, most OECD
nations confront common challenges and exhibit distinct approaches for many
issues. We illustrate how this is so by comparing the health systems of England,
Canada, France, and China with respect to (a) provider payment, (b) coordination
of care, (c) workforce and IT, and most important, (d) health system performance.
Provider Payment
All countries rely on multiple methods for paying physicians and hospitals.
NHS systems traditionally have relied more on salaried and capitation forms of
payment for physicians and budgets for hospitals. In the English system, about
two-thirds of general practitioners (GPs) and dentists work as independent contractors reimbursed through a blended payment system, 75% from capitation
payment and most of the rest (20%) from fee-for-service (FFS) payments based on
performance. Since 2012, GPs have been placed in charge of clinical commissioning groups (CCGs), which control about 70% of the NHS budget (NHS Clinical
Commissioners, 2018). CCGs are locally speci!c NHS bodies in charge of planning and commissioning health care for their area, including purchasing hospital
and specialty medical care services for their patients. “e NHS !rst introduced
a prospective payment system for reimbursing public and private hospitals in
2003 and, in April 2004, phased in a new national tari# system. Since 2012, the
NHS has adopted a Payment by Results (PbR) system based on the average cost of
providing the procedure or the treatment across the NHS as a whole.
Historically, Canadian primary care physicians have been paid on an FFS
basis. “e Ministries of Health for all provinces and territories are responsible for
negotiating an annual physician fee schedule based on a relative value scale (RVS)
for each reimbursable procedure or code. “e RVS may have developed from a
resource-based fee schedule (RBFS), which tries to capture the inputs required
to provide the service, or on historical charges. Studies have found wide variation in fee schedules across Canada (Roth & Adams, 2009). In more recent years,
some provinces have experimented with blended capitation schemes in family
health networks, family health teams, and family health organizations. Blended
capitation relies on age- and gender-adjusted payments, coupled with !nancial
incentives to follow “evidence-based” guidelines and FFS when physicians treat
patients who are not enrolled in these schemes (HealthForceOntario, 2014).
In France, physicians in the ambulatory sector and in private hospitals are
reimbursed largely on the basis of a fee schedule negotiated among physician
associations, the central administration of NHI funds, and the government.
Approximately 10% of GPs and 40% of specialists in private o$ce-based practice
have the option to extra-bill beyond the negotiated fees that represent payment
in full for all other physicians. “ese !gures vary by subspecialty and location.
Physicians who have opted to extra-bill may do so as long as their charges are
set with “tact and measure,” a standard that has never been legally de!ned but
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Chapter 4. Comparative Health Systems 81
which has been found, empirically, to represent a 50% to 100% increase to the
negotiated fees. Physicians who “extra-bill” receive more revenue per patient seen
but they need to recruit from a subset of patients able and willing to pay this extra
out-of-pocket payment. Physicians based in public hospitals are remunerated on
a part-time or full-time salaried basis, and those in private for-pro!t hospitals
may bill NHI based on the negotiated fees.
Before 1984, public hospitals in France were reimbursed on the basis of a retrospective, cost-based, per diem fee; after that, they were placed on global budgets
that were later gradually adjusted for patient case mix in the 1990s. Private forpro!t hospitals used to be reimbursed on the basis of a negotiated per diem fee;
in the 1990s, the per diem payments were also gradually adjusted for their case
mix. “e basis for case-based adjustment in France is an adaptation of the U.S.
diagnosis-related group (DRG) categories known in France as GHM (groupes
homogènes de malades). “e most recent modi!cation was introduced in 2004
(Schreyögg, Stargardt, Tiemann, & Busse, 2006) when activity-based payment
(ABP) was introduced to create a level playing !eld for reimbursement of acutecare services among public and private hospitals. As of 2012, the reimbursement
system for public and private hospitals has been completely aligned based on
the national ABP tari#s that take into account each hospital’s historical costs.
“is has resulted in expected activity growth, which in turn, results in downward
price adjustments because annual hospital costs are constrained by national and
regional hospital expenditure targets (Or, 2010).
In China, the expansion of health insurance is changing the nature of provider
payment, but by the end of 2013 most physicians were still paid salaries. Subnational
governments in China regulate prices in an e#ort to make health care a#ordable, and
over the past two decades, with encouragement from the central government, they
have introduced such incentives as pay-forperformance based on treatment protocols to
improve quality (Yip, Hsiao, Meng, Chen, &
Sun, 2010). Although the central government
hopes the expansion of health insurance will
limit hospital reliance on kickback payments
from medical device and pharmaceutical
companies, such payments continue to be
an important source of revenue for Chinese
health care providers (Wang et al., 2011; Shi
et al., 2018).
In comparison to England, Canada, France, and China, the United States pays
signi!cantly higher prices for medical care. Although there is some debate about
the factors that drive U.S. health care spending, consensus has emerged that price
is the most important factor in explaining why the United States spends so much
more than any other health care system in the world (Papanicolas, Woskie, & Jha,
2018). Two distinguishing characteristics of the U.S. health care system are that, in
contrast to other OECD countries, there is neither a national budget cap nor a formal
process of price negotiation between payers and representatives of physicians.
Two distinguishing
characteristics of the U.S. health
care system are that, in contrast
to other OECD countries, there
is neither a national budget cap
nor a formal process of price
negotiation between payers and
representatives of physicians.
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82 Part I. Health Policy
Coordination of Care
All countries su!er from problems of coordination among hospitals and
community-based services. “ey di!er, nonetheless, with regard to the resources
and organization of their delivery systems. France, for example, has more practicing
doctors per 1,000 population (3.3) than the United Kingdom (2.8), the United States
(2.6), Canada (2.7), or China (1.8) (OECD, 2015). France also has more acute hospital
beds per 1,000 population (4.1) than the United States (2.5), the United Kingdom
(3.0, 2013), Canada (2.0), or China (2.7, 2013) (OECD, 2013, 2015).
Since its creation in 1948, the NHS has been one of the largest public service
organizations in Europe. With more than 1 million employees, more than 2,500
hospitals, and a host of intermediary health care organizations, the NHS poses an
awesome managerial challenge (Klein, 2013, 2018). Perhaps because Britain has
fewer health care resources than most OECD nations, the British have been more
aggressive in e!orts to reduce ine#ciency than other wealthier countries. Because the
NHS faces the same demands as other systems to make technology available and to
care for an increasingly aged population, British policy makers recognize they must
pursue innovations that improve e#ciency in the allocation of limited resources.
Such e!orts, however, face numerous obstacles: opposition by professional bodies,
di#culties in %ring and redeploying health care personnel, and, not least, the
tripartite structure of the NHS, which, since its inception, has created an institutional
separation among hospitals, general practitioners, and community health programs.
“is separation is reinforced further by the fact that local authorities are responsible
for a great deal of prevention and health promotion as well as social care, making it
di#cult to integrate hospital and community-based care.
In Canada, less separation exists between physicians and hospitals because
specialists are paid FFS and work both in community-based practice as well as in
hospitals. Hospitals are largely private nonpro%t institutions with their own governing boards, but they are almost entirely publicly %nanced and subject to tight
budget constraints. Most community-based physicians must refer their patients
requiring diagnostic procedures and testing, as well as more specialized care, to
local hospitals, which can lead to extended waiting times for elective procedures
and problems in ensuring optimal coordination among hospital specialists and
community-based providers.
France also faces problems with the coordination of care between hospitals
and community-based providers. “ere is inadequate communication between
full-time, salaried physicians in public hospitals and solo physicians working in
private practice. Although GPs have informal referral networks to specialists and
public hospitals, no formal institutional relationships exist to ensure continuity of
medical care; disease prevention; health promotion services; posthospital followup care; or systematic linkages and referral patterns among primary-, secondary-,
and tertiary-level services. Schoen et al. (2012) document that the French health
care system is characterized by poor hospital discharge planning and a lack of
coordination among medical providers.
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Chapter 4. Comparative Health Systems 83
In China, before 1978 the health care delivery system in rural areas was organized by communes, which provided housing, education, and social services as
well as basic medical care. An important feature of the communes’ Cooperative
Medical System was the sta! of paraprofessionals known as “barefoot doctors”
(Rosenthal & Greiner, 1982). Most of the barefoot doctors were young peasants
who received a few months of training and o!ered basic primary and preventive
care, including health education. If the needs of patients were more complex, the
barefoot doctors would refer them to physicians at the commune health centers
or, if necessary, to the closest hospital. In urban areas, the health care delivery
system relied heavily on so-called “rst-level hospitals, community clinics with a
modest inpatient capacity, to provide ambulatory care.
With the introduction of market mechanisms in the health sector after 1978,
the government ended its barefoot doctor program in rural areas, leaving the
population in rural China without adequate access to health care services. It also
reduced its subsidies to state-owned “rst-level hospitals; forced to become more
self-reliant, these hospitals withdrew public health and primary health care services. Some “rst-level hospitals went bankrupt, and those that survived turned to
pro”table medical services rather than emphasizing primary care and prevention.
Since the 2009 reform, the rapid increase in health insurance coverage brought
nearly 1 billion people back under some form of “nancial protection. Service
utilization has increased and hospital care has become more a!ordable, but there
are still glaring disparities across regions and medical sectors (He & Meng, 2015).
Moreover, a strong system of primary care is conspicuously absent, and coordination among primary care and hospitals remains an elusive goal.
Workforce and Information Technology
Primary care versus specialty care balance. Among OECD health care systems,
an average of 31% of physicians are generalists. #e United States stands out, in
contrast, because about 90% of physicians are specialists, and only about 10%
are generalists (Laugesen, 2018). Despite this di!erence, when adjustments are
made, it turns out that one third of the physician workforce in the United States
and other OECD nations works in primary care. #e situation in China, however,
presents a striking contrast because only 57% of cities have community-based
primary care organization, and more than 40% of the population reports that it
does not have convenient access to a primary care center (Wang et al., 2011). In
addition, most general practitioners lack additional training after receiving their
undergraduate medical education.
Primary care is important because systems with a higher concentration of
primary care practitioners improve coordination and continuity of care. Access
to an e!ective system of primary care appears to result in higher life expectancy
at birth, lower infant mortality, lower mortality from all causes, lower diseasespeci”c mortality, and higher self-reported health status (Star”eld, Shi, &
Macinko, 2005; World Health Organization [WHO], 2008).
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84 Part I. Health Policy
Workforce shortages/surpluses. Concerns about the adequacy of primary
care in the United States are reinforced by discussions about the adequacy of the
health and social care workforce in the face of rapid population aging (Carrier,
Yee, & Stark, 2011). Increases in Alzheimer’s disease and other forms of dementia
have raised concerns about the extent to which the health and long-term care
systems will have a su!cient number of physicians, nurses, and other medical
professionals to address the needs of an aging society (Warshaw & Bragg, 2014).
Although a shortage of clinicians, particularly in primary care, is the major
concern in the United States, France, and China, some countries in Europe, particularly England, now wonder whether they may have too many doctors and
nurses. Before the global economic crisis began in 2008, many OECD countries
adopted policies designed to increase their supply of medical professionals.
After the economic slowdown, many countries expressed concern about an
“oversupply” of some health care workers (Ono, Lafortune, & Schoenstein, 2013).
Starting in 2000, for example, the English NHS adopted a workforce redesign
initiative to increase the number of doctors and nurses in the system, expand
the roles of existing professionals, and redistribute responsibilities to rely more
on teams of health care professionals. As a result, there is now concern that the
country may have too many hospital specialists, but there are persistent concerns
that it still does not have a large enough supply of well-trained social care workers, particularly for providing home care to older patients (Bohmer & Imison,
2013). Similarly, a recent assessment of health care needs in Ontario, Canada,
concluded that there will be an aggregate surplus of GPs and specialists in 20
years, even though some specialties and areas may experience shortages (Moat,
Waddell, & Lavis, 2016).
!e push for electronic medical records and other forms of health care IT.
“roughout the world, policy makers are searching for ways to reduce health
care spending while improving the quality of care. “e use of electronic health
records and other forms of health information technology (HIT) are often touted
as solutions to these problems (see Chapter 14). Harvey Fineberg (2012), the
president of the Institute of Medicine, argues that over the long term, HIT will
improve the quality and e!ciency of the health care system. Marmor and Oberlander (2012, p. 1217) dismiss the focus on HIT as a “fad” and suggest that the
desire to #nd a “big #x” to the problems of cost and quality has led policy makers
to embrace technical and managerial solutions, including the adoption of HIT,
along with various forms of managed care, health planning, and payment reforms
designed to align the incentives of providers and patients with public health goals.
“is argument supports the classic James Morone (1993) thesis that the
United States tends to search for a “painless prescription” to the major challenges
in health care. Indeed, comparative analysis suggests that such technical solutions as HIT to the problems of cost and quality have had little e$ect on cost or
quality in health care and that the United States should focus on more important
structural features of other health care systems, such as global budgets, fee schedules, systemwide payment rules, and concentrated purchasing power.
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Chapter 4. Comparative Health Systems 85
Advocates of HIT argue that newer developments in the use of so-called big
data are more likely to transform medical practice because of their capacity to
link information among many institutions within a health care system. !ey also
argue that the United States has never adopted HIT on a widespread basis, so
the failure of previous e”orts to improve quality or lower costs is not su#cient
evidence that HIT cannot contribute to these goals in the future.
It seems plausible to suggest that HIT may be a valuable tool for addressing
costs and quality in health care, but its value surely depends on the policy context
in which it is used. For England, Canada, and France, HIT may further enhance
the e#ciency of resource allocation by providing administrators, providers, and
patients with access to better information. In the United States, however, the
e”ect of HIT within the context of a fragmented, open-ended $nancing system
may be far more limited. Viewed from this perspective, it is easier to understand
the arguments of those who remain skeptical of HIT’s importance.
Health System Performance
Policy makers and researchers often want to compare the performance of di”erent systems and identify lessons for health policy. Although these e”orts have
generated important information, they have often succumbed to the temptation
of devising a composite indicator to rank health care systems against one another
(Oliver, 2012). !is practice encourages lavish attention from the media on the
search for the best health care system, the new holy grail of performance assessments. Unfortunately, such an approach lacks any e”ort to understand, assess,
and compare health care systems in relation to the cultural context, values, and
institutions within which performance indicators are embedded.
!e study of health system performance by the WHO is the most prominent example of the composite indicator approach to the comparative analysis of
health systems (WHO, 2000). WHO ranked the health systems of 191 member
states based on weighted measures of $ve objectives: (a) maximizing population
health (as calculated by disability-adjusted life expectancy, or DALE); (b) reducing inequalities in population health; (c) maximizing health system responsiveness; (d) reducing inequalities in responsiveness; and (e) $nancing health care
Although controversial because of its many methodological %aws and missing data, the WHO report generated tremendous discussion about health system
performance and the criteria that should be used to assess it (Musgrove, 2003).
Some of the controversy generated by the report can be attributed to complaints
from countries unhappy with their ranking, but prominent academics also criticized the study for relying on incomplete and inadequate data as well as on questionable methods (Williams, 2001).
WHO’s use of DALE as a measure of health status illustrates the problem of
using population health status to assess the performance of health care systems.
DALE includes causes of death that are amenable to health care as well as a
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86 Part I. Health Policy
host of social determinants of health. As a result, this measure is not “related
directly to the health care system” (Nolte & McKee, 2003, p. 1129). Using DALE,
life expectancy at birth and infant mortality are inadequate measures of health
system performance because the role of health care in improving population
health is small compared with interventions aimed at social and environmental
As Bradley and Taylor (2013) argue, one reason the United States performs so
poorly on such indicators is because we have failed to invest su!ciently in education, housing, employment, and other social programs that help to produce and
sustain good health. Between those who emphasize the decisive e”ect of social
determinants of health and those who focus on access to health care, there is a
middle ground: attention not only to the consequences of poor social conditions,
but also to barriers in access to what we have called e”ective health care services.
#ere is a vast literature that measures inequities in access to health care (see
Chapter 2). Such studies rely either on comparisons of inputs (e.g., physicians,
hospital beds) or on administrative or self-reported survey data to measure service utilization. An alternative approach attempts to capture the consequences
of poor access to disease prevention, primary care, and specialty services—in
other words, mortality amenable to health care (amenable mortality). Of course,
few causes of death are entirely amenable, or not amenable to health care, and
as medical therapies improve even more deaths may be classi$ed as potentially
avoidable. Nevertheless, based on an OECD study, this summary provides convincing evidence that the United States is not performing well in comparison to
other wealthy nations (Mossialos, Wenzl, Obsorn, & Sarnak, 2016).
Cross-national analysis of trends in avoidable mortality indicates that
amenable deaths have declined much faster over the last three decades than
other causes of death (Nolte & McKee, 2012). #is result lends further credence
to the validity of amenable mortality as an indicator of the e”ectiveness of public
health interventions and medical care. We have used this measure to compare
the health systems in megacities located within four of the countries we highlight
in this chapter: London, New York, Paris, and Shanghai (Gusmano, Weisz, &
Rodwin, 2009).
#rough ACOs in the United States (see Chapter 11) and various forms of
disease management and integrated service delivery proposals in other countries,
health care professionals are being encouraged to think about population as well
as individual health. #e e”ort to shift health systems in this direction is a positive development, but if we hope to understand the performance of health care
systems and the relationship between health care inputs and health outputs, it is
important to select such indicators as amenable mortality, which are more closely
related to the performance of these systems than are broad measures of health
such as life expectancy and DALEs.
#e extensive criticism of WHO’s e”ort to evaluate health system performance has not discouraged other groups from taking similar approaches. #e
Commonwealth Fund has a project designed to identify high-performing health
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Chapter 4. Comparative Health Systems 87
systems within the United States and other wealthy nations. It also draws on
more dependable data than WHO’s for its assessments in part because its scope
is more limited and focuses on nations for which population, health, and health
system data are more readily available. For example, the Commonwealth Fund
supplements many of the same data sources used by WHO with original surveys
of patients and primary care providers !elded by Harris Interactive (Commonwealth Fund, 2014).
It then uses these survey results, along with a host of other data sources, to
compare U.S. national averages on multiple criteria grouped by such categories
as health outcomes, quality, access, e”ciency, and equity (Schneider, Sarnak,
Squires, Shah, & Doty, n.d.). #e problem with such an approach, well summarized by Schneider and Squires (2017), is that little attention is paid to the validity
of the multiple criteria measured and no rationale is provided for weighting the
main categories equally and then ranking health systems on the basis of criteria
on which diverse publics and policy makers rarely agree.
Access to services across income groups. An important dimension of health
system performance is the extent to which a system provides access to health
care services by income group. In contrast to the United States, countries with
universal or near-universal coverage enjoy a relatively equitable distribution of
primary care visits (van Doorslaer & Masseria, 2004). Lower-income residents
of Australia, Canada, New Zealand, and the United Kingdom, for example,
are less likely to report barriers to health care than people with below-median
incomes in the United States (Blendon et al., 2002). A comparative study on
hospitalizations for ambulatory care sensitive conditions (ACSCs), a measure
of access to timely and e$ective primary care, !nds that rates are much lower in
England, France, and Germany than in the United States (Gusmano, Rodwin, &
Weisz, 2014).
A concern often voiced by conservative analysts in the United States is that
so-called “government-run” health care systems, by which they mean both NHS
and NHI systems, “ration” care (Goodman, Musgrave, & Herrick, 2004). Because
such systems operate within a budget, these analysts claim, they must limit access
to specialty and surgical health care services in ways that are unacceptable. #is
claim is supported by studies that compare access to certain expensive health
care services in England and the United States (Aaron, Schwartz, & Cox, 2005).
Although there is evidence that some expensive technologies, including revascularization and kidney dialysis, are used less frequently in England than in the
United States (Gusmano & Allin, 2011), this is not the case with respect to France
or Germany. For example, after controlling for need, the use of revascularization
(coronary artery bypass and angioplasty) is comparable in France, Germany, and
the United States (Gusmano et al., 2014).
Even among countries that provide universal coverage, there are di$erences
in access to specialty services by socioeconomic status. Residents of higherincome neighborhoods in Winnipeg, Canada, a country that strives to eliminate
!nancial barriers to care, receive “substantially more” specialty and surgical care
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88 Part I. Health Policy
than lower-income residents of the city (Roos & Mustard, 1997). In France, Germany, and England, access to some specialty health care services is signi!cantly
worse among residents of lower-income neighborhoods (Gusmano et al., 2009).
Inequalities in access to health care are even greater in BRIC countries and developing nations. Despite remarkable economic growth in recent decades, for example, there are “agrant disparities in access to health care within China.
Cost. As was evident during the debates over the ACA, there is a widely shared
belief among American policy makers that a national program providing for universal entitlement to health care in the United States would result in runaway
costs. In response to this presumption, nations that entitle all of their residents to
a high level of medical care, while spending less on administration and on health
care than the United States, are often held up as models. #e Canadian health system is the most celebrated example. French NHI is another case in point. England’s
NHS, although typically considered a “painful prescription” for the United States
(Aaron et al., 2005), nevertheless ensures !rst-dollar coverage for basic health services to its entire population and, as we have seen, spends less than half as much
on health care, as a percentage of GDP, and approximately one-half as much per
capita as in the United States (Table 4.2). Huang (2011) expects that China’s total
health care expenditures will increase rapidly over the coming decade, but its current spending, as a percentage of GDP, is far below the OECD average.
Stories in the media often suggest that pressures from population aging will
render existing welfare state commitments, including the Medicare and Medicaid programs in the United States, unsustainable. Despite these concerns, most
studies conclude there is no correlation between the percentage of the older
population (65 years and over) and health care expenditures as a percentage of
GDP. #e United States, which spends more on health care than any country in
the world, is among the OECD countries with the youngest age cohorts. In contrast, Britain, Italy, Sweden, Germany, and France, with older populations than
the United States, spend a far lower percentage of GDP on health care. Even if
one excludes the United States and examines only the European Union, there is
no correlation between population aging and health care spending.
Cross-national analysis of health care expenditure data indicates that, after
controlling for income, age has little e$ect on national health care expenditures.

United States 17.2%
France 11%
Canada 10.6%
United Kingdom 9.7%
OECD Average 8.9%
China 5.5%*

* Data only available up to 2014.
GDP, gross domestic product; OECD, Organisation for Economic Co-operation and
Source: Organisation for Economic Co-operation and Development. (2017). Health at a
glance 2017: OECD indicators
. Paris, France: OECD Publishing.
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Chapter 4. Comparative Health Systems 89
Proximity to death, not age, leads to an increase in health spending (Moon, 1996).
An analysis of health spending on older people in Switzerland found that expenditures are concentrated in the last few months of life (Zweifel, Felder, & Meiers,
1999). Although the OECD analysts project that “age-related spending for the
average country will rise by around 6 to 7 percentage points of GDP between
2000 and 2050,” they acknowledge that “part of this pressure is a result of cost
pressures from advances in medical technologies, rather than ageing per se”
(Australian Department of the Treasury, 2007).
Price, volume, and technology di!usion are the most important factors that
drive health care costs; as noted earlier, however, high U.S. prices explain why
the U.S. health care system is so expensive relative to other nations (Papanicolas
et al., 2018). Although Americans spend more than any other nation, health service use in the United States is actually below the median for the OECD on most
measures. A study for the McKinsey Global Institute (Angrisano, Farrell, Kocher,
Laboissiere, & Parker, 2007), based on four diseases, provides further support
for the role of prices in driving up U.S. health care costs. “e study found that in
1990, Americans spent about 66% more per capita on health care than Germans
but received 15% fewer real health care resources.
In addition to understanding the factors that drive health care spending, it
is important to confront the question: How much spending on health care is too
much? Most health economists argue that there is no right amount of money to
spend on health care. Cutler (2007) argues that we should focus less on the level
of health care expenditure and pay greater attention to whether the expenditures
generate more bene#ts than costs. However, e!orts to adopt explicit economic
evaluation of health technology provoked controversy in the United States.
“e ACA forbids federal government agencies from using cost as a criterion
for making coverage decisions. Among the countries compared in this chapter,
France, Canada, and England, to varying degrees, all use economic evaluations of
health technology to make coverage decisions. In France, economic evaluations
of new drugs are recommended but not required (Sorenson, 2009). In Canada,
these e!orts are more decentralized than in England, and “only a handful” of technologies are subject to cost-e!ectiveness analysis (Menon & Sta#nski, 2009). In
England, the National Institute for Health and Care Excellence (NICE) focuses on
new technologies only and is reputed to be the leading health technology assessment agency worldwide.
NICE, established in 1999 in response to growing concerns about variations
in the use of new technology, is supposed to meet three primary objectives:
(a) reduce unwarranted variation in prescribing patterns across England and
Wales, principally through setting practice guidelines; (b) encourage the di!usion and uptake of e!ective health technologies; and (c) ensure value for money
for NHS investment by assessing the cost-e!ectiveness of selected interventions. Record increases in NHS expenditures throughout the decade following
2000 were linked to meeting these objectives, particularly in terms of directing
spending to facilitate widespread and uniform access to the most cost-e!ective
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90 Part I. Health Policy
NICE prides itself on its transparency, methodological rigor, stakeholder
inclusiveness, consistency, independence from government, and timeliness, all of
which appear necessary to secure the legitimacy and e!ectiveness of its recommendations. Since 2003, it has been mandatory for local NHS purchasers and
providers to act on all positive recommendations on technology appraisals (i.e.,
recommendations that speci”c health care interventions be made available in the
NHS) within 3 months of their publication.
NICE arrives at conclusions about whether interventions are therapeutically bene”cial and cost-e!ective compared with other relevant alternatives by
reviewing a range of available evidence, assembled and synthesized by a publicly
funded network of academic institutions. #e role of social values in the appraisal
process is increasingly apparent as NICE reviews complex cases, for instance,
on whether select end-of-life cancer drugs be made available to NHS patients
despite their o!ering insu$cient value for money with respect to conventionally
accepted thresholds of cost-e!ectiveness.
#ere is some evidence that widespread adoption of NICE recommendations
for speci”c technologies, particularly cancer drugs and the use of varenicline for
smoking cessation, has reduced geographic variations in access to the technologies (Chalkidou, 2009). Also, there is evidence that NICE guidance has increased
costs to the NHS, which is not surprising because most cost-e!ective interventions are more expensive than the alternatives. #is does not bode well for those
in the United States who hope that economic evaluation of health technology will
contain the growth of health care costs, particularly if assessment e!orts are disproportionately focused on new, expensive technologies. Chalkidou (2009) estimates that since its creation, NICE’s decisions have cost more than £1.5 billion a
year. In this context, it should be noted that cost containment was never one of
NICE’s explicit objectives.
Quality. #e focus on quality is a relatively recent phenomenon. For many
years, the primary concern of most policy makers, particularly in developed countries, was on overcoming “nancial barriers to the health care system. In 2002, the
OECD created the Health Care Quality Indicators (HCQI) project to develop
and implement a set of international indicators. #e project includes representatives from 23 of the 30 OECD nations, as well as a number of international
partners, including the Commonwealth Fund, the Nordic Council of Ministers
Quality Project, and the International Society for Quality in Health Care (ISQua).
#e project team identi”ed “ve priority areas for monitoring quality: (a) cardiac
care, (b) diabetes mellitus, (c) mental health, (d) patient safety, and (e) primary
care and prevention/health promotion. #e OECD secretariat asked participating countries to identify expert panelists to review potential indicators (Mattke,
Epstein, & Leatherman, 2006). #e panels were charged with reviewing existing
indicators rather than developing entirely new measures. #ey used a consensus
process and selected 86 indicators on the basis of relevance, including the extent
to which the health system can in%uence the indicator, scienti”c soundness,
and feasibility. Not surprisingly, the project has identi”ed signi”cant variation
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Chapter 4. Comparative Health Systems 91
in quality as measured by these indicators
(OECD, 2013).
Some quality indicators, such as leaving a foreign body inside patients during
surgery, follow directly from the literature
on medical errors that can be influenced
by a health system. The relationships
between health system quality and other
indicators, however, are controversial. For
example, higher rates of 5-year survival
among patients diagnosed with breast or
cervical cancer may reflect better access to high-quality cancer care. It is possible, however, that these outcomes may reflect more aggressive efforts to
diagnose patients with cancer and have little to do with the quality of care
patients receive. Beyond these conceptual issues, countries continue to struggle with a lack of relevant data for quality monitoring. Even in countries with
relatively well developed health data systems, it is often difficult to link data
with unique patient identifiers in ways that allow researchers and policy
makers to understand quality of care across different episodes of care and
different providers.
In 2010, the United Kingdom’s coalition government published a white paper,
Equity and Excellence: Liberating the NHS, which called for the measurement of
health outcomes based on a number of speci!c indicators. To achieve this goal,
England developed the NHS Outcomes Framework (Secretary of State for Health,
2014) with indicators to evaluate local health care arrangements across !ve different domains: (a) preventing people from dying prematurely; (b) enhancing the
quality of life for people with long-term conditions; (c) helping people to recover
from episodes of ill health or after injury; (d) ensuring that people have a positive
experience of care; and (e) treating and caring for people in a safe environment
and protecting them from avoidable harm.
In France, the Haute Autorité de Santé (HAS), or National Authority for
Health, was established in 2004 as an independent public organization to promote quality of health services through accreditation, certi!cation, and development of practice guidelines. Today, HAS leads the European Network for Patient
Safety (EUNetPaS), which has developed a common agenda to promote patient
safety. After a contaminated blood scandal in the early 1990s, the French government established new institutions to conduct disease surveillance and protect
the population from unsafe foods, unsafe drugs, and unsafe blood. In addition,
France’s Ministry of Health recently initiated a small number of aggressive safety
campaigns with strong patient involvement, such as one supported by TV spots to
improve the use of antibiotics in preventing the appearance of resistant bacteria.
Based on a risk-scoring system for surgical wound infections, national prevalence
rates of methicillin-resistant
Staphylococcus aureus (MRSA) in France declined
from 2001 (33%) to 2006 (27%). “ese results are impressive in comparison with
Even in countries with relatively
well developed health data
systems, it is often dif!cult to
link data with unique patient
identi!ers in ways that allow
researchers and policy makers
to understand quality of care
across different episodes of care
and different providers.
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92 Part I. Health Policy
other European countries and the United States, where MRSA infections have
increased (Degos & Rodwin, 2011).
In 1994, the Canadian government established the Canadian Institute for
Health Information (CIHI) to improve its capacity to assess the health care
system and to identify standards for health system performance. CIHI maintains 27 databases and clinical registries. !e agency receives funding from
the federal (80%) and provincial (20%) governments (Marchildon, 2013). In
2004, the federal government adopted a 10-year plan to strengthen health care.
!e plan increased federal health transfers to the provinces by 6%, and the
provinces were supposed to place greater emphasis on reducing wait times
and improving quality (Allin, 2012). Some of these funds have been used to
track and reduce wait times. !e federal government has also encouraged the
use of health technology assessment, clinical guidelines, and best practices
to enhance patient safety. Critics argue that despite the increase in attention
to quality in individual provinces, problems of access, variation, and reform
remain formidable (Lewis, 2015). Moreover, Canada lacks a “guiding framework
that supports” quality improvement in primary care (Sibbald, McPherson, &
Kothari, 2013, p. 2).
In China, the issue of quality is also central to recent policy debates, but
their starting point is radically di”erent. When the Chinese government
reduced its subsidies for health care in the late 1970s, health care organizations
and providers often turned to pharmaceutical companies to make up for these
lost revenues. Rather than focus on providing primary and preventive care, for
example, many #rst-level hospitals focused on selling drugs to patients (Wang
et al., 2011). As a result, these institutions developed a reputation for poor quality, and patients were drawn to larger hospitals and academic medical centers,
creating overcrowding problems. Part of the motivation for expanding health
insurance in China was to improve the quality of care across the entire health
care system, but this goal remains as elusive as the challenge of coordination
(Wang et al., 2011).
Criteria used to evaluate the performance of health care systems—such as
access to, cost of, and quality of health care—are often called the “three-legged
stool” of health policy. Until recently, however, quality did not receive a great deal
of attention. Since the 1970s, researchers, policy makers, and patients have been
demanding better information about quality. In the late 1990s, the U.S. Institute
of Medicine led the world in calling attention to the importance of this issue,
based on a report that uncovered disturbing evidence of problems with safety and
quality in the United States (Kohn, Corrigan, & Donaldson, 2000). In contrast,
the SARS epidemic embarrassed the Chinese government and sparked e”orts to
improve access to and the quality of care. Finding solutions to such problems has
been a challenge because stakeholders cling to existing practices and technologies, data limitations make it di$cult to measure the quality of care, and fundamental disagreements remain about the meaning of quality and how to measure
value for money in health care.
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Chapter 4. Comparative Health Systems 93
Based on the experience of NHI and NHS systems in the countries we have examined, we would highlight four lessons for policy makers in the United States:
■■ Achieving the goal of universal health coverage requires legislation to make such coverage compulsory.
■■ Financing broader insurance coverage in the United States—beyond Medicare and
Medicaid—requires increasing government subsidies based on ability-to-pay criteria.
■■ Health care systems with universal coverage rely increasingly on economic evaluation
of health technology as a criterion for making coverage decisions.
■■ Containing health care costs has not been achieved without greater reliance than in
the United States on price regulation and systemwide budget targets.
!e ACA represents the most signi”cant health care reform since Medicare
and Medicaid in 1965 because it has increased signi”cantly the share of the population with health insurance coverage and redistributed the burden of health care
“nancing from those who are wealthier, younger, and healthier toward those who
are poorer, older, and sicker (see Chapter 3). We would argue that this legislation
draws heavily on the “rst two lessons of comparative experience (the mandate
and the move toward ability-to-pay criteria for “nancing health care) and less
so on the third (economic evaluation of health technology), and it ignores the
fourth (greater price regulation and budget targets). !is will bring the United
States closer to other wealthy nations in terms of population coverage. Yet the
U.S. health care system continues to present some striking contrasts to most
other wealthy nations. It remains a patchwork system characterized by a complex
combination of institutions that include an enclave of socialized medicine such
as the VHA, a social insurance program (Medicare), and social welfare programs
(Medicaid and Children’s Health Insurance Program [CHIP]); tax-subsidized
employer-based private insurance for about half of the population; and heavy
reliance on out-of-pocket payment for the population that remains uninsured,
similar to the situation in China, India, and most developing nations.
!e United States has the highest per capita expenditures; the highest salaries
for physicians and other professionals making up the health care workforce; and
the highest aggregate prices for hospitals, physicians’ services, and pharmaceuticals. Despite our drive to innovate and invest in the latest medical technologies, access to high-technology services, as well as to basic primary care services,
is highly inequitable compared with other OECD nations—but not with China,
which faces not only the usual inequities among populations of di#erent income
and educational levels, but also massive inequities among its urban and rural residents and, within cities, among its registered and migrant populations.
Another way in which the U.S. health care system di#ers from that of wealthy
OECD nations concerns the vast range of health insurance products we o#er
to our population, including the option (following the ACA) of not purchasing
health insurance, albeit with a “nancial penalty. Despite the emphasis on choice
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94 Part I. Health Policy
of insurer, many people !nd themselves con!ned to obtaining health care within
restricted provider networks outside which payment for services often becomes
una”ordable. #ere is no parallel to this problem in wealthy OECD nations such
as England, Canada, and France. In China, choice of too many insurance products is not the problem. #e situation there is far worse than in the United States
because a large part of the urban migrant population (about 250 million people) is typically excluded from decent health insurance coverage. #e problem
of internal migrants in China is substantial, but not surprising, for a system that
spends only 5.5% of its GDP on health care and has only recently set the goal of
providing universal coverage.
You are an employee of a think tank in Washington, DC. The director has been asked to testify
before a congressional committee on the following question: In reforming the ACA, what lessons should the United States learn from relevant experience abroad? Your job is to write
a memorandum that will help the director answer this question. In writing this memo, you
should address the following questions:
1. How can learning from abroad help policy makers engage in a process of self-examination of health policy at home?
2. Compare the NHS and NHI systems.
3. What should members of Congress know about China’s problems and aspirations in
health policy?
4. What lessons from abroad would be most relevant in reforming the U.S. health system?
1. What are some reasons for studying health care systems abroad?
2. How do NHI and NHS systems compare with the health care system in the United
3. How do most countries with similar levels of per capita income di”er from and resemble the United States with respect to cost, quality, and access to health care?
4. What can the United States learn from other OECD countries about how to extend
health coverage while containing health care expenditures?
5. How can health system performance be measured? Compare the approaches adopted
by WHO and the Commonwealth Fund.
6. How are the problems and opportunities di”erent for China than for the United States
and other OECD countries?
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Chapter 4. Comparative Health Systems 95
Aaron, H., Schwartz, W., & Cox, M. (2005). Can we say no? !e challenge of rationing health
. Washington, DC: Brookings Institution Press.
Allin, S. (2012). !e Canadian health care system, 2012. In S. !omson, R. Osborn, D.
Squires, & M. Jun (Eds.),
International pro”les of health care systems, 2012 (pp. 19–25).
New York, NY: !e Commonwealth Fund. Retrieved from
Angrisano, C., Farrell, D., Kocher, B., Laboissiere, M., & Parker, S. (2007, January).
Accounting for the cost of health care in the United States (Report). Retrieved from http://www.
Australian Department of the Treasury. (2007).
Intergenerational report 2007. Retrieved
Blendon, R. J., Benson, J. M., & Hero, J. O. (2014). Public trust in physicians: U.S. medicine in international perspective.
New England Journal of Medicine, 371, 1570–1572.
Blendon, R. J., Schoen, C., DesRoches, C. M., Osborn, R., Scoles, K. L., & Zapert, K. (2002).
Inequities in health care: A “ve-country survey.
Health A#airs, 21(3), 182–191.
Blumenthal, D., & Hsiao, W. (2005). Privatization and its discontents—!e evolving Chinese
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Population Health
Pamela G. Russo and Marc N. Gourevitch
Understand the differences between the medical and population health
models of producing health, including the difference between the concepts of
health care and health
Explain how the two models lead to different strategies for interventions to
prevent disease and improve health
Learn about the differential importance of various health determinants
Review the evidence regarding social and physical environmental influences
on behavior and on health outcomes
Review the variation in health and life expectancy between counties and
between countries
Describe innovative synergistic approaches that integrate the clinical and
population models
cross-sectoral collaborative approaches
determinants of health
dose-response effect
health care
medical model
medically indigent
multiple determinants of health
neighborhood effects
reverse causality
social determinants of health
© Springer Publishing Company DOI: 10.1891/9780826172730.0005
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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AN: 1998657 ; James R. Knickman, PhD, Brian Elbel, PhD, MPH.; Jonas and Kovner’s Health Care Delivery in the United States, 12th Edition
Account: s3563253.main.ehost

102 Part II. Keeping Americans Healthy
The population health model
The medical model
Comparing the medical and population health models
The influence of social determinants on health behavior and outcomes
Leading determinants of health: weighting the different domains
Health policy and return on investment
Much of this book concerns what happens within the walls of health care
institutions—hospitals, clinics, physician o!ces, and long-term care facilities.
Taking a more macro-level perspective,
however, reveals that health care is but one
of many factors that contribute to physical
and mental health in a population or society.
Other determinants—education and income,
genetics, behaviors, and environmental
exposures—are responsible for much of the health, or disease, in a population. In
fact, the e”ects of the systematic di”erences in
health care are far smaller than
the e”ects of the nonrandom di”erences in other determinants of health on a
population’s overall health outcomes. #ese in$uences
outside the health care
system greatly in$uence which groups of people are more likely to become ill in
the %rst place, to be injured, or to die early. #ese in$uences also help determine
people’s health care outcomes once they become sick, injured, or disabled. #is
chapter addresses the changes in health care and public policy emerging from the
growing appreciation of the profound in$uences on the population’s health that
outside the health care system, where the vast majority of people—or patients,
from a health care perspective—spend the overwhelming majority of their time.
#e notion that health is in$uenced by factors outside the health care
system is of course not new. Why, then, is it receiving renewed attention? More
than anything else, growing attention to population health re$ects widening
acceptance of, and mounting frustration with, the poor performance of the
United States on many indicators of health despite its excellence in many aspects
of health care. Decades of studies and reports have documented conclusively
that even in the face of unsustainably high spending on health care, the health of
the U.S. population lags behind that of nearly every other peer country (National
Research Council and Institute of Medicine, 2013). Armed with the more recent
understanding that countries with a higher ratio of social service to health care
spending have healthier populations (Bradley, Elkins, Herrin, & Elbel, 2011)
The physical and mental
health of our communities is
affected by more than just
health care.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 5. Population Health 103
and that inadequately addressed social factors are signi!cant drivers of health
care spending, policy makers are coming around to the notion that addressing
social determinants of health must be part of the solution to achieving national
health goals and health care cost-savings goals. Should policy makers seeking
to improve population health simply sidestep the health care sector if it
contributes only modestly to health at a societal level? Doing so would likely be
short-sighted, since health care is the sector in which resources earmarked for
health are almost exclusively concentrated in the United States. How, then, are
we to bridge the health care sector’s focus on and resources for health, with an
understanding of the broader societal factors that in fact determine so much
of health and disease? “erein lies the core challenge of the emerging !eld of
population health.
Population health employs an integrative model in understanding and seeking
to improve the health of groups of people, acknowledging that di#erent factors
intersect and combine to produce good or poor health. “e population health
model seeks to explain and intervene in the causes of the systematic di#erences in
health between di#erent groups (Kindig & Stoddart, 2003). To do so, it analyzes
the patterns or distribution of health between di#erent groups of people in order
to identify and understand factors leading to di#erences in outcomes. “ese
factors are often described as “upstream” causes in the sense that they in$uence
health through a series of pathways that may not be immediately visible (see also
Chapter 7).
Population health scientists use the term
determinants of health rather
factor or cause, and they use the term multiple determinants of health to
describe the determinants that arise from !ve important domains:
■■ “e social and economic environment—factors such as income, education, employment, social support, and culture (often referred to as the social determinants of
, or SDOH)
■■ “e physical environment, including urban design, housing, availability of healthy
foods, air and water safety, exposure to environmental toxins
■■ Genetics (and, more recently, epigenetics—the study of gene–environment interactions)
■■ Medical care, including prevention, treatment, and disease management
■■ Health-related behaviors, such as smoking, exercise, and diet, which in turn are shaped
by all of the preceding determinants
Health is therefore conceptualized as the result of exposure to di#erent patterns of these multiple determinants (Figure 5.1). Over the past 40 years, a signi!-
cant body of knowledge has developed that demonstrates the profound e#ects of
multiple determinants from di#erent domains as well as the interactions among
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104 Part II. Keeping Americans Healthy
them, their e!ects at di!erent stages in the life course from gestation to old age,
and their cumulative e!ects. Although the determinant categories are listed independently, they have substantial and complex interactions over the life course of
an individual or group.
Some health care outcomes can, in turn, a!ect the determinants; that is,
they can have a
reverse causality e!ect on determinants. For example, whereas
social determinants such as income have an e!ect on outcomes, the outcome
of being unhealthy also can have a negative e!ect on income (Kindig & Chin,
In contrast to the population health model, the medical model hones in
on individuals, focusing on the factors most immediately linked to the
pathophysiology underlying a person’s disease. It is a reductionist model in
the sense that it searches for the molecular and physiological mechanisms
that explain how speci”c factors produce illness or act as markers of incipient
disease. In turn, the therapeutic ideal is to “nd the “silver bullet” that will
Source: Institute of Medicine. (2003). !e future of the public’s health in the 21st century (p. 52). Washington,
DC: National Academies Press. Reproduced with permission from National Academies Press, Copyright
2002, National Academy of Sciences.
Broad social, economic, cultural,
health, and environmental conditions
and policies at the global, national,
state, and local levels
Innate Individual Traits:
Age, sex, race, and
biological factors
The biology
of disease
Living and working conditions
may include:
• Psychosocial factors
• Employment status and
occupational factors
• Socioeconomic status
(income, education,
• The natural and built
• Public health services
• Health care services
Family, and Community
Living and Working
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Chapter 5. Population Health 105
R2 = 0.51
0 1000 2000 3000 4000 5000 6000 7000 8000 9000
Source: Organisation for Economic Co-operation and Development. (2013). Health at a glance. Paris, France:
Author. doi: 10.1787/health_glance-2013-en
stop or reverse those mechanisms and thus cure or prevent progression of the
current medical problem.
!e medical model frames risk factors as working through disease-speci”c
pathways and typically analyzes risk factors as if they were independent in statistical modeling. !e medical model considers how di#erent biological systems
within the individual interact—for example, the endocrine system and the cardiovascular system—but the lens remains focused on the body.
Health care is generally reactive, meaning that it responds to abnormality, disease, or injury, and as a result has been characterized as a “sickness care
system” (Evans, Barer, & Marmor, 1994). Health care has traditionally been
delivered (and reimbursed) in acute episodes and has placed less value on and
provided less reimbursement for e#orts to promote health or to prevent illness
and injury. Although health care has achieved great strides in diagnosing, treating, and in some cases curing illness and injury, and although new knowledge
and technology are constantly increasing the capacity to preserve life, relieve
su#ering, and maintain or restore function, Americans’ chances for living long
and healthy lives are not improving, despite ever-greater U.S. spending on health
care (Figure 5.2).
!e United States is the outlier point on the far right—the highest health
care spending—yet Americans’ probability of survival to age 80 is lower than
that of other developed countries. !is marked discrepancy between the highest
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106 Part II. Keeping Americans Healthy
spending on health care and poorer survival rates is referred to as “the U.S. health
disadvantage” (National Research Council and Institute of Medicine, 2013). !e
di”erences between the medical and population health models can help explain
the reasons for the disparity between the United States and other developed
countries as well as the severe disparities within the United States among di”erent populations.
Consider two examples, obesity and tobacco use, that illustrate the di”erent explanatory and intervention approaches of the medical model versus
the population health model. In the medical model, when an adolescent with
obesity visits a health care provider, the
provider will likely assess the patient’s
family history, diet, and physical activity.
!ese may be followed by laboratory tests
to rule out hormonal or other physiological causes for obesity and to check for diabetes and other consequences of extreme
overweight. Interventions are likely to include referrals to nutritionists and
recommendations for decreasing calories and increasing physical activity,
with regular monitoring. In very serious cases (morbid obesity) or with failure
to achieve weight loss through these means, the patient may be referred for
bariatric surgery.
!e medical model does not focus on
why an epidemic of obesity has occurred
over the past 30 years or investigate why there are higher rates of obesity in lowincome and minority populations or grapple with the circumstances that make it
di#cult for many patients to comply with medical recommendations for eating
less and exercising more.
In contrast, the population health model has identi$ed a wide variety of
causes that have worked synergistically—an unintended conspiracy of causes
over time—to produce the high rates and di”ering patterns of obesity observed
among population groups. Such causes may include:
■■ Higher density in low-income neighborhoods of fast-food restaurants, which o”er
high-calorie, high-fat, low-nutrient, supersized meals at low prices
■■ !e presence of vending machines that sell high-calorie soft drinks as a source of
needed revenue in schools
■■ Subsidized school lunches with high caloric and fat content—a result of agricultural
■■ !e decrease in physical education classes and near-elimination of recess periods,
due to shrinking school budgets and a narrow focus on meeting academic test score
■■ Fewer children and adults walking or bicycling to school or other destinations, due in
part to the lack of sidewalks, safe pedestrian crossings, and bicycle lanes
The medical model does not
focus on
why an epidemic of
obesity has occurred over the
past 30 years.
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Chapter 5. Population Health 107
■■ Fewer safe places to play or walk in urban, low-income neighborhoods
■■ A lack of grocery stores with healthy food options such as fresh fruit and vegetables
in many neighborhoods, due to the higher cost and lower pro!t margins of these
■■ Marketing obesogenic foods to children
“ese social and physical environmental determinants strongly limit people’s
behavioral choices. It is di#cult to achieve lasting lifestyle behavioral changes
among people who
do have the economic resources to join gyms, have child care
while they exercise, and a$ord healthier food choices. Such goals are more challenging still when healthy choices are largely beyond !nancial reach.
In a population health framework, relevant interventions could include
zoning law changes; menu labeling; working with fast-food industries to provide
healthier, but low-cost menu options; educational policies that encourage healthy
food choices and increased physical activity in schools and after school; and so
on. Such interventions are not traditionally considered part of the health care
arena. Making the healthy choice the easier choice is not always su#cient; programs to change behavior boost the chances that people will make those healthy
choices their default choices. Such programs might include workplace or community programs to encourage physical activity in the form of walking, bicycling,
or other exercise or cooking classes using nutritious, a$ordable, noncalorie-dense
Tobacco use o$ers a second example. In the medical model, the focus is on
individual patients who smoke or chew tobacco. “e solution is framed in individual terms and is geared toward behavioral change through cessation counseling and nicotine replacement options. Success requires having access to providers
who support and encourage cessation (see Chapter 7).
In the population health model, the understanding of the problem includes
the in%uences of tobacco production, advertising, distribution, and patterns of
use in di$erent groups, as well as the policies used to intervene include smokefree laws, tobacco taxes, and regulation of advertising and marketing. “ese
population-wide policy changes have changed U.S. social norms regarding
the acceptability of tobacco use and led to dramatic decreases in the rate of
As with programs to increase physical activity and healthy eating, policy
changes to reduce smoking are usually coupled with increases in access to cessation programs at the community level, such as free quitlines and free nicotine
patches, which assist smokers in quitting. “e population health model also
enables targeting policies toward groups with the highest rates of tobacco use,
and it responds to tobacco industry actions to redirect their advertising from the
more a&uent smokers who are able to access cessation programs to new, more
susceptible markets, including youth, minorities, and people in developing countries (Kreuter & Lezin, 2001).
In short, key determinants of health are often shaped by policies and programs in sectors not traditionally considered as residing within the health care
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108 Part II. Keeping Americans Healthy
sector. In the obesity example above, the education sector is key to changes in
school environments. Changes in zoning laws can alter the proximity of fast-food
restaurants or liquor stores to schools or parks.
Cross-sectoral collaborative
are essential to addressing underlying causes of poor health and
therefore to improving health and health equity at the population level.
!e medical model is well accepted and respected by health care providers and
by basic science, clinical, and health services researchers. Indeed, medical knowledge is widely viewed as grounded in “hard science” and thus re”ecting “truth”
about the causes of disease. !e population health model, conversely, with its
inclusion of social science and diverse methods and data sources, is less widely
perceived as scienti#cally rigorous. While few may doubt that poverty and lack
of education are associated with worse health—as the Australian-born population health researcher John Lynch says, population health is the “science of the
bleedin’ obvious”—many are not aware of the magnitude and rigor of the scienti#c evidence underlying these #ndings or of the e$ectiveness of associated
population-level interventions.
In fact, substantial advances have been made in de#ning the pathways by
which social determinants in”uence health—in other words, how these factors
“get under the skin”—using a wide variety of research methods, from experimental psychology and neuroimaging, to exploring the pathophysiology of how
chronic stress causes in”ammation, to epigenetics. For a comprehensive review
of the research on the interaction between social determinants and human biology, see Adler and Stewart (2010).
Early and important research on health determinants was based on epidemiological #ndings linking morbidity and mortality to socioeconomic status,
de#ned by education, income, or occupational status. One of the earliest studies
to demonstrate the importance of such factors was Michael Marmot’s Whitehall
study, a longitudinal study conducted over two decades with results reported
throughout the 1970s and 1980s (Evans et al., 1994). !e British data were especially enlightening because they included a measure of social class, based on
!e Whitehall study collected extensive information on more than 10,000
British civil servants, from the lowest rung of the income and rank hierarchy to
the highest. Marmot found that the likelihood of death was about
three and a half
times higher
for those in the lowest status rank (clerical and manual workers) than
for those in the highest administrative jobs. Mortality rates increased steadily
with every reduction in rank.
Such a steady increase is known as a gradient in the population health
model and a
dose-response effect in the medical model, where it is taken
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Chapter 5. Population Health 109
as evidence of a robust relationship between causal factor and outcome. All
of the workers in this population had steady, paying jobs, and none had high
exposure to work-related toxins or other risks in the physical environment.
All had access to the British National Health System. The gradient in
heart disease mortality continued to be present after adjusting the data for
different rates of smoking, high blood pressure, and high cholesterol. In
other words, after controlling for the traditional medical model risk factors,
the 3:1 difference in death rate by social class could not be explained away.
Marmot and others went on to investigate the role of stress associated with
occupational rank.
Decades of study of the stress response have rigorously demonstrated its
negative impact on health, mediated by multiple physiological pathways. A wide
variety of stressful stimuli have been studied, including social subordination,
lack of job control, discrimination, social isolation, economic insecurity, job loss,
and bankruptcy. More recently, the impact of racism has also been studied in
this framework. A proposed common pathway is that greater exposure to stress
over time leads to chronic activation of physiological responses that, by virtue of
resulting conditions (e.g., neurophysiological adaptations, elevated blood pressure, heightened in!ammatory responses), result in elevated rates of morbidity
and mortality. For example, babies born to mothers who fear targeting by immigration raids are more likely to be of low birth weight (Novak, Geronimus, &
Martinez-Cardoso, 2017).
Scientists increasingly recognize that the mechanisms by which social determinants act depend on the context in which people encounter stressful events.
One area of research focuses on
neighborhood effects, which include the interaction of social and physical environmental determinants; for example, the negative interaction between the physical environment (poor housing, presence of
crime and violence, absence of stores with healthy foods) and social determinants
related to poverty.
Data on the links between social factors and health and the wide variations
in health among groups can be found in a report from the Robert Wood Johnson
Foundation Commission to Build a Healthier America (2014), a national, independent, nonpartisan group of leaders who investigated how factors outside the
health care system shape and a”ect opportunities to live healthy lives. #e Commission’s team of researchers compared average life expectancy by county and
found signi$cant variations. For example, the average life expectancy in Wolfe
County, Kentucky, is 70 years, compared with 78 years in nearby Fayette County—
a di”erence of 8 years. Such $ndings of stark di”erences in life expectancy or other
health outcome according to race/ethnicity, gender, sex, sexual orientation, place,
and income have focused attention on the goal of achieving health equity. Health
inequities “systematically put groups of people who are already socially disadvantaged (e.g., by virtue of being poor, female, and/or members of a disenfranchised
racial, ethnic, or religious group) at further disadvantage with respect to their
health” (Braveman & Gruskin, 2003). Building toward health equity, therefore,
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110 Part II. Keeping Americans Healthy
requires incorporating an intentional focus on combatting underlying causes of
inequity—from structural racism to lack of parity in wages to underinvestment in
early childhood education—into initiatives to improve population health.
Two of the most predictive factors of life expectancy are income and degree
of education. Examination of the relationship between measures of education
and income on U.S. life expectancy showed that:
■■ College graduates can expect to live at least 5 years longer than those who did not
complete high school.
■■ !e gap in life expectancy between the richest 1% and poorest 1% of individuals in
the United States is 14.8 years for men and 10.2 years for women (Chetty et al., 2016).
By way of context, in 2017, the federal poverty level (FPL) was $20,780 for a family of
■■ Even middle-income Americans can expect to live shorter lives than those with higher
incomes, whether or not they have health insurance.
!e Commission also examined the relationships among health status, educational attainment, and racial or ethnic group. !e measure of health status was a
self-reported assessment of one’s own health as excellent, very good, good, fair, or
poor. Self-reported health status corresponds closely with assessments made by
health professionals. Indeed, among adults studied by the Commission’s research
team, those who reported being in less than very good health had rates of diabetes and cardiovascular disease more than “ve times as high as the rates for adults
who reported being in very good or excellent health. Additional highlights of the
Commission’s results include:
■■ Overall, 45% of adults ages 25 to 74 reported being in less than very good health, with
rates varying among states from 35% to 53%.
■■ Adults with less than high school degrees were more than two to three times as likely to
be in less than very good health than college graduates. !ere was also a clear gradient
in health by educational level.
■■ Health status varied across racial or ethnic groups; non-Hispanic Whites were more
likely to be in very good or excellent health than other groups nationally and in almost
every state. In some states, non-Hispanic Black and Hispanic adults were
more than
as likely as White adults to be in less than very good health.
■■ Analyzing both social factors simultaneously, non-Hispanic Whites had better health
status than adults in any other racial or ethnic group
at every level of education. !e
gradient in health by educational level within each racial or ethnic group is shown in
Figure 5.3.
Educational attainment may in#uence healthy choices and better health via
multiple pathways. For example, people with more schooling may have a better
understanding of the importance of speci”c healthy behaviors, or higher educational attainment may lead to higher-paying jobs with greater economic security, healthier working conditions, better bene”ts, and greater ability to purchase
more nutritious foods and live in a safe neighborhood with good schools and
recreational facilities. Figure 5.4 demonstrates that behavior and education both
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Chapter 5. Population Health 111

Less than high-school graduate
High-school graduate
Some college
College graduate
43.6 41.0 39.5 41.8 36.5 41.4

Hispanic Asian American Indian
or Alaska Native
Percent of Adults Ages 25–74 Years,
in Less Than Very Good Health
Other White,
Source: Robert Wood Johnson Foundation Commission to Build a Healthier America (2009). Beyond health
: New directions to a healthier America. Princeton, NJ: Robert Wood Johnson Foundation.
a!ect health: At every level of educational attainment, adults who smoke and do
not participate in leisure-time exercise are less likely to be in very good health
than adults who do not smoke and do get exercise.
Similar to educational attainment, racial discrimination can a!ect health via
multiple pathways. A substantial base of evidence exists regarding the e!ect of
di!erent policies on both discrimination and health. Exposure to discrimination
in and of itself provokes a physiological stress response in the lab, and repeated or
sustained exposure leads to chronic, unhealthful activation of the stress response.
A variety of policies have combined to maintain or worsen Black–White segregation by neighborhood, despite the civil rights legislation of the 1960s. Residential
segregation in”uences diverse social determinants of health, including educational and employment opportunities, access to safe and a!ordable housing, routine opportunities for physical activity, food “deserts” with scarce access to fresh
healthy foods, and exposure to violence. #ere is strong evidence that reducing
or eliminating residential segregation would substantially diminish Black–White
di!erences in income, education, and unemployment, and in turn racial disparities in health (Williams & Collins, 2001).
As noted earlier, the population health model calls for integration of the
multiple determinants of health, with consideration of both negative and positive interactions among di!erent factors. #e relationships between socioeconomic status and health are complicated, but the most persistent disparities in
health between groups clearly involve the intersection of multiple types of social
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112 Part II. Keeping Americans Healthy
Less Than

Adults without healthy behaviors
Adults with healthy behaviors

Percent of Adults Ages 25–74 Years,
in Less Than Very Good Health
Some College College
Source: Robert Wood Johnson Foundation Commission to Build a Healthier America (2009). Beyond health
: New directions to a healthier America. Princeton, NJ: Robert Wood Johnson Foundation.
disadvantages (Adler & Stewart, 2010). !e interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual
or group result in overlapping and interdependent systems of discrimination or
disadvantage, as described by the concept of “intersectionality” (Schulz & Mullings, 2006).
!e “ve di#erent domains or categories of health determinants, described earlier in this chapter, do not make equal contributions to the health outcomes of
populations. !is is not “new news.” In the 1970s, !omas McKeown (1976)
concluded that improved health and longevity in England over the previous 200
years resulted from changes in food supplies, sanitary conditions, and smaller family sizes, rather than medical interventions.
In the United States, John Bunker and colleagues (1995) estimated that during the
20th century, medical care explained only
5 of the 30-year increase in life expectancy
During the 20th century,
medical care explained only 5
of the 30-year increase in life
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Chapter 5. Population Health 113
and, between 1950 and 1990, when many new therapies were developed for infectious diseases and heart disease, medical care accounted for only 3 of the 7 years
of life expectancy increase.
Medical care also can be responsible for
increasing mortality rates. A 2000
Institute of Medicine (IOM) report publicized the startling !nding that medical
errors accounted for approximately 2% to 4% of U.S. deaths annually (Kohn, Corrigan, & Donaldson, 2000), placing medical error among the top causes of death
(Bleich, 2005).
“ere was a period of time in the 1990s during which medical scientists
expected that genetics could explain much of the variation in health between
groups and individuals, yet the role of genetics in understanding such variation
remains unresolved. Recent initiatives to study genetic factors at the population
level, such as the National Institutes of Health (NIH) – sponsored All of Us project to enroll 1 million individuals in a cohort study collecting data on multiple
domains of health, will deepen knowledge on this important front.
Health behaviors (e.g., smoking, physical activity, substance abuse, sexual
activity, diet) are considered major determinants of health in both the medical and
population health models. Analysis of data from 22 European countries showed
that variations in health disparities could be attributed to variations in smoking,
alcohol consumption, and access to care but that the patterns of determinants of
inequality were di#erent for men and women, by country, and by which outcome
was measured (Mackenbach et al., 2008).
“e best weighting scheme to determine the combined e#ects of determinants from di#erent domains depends on the health outcome of interest. Some
outcomes will be more dependent on certain determinants than on others.
Researchers have therefore estimated the relative contributions of the multiple
determinants of health through what are called
summary measures of mortality
and morbidity—that is, measures that summarize the length and quality of life.
Signi!cant progress has been made in accumulating the empirical data that can
yield the best approximations of the relative weights of each domain on summary
health outcomes.
McGinnis and Foege (1993) reviewed the relevant literature from 1977 to
1993 to analyze the leading causes of U.S. deaths. “ey concluded that approximately
half of all deaths in 1990 were due to key behavioral factors, led by tobacco
use and followed by diet and physical activity. Related estimates included that
about 40% of deaths were caused by behavioral factors, 30% by genetics, 15%
by social determinants, 10% by medical care, and 5% by physical environmental
exposures. Ten years later, an IOM (2003) analysis revised the 1990 estimate of
50% of all deaths upward to 70% of all deaths being due to key behavioral and
environmental factors. “e Centers for Disease Control and Prevention (CDC)
updated the McGinnis and Foege analysis and concluded that smoking remained
the leading cause of preventable deaths, followed by poor diet and lack of physical activity (Mokdad, Marks, Stroup, & Gerberding, 2005).
“e annual national
County Health Rankings report, !rst launched in 2010,
ranks the overall health of every county within each of the 50 states and reports
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114 Part II. Keeping Americans Healthy




Source: University of Wisconsin Population Health Institute (2010). County Health Rankings and Roadmaps 2018. Retrieved from
the contribution of the multiple determinants of health on each county’s overall
health using a population health framework. Health outcomes are viewed as the
result of a combined set of factors, and these factors are also a!ected by conditions, policies, and programs in their communities. “e report is based on a
model that compares overall rankings on health outcomes with rankings on different health factors (Figure 5.5).
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Chapter 5. Population Health 115
!e County Health Rankings report estimates the in”uence on health and longevity of (a) health behaviors at 30%, (b) clinical care at 20%, (c) social and economic factors at 40%, and (d) physical environmental factors at 10%. !ough there
is a range of opinion on the merits of accounting for all causes of health and disease
in such models (Krieger, 2017), the rankings have powerfully demonstrated dramatic variation between one county and another in health outcomes and in health
determinants. !is variation is even greater than the variation in health care expenditures and health care outcomes that has been demonstrated over many years
by health service researchers. For example, the premature death rate in the least
healthy counties was two and one half times greater than in the healthiest counties.
!e bottom-line message of the
County Health Rankings project is that where
people live matters to their health. !e population health framework enables
communities to see which factors are contributing the most to their poor or good
health outcomes, and thus choose to act to improve the factors a#ecting health,
vitality, and productivity of all community residents.
In a logical world, the more that is known about the causes of a signi$cant problem, the more resources would be allocated toward reducing the most important
of those causes. In the United States, two-thirds of what we spend on health care
is attributable to diseases that are preventable. But we invest less than 5% of our
more than $3 trillion annual health spending on e#orts to prevent these illnesses,
whereas 95% goes to direct medical care.
Yet, for the reasons set forth above, only
perhaps 10% to 15% of preventable deaths
could be avoided by increasing the availability or quality of medical care.
!e population health model suggests
that investments and policy decisions in
areas that are not traditionally considered
the province of health care are more likely
to have a signi$cant e#ect on improving a
population’s health than increased spending
on medical services. Indeed, the share of the
U.S. GDP that is spent by the health care sector on processes, tests, and treatment of little value has been likened to theft from other sectors such as education,
in which comparable investment could have a far more profound and enduring
impact on health (Berwick & Hackbarth, 2012). An excellent review of the challenges and e#ect on health of policies in the areas of education, income transfer,
civil rights, macroeconomics and employment, welfare, housing, and neighborhoods is provided in a comprehensive text by Schoeni, House, Kaplan, & Pollack
Researchers are only beginning to be able to provide the evidence to guide
policy makers regarding the comparative e#ectiveness and costs of speci$c
The population health model
suggests that investments and
policy decisions in areas that are
not traditionally considered the
province of health care are more
likely to have a signi!cant effect
on improving a population’s
health than increased spending
on medical services.
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116 Part II. Keeping Americans Healthy
investment choices across the !ve categories of health determinants, re”ecting in
part methodologic challenges arising from interactions among determinants, the
latency over time of their e#ects, and the sparsity of robust longitudinal data sets.
Nevertheless, this evidence base is growing rapidly, as shown by research estimating that correcting disparities in education-associated mortality rates would
have averted eight times more deaths than improvements attributable to medical
advances between 1996 and 2002 (Woolf, Johnson, Phillips, & Philipsen, 2007).
Another example comes from a study by the Urban Institute, which calculated
the return on investment for prevention and concluded that an investment of $10
per person per year in proven community-based programs to increase physical
activity, improve nutrition, and prevent smoking and other tobacco use could
save the country more than $16 billion annually within !ve years. $is is a return
of $5.60 for every $1 invested (Trust for America’s Health, 2008).
$e Robert Wood Johnson Foundation Commission to Build a Healthier
America delivered a series of evidence-based policy recommendations to improve
health, including the following:
■■ Provide high-quality early developmental services and support for all children.
■■ Fund and design the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP, also
known as food stamps) programs to meet the need of hungry families for nutritious
■■ Eliminate so-called food deserts through public–private partnerships.
■■ Require healthy foods and physical activity in all schools (K–12).
■■ Ensure that decision makers in all sectors have the evidence they need to build health
into public and private policies and practices.
$e last strategy underscores the need to consider the health e#ects of policies,
programs, and projects in sectors not traditionally thought of as a#ecting health.
$is can be achieved through the use of health impact assessments (HIAs; www, which have a long history of use in the same countries
that have led the way in developing and acting upon the population health model.
HIAs have been used in a wide variety of decisions regarding transportation,
housing, zoning, and other aspects of the built environment and more recently
have been used to address social policies related to education, labor, criminal
justice, segregation, and other areas. HIAs are one of the tools that can be used to
bring a health lens to policy, program, and project decisions made in nonhealth
sectors, an approach known as health in all policies (HIAP).
While population health interventions have the potential to create much
greater improvements in the health of Americans than further spending increases
for medical services, a core challenge is to !nd sustainable approaches to !nancing them. Over the past 5 years, a number of innovative methods have been implemented to direct funding to community-level prevention initiatives addressing
social, physical, and economic environments. One model is a wellness trust: a
fund set aside speci!cally to support population-wide interventions or policies.
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Chapter 5. Population Health 117
Funds for a wellness trust can come from a number of sources, such as a tax on
insurers or hospitals, as was done in Massachusetts in 2013. Another innovation
is a variation on social impact bonds as health impact bonds (also referred to as
Pay for Success). Capital is raised from private investors to implement community or state prevention interventions, and the resulting health care cost savings
are returned to the investors as break-even or pro!t. A number of health impact
bonds are in progress, including home remediation of mold and other triggers of
childhood asthma to reduce unnecessary hospitalizations and emergency room
visits for asthma in multiple communities, or improving birth outcomes through
the Nurse-Family Partnership in South Carolina.
Another potential source of funding is community bene!t spending by
nonpro!t hospitals. Since the 1950s, to keep their tax-exempt status, nonpro!t
hospitals have owed certain duties to the community, largely focusing on providing charity care to the
medically indigent. Concurrently with the passage of
the Patient Protection and A”ordable Care Act (ACA), amendments were made
to the Internal Revenue Service code that increased the rigor and consistency
of hospital reporting, requiring hospitals to perform a community health needs
assessment every 3 years with collaboration from public health experts and the
community and to use the resulting !ndings as the basis for conducting community health improvement activities. Such activities can include investments
in community-based health services that are furnished outside of and are not
billable by the hospital, as well as more upstream interventions addressing social
and physical environmental determinants like investing in housing to improve
health. #ese ACA-based changes have stimulated increased collaboration by
many hospitals with public health and community partners, although the degree
to which hospitals are committing funds to identi!ed community priorities varies widely.
Other innovations include the concept of a “health dividend,” which refers
to the opportunity cost of waste in health care spending, estimated at $750 billion per year. If this waste could be eliminated and the funding recaptured, the
money could be used to improve key determinants of population health—for
example by investing in education, job training, or improving the built environment (McCullough, Zimmerman, Fielding, & Teutsch, 2012).
Additional potential population health !nancing innovations result from the
implementation of the ACA. #e Prevention and Public Health Fund, intended
to provide stable funding for increased activities to improve community health,
supported a number of programs to improve population health using place-based
strategies, such as Community Transformation Grants. However, the fund was
also used to !ll gaps in the implementation of health care changes under the ACA
and has been a continual target of those opposed to the health reform act.
Other opportunities have resulted from the ACA, including accountable
care organizations (ACOs) and Medicaid waivers and innovation grants. ACOs
are essentially networks of providers and hospitals that share responsibility for
the health care and health outcomes of a set of patients. ACOs provide savings
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118 Part II. Keeping Americans Healthy
incentives by o!ering bonuses when providers keep costs down and meet speci”c quality benchmarks, focusing on prevention and carefully managing patients
with chronic diseases. In other words, providers get paid more for keeping their
patients healthy and out of the hospital. To do this well requires that providers
and hospitals work in the community beyond the walls of their institutions to
ensure better care coordination—and better social and physical conditions for
promoting health. ACOs were designed to lay the foundation for the anticipated
transition by the Center for Medicare and Medicaid Services (CMS) toward
value-based payment. Another innovation opportunity came from state waivers
for delivery of Medicaid. For example, the Texas Medicaid waiver was constructed
such that 5% of the billions of dollars in the waiver was earmarked to support
public health interventions that would prevent illness or injury and thus save
Medicaid money. #ese payment model innovations, like those mentioned previously, require careful evaluation to document their ability to bring about population health improvements and to decrease health care costs. More recently, some
Medicaid managed care organizations have begun to move toward global budgeting, freeing them to be able to consider funding community interventions like
supportive housing if they led to better health outcomes (and lower total costs)
for their capitated populations. Innovative variations on this approach to improving both health care delivery and the health of clinical populations care have been
set in motion in numerous states through “accountable health communities” that
take on responsibility for both health care and identifying and addressing social
determinants of health among participants (Alley, Asomugha, Conway, & Sanghavi, 2016).
Recognizing the impact that factors outside the health care system can have
on health care utilization and costs, the health care sector is beginning to screen
patients for social determinants of health like housing, transportation, and food
insecurity. A challenge to this approach is that while it may be relatively easy
to identify a patient’s social stressor (e.g., unstable housing), putting into place
referral systems that are e$cient and e!ective and generate feedback to the provider (as expected for other referrals made during the course of clinical care) can
be a major challenge. Innovative solutions, such as local mapping of community
health-related assets and social service referral software integrated with the electronic health record, are beginning to demonstrate promise toward this important goal (Lindau et al., 2016).
Recognition of the importance and value of population health science and of the
population health model to advancing health in the United States has accelerated
greatly in the last decade. Examples include:
■■ An extensive literature of high-quality publications in top U.S. medical, health care,
and public health journals as well as books in multiple disciplines
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Chapter 5. Population Health 119
■■ National Institutes of Health and CDC funding of multidisciplinary population health
research and intervention programs
■■ Numerous National Academy of Medicine review committees and reports on the
multiple determinants of health and its Roundtable on Population Health Improvement
■■ Interdisciplinary population health centers and training programs at premier universities across the country and the emergence of departments of population health at
leading academic medical centers
■■ !e MacArthur Research Network on Socioeconomic Status and Health, a research
working group funded by the MacArthur Foundation, which operated from 1998 to
■■ National commissions on population health and prevention, including the Robert
Wood Johnson Foundation’s two reports from the Commission to Build a Healthier
■■ !e annual national County Health Rankings report based on a multiple determinants
of health framework as well as similar initiatives at the city level (e.g., the
City Health
!e population health model is increasingly accepted as a framework for
understanding the multiple determinants of health, with an emphasis on prevention and a strong basis in scienti”c evidence. Importantly, the term “population
health” also entered the lexicon of clinical practice in 2007 as part of the Institute for Healthcare Improvement’s (IHI) Triple Aim initiative to (a) improve the
health of the population, (b) enhance the experience and outcomes of the patient,
and (c) reduce per capita cost of care for the bene”t of communities. !e Triple
Aim initiative’s use of the phrase “population health” has led to some confusion in
terminology. Noting this, the IHI stated in 2014 that “population health” refers to
the broader determinants of health, whereas the Triple Aim refers to “population
medicine” as the management of a discrete population in a health care system,
health plan, or ACO to improve outcomes.
!ere is great potential for population health strategies to aid medical care
providers in improving the outcomes for their patients. As noted earlier in this
chapter, population health is not only about primary prevention; the social, behavioral, and environmental determinants of health also strongly a#ect patients’ ability and likelihood to carry out medical care providers’ recommendations about
changing lifestyle behaviors or preventing social crises (such as losing a job or
becoming homeless) that in turn trigger serious health crises.
As envisaged in the 2003 IOM report on the future of the public’s health,
collaboration among those using the medical, governmental public health, and
population health models would provide a more coherent national approach to
health improvement. Such an approach would include a common, integrated set
of metrics for determinants and outcomes, provide sustainable realigned funding, and result in more strategic and synergistic planning for the actions best
suited for improving the conditions needed for all Americans to have the opportunity to lead healthy lives.
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120 Part II. Keeping Americans Healthy
Recent data show that Americans consume, on average, more than three times the recommended level of sodium per day in their food and beverages. High salt intake contributes to
high blood pressure and its complications—stroke, heart attack, congestive heart failure, and
kidney failure. In fact, thousands of lives could be saved if sodium consumption were lowered
in people with high blood pressure. Write a memo for the U.S. Secretary of Health and Human
Services about what might be done to address concerns about the effect of high sodium intake
on health. In preparing your memo, consider the following questions:
1. How might we address this problem in the patient population using the medical model
that a health care provider might use versus a population health model that a public
health of!cial might use?
2. How far can and should governments go in attempting to create a more healthful environment? Intrinsic to many population health policies is the specter of the so-called
nanny state. In this case, is it necessary for everyone to be exposed to lower sodium in
their bread, in other common foods, and in restaurants, so as to protect people who have
salt-sensitive illnesses?
3. Should manufacturers bear the costs of manufacturing different versions of foods in
order to protect the public’s health? Should they be required to manufacture healthier
foods, even if customers prefer the less healthy versions? Or should they be liable if they
don’t manufacture healthier foods?
1. !e general public equates the word “health” with “health care.” Polls asking people
about their health typically result in responses about their health care experiences.
How do you de”ne health? How would you assess a population’s health if you could
ask the people in that population only one question on a survey?
2. Why do some people refer to the health care system as “the sickness care system”? Do
you agree or disagree with this term?
3. Cross-sectional research shows that, on average, people with disabilities secondary
to illness or injury have lower socioeconomic status than people without disabilities.
How could longitudinal research help to explain whether this is because people of
lower socioeconomic status are at higher risk of developing disabilities or because disability leads to loss of income and thus lower socioeconomic status? In a population
health model, how might lower socioeconomic status increase the risk of disability
secondary to illness or injury?
4. !e Commission to Build a Healthier America found that non-Hispanic Whites were
more likely to be in very good or excellent health than other groups nationally and in
almost every state. In addition, non-Hispanic Whites had better health status than
adults in any other racial or ethnic group at every level of education, but all groups
showed a gradient in health by educational level. What are some of the determinants
that are likely contributing to this disparity in health between non-Hispanic Whites
and other groups after controlling for di#erent educational levels?
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Chapter 5. Population Health 121
5. It is possible that a community’s County Health Rankings would suggest that the
biggest driver of poor health in that community is unemployment. How would you
present the case to your nonpro!t hospital board that the biggest community bene!t
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increase job openings in the community, rather than holding health fairs or o”ering
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Public Health:
A Transformation
in the 21st Century
Laura C. Leviton, Paul L. Kuehnert, and Kathryn E. Wehr
Discuss why a healthy population is in the public interest
Contrast defining characteristics of prevention-oriented public health and
treatment-oriented health care
Identify the core functions of public health
Define essential public health activities
Describe state, federal, tribal, and local authority for public health laws,
regulations, and services
Identify how challenges and opportunities are transforming public health
Association of State and Territorial Health Officers (ASTHO)
health (World Health Organization definition)
health impact assessments (HIAs)
health promotion
health status of entire populations
multisectoral collaborations
National Association of County and City Health Officials (NACCHO)
nongovernmental organizations
policy development
© Springer Publishing Company DOI: 10.1891/9780826172730.0006
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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AN: 1998657 ; James R. Knickman, PhD, Brian Elbel, PhD, MPH.; Jonas and Kovner’s Health Care Delivery in the United States, 12th Edition
Account: s3563253.main.ehost

124 Part II. Keeping Americans Healthy
population health
primary prevention
Public Health Accreditation Board (PHAB)
secondary prevention
Overview of a complex infrastructure
Public health requires a collective response from society
Public health is different from individual health care
The core functions of public health define essential public health activities
Governmental agencies have legal authority for the core functions
Various social, economic, and political forces are transforming public
!is chapter introduces the policies, programs, and practices that constitute public
health in the United States. Public health is “what society does collectively to assure
the conditions for people to be healthy” (Institute
of Medicine, 2002). It is the science, practice, and
art of protecting and improving the health of
populations (Kindig, 2015). We “rst describe
the goals and characteristics of public health
that di#erentiate it from health care treatment, and we outline the core functions of
public health. We then describe the complex network of laws, regulations, authorities, and services
involved. Federal, tribal, state, and local government agencies, often called the infrastructure, have legal authority for the core functions. At the same time, champions of
public health span many public, private, and nonpro”t organizations. In the concluding section, we describe forces at work to transform public health in the 21st century.
Historically, public health emphasized regulating and improving community
sanitation, monitoring environmental hazards, and care of poor mothers and children. Over time, it greatly expanded its role in
documenting and controlling communicable
diseases and encouraging health promoting
behavior. In the late 20th century, many local
health departments were the provider of last
resort for indigent health care. With passage
Public health is “what society
does collectively to assure the
conditions for people to be healthy”
(Institute of Medicine, 2002).
Public health focuses on
entire populations and the
design of policies, systems,
services, and environments to
achieve not just the absence
of disease, but a collective
sense of well-being.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 6. Public Health: A Transformation in the 21st Century 125
of the Patient Protection and A!ordable Care Act (ACA) in 2010, health departments began to reorganize and direct more resources to prevention as more people
received health insurance. “e ACA included an unprecedented single investment
in its Prevention and Public Health Fund, which also enabled this shift. However,
federal funding for prevention has since declined, the ACA is in jeopardy, state
funding has been level since 2010, and state and local health departments have
seen a 20% drop in personnel since 2008 due to budget cuts (see the following). It
is too soon to predict a long-term trend of support for government-funded public
health, given political volatility in 2018. What is certain is that the principles and
services we describe in this chapter are quite simply necessary to ensure the health
of populations. Public health activity only accounts for an estimated 1% to 3% of
national spending (Leider et al., 2016), yet greater spending per capita is linked to
decline in preventable deaths (Mays & Smith, 2011). And despite politics, there is
growing recognition that public health in the United States needs to move away
from piecemeal responses to health problems toward a more coherent and comprehensive approach. Public health champions are also working far beyond the
conventional health sector to advocate for a broader set of policies and systems
changes that improve and protect health.
Public Health Every Day
Public health activities a!ect the lives of Americans profoundly, but more often
than not these activities are invisible. A thought experiment shows how this
works. Imagine waking up and going through your morning routine. You slept 8
hours for a change because health experts claim that lack of sleep causes stress
and other health problems. You wander
into the bathroom and brush your teeth—
teeth that are still in your mouth and pain
free thanks to regular brushing and #ossing,
adequate nutrition, and routine dental visits.
You feel that good habits are your personal
responsibility, but you take for granted the
services and policies that made these choices possible. You also take for granted
that your environment keeps you healthy. Fluoride in your local water supply
helps strengthen your tooth enamel and prevents cavities. You rinse your mouth
with water that is safe to drink. Before it ever reached your faucet, it was checked
for sickness-causing bacteria, heavy metals such as lead (which harm children’s
brains and nervous systems), and chemicals such as polychlorinated biphenyls
(which cause cancer). When you #ushed the toilet, the waste did not get into the
water supply where it could kill you.
You get your children ready for school; so far, they have all survived, never having had measles, diphtheria, polio, or other diseases that killed and maimed so many
children in bygone days. “ank goodness for immunizations. “e kids’ breakfast
includes cereal and pure pasteurized milk. You looked at the nutritional label on
their cereal and saw whole grains and not too much sugar—some food companies
are feeling the pressure and voluntarily o!ering healthier kids’ cereals these days.
Public health activities affect the
lives of Americans profoundly,
but more often than not these
activities are invisible.
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126 Part II. Keeping Americans Healthy
!e news feed warns that a new in”uenza strain is spreading, and the authorities
have renewed their advisory for hand washing and travel precautions. Your sister
calls to announce she is going to have a baby! She is not aware that the toast she is
eating is forti#ed with folic acid, the B vitamin that prevents birth defects. !anks
to comprehensive sex education and family planning, the couple never had (or were
quickly treated for) gonorrhea and chlamydia infection, which can cause infertility.
!e two of you also discuss your father. He’s over 70 and not in the best health,
so he needs to get his “u and pneumonia shots right away! !e last time he had
“u, it turned into pneumonia; he went to the hospital and could have died. Both
of you are worried about him because he is overweight, still smokes, and never
exercises. Is a heart attack, diabetes, or stroke in his future? !e odds are not in
Dad’s favor. Programs to quit smoking are available in the community without
charge, so you agree that Dad’s doctor should try suggesting them again. Too bad
there are no sidewalks in Dad’s neighborhood; he loves to walk, but there is too
much tra$c. Does the senior center have an exercise program that might appeal
to him? You buckle the kids into their safety belts. When you get to your job, you
see signs that read: “607 days without an accident at this worksite” and “proud to
be tobacco free since 2008.” !ese everyday experiences are not just about making healthier choices on your own, but about public health giving the opportunities for healthier choices and making healthier choices the easy choices.
Divided Responsibilities and Issue-Specific Organizations
!e responsibility for the public’s health and the infrastructure to make it work
are divided among many agencies across all levels of government and many
nongovernmental organizations, professional associations, and businesses (see
Figure 6.1). In our thought experiment, for example, municipal authorities handle
waste water, but the federal government regulates chemicals in the water supply.
!e federal government recommends physical activity for older adults, but local
organizations like senior centers, YMCAs, private gyms, and city departments
of transportation, parks and recreation, and public safety all make it possible to
be physically active. !e federal government requires seat belts and air bags in
cars, but state laws mandate seat belt use and the penalties for violation, and local
police generally enforce the laws.
At least four factors account for the complexity and di%use responsibility for
public health in the United States. !e #rst factor is that the U.S. Constitution calls
for decentralized government; states have authority for public health, except where
speci#ed by federal and tribal law. How much authority the states in turn share
with local government varies a great deal and rests with diverse agencies, boards of
health, and municipal and tribal codes (Hodge, 2012; Institute of Medicine, 2011).
Second is the distinctive American tendency, #rst recognized by Alexis de
Tocqueville in the 1830s, to design laws, policies, and organizations that are
problem-speci#c, rather than general. For example, individual diseases receive
special legal recognition, and new federal programs, policies, and categorical
funding streams are created to deal with them. As seen in the following, such
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Chapter 6. Public Health: A Transformation in the 21st Century 127


Home Health
Faith Institution
Source: Centers for Disease Control and Prevention. (2013). !e public health system and the 10 essential
public health services. Retrieved from
problem-speci!c policies get in the way of comprehensive policies and systems to
prevent and treat disease and respond to health hazards. Diverse federal departments deal with such health problems as assuring pure food and drugs (Food
and Drug Administration [FDA] and United States Department of Agriculture
[USDA]), monitoring and controlling infectious diseases (Centers for Disease
Control and Prevention [CDC]), providing guidance to prevent chronic diseases
(CDC, National Institutes of Health [NIH]), improving tra”c safety (Department of Transportation [DOT], National Highway Tra”c Safety Administration
[NHTSA]), maternal and child health care (Centers for Medicare & Medicaid Services [CMS], Health Resources and Services Administration [HRSA]),
and ensuring a healthy and safe place to work (Occupational Safety and Health
Administration [OSHA], Mine Safety and Health Administration [MSHA],
National Institute for Occupational Safety and Health [NIOSH]).
A third distinctively American approach is the heavy reliance on nongovernmental organizations to achieve public health goals. Yet these organizations also
tend to be issue-speci!c: national organizations and their local a”liates such as
the American Red Cross, American Heart Association, the Planned Parenthood
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128 Part II. Keeping Americans Healthy
Federation of America, United Way Worldwide, YMCA of the USA, various
environmental organizations, and many community-based organizations speci!c to a town or city neighborhood. With shrinking governments, these organizations take on additional importance. Some organizations and
are taking on a broader set of local and state health issues and
!nding new ways to collaborate toward a shared goal (see below).
“e fourth cause of di#use responsibility (and complexity) lies in the broad
de!nition of health goals and ongoing debates over what should be done to
achieve them. “e World Health Organization asserts that
health is more than
the absence of disease, but rather “a state
of complete mental, physical and social
well-being” (Green & Kreuter, 2005). Wellbeing is achieved, for example, when children perform well in school and do not fear
neighborhood violence, when physical and
mental functioning is maintained well into
old age, and when people have a better quality of life. But where, then, do we draw the
line between health goals and other societal goals? Should we draw such a line?
Who has responsibility, and for which goals? “is is a matter of active debate,
especially as public health starts to address more of the social, environmental,
and economic determinants of health (see the following).
Two key assumptions distinguish public health from the health care delivery
systems discussed elsewhere in this book: (a) a healthy population is in the public interest and (b) working at a societal or community level (outside of what a
clinician can do in a health care setting), we can improve an entire population’s
The Health of Populations Is in the Public Interest
The goal of public health is to improve the health status of entire populations,
not just individuals. It is concerned with the incidence, prevalence, and
distribution of health problems and differences by places and populations.
In using these indicators, public health aims to identify health problems and
improve them through action at a community, state, or other collective level.
This aim is well justified by past successes. Between 1900 and 2015, average
life expectancy increased from 47.3 to 78.8 years (National Center for Health
Statistics, 2017). Medical care treatment did not accomplish this change.
Rather, society made pervasive improvements in 10 public health arenas
(see Exhibit 6.1). In the present day, health still is most strongly determined
by behavioral, community, environmental, and societal forces, not by health
care (see Chapter 7).
The World Health Organization
asserts that health is more
than the absence of disease,
but rather “a state of complete
mental, physical and social
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Chapter 6. Public Health: A Transformation in the 21st Century 129
The Public Interest Justifies a Collective Response
Public health is necessary because neither individual behaviors, nor medicine,
nor the private sector are enough to keep people healthy. !us, the public interest requires government services, or at least some form of e”ective collective
action. Since ancient times, people have taken collective action to protect themselves from disease and environmental disaster. In the 19th century, public health
was justi#ed on utilitarian grounds: the greatest good for the greatest number.
Healthy people are a more productive workforce and better able to defend the
nation. !e utilitarian argument is still compelling: For example, a high childhood obesity rate impairs America’s economic competitiveness and the combat
readiness of youth (Institute of Medicine, 2012). However, public health today is
also justi#ed as a human right, and public health is seen as a means to achieve
social justice by addressing social and economic disparities that contribute to
health inequities (Beauchamp & Steinbock, 1999).
Not everyone agrees with this rationale. Conservatives often reject social justice as a reason for collective action. In truth, most public health services serve
both utilitarian and social justice aims. For example, many publicly funded prevention e”orts are targeted to poor children, but these e”orts also help produce
a healthier workforce. Also, libertarians believe public health limits individual
liberty (Leviton, Needleman, & Shapiro, 1997). Indeed, public health policy and
practice usually balance individual freedoms and collective bene#ts. For example,
health departments have police powers to control infectious disease as a “clear
and present danger,” but they need to do so without appearing to abuse this
power. Some legal decisions have, in fact, limited public health activities where
they infringed on individual liberty.
Finally, some Americans may question whether government should be
involved in public health: Can’t private or nonpro#t organizations play the role
■■ Vaccination
■■ Motor vehicle safety
■■ Safer workplaces
■■ Control of infectious diseases
■■ Decline in deaths from coronary heart disease and stroke
■■ Safer and healthier foods
■■ Healthier mothers and babies
■■ Family planning
■■ Fluoridation of drinking water
■■ Recognition of tobacco use as a health hazard
Note: Based on the impact on death, illness, and disability in the United States and not ranked by order of
Source: US Centers for Disease Control and Prevention. (1999). Ten great public health achievements—
United States, 1900–1999.
Morbidity and Mortality Weekly Report, 48(12), 241–243. Retrieved from https://
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130 Part II. Keeping Americans Healthy
that government plays now? In fact, private and nonpro!t organizations do play
important roles, but without government there is no way to address what economists term “market failures” of health care. For example, private physicians lack
the health department’s legal authority to monitor, reach people, and intervene,
and disrupt the spread of sexually transmitted infections, food-borne disease outbreaks, rat infestations, lead poisoning among children, and other many other
problems. In the same way, free markets will not assure adequate water sanitation
systems or housing conditions.
Prevention and Health Promotion at a Population Level
Public health works on prevention at a collective level through health promotion,
changes in policy or law, professional and scienti!c consensus about prevention
e”orts, and recently, by incorporating health considerations in decisions of sectors outside the health care system.
Health promotion addresses behavior and
lifestyle: “the combination of educational and environmental supports for actions
and conditions of living conducive to health” (Green & Kreuter, 2005). Health
promotion often works through schools, businesses, recreational facilities, community associations, and health care settings.
#e U.S. Preventive Services Task Force (2018) uses three long-accepted categories to describe the full array of potential preventive interventions:
■■ Primary prevention, helping people avoid the onset of a health condition, including
■■ Secondary prevention, identifying and treating people who have risk factors or preclinical disease
■■ Tertiary prevention, treating people with an established disease in order to restore
their highest functioning, minimize negative impact, and prevent complications
#ese categories, especially tertiary prevention, obviously spill over into the
medical treatment of individuals, but at a systems or community level, they are
public health issues. Providers need guidance and support to carry them out. In
Table 6.1, we can see the di”erences between individual and collective prevention
for heart disease and stroke. Notice that successful prevention for an individual
(in this case, a person who might have a heart attack or stroke) depends on the
widespread availability of prevention services at a
population level. To understand more about how medical care and public health can support each other, see
the Surgeon General’s National Prevention Strategy:
Planning and Policy at a Population Level
An important U.S. Department of Health and Human Services (DHHS, 2013)
Healthy People 2020, provides a comprehensive review of priority health
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Chapter 6. Public Health: A Transformation in the 21st Century 131
risks, e!ective strategies, and public health focus areas for the nation, each with
many speci”c objectives. #ese areas are updated every 10 years. Progress in meeting the Healthy People objectives has been very uneven; many of the objectives
are quite ambitious (Sondik, Huang, Klein, & Satcher, 2010). Disease prevention
and health promotion are rarely completely e!ective because there are no “magic
bullets” that can prevent 100% of people from becoming sick or being injured.
For example, prevention has greatly reduced the rate of heart attacks, but some
heart attacks still occur. People die in car crashes in spite of safety improvements
that have resulted in lower fatalities overall. Not only is there no magic bullet, but
public health e!orts can’t be “one shot,” either. E!orts need to be maintained over
time. Otherwise, the nation tends to lose some of its health gains. For example
2018 saw increased sexually transmitted infections, likely due in part to pervasive
cuts in health department sta! (see below). Forty-“ve years ago Congress passed
the Safe Drinking Water Act, yet the aging water systems of inner cities contaminate children’s drinking water with lead. Public health problems are not simple
and they adapt over time. For example, we have not “solved” the tobacco problem
if young people use e-cigarettes and then turn to smoking. Such problems need a
combination of activities, so the reader will see lists of activities and responsibilities throughout this chapter. Each activity holds a story in itself.
Universal prevention means that everyone receives an intervention equally,
while targeted prevention involves identifying and serving people at higher risk.
When they are possible, universal approaches are often more e!ective in improving the health of populations. #e case of tra$c safety illustrates these approaches.
People who drive while intoxicated are clearly at high risk of injury to themselves
and others, and targeting drunk drivers improves road safety for everyone. However, universal protections, such as seat belts, air bags, and safer vehicles, contribute

Encourages patients to maintain
healthy weight, be physically
active, and not smoke
Works to establish bike and walking paths and to
eliminate trans-fats from foods, offers smoking quit
lines, advocates for smoke-free public spaces and
higher cigarette taxes, provides prevention guidelines
to medical care providers
Encourages regular checkups for
detecting and treating high blood
pressure, elevated cholesterol,
and other risk factors
Mounts public service campaigns about the
importance of controlling blood pressure and “knowing
your number” for cholesterol, provides guidelines to
medical care providers on diagnosis of blood pressure
and hypercholesterolemia
Treats heart attack to save the
heart muscle, treats stroke
to minimize nervous system
damage, treats atherosclerosis,
restores function, and prevents
recurrence through cardiac
rehabilitation and medication
Provides guidelines on treatment to medical care
providers, creates widespread awareness of the
symptoms of heart attack and stroke and the need to
seek help quickly to save the heart muscle, teaches
CPR, locates automated external defibrillators in public
places and worksites, establishes effective emergency
systems, sponsors patient support groups

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132 Part II. Keeping Americans Healthy
much more to reducing tra!c fatalities and injuries because they help everyone,
even those who never encounter a drunk driver (NHTSA, 2017).
Targeted prevention is an important focus for public health when the risk is
prevalent and when there are e”ective means to identify and treat it. For example, a
national campaign in the 1970s led to improved identi#cation and treatment of people
with high blood pressure. $is in turn greatly reduced premature death and disability
from cardiovascular disease (CDC, 2011). However, an initial goal was to make sure
that providers screened
all their patients for high blood pressure, a universal strategy
with a population focus. Combining both universal and targeted strategies can have
a cumulative bene#t. A balance of targeted and universal approaches is important to
avoid stigma or victim blaming of people at risk and to address health equity.
Increasing Focus on Health Equity
A term related to targeted prevention is health equity, meaning actions to eliminate health disparities or inequalities. As seen in Chapter 8, health disparity “is a
di”erence in which disadvantaged social groups—such as the poor, racial/ethnic
minorities, women, or other groups who have persistently experienced social disadvantage or discrimination—systematically experience worse health or greater
health risks than more advantaged social groups” (Braveman, 2006, p. 167). In
order to increase consensus about health equity, the Robert Wood Johnson Foundation provided this de#nition: “Health equity means that everyone has a fair and
just opportunity to be healthier. $is requires removing obstacles to health such as
poverty, discrimination, and their consequences, including powerlessness and lack
of access to good jobs with fair pay, quality education and housing, safe environments, and health care” (as cited in Braveman, Orleans, Proctor, & Plough, 2017,
para. 1). Health equity may address immediate and concrete issues, like safe tra!c
crossings in poor neighborhoods, or it may address “upstream” social determinants of health, like a”ordable housing and minimum wage. Health equity appeals
to social justice, but also supports the utilitarian focus on a healthier workforce.
Health equity is not a zero sum game with winners and losers, however. Disparities
are sometimes reduced when the majority population gets sicker—for example the
reduced life expectancy of middle-age Whites in recent years. But health equity is
never intended to impair other people’s opportunities to be healthy.
Definition of Core Functions
Public health serves three core functions, as seen in Figure 6.2, to solve health
problems at a population level (Institute of Medicine, 2002). Assessment of public health problems involves understanding their prevalence, severity, and causes,
using various well-tested statistical tools. While private and nonpro#t organizations often do such assessments, public health agencies have the primary
responsibility for surveillance of
population health status, monitoring of disease
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Chapter 6. Public Health: A Transformation in the 21st Century 133
Source: Centers for Disease Control and Prevention. (2013). !e public health system and the 10 essential
public health services. Retrieved from
essentialhealthservices .html
The 10 Essential Public Health Services describe the public health activities that all communities should
undertake and serve as the framework for the National Public Health Performance Standards (NPHPS)
instruments. Public health systems should:
Monitor health status to identify and solve
community health problems.
1 2 3 4 5 6 7
Diagnose and investigate health problems
and health hazards in the community.
Inform, educate, and empower people
about health issues.
Mobilize community partnerships
and action to identify and solve
health problems.
Develop policies and plans that
support individual and community
health efforts.
Enforce laws and regulations that
protect health and ensure safety.
Link people to needed personal health
services and ensure the provision of health
care when otherwise unavailable.
8 Ensure competent public and personal health care
9 Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
Research for new insights and innovative solutions to health problems.
Diagnose &

Develop Partnerships

Link to/
em M
trends, and analysis of the causes of those trends and points for intervention. As
seen in the !nal section, the assessment function is undergoing dramatic changes
in resources, technology, and even reframing of public health problems as direct
action on the social determinants of health.
The second core function,
policy development, is to create and advocate
for solutions to achieve public health goals. Formal policy development
includes devising laws and regulations to protect the public, as in the case of
environmental protection; funding and reimbursement for specific services
such as child immunizations; prohibiting smoking in public places; voluntary
agreements, such as businesses taking excess sugar out of the food supply;
and setting guidelines or standards for services or practices, such as laboratory testing for infectious diseases. However, policy development can also
involve multisectoral changes and agreements in communities, business,
health care, or nonprofit organizations. For example, tax credits may help to
finance a new supermarket in an underserved area so that people have access
to fresh fruits and vegetables. However, the community still needs to find an
operator who understands the business and will take the risk of opening the
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134 Part II. Keeping Americans Healthy
supermarket, the city needs to facilitate through zoning, the extension service
may put on cooking demonstrations to familiarize people with the produce,
the Supplemental Nutrition Assistance Program (SNAP) may provide twofor-one offers on produce, faith-based organizations may publicize the new
market, and so on.
!e third core function, assurance, involves enforcement of policy, as with
inspection of restaurant sanitation or nursing home safety; monitoring legal
compliance, as with smoke-free indoor air laws; ensuring proper implementation of necessary services, such as supervision of home visits to new mothers in
disadvantaged communities; and adequate crisis response, as when public health
allocates resources, trains, and drills to prepare for natural disasters.
In order to ful”ll all three core functions, public health departments are highly
dependent on other organizations and individuals. For
assessment, public health
relies on medical care providers, “rst responders, and others to provide the necessary data on births, deaths, reportable diseases, and environmental hazards. For
policy development, it relies on advocates, policy makers, businesses, and community collaborators who share a common interest in public health goals. For assurance, it relies on complementary health care
services and compliance with standards and
regulations. Public health agencies do not
have the legal authority, “nancial capability,
or personnel to address all health problems
by themselves.!ey need to collaborate with
other organizations that have the power,
in#uence, and resources to achieve better
population health outcomes, for example, in
promoting worker safety, assuring safe food,
or building bicycle and pedestrian-friendly
streets for physical activity.
Core Functions: An Example
!e following example, concerning the birth defect spina bi”da, illustrates the
cyclical problem-solving approach used in public health (see Figure 6.2 and www.”da/data.html). Di$erent types of assessment, policy
development, and assurance issues emerge during this cycle.
1. Monitor the problem: Spina bi”da is a neural tube defect that develops in the “rst 3 to
4 weeks of pregnancy, when the “neural tube” that will form the spine does not close
properly. In its most severe form, spina bi”da leads to leg paralysis, bowel and bladder control problems, and, without treatment, mental retardation. Spina bi”da a$ects
3.05 out of every 10,000 live births
2. Diagnose and investigate causes: !e CDC projects that 50% to 70% of spina bi”da
cases can be prevented if women take enough folic acid (a B vitamin) before and during
pregnancy. Folic acid is most e$ective in promoting healthy neural tube development
Public health agencies do
not have the legal authority,
financial capability, or personnel
to address all health problems
by themselves. They need
to collaborate with other
organizations that have the
power, influence, and resources
to achieve better population
health outcomes.
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Chapter 6. Public Health: A Transformation in the 21st Century 135
when taken before pregnancy and during the critical !rst weeks. For this reason, CDC
recommends that, even
before they become pregnant, women take a multivitamin with
400 mg of folic acid every day and eat foods rich in folic acids
(policy development).
3. Develop policies: Unfortunately, women may not know they are pregnant until the
defect has developed, as roughly half of all pregnancies are unintended. Also, foods
that naturally contain folic acid may not be readily available to the poor or to individuals eating certain diets
assessment. One alternative is to fortify common foods with
folic acid. Since 1998, the government has required that enriched cereal, pasta, #our,
and bread products include folic acid
(policy development).
4. Enforce laws and regulations: $e USDA enforces folic acid requirements. WIC
centers must give pregnant women nutrition education and provide the enriched
foods (see and DietRelated; Outcomes);
5. Evaluate effectiveness: After the forti!cation requirement began, the rate of spina
bi!da in the United States declined by 31% from the rate before the policy
6. Diagnose and investigate: Many scientists believe we could prevent more cases of spina
bi!da if new regulations increased the amount of folic acid in grain products. $e USDA
now requires folic acid in corn masa (for tortillas);
(policy development, assessment).
If people think about public health at all, they often think of federal agencies such
as the CDC, which issues public guidance on prevention and warnings about the
#u season. $ey might also think about the Environmental Protection Agency
(EPA) for hazardous waste cleanup or NIH for the basic science, as in the case of
folic acid. However, it is the states that have primary authority for public health,
under the 10th Amendment to the U.S. Constitution. In contrast, the Constitution recognizes tribes as sovereign nations and designates federal responsibility for
their health. $us, we begin with state and tribal law and state health departments.
State Authority for Public Health
State law. $e 50 states vary greatly on how they de!ne and delegate public
health authority and responsibility. States enacted public health statutes over
time to respond to speci!c diseases or health threats. $ese laws are fragmented
and often have not kept up with developments in science, practice, or societal
change, so public health law has become a powerful force to improve e%ectiveness (Institute of Medicine, 2011). For example, some state laws have separate
sections for speci!c communicable diseases, instead of standard approaches
to address infectious disease in general. $is fragmentation leaves them with
no standards for addressing new infectious diseases, advances in public health
practice, and changes in constitutional law. State laws need updating to permit
new multisectoral health promotion e%orts—for example, collaborations among
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136 Part II. Keeping Americans Healthy
public health, transportation, and parks and recreation to encourage more physical activity. State laws may also neglect important safeguards for privacy, due
process, and protection from discrimination. One proposal, the Model State
Public Health Act, was to modernize the entire body of states’ public health laws.
While the Model Act itself did not have much uptake, parts of its subject matter
have been featured in many new state bills and laws (Hodge, 2012; Institute of
Medicine, 2011). !is kind of incremental policy change is typical in the United
States. !e Network for Public Health Law provides states with legal technical
assistance that is usually more topical and less comprehensive than the Model
Act (
Other improvements are needed for problems that cross state lines. Chief
among these are problems arising from human-made and naturally occurring
events such as the anthrax attacks in the fall of 2001, the increase in devastating hurricanes and other severe weather events since 2005, the 2009 H1N1
in”uenza pandemic, and the 2014 Ebola outbreak. !ese events underscored
the need for legal reforms to enhance public health emergency preparedness by
addressing a variety of issues, including (a) declaring public health emergencies
separate from other types of disasters; (b) expediting public health powers such
as those needed to collect health data, to screen, vaccinate, or treat exposed
people, to seize property to abate hazards, or to isolate or quarantine residents;
(c) recruiting and deploying trained health professional volunteers; and (d) providing liability protections to health professionals and entities, among others
(Hodge, 2012). As of 2015, 34 states and Washington, DC, incorporated “public health emergencies” or similar terms in their statutes (Network for Public
Health Law, 2015).
State health departments. In 2016, 29 state health departments were freestanding as separate agencies, while 21 states combined public health into umbrella
agencies with related programs, such as Medicaid, human services and welfare,
mental health and substance abuse, or environmental management. !e website of the
Association of State and Territorial Health Officers (ASTHO, www provides a wealth of detail on the characteristics and #nancing of state
health departments.
A state’s chief health o$cial directs the department of public health and may
report directly to the governor or to an o$cer in the governor’s cabinet. !e
state health department’s position in the chain of command and the governor’s
priorities a%ect the authority and power of its director. Medicaid and other state
public assistance programs tend to garner most of a governor’s attention because
of their cost—sometimes Medicaid is part of the state health o$cer’s authority,
but usually not. !ese other programs can a%ect public health drastically given
the social, economic, and environmental determinants of health. !e ways various health-related functions and programs are organized a%ects how well public
health activities can be coordinated. For example, environmental protection is
often located in another agency outside the health department, in which case
conservation, wilderness preservation, or litigation around toxic spills may head
that agency’s agenda. !is situation often leaves less opportunity for e%ective
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Chapter 6. Public Health: A Transformation in the 21st Century 137
interaction with the health department, even though it must monitor potential
health consequences of environmental exposures.
Tribal public health. !ere are 565 federally recognized tribes, with additional tribes recognized by state governments. Each tribe has a distinct language,
culture, and governance structure. Tribal governments are sovereign nations and
have a government-to-government relationship with the federal government that
the U.S. Constitution, Supreme Court decisions, treaties, and legislation established. Tribes gave their land and natural resources to the federal government in
exchange for education, health care, and other services.
Since 1955, the Indian Health Service supports and delivers health care and
public health services to American Indians and Alaska Natives. Tribes may provide
public health services together with federal agencies, local and state health departments, Tribal Epidemiology Centers, and other private or public third parties. !e
nature and extent of these partnerships vary by tribe, region, and type of service.
Tribal sovereignty and federal, state, and local agreements with tribes are particularly important when it comes to understanding policy and law across a wide
range of public health issues—from injury and harm prevention, to environmental
health, to animal control, to health services—and why tribal public health codes
are important to recognizing tribal authority, honoring tribal culture, coordinating public health responses across jurisdictions, and ensuring adequate resources.
Intergovernmental Relations
Federal–state relations. Although the states have constitutional authority to
implement public health, a wide variety of federal programs and laws a”ect their
work. Federal law relating to public health preempts state laws, just as state law
preempts local laws. However, tribal governments are sovereign nations so that
tribal law supersedes all but federal laws. Preemption a”ects public health because
the federal government can require minimum protections below which states
cannot go—a “#oor preemption.” For example, the Clean Water Act requires a
minimum standard for water in all states, although states are allowed to have
more stringent standards. But “ceiling preemption” can pose an obstacle to prevention when states and localities are more aggressive than the federal government. For example, the tobacco industry challenged state and local regulation of
tobacco in the courts citing less stringent federal regulations. Preemption of local
law plays out the same way, as in recent local e”orts to prevent childhood obesity by limiting junk food and sugar-sweetened beverages. Ten states have passed
preemption laws to prohibit such local e”orts at the behest of food and beverage
companies (Dana & Nadler, 2018).
1 For more information on the organization of tribal public health, see
docs/07012010/NIHB_HealthProfile%202010.pdf and
2 For more information on policies relating to tribal public health, see
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138 Part II. Keeping Americans Healthy
!e federal agencies working in public health are described in Chapter 3.
States must constantly interact with these federal agencies. For example, DHHS
supports state health departments with grants and technical assistance for
maternal and child health and preventive services, child welfare services, substance abuse treatment and prevention, and mental health services. DHHS also
funds the states to train the public health workforce. CDC provides grants and
cooperative agreements to states, cities, and community-based organizations for
HIV prevention, chronic disease control, and improving state and local infrastructure (see below). USDA provides health departments with direct support
for food assistance and nutrition education. EPA provides direct resources to
the states for environmental management. Most of these funding streams are
categorical—that is, the funding is intended for speci”c categories of people or
special purposes. Congress authorizes categorical funding to address a speci”c
health problem, such as preventing AIDS or addressing bioterrorism. However,
categorical funding limits states’ #exibility to deliver a range of relevant services
with available resources. Block grants o$er greater #exibility to states; however,
Congress often reduces block grant funding over time.
Delegation of state authority to local health departments. States vary in
terms of the authority they give to local governments and local public health
departments. In 2016, 14 states had centralized public health departments, meaning that employees of the state led the local health units, and the state retained
authority over many decisions relating to the budget, public health orders, and
the selection of local health o%cials. Health departments were decentralized in
27 states: Local governments made many decisions and sta$ed the local health
units. Four states shared authority, decision making, and employment with local
governments. !e remaining “ve states were mixed, meaning that some features
were centralized while others were shared or decentralized.
National Association of County and City Health Officials (NACCHO)
website ( o$ers further detail on the wide variety of organizational arrangements, responsibilities, “nancing, sta%ng, and authority of the
estimated 2,533 local health departments. One reason for this variety is simply
historical. !e “rst public health agencies were formed in the early 1800s and
were primarily city based. Later in the 19th century, state health agencies began
to form. !roughout the 20th century, county health departments developed.
One can see the e$ects by comparing older states to states admitted to the union
more recently: Massachusetts had 328 local boards of health in 2016,
3 while Oregon4 had 34 county health departments (NACCHO, 2017b).
Collaboration among federal, tribal, state, and local health departments. Health departments are exploring ways to coordinate public health
responses and share services, functions, and sta$ across jurisdictional boundaries. From “handshake agreements” to more formal memoranda of understanding
3 A 2016 Massachusetts law may lead to consolidation of local health departments over time.
4 Oregon has about half the population of Massachusetts but almost 10 times the land area.
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Chapter 6. Public Health: A Transformation in the 21st Century 139
to consolidations and mergers, these sharing arrangements often seek to balance e!ectiveness and e”ciency in assuring the core public health functions
(NACCHO, 2017b).
Local, state, tribal, and federal agencies all have strengths and resources for
public health. States, tribes, and localities usually understand their own problems best and how their context a!ects services. Meanwhile, the federal government has greater resources and scienti#c expertise for tackling large and complex
health threats. $e CDC, for example, leads the investigation of serious disease
outbreaks, such as in%uenza, and makes recommendations for both clinical and
community prevention. $e federal government also steps in when health threats
cross state borders, or when states cannot comply with federal regulations, o!ering technical assistance and #nancial support.
Public Health Services
State responsibilities. $ese generally include disease and injury prevention,
sanitation, controlling water and air pollution, vaccination, isolation and quarantine, inspection of commercial and residential premises, food and drinking water
standards, extermination of vermin, %uoridation of municipal water supplies, and
licensure of physicians and other health care professionals. However, the speci#c
activities and services provided vary widely across states and localities. For example, tribal, state, and local health departments work to prevent chronic disease,
but their approaches focus to varying degrees on education, social marketing, or
policy and environmental changes (see Chapter 7).
10 essential services. In the face of this variation, most public health professionals agree that all health departments should provide the 10 essential services
listed in Figure 6.2. Many health departments are challenged to provide these services on their own, given their resource and sta”ng limitations. For example, most
local health departments are small and rural, with 62% serving fewer than 50,000
people, and usually have 15 or fewer full-time sta!. Many health departments have
weak sta! capacity in some of the 10 essential services, and higher education is not
providing the appropriate training. Many experienced professionals are on the verge
of retirement, and replacements are in short supply given the low salaries and rural
location of many local health departments. Many health departments are thinking
creatively about how to meet these challenges, the topic of the #nal section.
Public health emergencies. Since the 2001 anthrax attacks, public health
agencies have faced the added responsibility of protecting the public against bioterrorism threats and other communicable disease emergencies. $e 2018 %u
season was severe, and experts believe that we may soon experience one like the
1918 pandemic that killed an estimated 675,000 U.S. residents. Diseases spread
much more quickly than they did in the past because of international travel, urban
overcrowding and poverty, climate change, and misuse of antibiotics that produce multiple drug-resistant infections. Interventions include global surveillance
networks, stockpiles of vaccines, and better communications and data sharing to
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140 Part II. Keeping Americans Healthy
deal with outbreaks. Although preparedness is much better than in 2001, a recent
study found that 28 states had inadequate policies and capabilities to protect
against threats from communicable diseases (Trust for America’s Health, 2015).
New training, competencies, and accreditation. In 2011, national voluntary performance standards were created for public health agencies, with development, re!nement, and review by the Public Health Accreditation Board
(PHAB). Among departments that had been accredited for at least 1 year, a recent
survey found that over 90% believed that their departments had better opportunities for quality and performance improvement, were better able to identify strengths and weaknesses, had better accountability and transparency, and
had better management practices (Kronstadt et al., 2016). At the end of 2017,
31 states, 1 statewide system of many local departments, 1 tribal, and 179 (7%)
local health departments were accredited, while 158 were seeking accreditation.
Accredited departments serve about 66% of the U.S. population. “e PHAB website gives updates on progress and details of the accreditation standards (www PHAB also developed a consensus set of core competencies for
public health practice at entry, supervisory, and executive levels. Movement to
upgrade the competence of individual public health workers is seen in new management academies, continuing education, and certi!cate programs (Schae#er,
Schultz, & Salerno, 2009).
Government agencies are important, but they are really only part of the public
health infrastructure. Moreover, government is shrinking in the early 21st century. Champions of the public’s health are meeting this challenge by working
in new ways, communicating more e#ectively with the public, advocating for a
wider variety of policies that a#ect health, and engaging new partners that are
vital to achieving public health goals.
Shrinking government. According to
ASTHO and NACCHO, state and local
health departments were hit hard by the
recession of 2008–2010, with job losses
totaling about 20% of the total public health
workforce. During the recession, nearly
every health department reported making
cuts to programs and services, and the following decade saw continued, severe cuts in
sta$ng and programs. State public health
spending has been mostly level since 2010,
Champions of the public’s health
are meeting this challenge
by working in new ways,
communicating more effectively
with the public, advocating for
a wider variety of policies that
affect health, and engaging
new partners that are vital to
achieving public health goals.
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Chapter 6. Public Health: A Transformation in the 21st Century 141
with median spending of $31.62 per capita (Segal & Martin, 2017). Yet in the
future, these agencies will need to do even more to manage new disasters and
epidemics, meet the standards of accreditation, and achieve health equity. Both
national developments and creative partnerships at the regional, state, and local
level may help to meet this challenge.
Wide swings in federal support. Under the Obama administration, the
American Recovery and Reinvestment Act of 2009 provided $650 million for prevention activities, and ACA authorized $15 billion over 10 years for the Prevention
and Public Health Fund. Almost from its inception, however, Congress reduced the
Prevention Fund to pay for various o”sets in the federal budget, and the February
2018 budget deal cut $1.36 billion from the fund. Although there have been a few
budget victories, current debates continue to challenge public investments in public health. #e American Public Health Association (APHA) website (www.apha
.org) gives updates on the Fund and other federal support for public health.
#e Obama administration aimed to augment planning and coordination of
prevention across sectors. For example, childhood obesity prevention e”orts
spanned the USDA, CDC, NIH, and Department of Education (Institute of Medicine, 2012). All cabinet-level agencies came together to develop and execute the
National Prevention Strategy through the National Prevention Council. A Surgeon
General’s report outlined how medical care and public health could support each
other ( Only
time will tell how political changes will alter these and other federal coordination
e”orts. At the state and local levels, however, there is a growing realization that
public health must rely on the range of partners with power and resources and
across a variety of sectors to bring about needed changes in the conditions that
a”ect the quality and length of people’s lives.
Public health institutes. As de$ned by the National Network of Public Health
Institutes (, these institutes are “nonpro$t organizations dedicated to advancing public health practice and making systematic improvements
in population health … [they] emerged as a complement to governmental public health systems for addressing the most pressing current and emerging public
health issues.” #e website for the National Network provides details on the 44
institutes and related services in all 50 states as well as tribal communities (www As
nongovernmental organizations, they can accept private funds,
leverage funding from multiple sources, and serve as $scal intermediaries for
health departments to speed the delivery of services and processes (e.g., hiring
sta” and buying supplies or equipment). Institute sta” can advocate vigorously
for public health programs and funding, whereas government employees have
restrictions. Institutes can o”er a credible, neutral, third-party voice on issues
and can convene all the interested parties to address a broad health problem and
implement a multisector strategy.
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142 Part II. Keeping Americans Healthy
A new role for the health care sector. For more than 40 years, many local
health departments provided direct health care services, leaving fewer resources
to improve the health of
populations. !e ACA aimed to free up these resources
by insuring many more people, who may choose providers other than the health
department. Some health departments explored ways to divest their primary
care services to other community providers while still ful”lling their duties to
assure health care in their jurisdictions, especially for vulnerable populations
(Kuehnert & McConnaughay, 2012). Where they continue to provide health
care services, health departments are now able to collect third-party reimbursements, collections they have not had to do or been able to do historically.
ACA also alleviated pressure on health departments by giving incentives for
providers to work in underserved areas and by reimbursing private plans for
essential prevention services, such as vaccinations and screening, if the plans
meet federal standards.
At the same time, hospitals and health care systems have started to develop
strategies for population health, often in collaboration with health departments
and other community organizations. Hospitals’ interest extends to the whole sector, including for-pro”t hospitals like Humana. Nonpro”t hospitals are required
to satisfy their community bene”t obligations under the ACA by conducting a
Community Health Improvement Plan and aligning their community investments to this plan. Safety-net hospitals have incentives to keep their populations
well, given new reimbursement models, such as those that limit reimbursement
of preventable readmissions to the hospital. An American Hospital Association
survey (Health Research & Educational Trust, 2016) documented its members’
interest in better prevention as well as the highest priority needs their communities were experiencing. !e American Hospital Association also reported on
actions that leading hospitals were taking to address community health needs
beyond their walls, such as Sitka, Alaska’s work to become nationally recognized as a walk-and-bike friendly community, and Fort Worth, Texas’s e#orts to
improve parenting skills and reduce family violence (Health Research & Educational Trust, 2016, 2017).
New resources for assessment. As part of their federal community bene”t requirements, nonpro”t hospitals must conduct community health needs
assessments once every 3 years. !ese assessments aim to engage multisectoral
community coalitions to identify priority needs (
Some states require additional activity. Also, PHAB accreditation sets health
department standards for more consistent and high-quality assessment. New
data sources such as electronic health records, shared and linked databases, “big
data” analytics, and techniques like geographic information systems (GIS), allow
rapid response to potential public health emergencies. Equally important, however, they help policy makers and community coalitions to understand health
di#erently, including opportunities to promote health and reduce health disparities. For example, GIS makes it possible to design communities proactively
to prevent obesity (Institute of Medicine, 2012) or reduce triggers for asthma
(e.g., Propeller Health at
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Chapter 6. Public Health: A Transformation in the 21st Century 143
Effective Communication and Advocacy
Putting the public back in public health. Champions of the public’s health need
to build a constituency that understands public health’s value, in order to create
coalitions, gain allies to solve public health problems, and advocate e!ectively for
solutions to improve health and achieve health equity. “e general public does not
understand public health, often supposing it refers solely to programs for the poor.
“e public—and policy makers—react to speci#c problems and crises. “ey do not
see the disease cases, injuries, disabilities, and deaths that have been prevented.
When an eroded infrastructure hinders crisis response—such as when the 2001
anthrax episode overwhelmed many public health laboratories or after Hurricane
Katrina, when even such a basic function as handling the dead broke down—they
do not understand why the problem is not
solved quickly. In reality, public health is
often invisible because it is generally so e!ective. With this in mind, how can public health
develop an e!ective public constituency?
Building and maintaining trust. Public health practitioners sometimes can
be seen as authoritarian or paternalistic, especially when they stress science and
technology (“what’s good for you because science says so”) while ignoring collaboration, community history, democratic processes, and people’s preferences. “is
tendency weakens their connections to grassroots groups and local leadership and
limits input from (and active listening to) their constituents. “e last years of the
20th century heightened public awareness of the need for a new form of leadership
in public health—one that engages people on their own terms, in order to engender
trust and cooperation. For example, the EPA learned to work with communities
a!ected by toxic contaminants. But in the early days, it did not listen to the public
about their concerns, did not provide the information they needed, or gave them
incomprehensible “techno-babble” that enraged community leaders (Leviton
et al., 1997). “e old bureaucratic ways of doing business were simply not e!ective when people had legitimate concerns.
“e most di$cult lesson for public health came from the Tuskegee Syphilis
Experiment (Jones, 1993). In 1932, 600 poor African American men in Macon
County, Alabama, unknowingly became syphilis research subjects when the Public Health Service and the Tuskegee Institute began a study of the natural course of
syphilis and o!ered the men “free medical care.” Of 600 subjects, 339 had syphilis
but were left untreated for up to 40 years, even though a penicillin cure became
available in 1947. As many as 100 of the men died of syphilis, and many more suffered long-term disabilities before a public outcry and a federal advisory panel’s
recommendations halted the study in 1972. Along with the Nuremberg Code on
medical experiments, this episode led Congress to require new protections for
participants in human research. In 1997, President Bill Clinton o!ered an o$cial
public apology to the Tuskegee Study’s eight survivors and participants’ families.
However, public health—and the health care system more generally—never fully
regained African Americans’ trust.
How can public health develop
an effective public constituency?
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144 Part II. Keeping Americans Healthy
More effective voices. ASTHO, NACCHO, and APHA o!er important communication tools to increase e!ectiveness in advocating for policies and resources
at state and local levels. Public health also has advocates such as the Trust for
America’s Health (, which draws attention to speci”c
health problems—what Americans generally respond to—and ties these issues
to the need for better public health infrastructure and investment. #e Trust has
also been able to bring together diverse constituencies interested in similar kinds
of health protections to amplify the collective message about these issues. #e
County Health Rankings and Roadmaps ( convey a snapshot of the health and well-being of counties within each state. #ese
rankings have been found to attract the interest of policy makers and the public, and stimulate community discussions and collaborations to improve health
(Wandersman, Osher, Winfrey, et al, 2018).
Advocacy in public health generally has a two fold purpose. It aims to
strengthen public health resources and infrastructure, but also to make changes
that health departments cannot make on their own. For example, advocates outside government have worked for many years to strengthen laws and regulations
on issues such as newborn screening and lead remediation. Nongovernmental
advocacy led to increased taxes on cigarettes and smoke-free indoor air laws,
both of which discourage smoking (Center for Public Program Evaluation, 2011).
To help prevent childhood obesity, public health advocates work to change state
and local policies to require healthier foods and beverages in school and childcare, o!er more opportunities for physical activity, and “nance new supermarkets in underserved areas (Robert Wood Johnson Foundation, 2017).
Public health advocacy deals with a wider range of topics today than ever
before. Because health is rooted in a wide variety of social and economic conditions, the “eld advocates for the principle of “health in all policies.” In this
approach, health advocates engage policy makers across various sectors to make
sure that decisions will promote, or at least not adversely a!ect, health. #e state
of California, for example, has established a Health in All Policies Task Force
(Caplan et al., 2017) to help the state’s Strategic Growth Council achieve its goals,
including “improving air and water quality, protecting natural resources and agricultural lands, increasing the availability of a!ordable housing, improving infrastructure systems, promoting public health, planning sustainable communities,
and meeting the state’s climate change goals”—all tied to the health of the state’s
Health impact assessments (HIAs) help policy makers and community
leaders to identify the health impacts of decisions about nonhealth issues, such
as economic development, housing, and transportation plans. #e HIA is a structured process to gather, analyze, and present scienti”c data, health expertise, and
public input to a public policy body so that policy choices can be made that will
protect or promote health. HIAs have been used e!ectively around the world and
have become more widespread in the United States over the past nine years with
the development of the Health Impact Project (
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Chapter 6. Public Health: A Transformation in the 21st Century 145
The Case for Multisector Collaboration
!roughout this chapter, we have attempted to show the many ways in which a
wide variety of organizations take on the public health role when they focus on
populations. !is approach means that other interests can align with the public
health mission. For example, walkable communities can appeal to real estate developers, city planners, public health practitioners, and advocates—all for somewhat
di”erent reasons. Across the nation, community coalitions are reframing suburban sprawl as something that discourages physical activity and therefore has consequences for people’s health. Likewise, community violence is framed as a public
health problem as well as a problem for community and child well-being, business development, public safety #rst responders, and hospitals. And employers
and public health advocates alike see advantages to workplace health promotion,
smoke-free campuses, and employment policies such as paid family and sick leave.
Pro#le data from 600 health department managers indicate that managers
are more e”ective when they know how to collaborate across sectors (Altman,
2007). Collaboration means they can access other organizations’ power, connections and resources. Given its importance, PHAB is developing standards for
multisector collaboration. Tribal, state, and local public health departments have
always connected to grassroots leadership and other public services in order to
solve collective problems. However, their leadership abilities for multisector collaboration are now being cultivated as never before in what has become known as
the collaborative leadership approach or collective impact. Collaborative leadership means understanding where public health shares common goals with other
interest groups and building coalitions based on those common interests. In the
same way, public health organizations are now participating more e”ectively in
emergency preparedness and in health care reform because they can show where
the public health interest is aligned with national defense and preparation for
natural disasters, on the one hand, and health care quality and cost containment,
on the other.
!e leadership of coalitions cannot simply be left to health departments,
however. In underresourced communities, leadership may come from hospitals, nongovernmental organizations, or even business. An important vehicle for
coalition building is the 100 Million Healthier Lives Campaign (www.100mlives
.org), which strives to achieve the Triple Aim: maximizing population health and
patients’ experience of care while reducing the per capita cost of care.
Conditions in our communities, our homes, and our workplaces a”ect our health
and determine whether all people have a fair opportunity to achieve their best possible health. Enabling these conditions is just too big for governmental public health
to take on alone and certainly too big for health care service providers. Instead,
across sectors like housing, transportation, education, and economic development,
we need to consider the health e”ects of our decisions. !ere are glimmers where
this is already happening, for example, with the Culture of Health Prize (www.rwjf
.org/prize). But the glimmers need to become beacons if we as a nation are going to
shift from focusing on treating people who are sick to keeping people well.
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146 Part II. Keeping Americans Healthy
Public health di!ers from individual health care by focusing on entire populations
and designing policies, systems, services, and environments to achieve not only
the absence of disease, but a complete sense of well-being. If public health goals
are to be met, however, some changes are needed: (a) a greater consensus that
the health of the individual is important to the community and society, (b) more
e!ective ways to address the upstream social determinants that are at the root
of today’s health problems and disparities in health outcomes, (c) more comprehensive approaches to addressing population health problems, and (d) a focus
on multisectoral collaborations because government cannot do it all. Sometimes
government must lead, and sometimes it must follow, but in the future, we will
#nd governmental public health departments walking hand in hand with their
many partners and building on the assets of the communities it serves to preserve
and protect the public’s health.
You are an analyst for a federal agency. Congress has ordered your agency to come up with
policy options to find a cure for birth defects. You recognize that (a) birth defects have many
causes, (b) some can be treated, (c) some can also be prevented, but (d) not all of them can
be “cured.” You analyze this issue using the core functions of public health and the problemsolving process outlined under Core Functions of Public Health.
Based on the information about spina bifida in this chapter, you decide it should be the
focus for policymaking on birth defects. You decide to propose four options to Congress: more
research on treatment of spina bifida, more health education for women about folic acid, more
promotion of birth control to reduce the proportion of unplanned pregnancies in the country,
and new regulations to increase the amount of folic acid in grain products. You may also see
other options, so be sure to discuss them!
1. For each option, what would you need to know to determine effectiveness? Costeffectiveness?
2. What are the tradeoffs in each course of action?
3. Who would support this option, who would be opposed, and does it matter?
4. Is there a single best option? Why?
1. What examples of public health and prevention can you identify in your daily life?
How do you believe they have a!ected your health?
2. Pick two such examples in either your own life or the text; then research which federal
laws and agencies, state laws and agencies, local health departments, nonpro#t organizations, or city and county government units a!ect this aspect of your health. $e
more complete your answer, the better your answer is!
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Chapter 6. Public Health: A Transformation in the 21st Century 147
3. What is the di!erence between individual- and population-based prevention e!orts?
For population-based prevention, what is the di!erence between universal and targeted strategies?
4. What does a population focus take in terms of planning, consensus building, and
resources for implementation? In the case of safety belts? Heart attack prevention?
5. Why can’t public health do more to achieve its goals? Name some of the political,
legal, logistical, and resource challenges.
6. What should be left to the public sector to do, to achieve public health goals? Where
could the private sector do more to help? Why?
7. Give some examples of the constituencies that public health will have to reach in
order to implement its goals in the case of chronic disease prevention and in the case
of childhood immunizations. How are the constituencies similar or di!erent for these
8. How would you personally balance individual liberty, the common good, and social
justice in public health? What would have to change to achieve this balance? Give
speci”c examples in the area of public health you are best acquainted with.
9. In what ways might public health build a stronger constituency?
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Network Engagement

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Health and Behavior
Brian Elbel, Elaine F. Cassidy, Matthew D. Trujillo,
and C. Tracy Orleans
Learn about the contributions of personal health practices (e.g., tobacco use, risky
drinking, physical activity, diet, obesity) to individual and population health status
Understand how strategies for changing individual and population health
behavior have evolved, and identify the targets and characteristics of effective interventions
Learn about the social, policy, and environmental determinants of healthy and
unhealthy behaviors and the disparities and inequities in exposure to them
Understand models and prospects for addressing behavioral risk factors
through national health care quality improvement efforts and health reform
Describe provider-oriented interventions for changing individual and population health behavior and their influence in achieving national health care
quality objectives
behavioral risk factors
chronic care model
energy balance equation
practice ecology model
quality improvement
social determinants of health
social ecological models
social marketing strategies
© Springer Publishing Company DOI: 10.1891/9780826172730.0007
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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AN: 1998657 ; James R. Knickman, PhD, Brian Elbel, PhD, MPH.; Jonas and Kovner’s Health Care Delivery in the United States, 12th Edition
Account: s3563253.main.ehost

152 Part II. Keeping Americans Healthy
Behavioral risk factors: overview and national goals
Changing health behavior: closing the gap between recommended and
actual health lifestyle practices
The role and impact of primary care interventions
Multilevel models for population-based health behavior change
Changing provider behavior: closing the gap between best practice and
usual care
Health care professionals, who live in a world in which often heroic e!orts are
needed to save lives, can easily believe that medical care is the most important
instrument for maintaining and ensuring health.
“is chapter explains, however, that behavioral
choices—and the social, environmental, and policy factors that in#uence them—are key determinants of Americans’ health and well-being.
To some extent, the task of helping people adopt healthy lifestyles falls into multiple
realms, including behavioral psychology, public health, and even social marketing. However,
current models for shaping healthy lifestyles
include major roles for medical providers and the
health care systems in which they practice. “erefore, clinicians, health care payers, managers of provider organizations, and health care policy makers need to
understand and address the powerful behavioral determinants of health and illness.
“is chapter begins with a brief overview of the major
behavioral risk factors that contribute to the growing burden of preventable chronic disease in the
United States—tobacco use; alcohol abuse; and sedentary lifestyle and unhealthy
diet, including the joint e!ects sedentary lifestyle and unhealthy diet have on
adult and childhood obesity and overweight. “ere is now voluminous and incontrovertible evidence for the roles these behaviors and risk factors play in shaping
public health, along with growing knowledge of the power of
social determinants of health and health outcomes: education; income; access to safe places to
walk, bike, and play; and healthy a!ordable foods (as noted in Chapters 5 and 6).
“e chapter then describes the progress that has been made over the past
four decades to help adults modify these risk factors by intervening both at the
individual level—with behavioral and clinical treatments that can be delivered
in health care settings—and at the broader population level—with public health
environmental and policy changes and social marketing and media strategies that
Chronic diseases such as
cancer and heart and lung
disease have now replaced
acute and infectious diseases
as the major causes of death
in the United States. Yet a
large part of the burden these
illnesses cause is actually
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 7. Health and Behavior 153
can prompt and support the development and maintenance of healthy behavior.
!eoretical advances (e.g., social learning theory and stage-based and social ecological models) have led to a clear understanding of the need for broad-spectrum,
multilevel ecological approaches, and new science-based clinical and community
practice guidelines have been developed to guide them.
While it is increasingly widely understood that social determinants play a major
role in shaping health and health outcomes multifaceted e”orts have been successful in encouraging clinicians to use proven health behavior change protocols in their
interactions with patients. Many parallels can be drawn between what we have learned
about ways to promote health through individual behavior change and what we have
learned about strategies to improve health care quality through provider behavior
change. Health reform legislation at the local, state, and national levels increasingly
recognizes that the signi#cant progress in both areas holds unprecedented potential
for breakthrough improvements in national health status and health care quality.
Acute and infectious diseases are no longer the major causes of death, disease,
and disability in the United States. Today, chronic diseases—cancer, heart, and
lung disease—are the nation’s leading causes of illness and death (Mokdad et al.,
2018). Given the continued aging of the population, both the prevalence and the
costs of chronic illness care will continue to rise. Yet, much of the growing burden
of chronic disease is preventable.
More than two decades ago, McGinnis and Foege (1993) estimated that 50% of
the mortality from the 10 leading causes of death could be attributed to personal
behavior. A more recent analysis by Mokdad and colleagues (2018) reinforced this
estimate, #nding that tobacco use, high body mass index (BMI), dietary risk, and
alcohol and drug abuse are the four largest risk factors for mortality in the United
States. Moreover, research #ndings over the past two decades have established that
modifying these behavioral risk factors leads to improved health and quality of life
and to reduced health care costs and burden (Orleans, Ulmer, & Gruman, 2004).
Almost 90% of Americans have reported they have at least one of these risk
factors, and 52% have reported having two or more, with the highest prevalence of
individual and multiple behavioral risks occurring in low-income and racial and
ethnic minority groups (Coups, Gaba, & Orleans, 2004). Given these statistics,
it is not surprising that many of the leading health indicators tracked by
People 2020
(U.S. Department of Health and Human Services, 2011)which
updates the nation’s primary objectives for promoting longer, healthier lives and
eliminating health disparities—relate to healthy lifestyles. Although recent analyses suggest that our nation had an uneven record in achieving
Healthy People
(U.S. Department of Health and Human Services, 2000) targets in previous
years (see Chapter 6), more well-rounded improvements across multiple health
indicators are needed in order to advance quality of life and signi#cantly reduce
health disparities (Koh, 2010). Selected indicators for tobacco use, alcohol abuse,
physical activity, diet, and obesity are shown in Table 7.1.
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154 Part II. Keeping Americans Healthy

BASELINE a (%) 2020 GOALS (%)
Tobacco Use
Cigarette smoking
■■ Adults (18 years and older)
■■ Adolescents (grades 9 through 12)
Exposure to secondhand smoke
■■ Children (6 years and younger)
Alcohol Misuse/Risky Drinking
Proportion of adults who drank excessively
during past 30 days
Binge drinking
■■ Adults (18 years and older)
■■ Adolescents (12 to 17 years old)
Deaths from alcohol-related auto crashes
Physical Activity
Regular moderate physical activity
■■ Adults (18 years and older)c
■■ Adolescents (grades 9 through 12)d
Vigorous physical activity
(at least 3 days per week for 20 minutes)
■■ Adults (18 years and older)c
■■ Adolescents (grades 9 through 12)d
Diet and Overweight (Older Than Age 2)
■■ Proportion of people eating at least two
servings of fruit daily
■■ Proportion of people eating at least three
servings of vegetables (at least one of
which is dark green or orange) daily
■■ Proportion of people eating at least six
servings of grain products (at least three
being whole grains) daily
Overweight and obesity
■■ Obesity among adults (aged 20 years and
■■ Overweight and obesity among children
and adolescents (aged 6 to 19)
3 7

a Baseline data extracted from sources between 1988 and 1999.
b Per 100 million vehicle miles traveled.
c At least 30 minutes per day.
d At least 30 minutes 5 or more days per week.
Source: U.S. Department of Health and Human Services. (2011). Healthy People 2020: Understanding and improving health. Washington, DC: Author.
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Chapter 7. Health and Behavior 155
!e past decade of social science, behavior change, and population health
research also has revealed the profound sociodemographic inequities in access
to community-level and health care supports for healthy behavior and health
behavior change (Adler, Bachrach, Daley, & Frisco, 2013). !ese inequities are
powerful drivers of health disparities and threats to the health of the nation.
In fact, the Robert Wood Johnson Foundation’s Commission for a Healthier
America convened in 2013 to emphasize that the nation’s health depends
fundamentally on ensuring equitable access to the supports and resources
needed for making healthy choices in the environments where people live,
learn, work, and play.
Tobacco Use
Tobacco use causes more preventable deaths and diseases than any other behavioral
risk factor, including at least 480,000 premature deaths from several forms of
cancer, heart, and lung disease (U.S. Department of Health and Human Services
[DHHS], 2014). It accounts for annual health care costs of $170 billion, in addition
to an estimated $156 billion in lost productivity costs (Xu, 2014; DHHS, 2014).
Smoking remains the single most important modi”able cause of poor
pregnancy outcomes, accounting for 20% of low birth weight deliveries, 8%
of preterm births, and 5% of perinatal deaths. For infants and young children,
parental smoking is linked to sudden infant death syndrome (SIDS), respiratory
illnesses, middle ear infections, and decreased lung function, with annual
direct medical costs estimated at $4.6 billion. Quitting, even after 50 years
of smoking, can produce signi”cant improvements in health and less use of
health care services.
Although the adult smoking prevalence rate decreased to 15.5% in 2016 (Jamal
et al., 2018), smoking prevalence among adults remains well above the
People 2020
target of 12% (Ward, Barnes, Freeman, & Schiller, 2012). Nearly one
in “ve adults still smokes, with the highest rates (29%) among members of lowincome populations (Centers for Disease Control and Prevention [CDC], 2018).
And even though rates of smoking during pregnancy also have dropped in the
past decade, 10% of women reported in 2011 that they smoked during pregnancy
(CDC, 2017). Vaping and e-cigarette use is also a broad concern, particularly
among youth, with controversy over its potential for harm reduction at the same
time (as noted below).
Each day, more than 3,200 children and teens become new smokers, and 30%
of those young people will become addicted to tobacco (DHHS, 2014). Some 18%
of high school students smoke cigarettes, and more than 8 million Americans,
mostly adolescent and young adult males, report using smokeless tobacco, which
is linked to oral cancer, gum disease, and tooth loss (American Cancer Society,
2012; CDC, 2013d). Furthermore, public health and tobacco control experts are
concerned that the availability and marketing of electronic cigarettes (e-cigarettes)
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156 Part II. Keeping Americans Healthy
may reverse recent declines in youth tobacco use initiation and tobacco addiction by re-glamorizing smoking and igniting lifelong nicotine addiction (Richtel, 2013). In addition, the most recent survey data from 2009 and 2010 suggest
that 42% of children ages 3 to 11 and 28% of adult nonsmokers were exposed to
secondhand smoke. Socioeconomics may play an important role in in!uencing
smoking behaviors and exposure to tobacco-control policies. A study by Giovino
and colleagues (2009) revealed that increasing median household income was
associated with decreasing prevalence of smoking, higher cessation rates among
smokers, higher state cigarette excise tax rates, and stronger legal protections
from tobacco smoke pollution.
Alcohol Use and Misuse
“e millions of Americans who abuse or misuse alcohol include those who are
alcohol dependent as well as those who engage in drinking behavior that is risky
(e.g., because they drive after drinking alcohol) or harmful (e.g., because they
su#er the e#ects of episodic binge drinking). About 5% of the U.S. adult population meets the criteria for alcoholism or alcohol dependence, and another 20%
engages in harmful or risky drinking, de$ned as drinking more than 1 drink per
day or 7 drinks per week for women, more than 2 drinks per day or 14 drinks
per week for men; periodic binge drinking (5 or more drinks on a single occasion for men; 4 or more for women); drinking and driving; or drinking during
“e 2017 Monitoring the Future Survey indicated that 16.6% of high school
seniors reported that they engaged in binge drinking in the two weeks before the
survey (Miech et al., 2018). Alcohol misuse is most common in young adults,
particularly among White and Native American men. And excessive alcohol use
among U.S. college students remains a problem with college students, compared
with their noncollege peers, reporting more instances of heavy drinking and
being drunk (Johnston, O’Malley, Bachman, & Schulenberg, 2013a). It should
be noted, however, that low and moderate levels of alcohol use in adults (below
those de$ned as risky) have been linked to modest health bene$ts, such as lowered risk for heart disease.
Alcohol misuse accounts for approximately 80,000 deaths and more than
2 million years of potential life lost a year (CDC, n.d.). “e estimated cost of
excessive alcohol use was recently estimated at $249 billion (CDC, 2016). Of this
$249 billion, $191 billion was attributed to binge drinking, $24 billion to underage
drinking, and $5.5 billion to drinking during pregnancy (Sacks, Gonzalez,
Bouchery, Tomedi, & Brewer, 2015).
Factors associated with alcohol access, such as alcohol retail density and
alcohol-related advertising, can vary by certain neighborhood sociodemographic
characteristics. For instance, compared with individuals living in high-income,
high-education, mostly White neighborhoods, those living in low-income, loweducation, predominantly minority neighborhoods have relatively higher densities of alcohol retail outlets available to them (Berke et al., 2010). Disparities
also exist in completion rates for alcohol treatment, with people from minority
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Chapter 7. Health and Behavior 157
backgrounds having signi!cantly lower completion rates than their White counterparts (Saloner & LêCook, 2013).
“e health bene!ts of treating alcohol dependence are well established,
and the U.S. Preventive Services Task Force (USPSTF) found that brief behavior change interventions to modify risky drinking levels and practices produced
positive health outcomes detectable 4 or more years later.
Physical Activity and Sedentary Lifestyle
“e health risks associated with physical inactivity and sedentary lifestyle are
numerous. “ey include heart disease, type 2 diabetes, stroke, hypertension,
osteoarthritis, colon cancer, depression, and obesity (Micha et al., 2017; Yu et al.,
2016). Engagement in physical activity helps to maintain healthy bones, muscles,
joints, and weight, and it is also associated with positive psychological bene!ts.
Physical activity has been shown to reduce feelings of anxiety and depression and
promote feelings of well-being.
In 2011, 48% of adults engaged in at least 75 minutes per week of moderate-tovigorous aerobic exercise, a proportion that met the
Healthy People 2020 guideline for recommended physical activity among adults. In comparison, national
guidelines recommend at least 60 minutes of moderate-to-vigorous physical
activity every day for children and teens, but the majority of young people do
not meet this goal (Troiano et al., 2008). Sedentary behavior also has risen for
U.S. youth, with the amount of time young people spend in sedentary behaviors, including all forms of screen time, increasing dramatically in recent years
(Rideout, Foehr, & Roberts, 2010). Sedentary behaviors are independently linked
to a higher risk for obesity, diabetes, and other chronic health problems among
adults, even those who are physically active and consume healthy diets (Hamilton, Hamilton, & Zedric, 2007).
Re$ecting the power of social determinants of health, the adults, youth, and
families most at risk for inactivity include those with lower income and education
levels, those living below the poverty line in all racial and ethnic groups, members
of several racial/ethnic minority groups (e.g., African Americans, Hispanics), and
those with disabilities. Sallis and colleagues (2011) found neighborhood-level
income disparities for numerous variables a%ecting everyday physical activity.
For instance, residents of high-income neighborhoods reported more favorable
pedestrian and building facilities, safety from tra&c, safety from crime, and access
to recreation facilities than residents of low-income areas. Furthermore, growing evidence shows that within the United States, African American and Latino
youth, and youth living in lower-income communities, do not have as many built
and social environmental supports for physical activity as White children or those
living in middle- and higher-income communities (Taylor & Lou, 2012).
Although the societal costs of physical inactivity are di&cult to quantify, the
CDC has estimated that nearly $95 billion (adjusted to 2009 dollars) would be
saved if all inactive American adults were to become active (CDC, 2013c). In
addition to providing objectives for physical activity behaviors,
Healthy People
includes objectives for policies that facilitate physical activity, particularly
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158 Part II. Keeping Americans Healthy
Four of the 10 leading causes of
death—coronary heart disease,
some cancers, stroke, and type 2
diabetes—are associated with
an unhealthy diet.
for children. !ese policy objectives focus on policies that promote physical activity in childcare settings as well as during recess and physical education classes in
Diet and Nutrition
Approximately 45% of deaths from heart disease, stroke, and type 2 diabetes in
2012 can be attributed to poor diet (Micha et al., 2017). Poor diet and nutrition also has contributed to a surge in overweight and obesity that has reached
epidemic proportions over the last 20 years, particularly within low-income and
minority populations with limited access to healthy a”ordable foods and greater
advertising for unhealthy foods.
Four of the 10 leading causes of death—coronary heart disease, some
cancers, stroke, and type 2 diabetes—are associated with an unhealthy diet. !e
relationships between dietary patterns and health outcomes have been examined
in a wide range of observational studies and randomized trials with patients at
risk for diet-related chronic diseases. !e majority of studies suggest that people
consuming diets that are low in fat, saturated fat, trans fatty acids, and cholesterol and high in fruits, vegetables, and whole grain products containing #ber
have lower rates of morbidity and mortality from coronary artery disease and
several forms of cancer (Micha et al., 2017;
Yu et al., 2016). Moreover, dietary change
has been found to reduce risks for many
chronic diseases as well as for overweight
and obesity.
!e 2010 Dietary Guidelines for Americans recommended that Americans reduce
their caloric intake from solid fats and
added sugars and increase the amount of fruits, vegetables, and whole grains
in their diets. Again, as Table 7.1 shows, gaps exist between the recommended
guidelines and actual diets of American children and adults. Numerous studies have documented wide racial, ethnic, and socioeconomic inequalities in
access to healthy food outlets, particularly chain supermarkets (Powell, Han, &
Chaloupka, 2010), and that access to healthy food is associated with lower
risks of obesity and diet-related chronic
diseases. In 2010, PolicyLink and the Food
Trust published “!e Grocery Gap: Who
Has Access to Healthy Food and Why It
Matters,” a comprehensive review of two
decades of food access research (Treuhaft & Karpyn, 2010). !is review found
evidence that access to healthy food was
particularly limited for low-income communities, communities of color, and rural
The 2010 Dietary Guidelines
for Americans recommended
that Americans reduce their
caloric intake from solid
fats and added sugars and
increase the amount of fruits,
vegetables, and whole grains
in their diets.
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Chapter 7. Health and Behavior 159
As poor dietary habits and physical inactivity have become endemic, national
obesity rates have soared. Nearly 70% of all American adults are overweight or
obese—up almost 10% from just one decade ago. !is trend is alarming, given
the strong links between obesity and many chronic diseases. Total global expenditures related to overweight- and obesity-related problems were estimated at
nearly $2 trillion—a number that will continue to increase without e”ective
interventions to teach and reinforce healthy behavior and change the physical
and media environments and economic incentives that enable, promote, and supply healthy diets. Even modest weight loss (e.g., 5% to 10% of body weight) over a
period of 12 to 24 months can reduce these risks and prevent the onset of diabetes among adults with impaired glucose tolerance.
More alarming is the prevalence of overweight and obesity among children
and adolescents (ages 6 to 19), which has increased signi#cantly over the past
three decades. Like adults, overweight youth are at risk for coronary heart disease, hypertension, certain cancers, and even type 2 diabetes early in life. !e
highest and fastest-rising rates of childhood obesity are seen among children
and adolescents of African American or Latino descent and children (particularly girls) from low-income backgrounds and residing in communities with historically limited access to the resources and opportunities for physical activity
and healthy diets—making e”orts to reach these groups a public health priority
(White House Task Force on Childhood Obesity, 2010).
Reducing obesity among adults, adolescents, and children are leading
health goals for
Healthy People 2020, which set the target rates of adult and
child and adolescent obesity at 31% and 15%, respectively. In 2012, the Institute
of Medicine (IOM) released the report
Accelerating Progress in Obesity
Prevention: Solving the Weight of the Nation
, which identi#ed #ve critical
environments in which reform was urgently needed to prevent obesity:
(a) environments for physical activity, (b) food and beverage environments,
(c) message environments, (d) health care and work environments, and (e)
school environments. In a 2013 follow-up report,
Creating Equal Opportunities
for a Healthy Weight
, the IOM focused on the research, policies, and actions
most needed to ensure greater equity in opportunities to achieve a healthy
weight and address the pervasive disparities in obesity prevalence and health
and economic tolls in the United States.
In 1982, the IOM published Health and Behavior, one of the #rst scienti#c documents to establish convincingly the links between behavioral risk factors and
disease, and to identify the basic biopsychosocial mechanisms underlying them.
!e IOM recommended intensi#ed social and behavioral science research to
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160 Part II. Keeping Americans Healthy
develop interventions that could help people change their unhealthy behaviors
and improve their health prospects. !is section presents a broad overview of the
ensuing research—research that has attempted to close the gap between what we
know and what we do when it comes to adopting and fostering healthy lifestyles.
A Brief History of Behavior Change Interventions
Early behavior change e”orts in the 1970s and 1980s relied primarily on public
education campaigns and individually oriented health education interventions.
!ey were guided by the health belief model and similar theories (the theory of
reasoned action, the theory of planned behavior), which emphasized the cognitive
and motivational in#uences on health behavior change and recommended raising
awareness of the harms of unhealthy behavior versus the bene$ts of behavior
change as a primary intervention. !ese cognitive/decisional theories were based
on an underlying premise that people’s intentions and motivations to engage in
behavior strongly predict their actually doing so (i.e., “if you tell them, they will
change”). Because raising health risk awareness and motivation was a primary
goal, the doctor–patient relationship was seen as a unique and powerful context
for e”ective health education.
Both population-level and individual clinical health education e”orts based
on these theories achieved initial success. For instance, tens of thousands of
smokers quit in response to the publication of the $rst U.S. Surgeon General’s
Report on Smoking and Health in 1964 and the multiple public education campaigns that followed.
By 2000, hundreds of studies had con$rmed that even brief physician advice
could be an important catalyst for health behavior change—boosting the number
of patients who quit smoking for at least 24 hours or who made some changes
in their diet and activity levels. But a growing body of research found these successes to be modest—the interventions were important and perhaps
for changing people’s health knowledge, attitudes, and beliefs, as well as broader
social norms, but
not su!cient to produce lasting behavior change. Cumulative
$ndings made it clear that people needed not only motivation, but also new skills
and supports to succeed in changing deeply ingrained health habits, including
supportive community, social, and media environments.
!ese $ndings spurred the development and testing of expanded
multicomponent, cognitive behavioral treatments designed not only to (a) raise
perceptions of susceptibility to poor health outcomes and bene$ts of behavior
change, but also to (b) teach the skills required to replace ingrained unhealthy
habits with healthy alternatives and to (c) help people make changes in their natural
(home, work, social) environments to assist them in successfully establishing and
maintaining new behaviors. Social learning theory, which emphasized interactions
between internal and external environmental in#uences on behavior, provided the
primary theoretical basis for this evolution, and it remains the dominant model
for e”ective cognitive behavioral health behavior change interventions.
Lifestyle change interventions derived from social learning theory combined
education and skills development. !ey included techniques such as modeling
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Chapter 7. Health and Behavior 161
and behavioral practice to help people learn not just why, but how, to change
unhealthy habits. For instance, they taught e!ective self-management and behavior change skills, such as goal-setting, self-monitoring, and stress management
skills for people who had relied on smoking, eating, or drinking as coping tactics. “ey taught skills for reengineering the person’s immediate environments,
replacing environmental cues and supports for unhealthy behavior with new cues
and supports for healthy ones (e.g., removing ashtrays; replacing unhealthy highcalorie foods with healthy alternatives; #nding exercise buddies; and avoiding
high-risk events, such as o$ce parties at which risky drinking was expected).
“e “nudge” principles of modern behavioral economics that, for instance,
are used to advocate for replacing soda with water and French fries with apple
slices in fast-food children’s meals have their roots in these approaches. Another
principle was that problem solving should start with helping people set realistic,
personal behavior change goals and go on to address the unique barriers and
relapse temptations they face. Finally, new social learning theory treatments
taught patients to take a long-range perspective, viewing repeated attempts over
time as part of a cumulative learning process rather than as signs of failure.
E!ective multicomponent treatments were initially delivered and tested in
multisession, face-to-face group or individual clinic-based programs, typically
o!ered in clinical or medical settings and usually led by highly trained (e.g., MD,
PhD) professionals. Results were extremely encouraging, with substantial behavior change—for example, smoking quit rates as high as 40%—maintained 6 to
12 months after treatment. However, participants were typically self-referred or
recruited based on high readiness or motivation for change and thus represented
a small fraction of those who could bene#t.
“e next push was to distill core elements of this treatment approach
into lower-cost formats with much wider reach. “ese formats included
paraprofessional-led worksite clinics, self-help manuals and programs, and brief
primary care counseling. Absolute treatment e!ects were smaller—for example,
20% long-term smoking quit rates—but potential population e!ects were much
greater. Only 5% to 10% of smokers might ever attend intensive clinics, whereas
70% of U.S. smokers might receive brief, e!ective tobacco interventions during
visits with their primary care physicians, introducing a context that could double
the nation’s annual quit rate. Access to telephone quitlines providing free or
no-cost counseling and medication proved equally e!ective and had the bene#t
of better reaching smokers in sociodemographic populations with limited access
to high-quality health care (Schlam & Baker, 2013).
Development of the stages-of-change model in the mid-1980s accelerated the
shift from individual to population intervention models and has had a profound,
lasting e!ect on the design and delivery of health behavior change programs.
Studying how people went about changing on their own, Prochaska and DiClemente (1983) discovered that health behavior change was a multistage process:
■■ Precontemplation: no plans to change behavior; behavior is not seen as a problem
■■ Contemplation: serious plans to change behavior within the next 6 months, weighing
the pros and cons, and building supports and con#dence
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162 Part II. Keeping Americans Healthy
■■ Preparation: plans to change are imminent; small initial steps are taken
■■ Action: active attempts are made to quit smoking, drink less, become more active, or
change to a healthier diet and to sustain changes for up to 6 months
■■ Maintenance: change is sustained beyond 6 months
■■ Relapse: the individual returns to any earlier stage and begins to recycle through the
earlier stages
Based on these !ndings, di”erent skills, knowledge, and types of treatment
were recommended to help people in each stage; motivational and educational
interventions were helpful to people in the precontemplation and contemplation
stages, and active cognitive behavioral interventions were needed for those in
the preparation, action, and maintenance stages. Many population surveys found
that, at any given time, the vast majority of people (80%) are in the precontemplation and contemplation stages, which helped to explain why so few enrolled
in weight-loss or quit-smoking clinics, even when these were free and accessible.
#e stages-of-change model has been successfully applied to numerous behavioral health risks and has helped people with multiple risk factors make progress
in changing several at the same time. One of the greatest e”ects of this model was
to propel a dramatic shift away from one-size-!ts-all approaches to individualized, stage-tailored strategies that could be applied e”ectively to entire populations—in communities, worksites, and health care settings—assisting people at
all stages of change, not just the motivated volunteers in action stages, but also
those needing motivation and support to reach action stages. #e model stimulated the development and wider use of e”ective motivational interventions for
clinical settings, especially motivational interviewing, which seeks to help people
strengthen their determination to change behavior (Emmons & Rollnick, 2001).
Originating as they did in the study of successful self-change, stages-of-change
models fueled a burgeoning movement toward low-cost self-help tools and treatment formats. Some tools capitalized on computer-based and interactive communication technologies to design and deliver print and web-based materials,
interactive video, and telephone interventions geared to the individual’s stage of
change. #ese treatments also addressed many other variables important for tailoring treatment methods and improving treatment outcomes—for example, degree
of nicotine addiction, unique behavior change assets, barriers, and cultural norms.
A !nal force in the evolution from individual to population-based approaches
was the emergence of
social marketing strategies, which apply the concepts
and tools of successful commercial marketing to the challenge of health behavior change. Basic marketing principles and methods—including market analysis,
audience segmentation, and a new focus on consumer wants and needs—catalyzed
the development of culturally appropriate communication and intervention
strategies for reaching underserved, high-risk, low-income, and racial/ethnic
minority populations for whom the prevalence of behavioral health risks is often
highest and access to health-promoting environments and resources is often
lowest. For instance, one model program employed social marketing strategies
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Chapter 7. Health and Behavior 163
to tailor a no-cost smoking cessation intervention to the needs of African American
smokers, using messages on Black-format
radio stations to promote culturally tailored
quitline counseling and materials. Results
included a higher quitline call rate and a
higher quit rate among African Americans
receiving the tailored intervention versus a generic one.
Social networks have been found to help motivate and support health behavior change in multiple areas—including weight loss, alcohol use, and smoking
cessation (Volpp & Mohta, 2017). !rough the Internet, individuals can share
and receive health information through open forums, such as those provided
through Facebook or Twitter. !ey can upload health-related apps or access
online communities intentionally designed to promote good health. Additionally,
social media platforms can provide a more stable source of support as individuals
switch social media user names less frequently than they do cell phone numbers
(Volpp & Mohta, 2017). !ese social media tools have made health interventions
more accessible than ever before by delivering strategic, e”ective, user-friendly
messages directly to target audiences, even right into people’s hands via their
hand-held mobile devices.
!e use of using social media tools to promote health has become so widespread in the past decade that the CDC now o”ers communication guidelines
and a social media toolkit for creating social messages in health communications
and activities (CDC, 2013a). Similarly, in 2013, the National Library of Medicine,
a division of the DHHS, announced its plan to install software that will mine
Facebook and Twitter to assess how Tweets and Facebook posts can be used as
change agents for health behaviors. Still, more research is needed to assess the
e”ect of social media on health behavior.
!e progress in health behavior change research and treatment set the stage for
the development of brief, individually oriented, primary care health interventions
that could be o”ered and tailored to all members of a practice, health plan, or
patient population.
!ese e”orts were based on a strong rationale for primary care interventions
to address behavioral health risks. Patient surveys have repeatedly found that
patients expect and value advice from their providers about diet, exercise, and
substance use and are motivated to act on this advice. Most primary care providers describe health behavior change advice and counseling as an essential part of
their role and responsibilities.
!e unique extended relationship that is the hallmark of primary care a”ords
multiple opportunities, over time, to address healthy behavior in a “string of
Social marketing strategies
apply the concepts and tools
of successful commercial
marketing to the challenge of
health behavior change.
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164 Part II. Keeping Americans Healthy
pearls” approach, capitalizing both on teachable moments—for example, introducing physical activity or diet counseling when test results show elevated cholesterol levels—and on a therapeutic alliance that often extends beyond the patient
to include key family members. Moreover, evidence suggests that the health bene!ts and cost-e”ectiveness of evidence-based preventive health behavior change
interventions rival, and frequently surpass, those of remedial disease treatments
(Maciosek et al., 2006).
In the minimal contact primary care counseling interventions that were distilled from the successful multicomponent models, the physician was seen as the
initial catalyst for change, providing brief motivational advice, social support,
and follow-up, with referral to other sta” members or community resources for
more intensive assistance. Stage-based and social marketing approaches held
the potential to reach and assist entire populations of patients, including those
not yet motivated for change and those in underserved and high-risk groups.
As social media introduced innovative options to promote health information,
computer-based, patient-tailored, and population-targeted interventions provided new ways to reduce provider burden. In fact, in 2013, the Community
Preventive Services Task Force added mobile phone–based quit smoking counseling to its roster of recommended tobacco control interventions.
Progress in developing e”ective minimal-contact, primary care interventions
occurred !rst in the area of smoking cessation, culminating in the development of an
evidence-based, practice-friendly intervention model now known as the 5 A’s: Ask,
Advise, Agree, Assist, Arrange follow-up. #e 5 A’s model was found to be e”ective
when used by a variety of health care providers (physicians, nurses, dentists, dental
hygienists), with as few as two to three minutes of in-o$ce provider time.
#e model starts with
asking about tobacco use, leading to clear and personal
advice to quit for smokers (or congratulations for quitters), and the o”er of
help. #e
agree step starts with assessing patient readiness to quit and goes
on to establish a goal and quitting plan. For those not ready to quit,
includes a recommended motivational intervention; for those who are ready
to quit,
assistance combines brief face-to-face or telephone-based behavior
change counseling with Food and Drug Administration (FDA)–approved
pharmacotherapy, such as nicotine gum, patch, nasal spray or inhaler; bupropion
hydrochloride (Zyban); varenicline (Chantix); or some combination of these,
unless medically contraindicated (e.g., in pregnancy).
Behavioral counseling was e”ective when provided through multiple formats—
self-help materials
and face-to-face or telephone counseling—and there is a clear
dose-response relationship between the amount of counseling and quit rates.
E”ective follow-up
arrangements include planned visits, calls, or contacts to
reinforce progress, adjust the quitting plan to better meet individual needs, or refer
for more intensive help. One-year quit rates for patients receiving these interventions
are typically two to three times higher than the 5% to 7% quit rates among people
who try quitting on their own. In fact, the CDC and Prevention and Partnership
for Prevention found the 5A’s intervention to be one of the most e”ective and coste”ective of all evidence-based clinical preventive services (Maciosek et al., 2006).
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Chapter 7. Health and Behavior 165
!e 5 A’s model has been formally adopted by the USPSTF as a unifying conceptual framework or guideline applicable to addressing all behavioral health risks,
including risky drinking, physical activity, diet, and obesity. In most cases, the
USPSTF found that counseling interventions could produce clinically meaningful,
populationwide health improvements that were sustained for at least 6 to 12 months.
Although there are many common elements, the speci”c intervention components
and intensity of recommended strategies vary from behavior to behavior, as does
their e#ectiveness with unselected versus high-risk patients. Primary care providers may intervene more forcefully with healthy patients when they are known to be
at high risk for a particular chronic disease, and patients at high risk may feel more
vulnerable and motivated to act on the advice and assistance they receive.
!e “rst step is always to
assess not only the relevant behavior (using a standard
health-risk appraisal or brief screening that can easily be administered in a busy
practice setting), but also the individual factors that are helpful in tailoring the
intervention, such as medical and physiologic factors, motives, barriers, patient’s
stage of change, social support, and cultural values. Based on this information, and
with reference to the patient’s immediate health concerns and symptoms, the clinician provides brief, personalized
advice, expressing con”dence in the patient’s ability to change and soliciting the patient’s thoughts about the recommended changes.
!e next critical step is to negotiate and
agree on a collaboratively de”ned
behavior change goal and treatment plan, which commonly includes practical
problem solving to
assist the patient in addressing personal change barriers,
building social support, developing a more supportive immediate social and
physical environment, and securing adjunctive behavior change resources and
pharmacologic aids, such as nicotine replacement. Adjunctive resources can
include evidence-based face-to-face, telephone, or mobile phone counseling; targeted or generic self-help materials; and interactive Internet-based tools that are
tailored to a patient’s gender, age, racial/ethnic or cultural group, health status or
condition, stage of change, and other relevant variables. !ese resources can be
used before, during, and after the o$ce visit.
!e “nal step is to
arrange follow-up support and assistance, including referral to more intensive or customized help, or to online tools and supports to help
the patient maintain behavior change maintenance.
!ese new guidelines provided unprecedented scienti”c support for the
USPSTF assertion that “the most e#ective interventions available to clinicians for
reducing the incidence and severity of the leading causes of disease and disability
in the United States are those that address patients’ personal health practices”
(USPSTF, 1996, p. iv).
However, several important limitations and gaps remain. !e greatest limitation is the lack of long-term maintenance after successful behavior change for 12
months or longer. !is is not surprising, given that patients return to the environments that shaped and supported their unhealthy lifestyles and choices. Higher
maintenance rates are achieved in clinic-based programs that o#ered extended
booster or maintenance sessions, providing ongoing social support and behavior change assistance, or in those that helped patients to create an enduring
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166 Part II. Keeping Americans Healthy
“therapeutic microenvironment” to shield them from unhealthy in!uences—for
example, implementing an in-home smoking ban, arranging for the delivery of
recommended diet foods, or arranging ongoing behavior change buddies.
Researchers and policy makers agree that current research and evidence gaps
are the result of too few studies that have developed and tested primary care
interventions for children, adolescents, and underserved populations.
“e shift to population-based models of health promotion and disease prevention was prompted by several factors:
■■ “e success of e#ective, brief, and intensive interventions based on social learning
theory, which gave greater prominence to environmental factors in behavior
■■ “e emergence of new stage-based and social marketing models for populationwide
■■ “e disappointing reach and long-term e#ectiveness of even the most successful
cognitive behavioral treatments
“e lackluster performance of individual treatment approaches was especially
apparent when contrasted with new evidence from public health research showing far-reaching and lasting health e#ects from environmental and policy changes
that eliminated the need for individual decision making. A prime example is the
development of safer roads and more crashworthy automobiles, combined with
shifts in laws and norms regarding seat belt use and drinking and driving, which
collectively produced a dramatic decline in auto-related deaths and injuries.
With the stage well set, the $nal push for a change in approach came in the 1990s
with the development of
social ecological models of health behavior. “ese models
integrate behavioral science with clinical and public health approaches. “ey rede-
$ned what the targets of successful health interventions need to be—not just individuals but also the powerful social contexts in which they live and work. And they
emphasized that a person’s health behavior is a#ected by multiple levels of in!uence:
interpersonal factors (e.g., physiologic factors, knowledge, skill, motivation), social
factors (e.g., social–cultural norms, supports, and networks), organizational and
community factors, broader environmental in!uences, and public policies.
Proponents of the ecological model recommend multilevel strategies that
address all these levels of in!uence (Glickman, Parker, Sim, Del Valle Cook, & Miller,
2012; IOM, 2000, 2013; Koh, 2010). Speci$cally, they propose that educational and
clinical interventions to improve the motivation, skills, and supports for individual
behavior change (e.g., for permanently quitting smoking or risky drinking, or for
adopting and maintaining healthier activity and eating patterns) would be more
successful when policies and in!uences in the wider environment prompt and
reinforce healthy behavior through, for example, clean indoor air laws and access
to safe and attractive places to walk or bike and obtain healthy, a#ordable foods.
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Chapter 7. Health and Behavior 167
A strong, early proponent of the ecological approach to prevention, McKinlay
(1995) proposed a template for more e!ective population health promotion strategies that linked individual-level, clinical health behavior change strategies with
broader, population-level health promotion e!orts, including upstream policy
and environmental interventions. “e model McKinlay proposed (see Table 7.2)
recommended interventions across a broad spectrum of factors, linking
downstream individual clinical approaches with midstream interventions aimed at
health plans, schools, worksites, and communities with
upstream macro-level
public policy and environmental interventions strong enough to subvert or redirect countervailing societal, economic, and industry forces. In essence, McKinlay was one of the $rst to argue that success in achieving lasting populationwide
health behavior change required a “full court press.”
In its landmark review of the past three decades of progress in population
health promotion, the IOM’s (2000) report,
Promoting Health: Intervention
Strategies from Social and Behavioral Research
, recommended individual-level
interventions aimed at those who possess a behavioral risk factor or su!er from
risk-related disease. For these groups, the emphasis is on changing rather than
preventing risky behavior. Population-level interventions that target de$ned populations in order to change and/or prevent behavioral risk factors may involve

Individual-level interventions
aimed at those who possess a
behavioral risk factor or suffer from
risk-related disease; emphasis on
changing rather than preventing
risky behavior
Population-level interventions
that target de!ned populations
in order to change and/or
prevent behavioral risk factors;
may involve mediation through
important organizational channels
or natural environments
State and national public policy/
environmental interventions that
aim to strengthen social norms
and supports for healthy behavior
and redirect unhealthy behavior
■■ Group and individual counseling ■■ Worksite and community-based
health promotion/disease
prevention programs
■■ National public education/
media campaigns
■■ Patient health education/cogni
tive behavioral interventions
■■ Health plan–based primary
care screening/intervention
■■ Economic incentives (e.g.,
excise taxes on tobacco
products; reimbursement for
effective primary care, diets,
and extensive counseling)
■■ Self-help programs and tailored
■■ School-based youth prevention
■■ Policies reducing access to
unhealthy products (e.g., pric
ing, access, labeling)
■■ Pharmacologic treatments ■■ Community-based interven
tions focused on de!ned at-risk
■■ Policies reducing the advertis
ing and promotion of unhealthy
products and behavior

Source: From McKinlay, J. B. (1995). !e new public health approach to improving physical activity and autonomy in older populations. In E. Heikkinen, J. Kuusinen, & I. Ruoppila (Eds.), Preparation for aging (pp. 87–102).
New York, NY: Plenum.
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168 Part II. Keeping Americans Healthy
mediation through important organizational
channels or natural environments. State and
national public policy/environmental interventions aim to strengthen social norms and
supports for healthy behavior and redirect
unhealthy behavior.
!e IOM used McKinlay’s broadspectrum, multilevel model for describing
the balance needed between the dominant
clinical and individually oriented approaches to disease prevention on the one
hand and the population-level approaches addressing the generic social and
behavioral factors linked to disease, injury, and disability on the other. Observing
that many forces in the social, cultural, and physical environment often constitute
enormous barriers to health behavior change (IOM, 2000, p. 2), the authors
recommended population-based health promotion e”orts that:
■■ Use multiple approaches (e.g., education, social support, laws, incentives, behavior
change programs) and address multiple levels of in#uence simultaneously (i.e., individuals, families, communities, nations)
■■ Take account of the special needs of target groups (e.g., based on age, gender, race,
ethnicity, and social class)
■■ Apply a long view of health outcomes because changes often take many years to
become established
■■ Involve a variety of sectors in society that have not traditionally been associated with
health promotion e”orts, including law, business, education, social services, and the
Examples From Tobacco Control
!e last three decades of progress in national tobacco control, hailed by some as
one of the greatest public health successes of the second half of the 20th century,
is the example most often used to illustrate the power and promise of ecological
approaches for health intervention.
Although major disparities in tobacco use and its addiction remain, regressive
tobacco tax and price increases have proved especially e”ective in certain highrisk and underserved populations—including adolescents, pregnant women, and
low-income smokers. State telephone quitlines (1-800-QUIT-NOW) o”ering
cost-free counseling and medication have greatly expanded the reach of evidencebased individual cessation treatments to traditionally underserved low-income
and minority populations.
Re#ecting the growth in research evaluating the population e”ects of midstream and upstream interventions for tobacco control, the CDC’s Task Force
for Community Preventive Services was launched in 1996 to conduct systematic
reviews of community-based and policy interventions to change health behavior, similar to the reviews conducted by the USPSTF of downstream clinical
It is unreasonable to expect
that people will change their
behavior easily when so many
forces in the social, cultural, and
physical environment conspire
against such change (Institute of
Medicine, 2000).
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Chapter 7. Health and Behavior 169
preventive interventions. Based on its review of evidence for 14 di!erent tobacco
control interventions, the CDC makes these recommendations:
■■ Smoking bans and restrictions to reduce exposure to environmental tobacco smoke
■■ Tax and price increases and mass media campaigns to reduce the number of youth
who start smoking and to promote cessation
■■ Telephone quitline and mobile phone-based support, as well as a number of health
care system interventions, also to increase cessation
Similar ecological models have been described and proposed for each of the
other major behavioral risk factors discussed in this chapter—risky drinking,
physical inactivity, dietary behavior change, and obesity. “ese are summarized
on the CDC’s Community Preventive Services Task Force Community Guide
website (CDC, 2013b) and in the Task Force’s 2013
!ird Annual Report to
(CDC, 2013), presenting more than 200 evidence-based recommendations for promoting better health among community members.
Examples From Childhood Obesity Prevention
A great sense of urgency surrounds the need to identify evidence-based “fullcourt press” strategies that can halt the nation’s current obesity epidemic,
especially among children (Glickman et al., 2012; Kumanyika, Parker, & Sim,
2010; White House Task Force on Childhood Obesity, 2010). “e dramatic rise
in the prevalence of overweight and obesity among youth and adults over the
past several decades is primarily due to environmental and economic changes
a!ecting behavior on both sides of the
energy balance equation; that is, the
amount of energy (calories) used versus the amount consumed.
“e cumulative e!ects of technology—such as automobile-dependent transportation and more sedentary jobs—along with changes in lifestyles in typical
suburban environments, which limit the places to which adults and children can
walk, have reduced the amount of physical activity in everyday life.
At the same time, increased access to low-cost, sugar-laden, and high-fat foods
and beverages; increased exposure to marketing for these unhealthy products;
larger portion sizes; increased restaurant use; an exodus of grocery stores and
other sources of fresh fruits and vegetables from cities to suburbs; and the rising
cost of fresh produce relative to soda and snack foods have all played a critical role
in promoting excessive caloric intake, especially for low-income and racial/ethnic
minority populations facing inequalities in access to healthy a!ordable foods. Pervasive racial/ethnic disparities in access to safe places to walk, bike, and play have
sparked numerous studies documenting socioeconomic di!erences in access to
community sports areas, parks, swimming pools, beaches, and bike paths.
Continued progress is being made to understand the environmental and policy factors that a!ect physical activity and identify promising multilevel, broadspectrum interventions to address the nation’s obesity epidemic. “e CDC’s
Community Preventive Services Task Force reviewed research on interventions
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170 Part II. Keeping Americans Healthy
and found evidence for recommendations spanning the full McKinlay model.
!ese include the following:
■■ Downstream health behavior change programs that increase social supports for physical activity and exercise (e.g., health care provider reminder systems plus provider
■■ Midstream requirements for school physical education classes that increase the time
students spend in moderate or vigorous physical activity and “point of decision”
prompts on elevators and escalators that encourage people to use nearby stairs
■■ Upstream e”orts to create, or increase, access to safe, attractive, and convenient places
for physical activity, along with informational outreach to change knowledge and attitudes about the bene#ts of and opportunities for physical activity
Additionally, the IOM used a systems approach to analyze hundreds of strategies for obesity prevention and prioritize the most promising recommendations
(Glickman et al., 2012). Together, these guidelines have provided a strong, sciencebased blueprint for multisector e”orts by professionals in public health, urban
planning, transportation, parks and recreation, architecture, landscape design,
public safety, and the mass media to close the gaps between recommended and
actual physical activity levels for U.S. children and adults.
Some upstream e”orts come in the form of federal payments that can help
communities create or improve access to healthy options. !e Patient Protection
and A”ordable Care Act (ACA), passed in 2010, provided states and communities with a new stream of funds to promote healthy living by creating and improving multiple factors—such as housing, education, child care, and food outlets—in
ways that address health disparities, improve access to behavioral health services,
and reduce and control behavioral risk factors.
Other federal and state health-related policy changes have been in$uential in
reducing childhood obesity, particularly among children from low-income families who participate in the Special Supplemental Nutrition Program for Women,
Infants, and Children (better known as WIC). A 2008 overhaul of the WIC food
package changed the mix of foods covered by the program, making more fruits
and vegetables, skim and low-fat milk, and whole grain breads and cereals available to participants. Grocery stores and schools serving WIC children changed
their inventories to meet the new standards, which bene#ted not only WIC families but also entire communities. In 2013, evidence pointed to declining obesity
rates among children from low-income communities in 18 states and one U.S.
territory (CDC, 2013c).
Among U.S. cities, Philadelphia set itself apart by reporting a signi#cant
decrease in obesity between 2006 and 2010, particularly among school children in
grades K through 12 and adolescents of color. !ese decreases emerged after the
city instituted a decade-long, multipronged e”ort to combat obesity and in$uence
health behavior. Over those 10 years, Philadelphia implemented the following:
■■ Nutrition education to public school students whose families are eligible for the federal Supplemental Nutrition Assistance Program
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Chapter 7. Health and Behavior 171
■■ Financial incentives to attract grocers to open stores in underserved areas
■■ A school districtwide wellness policy
■■ Improved nutritional o!erings in schools, which included the removal of deep-fried
foods, sodas, and sugar-sweetened beverages
■■ Improved in-store food marketing practices in local grocery and locally owned corner
■■ Required calorie postings at chain restaurants
With respect to high-risk populations and environments, systematic surveillance can increasingly monitor the prevalence of behavioral risk factors and
related health-promoting programs, resources, and policies. Such surveillance
systems, which already exist for tobacco control and are rapidly developing for
physical activity, establish a national baseline that makes it possible to assess
the e!ects of speci”c interventions and to evaluate important local, state, and
national intervention e!orts (Sallis et al., 2011). Although some events and political changes may create opportunities for rapid change, as did the Tobacco Master
Settlement Agreement, a long-term view is essential. Most successful health promotion and social change e!orts have required decades of hard work.
As we learned from the success of tobacco control, highly credible scienti”c
evidence can persuade policy makers and withstand the attacks of those whose
interests are threatened. Collaboration among public health researchers, advocates, communicators, strategists, and health care providers is needed to ensure
that high-quality evidence reaches policy decision makers at the right times.
#e di$culty of implementing e!ective broad-spectrum approaches should
not be underestimated. Powerful political opponents bene”t from the sale, promotion, and marketing of unhealthy products. Other barriers include industry
lobbying, chronically limited public support for healthy public policies, and inadequate funding for and enforcement of e!ective policies and programs. Creating
a favorable political climate requires advocacy in order to instigate broad public
pressure and support for change, clear and well-communicated evidence of public demand and support for change, and evidence of the bene”cial health and
economic e!ects of proposed programs and policies.
One of the most basic measures of national health care quality is the extent to
which patients receive recommended, evidence-based care. Evidence-based
guidelines exist for prevention-oriented primary care interventions related to
behavioral risks, and putting these guidelines into practice has become an important objective for national health care
quality improvement e!orts.
#e IOM’s (2001) transformative report,
Crossing the Quality Chasm, set
forth a bold national agenda for improving health care quality across the full
spectrum of care, from prevention to acute and chronic illness and palliative care,
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172 Part II. Keeping Americans Healthy
including health behavior change. A follow-up IOM report (Adams & Corrigan,
2003) selected health behavior change interventions for tobacco and obesity as
two of the top 20 priorities for national action.
!ese reports and the reviews and recommendations issued over the past decade
by the USPSTF and CDC’s Community Preventive Services Task Force have had a
signi”cant in#uence on the prevention and public health provisions of the ACA,
enacted in 2010. !ey helped researchers, health professionals, and policy makers
understand the need for a multisystemic approach to obesity prevention—one
that involved a range of recommendations
to build sustainably healthy communities
that o$er opportunities for everyone to
make healthy, productive choices. !is
strategy was outlined in the IOM’s 2012
Accelerating Progress in Obesity
Prevention: Solving the Weight of the Nation
(Glickman et al., 2012), which emphasized
the need for targeted health interventions
to reduce the inequitable distribution of
health promotion and health care resources
and risk factors that contribute to health
disparities among members of low-income,
low-resource communities.
Despite strong evidence for behavioral
prevention in primary care, signi”cant gaps persist between recommended and
actual care. One of the landmark studies of the quality of outpatient health care
found that U.S. adults, on average, receive about
half the services recommended
for people with their speci”c health problems and even less—only 18%—of
the recommended lifestyle screening and counseling services (McGlynn et al.,
2003). It is safe to say that most patients who could bene”t from health behavior change counseling—particularly those from lower-income and economically
disadvantaged racial/ethnic populations, communities, and neighborhoods—are
not receiving it. In most studies, patients receive only the “rst two of the 5 A’s—
assessment and advice.
■■ Tobacco use: According to national data in 2010, 68% and 19% of visits to o%ce-based
ambulatory care settings involved tobacco use screening and tobacco cessation counseling, respectively (DHHS, 2011). !ese percentages, though higher than those in the
baseline year of 2007, are below the
Healthy People 2020 target.
■■ Alcohol use: A 2005 study found that less than one-third of individuals who saw a
general medical provider were screened for alcohol or drug use (D’Amico, Paddock,
Burnam, & Kung, 2005). !e probability of problem drinkers in the study’s sample
being screened for alcohol use was less than 50%.
■■ Physical inactivity and unhealthy diet: National surveys indicate that in 2010,
9% of physician visits by children and adults included counseling about exercise
(DHHS, 2011). Among patients diagnosed with diabetes, cardiovascular disease, or
The Institute of Medicine’s
2012 Report,
Progress in Obesity Prevention
presents an ambitious vision of
“a society of healthy children,
healthy families, and healthy
communities in which all people
realize their full potential” made
possible through “large-scale
transformative changes focused
on multi-level environmental and
policy changes” (p. 19).
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Chapter 7. Health and Behavior 173
hyperlipidemia, the percentage of their physician visits that included counseling or
education related to exercise was 12%. Survey data also found that in 2010, 14% of
physician visits by children and adults included counseling about nutrition or diet.
!is percentage increases to 19% for patients diagnosed with diabetes, cardiovascular
disease, or hyperlipidemia.
■■ Obesity: In 2008, just under half of primary care physicians regularly assessed BMI
for their child, adolescent, and adult patients (DHHS, 2011). Similarly, multiple
surveys of family practitioners (Sesselberg, Klein, O’Connor, & Johnson, 2010) and
pediatricians (Klein et al., 2010) found that only about half of these primary care
providers (45% and 52%, respectively) routinely assess BMI in children over age 2.
Among adult patients diagnosed with obesity, the percentage of physician visits that
include counseling or education regarding weight reduction, physical activity, or
nutrition was 28% (DHHS, 2011).
Systematic evidence reviews beginning in the 1990s have found that most educational approaches, including traditional continuing medical education (CME),
had limited e”ect. More interactive and skills-based educational e”orts that used
principles of adult learning and social-learning theory (including modeling by
respected peer “opinion leaders”) were somewhat more e”ective. Multicomponent interventions that addressed the multiple intrapersonal and environmental
barriers to provider adherence, especially system barriers, were most e”ective.
!e limited success of “if you tell them, they will change” provider education
strategies drew critical attention to the many system-level barriers to adherence
to evidence-based guidelines and recommendations, including the pressure of
time (in the face of more urgent medical issues), inadequate o#ce supports, a
lack of provider and patient resources, and missing $nancial incentives.
Follow-up studies con$rmed that clinician training was most e”ective when
combined with e”orts to create o#ce supports to prompt, facilitate, and reward
the delivery of preventive interventions, especially behavioral counseling, and
that the most successful interventions were not one-size-$ts-all, but tailored to
the unique circumstances present in any particular o#ce practice.
Multilevel Models for Improving Delivery of Effective Health
Behavior Change Interventions
Collectively, these $ndings led to a shift in understanding what the targets of
interventions to change
provider health care practices needed to be. Crabtree and
colleagues (1998) introduced a
practice ecology model, emphasizing the need to
address not just the behavior of individual providers, but also the powerful e”ects
of the health care systems and environments in which providers practice.
!ey and other proponents of a broader view of health care improvement
emphasized the need for broad-spectrum strategies addressing multiple levels of in%uence: downstream intrapersonal/individual provider-level factors;
midstream interpersonal/practice team, o#ce microsystems and health plan
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174 Part II. Keeping Americans Healthy
in!uences; and upstream macro-level health care systems and policies (Goodwin
et al., 2001; see Figure 7.1).
Responding to the same evidence, the IOM’s (2001)
Crossing the Quality
report recommended a fundamental reengineering of the nation’s health
care system—moving from a system designed primarily to support and pay for
the delivery of reactive acute and remedial illness care to one that would support
and pay for the proactive, preventive, and behavioral care needed to prevent and
manage chronic disease.
It has been said that “an ounce of prevention takes a ton of o”ce system
change.” Until recently, we lacked a coherent model for what this “ton of change”
involved. Filling this void, Wagner, Austin, and Von Kor# (1996) reviewed the
research on e#ective chronic illness care and prevention and devised a model for
the multiple interlocking systems supports required for e#ective planned, proactive chronic illness care—the
chronic care model.
$is model applies equally to the
prevention and to the treatment of chronic
disease, both of which require helping patients to change the behavioral risk factors
that cause or complicate their illnesses. $e chronic care model helped to pave the
way for the concept of the “medical home” as a means for reorganizing primary care
practices to improve health outcomes and reduce health care costs and disparities.
$e six key elements of the chronic care model can be implemented at the level
of the o”ce practice or larger health care delivery system. Each element includes
interventions that are planned rather than reactive, are patient-centered and
informed by individually relevant patient data, are proactive, involve scheduled
CQI, continuous quality improvement; CME, continuing medical education; NCQA/HEDIS, National
Committee for Quality Assurance/Healthcare E!ectiveness Data and Information Set.
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Chapter 7. Health and Behavior 175
outreach and follow-up, and are population-based—that is, focused on an entire
panel of patients with a speci!c behavioral risk factor, disease, or condition and
not just on individuals who seek care. Both prevention and treatment of chronic
conditions require regular (nonsymptom-driven) screening and counseling for
health behavior change, involve ongoing planned care with proactive follow-up,
depend on active patient involvement in decision making and adherence, and
require links to supportive community resources and services.
As an example, the chronic care model proved a helpful heuristic for describing an organizationwide initiative at Group Health Cooperative of Puget Sound
that integrates screening and treatment for tobacco use with routine primary
care. “is successful plan applied all six model elements as follows:
■■ Health care organization: Health plan leaders made reducing tobacco use their top
prevention priority, provided !nancial and other incentives to providers (including
hiring dedicated clinic counselors), and eliminated patient copayments for counseling.
■■ Clinical information systems were used to create a registry of the tobacco users enrolled
in the health plan, track their use of treatment resources and programs, and generate
proactive telephone quitline calls for patients and feedback reports for providers.
■■ Decision support tools included extensive provider training, ongoing consultation,
automated patient assessment and guideline algorithms, and reminder tools.
■■ Practice redesign and self-management support included self-help materials and a
telephone quitline to deliver counseling and pharmacotherapy without burdening the
■■ Community resources and policies included referral to community and worksite quitsmoking clinics and related healthy lifestyle change programs and focused on stress
management, exercise, and weight loss, as well as support for worksite smoking cessation. “eir e#orts also involved campaigns and smoking restrictions and expanded
state funding for tobacco prevention and control programs.
“e chronic care model has provided a unifying approach to health care quality improvement that cuts across di#erent types of health behavior and chronic
conditions with the promise of a more e$cient, sustainable, and cost-e#ective
approach to health care quality improvement. “is is especially the case given
the development of several successful continuous quality improvement (CQI)
techniques for putting chronic care model–based system changes into place.
Promising midstream CQI techniques have been used to design and test o$ce
system changes to !nd ways to eliminate barriers and strengthen the supports for
recommended care, often through a series of “rapid cycle” (plan-do-study-act)
improvement e#orts.
Successful preventive CQI interventions have been delivered through learning
collaboratives involving multiple health care teams from di#erent organizations
that meet and work over a 12- to 18-month period with faculty experts in CQI
techniques and in the type of care targeted for improvement (e.g., tobacco dependence, obesity, diabetes management). Individual practice-level, chronic care
model–based improvements involve planning, implementing, evaluating, and
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176 Part II. Keeping Americans Healthy
re!ning changes in individual practices. “ese e#orts have substantially increased
the proportion of patients—including the most disadvantaged patients—who
receive evidence-based preventive care and for whom individual behavior change
plans were developed and implemented.
E#ective individual practice consultation models for CQI with a focus on
multiple risk behavior change were pioneered in the STEP-UP (Study to Enhance
Prevention by Understanding Practice) trial conducted by Goodwin and colleagues (2001). “is randomized, controlled trial tested a brief practice-tailored
approach to improving preventive service delivery, emphasizing improving rates
of health habit counseling and the usage of e#ective community-based programs
and supports for health behavior change.
Intervention practices received a 1-day practice assessment, an initial
practicewide consultation, and several brief follow-up visits to assess and address
practice-speci!c barriers. All interventions were delivered by a specially trained
nurse facilitator who helped practices to identify promising changes and presented
a menu of tools for implementing them (e.g., reminder systems, $ow sheets, patient
education materials, clinical information systems), including a practice improvement manual. “is brief CQI intervention resulted in signi!cant improvements at
6 and 12 months, which were maintained at a 24-month follow-up.
Improvements in behavioral counseling services were especially dramatic. “e
investigators attributed these lasting results to the maintenance of the practice and
system changes that were made—changes that may have been easier to institutionalize because they were tailored to the unique characteristics of each practice.
“e success of the STEP-UP trial and similar chronic care model–based
primary care practice redesign approaches inspired the Robert Wood Johnson
Foundation’s Prescription for Health national program. “is program funded 27
studies in primary care practice–based research networks to discover and test
innovative ways of delivering 5 A’s interventions for two or more health behaviors:
tobacco use, sedentary lifestyle, unhealthy diet, and/or risky drinking.
Projects in round 1 of the program demonstrated that practices could identify at-risk patients and motivate them to make changes. Round 2 projects built
linkages between clinical practices and community resources to reduce provider
burden and help patients sustain behavior changes. Each project required policy
and environmental changes in the practice (e.g., reminder systems, patient registries, performance incentives) to facilitate delivery of evidence-based counseling
and related treatments and to facilitate use of needed follow-up support from
community resources, such as telephone quitlines. Results showed that primary
care providers were able to deliver e#ective health behavior change interventions
when working in supportive health care systems and practices.
In the long run, just as upstream macro-level societal and policy change is
needed to sustain individual behavior change, upstream macro-level health system
and policy change is needed to improve care in o%ce practices and health plans.
Such changes include quality performance measurement and public reporting, “payfor-performance” initiatives that reward providers based on the quality of care they
o#er, and improved information technology to drive and support care improvement.
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Chapter 7. Health and Behavior 177
Some research has found that providers were more likely to o!er health behavior
change counseling when a portion of their
capitation payment depended on their doing
so. Providers in physician organizations
were found to be more likely to o!er proven
health promotion services if their performance measures were publicly reported or
they received public recognition or economic bene”t, and they had greater clinical
information technology capacity (McMenamin et al., 2004).
Changing health-related behavior represents a prime target for improving
national health and health care. Never have we known more about the importance
of addressing the lifestyle factors that pose the most serious threats to Americans’
health, produce the greatest demands on our health system, and contribute most
to health care costs. #e growing burden of chronic disease, a national epidemic
of obesity, and escalating health care costs—at a time when health care spending
already is growing faster than the U.S. gross domestic product—makes establishing a stronger preventive orientation in the nation’s health care and public health
systems an urgent priority.
Never have we known as much about how to motivate, support, and assist
individuals to make lasting lifestyle changes or how to support and assist health
care professionals to deliver evidence-based preventive care aimed at behavior change. #e tremendous parallel gains made in what we have learned about
how to achieve e!ective health promotion for individuals and health care quality
improvement for providers have created unprecedented potential.
#e landmark ACA represents one promising strategy that places prevention
at the heart of the e!orts needed to improve the nation’s health and health care.
Its prevention-oriented provisions include (a) full Medicaid and Medicare coverage
for all preventive health services recommended by USPSTF, including those focused
on health behavior change; (b) funding for community-based prevention grants to
implement programs and policy; (c) environmental changes to improve nutrition,
increase physical activity, reduce tobacco use and substance abuse, and reduce health
risk disparities; (d) funding for childhood obesity community demonstration projects;
and (e) the establishment of a National Prevention, Health Promotion, and Public
Health Council to set and track goals and objectives for improving health through
federally supported prevention, health promotion, and public health programs.
#e law also requires funding for the continuation and greater coordination of
the USPSTF and CDC’s Community Preventive Services Task Force. Combined,
these e!orts hold unprecedented potential to capitalize and build on the strong
evidence for health-related behavior change created over the past three decades.
Just as upstream macro-level
societal and policy change is
needed to sustain individual
behavior change, upstream
macro-level health system and
policy change are needed to
support and improve care in
of!ce practices and health plans.
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178 Part II. Keeping Americans Healthy
You have just been hired as the director of strategic planning for a health plan that insures
30% of the residents in a metropolitan area of 500,000. Most of those insured by this health
plan are employed by large companies in the metropolitan area, and these companies pay for
their employees’ health insurance. The health plan leaders and the employers both recognize
that their business model depends on their success in addressing behavioral risk factors that
play a critical role in the prevention and management of chronic diseases, the containment of
health care costs, and the enhancement of employee productivity.
In your new role, you are asked to create a comprehensive plan for addressing these
behavioral risk factors—by improving both the clinical care provided and the plan’s
community-based efforts. Speci!cally, you want to develop strategies to reduce the levels of
tobacco use, unhealthy diet, and physical inactivity. In constructing your plan, consider the
following questions:
1. What mix of interventions would you need to consider that might change enrollee behavior, provider behavior, and community policies and environments and maximize the costeffectiveness of this plan?
2. What is the evidence that these interventions would work?
3. What would be the implementation challenges of the plan?
1. Brie!y describe the e”ects of personal health behavior (e.g., tobacco use, risky drinking, diet, and physical activity) on individual and population health status and health
care costs in the United States.
2. How have health behavior change programs and interventions evolved over the past
40 years?
3. In order to achieve e”ective behavioral interventions, most physicians use clinical
practice guidelines that are based on the 5A’s model. Brie!y describe this model, using
tobacco cessation counseling as an example.
4. Describe the parallel shifts that have taken place during the past 30 years in understanding what the essential targets must be for successful interventions (a) to increase
patients’ adherence to recommended prevention-oriented health behavior and
(b) to increase providers’ use of recommended clinical preventive behavior change
5. With reference to McKinlay’s population-based intervention model, outline possible
downstream, midstream, and upstream strategies that can be used to
achieve one of the following: (a) curb binge drinking on a college campus; (b) increase
smoking cessation, especially among pregnant smokers enrolled in a Medicaid managed care plan; or (c) increase physical activity and healthy eating among middle school
students in an urban center. Be sure to mention the di”erent sectors that would need
to be involved (public health, law enforcement, local business, school o#cials, policy
makers, community planning, transportation, health plan leaders/providers, and so on).
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Vulnerable Populations:
Meeting the Health Needs
of Populations Facing
Health Inequities
Monique J. Vasquez, Jacqueline Martinez Garcel,
Elizabeth A. Ward, and Lourdes J. Rodríguez
Understand the predisposing and enabling factors that increase the vulnerability of people disproportionately affected by health inequities
Identify the growing number of health inequities
Describe how the Great Recession has led to a strained social service sector
Explain how the U.S. health care system provides and pays for services to
vulnerable populations
Discuss social needs of populations affected by health inequities and the
safety net currently provided by the social service sector
Identify challenges and opportunities to reduce health care costs and improve
health outcomes of people disproportionately affected by health inequities
behavioral health services
cash assistance programs
chronic illnesses
Disproportionate Share Hospitals (DSH) program
dual eligibles
enabling factor
© Springer Publishing Company DOI: 10.1891/9780826172730.0008
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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Account: s3563253.main.ehost

184 Part II. Keeping Americans Healthy
health need factor
patient engagement
predisposing factor
safety-net providers
Understanding factors and systems that affect people disproportionately
affected by health inequities
The growing number of health inequities
Uneven footing after the Great Recession and a strained social service sector
Organization and financing of health care, population/public health/
prevention, and other services for populations experiencing health inequities
Social service needs
Federal and state financing of care for vulnerable populations
Challenges for service delivery and payment
Emerging and tested ideas for better health delivery
Opportunities in the ACA to meet health care needs of vulnerable populations
Challenges of health care reform and threats to the ACA
In order to better understand health, we must understand the way in which life
experiences a!ect the health and well-being of di!erent groups. When power and
oppression result in groups being treated di!erently because of race, ethnicity, income, gender,
sexual orientation, immigration status, ability
level, or other factors, people in groups that
have less power or social status are more vulnerable to health inequities. “is vulnerability makes it harder for people to be healthy,
to stay healthy, to prevent illness, and to
have better outcomes when they become sick
or ill. “roughout the 20th century, the United
States—one of the wealthiest nations in the
world—has made strides toward increasing access to health care for vulnerable
populations. “e advent of employer-based health insurance, passage of
With the nation’s population
growing both older and
more diverse in terms of
demographics and income,
policymakers face increasing
challenges in ensuring that
health care is provided to
vulnerable populations, and
at affordable costs.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 8. Vulnerable Populations 185
and Medicaid in the 1960s, the establishment of community health centers in the
1970s, and the creation of the Children’s Health Insurance Program in the 1990s
all worked together to connect medically and socioeconomically disadvantaged
populations to the U.S. health care system. !e passage of the landmark Patient
Protection and A”ordable Care Act (ACA) in the 21st century was yet another
major victory in narrowing the gap between those who have access to health care
services and those who have been historically marginalized from them. Progress
thus far, however, has barely scratched the surface of a mounting problem—the
health and well-being of people living in the United States who are disproportionately a”ected by health inequities. !ere remain millions of people living in the
United States who have not bene#ted from these improvements. Moreover, the
solutions developed to address the needs of people disproportionately impacted
by health inequities have been fragmented and categorical. Populations disproportionately a”ected by health inequities are strong. !ey have weathered and
fought against generations of oppression, but our current system provides little
support for the growing number of people disproportionately a”ected by health
inequities. As demographics shift in the United States, the population is becoming older, the number of people of color is increasing, and a growing number of
people are living with chronic disease(s). Income gaps have been increasing since
the 1970s, and wealth gaps have increased dramatically, with the top 1% owning
almost half (49%) of the wealth in 2016 (Stone, Trisi, Sherman, & Debot, 2015). At
the same time, there is a strained social sector that provides support for vulnerable
Current solutions come with growing price tags. As a result, they are at heightened risk of funding cuts. !is is the case with the ACA, at threat of being repealed,
undermining access to health care services for those who are already vulnerable to
health inequities. Developing solutions that will contain health care expenditures
and meet the health needs of vulnerable populations is one of the leading challenges facing policy makers in the United States.
In order to meet these shifting needs and
address health inequities, our health care
system must utilize innovative approaches
to increase access to care and rethink the
ways in which health care is delivered.
!is chapter examines the factors
a”ecting populations disproportionately
impacted by health inequities. !e #rst section provides an overview of the segments
of the population that fall under this category as well as a framework for understanding enablers of vulnerability. In subsequent sections, we explore the organization
and #nancing of health care for vulnerable populations, examine limitations, and
explore the importance of social services to achieve and maintain health. Finally,
we discuss the role of the ACA in addressing the health needs of people experiencing disproportionate health inequities.
Developing solutions that will
contain health care expenditures
and meet the needs of
populations disproportionately
affected by health inequities is
one of the leading challenges
facing policy makers in the
United States.
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186 Part II. Keeping Americans Healthy
Whether we identify as part of this population ourselves or whether they are our
friends, loved ones, or neighbors, the lives of people who are disproportionately
a!ected by health inequities are interwoven into our communities and
neighborhoods. People a!ected by inequities are everywhere, regardless of
whether we live in a thriving metropolis, a gated suburban community, or a
small town in rural America. In order to better understand how groups of
people are impacted by health inequities, we must “rst distinguish between
inequalities and inequities. Figure 8.1 illustrates the di!erence between the
two terms.
#e illustration shows three people confronted with a barrier, the fence, that
prevents them from watching a ball game. #e “rst panel shows what happens
when an intervention seeks to be equal; although each individual has been provided with the same resources, one person is excluded from being able to see
the game, even though they have equal access to the resource (the box). In the
second panel, the same amount of resources (boxes) are distributed, but this time
resources are distributed in an intentional way that takes into account the needs
of each person relative to the barriers (the fence). Rather than seeking equality,
health equity seeks to address the systemic barriers that groups of people face
that result in disproportionate poor health outcomes. It can be tempting to view
the individual on the right from a de”cit lens or simply label them as “in need.”
Source: Interaction Institute for Social Change. Retrieved from
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Chapter 8. Vulnerable Populations 187
It is more useful, however, to recognize that there are a variety of factors that,
when ignored, make it di!cult for individuals and groups to overcome systemic
barriers. “e World Health Organization (WHO) de#nes health inequities as systematic di$erences in health that occur between and within countries and are
avoidable and unfair (Commission on Social Determinants of Health, 2008). In
their 2008 study, the WHO discusses the need to embrace a holistic view toward
the social determinants of health in order to understand how “circumstances
in which people grow, live, work and age, and the systems put in place to deal
with illness” a$ect health inequities (Commission on Social Determinants of
Health, 2008).
“e United States has a long history of oppression, discrimination, social
exclusion, and marginalization of groups that are non-European; that are poor,
or not male; and who, because of these factors, are not part of an advantaged
social or economic group. “is history began with the colonists’ violence,
exploitation, and decimation of Native American peoples and the forced migration and enslavement of people from Africa. Despite improvements, mainly at
the impetus of marginalized peoples pushing for change, many policies, systems, and institutions in the United States continue to oppress people of color;
people who are poor; people living with physical disabilities; people with mental health issues; people practicing nondominant faiths; and people who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ). Factors such as
poverty, discrimination, unbalanced power dynamics, and lack of equal and fair
access to opportunities further contribute to poor health outcomes (Braveman,
Arkin, Orleans, Proctor, & Plough, 2017). Braveman et al. (2011) discussed that
these health inequities serve to further marginalize oppressed groups, noting
that “Health di$erences adversely a$ecting socially disadvantaged groups are
particularly unacceptable because ill health can be an obstacle to overcoming
social disadvantage.” “e obstacles that people from historically marginalized
populations face make them vulnerable to poor health status, poor health outcomes, and health care access.
Vulnerability can be in&uenced by a variety of factors, including disease
status (such as chronic conditions, mental illness, HIV-positive status), demographics (such as socioeconomic status [SES], educational attainment, housing
situation, racial/ethnic background, immigration or refugee status), age group
(such as children or the elderly), or the ability to access health services (uninsured, those who live in a remote rural area, those who lack a regular source
of care) (Aday, 2001). For instance, children, senior citizens, refugees, immigrants, non-native English speakers, formerly incarcerated individuals, people
who experience homelessness, and many other groups are more vulnerable
to health inequities due to risk of discrimination, oppression, and diminished
agency or power.
Our humanity and the range of life experiences we face put us all at risk of
being vulnerable at di$erent points in our lives. We are all susceptible to a host of
negative or stressful events such as sudden or chronic or acute illness, unemployment, homelessness, or divorce. “ere are, however, individual and community
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188 Part II. Keeping Americans Healthy
factors that mediate this risk. For instance, according to the Conservation of
Resources theory, the e!ect of a stressful life event on a person who lives in a
poor neighborhood with limited access to resources is much more adverse than
that on a person who lives in a wealthy neighborhood with access to a variety of
options to ameliorate the problem (Hobfoll, 2001).
“e Conservation of Resources theory states that people are motivated to
obtain, keep, and protect resources they value, which can range from a house
or vehicle to marriage, employment, self-esteem, credit, knowledge, or money
(Hobfoll, 2012). Resource loss, which can be caused by an adverse event or disaster, has a stronger impact on an individual than if they had gained resources. An
individual will need to invest resources in order to recover or protect against
resource loss, but those who already have limited resources prior to a disaster will
have less capacity to manage stress and leverage resources when resources are
lost (Hobfoll, 2012). As an example, over the last few decades, a series of natural
disasters has caused many Americans to lose their loved ones, their homes, and
their possessions and to be at risk for signi#cant medical and/or mental health
issues. Since 2005, extreme weather conditions caused by hurricanes Katrina,
Rita, Harvey, Irma, and Maria devastated parts of Texas, Louisiana, Florida, and
Puerto Rico. Everyone a!ected by a hurricane will experience resource loss, but
the people with fewer resources—such as people living in poverty, renters, people
with low-quality housing, people with low-levels of social support or social capital, people who have a disability or chronic medical condition, or people who are
elderly—may #nd themselves with increased vulnerability because of their circumstances prior to the disaster. Vulnerability can be two fold as people who are
disproportionately a!ected by inequities are also likely to live in high-risk areas,
including $ood zones and in substandard housing (Cutter & Emrich, 2006).
A Framework for Understanding Vulnerability
Shi and colleagues (2008) introduced a general model of vulnerability, which was
adapted from a model from Andersen and Aday that categorized risks as predisposing,
enabling, and need (Andersen, 1995). “e general model of vulnerability can be
used to understand the convergence of individual, social, community, and accessto-care risks (Shi & Stevens, 2010). In this model, individual risk factors, such as
demographics (age, gender, race/ethnicity, SES), health status, health insurance,
and individual belief systems associated with health behaviors, are studied in light
of the larger context of a person’s life. Environmental (or ecological) risk factors
include the geographical location (rural versus urban), SES of an entire community
(neighborhood income level and unemployment rates), resource inequalities, and
the social capital (or social cohesion) of the neighborhood.
Vulnerability to poor health, as posited by this model, is determined by a
convergence of predisposing, enabling, and need characteristics at the individual
and ecological levels.
For example, a man who has hypertension (
health need factor), is African
American (
predisposing factor), and is uninsured (enabling factor) would be
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Chapter 8. Vulnerable Populations 189
Enabling Enabling
Need Need
Quality of Care
Risk Factors
Health Outcomes
Access to Care
Mental, and
Social Health
Mental, and
Social Health
Source: Shi, L,Stevens, g.d., Faed, P., & Tsai, J. (2008). Rethinking vulnerable population in the United States: an introduction to a general mode of vulnerability. Harvard Health Policy Rev, 9(1), 43–48.
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190 Part II. Keeping Americans Healthy
considered more vulnerable than a man who has hypertension but is not part of
a historically marginalized population.
In this model,
health needs directly imply vulnerability, predisposing factors
indicate the propensity for vulnerability, and enabling factors re!ect the resources
available to overcome the consequences of vulnerability (Shi & Stevens, 2010).
Health Need Factor
In this chapter, we frame health needs using the de”nition of health developed
by the WHO, which de”nes health as a “state of complete
physical, mental, and
social well-being and not merely the absence of disease or in”rmity” (WHO,
1948). #is de”nition may be understood as follows:
■■ Physical health needs are characterized according to the physiological and physical
status of the body. Problems a$ecting physical health include speci”c acute or chronic
diseases (such as HIV/AIDS, diabetes, asthma) or disabilities.
■■ Mental (or psychological) health needs are characterized by emotional and behavioral
health—in essence, by an individual’s state of mind. Problems a$ecting mental health
include speci”c mental illnesses, chronic dependence on drugs or alcohol, or a susceptibility to harm oneself or others.
■■ Social health needs extend beyond the individual and include both the quantity and
quality of social contacts with other people. Individuals who have been marginalized
or ostracized from their communities (such as individuals experiencing homelessness,
immigrants or refugees, the formerly incarcerated, people living in an abusive home)
would be characterized as having unmet social health needs (Aday, 2001).
Poor health along one dimension, as in the previous example’s physical health,
is very likely to converge with poor health along others, such as the individual’s
psychological or social needs. For instance, a person who does not have insurance
would be more susceptible to depression because of the compounding stresses
associated with receiving a diagnosis, managing a chronic health condition, and
confronting the high cost of medical bills.
Predisposing Factor
In the previous example, being African American is listed as a predisposing factor
because African Americans experience a multitude of health inequities, including
higher chronic disease rates, barriers and obstacles to receiving medical care, worse
disease outcomes, and higher mortality and morbidity rates; in addition to systemic
disparities in income, educational outcomes, and access to resources, multiple
studies have linked adverse health outcomes to the cumulative burden of stress and
racial discrimination (Williams, 2012; Williams, Priest, & Anderson, 2016).
In a longitudinal study, 17- to 19-year-old African Americans who reported
high levels of racial discrimination had higher levels of cytokine at age 22 than their
peers (Brody, Yu, Miller, & Chen, 2015). Cyokine are proteins secreted by cells and
found in the blood that serve an important modulating function in the immune
system. Higher levels of cytokine are linked to low-grade in!ammation, which can
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Chapter 8. Vulnerable Populations 191
cause increased risk of chronic disease and problems associated with aging such
as hypertension, obesity, insulin resistance, diabetes risk, and stroke. Researchers
also found that youth who showed positive racial identity did not show the same
association between discrimination and cytokine (Brody et al., 2015). Studies focused
on adults show an association between hypertension risk, control of hypertension
symptoms, and elevated blood pressure with perceived discrimination (Cu!ee,
Hargraves, & Allison, 2012). A survey conducted in 2017 of African Americans,
Asian Americans, Latinos, Native Americans, White Americans, and LGBTQ
adults asked about experiences with discrimination. African Americans reported
experiencing high levels of discrimination when being considered for a promotion or
receiving equal pay at work (57%), during job applications (56%), and being unfairly
stopped or unfairly treated by police due to their race (National Public Radio, 2017).
“e American Psychological Association (APA) found that people who experienced
discrimination reported worse health and higher levels of stress (APA, 2016).
Predisposing factors include not only individual risk but also community
risk. Community risk includes issues that a!ect groups of individuals such as
less access to parks and places to exercise, less access to a!ordable and accessible
healthy foods, and increased stress levels from low-wage jobs (Shi, Stevens, Faed
& Tsai, 2008). Socioeconomic determinants of health are structural determinants
and conditions that in#uence health; they include a variety of factors such as economic stability, neighborhood and physical environment, education, food, community and social context, and certain characteristics of the health care systems
(Heiman & Artiga, 2015). Health experts believe these factors have a much larger
in#uence than health care itself (Heiman & Artiga, 2015), and the WHO places
a high priority on addressing the social determinants of health and training a
workforce that both understands and can raise public awareness about the social
determinants (Commission on Social Determinants of Health, 2008).

and Physical
Education Food Community
and Social
Health Care
Medical bills
arly childhood
Access to
linguistic and
uality of care

Health Outcomes
Mortality, Morbility, Life Expectancy, Health Care Expenditures, Health Status, Functional Limitations
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192 Part II. Keeping Americans Healthy
Enabling Factors
Previously, we described that enabling factors mediate our access to resources
necessary to overcome the consequences of vulnerability. One example is social
capital. Social capital is measured by the quantity and quality of interpersonal ties
among people and groups sharing a community, which can be de!ned geographically or by a common characteristic. It is critical for mitigating or minimizing the
e”ect of negative life events on health. Family structure, friendship ties, religious
organizations, and neighborhood connections provide social capital to members
in the form of social support and associated feelings of belonging, psychological
well-being, and self-esteem (Aday, 2001).
Building on the example of an uninsured
African American man who has hypertension and symptoms of depression: If, in addition, he is also socially isolated, with little
or no social network in his community, it is
unlikely that he will succeed in long-term
e”orts to improve his health, such as establishing healthier eating habits or adhering to a
strict medication regimen. A strong social support system is key to making a signi!-
cant di”erence in the likelihood of starting—and sticking with—lifestyle changes.
#e general model of vulnerability is used throughout this chapter to illustrate
best practices, including an examination of predisposing factors, enabling factors,
and need; later in the chapter are recommendations for programs and policies
that can improve the health outcomes of this population. Before we describe the
network of existing services and programs—and their !nancing mechanisms—
that care for the needs of vulnerable populations, we focus in the next section
on why the number of vulnerable groups is increasing in the United States. #is
increase is one of the critical reasons health care leaders and policy makers must
!nd more e”ective and e$cient ways to address the needs of vulnerable populations than are currently available.
#ree leading and concurrent factors have contributed to the growing number
of populations who are currently at risk of disproportionally experiencing health
■■ #e di”erential rise in prevalence of chronic conditions such as diabetes, cancer, and
cardiovascular disease
■■ Shifting demographics of the overall U.S. population, especially the growing income
inequality between rich and poor, the shift to a majority of people of color population,
and the graying of the baby boomer generation
■■ An uneven footing after the Great Recession for already vulnerable communities and
a strained social service sector
A strong social support system
is key to making a signi!cant
difference in the likelihood of
starting—and sticking with—
lifestyle changes.
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Chapter 8. Vulnerable Populations 193
Prevalence of Chronic Conditions
Chronic illnesses, such as heart disease, diabetes, cancer, respiratory diseases,
and arthritis, are ongoing medical conditions that can be treated but not cured.
!ese conditions require constant management, and they signi”cantly alter the
daily life of those who su#er from them. !e 2012 National Health Interview Survey estimated that 49.8% of civilians who are not institutionalized, or 117 million
adults, had at least one chronic physical health condition. In the United States,
the rise in chronic conditions has been unprecedented, and these conditions have
exacted an enormous human and “nancial toll.
While everyone is at risk for developing a chronic illness, vulnerable groups
are more likely to have a chronic illnesses because of disparities in resources and
tools to prevent illness and maintain health and well-being. Lifestyle behaviors
that can often be associated with the socioeconomic determinants of health—
such as tobacco use; lack of regular physical activity; and consumption of diets
rich in saturated fats, sugars, and salt—have greatly contributed to the increase
in chronic conditions in the United States (Bauer, Briss, Goodman, & Bowman,
2014). Studies have shown that people who live in areas of more socioeconomic
disadvantage are more likely to take part in these risky health behaviors (DiezRoux, 2003; Do, 2009; Lang et al., 2009). In order to truly address health inequities, particularly as they pertain to socioeconomic determinants of health, we
must explicitly focus on health equity throughout intervention design and implementation; otherwise, we run the risk of inadvertently increasing disparities in
populations. For instance, public smoking campaigns in the past have been more
e#ective with a$uent educated populations, not because they are the ones who
care more about their health, but because the interventions did not have marginalized populations and lower socioeconomic populations in mind during their
implementation (Braveman et al., 2017).
Although having a chronic physical or mental health condition does not mean
that an individual will not have a good quality of life, for many, one or more of
these conditions can be disabling, thereby reducing the quality of life and leading
to isolation and depression. Vulnerable groups are more likely to feel the impacts
of chronic disease in a di#erent way than populations with more resources or
socieconocomic status. Groups with fewer resources may struggle to “nd and
access care to monitor and treat their condition, to pay for treatment, and to have
adequate social support. Additionally, vulnerable populations may struggle to
change the very lifestyle behaviors that put them at risk for a chronic illness in the
“rst place, because a diagnosis rarely has the ability to alter the socioeconomic
determinants of health. !us, it is di%cult for already vulnerable populations to
seek care and manage their illness. Chronic illness also impacts an individual’s
ability to maintain employment and care for themselves and family members,
which in turn can increase their vulnerability. !e prevalence of
multiple chronic
conditions—comorbidity of any combination of the previously mentioned conditions—makes it even harder to coordinate e#orts and address the problems
at hand. More than 25% of adults had two or three chronic conditions (Ward,
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194 Part II. Keeping Americans Healthy
Schiller, & Goodman, 2014). !ese estimates look worse for speci”c segments
of the population, especially people of color and the poor. If these trends continue unchanged, we can expect the number of adults with at least one chronic
disease to reach more than 171 million by 2030 (Figure 8.4) (Wu & Green, 2000).
Not only is the toll on life high—with 7 out of 10 deaths each year attributed to
chronic conditions—but so is the toll on the health care system because people
with chronic conditions account for more than 80% of hospital admissions (Partnership for Solutions, 2004).
Shifting Demographics in the United States
Growing Income Inequalities
In 2014, the United States marked the 50th anniversary of President Lyndon
B. Johnson’s War on Poverty. As a nation, however, the United States has fallen
short of the commitment made in 1964 that American citizens would have a fair
opportunity to pursue a productive future, earn a decent living wage, and live in
a safe community with access to good schools. In 2016, more than 40.6 million
Americans—approximately 12.5% of the population—were living at or below the
federal poverty threshold ($24,600 for a family of four) (U.S. Census Bureau, 2017).
In 2016, more than one-third of the poor—5.8% of the overall U.S. population—
lived in deep poverty, earning less than $6,000 a year. While poverty rates have
#uctuated with the economy, the number of people in deep poverty has increased
over time from 3.7% of the population in 1975. !e rate of deep poverty increased
Number of People With Chronic Conditions
Source: Wu, S.-Y., & Green, A. (2000). Projection of chronic illness prevalence and cost in!ation.
Santa Monica, CA: RAND Corporation. Retrieved from http://www.! sites/
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Chapter 8. Vulnerable Populations 195
in the early 1980s, reaching 5.9% in 1983. It lowered again until 1993 where it
peaked at 6.2% before going back to a range of 4.5% to 5.7%. !e rate of deep
poverty rose to its highest level in 2010 at 6.7% and has remained high since the
recession, with 2016 as the “rst time it has dropped below 6% since that time (U.S.
Census Bureau, 2017).
Poverty has persistently a#ected certain segments of the population more
than others. Children under the age of 18 are more likely to live in poverty. In
2012, nearly 22% of children—one out of every “ve—were living in poverty. Certain racial and ethnic groups are more likely to be poor than others. Poverty rates
for African Americans (27%) and Latinos (25%), as well as their children (38% and
33%, respectively), are signi”cantly higher than for White Americans (10%) and
their children (20%). To put this in perspective, one out of every three African
American children and one out of every four Latino children lives in poverty.
Single-parent families are also more likely to live in poverty. !irty-one percent
of female-headed households, for instance, live in poverty, compared with 6% of
married-couple households. People with disabilities (28%) are more than twice as
likely to live in poverty as their counterparts without a disability (12%).
Although poverty has been concentrated in cities and in rural communities
throughout U.S. history, there has been a steady increase in the number of people living in poverty in suburban neighborhoods. In 2008, the number of suburban poor exceeded the urban poor in central cities by 1.5 million. Although the
rates of poverty continue to be higher in urban areas than in suburbs (18% versus
9.5%), poverty rates are increasing at a faster pace in suburban areas (Allard &
Roth, 2010). !is is an especially troubling trend, since suburban communities
tend to be mostly residential (with little or no access to commercial services), disconnected from public amenities (i.e., mass transit), and lacking in public spaces
for social interaction.
Income—or lack thereof—is one of the key enablers of vulnerability. People
with “nancial resources not only have the ability to obtain access to the highestquality health services, but also have access to other material goods that bene”t
health and greater opportunities to build the social capital that can serve as a buffer for adverse life events. Income also has a more substantive and complex e#ect
on health when it is considered in the context of a neighborhood. Concentrated
wealth has a larger e#ect on the environment (neighborhood) that shapes a person’s position along the socioeconomic gradient, which includes an individual’s
education level and employment opportunities. In the United States, where you
live determines the quality of the education system your children have access to
because the local tax base determines funding for public schools. In communities with concentrated poverty, students have lower average test scores, fewer
quali”ed teachers, fewer interactions with colleges and potential employers,
higher levels of teen pregnancy, and higher high school dropout rates than public
schools in neighborhoods with more resources (Willms, 1999).
!us far, we have explored the e#ect of absolute income and SES status on
health and the role of SES as an enabling factor of vulnerability. However, distribution of income is also an important factor in determining the health of a
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196 Part II. Keeping Americans Healthy
population. Income inequalities are on the
rise in the United States; in fact, in 2012 the
gap between the richest 1% and the remaining 99% was the largest it has been since
the 1920s. According to recent analysis,
the 400 richest people in the United States
have more combined wealth than the bottom 150 million put together. !e relationship between income inequality and health
has broader implications in determining
health outcomes beyond personal income.
Concentrated wealth leads to concentrated poverty, which in turn leads to poor
neighborhoods and communities.
Myriad studies have shown the correlation between disadvantaged communities and poor health outcomes (Diez-Roux, 2003; Do, 2009; Lang et al., 2009).
!e widening gap between rich and poor leads to a greater separation between
the institutions, organizations, and services that promote and protect health.
People living in neighborhoods with many resources are more likely to engage
in healthy behaviors, whether these behaviors are due to the wider availability
of primary care services, stores o”ering healthy food, or environments for safe
physical activities. An entire population is at greater risk of poor health outcomes
when they are persistently exposed to poverty, have limited access to high-quality
health organizations, and have major stressors impeding their daily life activities.
Growing Numbers of People of Color
!e U.S. Census Bureau predicts that by 2044, the United States will be made
up by a majority of people of color as opposed to a nation with a majority White
population. (Pastor, Scoggins, & Treuhaft, 2017). Our nation has not e”ectively
addressed racial and ethnic inequities, which means that while the number of
people of color increase, it is accompanied by the problematic and disproportionate burden created by systemic inequities that negatively impact people of color.
!ere is a growing need to address these inequities, especially for the subset of
people of color who are most vulnerable to health challenges due to low incomes
and frequent challenges related to the social determinants of health. While it is the
case that most people with low incomes face health challenges, being a person of
color intersects with SES; thus, a person of color living in poverty will experience
worsened health impacts than a person living in poverty without this identity.
Inequities in health associated with race, for example, do not simply put patients
of color at risk of receiving less e”ective care, they also appear to be often at risk of
receiving more ine”ective care (Schpero et al., 2017) when they receive care. Inequities are also associated with system related factors such as ambulance diversion
(Hsia, Sarkar, & Shen, 2017), organ allocation protocols (Mathur, Ashby, Sands,
& Wolfe, 2010; Patzer & McClellan, 2012), and implementation of care delivery
models such as the patient-centered medical home (Washington et al., 2017).
People living in neighborhoods
with many resources are more
likely to engage in healthy
behaviors, whether these
behaviors are due to the wider
availability of primary care
services, stores offering healthy
food, or environments for safe
physical activities.
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Chapter 8. Vulnerable Populations 197
The Graying of America
On January 1, 2011, the !rst baby boomers turned 65 years old. Over the next
5 years, 8,000 people will turn 65 each day, qualifying many for Medicare. “e
population aged 65 and over increased from 35 million in 2000 to 41 million in
2011 (an 18% increase). As of 2013, people over 65 represented 13% of the U.S.
population, about one in every eight Americans. In 2030, when the entire baby
boom generation will have turned 65, seniors will make up one-fourth of the population. “e segment of the population 85 years and older is projected to increase
from 5 million in 2011 to 9 million in 2030 (Knickman & Snell, 2002).
Baby boomers will live longer than previous generations because of improvements in health care, technology, and lifestyles. “e elderly of 2030 will also be
better educated than the current elderly population, with rates of college graduation two times higher and high school dropout rates one-third less than the current elderly generation (Knickman & Snell, 2002). “is is good news for the future
health of baby boomers because there is a strong association between education and disability. College graduates have a disability rate about half that of high
school dropouts (Knickman & Snell, 2002). However, with the aging of America
and longer average life spans, the rates of chronic conditions associated with an
older population will also grow.
According to the Centers for Disease Control and Prevention (CDC), the average American over the age of 65 has multiple chronic conditions such as hypertension (72%), arthritis (51%), heart disease (31%), cancer (24%), and diabetes
(20%). In 2010, about 13.6 million persons aged 65 or older were discharged from
short-stay hospitals. “eir rate of discharge is three times the comparable rate
for persons of all ages. “e average length of stay in a hospital is longer for older
people. “e average length of stay for persons aged 65 to 74 was 5.4 days; for those
aged 75 to 84, it was 5.7 days; and for those aged 85 and over, it was 5.6 days. “e
comparable rate for persons of all ages was 4.8 days.
Health expenditures are a greater !nancial burden for older people, in particular for those with lower SES. “e majority of Medicare recipients (83%) are over
65 (Centers for Medicare & Medicaid Services [CMS], 2016). In 2013, the average out-of-pocket health care expenditures for all Medicare recipients was $5,503.
Average costs increased with age with people aged 65–74 with expenses at $4,676,
people aged 75–84 at $5,745, and out of pocket costs rising to $10,208 for people
85 and over (Cubanski, Neuman, Damico, & Smith, 2018). “is is an especially
large amount given that half of all people enrolled in Medicare live on less than
$26,000 a year, and the average Social Security income (SSI) in 2013 was $13,375.
For elderly populations on Medicare with no other income other than SSI, out-ofpocket health care spending in 2013 averaged a large portion of their income at
nearly a third (34%) for ages 65–74, 40% for those aged 75–84, and 74% for ages 85
and older. (Cubanski et al., 2018). “ese numbers are expected to increase by 2030
at 44%, 48%, and 87%, respectively. Out-of-pocket health care expenses made up
a larger proportion of costs for women, even though they had slightly higher SSIs,
their cost of care was higher, particularly for women over 75 (Cubanski et al., 2018).
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198 Part II. Keeping Americans Healthy
!eir age (a predisposing factor of vulnerability), coupled with the risk of
“nancial hardship (an enabling factor) and the increased possibility of chronic
conditions (another enabling factor), places older Americans—especially those
living in impoverished neighborhoods—at highest risk of vulnerability.
Between December 2007 and June 2009, the United States experienced an economic recession that was one of the longest and, by most measures, the worst
since the Great Depression (Grusky, Western, & Wimer, 2011). !is Great Recession began with the bursting of an $8 trillion housing bubble, which was then followed by massive job loss. A decade later, as a country, we “nd ourselves in a good
news/bad news moment. !e good news is that the Great Recession is behind
us. While most economic markers experienced low points through 2009–2010,
they began to recover by 2012–2014. For example, the annual Median Household
Income in the United States recovered from the Great Recession low of $54,569
in 2012 to an record high of $60,309 by 2016 (Federal Reserve Economic Data
[FRED], 2018). In December 2014, President Obama declared the Great Recession over and bailout measures instituted during the Bush and Obama administrations as mostly e$ective (Weisman, 2014).
!e bad news is that, despite more fully employed people, wage increases
have been sluggish and, since the Great Recession disproportionally a$ected
already vulnerable populations, imposing a larger burden and negative impact—
recovery has not been equitable. An analysis of the National Asset Scorecard and
Communities of Color found that while during the Great Recession White families typically saw 16% of their wealth taken, African American families had more
than half (53%) of their already proportionally lower wealth stripped away. Before
the Great Recession, African American families had less than a dime of wealth
for every dollar of wealth held by White families. After the recession, African
American families had, on average, about 6 cents for every dollar compared to
their White counterparts (Hamilton, Darity, Price Sridharan, & Tippett, 2015).
While the U.S. government passed a tax reduction plan aimed at alleviating the negative impact of the Great Recession, the bene”ts favored the wealthy
more than low- to middle-income persons (Saez & Zucman, 2016). To o$set the
resulting budget de”cits, policy makers reduced funding to the social service sector that aids vulnerable populations and keeps those at the edge from becoming
vulnerable (Stern & Axinn, 2018). In sum, the positive direction of the overall
economy has not been equitably distributed, and the tax cut is highly likely to
exacerbate economic and hence health and other inequities.
!e very same agencies that help to alleviate the economic and social e$ects
on families and communities are being stretched to the limit while experiencing cuts to their own budgets. One of such agencies is the U.S. Department of
Agriculture (USDA), which has experienced cuts to their Supplemental Nutrition
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Chapter 8. Vulnerable Populations 199
Assistance Program (SNAP). In 2018, SNAP bene!ts averaged close to $1.40 per
person per meal (Center on Budget and Policy Priorities, 2018). #ese cuts a$ect
some of the most vulnerable populations that participate in SNAP—including 22
million children (10 million of whom live in “deep poverty,” with family incomes
below 50% of the poverty line) and 9 million people who are elderly or have a
serious disability. Furthermore, while SNAP caseload declined as the economy
improved and the country recovered from the Great Recession, some of the
decline (at least 500,000 people) is the result of a provision that limits SNAP bene!ts for unemployed adults aged 18–49 who are not disabled or raising children.
#e 3-month limit, while contributing to falling caseloads, threatens to put individuals over the vulnerability edge.
We have de!ned vulnerable populations and described the pathways through which
predisposing and enabling factors lead to vulnerability. We have also described
three main reasons why the number of vulnerable groups is projected to grow. In
this section, we provide an inventory of the existing resources and strategies set
in place to care for the vulnerable. First, we o$er a brief description of institutions
and structures within the health care system that deliver services for vulnerable
populations. #en, we describe !nancing mechanisms at the federal, state, and
private levels that support health care and social services for vulnerable groups.
More thorough and general treatments (not speci!c to vulnerable populations) of
some of the topics presented here are o$ered in other chapters of this book.
Public Hospitals
Public hospitals make up a large part of the safety net, providing services to large
portions of people who are uninsured, the underinsured, and those on Medicaid
and often serve some of the sickest, poorest, and most vulnerable populations.
#e mission of a public hospital within the safety net system is, quite simply, to
be the guarantor of health for the public (Gourevitch, Malaspina, Weitzman, &
Goldfrank, 2008). Public hospitals focus on providing care to the most vulnerable
groups within a community: the homeless, the disabled, documented and undocumented immigrants, high-risk mothers and infants, and those with limited pro-
!ciency in speaking and reading English. Public hospitals also provide services to
the incarcerated, respond to disasters within communities, provide trauma care,
and administer behavioral health and substance abuse treatment when necessary
(Gourevitch et al., 2008).
Most patients who receive health care services from public hospitals are low
income and uninsured; they also su$er disproportionately from preventable
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200 Part II. Keeping Americans Healthy
chronic health conditions. Many of these patients visit the emergency departments (EDs) of public hospitals to receive primary care because they lack a
primary care provider. Patients who use the ED for most of their health care,
regardless of urgency, are referred to as high utilizers (see case exercise 2).
Federally Qualified Health Centers
Federally quali!ed health centers (FQHCs) are systems of safety-net providers
that serve predominantly vulnerable groups living in underserved communities.
“ese centers are overseen by the Health Resources and Services Administration
(HRSA) of the U.S. Department of Health and Human Services (DHHS).
“e FQHC program allocates special Medicare and Medicaid cost-based
reimbursement payments to health centers for legislatively speci!ed services. To
qualify as an FQHC, a safety-net provider must meet the following criteria:
■■ Provide services in communities identi!ed as “predominantly medically underserved
areas” or provide services to a target population documented to be underserved
■■ O#er the required primary and preventive health services, meet speci!c sta$ng
requirements, and o#er a sliding-fee payment scale for services rendered
■■ Participate in an ongoing quality assurance program
■■ Have a governing board of directors that includes representatives from the populations served
FQHCs include these facilities:
■■ Community health centers (CHCs)
■■ Migrant health centers (MHCs)
■■ Health care for the homeless centers (HCHs)
■■ Public housing primary care centers (PHPCCs)
Community Health Centers
Riding on the successful passage of the 1964 Civil Rights Act and President Johnson’s War on Poverty e#orts, Tufts University physicians H. Jack Geiger and Count
Gibson submitted proposals to the federal O$ce of Economic Opportunity (OEO)
for funding to establish what they called “neighborhood health centers” in innercity, underserved areas across the United States (Hawkins & Groves, 2011). “e
Economic Opportunity Act of 1964 provided federal funds for two such centers;
both were built in Boston, Massachusetts, in 1965 (National Center for Farmworker Health, n.d.). Building on a community-based health care model already
thriving in South Africa, these two CHCs o#ered comprehensive primary health
care that focused on outreach, disease prevention, social support services, and
patient education activities, including nutritional education and counseling and
sanitation education. Dr. Geiger and Dr. Gibson believed that treating patients
with dignity and respect, regardless of age, race, health status, or income level,
and engaging them in their own health and health care were of critical importance
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Chapter 8. Vulnerable Populations 201
and promoted these beliefs as central tenets of CHC care (Adashi, Geiger, & Fine,
2010). !ese numbers have increased over the last few years. In 2010, there were
more than 8,000 CHCs, which served about 20 million people in the United States,
or 5% of the population (Adashi et al., 2010); in 2015 more than 9,750 CHCs served
more than 24.3 million individuals, or about nearly 8.3% of U.S. residents. More
than half the population served (55%) lived in rural areas. !is number of CHCs
has increased in the past few years, in part due to the increase in federal funding,
and the ACA’s provisions, which increased the number of people eligible for in
individuals eligible to receive care. A trust fund speci”cally for health centers was
also created through the ACA (Paradise et al., 2017).
Migrant Health Centers
MHCs serve the migrant and seasonal farm workers who come to the United
States each year to harvest, plant, and tend to agricultural crops. Patients pay for
care on a sliding scale (an average visit costs $30). Currently, 156 MHCs operate
within the CHC system in the United States. In 2011, the federal government
spent $166 million to help pay for the care of close to 1 million migrant and seasonal farmworkers (Galewitz, 2012).
Health Care for the Homeless Centers
Although eligible for federally funded health care, approximately 70% of homeless
health center patients lack health insurance and face signi”cant barriers to care
elsewhere in their communities (National Health Care for the Homeless Council, 2008). !e Health Care for the Homeless program was initially authorized
under the Stewart B. McKinney Homeless Assistance Act of 1987. HCHs provide
comprehensive medical services to the homeless, including pediatric and adult
primary care, screening, health education, referrals for specialty medical care,
transportation services, social service outreach, and both long- and short-term
rehabilitative care. By statute, the HCH program receives 8.7% of the total health
center appropriations for all FQHCs.
Public Housing Primary Care Centers
PHPCCs are health centers that provide comprehensive medical care and social
support services to individuals who live in public and assisted housing. Currently
there are 63 PHPCCs in 25 states and Puerto Rico, and these centers provided
services to nearly 171,731 public and assisted housing residents in 2012 (National
Center for Health in Public Housing, 2012).
Rural health clinics (RHCs) were created as a result of the Rural Health Clinic
Services Act of 1977. !is federal legislation provided reimbursement not just
for services provided by full-time doctors but also for preventive and primary care
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202 Part II. Keeping Americans Healthy
services done by health professionals called mid-level providers (MLPs), such as
nurse practitioners (NPs) and physician assistants (PAs) at clinics in underserved
rural areas across the United States. !is legislation was established both to
alleviate the burden on the limited number of full-time doctors and specialists
and to cut down on emergency care spending (DHHS, O”ce of Rural Health
Policy, 2006).
Rural health networks (RHNs)—also known as rural health alliances, cooperatives, or a”liations—are systems of care in rural areas that include at least
one rural hospital and two other separate community health organizations, such
as a nursing home or a public health unit. !ese networks operate by pooling
resources in ways such as developing continuing education programs, investing
money in electronic medical record systems for easier care coordination between
providers, and supporting advocacy activities within the communities served by
the RHN (DHHS, O”ce of Rural Health Policy, 2006). !ese networks were created out of necessity to foster collaboration and discourage reduction in services
due to unwarranted competition (Moscovice, Gregg, & Lewerenz, 2003).
Indian Health Services
Because of the history of oppression and enduring health inequities Native
Americans are considered a special group and have continued to face disproportionate health inequities. !e relationship between the U.S. federal government and North American native peoples (Indian tribes) began in 1787 and has
evolved ever since with various laws, treaties, and executive orders to protect
their status (DHHS, Indian Health Services [IHS], 2014).
!e IHS has an annual budget of about $4.8 billion and is the primary federal
health care provider for approximately 2.2 million of the estimated 3.7 million
American Indians and Alaska Natives who belong to the more than 567 federally
recognized tribes in 37 states (DHHS, IHS, 2017).
!rough a network of 45 hospitals and more than 293 clinics, IHS programs
provide Native Americans with preventive, primary, dental, and emergency medical care; mental health and substance abuse prevention and treatment; nutrition
education; access to referrals and resources; and social service support, including
(but not limited to) assistance in applying for federally designated public housing for Native Americans and other need-based bene#t programs such as SNAP,
Women, Infants, and Children (WIC), and Temporary Assistance for Needy
Families (TANF).
Mental Health and Chemical Dependency Services
In 1963, Congress passed the Mental Retardation Facilities and Community Health
Centers Construction Act, which provided federal funding for the development
and implementation of community-based mental health centers (CMHCs). With
the exception of the most severely mentally ill, most previously institutionalized
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Chapter 8. Vulnerable Populations 203
patients were released into their communities and encouraged to seek care at
these new CMHCs and other, similar facilities (Unite for Sight, n.d.).
Unfortunately, CMHCs are underfunded and understa!ed; as a result, many
people living with mental illness or chemical dependence are not receiving the
proper comprehensive care they need. Many ultimately end up homeless or in
prison. According to the
Journal of Community Mental Health, the combination
of deinstitutionalization and inadequate and underfunded community care has
led to transinstitutionalization, a phenomenon in which prisons, instead of psychiatric or detoxi”cation facilities, become the main providers of highly structured, controlled living environments for the severely mentally ill and chemically
dependent (Prins, 2011).
Not only are mentally ill individuals more likely to be incarcerated or homeless, they also contribute signi”cantly to the cost of ED care in hospitals across
the country. By one federal estimate, spending by general hospitals to care for
these patients will nearly double in 1 year—from $20.3 billion in 2013 to $38.5
billion in 2014 (Creswell, 2013).
Special Populations: HIV/AIDS Programs
Legislation to address the AIDS epidemic was “rst enacted in 1990 as the Ryan
White Comprehensive AIDS Resources Emergency (CARE) Act. Since then, the
legislation has been amended and reauthorized four times to accommodate new
and emerging medical and social needs; it is now called the Ryan White HIV/
AIDS Program (Henry J. Kaiser Family Foundation, 2013). HRSA estimates that
more than 500,000 individuals receive at least one medical, health, or related support service through a Ryan White program each year (Henry J. Kaiser Family
Foundation, 2013). #e multiple parts of the Ryan White Program all emphasize
risk reduction and prevention through interventions at both individual and community levels. For those a!ected, intensive case management in a communitybased health care setting is critical to a long life (Aday, 2001).
Despite the delayed response to the HIV/AIDS epidemic in the United States,
the wraparound services provided through the Ryan White Program serve as a
model for responding to health needs with a whole person approach. No other
vulnerable population has been able to advocate as e!ectively for that level of
Spanish philosopher José Ortega y Gasset posited, “Yo soy yo y mi circunstancia,
y si no la salvo a ella no me salvo yo
”, which loosely translates as “I am myself and
my circumstance; if I do not help it, I cannot help myself.” In that same spirit,
social needs are the
circunstancia that enables the events that lead people with
predisposing characteristics to become vulnerable. Toward the end of the 19th
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204 Part II. Keeping Americans Healthy
century and sporadically throughout the 20th century, the United States made
attempts to advance social change. Examples include President Franklin D. Roosevelt’s New Deal in response to the Great Depression; the previously mentioned
War on Poverty waged by President Johnson; President John F. Kennedy’s work in
support of progressive taxation, a!ordable housing, and extension of social welfare, and President Barack Obama’s passage of the Patient Protection and A!ordable Care Act (ACA). “e existing safety net of social services is an amalgam
of programs that, though not completely infallible, provides some support for
vulnerable populations, potentially making the di!erence between maintaining
good health outcomes and succumbing to illness.
In this section, we highlight three types of social service programs: (a) food
assistance, (b) monetary assistance, and (c) housing assistance.
Food Assistance
All food assistance programs listed in this section are administered and funded
through the USDA Food and Nutrition Service Agency.
Supplemental Nutrition Assistance Program
“e #rst food assistance program was implemented in May 1939 but was shut
down in 1943 because “unmarketable food surpluses and widespread unemployment no longer existed” (USDA, Food and Nutrition Service, n.d.). It wasn’t until
President Kennedy came along 18 years later that a second food assistance program was implemented. Kennedy’s program eliminated the concept of di!erent
stamps for di!erent foods and encouraged bene#ciaries to use their stamps to
buy healthy food (USDA, Food and Nutrition Service, n.d.). In September 2007,
the Food Stamp Program was renamed SNAP (Supplemental Nutrition Assistance Program) to decrease the stigma associated with the term “food stamps”
and to encourage those who need bene#ts to apply for them. SNAP enrollment
has generally increased over time and was at its highest point in 2013, when more
than 47 million individuals received SNAP bene#ts. Since 2013, this number of
SNAP enrollees has declined annually to mid-2010 levels with more than 42
million receiving SNAP bene#ts in 2017 (U.S. Department of Agriculture, 2018).
Women, Infants, and Children
“e Special Supplemental Nutrition Program for Women, Infants, and Children was authorized by the Child Nutrition Act of 1966 and o$cially launched
in 1974. WIC state agencies receive federal funding to pay for WIC foods,
nutrition-related services, and administrative costs (Association of State and Territorial Health O$cials, 2010). Pregnant, breastfeeding, or postpartum women,
as well as infants and children up to age 5, are eligible for bene#ts if (a) they
meet a predetermined income standard; (b) they already receive SNAP, Medicaid,
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Chapter 8. Vulnerable Populations 205
or TANF bene!ts; or (c) they have documentation from a medical professional
explaining that the mother, her children, or both are at nutritional risk (Kent,
2006). Preliminary data for 2017 estimates that WIC had more than 7.2 million
participants. “e program costs an average of $41.22 per month per participant
(USDA, Food and Nutrition Service, 2018).
Other Federal and Private Food Programs
“e USDA Food and Nutrition Service administers 11 additional supplemental
nutrition programs, ranging from reduced-price or free lunch programs for elementary school children (“e National School Lunch Program [NSLP]) to emergency food assistance programs that organize and fund food banks, pantries, and
soup kitchens to distribute food items to low-income people (USDA, Food and
Nutrition Service, n.d.).
“e rise in food insecurity since the 1980s has not kept up with federal food
program availability. “us, a network of private food assistance programs has
emerged to try to !ll the gap between need and federal support. “is private
food assistance network relies on food donations; at-cost bulk purchasing; and
food rescue of perishable, nonperishable, and prepared foods (Daponte & Bade,
Monetary Assistance
Support for vulnerable individuals and families in the form of monetary assistance is aimed at o#ering both short-term and long-term !nancial relief to meet
basic needs. Several federal agencies administer monetary assistance.
Temporary Assistance for Needy Families
TANF is a monthly cash assistance program for low-income families with children established under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 as a replacement to the Aid to Families with Dependent
Children (AFDC) program. TANF is overseen by the O$ce of Family Assistance
(part of the DHHS Administration for Children & Families), but control over
implementation is given to states (Purtell, Gersho#, & Aber, 2012).
Supplemental Security Income
President Richard M. Nixon passed the federal Social Security Amendments of
1972 in an e#ort to centralize the administration of Social Security and reduce
inequalities among the state-run adult assistance programs already in existence.
Today, the federal Supplemental Security Income (SSI) program administers cash
assistance each month to eligible individuals aged 65 and older, the blind, and
mentally or physically disabled children and adults. A preset federal bene!t rate
determines bene!t levels (U.S. Social Security Administration, n.d.).
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206 Part II. Keeping Americans Healthy
Unemployment Insurance
Unemployment insurance (UI) is available to people who have lost their jobs
through no fault of their own but as a result of circumstances such as employer
cutbacks. Federal funds are distributed through the U.S. Department of Labor
to each state; states then administer their UI programs according to statedetermined criteria.
Housing Assistance
!e “rst major investment in housing assistance in the United States took place
in 1932, when—in the midst of widespread unemployment and homelessness
resulting from the Great Depression—Congress passed the Emergency Relief
and Construction Act (U.S. Department of Housing and Urban Development,
n.d.). !is act created the Reconstruction Finance Corporation (RFC), an agency
whose responsibility it was to make loans to private corporations that were providing housing for low-income families. From 1932 to 1956, four housing acts
were enacted; these continued through the 1960s and into the 1970s. Funding
included federal investments in new housing construction; the preservation of
existing housing resources; and the development of safer, better public housing
!e McKinney-Vento Homeless Assistance Act of 1987 established the Supportive Housing Program (SHP) especially for the homeless. !e 2009 American
Recovery and Reinvestment Act (ARRA) included new housing programs, most
notably the Homelessness Prevention and Rapid Re-Housing Program (HPRP).
!is program allocated $1.9 billion in funding to homelessness housing. Funds
allocated for HPRP helped with short-term or medium-term rental assistance
and housing relocation and stabilization services, including such activities as
mediation, credit counseling, security or utility deposits, utility payments, moving cost assistance, and case management.
!is section has not presented an exhaustive list of federal and private social
services available for vulnerable populations. For example, in terms of housing,
there are services that o#er long-term care for elderly and disabled people, such
as nursing homes, and supportive at-home services that allow for aging in place,
such as home health aides.
!e next section o#ers a more detailed picture of the payment system that
covers the health care of vulnerable populations.
!ere are three main payers for health care for the vulnerable: (a) the federal
government; (b) the states; and (c) private sources, including employers, insurers,
and philanthropic organizations.
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Chapter 8. Vulnerable Populations 207
At the federal level, the primary health care payment programs are Medicare,
Medicaid, and the Children’s Health Insurance Plan (CHIP). !ese programs are
managed by the CMS; however, each state has the power to administer its Medicaid program. Medicaid-eligible individuals typically include low-income individuals and families who fall below a certain federal poverty level (FPL) threshold
and those receiving SSI. As we discuss toward the end of the chapter, the ACA
has greatly increased the enrollment for both CHIP and Medicaid.
Medicaid provided health coverage for approximately 34.5 million children (including the 6.5 million receiving coverage through CHIP), 26.7 million adults, 5.7 million seniors, and 10.6 million persons with disabilities on
average monthly in 2016 at a total cost of $565.5 billion (CMS, 2018a). CMS
reports that under the current law, national health spending is expected to
grow under in the period 2017–2026, at an average rate of 5.5% each year,
resulting in an estimated $5.7 trillion in 2026 (Center for Medicare & Medicaid
Services, 2018b).
Individuals eligible for Medicare include the elderly (ages 65 and older), some
people under 65 with qualifying disabilities, and people with kidney failure requiring dialysis. !e most recent estimate of Medicare expenses in 2016 reported a
yearly program cost of $672.1 billion, with bene”ciaries exceeding 57.1 million,
including 8.8 million people who are disabled, and 48.1 million people aged 65
and older (CMS, 2018b).
Individuals who are
dual eligibles qualify for both Medicare and Medicaid
and are among the sickest and poorest in the United States; more than half
have three or more chronic conditions, and more than 40% have a mental
health diagnosis (CMS, 2018c). !is population is three times more likely than
the Medicare-only population to be disabled (Fontenot & Stubble”eld, 2011).
Although they represent a relatively small percentage of the overall Medicare
and Medicaid populations, the cost for people who are dual eligible totals $306
billion (approximately 33%) of annual spending between the two programs
(CMS, 2018c). Disproportionate levels of funding for state Medicaid programs
means the resources available for people with dual eligibility vary from state
to state. Part of the high cost can be reduced through better care coordination
and treatment, as individuals who are dual eligible must also bear the burden of
navigating both programs. !e Medicare-Medicaid Coordination O#ce aims
to increase e$ectiveness and coordination between the two programs; however,
this is only a recent development as it was created by section 2602 of the ACA
(CMS, 2011).
!ere is a segment of the vulnerable population that neither quali”es for
subsidized care nor receives care through an employer or other private funder.
To o$set the burden of o$ering care for the uninsured, federal law o$ers a
modi”ed payment strategy called the Medicaid and Medicare
Disproportionate Share Hospital (DSH) program. DSH payments are available to qualifying
hospitals that have a high number of Medicaid and Medicare patients and uninsured individuals (Mitchell, 2013). Under the ACA federal payments through
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208 Part II. Keeping Americans Healthy
the DSH were scheduled to be reduced in 2014. !is reduction of a total of $43
billion was delayed and will take place in 2018, starting with a $2 billion cut.
!e reduction is set to increase incrementally until it reaches a $8 billion cut
by 2025. !is will signi”cantly reduce DSH funds, as federal spending for DSH
allotments in 2014 was $11.7 billion (Cunningham, Rudowitz, Young, Gar”eld,
& Foutz, 2016). Cuts to DSH pose risks to safety net hospitals and public hospitals that serve higher numbers of populations who are either without insurance,
on Medicaid or Medicare and who rely more heavily on DSH funding (Cunningham et al., 2016).
!e systems of care and “nancing mechanisms currently available in the United
States, well intentioned as they are, fall short of their goal of taking care of vulnerable populations. At best, the programs and services are disjointed and, at
worst, they o#er temporary solutions that deal with isolated problems, and for
very targeted populations. For instance, a person’s drug or alcohol dependency
may preclude him or her from eligibility for supportive housing. Yet, stable housing has been linked to recovery from addictions. !e common response by policy
makers—and common practice by researchers—is to focus on distinct populations when examining and addressing the needs of vulnerable populations. Disparate and disjointed programs are created to address the needs of children, the
elderly, the physically disabled, the chronically ill, the mentally ill, substance
abusers, persons with HIV/AIDS, the homeless, residents of rural areas, immigrants, individuals with limited or no English pro”ciency—the list goes on and
on. Yet, the distinctions among many of these vulnerable groups are thin and
arti”cial. Many of these groups share common traits and experience a convergence of multiple vulnerable characteristics. !ese subpopulations are more
likely to live in poor communities; less likely to have access to high-quality health
and education; and less likely to have the “nancial resources to secure adequate,
stable, a#ordable housing.
!e programs and services available are not very cost-e#ective; this puts
them at the mercy of critics who would prefer less government involvement in
the care of vulnerable individuals and their families. !e current market-driven
health care delivery and payment system is one that gives providers “nancial
incentives for the volume, not the quality, of services delivered. Some areas for
improvement related to delivery and payment are discussed later. In this section,
we “rst point out how (and where) the current ways in which care is delivered
and payment is structured fall short of their goal to take care of the vulnerable
while containing cost. Second, we highlight emerging service delivery models
and innovative payment strategies created to reach the Triple Aim—better care
for individuals, better health for populations, and lower cost—as it pertains to
vulnerable populations.
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Chapter 8. Vulnerable Populations 209
A Fragmented Delivery System
Health care initiatives to reduce the barriers created by vulnerability rarely recognize the common overlap of risk factors, and
few studies have examined the combined
in!uences of multiple risks on obtaining
needed health care services (Shi & Stevens,
2005). “e main issues that emerge in a
review of delivery systems created to care
for vulnerable populations include (a) fragmented and siloed structures and (b) a focus
on health and psychological needs that does
not always recognize the link between social
needs and health.
Fragmentation refers to care that is delivered by di#erent providers who are
not co-located or within proximity of each other. Where fragmentation exists,
patients must make and manage multiple appointments that may require, for
example, more days o# from work to attend appointments. Silo structures refer
to care o#ered by multiple providers who do not consult with each other. An
endocrinologist, for instance, may be unaware of the medications prescribed by a
psychiatrist treating a patient’s depression—which may have weight gain as a side
e#ect, thus disrupting the patient’s diabetes management.
Although there has been budding awareness of the importance of meeting social and other nonclinical needs in relationship to health, the U.S. delivery system has not made the necessary transformation to make this possible. For
example, food insecurity would make it hard for a person managing cardiovascular disease to eat more fruits and vegetables because that person may depend
on a local emergency food provider that is unequipped to receive and distribute
Volume Versus Value
A major weakness of our current payment system is that it encourages a
volume-driven health care system rather than a value-driven health care
system. Under fee-for-service (FFS), providers (such as hospitals, physicians,
and health centers) gain increased revenue and pro$t by delivering more services
to people.
“is payment model becomes an enormous barrier to delivering e#ective
and e%cient care to vulnerable populations. Providers have little or no incentive to spend the necessary time with an individual who has complex medical,
behavioral, and social needs in order to determine a course of action that will
address the underlying complexities of the patient’s life. Providers are more likely
to address the present health crisis a#ecting the individual—usually by delivering
Health care initiatives to
reduce the barriers created by
vulnerability rarely recognize the
common overlap of risk factors,
and few studies have examined
the combined in!uences of
multiple risks on obtaining
needed health care services.
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210 Part II. Keeping Americans Healthy
more diagnostic tests, prescribing more medication, or making more referrals
to costly specialists. FFS payment systems also reinforce fragmentation of care
by paying multiple providers for multiple services or tests for the same patient,
regardless of whether the care is coordinated or duplicative.
Behavioral and social services operate in an entirely di!erent realm than medical care; such a vast, complex web of disconnected services is available for vulnerable populations that the time and e!ort required to coordinate and manage
transitions across necessary services are beyond any reimbursement rate set by
public or private payer. Instead, there is a perverse payment system that rewards
the provider for delivering more health care services, rather than addressing (by
connecting patients to critical services) the pressing social and behavioral problems that negatively a!ect the patient’s health outcomes.
Reactive Versus Preventive Care
Only a small fraction of health care spending is devoted to the promotion of
healthier behavior, despite the fact that preventable chronic diseases are linked to
smoking, obesity, lack of exercise, and drug and alcohol use (DeVol et al., 2007).
“ere are very few incentives in the health care system to promote prevention
and early intervention, especially in the case of chronic diseases. Only a small
percentage of health care spending is devoted to promoting healthier behavior,
despite the fact that preventable chronic diseases are linked to lifestyle behaviors,
such as smoking, exercise, and drug and alcohol use, and to social determinants
of health (McGinnis, Russo, & Knickman, 2002). “is is explored more in Chapter 5 on population health.
Health care leaders and policy makers are grappling with how to improve our
health delivery system. In this section, we highlight emerging service delivery
models created to improve health outcomes for vulnerable groups while containing the cost of care. De#nitions and descriptions of these budding models are
explained, along with case studies that have implemented these models.
Delivery Strategies That Work
Growing evidence shows that three distinct delivery strategies—care coordination, patient engagement and team-based care, and integration of care—help to
meet the needs of vulnerable populations. We describe these strategies and discuss the
meaningful use of data to drive them.
Care Coordination
Creating successful integrated delivery systems for vulnerable populations
requires several factors: (a) an emphasis on primary care; (b) coordination
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Chapter 8. Vulnerable Populations 211
of all care, including behavioral, social, and public health services; and (c)
accountability for population health outcomes (Witgert & Hess, 2012). !e
Agency for Healthcare Research and Quality (AHRQ) de”nes care coordination as:
[T]he deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate
delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and
is often managed by the exchange of information among participants responsible
for di#erent aspects of care. (AHRQ, 2014)
According to a 2011 report published by the American Hospital Association,
promising practices that will improve care coordination include (among other
practices) conducting periodic home visits, facilitating and encouraging data
sharing through the use of integrated health information systems (i.e., electronic
medical records [EMRs]), providing non–health care services such as transportation to appointments, and employing and incorporating specially trained teams
of providers that are aware of each patient’s cultural and language backgrounds
and can administer guidance and advice as they see “t (Fontenot & Stubble”eld,
Patient Engagement and Team-Based Care
Patient engagement is generally de”ned as the process of involving individuals in their health care, disease management, or preventive behaviors. Providers
can—and do—play an important role in the health outcomes of their patients;
however, after a patient has left the doctor’s o$ce, the patient’s health is largely in
his or her own hands. Low income, lack of education, language barriers, and not
having a regular source of care are some of the many risk factors that may create
signi”cant barriers to accessing necessary health care services (Shi & Stevens,
2005). Patients are expected to follow recommended care management plans,
communicate regularly with their providers, and make positive lifestyle changes;
however, patients—especially those within vulnerable populations—lack the
energy, money, knowledge, and skills needed to navigate successfully their often
complex health conditions, regardless of whether they are sick or well (Center for
Advancing Health, 2010).
Patient engagement works best when it involves a team that not only possesses clinical expertise, but also considers patients’ socioeconomic needs (such
as the importance to clinical outcomes of stable housing) and provides coordination (e.g., across multiple providers or between community-based organizations and the health system). !e ideal care team includes not only physicians
and nurses directing decisions related to medical care, but also psychiatrists,
psychologists, or other licensed clinical social workers who support behavioral
and mental health, as well as social workers who can provide counseling and
access to social services via referrals (Manahan, 2011; Volkmann & Castanares,
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212 Part II. Keeping Americans Healthy
2011). More and more, such multidisciplinary teams include outreach specialists and community health workers, especially when addressing the needs of
vulnerable populations (Martinez Garcel, 2012; Volkmann & Castanares, 2011).
A 2014 report on Bronx Lebanon Hospital’s utilization of community health
workers (CHWs) showed that CHWs help to reduce the number of ED visits
and hospitalizations, thus reducing health care costs and contributing to the
management of chronic disease (Findley, Matos, Hicks, Chang, & Reich, 2014).
Case Exercise 8.1 expands on the Bronx-Lebanon Hospital example (Findley
et al., 2014).
CHWs play a critical role in patient engagement. !ey can explain reasons for
their actions in layman’s terms and provide a support system that allows patients
to feel they have the power to navigate the system and take control of their condition. When care coordination includes the support of individuals such as CHWs,
patients have the help they need to think through how to integrate self-management of their chronic conditions into their existing life circumstances and—in
the best of cases—are directed to the auxiliary services they need to get a handle
on their nonmedical problems, stabilize their routines, and have better health
Bringing It All Together: An Integrated System
Populations that are vulnerable due to low income or poor health stand to bene”t
from the integration of care. Integrated health care delivery systems provide or
arrange a coordinated continuum of health care services to a de”ned population, and these delivery systems hold themselves accountable for the outcomes
and health status of their patients (Witgert & Hess, 2012). By ensuring appropriate care, avoiding duplication of services, and reducing fragmentation within a
preventive framework, integrated delivery systems seek to promote health care
equality while controlling costs.
Use of Data in Improving Care
EHRs (electronic health records) and advances in information technology (including geographic information systems) have created new opportunities to improve
the e#ectiveness and e$ciency of care—particularly for vulnerable populations.
Such technological advances have facilitated the use of large data sets to inform
health care delivery and to conduct comprehensive cost and utilization analysis
by population type, geography, and more.
One of the most compelling examples of data-reliant integrated care is the
work of New Jersey’s Camden Coalition of Healthcare Providers (CCHP), which
utilizes the Camden Health Information Exchange (HIE) to track, monitor, and
target services for the highest-cost patients across health systems in Camden.
Case Exercise 8.2 expands on the example of the Camden Coalition.
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Chapter 8. Vulnerable Populations 213
The South Bronx is home to a vibrant community, albeit poor, young, and with high rates
of every illness now reaching epidemic proportions in the United States: diabetes, asthma,
HIV, drug use, and obesity, to name a few. It is also the home of the Bronx-Lebanon Hospital
Department of Family Medicine’s Patient-Centered Medical Home.
The hospital’s chair of family medicine, Dr. Douglas Reich, was grappling with the department’s goal of improving health outcomes for the patients with the most complex life contexts.
Beyond completing the very important clinical tasks of diagnosis and treatment, Reich’s clinicians lacked the time and the skills to conduct meaningful discussions that would help to
provide a better context for patients’ care: What were the barriers to following a treatment
regimen? What was getting in the way of managing illness? Was there room for prevention?
An even greater challenge was reaching the hundreds of people who were in need of health
care but going without.
In 2007, the Community Health Worker (CHW) program was established. CHWs, supervised
directly by the department chair, received extensive training to ful!ll their role as care managers. Integration into the care team was achieved by creating opportunities for shared learning
and cross-education about team roles, for CHWs and clinical members alike, through continuing education, rounds, staff meetings, and so on.
Achieving CHW program sustainability required additional infrastructure, and protocol
changes were necessary, the following among them:
■■ Recognition of CHW team contributions, including assessments and feedback within the
department and hospital administration
■■ Shared group visits with a CHW and a physician
■■ Elaboration of the care management process
■■ Focus of work on interactions with patients
The patients assigned to CHWs demonstrated improvements in medication compliance,
increased self-management of chronic conditions, and showing up for follow-up primary care
appointments. In several cases, there has been a reduction of ED use and inpatient hospitalization. The CHW program at Bronx-Lebanon Hospital Department of Family Medicine has
yielded important lessons for other patient-centered medical homes interested in expanding
their care teams to enhance patient engagement.
Founded in 1828, Camden, New Jersey, was once the center of a thriving manufacturing
industry. As with many other U.S. cities, deindustrialization led to high poverty rates that,
coupled with political corruption and consistently high rates of violent crime, earned the city
the dubious title of poorest city in the country. In addition to high unemployment rates, Camden is home to many Medicaid and Medicare bene!ciaries and to others who are uninsured.
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214 Part II. Keeping Americans Healthy
Dr. Jeffrey Brenner, a family physician operating a solo practice in Camden, recognized
patterns of overspending that did not result in better health outcomes for Camden residents.
In 2002, he and a small group of other primary care providers began meeting over breakfast
once a month to discuss the issues they faced in their practices. It quickly became evident
that all of the providers experienced many of the same barriers. In 2003, Dr. Brenner and colleagues founded the Camden Coalition of Healthcare Providers and set out to convince local
stakeholders that an integrated health delivery model, in which patient data were shared and
care coordinated, would result in better care for Camden residents (Gawande, 2011).
The coalition showed how vulnerable populations, in absence of a well-integrated and
supportive health care system, have higher numbers of ED visits, suffer from more chronic
disease, have access to fewer preventive services, and seek more reactive care than their
peers living less chaotic lives. The analysis looked at 480,000 records for 98,000 patients by
pooling data from the major health care institutions serving Camden for the period between
2002 and 2009. They results showed that 50% of Camden residents used the ED or the hospital in one year. Those individuals with the highest number of ED visits and hospitalizations
citywide (“super utilizers”) accounted for 324 visits in !ve years and 113 visits in one year.
Thirty percent of costs were incurred by 1% of patients, 80% of costs were incurred by 13% of
patients, and 90% of costs were incurred by only 20% of patients. The most expensive patient
incurred $3.5 million in health care costs.
For vulnerable populations, crisis is the baseline. At the heart of crisis is the con”uence
of economic, social, geographic, and demographic factors that create the conditions for poor
health and make management of illness a dif!cult task. When conducting a spatial analysis
of Camden hospital cost data, the coalition found areas of the city with high concentrations of
utilizers. In fact, several buildings each year were responsible for between $1 and $3 million
in hospital costs. Furthermore, 6% of city blocks accounted for 18% of patients and 37% of
billable visits.
The Camden team created an integrated model of care in response to these !ndings. Members of the care team check in with individual patients to ask about issues including, but not
limited to, their un!lled prescriptions, reasons for missing appointments, and any emerging
health issues. All patients have access to the coalition’s health care crisis hotline, always
staffed by a health care provider who can offer advice in an emergency situation.
Since the coalition formed in 2003, analysis of the data from the !rst 36 super utilizers
has shown a 40% reduction in hospital and ED visits per month, and a 56% reduction in their
average combined hospital bills (from $1.2 million to $500,000; Gawande, 2011).
Opportunities in the ACA to Meet Health Care Needs of
Vulnerable Populations
On March 23, 2010, President Obama signed the ACA into law and altered the
landscape of U.S. health care policy, with the intention to increase and improve
health care access and quality of care for vulnerable populations. In addition,
the ACA provided major investments to expand FQHCs and initiated e!orts to
change how health care is delivered and paid for in the United States.
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Chapter 8. Vulnerable Populations 215
!e sections below discuss the and the improvements and opportunities for
increased access under the ACA as well as its gaps and current limitations.
Increased Insurance Coverage for Individuals
One of the most immediate e”ects of the ACA is that it has increased coverage for
millions of people, particularly for low-income adults (Sommers, Blendon, Orav,
& Epstein, 2016). !e United States is currently at a historically low uninsured
rate (Kantarjian, 2017); in 2010 an estimated 48.3 million people were uninsured,
in 2015 that number dropped to 28.7 (National Health Interview Survey, 2015).
!e ACA has played a signi#cant role in increasing coverage and has provided
a variety of pathways that allow people to access coverage who might otherwise
not be eligible (Kantarjian, 2017; Frean et al., 2016). !is included a provision that
allowed for extended coverage from a parent’s insurance until a young adult was
26 years old and expanded Medicaid eligibility to adults with incomes up to 138%
of the FPL. It also included tax credits and subsidies based on income for people
within 100% and 400% of the FPL, which lowered the cost of insurance through
the health care marketplace, and laws that prevented insurers from discrimination against individuals with preexisting health condition and an insurance mandate (Frean et al., 2016).
While researchers could not explain all of the increases in health insurance
coverage through the ACA, they estimate that of the 60% they can link to speci#c
provisions, 40% of the gains are due to price subsidies and 60% is from Medicaid
expansion (Frean et al., 2016). As of January 2018, all but 18 states have adopted
Medicaid expansion (Henry J. Kaiser Family Foundation, 2018). While the decision to not expand Medicaid has resulted in disproportionate rates of access to
care among states, the expansion of Medicaid is linked to an increase in coverage, even in states where coverage was not expanded. In states where Medicaid was expanded, uninsured people who were previously ineligible enrolled in
Medicaid for the #rst time. In non-Medicaid expansion states, scholars believed
a “woodwork e”ect” took place in which individuals who were previously eligible
for Medicaid but had not been enrolled seemingly came out of the woodwork
(Frean et al., 2016).
Improving Access to Community Health Centers
!e ACA included large investments to expand FQHCs. !rough the expanded
availability of health insurance, particularly Medicaid, to low-income people,
the ACA also included large investments in expanding FQHCs to improve care
to this population. For instance, the law appropriated $11 billion in mandatory funding increase for Section 330 grants from 2011 to 2015. !e law also
boosts funding for FQHCs through increased payment rates for primary care
physicians serving Medicaid bene#ciaries. As of 2014, Medicaid providers will
be paid at 100% of the rate paid to Medicare providers. !ese provisions will
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216 Part II. Keeping Americans Healthy
lead to increased access to primary care for vulnerable populations, both by
increasing the capacity of this safety net and by creating a !nancial incentive
through increased reimbursement for physicians to accept more people covered
by Medicaid.
Advancing Payment and Delivery Reform
“e ACA called for several underlying themes to alter proposed models of care
and payment structures: (a) a move toward value-based purchasing of health
services; (b) increased coordination of health, social services, and prevention;
and (c) better integration of physical and
behavioral health services. “e proposed models can potentially have a positive e#ect on the health outcomes
of vulnerable populations while reducing the cost of services delivered to this
For example, the ACA encourages state Medicaid programs to develop
medical homes, known as Health Homes, for Medicaid patients with two or
more chronic conditions or patients who have one serious and persistent mental
health condition. “e CMS issued speci!c elements that need to be included as
part of a Health Home. “ese elements include comprehensive care management; intensive care transition services for patients moving out of acute care
services (such as hospitals, home-based care, and outpatient facilities); care
coordination among physical health, behavioral health, and social and community services (such as supportive housing); and individual and family support to
“rough better coordination of services through primary care, specialty and
hospital care, behavioral health, social service support, and stronger patient monitoring, Health Homes could improve health outcomes and reduce unnecessary
care. One study estimated that the U.S. health system would save approximately
$175 billion over 10 years if primary care providers shifted to this coordinated
system of care (“e Lewin Group, 2009).
“e ACA has also prompted a move away from the traditional FFS model to
payment models that would align reimbursement and incentives to the value of
care provided and hold providers accountable for health outcomes. “is move
toward value-based purchasing of services is central to a major Medicare demonstration supported by the ACA: accountable care organizations (ACOs).
ACOs are groups of doctors, hospitals, and other health care providers who
come together voluntarily to give coordinated, high-quality care to their Medicare patients (Bachrach, Bernstein, & Karl, 2012). As de!ned by the ACA, ACOs
must manage the health care needs of a minimum of 5,000 Medicare bene!ciaries
for at least three years. “e goal of an ACO is to ensure that patients, especially
the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. “is approach to care
should lead to reductions in the total cost of care for the assigned population
of patients. Providers participating in an ACO will share accrued savings with
Medicare. In the end, providers get paid more for keeping their patients healthy
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Chapter 8. Vulnerable Populations 217
and out of the hospital—as opposed to getting paid more only for providing more
services. If an ACO is unable to save money, it can potentially be at risk for losing
money associated with the costs of investments made to improve care, or it may
have to pay a penalty if it does not meet performance and savings benchmarks.
Additional payment reform e!orts enacted by the ACA include bundled payment demonstration programs and reduced payments for potentially preventable
readmissions and complications. “e common goal of all of these e!orts is to
improve the quality of care and rein in cost of health care, with a special focus on
vulnerable populations.
Limitations of the ACA
“rough the ACA, it is up to each individual state to expand eligibility for Medicaid. As of January 16, 2018, 18 states have rejected the Medicaid expansion
(Henry J. Kaiser Family Foundation, 2018). As a result, an estimated 4.8 million
uninsured adults in 2016 were estimated to fall in a coverage gap, where they
did not earn enough to qualify for Medicaid but did not make enough money to
qualify for federal subsidies to help them buy into the health exchanges (Buettgens & Kenney, 2016). People of color are disproportionality a!ected by a lack
of Medicaid expansion, as they make up more than half of those who are in the
coverage gap, including an estimated 1.2 million African Americans (Buettgens
& Kenney, 2016). “is is in part because the states where Medicaid expansion
was not passed are also states where there is a high proportion of people of color
(Gar$eld, Damico, Stephens, & Rouhani, 2014). Texas, Florida, and Georgia
account for more than 50% of people who would be eligible for Medicaid if it
were expanded (Kantarjian, 2017). In addition to the gap in coverage, there are
many low-income people who quali$ed for ACA subsidies but did not enroll in
the Marketplace because of high premium costs.
“e ACA speci$cally excludes undocumented immigrants and their families from its provisions, leaving out the approximately 11 million undocumented
immigrants who reside in the United States. “ese same individuals and families
are likely to live in poverty, experience language and cultural barriers to accessing
health care services, and have higher risk factors for chronic conditions.
As a result of these ACA limitations, the safety-net hospitals that provide care
to vulnerable populations will experience a signi$cant burden. “is is especially
troubling in the states with high concentrations of undocumented immigrants
and a higher proportion of people who remain ineligible for insurance. Under
the ACA, a reduction is scheduled in payments to disproportionate share hospitals, which have helped to absorb the e!ects of providing uncompensated care.
“is reduction will add to the strain on the resources of these institutions (Davis,
Another important limitation of the ACA that will a!ect the health and
well-being of vulnerable populations is its narrow focus on the traditional
health care system. Although the law sets in motion delivery system and payment transformations that will help to bridge traditional health care institutions
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218 Part II. Keeping Americans Healthy
with agencies, programs, and services that address some of the key drivers of
poor health (such as housing and behavioral health services), it falls short of
making the necessary investments in the social service sector that will help vulnerable populations get on—and stay on—the path to a healthy life. !e United
States is one of only three industrialized countries to spend most of its health
and social services budget on health care itself (Bradley & Taylor, 2013). For
every dollar the United States spends on health care, an additional 90 cents is
spent on social services. In peer countries, for every dollar spent on health care,
an additional $2 is spent on social services. Researchers who looked at spending across health care relative to social services found that countries with high
health care spending compared with social spending had lower life expectancy
and higher infant mortality rate than countries that favored social spending.
European countries that have made greater investments in social services relative to health have experienced leaps in life expectancy (well over 80 years) and
infant mortality rates that are half those in the United States. Most medical providers concur with this logic. In a Robert Wood Johnson Foundation–funded
national survey, four out of “ve physicians agreed that unmet social needs lead
directly to worse health.
If the United States is to make a dent in improving the health outcomes of
vulnerable populations, we must go beyond shifting dollars from one part of the
health care system to another. Rather, we must make a transformative shift in
where the investments are made—and accept that subpar social conditions have
a direct consequence on health. As Bradley and Taylor state:
Homelessness isn’t typically thought of as a medical problem, but it often precludes
good nutrition, personal hygiene, and basic “rst aid, and it increases the risks of
frostbite, leg ulcers, upper respiratory infections, and trauma from muggings, beatings, and rape. (Bradley & Taylor, 2013)
A program in Boston that tracked the medical expenses of 119 chronically homeless people found that, in a “ve-year period, these individuals accounted for
18,834 emergency department visits estimated to cost more than $12 million.
Challenges of Health Care Reform and Threats to the ACA
At this time, health care reform is largely debated issue. !ere is heated political debate over whether health care is a right or is a privilege, which individuals
should be eligible for care, and how health care can be improved. President Trump
has used a series of executive orders to alter aspects of the ACA (Adamcyzk,
2017; Sanger-Katz, 2017). !ere have been several attempts in Congress to dismantle the ACA, including the American Health Care Act of 2017, which would
put 23 million people at risk of losing their insurance, but so far these orders have
not passed in Congress (Pearl, 2017). In October 2017, the DHHS announced it
would no longer make payments after President Trump’s decision to stop making
payments to insurance companies that subsidize care for low-income members
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Chapter 8. Vulnerable Populations 219
(Alonso-Zaldivar, 2017; Sanger-Katz, 2017). !is cut impacts insurers’ decisions
about future pricing and coverage, which further a”ects low-income members
ability to a”ord insurance if cost goes up.
Populations adversely impacted by health
inequities are at greatest risk of poor physical, behavioral, and social health. !ey have
high rates of disease burden and mortality.
When receiving care, people who are poor,
people of color, and people who have faced
historical oppression have the hardest time
accessing timely, high-quality health care
and, when receiving care, are more likely to
have worse health outcomes than the general population. Despite an extensive body of literature and myriad federal e”orts
to eliminate these inequities in health and health care between vulnerable groups
and the general population, the United States has barely made progress.
To some extent, the topic of eliminating disparities has been diluted and overused. It is almost as though the topic of health disparities has become an accepted
part of our health literary repertoire. But this issue contains an underlying, explosive problem: !e prevalence of vulnerable populations is increasing; if we fail to
institute policies and programs to improve the health of vulnerable populations,
little will be done to contain the cost of care in the United States. We will continue
to spend more on health but have signi#cantly poorer health status compared
with other industrialized countries.
In this chapter, we have o”ered an integrated framework that sets examines
how health inequities disproportionately a”ect certain groups due to social and
economic contexts. As opposed to examining the health of discrete subgroups
of people disproportionately impacted by health inequities, which are not
mutually exclusive, the chapter provided a general overview of the predisposing and enabling factors that lead to vulnerability. !e approach re$ects the
co-occurrence of risk factors
and helps to explain why existing approaches to
meet the health needs of this population will continue to fall short. !ough
well intended, current policies and programs are a patchwork of categorical,
fragmented, and uncoordinated attempts that cost a lot of money.
Health inequities are primarily a social issue created through social forces.
It will be addressed adequately only through broader social, communitywide
investments. A shift to community-oriented policies and programs that address
the social origins of vulnerability can lead to greater improvements in health
outcomes. !ese programs and policies should aim to produce networks of
collaboration and integration—rather than wedges of bureaucratic division—
across medical care, public health, social and economic solutions, and policies
The prevalence of vulnerable
populations is increasing; if
we fail to institute policies and
programs to improve the health
of vulnerable populations, little
will be done to contain the cost
of care in the United States.
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220 Part II. Keeping Americans Healthy
The commissioner of health in a large, mostly urban county has secured your services as a
consultant to identify strategies to meet the needs of the growing refugee population legally
settling in her region. A refugee is a person who has !ed from his or her home country and
cannot return because of a well-founded fear of persecution based on religion, race, nationality, political opinion, or membership in a particular social group. The commissioner of health
has at her disposal both federal and state resources and good relationships with colleagues
from other county agencies, such as planning, transportation, education, aging, and so on.
As a consultant, you have been asked to propose a coordinated plan to use existing
resources and relationships to better serve the needs of the growing refugee population. When
considering your plan, be sure to address the following questions:
1. What type of information would you collect, and how would you use it?
2. Whom else would you engage in developing a plan?
3. How will you ensure that the refugee population has access to existing and new services?
4. Explain how your plan will meet the immediate and long-term needs of this group as part
of an improved system of health care and social services.
1. How have shifting demographics, the rise in prevalence of chronic conditions, and
the strained social service sector contributed to the growing number of vulnerable
2. A wide array of medical and social services exists to help meet the complex needs of vulnerable populations; however, the United States has been unable to curb health care costs
or improve health outcomes for this segment of the population. What are some of the
underlying problems with the current approach to services for vulnerable populations?
3. How does the current payment system fall short in meeting the needs of vulnerable
4. Review the limitations for meeting the needs of vulnerable populations in the ACA
provisions. Propose ways in which you would address these limitations using (a) new
policies, (b) existing policies and structures, and (c) innovative ideas (such as public/
private partnerships).
that permanently !x the risks and consequences of vulnerability. Investing time,
energy, and resources in improving the health of vulnerable populations as a
national priority is more than a social and moral imperative—it is an economic
one. “e human and !nancial costs of this problem weigh heavily on the future
of the United States to continue as a beacon of justice and equality and a global
!nancial leader. Who are considered vulnerable populations, and what does this
tell us about the nature of the problems that predispose and enable vulnerability
in the United States?
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The Health Workforce
Joanne Spetz and Susan A. Chapman
Identify who is part of the health workforce
Understand the importance of the entire health workforce in delivering health
care services
Describe the different education paths for the health workforce
Critically assess the reasons for shortages of health care providers
Review new models and new roles of deploying health workers
Assess the effects of health reform on the health workforce
health professionals
interprofessional education
labor market
on-the-job training
scope of practice
Who is part of the health workforce?
Traditional approaches to health workforce planning
Health workforce education
Critical issues for the health workforce
Building the future health care workforce
© Springer Publishing Company DOI: 10.1891/9780826172730.0009
Copyright 2019. Springer Publishing Company.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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AN: 1998657 ; James R. Knickman, PhD, Brian Elbel, PhD, MPH.; Jonas and Kovner’s Health Care Delivery in the United States, 12th Edition
Account: s3563253.main.ehost

232 Part III. Medical Care: Treating Americans’ Medical Problems
!e health care workforce is essential to the delivery of health care; essentially all
types of health services require the contributions of individual workers. !e health
care workforce includes well-known professionals such as nurses, pharmacists, and dentists; it also includes many other, less obvious
professions that encompass a wide variety of
technicians, therapists, assistants, administrative personnel, and managers. In 2016, there
were approximately 16.4 million jobs in the health care industry in the United
States, and compensation for these jobs accounted for nearly half of total health
care spending—$1.03 billion of the $2.1 billion spent on health care (U.S. Bureau
of Economic Analysis, 2017; U.S. Bureau of Labor Statistics, 2017). !e health
workforce’s central role in all aspects of health care and its signi”cant contribution to total health care costs guarantee that any policies intended to change how
health care is “nanced or delivered will be fundamentally shaped by their interactions with the workforce. !is fact becomes more complex when one recognizes
that the health workforce plays an important role in economic development and
income distribution. Health care jobs often pay well and are stable, and they are
frequently “lled by people living where the health care is provided (Gitterman,
Spetz, & Fellowes, 2004; Zacker, 2011). As health reform reshapes the system of
health care in the United States, we will continue to see major changes in the size,
composition, and practice of health professionals. Such changes will be complicated by the broader role of health care employment in our economy and society.
!e health workforce includes all health professionals and workers who contribute to the delivery of health care. !e determination of who falls into this de”nition
can involve some debate. Many occupations are consistently classi”ed as within
the health workforce, such as physicians, radiation technologists, dental assistants,
and nurses. Health occupations also include people who do not work in health care
delivery settings but instead provide health services in homes, educational institutions, and other places, such as home care aides, personal care assistants, and school
nurses (Bipartisan Policy Center, 2011; Matherlee, 2003). In 2016, these and related
health care occupations included more than 13.1 million people, accounting for
nearly 1 in 12 workers in the United States (U.S. Bureau of Labor Statistics, 2017).
!e largest health care occupation is registered nurses (RNs), of whom about
2.9 million were employed in 2016 (U.S. Bureau of Labor Statistics, 2017). RNs
work in nearly all health care settings; about 54.4% work in hospitals (Budden,
Moulton, Harper, Brunell, & Smiley, 2016). Personal care aides, of whom there are
about 1.5 million, are the second-largest occupation in health care and primarily
By about 2025, the nation’s
health care sector is expected
to be facing a shortfall of
2.3 million new workers.*
*To hear the podcast, go to or access the ebook on Springer Publishing ConnectTM.
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Chapter 9. The Health Workforce 233
provide services and support in the home. Unlicensed nursing assistants are the
third-largest health care occupation, with about 1.4 million workers employed.
Unlicensed nursing assistants usually work in hospitals and long-term care facilities. About 603,000 certi!ed nursing assistants and 702,400 licensed practical/
vocational nurses work in skilled nursing facilities (U.S. Bureau of Labor Statistics, 2017). About 649,850 physicians were employed in the United States in 2016.
Other large occupations in health care include home health aides, medical
assistants, dental assistants, pharmacy technicians, and emergency medical
technicians/paramedics. “e health care occupations also include licensed alternative and complementary providers, such as chiropractors and acupuncturists.
Table 9.1 presents data on the wide variety of health care practitioner and support
occupations in the United States with jobs in hospitals, outpatient settings, and
long-term care.
“e broadest de!nition of the health workforce includes anyone who works
in a health care occupation or the health care industry, even if that worker is not
directly involved in providing health care services—for example, insurance billing
specialists, facilities managers, accountants, and other occupations. Within the
health care industry, about 3.3 million people are employed in o$ce, administrative, and support occupations, such as secretaries and administrative assistants,

Registered nurse 2,857,180
Nursing assistant 1,443,150
Personal care aide 1,492,250
Home health aide 814,300
Licensed practical nurse/vocational nurse 702,400
Physician/surgeon 649,850
Medical assistant 623,560
Pharmacy technician 398,390
Dental assistant 327,290
Pharmacist 305,510
Emergency medical technician/paramedic 244,960
Radiological technologist 200,650
Physical therapist 216,920
Dental hygienist 204,990
Medical records and health information technician 200,140
Medical and clinical laboratory technologist 166,730

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234 Part III. Medical Care: Treating Americans’ Medical Problems
information and records clerks, food preparation and food service workers, custodial services, security, and education and training.
!is chapter focuses on the workforce of more than 16 million people dedicated to delivering medical care services broadly de”ned. In addition, many other
American workers focus on e#orts to promote health among the population.
Workers in public health departments across the country deliver essential social
services that impact people’s health and well-being and other practitioners deliver
alternative health care services. Researchers, advocates, innovators, and others
focus on developing new approaches to delivering health care and keeping people
healthy. All these workforce resources are dedicated to the American health enterprise. Approximately 450,000 people work in public health agencies that focus on a
broad range of activities that prevent poor health at the community level (Sumaya,
2012). It is more di$cult to assess the scope of health promotion work done in
other sectors, but it is clear that many people spend time on activities that a#ect
the health of Americans throughout the private, public, and nonpro”t sectors.
Approaches to health workforce planning vary across countries. Countries with
national health care systems often closely manage the employment of health professionals, as well as the pipeline of new graduates from education programs. Many
countries, including the United States, do not have a highly centralized health care
system and engage in limited national health workforce planning e#orts. Planning
is left primarily to the private sector and local government agencies.
!e traditional supply-and-demand approach to workforce planning compares the number of working health professionals to estimates of the demand for
health workers. Projections of supply are typically built from data about the current number of workers, the number of new entrants per year, the number leaving the profession per year, and the share that is employed. In some cases, supply
estimates account for other factors that may a#ect supply, such as the loss of
health professionals to international migration. However, supply estimates rarely
can estimate changes in overall supply that might arise due to the development of
new health care occupations.
Projections of demand are usually based on current approaches to providing
health care services. Some demand projections attempt to establish a targeted
number of providers in order to deliver a desired level of services to the population. However, this “ideal” need-based demand may not align with budgetary
realities and thus not match the demand we actually see in the
labor market. For
example, during economic recessions, demand for health workers usually drops
even though demand for health services may remain stable because employers
have less money for hiring. If the amount of money available in the health system
is not su$cient to recruit workers and pay salaries, need-based demand and economic demand will diverge.
Two fundamental shortcomings of workforce planning are that (a) it is usually tied to current care delivery models and (b) it treats each health professional
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Chapter 9. The Health Workforce 235
independently. Innovative approaches to
care delivery and team-based care could
address many reported shortages of health
professionals. For example, a growing body
of research argues that new, integrated primary care delivery models, e!ective use
of information technology, and expanded
roles for nonphysician health professionals
could solve shortages of primary care physicians (Auerbach et al., 2013; Bodenheimer
& Smith, 2013; Green, Savin, & Lu, 2013;
Rosenthal, 2014; U.S. Health Resources and Services Administration [HRSA],
2016; Willard & Bodenheimer, 2012). For example, the patient-centered medical
home (PCMH) model of care (described in more detail below) brings together
teams of physicians, advanced practice clinicians such as nurse practitioners
(NPs), licensed nurses, medical assistants, health coaches, community health
workers, and other professionals. Each worker plays a unique and expanded role,
and this team-based approach can improve patient outcomes and satisfaction
while reducing the demand for physician time (Alexander et al., 2015). But health
workforce planning models are not designed to account for the variety of ways in
which such teams might be structured and how they can shift demand for each
type of professional.
Educational and training requirements vary signi”cantly across health care occupations: Some health workers enter the “eld without a high school diploma, whereas
others complete many years of postgraduate education. Many occupations, such
as personal care aides and medical secretaries, require little or no formal preparation, and training occurs on the job. In other occupations, such as medical assistants and pharmacy technicians, there is variation in employers’ preferences for
formal education programs versus longer-term,
on-the-job training.
Most technical health care occupations require some formal postsecondary education but not a degree; such occupations include surgical technicians,
licensed practical/vocational nurses, and emergency medical technicians. A large
share of education in these occupations occurs in private vocational schools; for
example, about 82% of medical assistants are trained in private and for-pro”t
schools (U.S. National Center for Education Statistics, 2015). #ese schools often
lack program-speci”c accreditation and standardized curricula. Some technical
professions, such as dental hygienist, respiratory therapist, clinical laboratory
technician, and radiology technician, require at least an associate degree. Registered nursing requires a minimum of an associate degree in most states, but
many RNs complete baccalaureate education before becoming licensed. Finally,
professions such as medicine, pharmacy, physical therapy, and optometry require
postgraduate education, typically at the doctoral level.
A growing body of research
argues that new, integrated
primary care delivery models,
effective use of information
technology, and expanded
roles for nonphysician health
professionals could solve
shortages of primary care
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236 Part III. Medical Care: Treating Americans’ Medical Problems
Postsecondary education is available from many institutions: private vocational schools, public adult school programs, community colleges, and public
and private colleges and universities. !e costs of educational programs vary
signi”cantly. Private education is generally much more expensive than public
education; in the 2014–2015 academic year, annual costs for public postsecondary education institutions averaged $16,188, whereas these costs averaged
$37,424 for private institutions (U.S. National Center for Education Statistics,
2016). Although prospective students might prefer to attend public institutions,
these often have many fewer admission spaces than applicants. Health worker
education is relatively expensive to deliver because it often requires the use of
laboratories and clinical sites and involves closely supervised clinical training.
Many public colleges and universities receive a “xed amount of funding per student, regardless of the major “eld of study. !us, these schools face a “nancial
loss if they expand their health professions
programs rather than expanding less-costly
programs. Moreover, because most health
care jobs have relatively high pay, it can be
di#cult for colleges to recruit faculty.
Di$erences in the costs of educational
programs a$ect choices made by students, especially when cost is compared
with expected earnings. For example, the education of a primary care physician
requires 4 years of postgraduate medical school education, followed by 3 or more
years of residency. Preparation for a specialized “eld of medicine requires more
time; for example, a cardiologist must complete 2 or 3 years of postresidency
fellowship after his or her residency. Some research has demonstrated that medical students’ choice of specialty is in%uenced by potential earnings compared
with education debt and that the lower earnings of primary care physicians do
not compare favorably, even though other “elds of medicine require more years
of residency and fellowship training (Bodenheimer, Berenson, & Rudolf, 2007;
Grayson, Newton, & !ompson, 2012; Hauer et al., 2008). Similar patterns have
been reported for dentistry (Nicholson, Vujicic, Wanchek, Ziebert, & Menezes,
2015). !ere also are mismatches between the cost of education and expected
earnings for many lower-skill health occupations. For example, medical assistant
wages averaged $15.17 per hour in 2016 (U.S. Bureau of Labor Statistics, 2017),
yet some medical assistants attend private training programs that charge tuition
and fees of more than $10,000 for a program of less than 1 year (U.S. Department
of Education, 2018).
Interprofessional Education
Health workforce education is traditionally focused on single professions. Physicians attend medical schools, nurses study in nursing schools, and dentists attend
dental schools. !ese siloed education programs rarely o$er opportunities to
Differences in the costs of
educational programs affect
choices made by students,
especially when cost is compared
with expected earnings.
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Chapter 9. The Health Workforce 237
learn together either in the classroom or through clinical experience. Alternative health care professionals, such as chiropractors, are rarely educated alongside physicians or other professionals. However, a growing body of evidence !nds
interprofessional education (IPE) and subsequent interprofessional practice, can improve the ability of health care professionals to provide high-quality
patient-centered care (Barr, Koppel, Reeves, Hammick, & Freeth, 2005), including
mental health care (Richards et al., 2013). Although the rapid emergence of initiatives to promulgate IPE seems recent, their roots date back to more than 40 years
ago, when the Institute of Medicine (IOM) published “Educating for the Health
Team” (1972). “e IOM’s second report on this subject, “Health Professions Education: A Bridge to Quality” (Greiner & Knebel, 2003), brought more attention to
the imperative to revamp health workforce training. “e report’s authors argued
that the silo approach to educating health professionals contributes to continuing
problems in the health care system.
Many private foundations, advocacy groups, and educational institutions are
now actively developing and implementing IPE programs to address future health
care needs. “e Interprofessional Education Collaborative—a consortium that
includes national organizations representing educators in allopathic and osteopathic medicine, dentistry, nursing, public health, and pharmacy—has made
speci!c recommendations regarding the competencies required for successful
interprofessional collaborative practice (Interprofessional Education Collaborative, 2011). “e competencies fall under four domains: (a) values and ethics for
interprofessional practice, (b) roles and responsibilities for collaborative practice,
(c) interprofessional communication, and (d) interprofessional teamwork and
team-based care. “e National Center for Interprofessional Practice and Education, established through a cooperative agreement between the federal government and four private foundations, is leading, coordinating, and studying the
advancement of interprofessional collaboration, with a particular focus on the
e#ect of IPE on quality, patient outcomes, and costs.
Innovative Models for Health Workforce Education
Traditionally, health professional students receive didactic instruction in the
classroom setting and develop clinical skills in health care delivery settings such
as hospitals, dental o$ces, and primary care clinics. As health professions programs have expanded, there has been increasing competition for clinical education sites, and some sites have reduced the number of students allowed to train
due to concerns about patient safety, demands for longer orientation periods,
and restrictions on access to electronic health records (Hayden, Smiley, Alexander, Kandong-Edgren, & Je#ries, 2014; Ironside & McNelis, 2009). “e development of increasingly sophisticated patient simulators, including high-!delity
mannequins, has facilitated growing use of simulation-based clinical education
(Hayden et al., 2014) as has recognition that simulation can be used to develop
clinical skills without risk to patients (Ziv, Wolpe, Small, & Glick, 2006). In 2002,
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238 Part III. Medical Care: Treating Americans’ Medical Problems
only 66 nursing programs were known to use patient simulators (Nehring & Lashley, 2004), but by 2010 at least 917 programs were using this technology (Hayden,
2010). Reviews of simulation in prelicensure education for multiple health professions, including medicine, nursing, and rehabilitation therapy, !nd that use
of simulation is associated with high satisfaction and con!dence as well as similar clinical performance between groups that have varying levels of simulation
experience during their education (Alanazi, Nicholson, & “omas, 2017; Cant &
Cooper, 2017; Hayden et al., 2014; Laschinger et al., 2008). Simulation education
also is playing an increasing role in supporting IPE and the development of skills
to practice e#ectively in health care teams (Palaganas, Epps, & Raemer, 2014).
Technological development also has fostered the growth of online health professions education for both initial education and continuing postlicensure education. Prelicensure programs frequently use “$ipped classroom” and “blended
classroom” approaches, in which there is a combination of in-person and online
learning modules (Wittich et al., 2017). Research on blended learning in health
professions education indicates that it has positive e#ects on learning both didactic and clinical content (Liu et al., 2016; McCutcheon, Lohan, Traynor, & Martin, 2015). Postlicensure education, including both advanced degree programs
and continuing education for license renewal, is increasingly o#ered online, in
web-based formats, and via videoconferencing (Cook et al., 2008). “ese strategies are highly e#ective for licensed professionals (Chipps, Brysiewicz, & Mars,
2012; Cook et al., 2008; Du et al., 2013; Richmond, Copsey, Hall, Davies, & Lamb,
2017). “ese innovative education approaches can improve the accessibility of
postlicensure degree programs and continuing education for those living in rural
communities (Chipps et al., 2012) and with mobility limitations (Marcyjanik &
Zorn, 2011).
In the face of rising costs and lengthy programs for health professions education, some U.S. schools have launched and expanded shorter training programs, most notably for medicine. “ree-year medical education programs are
not new; during the early 1970s, it was reported that 27% of schools of medicine
o#ered 3-year programs (Beran, 1979). Additional schools o#ered 6-year combined B.S.-M.D. programs. However, these programs were largely abandoned
owing to quality of life issues for students and faculty and the preference among
residency directors for 4-year program graduates (Kettel, Dinham, Drach, &
Barbee, 1979; Trzebiatowski & Peterson, 1979), even though there were no systematic reports of inadequacy of student preparation (Beran, 1979; Garrard
& Weber, 1974; Hallock et al., 1977; Kettel et al., 1979). In the 2000s, interest
in 3-year medical school programs was renewed in both allopathic and osteopathic medical schools, primarily as a strategy to increase interest in primary
care (Bell, Ferretti, & Ortoski, 2007; Raymond, Kerschner, Hueston, & Maurana, 2015). Some of these programs combine a 3-year undergraduate medical
program with a 3-year family or internal medicine residency. In 2012, it was
reported that more than 60 medical schools o#ered combined B.S.-M.D. programs lasting 6 or 7 years, and a small but growing number of schools were
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Chapter 9. The Health Workforce 239
o!ering 3-year medicine-only programs (Eaglen et al., 2012; Emanuel & Fuchs,
2012; Raymond et al., 2015). Accelerated education programs also are growing for nursing, including master’s degree entry and second-bachelor’s degree
programs designed for students with bachelor’s degrees in non-nursing “elds
(Aktan et al., 2009; Lindsey, 2009).
Increasing Educational Expectations
Concurrent with trends toward accelerated education and innovative education
delivery modalities has been a push among some professions, including pharmacists, NPs, certi”ed registered nurse anesthetists, and physical therapists, to
increase educational standards. For example, to support expanded roles of pharmacists in direct patient care and collaborative practice, in 2004 the Accreditation
Council for Pharmacy Education ended approval of 5-year bachelor’s of pharmacy
programs and made the Doctor of Pharmacy (PharmD) the only accredited pharmacy degree in the United States (Council on Credentialing in Pharmacy, 2010;
Maine, Knapp, & Scheckelho!, 2013; Schommer, Cline, & Larson, 2005). #at
same year, the American Association of Colleges of Nursing (AACN) approved
a position statement that supported adoption of the doctor of nursing practice
(DNP) degree by 2020 as the entry-level standard for advance practice RNs,
which includes NPs, certi”ed nurse midwives, clinical nurse specialists, and nurse
anesthetists (Martsolf, Auerbach, Spetz, Pearson, & Muchow, 2015). Although
the nurse anesthesia certi”cation board has dictated that all new graduates must
receive a DNP by 2025, only 25% of advance practice RN programs o!ered the
option for baccalaureate-educated RNs to go directly to a DNP in 2015. For PAs,
entry-level doctoral programs are now being launched, with the “rst one focused
on emergency medicine at Baylor University. Physical therapy, occupational therapy, laboratory medicine, speech therapy, and audiology also have moved toward
a clinical doctorate as the recommended or required entry-level education.
Many other health occupations are moving toward greater education requirements, including some that do not require bachelor’s-level education. #e IOM
recommended in 2011 that 80% of RNs attain a bachelor’s or higher degree by
2020 (IOM, 2011a), although this target will not be reached by that year. Similarly, the American Association for Respiratory Care issued a statement in 2015
that the share of respiratory therapists holding or working on a bachelor’s degree
should rise from 65% to 80% by 2020 (American Association for Respiratory
Care, 2015).
Supporters of increasing education standards for health professionals focus
on the additional time required to develop skills in patient care management as
well as development and execution of quality improvement programs. #ose who
oppose these education changes argue there is no evidence that higher educational requirements lead to better patient care and that higher levels of education increase costs for students and the health care system (Dickerson & Trujillo,
2009; Martsolf et al., 2015; Siler & Randolph, 2007).
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240 Part III. Medical Care: Treating Americans’ Medical Problems
!e implementation of the Patient Protection and A”ordable Care Act (ACA)
and a growing focus on the a”ordability of health care have brought new
urgency to the need to reform the delivery of health care in the United States.
For nearly 20 years, it has been recognized that signi#cant changes are needed
to improve the quality of care, increase the
health status of the U.S. population, and control health care costs (IOM, 2001; Kohn, Corrigan, & Donaldson, 2000). !ese changes,
however, may be di$cult to implement in
the face of ongoing and worsening shortages of health professionals. !e most critical issues facing the health workforce now, in
addition to the educational reforms described earlier, include ongoing shortages;
changes in health care #nancing, which are rapidly spurring changes in the organization of care delivery; developing a workforce that can e”ectively coordinate the
care of patients; integrating physical health care services with behavioral health
and dental care; optimizing the use of information technologies in care delivery
and quality improvement; the need to revamp regulations so that health professionals can meet health care needs more e$ciently and e”ectively; and leveraging
the potential of health care labor unions and labor–management partnerships.
Health Professional Shortages
!e expansion of insurance coverage under the ACA led to a surge in the demand
for health services (Wishner & Burton, 2017), which exacerbated preexisting shortages of primary care providers and other health professionals (Bodenheimer &
Pham, 2010; Colwill, Cultice, & Kruse, 2008; IHS Inc., 2015; Institute of Medicine,
2014; Nicholson, 2009) and heightened concerns that there is not an adequate
workforce to meet the health care needs of the population (Ormond & Bovbjerg,
2011). Even if the ACA were to be modi#ed or repealed, population growth, the
aging of the U.S. population, and increased rates of chronic illness are expected to
increase the workloads of primary care providers over the next 15 years (Colwill
et al., 2008; IOM, 2008). !e proportion of the U.S. population over age 65 is rising rapidly, from 14.9% in 2015 to a projected 20.6% in 2030 (U.S. Census Bureau,
2014). !is is important for the health care workforce for several reasons:
■■ Health care for older Americans costs more than for other age groups. Data from 2006
show average annual costs ranging from about $11,000, for those ages 65 to 74, to
nearly $24,000 annually, for those over age 85 (Federal Interagency Forum on AgingRelated Statistics, 2010, p. 50). !ose costs rise even more when one adds the cost of
chronic conditions: Costs average $5,100 for those with no chronic conditions to more
than $25,000 annually for those with more than #ve chronic conditions.
For nearly 20 years, it has been
recognized that signi!cant
changes are needed to improve
the quality of care, increase
the health status of the U.S.
population, and control health
care costs.
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Chapter 9. The Health Workforce 241
■■ Older adults use more services from health professionals. !ose over age 65 account
for about 26% of all physician visits, 35% of all hospital stays, 34% of prescriptions, and
90% of nursing home use (IOM, 2008).
■■ Many health professions’ curricula do not contain signi”cant content in caring for
older adults. At a time when we will most need generalists and specialists in geriatric care, the U.S. workforce is ill-prepared for these challenges (Kottek, Bates, &
Spetz, 2017).
■■ Members of the workforce that provide the bulk of long-term care in the home, community, and nursing homes are poorly paid, lack recognition for their work, and have
high rates of job dissatisfaction and turnover (IOM, 2008).
Shortages exist when demand is greater than supply. !e economic response
to a shortage is an increase in wages, which leads to greater supply (because compensation is more lucrative) and lower demand (because labor costs employers
more). However, this normal economic response does not always occur in the
labor markets for health professionals. First, wages may not change. !e historical fee-for-service (FFS) reimbursement system favors specialized, complex, and
procedurally oriented services. Because standard o#ce visits receive lower payment, total compensation for primary care providers is lower. Signi”cant changes
in payment methods will be needed to rectify this di$erential; accountable care
organizations (ACOs), PCMHs, and other such innovations may have some
impact, but the degree to which they will support growth of the primary care
workforce is yet unknown.
!e second reason health care labor markets might not follow standard economic behavior is that their supply is constrained by
licensure and educational
requirements. !e time required to prepare a new health care professional for
entry into the workforce can be many years. For example, the education of a primary care physician requires 4 years of medical school education, followed by 3 or
more years of residency. Interest in primary care among medical school students
has been dropping for years, with particularly little interest in family medicine
(Council on Graduate Medical Education, 2010; McGaha, Schmittling, DeVilbiss
Bieck, Crosley, & Pugno, 2010). Registered nurses, who must have a license recognized by the state in which they practice, must complete at least 2 years of
postsecondary education before they are quali”ed to take a licensing examination
(Buerhaus, Staiger, & Auerbach, 2009). Many other health professions, including
physical therapists, medical technologists, and respiratory therapists, face similar
licensing and education requirements.
Further constraining the supply of health professionals are limits on educational capacity. Allied health educational programs exemplify some of the challenges in producing an adequate number of health professionals. Educational
programs can be expensive to operate, with small class sizes and the cost of supplies for clinical practicums. !is is true for many occupations, including radiologic technicians, imaging specialties, and medical laboratory technologists.
Many allied health professions education programs are taught in community
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242 Part III. Medical Care: Treating Americans’ Medical Problems
college settings, where !nancial resources may be more limited than in universities and private colleges (IOM, 2011b).
In addition to the challenge of educating enough health professionals, there is
often a problem with the geographic distribution of those workers. In the United
States, it has historically been di”cult to recruit professionals into rural and
poorer urban areas, particularly when jobs are plentiful elsewhere (Bourgueil,
Mouseques, & Tajahmadi, 2006). Despite direct government interventions in the
form of academic stipends and loan forgiveness programs, access to primary care
in particular remains a problem in many states and in speci!c regions of some
states. Several analyses of health workforce needs for the ACA have reported that
the maldistribution of professionals is a critical problem across professions (e.g.,
Bates, Blash, Chapman, Dower, & O’Neil, 2011). #ese and other studies have
reported that training and retaining allied health workers in rural areas is also
a challenge (California Hospital Association, 2011). For this reason, many rural
health care programs use a “grow your own” approach recruiting and training
students from rural areas to increase the likelihood they will stay to work in the
area (IOM, 2011b).
Health worker shortages, and the rising wages that accompany them, have
led many health policy experts to advocate for increasing the roles of nonphysicians and allied health workers in care delivery. As discussed above, greater use of
team-based care and nonphysician health professionals could address physician
shortages, at least to some degree (Auerbach et al., 2013; Bodenheimer & Smith,
2013; HRSA, 2016). Similarly, licensed vocational nurses, who have a certi!cate or
associate degree, can perform many tasks reserved for RNs (Seago, Spetz, Chapman, Dyer, & Grumbach, 2004). #e degree to which health care delivery systems
engage in the substitution of health professionals depends both on their relative
wages and regulations that designate the
scope of practice of each professional.
Changes in Health Care Financing and the Organization of Care
Some provisions of the ACA are intended to increase the e”ciency of health
care delivery and are likely to a$ect the mix of health workers demanded.
Performance-based payment programs, for example, give health care organizations a !nancial incentive to focus on implementing models of care that can
increase the quality of care at a reasonable cost (Davis & Guterman, 2007). For
example, many studies have found that higher RN sta”ng levels in hospitals
are linked to better patient outcomes (e.g., Aiken, Clarke, Sloane, Sochalski, &
Silber, 2002; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Lang, Hodge, Olson,
Romano, & Kravitz, 2004; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Historically, however, hospitals have had little !nancial incentive to
increase nurse sta”ng because higher-quality nursing care is not rewarded and
nursing wages are expensive. Performance-based payment may lead hospitals to
reconsider the value of increasing nurse sta”ng because there could be a !nancial gain in improving quality (Kurtzman & Buerhaus, 2008).
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Chapter 9. The Health Workforce 243
Two other innovations in health care
!nancing are Medicare’s bundled payment
and ACO programs, both of which create
!nancial incentives for health care providers to take full responsibility for an episode
of care. “is is a signi!cant change from the
FFS approach by allowing health care organizations to retain !nancial savings from
delivering care e#ciently, as long as quality
is improved or maintained. “e potential
for !nancial gain gives health care providers an incentive to reassess their processes for providing care. ACOs have increased their use of interprofessional
health care teams, particularly for patients with high costs and complex illness (Sandberg, Erikson, & Yunker, 2017). Bundled payments, which provide
a single payment for hospital services during both initial hospitalization and
any subsequent hospitalization for a !xed period of time, also lead hospitals to
invest in services to prevent rehospitalizations.
Care Coordination
“e di$usion of payment systems that provide incentives to increase the e#ciency
of care delivery has given hospitals incentives to reduce the length of hospital
stay and ambulatory care providers incentives to reduce unnecessary ambulatory
care and emergency department visits. “is places increased importance on
coordinating the continuation of care and communication with the health care
team in the home. Care coordination and the employment of care managers are
associated with reduced hospitalizations and avoidable emergency department
visits (Conway, O’Donnell, & Yates, 2017; Erikson, Pittman, LaFrance, &
Chapman, 2017; Sandberg et al., 2017). Research has shown that health systems
are making greater investments in hiring and training nurses, social workers,
medical assistants, and other workers for care coordination (Ladden et al., 2013).
“ese workers hold a variety of job titles, including care coordinator, care manager,
case manager, and care navigator (Erikson et al., 2017). Erikson and colleagues
(2017) found that health systems often hire RNs for patients requiring clinical
management and social workers for patients needing social services; however,
these roles are often blended. As care coordination jobs become more prevalent
in the future, a challenge will be preparing the workforce for the skills needed
in these new roles: team communication, use of remote monitoring technology,
telehealth, and working with family caregivers.
“e ACA also includes provisions to support the PCMH model of care. A
PCMH engages a team of providers in the delivery of care, typically including
physicians, NPs, RNs, medical assistants, health educators, and pharmacists. Ideally, behavioral and mental health services are integrated into the PCMH (Bates
et al., 2011). Medical assistants might conduct expanded health assessments
Bundled payments, which
provide a single payment for
hospital services during both
initial hospitalization and any
subsequent hospitalization for
a !xed period of time, also lead
hospitals to invest in services to
prevent rehospitalizations.
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244 Part III. Medical Care: Treating Americans’ Medical Problems
and review patient records to identify those who need contact to ensure followup appointments and prescription re!lls occur (Chapman & Blash, 2017). RNs
often engage in care coordination and management, linking patients to specialists and other services. Health coaches support patients in adopting care plans
including diet and exercise, and community health workers engage patients with
community and social support services. Evaluations of the PCMH model !nds it
has positive impacts on quality of care and use of preventive services as well as
lower overall costs of care (Alexander et al., 2015). “is and similar team-based
approaches to providing primary care services may help to address anticipated
shortages of primary care providers by increasing the roles of other health care
professionals (Auerbach et al., 2013; Bates et al., 2011). In order for these models
of care to be fully successful, however, educational programs need to be realigned
to focus on interprofessional teams.
Integration of Physical Health, Behavioral Health, and Dental Care
Behavioral health care includes services for mental health and substance use
disorders. “e demand for behavioral health care services has increased for two
primary reasons. “e Mental Health Parity and Addiction Equity Act of 2008,
along with the ACA, ensured that mental health and substance abuse bene!ts
be no more restrictive than those for medical and surgical care (Frank, Beronio,
& Glied, 2014). “e ACA included mental health care as one of 10 essential bene!ts in all health care plans o#ered in the state insurance exchanges (Beronio, Po,
Scopec, & Glied, 2013). Even prior to these changes, there were national shortages of behavioral health providers. HRSA identi!es approximately 4,000 mental
health professional shortage areas in the United States (U.S. Health Resources and
Services Administration, 2016). Behavioral health providers include a wide range
of professionals and levels of preparation, including psychiatrists, psychologists,
psychiatric mental health nurse practitioners (PMHNPs), social workers, substance abuse counselors, and persons with lived experience called peer providers
who support persons in the recovery process. Some of the challenges in assuring
access to behavioral health care workers include a lack of growth in the number of
psychiatry trainees for more than a decade (National Resident Matching Program,
2017), PMHNP scope of practice limitations (Phoenix, Hurd, & Chapman, 2016),
maldistribution of the available workforce geographically and between public and
private practice, and the stigma of working in behavioral health. Behavioral health
is generally not well integrated with primary care services because services are
often provided at separate locations and have di#erent payment systems and electronic health records, and care coordination among the team members is di$cult.
“ere are promising e#orts in integrating primary and behavioral health care, but
much more needs to be done (Skillman, Snyder, Frogner, & Patterson, 2016).
Oral health care also has traditionally been separated from medical care,
even though dental disease has impacts on respiratory disease, cardiovascular disease, and diabetes (IOM, 2011c). Dental pain accounts for more than
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Chapter 9. The Health Workforce 245
1.3 million emergency department visits each year and up to 5% of adult primary care visits (Allareddy et al., 2014; IOM, 2011c). Increasing awareness of
the importance of oral health, along with requirements in the ACA that state
Medicaid plans insure oral health services for children, has prompted integration of dental and medical services by some providers. Some federally quali!ed
health centers and private medical groups have trained pediatricians to provide
enhanced dental screening and apply “uoride varnish to children’s teeth (Braun
et al., 2017; Pahel, Rozier, Stearns, & Quiñonez, 2011). NPs and physician assistants employed in primary care settings also are delivering similar services
(Mertz, Spetz, & Moore, 2017).
Information Technologies and the Workforce
#e continuing evolution of information technology in health care is changing
the work of health professionals as well as the way they communicate with each
other and with family members. Electronic health records enable health workers to exchange information rapidly and to engage patients more actively in care.
Electronic health records that facilitate greater use of telephone communication
with patients have been associated with a decrease in primary care visits (Chen,
Garrido, Chock, Okawa, & Liang, 2009) as well as fewer avoidable hospitalizations (Lammers, McLaughlin, & Barna, 2016). Even though the expanded use of
electronic health records is improving e$ciency, enhancing quality, and increasing patient engagement in health care, the implementation of such technologies
has demanded notable changes in skills and work”ow. Electronic health records
organize information di%erently than traditional paper charts, and health professionals need to navigate through structured menus to enter information rather
than rely on simple templates and free text. Many organizations have found that
in the short term these systems—and changes to the systems—disrupt work”ow,
and workers with poor typing and computer skills are challenged to use them
(Spetz, Phibbs, & Burgess, 2012). To make the best use of these systems, health
workers need enhanced computer skills, and health care organizations must
carefully redesign work”ow to take best advantage of what electronic health
records o%er.
Telemedicine also is rapidly changing the capacity of the health care
workforce, particularly in rural areas. Early use of telemedicine was limited largely
to telephone communication, but high-resolution digital imaging, real-time twoway video communication, and rapid transmission of electronic health records
make it possible for remote clinicians to access enough information to engage
in complex consultations remotely. Rural communities are increasingly using
electronic consultations to give patients access to specialists without traveling.
Widespread adoption of these technologies in both urban and rural settings
could greatly expand the capacity of the current workforce to meet health care
needs (Courneya, Palattao, & Gallagher, 2013; Green et al., 2013; Weiner, Yeh, &
Blumenthal, 2013).
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246 Part III. Medical Care: Treating Americans’ Medical Problems
The Need for Regulatory Reform
!e growth of team-based models of care, such as the PCMH, and continuing
concerns about shortages of physicians have led many researchers and policy
analysts to argue that nonphysician providers can and should play a larger role
in the delivery of primary care. For example, about half of NPs focus on the provision of primary care services (Spetz, Fraher, Li, & Bates, 2015). Many studies
demonstrate that the quality of care delivered by NPs is at least equivalent to that
of physicians, and some research has found that NPs have stronger patient communication skills (Horrocks, Anderson, & Salisbury, 2002; Lenz, Mundinger, &
Kane, 2004; Newhouse et al., 2011). However, NPs face scope-of-practice laws
that require them to work under physician supervision and limit their ability to
prescribe medications (Sekscenski, Sansom, Bazell, Salmon, & Mullan, 1994;
Wing, O’Grady, & Langelier, 2005). Removal of these barriers would enable NPs
to practice to their fullest potential to meet health care needs (IOM, 2011a). Regulations also limit the work of other health professionals, such as licensed practical nurses (LPNs) and medical assistants (Seago et al., 2004).
More than three-fourths of health workers are employed in licensed occupations. !ese occupations practice in the context of regulations regarding their
scope of practice which, for some states, stipulate whether they must be supervised or collaborate with other professionals and whether they can be reimbursed
directly by insurance companies (Kleiner & Park, 2010). !e often-stated purpose
of scope-of-practice regulation across the professions is consumer protection:
safeguarding consumers who cannot independently evaluate the skills or competence of health practitioners. State regulations, including licensure requirements, are meant to outline the basic education, skills, and competency of a
health care professional. Sometimes these regulations outline what practitioners
of a particular profession can do safely, and in some cases the regulations focus
on what members of the profession are not allowed to do. Both the breadth of
work permitted and prohibitions can be found in some state regulations. When
there is overlap in the potential roles of health professionals, scope of practice
regulations are more controversial and vary more across states (Kleiner, Marier,
Park, & Wing, 2014). Health care organizations also control the practice of health
professionals by establishing their own rules about what each provider can and
cannot do. For example, some hospitals do not permit NPs and PAs to oversee
patient care, and pharmacists are restricted from managing medications in some
!e e”ect of NP scope-of-practice regulations has been studied more than
those of other professions. !ere is substantial variation in the scope of practice
permitted across states (Christian, Dower, & O’Neil, 2007). In 23 states and the
District of Columbia, NPs are permitted to provide care independently, but in
other states NPs are not permitted to practice without physician collaboration
or supervision, often requiring written practice protocols and sometimes including restrictions on the number of NPs with whom a physician may collaborate
(American Association of Nurse Practitioners, 2017). Even when NPs can practice
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Chapter 9. The Health Workforce 247
independently, they may be required to have a collaborative or supervisory relationship with a physician to prescribe medications. Restrictive scope-of-practice
regulations for NPs have been linked to lower utilization of primary care services (Stange, 2013) and higher costs in retail health care clinics (Spetz & Parente,
2013). At the same time, several systematic reviews have concluded that primary
care services provided by NPs are of similar quality as physician care (Horrocks
et al., 2002; Lenz et al., 2004; Newhouse et al., 2011). In order to fully leverage the
capacity of the health workforce and align care processes to emerging !nancial
incentives, scope-of-practice regulations may need to be reconsidered.
Since 2000, there has been a trend toward regulatory changes that allow many
NPs and PAs greater practice independence (Gadbois, Miller, Tyler, & Intrator,
2014). Other professions also have seen expansions in their scope of practice.
Dental hygienists are now practicing more autonomously in many states than in
the past, particularly in public health settings such as schools, nursing homes,
and correctional facilities (Mertz et al., 2017). In addition, new categories of
licensed health professionals have been added, such as dental therapists, who
are authorized to diagnose dental disease, treat caries, and perform extractions
in Minnesota, Maine, and Vermont as well as within the Alaskan Native Tribal
Health Consortium (Nash, 2009; Pew Charitable Trusts Dental Campaign, 2016).
Health Care Unions and Labor–Management Partnerships
Growing numbers of health care workers are represented by unions; this trend
dates to the 1970s when regulations permitted employees of nonpro!t organizations to become unionized and eased the unionization of public-sector workers.
About 14% of health practitioner and technical workers are represented by unions,
as are 10% of health care support occupations (U.S. Bureau of Labor Statistics,
2014). Unionized health workers tend to receive higher wages than those not represented by unions. Unions also have sought other concessions from employers,
particularly hospitals, such as establishment of !xed nurse-to-patient ratios, preferred shifts based on employment tenure, and improved health and retirement
bene!ts. Health care workers have engaged in highly visible strikes and labor
actions; they are politically active, supporting legislation and candidates.
Some employers have developed good working relationships with their
unions. For example, in 1997 the Service Employees International Union, which
represents multiple health occupations, and 10 other unions partnered with
Kaiser Permanente in a landmark agreement. “e partnership focused on multiple
goals, including improving quality of care for members, making Kaiser Permanente more competitive in its markets, making Kaiser Permanente an “employer of
choice,” and providing Kaiser Permanente employees with the “maximum possible
employment and income security” (Kochan, McKersie, Eaton, & Adler, 2009). Since
then, the unions and Kaiser Permanente have worked closely together to establish
internal training programs, scholarships and grants for pursuing advanced education, and job transition programs. When Kaiser Permanente established a systemwide health information technology system, it worked with the union to ensure
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248 Part III. Medical Care: Treating Americans’ Medical Problems
You are the newly hired director of human resources (HR) for a large inner-city health care
organization. The CEO has asked you to develop a strategic response to numerous HR problems. The main problem has been the inability to recruit new physicians and RNs. This problem
is compounded by a lack of teamwork among clinicians and between service departments and
a high rate of turnover of some of the best workers while less able workers remain employed.
In writing your strategic response, consider the following questions:
1. What strategies could be undertaken in the short term to address these problems?
2. What approaches could be taken in the long term?
3. Which of these approaches can be undertaken by the HR department on its own, and
which require collaboration with employee groups and/or HR directors at neighboring
4. Choose three short-term priorities and defend them. How might they segue into a longterm strategy?
1. What are advantages of need-based models of demand? What are disadvantages of
this approach to estimating demand?
2. If changes to scope-of-practice regulations could help to abate health worker shortages and reduce the cost of health care, why are such changes not made?
3. What speci!c skills are needed for health care practitioners to coordinate care across
hospital, outpatient, skilled nursing, and home care settings?
that employees received training and to !nd new roles for workers, such as clerks,
whose jobs would be obviated by the electronic records. Although this partnership has not been without challenges, it has served as one model of a collaborative
labor–management approach, rather than an adversarial relationship.
“e health workforce is central to the health care system, and changes in its
deployment and utilization will have signi!cant e#ects on health care quality and
costs. “e ACA and rising concerns about the e$ciency of health care delivery
are bringing renewed attention to the importance of team-based care models,
IPE, and scope-of-practice regulations. At the same time, concerns and ongoing and emerging shortages of health workers persist. “e U.S. Bureau of Labor
Statistics estimates that the number of people employed in health occupations
will rise to more than 15 million by 2026, accounting for nearly 1 in 11 jobs. “e
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