Introduction to Health Care
and Public Health in the U.S.
Introduction to and History of
Modern Health Care in the U.S.
Lecture a
This material (Comp 1 Unit 1) was developed by Oregon Health & Science University, funded by the Department
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Award Number 90WT0001.
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Introduction to and History of
Modern Health Care in the U.S.
Learning Objectives - 1
• Define key terms in health care and public
health (Lectures a, b, c, d)
• Describe components of health care
delivery and health care systems
(Lecture a)
• Discuss examples of improvements in
public health (Lecture b)
2
Introduction to and History of
Modern Health Care in the U.S.
Learning Objectives - 2
• Define core values and paradigm shifts in
U.S. health care (Lecture c)
• Describe the technology used in the
delivery and administration of health care
(Lecture d)
3
Some Definitions: Health
• Often thought of as the absence of
disease
• World Health Organization (WHO)
– “…state of complete physical, mental and
social well-being and not merely the absence
of disease or infirmity”
• “Illness” is a state of poor health
4
Health Care
• The prevention and treatment of illness
• Delivered by people from varied disciplines
– Medicine – Laboratory Science
– Dentistry – Pharmacy
– Nursing – Other allied health
professions
• Work together as interdisciplinary teams to
deliver care
5
Health Care Delivery
• Delivered in different places
• Inpatient facilities
– Hospitals
o Institutions for treating sick or injured people
o Historically places for shelter, almshouses
– Nursing and residential care
• Outpatient facilities
6
Health Care Delivery - Hospitals
• Types of hospitals:
o General medical and surgical
o Specialty (orthopedic, pediatrics, women’s
services)
o Psychiatric
• Publicly or privately owned
• Patients can be admitted:
– Via emergency department
– Directly from physician’s office
7
Health Care Delivery – Nursing
and Residential Care Facilities
• Short-term or long-term facilities
• Long-term care classified by level of care
• Skilled nursing facilities (nursing homes)
– Proliferated after amendment of the Social
Security Act
– Originally part of the welfare system
– Now part of the health care system
8
Health Care Delivery –
Outpatient Facilities – 1
• Physicians offices • Dental offices
– Primary care – General dentists
– Specialty care – Specialists
– Single specialty or o Orthodontists
multispecialty o Endodontist
o Oral Surgeons
9
Health Care Delivery –
Outpatient Facilities – 2
• Medical and diagnostic laboratories
– X-rays
– CT Scans and MRIs
– Biologic Specimens
• Other ambulatory health services
– Ambulance services
– Home health care
– Hospice
– Visiting Nurse Services
10
The Health Care Industry
• One of the largest industries in the U.S. and
rapidly growing in employment
– 2014 - 18.0 million jobs for wage and salary workers
– Estimated to grow to 21.9 million jobs by 2024
• Top four fastest growing job categories
– Home health care services
– Outpatient care centers
– Offices of other health practitioners
– Other ambulatory health care services
11
Overviews of Health Care Systems
• Askin (2014)
– Started by two medical students who are now
physicians
– Overview of U.S. health care system, now in
second edition,
https://healthcarehandbook.wustl.edu
• Reid (2010)
– Comparative overview of different models of
health care around world assessed by
Washington Post journalist
12
Reid’s Four Systems and
Their U.S. Analogs (2010)
Name Description Countries U.S. Analog
Beveridge Provided and financed Great Britain, Veterans
by government Hong Kong, Administration
Cuba (VA)
Bismarck Regulated private Germany, Employer-
insurance – must cover France, provided health
all Switzerland insurance
National Private system with Canada, Medicare,
health government-run Taiwan, South Medicaid
insurance insurance Korea
Out-of-pocket Pay as you go Most poor U.S. uninsured
countries
Reid, 2010
13
Some Definitions of Care
• Primary care: Initial and ongoing care,
typically provided in an office or clinic
• Secondary care: Specialty care provided
in the community
• Tertiary care: Highly specialized care
usually provided by referral in a large,
typically academic, medical center
14
Health Care System Stakeholders
(the “p”s)
• Patient: The one who gets health care, often
called a consumer or citizen when they are well
• Provider: Those who provide health care, e.g.,
physicians, nurses, allied health
• Purchaser: Those who buy health care, usually
employers or the government
• Payor: Those who pay the health care system,
i.e., the insurance companies and government
• Public health: Protectors of the public’s health
15
How Health Care is Financed - 1
• No matter who pays the cost (patient,
employer, or government), most health
care is financed on the notion of insurance
– Everyone pays some, those who need it use it
– Although modern system may be better
described as “pre-paid” health care than
insurance
16
How Health Care is Financed - 2
• Payment methods
– Private fee-for-service
– Private managed care, a.k.a., HMOs
– Government-financed, a.k.a., single-payor
– Government-provided
17
Brief History of
Health Care Finance - 1
• Mid-20th century
– Introduction of health insurance
– Growth of “open-ended” spending
• Late 20th century
– Efforts to control costs, culminating in
managed care
– Empowerment of patients/consumers and
growth of Internet
18
Brief History of
Health Care Finance - 2
• 21st century
– Costs continued to rise well above inflation
but have leveled off in recent years
– Still, are we on a collision course with
increasing costs, aging baby boomers, more
costly technology, etc.?
19
Major Health Care
Payors in U.S. - 1
• Private health insurance: For most
employed citizens and their dependents,
except those in lower-paying jobs
• Medicare: Government insurance for
elderly and disabled
• Medicaid: Government insurance for
indigent
20
Major Health Care
Payors in U.S. - 2
• State Children’s Health Insurance
Program (S-CHIP): Government insurance
for uninsured low-income children
• Other expenses due to out-of-pocket,
public health, and other expenditures
21
Introduction to and History of
Modern Health Care in the U.S.
Summary – Lecture a
• Important definitions
– Health
– Health care
– Health care systems
• Different types of health care delivery
– Inpatient
– Outpatient
• Different models that range from private to
public funding – most are combination
22
Introduction to and History of
Modern Health Care in the U.S.
References – 1 – Lecture a
References
Askin, E and Moore, N (2014). The Health Care Handbook - A Clear and Concise Guide
to the United States Health Care System, Second Edition. St. Louis, MO, Washington
University in St. Louis.
Definition of Healthcare. Preamble to the Constitution of the World Health Organization
as adopted by the International Health Conference, New York, 19 June - 22 July
1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of
the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
A. (n.d.). Health Care Careers Directory 2012-2013. American Medical Association.
ISBN#: 978-1-60359-770-8.
Health Care and Social Assistance: NAICS 62, US Bureau of Labor Statistics,
http://www.bls.gov/iag/tgs/iag62.htm.
23
24
Introduction to and History of
Modern Health Care in the U.S.
References – 2 – Lecture a
References
Henderson, R (2015). Industry employment and output projections to 2024. Monthly
Labor Review, , Retrieved January 17, 2017,
http://www.bls.gov/opub/mlr/2015/article/industry-employment-and-output-projections-
to-2024.htm
Reid, TR (2010). The Healing of America: A Global Quest for Better, Cheaper, and Fairer
Health Care. New York, NY, Penguin Books.
World Health Report 2000 - Health systems: improving performance. (2000). Retrieved
January 20, 2017, from WHO website: http://www.who.int/whr/2000/en/ .
Charts, Tables, Figures
1.1 Table: BLS Quarterly Census of Employment and Wages, 2008. (2008). Retrieved January 20,
2017, from US Bureau of Labor Statistics website: http://www.bls.gov/cew/.
25
Introduction to Health Care and
Public Health in the U.S.
Introduction to and History of
Modern Health Care in the U.S.
Lecture b
This material (Comp 1 Unit 1) was developed by Oregon Health & Science University, funded by the Department
of Health and Human Services, Office of the National Coordinator for Health Information Technology under
Award Number 90WT0001.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
Public Health
• Charles Edward Winslow
– “Public health is the science and art of preventing
disease, prolonging life and promoting health
through the organized efforts and informed
choices of society, organizations, public and
private, communities and individuals.”
• Thomas Frieden
– “Public health focuses on denominators — what
proportion of all people who can benefit from an
intervention actually benefit”
27
10 Great Public Health
Achievements – U.S., 1900-1999
• Vaccination • Safer and healthier
• Motor-vehicle safety foods
• Safe workplaces • Healthier mothers and
• Control of infectious babies
diseases • Family planning
• Decline in deaths • Fluoridation of
from coronary heart drinking water
disease and stroke • Recognition of
tobacco use as a
health hazard
28
Control of Infectious Diseases
• Typhoid • Smallpox
– Spread by ingesting – Epidemic viral
contaminated food illness
or water – Early 1950s About
– 1891 Death rate in 50 million cases of
Chicago was 174 smallpox each year
per 100,000 people worldwide
– Now only about 400 – 1977 Smallpox
cases are seen in eradicated
the U.S. each year
29
Control of Nutritional Deficiencies
• Goiter
– Enlargement of the thyroid gland in the neck
– Fortification of salt with iodine virtually eradicated
nutritional goiter in the U.S.
• Tooth Decay
– Adding fluoride to drinking water substantially reduces
the incidence of dental caries
– 1945 Fluoride added to drinking water in Grand
Rapids, Michigan
– Over 10,000 U.S. communities fluoridate their water
30
How Has Public Health
Improved Health Care? - 1
• Improvements in understanding disease
– Epidemiology: The basic science of public
health
o Quantitative basic science
o Method of causal reasoning based on developing
and testing hypotheses pertaining to occurrence
and prevention of morbidity and mortality
o Tool for public health action to promote and protect
the public’s health
31
How Has Public Health
Improved Health Care? - 2
• Example of epidemiology at work:
– 1854 Cholera epidemic in London, England
– Cholera is a bacterial disease
– Lack of sanitation and overcrowding led to the
spread of disease
– Dr. John Snow linked the spread of disease to
contaminated Broad Street public water pump
– Snow’s hypothesis: Cholera was spread by
contaminated water
32
How Has Public Health
Improved Health Care? - 3
• Improvements in data collection have led
to the use of better scientific methods to
collect data and carry out experiments
– Field surveys
– Cohort studies
– Randomized controlled trials
33
How Has Public Health
Improved Health Care? - 4
• Improvements in data collection
– Framingham Heart Study
o Followed patients for a number of years to identify
factors that contribute to the development of
cardiovascular disease (CVD)
o Over the years, multiple generations of participants
have helped identify major CVD risk factors
o Helped to understand the effects of CVD on other
diseases
34
How Has Public Health
Improved Health Care? - 5
• Improvements in data analysis
– Use of tools such as multivariate analysis and
meta-analysis
• Improvement in disease surveillance
– The Real-Time Outbreak and Disease
Surveillance (RODS) Laboratory at the
University of Pittsburgh, Department of
Biomedical Informatics
35
How Has Public Health
Improved Health Care? - 6
• Improvement in training
– Establishment of many schools of public
health in the early 20th century
– Professional degrees such as Master of
Public Health (M.P.H.)
• Improvements in infrastructure
– Federal
– State
– Local health departments
36
Introduction to and History of
Modern Health Care in the U.S.
Summary – Lecture b
• Public Health Definition
• Public Health Successes include the
control of:
– Infectious diseases
– Nutritional deficiencies
– Understanding disease
• Public Health has improved
– Data collection
– Training and infrastructure
37
Introduction to and History of
Modern Health Care in the U.S.
References – 1 – Lecture b
References
Centers for Disease Control and Prevention - Ten great public health achievements—
United States, 1900–1999. (1999, April 2). MMWR, 48(12), 241-243.
Definition of Epidemiology from Principles of Epidemiology in Public Health Practice, 3rd
edition, CDC Self Study Course SS1978. Retrieved January 19, 2017, from Centers
for Disease Control and Prevention:
https://www.cdc.gov/ophss/csels/dsepd/ss1978/ss1978.pdf.
Frieden, TR (2015). Shattuck Lecture: The Future of Public Health. New England Journal
of Medicine. 373: 1748-1754.
Ripa, L. W. (1993). A Half-century of Community Water Fluoridation in the United States:
Review and Commentary. Dept. of Children’s Dentistry; SUNY Stony Brook, 53(1),
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8474047.
Smallpox. (n.d.). Retrieved January 19, 2017, from
http://www.who.int/csr/disease/smallpox/en/
38
Introduction to and History of
Modern Health Care in the U.S.
References – 2 – Lecture b
References
Typhoid Fever in the United States. (2001, April 25). Retrieved January 19, 2017, from
https://www.nichd.nih.gov/news/releases/pages/typhoid_background.aspx
Typhoid Fever. (2013, May 14). Retrieved January 19, 2017, from
https://www.cdc.gov/typhoid-fever/index.html
Vandenbroucke, J. P. (1998). Clinical investigation in the 20th century: the ascendency of
numerical reasoning. Lancet, 352 (suppl 2)(12), 6.
https://www.ncbi.nlm.nih.gov/labs/articles/9798639/
Framingham Heart Study. (n.d.). Retrieved January 19, 2017, from
http://www.framinghamheartstudy.org/
Winslow, C. E. (1920). The Untilled Fields of Public Health. Science, n.s. 51, 23.
39
