Factors that shaped US Health Services System

• Revolution: Americans concerned with Individual liberty & valued self reliance
• Civil War: Gov't should not compete with Private business

• Epidemics (yellow fever, cholera, influenza)
• "The Great Fever" killed around 38,000 
• War related injurys

• Medicine was ineffective and cheap

Three Spheres of medical practice

1. Domestic Medicine (Family)
2. Professional Medicine 
3. Popular Medicine (Indian doctors and bonesetters)

• In patient's homes
• Hospitals were for poor, homeless, and insane
• Public health focused on sanitation

• Standards not put strong enough when graduating from Medical Schools.

• Formation of Association of American Medical Colleges (AAMC).  Set minimum standards for medical education.
• Flexner Report

AMA invited Carnegie Foundation to investigate

• Medical education was not professing
• Should be strengthened on Johns Hopkins Model and rest should be closed
• America needs fewer, but better doctors

Hospitals now center of med. education/practice

• Redefined as med. science, not social welfare
• Rise of Surgery
• More faith in doctors
• 24 hour care, nursing emerges
• Care becomes more expensive (Biz not charity)

• World War 1 (1914-1918)
• Great Depression (1929-1939)
• World War 2 (1939-1945)

• All medical education into universities
  • Dominated by scientists and researchers
  • SPECIALISTS emerge
• Intro to For-Profit Hospitals
  • Physicians service as administrators
• Physicians were powerful and autonomous 
• Public Health emphasis on personal hygiene & private physicians as force in prevention

• Health Insurance was created because people wanted more care, and it was more expensive, so insurance made it affordable.

• Baylor hospital offered insurance for inpatient care to public school teachers for $.50/month
• Model became more popular during depression
  • Marketed to groups of workers

• WW II: Wage Freeze
  • Employers struggled to compete for employees
  • Offered health insurance as non-wage form of compensation
• IRS changed tax laws to make employer-based health insurance more attractive to employers and employees

• Postwar expansion followed by period of recession, rising unemployment, and slow economic growth
• Vietnam War (1955-1975)

• Primary health needs (heart disease & cancer)
• Health Services at this time:
  • Significant gov't investments in 1950s
    • Med Research: huge increase in budget 
    • Hill-Burton Program: construction funds for community hospitals
    • No federal interference/oversight
  • Rising Rate of medical specialization
    • Financial Rewards
    • Incentives for training programs for specialists

• Crisis because of enormous costs w/o improvement
• Growing distrust in physicians
• Need more primary care, fewer hospitals and incentives to treat undeserved communities.

Major change in government's involvement in the financing of health services

1. Investigate Outbreaks

Poor Access:  lack of preventative care, poor health outcomes, decreased quality of life

Unrestrained Access:  rich people going too much leads to uncoordinated treatment plans, increased costs, and higher risk of healthcare induced infections

1) Sociocultural

2) Financial

3) Temporal

4) Physical

5) Geographic

• Who are the underinsured?

Rising deductibles, copays.

Coverage limitations and exclusions

Who are the uninsured?

• 45.7 million nonelderly Americans in 2008
• 17% of the nonelderly population in U.S.
• Low income run highest risk
• Adults run higher risk than children
• Hispanics make up largest percentage
• Majority have gone over 3 years without coverage

• Medicaid expansion to cover ALL low-income Americans
• Students covered on parents plan until 26
• Access to people with pre-existing illnesses
• Increased Preventative care and testing
• Incentives to Small Businesses
• Penalties to large companies for not covering (50)

Non-Medical Issues:

• living and working conditions
• Income and education
• Health behaviors

Differences in:

• Access to care
• quality of care
• utilization

• Not enough hospitals in rural/urban areas (lack of incentive)
• Cultural and language barriers
• Bad past experiences
• stereotypes

How to reduce healthcare disparities?

• Insurance Coverage for all 
• Represent more minorities in healthcare delivery
• Improving geographical access
• Reduce language barriers
• Raising awareness and education in a population

• Infant mortality rate and weight
• Mortality rate
• Morbidity rate
• Life Expectancy 

Environment

• Physical: Geography, food, housing, water
• Social:  Education, occupation, income, relationships

Specialization because doctors are taught by academic specialists  as scientists in research hospitals.  As medical breakthroughs starting taking place, so did the cost of care.  Also, specialization is regarded as more prestigious and charges more than primary.  Third-Party Payers view specialists as a premium compared to PCP and compensate them with higher reimbursements.