2. High technology
Sophisticated institutions
Leading edge research
High level training for health professionals
3. • Lack of standardized payment system
• Unequal access for citizens
• No central coordinating agency
• Wide array of service settings that are not
inter-connected
• Few universal quality standards
• Greater proportion of total economic output
• Poorer outcomes than many developed
countries
4.
5. • 10 million people employed in health care
• 664,000 MDs
• 37,000 Dos
• 2 million nurses
• 162,000 dentists
• 200,000 pharmacists
• 700,000 health care administrators
• 500,000 rehab therapists
6. 6,200 hospitals
16,700 nursing homes
5,400 mental health facilities
13,500 home health agencies
1,200 FQHCs
3,400 RHCs
10. Women cared for the sick
Healers, herbalists, midwives
Passed traditions and knowledge from
generation to generation
Care centered in the home
Care given by family and community
members
11. Physicians were rising in Europe, but not in
America
Until 1800s, training was by apprenticeship
Basic science research was centered in Europe
American physicians focused on applied
medicine – “practical” techniques
Medical
Journal
12. In 1800, 4 medical schools in US
In 1850, there were 42
AMA formed in 1847
Reform of medical education began in the
1870’s and turned radically in 1910
13. • Urbanization
• Science and technology
• Rise of hospitals
• Cultural authority
• Maintenance of independent (non-employee)
status through organization and cohesiveness
• Licensing
• Educational reform
14. Nursing arose from healing and religious
traditions
Development of nursing entwined with status
of women over the centuries
Nightingale ushered in era of “modern” nurse
in 1860
NC first state to license “registered nurses” in
1903
State practice acts formalized profession
15. Apprenticeship
Hospital schools
Goldmark Report (1923) found nursing
education inadequate in hospital programs
Shift to college and university education
initiated in 1893 and continues today
17. Earliest hospitals in US were almshouses or
were to isolate people with infectious disease
or mental illness
General hospitals developed in response to
◦ Urbanization
◦ Technology
◦ Medical specialization
By 1900, 4,000 hospitals were in operation
18. Originated to assure clean water, control
epidemics
Public health nursing gained strength
Gradually took over
immunizations, communicable
disease, sanitation
Public health remained separate from
physician practice
19. 1916 to 1920
Attempts by social reformers in 16 states to
pass a bill requiring compulsory “health
insurance” for workers
Organized labor against it
AMA “studied” it
No surprise – no success
20. Effects of Great Depression on hospitals and
physicians
Hospitals started a pre-payment plan
Physician groups started a pre-payment plan
for physician services in the hospital, mainly
surgery
Private companies saw their success and
joined in – and a new industry was born
21. 1935 – Social Security Act
1946 – Hill-Burton Act
1952 – failed health care reform under
President Truman
1965 – Medicare and Medicaid passed in
Lyndon Johnson’s vision for the Great Society
◦ Title VIII and Title XIX of the Social Security
Amendment of 1965
22. Attempts to bring more system-ness through
National Health Planning Act of 1974
Rise of HMOs
◦ HMO Act of 1973
Rising costs
National Health
Planning Act of 1974
HMO Act of 1973
23. Rise of for-profit health care providers and
organizations
Increasing corporate dominance
Vertical and horizontal integration of health
care organizations
Especially in 80s, private sector assumed
substantial control of health care delivery
24. Health Insurance and Portability and
Affordability Act, 1996
Balanced Budget Act,1997
President Clinton’s health care reform
attempt
25. “A medical care system that had begun to
attract investors and in which business
interests had started to re-shape the
behaviors of doctors and health care
facilities…”
◦ Arnold Relman, MD
◦ Editor-in-Chief, New England Journal of
Medicine, 1980
26. http://money.cnn.com/magazines/fortune/fo
rtune500/2010/performers/companies/profi
ts/
Driven by profits
Driven by technology
28. Uninsured and underinsured do not have
access to care (access)
Costs continue to skyrocket (cost)
Outcomes lag behind other developed
countries (quality)
29. Uninsured
15%
Employer- Medicaid/
Sponsored Other Public
Insurance 13%
52%
Medicare
14%
Private Non-
Group
5%
30. Uninsured
17%
Medicaid/
Other Public
Employer-
18%
sponsored
Insurance
60%
Private Non-
group
5%
31. 66% uninsured families have 1or more full
time worker(s)
67% uninsured families below 200% poverty
level
Individuals between age 30 and 54 comprise
the largest group of uninsured
32. Patient Protection and Affordable Care Act
(March 23, 2010)
◦ Far reaching changes to all aspects of health care
system
◦ http://www.kff.org/healthreform/upload/8061.pdf
34. Health care as Health care as
economic model social resource
Assumes free Requires
market position government
Market-based involvement
demand for Assumes
services government led
Services provided position
on ability to pay Ability to pay not
Access is reward for necessary
personal effort Access is a right
35. Individual Collective
responsibility for responsibility for
health health
Benefits based on Basic benefits for
individual everyone
purchasing Strong obligation to
Limited obligation collective good
to collective good Public solutions
Private solutions Planned rationing
Rationing based on of health care
ability to pay
