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H EALTH POL ICY I N T R O D U C T I O N T O

Leiyu Shi

Shi

One North Franklin Street, Suite 1700 Chicago, Illinois 60606-3529 Phone: (301) 362-6905, Fax: (240) 396-5907 ache.org/HAP Order No.: 2238

ealthcare policies continue to evolve and subsequently must be integrated into healthcare system operations. This book introduces readers to health policymaking,

critical health policy issues, health policy research and evaluation methods, and international perspectives on health policy. Leiyu Shi takes a unique perspective by integrating all these topics into this one-of-a-kind book. Real-world cases and examples reinforce the theories and concepts throughout the book and address all healthcare settings, including public health, managed care, ambulatory care, extended care, and hospitals.

Introduction to Health Policy provides an overview of:

✦✦ Health determinants and health policy formulation

✦✦ Major types of health policies, including those affecting special populations, such as racial and ethnic minorities, low-income individuals, senior citizens, women and children, people with HIV/AIDS, people with mental illness, and the homeless

✦✦ Health policy issues related to financing and delivery of healthcare in the United States and abroad

✦✦ The importance of an international perspective from both developed and developing countries

✦✦ Processes and context for federal, state, and local health policymaking

✦✦ Health policy research methods for use in studying and analyzing policy issues

Leiyu Shi, DrPH, is professor of health policy and health services research at the Johns Hopkins University Bloomberg School of Public Health in the Department of Health Policy and Management. He also serves as director of the Johns Hopkins Primary Care Policy Center. He received his doctoral degree from the University of California, Berkeley, majoring in health policy and services research. He has conducted extensive studies on the association between primary care and health outcomes, in particular the role of primary care in mediating the adverse impact of income inequality on health outcomes. Dr. Shi is also well known for his extensive research on vulnerable populations in the United States. He is the author of nine textbooks and more than 150 scientific journal articles.

“Dr. Shi’s book introduces readers to the opportunities and issues of policymaking in both US and international contexts. His knack for illustrating complex theory with

challenging and relevant real-life examples makes this field really come to life.” —Gregory D. Stevens, assistant professor of family medicine and preventive medicine,

Keck School of Medicine, University of Southern California

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AUPHA/HAP Editorial Board for Undergraduate Studies

Rosemary Caron, PhD, Chairman University of New Hampshire

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Tracy J. Farnsworth, EdD Idaho State University

Riaz Ferdaus, PhD Our Lady of the Lake College

Brenda Freshman, PhD California State University

Mary Helen McSweeney-Feld, PhD Towson University

John J. Newhouse, PhD St. Joseph’s University

Rubini Pasupathy, PhD, FACHE Texas Tech University

Jacqueline E. Sharpe Old Dominion University

Daniel J. West Jr., PhD, FACHE University of Scranton

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Health Administration Press, Chicago, Illinois

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Library of Congress Cataloging-in-Publication Data

Shi, Leiyu. Introduction to health policy / Leiyu Shi. pages cm Includes index. ISBN 978-1-56793-580-6 (alk. paper) 1. Medical policy--History. 2. Health care reform. 3. Public health--International cooperation. I. Title. RA393.S473 2014 362.1--dc23 2013005276

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mailto:hapbooks@ache.org
http://www.copyright
I dedicate this book to my wife, Ruoxian,

and my children, Sylvia, Jennifer, and Victor Shi.

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v i i

BRIEF CONTENTS

Preface ..................................................................................................................xiii

PART I Introduction .......................................................................................1

Chapter 1 Overview of Health Policy .................................................................3

PART II Health Policymaking ........................................................................29

Chapter 2 Federal Health Policymaking ...........................................................31 Chapter 3 Health Policymaking at the State and

Local Levels and in the Private Sector ...........................................53 Chapter 4 International Health Policymaking ..................................................74

PART III Health Policy Issues ..........................................................................97

Chapter 5 Health Policy Related to Financing and Delivery .............................99 Chapter 6 Health Policy for Diverse Populations ............................................118 Chapter 7 International Health Policy Issues ..................................................150

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v i i i B r i e f C o n t e n t s

PART IV Health Policy Research ...................................................................183

Chapter 8 Overview of Health Policy Research ..............................................185 Chapter 9 Health Policy Research Methods ...................................................216 Chapter 10 An Example of Health Policy Research ..........................................255

by Sarika Rane Parasuraman

Glossary ...............................................................................................................295

Index .....................................................................................................................303

About the Author ..............................................................................................320

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P r e f a c e i x

DETAILED CONTENTS

i x

Preface ..................................................................................................................xiii

PART I Introduction .......................................................................................1

Chapter 1 Overview of Health Policy ..................................................................3 Learning Objectives ...............................................................................................3 Case Study: Healthcare Reform: Hillary Clinton and Barack Obama .....................4 Health Defined ......................................................................................................5 Public Health Defined ...........................................................................................8 What Are the Determinants of Health? ..................................................................9 Policy Defined .....................................................................................................15 Health Policy .......................................................................................................16 Determinants of Health Policy .............................................................................18 Stakeholders of Health Policy ...............................................................................21 Why Is It Important to Study Health Policy? ......................................................23 Key Points ............................................................................................................24 Case Study Questions ..........................................................................................24 For Discussion .....................................................................................................24 References ............................................................................................................25

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x D e t a i l e d C o n t e n t s

PART II Health Policymaking ........................................................................29

Chapter 2 Federal Health Policymaking ............................................................31 Learning Objectives .............................................................................................31 Case Study: The Development of Medicare and Medicaid ...................................32 The US Political System .......................................................................................33 Policymaking Process at the Federal Level ............................................................34 Attributes of Health Policymaking in the United States .......................................43 Role of Interest Groups in US Health Policymaking ............................................46 Key Points ............................................................................................................49 Case Study Questions ..........................................................................................49 For Discussion .....................................................................................................49 References ............................................................................................................50 Additional Resources ............................................................................................51

Chapter 3 Health Policymaking at the State and Local Levels and in the Private Sector ...............................................53

Learning Objectives .............................................................................................53 Case Study: Massachusetts Healthcare Reform .....................................................54 State Governmental Structure ..............................................................................55 Local Government Structure ................................................................................57 Private Health Research Institutes ........................................................................60 Private Health Foundations .................................................................................61 Private Industry ...................................................................................................63 Attributes of Health Policy Development in Nonfederal Sectors ..........................65 Key Points ............................................................................................................68 Case Study Questions ..........................................................................................68 For Discussion .....................................................................................................68 References ............................................................................................................69

Chapter 4 International Health Policymaking ...................................................74 Learning Objectives .............................................................................................74 Case Study: China’s Healthcare Reform ...............................................................75 World Health Organization .................................................................................76 Health Policymaking from Selected Countries .....................................................79 Key Points ............................................................................................................90 Case Study Questions ..........................................................................................91 For Discussion .....................................................................................................91 References ............................................................................................................91 Additional Resources ............................................................................................95

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PART III Health Policy Issues ..........................................................................97

Chapter 5 Health Policy Related to Financing and Delivery .............................99 Learning Objectives .............................................................................................99 Case Study: The Federally Funded Health Center Program:

Providing Access, Overcoming Disparities .....................................................100 Financing US Healthcare ...................................................................................101 US Healthcare Delivery .....................................................................................105 Policy Issues Related to Healthcare Financing and Delivery ...............................109 Key Points ..........................................................................................................114 Case Study Questions ........................................................................................114 For Discussion ...................................................................................................114 References ..........................................................................................................115

Chapter 6 Health Policy for Diverse Populations ............................................118 Learning Objectives ...........................................................................................118 Case Study: The Health Center Program ............................................................119 Defining Vulnerability ......................................................................................120 Health Policy Issues for Diverse Populations ......................................................121 Health Policy Issues for Vulnerable Subpopulations ...........................................128 Key Points ..........................................................................................................139 Case Study Assignment ......................................................................................139 For Discussion ...................................................................................................140 References ..........................................................................................................140

Chapter 7 International Health Policy Issues...................................................150 Learning Objectives ...........................................................................................150 Case Study: Climate Change and Public Health.................................................151 Health Policy Issues in Developed Countries .....................................................154 Health Policy Issues in Developing Countries ....................................................161 Key Points ..........................................................................................................173 Case Study Questions ........................................................................................173 For Discussion ...................................................................................................173 References ..........................................................................................................174

PART IV Health Policy Research ...................................................................183

Chapter 8 Overview of Health Policy Research ..............................................185 Learning Objectives ...........................................................................................185 Case Study: The RAND Health Insurance Experiment ......................................186

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x i i D e t a i l e d C o n t e n t s

Defining Health Policy Research ........................................................................187 The Process of Health Policy Research ...............................................................193 Communicating Health Policy Research ............................................................205 Implementing Health Policy Research................................................................207 Key Points ..........................................................................................................212 Case Study Questions ........................................................................................212 For Discussion ...................................................................................................212 References ..........................................................................................................212

Chapter 9 Health Policy Research Methods ....................................................216 Learning Objectives ...........................................................................................216 Case Study: Health Centers and the Fight Against

Health Disparities in the United States ..........................................................217 Quantitative Methods ........................................................................................218 Qualitative Methods ..........................................................................................234 Key Points ..........................................................................................................242 Case Study Assignment ......................................................................................243 For Discussion ...................................................................................................243 References ..........................................................................................................243 Additional Resources ..........................................................................................253

Chapter 10 An Example of Health Policy Research ...........................................255 by Sarika Rane Parasuraman

Learning Objectives ...........................................................................................255 Questions for Policy Analysis .............................................................................256 Policy Analysis: Responses to Exam Questions ...................................................257 References ..........................................................................................................284

Glossary ...............................................................................................................295

Index .....................................................................................................................303

About the Author ..............................................................................................320

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x i i i

PREFACE

For decades, US policymakers have been struggling to find solutions to our healthcare challenges. Thus, healthcare reform is among the top priorities of almost every admin-istration. This introductory textbook on US health policy covers the related areas of health poli-

cymaking, critical health policy issues, health policy research, and an international perspective on health policy and policymaking.

The book offers the following features:

◆ Real-world cases to exemplify the theories and concepts presented from a variety of perspectives, including the hospital setting, public health, managed care, ambula- tory care, and extended care

◆ Learning objectives and key points ◆ Discussion questions ◆ A glossary ◆ Boxes, including Learning Points, For Your Consideration, Key Legislation, and

others, as well as exhibits to present background information on concepts, exam- ples, and up-to-date information

◆ Instructor’s materials, including PowerPoint slides and answers to the discussion questions that appear in each chapter

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x i v P r e f a c e

ORGANIZATION OF THE BOOK This book is organized in four parts: an introduction, an overview of health policymak- ing, a health policy issues section, and a discussion of health policy research and analysis. Chapter 1, the sole chapter in Part I, introduces key terms related to, and the determinants of, health and health policy. It lists the key stakeholders in health policymaking and pres- ents important reasons for studying health policy. The chapter lays the foundation for the rest of the book.

Part II examines the policymaking process at the federal, state, and local levels; in the private sector; and in international settings. Chapter 2 focuses on the policymaking process at the federal level of the US government. Important activities within the three policymaking stages—policy formulation, policy implementation, and policy modifica- tion—are described. The key characteristics of health policymaking in the United States are analyzed, and the role of interest groups in making that policy is discussed.

The focus of Chapter 3 is the US policymaking process at the state and local levels and in the private sector, which includes the research community, foundations, and private industry. Examples of policy-related research by private research institutes and foundations are described. The impact of the private sector’s services and products on health and policy is illustrated using the fast-food industry and cigarette companies as examples.

Chapter 4 discusses international health policymaking. The World Health Orga- nization is presented as an example of an international agency involved in policymaking related to health and major health initiatives. Five countries—Canada, the United King- dom, Sweden, Australia, and China—are highlighted to illustrate diverse policymaking processes in various geographic regions. The experiences of these countries show that dif- ferent political systems and policymaking processes lead to different approaches to popula- tion health and healthcare delivery.

In Part III, we discuss the policy issues related to social, behavioral, and medical care health determinants; to people from diverse populations; and to international health. Chapter 5 describes how US healthcare is financed and delivered. Private and public health insurance programs are summarized, and the subsystems of healthcare delivery—managed care, the military system, care for vulnerable populations, the public health program, the long-term care system, and oral health delivery—are introduced. After summarizing the major characteristics of US healthcare delivery, the chapter provides examples of health policy issues related to financing (regulatory and market approaches) and delivery (health- care workforce, certification and accreditation of healthcare organizations, antitrust regula- tions, access-to-care issues, and patient rights concerns).

Chapter 6 defines vulnerable populations and discusses the dominant healthcare policy issues related to those populations. People from diverse populations include racial or ethnic minorities, those with low income, the elderly, women and children, people with HIV/AIDS, the mentally ill, and the homeless. In each segment, the magnitude of

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P r e f a c e x v

the problem is summarized and a detailed discussion of the policies and strategies meant to address the problem is presented.

In Chapter 7, dominant health policy issues in the international community are discussed, with examples given for select countries. The chapter begins by discussing issues shared by developed countries, such as modifying health systems to better serve aging and diverse populations while maintaining high-quality care at a low cost. It then discusses challenges faced by developing nations, such as creating and maintaining high-functioning health systems with limited resources and dealing with the burdens of morbidity and mor- tality associated with poverty. Several emerging issues are also illustrated that could affect global health in the future.

Part IV presents an overview of policy analysis, focusing on examples of commonly used quantitative and qualitative methods. Chapter 8 introduces health policy research (HPR) and highlights the discipline’s defining characteristics, including applied, policy- relevant, ethical, multidisciplinary, scientific, and population-based studies. The HPR pro- cess is summarized, and the chapter concludes with a discussion of ways to communicate findings and the challenges in implementing those findings in practice.

In Chapter 9, we illustrate commonly used methods in health policy research. Quantitative methods include experimental research, survey research, evaluation research, and cost–benefit and cost-effectiveness analysis. Because evaluation research is closely tied to policy research, the process involved in this type of research is described in greater de- tail. Qualitative methods include participant observations, in-depth interviews, and case studies.

Chapter 10 provides an example that illustrates the key steps in health policy analy- sis: assessing the determinants of a health problem, identifying policy intervention to the problem, critically evaluating the policy intervention, and proposing next steps in address- ing the problem.

ACKNOWLEDGMENTS My PhD advisee Sarika Rane Parasuraman contributed Chapter 10 (an applied example) and is hereby acknowledged. The preparation of this book was also aided by Xiaoyu Nie and Hannah Sintek, who served as my administrative assistants. The editorial staff of Health Administration Press, in particular Joyce Dunne and Janet Davis, have provided hands-on assistance in editing the manuscript to make it more compatible with the audi- ence. Of course, all errors and omissions remain the responsibility of the author.

Leiyu Shi Professor of Health Policy

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1

PA RT I

INTRODuCTION

The introduction, which consists of Chapter 1, provides an overview of health policy. It defines key terms related to health policy, reviews the frameworks of health determinants, and outlines the concept of health policy formulation. In addition, the chapter intro- duces topics related to health policy, including stakeholders, the major types of health policies, and the importance of studying health policy. The introduction should provide readers with a foundation for examining how health policy is set in the United States and elsewhere.

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3

Learning Objectives

Studying this chapter will help you to

➤➤ define➤key➤terms➤related➤to➤health➤policy,➤

➤➤ appreciate➤the➤influence➤of➤health➤determinants,

➤➤ understand➤the➤framework➤of➤health➤policy➤formulation,

➤➤ identify➤the➤stakeholders➤in➤health➤policy,➤

➤➤ describe➤the➤major➤types➤of➤health➤policies,➤and

➤➤ discuss➤the➤importance➤of➤studying➤health➤policy.➤

C H A P T E R 1

OvERvIEw OF HEALTH POLICy

I have never had a policy. I have simply tried to do what seemed best each

day, as each day came.

— Abraham Lincoln

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4 I n t r o d u c t i o n ➤ t o ➤ H e a l t h ➤ P o l i c y

CASE STuDy

HEALTHCARE REFORM: HILLARy CLINTON AND BARACK OBAMA

Two➤major➤healthcare➤reform➤initiatives➤have➤played➤out➤on➤the➤US➤political➤landscape➤in➤the➤

last➤two➤decades:➤the➤Health➤Security➤Act,➤developed➤by➤the➤Clinton➤administration➤in➤the➤

1990s➤and➤spearheaded➤by➤then➤First➤Lady➤Hillary➤Clinton,➤which➤failed➤to➤pass➤into➤law,➤and➤

the➤Patient➤Protection➤and➤Affordable➤Care➤Act➤(ACA),➤drafted➤by➤the➤Obama➤administration,➤

which➤became➤federal➤law➤in➤March➤2010.

The➤hallmark➤of➤the➤Clinton➤plan➤was➤its➤universal➤coverage➤mandate,➤which➤required➤

all➤employers➤to➤contribute➤to➤a➤pool➤of➤funds➤intended➤to➤cover➤the➤costs➤of➤ insurance➤

premiums➤for➤their➤workers,➤with➤caps➤on➤total➤employer➤costs➤and➤subsidies➤for➤small➤busi-

nesses.➤Competition➤among➤private➤health➤plans➤and➤a➤cap➤on➤the➤growth➤of➤insurance➤pre-

miums➤was➤to➤have➤held➤costs➤in➤check,➤and➤additional➤financing➤was➤to➤have➤been➤provided➤

through➤savings➤from➤cuts➤in➤projected➤Medicare➤and➤Medicaid➤spending➤and➤increased➤

taxes➤on➤tobacco➤(Oberlander➤2007).

The➤Obama➤plan➤focused➤on➤reforming➤the➤private➤health➤insurance➤market,➤extending➤

insurance➤coverage➤to➤the➤uninsured,➤providing➤better➤coverage➤for➤those➤with➤preexisting➤

conditions,➤improving➤prescription➤drug➤coverage➤in➤Medicare,➤and➤extending➤the➤life➤of➤the➤

Medicare➤trust➤fund➤accounts.➤The➤ACA➤is➤expected➤to➤be➤financed➤through➤taxes,➤such➤as➤a➤

40➤percent➤tax➤on➤“Cadillac”➤insurance➤policies—policies➤that➤offer➤the➤richest➤benefits—

taxes➤on➤pharmaceuticals,➤medical➤devices,➤and➤indoor➤tanning➤services➤(KFF➤2011);➤and➤

other➤offsets➤(provisions➤of➤the➤law➤that➤reduce➤the➤overall➤cost➤of➤enacting➤the➤legislation,➤

such➤as➤penalties➤on➤uninsured➤individuals).

The➤political➤landscape➤in➤2009,➤as➤President➤Barack➤Obama’s➤healthcare➤reform➤ini-

tiative➤was➤being➤debated,➤was➤similar➤to➤that➤ in➤the➤early➤1990s:➤Both➤the➤Clinton➤and➤

Obama➤administrations➤were➤affiliated➤with➤the➤Democratic➤Party,➤both➤chambers➤of➤the➤US➤

Congress➤were➤controlled➤by➤Democrats,➤and➤national➤opinion➤strongly➤favored➤healthcare➤

reform➤(Sack➤and➤Connelly➤2009).➤

However,➤ whereas➤ the➤ Obama➤ reform➤ initiative➤ became➤ law,➤ the➤ Clinton➤ healthcare➤

reform➤ package➤ was➤ defeated➤ in➤ Congress.➤ Although➤ Americans➤ supported➤ healthcare➤

reform➤in➤theory,➤the➤Clinton➤plan➤was➤derailed➤by➤the➤heavy➤opposition➤of➤the➤medical➤and➤

insurance➤industries➤and➤by➤anti-tax➤rhetoric.➤The➤disenchantment➤of➤the➤electorate➤follow-

ing➤that➤failed➤effort➤helped➤Republicans➤gain➤control➤of➤the➤House➤of➤Representatives➤and➤

Senate➤in➤the➤1994➤election➤(Trafford➤2010).➤

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➤ C h a p t e r ➤ 1 : ➤ O v e r v i e w ➤ o f ➤ H e a l t h ➤ P o l i c y ➤ 5

At 17.9 percent of the nation’s total economic activity, also known as the gross domestic product, healthcare spending in the United States leads all countries in overall and per capita measures (KFF 2012). Yet its health system does not per- form well compared to those of other industrialized countries. A 2010 World Health Or- ganization (WHO) report ranks the US health system thirty-sixth among 191 countries, and a Commonwealth Fund study completed the same year ranks it last among six other countries—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—on the basis of quality, efficiency, access, equity, and healthy lives measures (Davis, Schoen, and Stremikis 2010).

Why have health policies tended to fail in the United States while they appear to be succeeding in other countries? The answer might be found in the context—the United States—and the determinants of health and health policy in the United States.

The main purpose of this chapter is to present a framework of health policy de- terminants and discuss their impact in the United States. Understanding this framework helps the reader appreciate factors that contribute to health policy development in general and in the United States in particular. The chapter first defines key concepts related to health policy and later discusses the importance of studying health policy, including an awareness of the international perspective. The stakeholders of health policy are also pre- sented and analyzed as key parts of the policy context.

HEALTH DEFINED WHO (1946) defines health as “not merely the absence of disease or infirmity but a state of complete physical, mental and social well-being.” This broad definition recognizes that health encompasses biological and social elements in addition to individual and commu- nity well-being. Health may be seen as an indicator of personal and collective advance- ment. It can signal the level of an individual’s well-being as well as the degree of success achieved by a society and its government in promoting that well-being (Shi and Stevens 2010). This definition of health strikes a common chord among governments that allows policymakers at WHO, and others in the global health community, to build the case that issues such as poverty; lack of education; discrimination; and other social, cultural, and political conditions found around the world are essentially public health issues.

However, health is also the result of personal characteristics and choices. This con- cept is the source of the fundamental tension in public health and has been a major topic in the United States in the past few years. Major debates continue over whether people can be forced to take actions to ensure their own health, such as buying health insurance (the individual mandate in the Affordable Care Act), or be prohibited from performing actions that are unhealthy, such as limiting soft drinks in schools. Health policy in the United States must attempt to balance the good of the public health with personal liberty, often a difficult compromise to make. Indeed, the conflict between WHO’s definition of health

Gross domestic

product

Refers to the value of

all goods and services

produced within a

country for a given pe-

riod; a key indicator of

the country’s economic

activity and financial

well-being.

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6 I n t r o d u c t i o n ➤ t o ➤ H e a l t h ➤ P o l i c y

and much of the social, cultural, and political issues surrounding the US healthcare system is one of the most important areas of debate facing health policymakers.

PHySICAL HEALTH

The most common measure of physical health is life expectancy—the anticipated num- ber of remaining years of life at any stage. Exhibit 1.1 shows the ten countries ranking highest in their population’s life expectancy as of 2006 and includes the US ranking for comparison.

Although good or positive health status is commonly associated with the definition of health, the most frequently used indicators measure the lack of health or the incidence of poor health—for example, mortality, morbidity, disability, and various indexes that

Life expectancy

Anticipated number of

years of life remaining.

Mortality

Number of deaths in a

given population within

a specified period.

Morbidity

Incidence or prevalence

of diseases in a given

population within a

specified period.

Disability

A physical or mental

condition that limits

an individual’s ability

to perform functions

generally characterized

as normal.

KEy LEGIsLATIon What Is the Status of Healthcare Reform in the United States?

In➤ the➤ United➤ States,➤ healthcare reform➤ typically➤ denotes➤ a➤ government-sponsored➤

program➤that➤attempts➤to➤make➤health➤insurance➤available➤to➤the➤uninsured.➤Although➤

universal➤health➤insurance➤is➤a➤difficult➤goal➤to➤realize,➤incremental➤reforms➤have➤been➤

successful➤when➤the➤political➤and➤economic➤environments➤were➤favorable.➤The➤first➤such➤

program➤came➤in➤the➤form➤of➤the➤Old➤Age➤Assistance➤program,➤which➤was➤enacted➤as➤part➤

of➤the➤1935➤Social➤Security➤Act.➤It➤provided➤direct➤financial➤assistance➤to➤needy➤elderly➤

persons.➤

Full➤health➤insurance➤for➤the➤elderly➤became➤available➤under➤the➤Medicare➤program,➤

as➤did➤health➤insurance➤for➤the➤indigent➤under➤the➤Medicaid➤program.➤Both➤programs➤were➤

created➤in➤1965➤under➤the➤Great➤Society➤reforms➤of➤President➤Lyndon➤Johnson➤in➤an➤era➤

when➤civil➤rights➤and➤social➤justice➤had➤taken➤central➤stage➤in➤the➤United➤States.➤Later,➤

authorized➤under➤the➤Balanced➤Budget➤Act➤of➤1997,➤the➤State➤Children’s➤Health➤Insur-

ance➤Program➤(later➤renamed➤the➤Children’s➤Health➤Insurance➤Program)➤was➤developed➤

whereby➤states➤can➤use➤federal➤funds➤to➤cover➤children➤up➤to➤age➤19➤through➤the➤states’➤

existing➤Medicaid➤programs.➤

One➤of➤the➤most➤significant➤healthcare➤reform➤efforts➤resulted➤in➤the➤Affordable➤Care➤

Act➤of➤2010,➤designed➤to➤bring➤about➤major➤changes➤to➤the➤delivery➤of➤US➤healthcare.➤The➤

key➤objective➤of➤the➤ACA,➤to➤be➤implemented➤in➤full➤in➤2014,➤is➤to➤provide➤most➤(if➤not➤all)➤

Americans➤with➤health➤insurance➤coverage.

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combine these factors. One such measure is quality-adjusted life years, which combines mortality and morbidity in a single index. The Learning Point box titled “Measures of Mortality, Morbidity, and Disability” lists categories by which each indicator is measured.

MENTAL HEALTH

In contrast to physical health, measures of mental health are limited. The major catego- ries of mental health measures are mental conditions (e.g., depression, disorder, distress), behaviors (e.g., suicide, drug or alcohol abuse), perceptions (e.g., perceived mental health status), satisfaction (with life, work, relationships, etc.), and services received (e.g., coun- seling, drug treatment).

SOCIAL WELL-BEING

The most commonly used measure of relative social well-being is one’s socioeconomic status (SES). An SES index typically considers such factors as education level, income, and occupation. Quality of life is another common measure and may include one’s ability

Quality-adjusted

life years

A combined mortality–

morbidity index that

reflects years of life

free of disability and

symptoms of illness.

Life expectancy at birth (years)

Rank Country

(state/territory) Overall Male Female

➤➤1 Japan 82.6 78.0 86.1

➤➤2 Hong➤Kong 82.2 79.4 85.1

➤➤3 Iceland 81.8 80.2 83.3

➤➤4 Switzerland 81.7 79.0 84.2

➤➤5 Australia 81.2 78.9 83.6

➤➤6 Spain 80.9 77.7 84.2

➤➤7 Sweden 80.9 78.7 83.0

➤➤8 Israel 80.7 78.5 82.8

➤➤9 Macau 80.7 78.5 82.8

10 France➤(metropolitan) 80.7 77.1 84.1

36 United➤States 78.3 75.6 80.8

SOURCE: Data from DESA (2007).

ExHIBIT 1.1 Top Ten Countries with the Longest Life Expectancy, with the United States as Comparison

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8 I n t r o d u c t i o n ➤ t o ➤ H e a l t h ➤ P o l i c y

to perform various roles (e.g., self-care, family care, social functioning), perceptions (e.g., emotional well-being, pain tolerance, energy level), and living environment (e.g., pollution levels, crime prevalence). A third set of social well-being measures, often used by sociolo- gists, is composed of social contacts and social resources. Examples of social contacts include visits with family members, friends, and relatives and participation in social events, such as membership activities, professional conferences, and church gatherings. The social contacts factor can be used as an indicator of social resources by determining whether an individual can rely on his social contacts for needed support and company and whether these contacts meet the individual’s needs for care and love.

PuBLIC HEALTH DEFINED Winslow (1920) defined public health as “the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized commu-

Social contacts

The frequency of social

activities a person

undertakes within a

specified period.

Social resources

Interpersonal rela-

tionships with social

contacts and the extent

to which the individual

can rely on them for

support.

LEARnInG PoInT Measures of Morbidity, Mortality, and Disability

Morbidity➤measures

•➤ ➤Incidence➤(number➤of➤new➤cases➤in➤a➤defined➤population➤within➤a➤specified➤period)➤of➤

specific➤diseases

•➤ ➤Prevalence➤(number➤of➤instances➤in➤a➤defined➤population➤within➤a➤specified➤period)➤

of➤specific➤diseases

Mortality➤measures➤

•➤ Crude➤(unadjusted➤for➤any➤other➤factors)➤death➤rate➤

•➤ Age-specific➤death➤rate➤

•➤ Condition-specific➤death➤rate➤

•➤ Infant➤mortality➤

•➤ Maternal➤mortality➤

Disability➤measures

•➤ Restricted➤activity➤days➤(e.g.,➤bed➤days,➤work-loss➤days)➤

•➤ ➤Limitations➤in➤performing➤activities➤of➤daily➤living➤(i.e.,➤bathing,➤dressing,➤toileting,➤

getting➤into➤or➤out➤of➤a➤bed➤or➤chair,➤continence,➤eating)

•➤ ➤Limitations➤in➤performing➤instrumental➤activities➤of➤daily➤living➤(i.e.,➤doing➤housework➤

and➤chores,➤grocery➤shopping,➤preparing➤food,➤using➤the➤phone,➤traveling➤locally,➤tak-

ing➤medicine)

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nity efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.” It focuses on prevention and involves the efforts of society as a whole. Finally, public health is intended to protect lives and improve the health of populations around the globe.

Whereas healthcare is intended to treat, influence, and care for individuals, pub- lic health operates on a larger scale. The field is defined by the American Public Health Association (APHA n.d.) as (1) “the practice of preventing disease and promoting good health within groups of people” and (2) the research and surveillance conducted to better understand the health issues facing a group and, in turn, to craft good health policy.

Public health has broad implications for a population. Successful public health activities and initiatives can save money by promoting healthy living and prevention, thus reducing healthcare costs and disease burden. In addition, these activities can improve quality of life and reduce suffering caused by ill health in a population (APHA n.d.). The practice of public health leads to direct (e.g., healthier children, less chronic disease, less need for acute care) and indirect (e.g., fewer days missed from school and work;