HPA 101 Exam 1 PSU

the total health care spending in the U.S. is approximately

$3.5 trillion per year

Membership of the Policy Community

(1) the legislative committees with jurisdiction in a policy domain, (2) the executive branch agencies responsible for implementing policies in the public domain, and (3) the interest/stakeholder groups in the private domain. The first two categories are the suppliers of the policies demanded by the third category.

National Health Insurance Model

(Canada, Australia, South Korea) Health insurance is provided by the government and financed by premiums; providers are private.

Through this system, all basic services, visits to primary care physicians and specialists, inpatient care, or x-ray and pathology services are free. Overall, Great Britain spends approximately 41 percent of what the United States spends per capita on health care

(NHS) is publicly funded and run and provides universal health coverage. It also operates out of social justice

Providers often try to influence policy so that their reimbursement from public programs like Medicare and Medicaid would not go down.

**The pharmaceutical industry has pushed hard to ensure that the government should not be able to bargain down drug prices for users of government health care programs**. The insurance industry spent millions lobbying Congress so that the Affordable Care Act would be worded in the most beneficial way possible as far as their bottom lines were concerned

Germany has a universal, multi-payer health care system with two main types of health insurance:

-"Standard health insurance" - provided by competing, not-for-profit, nongovernmental health insurance funds called "sickness funds" -"Private Health Insurance"

The five guiding principles of the Canada Health Act. Health care must be:

-Available to all eligible residents of Canada -Comprehensive in coverage -Equal access without financial and other barriers -Portable within the country and while traveling abroad -Publicly administered

Some other countries have

-National health insurance is available to all of its citizens and financed by taxes collected by the government. -National health systems where the government not only provides national health insurance but also manages the health care delivery infrastructure

For a health determinant to be considered the (or a) cause of a health outcome it must meet the following conditions.

-There must be a positive association between health determinant and the health outcome. -There must be a temporal relationship (i.e. the cause should occur before the outcome). -The association between the identified determinant and the health outcome should be strong and specific.

The United States health care system is the most expensive in the world

17.9% health expenditure as a share of GDP compared to Canada 9.3% , Great Britain 9.3%, and Germany 7.7%

Federal law defines the general criteria of coverage that are translated into standard health insurance benefit packages

89 percent of Germans obtain their health insurance via sickness funds. The remaining 11 percent (typically more affluent Germans) opt-out of the sickness funds and purchase private insurance.

Policy

A proposed or adopted course or principle of action

Structure Quality Policy

A significant initiative towards improving structure are electronic health records (EHRs), which are digital formats of a patient's medical record that when implemented into the health care system should reduce cost and provide greater coordination across the system

critical policy issues related to 3 cornerstones of care

Access, Cost, Quality Government health policies have been enacted to resolve or prevent perceived deficiencies in health care delivery. Not surprisingly, most health policy initiatives and legislative efforts have focused on access to care, cost of care and the quality of care.

Mezzolevel Policy

Administrative Policy that organizations generate to direct and regularize their operations Example: State Medicaid programs will have manuals describing intake, eligibility, record keeping, what is and is not appropriate to discuss with an applicant, referrals, and so forth.

Quality of Care

Along with access and cost, quality of care is the third main concern of health care policy. The federal government began to provide greater attention to policing the quality of medical care with the Health Care Quality Act of 1986.

Government Supplements the Private Sector

Americans generally prefer market solutions over government intervention in health care financing and delivery, and for this reason, they have a strong preference for keeping the government's role in the delivery of health care to a minimum. Government involvement in health care has grown incrementally in the US due to "market failures." The most credible argument for policy intervention begins with the identification of situations in which markets fail or do not function efficiently.

Group 3: Health Providers

Among the very powerful health care interest/stakeholder groups in the United States are professional provider associations including: The American Medical Association (AMA) The American Association of Health Plans (AAHP) The Pharmaceutical Research and Manufacturers of American (PhRMA) The American Hospital Association (AHA) The American Nurses Association (ANA)

Predisposing Determinants are characteristics that influence an individual's health behavior

As a determinant for making some individuals more vulnerable to poor health outcomes, one can find numerous studies citing gender, age, and occupation for "why" some people experience poor health.

Healthy People 2020 and 2030 goals

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, attain health literacy, and improve the health of all groups. Create social, economic, and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. Engage stakeholders, policymakers, and the public to design policies that improve health.

Similar to Canada, Great Britain has less medical technology available

Britain has 6 MRI machines for every million inhabitants compared to the United States 39 MRI machines for every million people.

Disease and injuries

Cardiovascular disease, Diabetes, Fall with hip fracture, Alcoholism

John Snow and Cholera disproved the Miasmic Theory of Disease

Cholera epidemics in London, mid 1850s Suspected an association with water supply, which came from the Thames River "Natural experiment" Questioned households where a cholera death had occurred Most deaths associated with one company

Regulatory Tools

Designate a use of health policy in which the government prescribes and controls the behavior of a particular target group by monitoring the group and posing sanctions if it fails to comply. For example, state insurance departments across the country regulate health insurance companies in an effort to protect the customers from excessive premiums, dishonest practices, and defaults on coverage in case of the financial failure of an insurance company

Structure

Does the system have sufficient workforce, provider organizations, resources, technology, etc. to deliver high-quality patient care? Examples of structure measures include: Provider (physicians, nurses, etc.) to patient ratios Staff experience and capabilities (e.g. training, certifications) Availability of MRIs, Cat-Scans, and other equipment Use of EHR and Computerized Provider Order Entry (CPOE) systems

When private interests result with public costs

Example only 20 states require motorcyclists to wear helmets Because the public bears the burden of the increased costs associated with injuries to and deaths of non-helmeted riders, some argue that the individual rider's interest of wanting the freedom not to wear a helmet should be overridden.

Biomedical Model of Health

Focuses on the physical or biological aspects of disease and illness. It is a medical model of care practised by doctors and health professionals and is associated with the diagnosis, cure and treatment of disease. The absence of illness. According to this model, the human body is comprised of different organs and systems that operate like any other machine. Sickness is a deviation in the normal functioning of the body caused by some pathological agent (e.g. a virus or bacterium) or other impairment in a body part or organ system.

Difficulty of having any significant change in cost, quality, or access.

For example, to make healthcare more affordable would increase access to it but most likely decrease the quality of care delivery. You might increase the quality of healthcare, but that will increase costs and limit access to it. You could also increase access to healthcare, but that will cost money, or result in lower-quality care.

Health Outcomes

Functional Status, Subjective sense of well being, death, quality of life experience

The measures often used for comparing the United States' national health expenditures with other countries is either as an overall percentage of our Gross Domestic Product (GDP) or per capita.

GDP is an aggregate measure of total economic production for a country. It represents the value of all goods and services produced by the country's economy during a given year.

The work of Snow, and later Louis Pasteur in the 1860s and Robert Koch in the 1870s, led to a Single-cause/Single-effect Framework known as Germ Theory soon prevailed over Miasmic Theory

Germ Theory states that many diseases are caused by the presence and actions of specific microorganisms within the body (i.e. single cause/single effect).

Principal Features of US Health Policy

Government Supplements the Private Sector, Incremental reform, Multiple Stakeholder Groups, Tensions between Federal and State Governments

Inducement Tools

Government tries to influence behaviors by providing involve the direct provision of income, services, or goods to a particular target group. Some examples of government inducements in health care include funding of medical research through the NIH, the construction of facilities (e.g., hospitals under the Hill-Burton program), and the initiation of new institutions (e.g., HMOs and ACOs).

Social Justice system

Health care is a basic social good Health care is a social responsibility Access to health care is a basic right Health care is a unique good that defies the basic economic principles of supply and demand

market justice system

Health care is a commodity Health care is an individual responsibility Access to health care earned by individual effort The provision and consumption of health care respond to the basic economic principles of supply and demand

incremental reform

Health care reform under the ACA can be best described as _________.

Health Disparities and a Model of Health Vulnerability

Health disparities generally refer to differences in health outcomes across subgroups in a given population. Segments of the population at risk of poor health and health care disparities are usually considered as being vulnerable. The concept of vulnerability has become increasingly popular in the health literature.

Three Domains Model

How we measure quality of care. The three domains are also hierarchical. Structure is the foundation of the quality of health care. Good processes require a good structure. Structure & processes influence the quality of outcomes. The model does not account for social and individual lifestyle and behavioral factors that also have a significant influence on health status.

Legislative Process for Developing Federal Health Policy

Identifying the problem, drafting a bill, sponsoring a bill, introducing a bill, committee examination of a bill, schedule floor action on the bill, debating the bill, voting on the bill, referral to other chamber, conference committee, final action of the bill

Socialized Health Insurance System (Germany)

In Germany, the federal and state governments and the private sector have specific responsibilities for the financing, organization, and delivery of health care.

When public interest results with private costs

In the months after its passage, both state governments and private interest/stakeholder groups challenged the individual mandate. These groups argued that the requirement to buy insurance would allow Congress essentially unlimited power to intrude on individual freedom. The Supreme Court initially ruled 5-4 that the federal government could impose the individual mandate. Then in 2017, Congress passed tax reform legislation that reduced the individual mandate penalty to $0 beginning in 2019.

Tensions between Federal and State Governments

Individual states play a large role in the development and implementation of health policies. States are vested with broad legal authority to regulate almost every facet of the health care system. They license and regulate health care facilities and health professionals; restrict the content, marketing, and price of health insurance (including professional liability or malpractice insurance); set and enforce environmental quality standards; and enact a variety of controls on health care costs. States bear a large responsibility for financing health services for the poor through medicaid mostly (in which financing is shared with the federal government)

All of the following are true about a Miasma EXCEPT for:

It is spread mainly through water.

The Biomedical Model is important because of which of the following?

It is the primary framework that shaped the evolution of health care policy in the U.S. It is responsible for the transformation of medicine in the United States. It promoted improvements in medicine and technology that relate to our increased ability to diagnose and treat disease. It helped to increase life expectancy in the United States.

Access

It may refer to whether an individual has a usual source of care, the actual use of health services, or it may reflect the acceptability of particular services. Access to care can be defined as the ability to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner.

Incremental Reform happens through successive legislative enactments over several years

Multiple levels of federal and state bureaucracy must interpret the legislation. Rules and regulations must be written for its implementation. During this process, political actors, interest/stakeholder groups, or project beneficiaries may influence the ultimate design of the program. Final results can be skewed from the original intent of its congressional sponsors. Making policy reform difficult

Need Determinants depend on the individual's determinants in the predisposing and enabling categories influences on the needs of the individual

Need determinants are the signs and symptoms of disease or injury. Need determinants represents both perceived need(s) by the individual and actual need(s) that have been determined by a health care professional. The association of predisposing, enabling and need factors helps explain to what extent individuals are vulnerable to negative health outcomes.

Outcome Quality Policy

One major example of outcome quality policy are the Healthy People Initiatives. Since 1980, the United States has undertaken 10-year plans outlining certain key national health objectives to be accomplished during each of the 10-year time frames. These initiatives have been founded on the integration of medical care with preventive services, health promotion, and education; integration of personal and community health care; and increased access to integrated services.

the U.S. government has invested billions in the development of the private health care infrastructure, workforce, and research.

Our reliance on the private market and the need for government involvement to address market imperfections often raises a conflict between market justice versus social justice.

State governments own most university hospitals, while municipalities play a role in public health activities and own about half of the hospital beds.

Private providers deliver health care. The sickness funds are responsible for paying physicians and hospitals.

The legislative process can create different types of policies. These policies, however, rely on two basic types of policy tools:

Regulatory tools and Inducement Tools.

Process Quality Policy

Some of the main developments in this area are clinical practice guidelines, cost-efficiency, critical pathways, and risk management. Clinical practice guidelines: Explicit descriptions representing preferred clinical processes. A clinical practice guideline constitutes a plan for managing a clinical problem based on evidence, whenever possible, and on consensus in the absence of evidence. Cost-efficiency (also referred to as cost-effectiveness): This is an important concept in quality assessment. A service is cost-efficient when the benefit received is greater than the cost incurred in providing the service. Critical pathways: Outcome-based and patient-centered case management tools that are interdisciplinary and that facilitate coordination of care among multiple clinical departments and caregivers. A critical pathway is a time line that identifies planned medical interventions along with expected patient outcomes for a specific diagnosis or class of cases, often defined by a diagnosis-related group.

Single-Cause/Single-Effect Framework

The Single-cause/Single-effect Framework became a powerful explanatory framework in the mid-19th Century. Prior to this time, many believed that miasmas were the main determinant for disease and sickness.

No central governing agency

The United States has no central governing agency that authorizes the financing, payment, and delivery of health care to all residents

Cost of Care

The United States has the latest developments in medical technology and well-trained specialists, but these advances amount to the most expensive means possible to provide care to patients, making the U.S. health care system the most costly in the world. No other aspect of health care policy has received more attention during the past 35 years than efforts to contain increases in health care costs. Federal and state governments have limited ability control costs outside of the public insurance programs of Medicare and Medicaid.

Health Field Concept

The basic assumption of the Health Field Concept is that there are four main categories of causes for human health. These are: Biology (20%) Lifestyle (50%) Environment (20%) Organization of Health Care (10%) The Health Field Concept was developed in the 1970s as the centerpiece of Canadian health care reform.

Macrolevel policy

The broad laws, regulations, or guidelines that provide the basic framework for the provision of services and benefits Example: Title XIX of the Social Security Act which pertains to the structure and delivery of services under Medicaid

Group 1: Employers

The health policy concerns of American employers are mostly shaped by the degree to which employers are involved in the provision of health insurance benefits for their employees, their dependents, and their retirees

Group 2: Consumer Groups

The interests of consumers are not uniform, nor are the policy preferences of their interest groups. Most often "cause" interest/stakeholder groups represent the views of consumers. Cause groups represent a segment of society but whose primary purpose is promoting a particular cause or value. These groups are wide-ranging, including churches and religious organizations, veterans' groups, and groups supporting the rights of people with disabilities among many others.

Higher-income workers sometimes choose to pay a tax and opt-out of the standard plan, in favor of 'private' insurance.

The latter's premiums are not linked to income level but instead to health status.

In Germany employers and employees finance health care through government-mandated contributions if they are receiving standard health insurance

The level of their contribution is based on their salary. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level.

Multiple Stakeholder Groups

The most common explanation for health policy outcomes in the US is based on the role of interest groups and the policies that result from compromises designed to satisfy their demands.

National Health Service

The publicly funded health care system in the U.K.

Simplified Casual Web Model

The solid arrows represent potential causal relationships between factors, diseases, and outcomes. The dashed arrows represent potential feedback from outcomes and diseases on proximal and distal factors. Proximal and distal factors operate through both intermediate factors and directly on health outcomes.

Association relationship that may exist between a health determinant and a health outcome

The three types of association are: Positive association where the health determinant and the health outcome always occur together. Negative association where the health determinant and the health outcome tend not to occur together. No association where the health determinant and the health outcome are independent of one another.

The most effective demanders of policies are the well-organized interest or stakeholder groups

These groups have self-interested motivations or a stake in how healthcare is financed, produced, organized, and delivered. These varied interests affect health policy just as they do any

Through the recent Affordable Care Act (aka Obamacare) the federal government provided subsidies to individuals who cannot obtain insurance from their employer or who are self-employed.

These subsidies in 2018 were about 55 billion dollars.

Microlevel policy

This is what happens when health professionals translate macro- and mezzo level policy into actual service to consumers Example: case manager explaining to an individual how the Medicaid program covers groups of people based on certain categorical requirements

NHS England is the central governing agency and is responsible for managing the NHS budget, overseeing the 211 local Clinical Commissioning Groups

This makes the NHS have greater integration and accountability than the U.S. health care system.

Enabling Determinants

To a certain extent enabling determinants can mitigate (or in their absence exacerbate) predisposing determinants.

the United States is not spending too much on the things that make us healthy, it's just spending too much on medical care which only takes care of us when we are sick.

When you combine the amount of spending on "health care" and the amount a country spends on social welfare programs for housing, education, nutrition, and jobs, the United States no longer spends more than its peer nations. Our combined spending on health and social welfare place us in the middle.

Canada, Great Britain, and Germany all have

a Central Governing Agency running their healthcare

Healthcare in the United States is distributed via

a Private (Imperfect) Market

The Healthy People Action Model is

a Social Model of Health. Unlike the narrow focus of the biomedical model, the social model attempts to address the range of causes that influence health and for this reason, it is not surprising that the Healthy People initiative is almost 40 years in the making.

Through comparative assessments, policy-makers are provided

a benchmark that allows them to identify in which areas they are performing above or below expectations.

The making of a health policy in the United States is

a complex process involving both private and public sectors (including multiple levels of government).

Social Models see health as

a shared responsibility between the individual and their society -Social Models of Health are not so much concerned with the causes of disease, rather it focuses to identify the main factors that make and keep people healthy

The US has a hospital-centric system resulting in

a system that is higher in cost, more unequal in allowing people to access health care, and average in health outcomes when compared to other industrialized countries

Access to Care

ability of an individual to obtain health care services when needed. access is restricted to those who (1) have health insurance through their employers, (2) are covered under a government health care program like Medicare or Medicaid, (3) can afford to buy insurance out of their own private funds, and (4) are able to pay for services privately.

the Biomedical Model tends to dominate our thinking in the United States regarding the organization and financing of our health care system.

about 88% of health care expenditures in the United States support the infrastructure and activities associated with medical care. the Biomedical Model is limited in how it can address chronic diseases, conditions that often have multiple causes, longer durations, and are not easily treated.

Indirect causes

are distal (further away) from the ---health outcomes Other cases where the association between health determinates and outcomes are negative and strong or positive and not so strong might be described as indirect causes.

Even though the United States does not posses a central governing agency, public policy influences the organization and delivery of health care

because health care is a policy-based profession, you should be aware of the policy-making environment

Universal access is provided by

by a health care delivery system that in most cases is managed by the government, and provides a defined set of health care services to all citizen

Costs

consumers and financiers speak of the price of health care services as the cost of health care. From a provider's perspective, the notion of cost refers to staff salaries, capital costs for building and equipment, rental of space, purchase of supplies, and other costs of production.

Iron Triangle of Health Care

cost, quality, access you can't impact one aspect without impacting the other

In other countries the central governing authority

defines a "global budget" for health care, meaning that the country decides the entire amount it will spend on health care during the fiscal year & also decides the extent of infrastructure and workforce development, etc. In short, countries with a central governing authority have greater control over health care costs, development, and health insurance coverage.

Canada spends approximately 47 percent of what the United States per capita on health care expenditures.

due to Canada's medical technology infrastructure is smaller than the United States. For example, there are 39 magnetic resonance imaging (MRI) machines for every million people in the United States while Canada only has nine MRI machines for every million Canadians.

Social Justice

emphasizes the well-being of the community over that of the individual; thus the inability to obtain medical services because of a lack of financial resources would be considered unjust. An example of this fusion is the distribution of private insurance. Instead of a public insurance program like some other countries, the United States opted in the 1940s to distribute health insurance through employment.

Social Model of Health

has its basis in the multiple-cause/single-effect framework of the health field concept. Unlike the narrow focus of the Biomedical Model, the Social Model attempts to address the range of causes that influence health.

Proximal Determinants

health beliefs, lifestyle, health insurance

Germany's standard health insurance benefit package spends more on

health promotion than the United States

Physiological factors

high cholesterol, high blood pressure, serum cortisol, blood glucose

Germ Theory of Disease

idea that infectious diseases are caused by microorganisms Germ Theory remains a guiding theory that underlies our contemporary Biomedical Model of Health.

In a socialized health insurance system,

insurance and payment functions are closely integrated

Casual Web of Health

is a metaphor that emphasizes the interconnectedness of causal factors for individual and population health. In some cases, the association between health determinates and outcomes is positive and strong.

Multiple-Cause/Single Effect Framework

is a natural extension of the Single-cause/Single-effect Framework. It is more complex than the Single-cause/Single effect Framework as it recognizes that biological causes of disease may be mitigated by environmental and/or personal lifestyle factors. So a Multiple-cause/Single-effect Framework expands our understanding of health beyond simply the absence of signs and symptoms of the disease.

Health in all policies

is an approach to improving the health of the U.S. population by incorporating health considerations a wide range of social policies including transportation, housing, a living wage, etc.

Epidemeology

is the study of how often diseases occur in different groups of people and why.

Another way to consider the information in the simplified causal web

is to think of the distal determinants as predisposing factors and proximal factors as enabling determinants

The United States, health coverage for these core services is provided mainly through private health insurance, and 67.2% of the population had this for their basic coverage in 2017. Publicly financed coverage insured 37.7% of the population (the elderly, individuals with low-income levels or those with disabilities)

leaving 8.8% of the population (28.5 million people) uninsured

Process

measures focus on the actual delivery of health care or the specific way in which care is provided. Examples of process measures include: Appropriateness of diagnostic tests Immunization adherence Utilization of preventative services Prescription drug order and/or administration accuracy Wait time to see a primary care physician or specialist

other industrialized countries have no uninsured populations

most Western European countries have national health insurance or national health systems that provide universal access to health care services

On average the US spends

nearly double per person on health care to that of similar wealthy countries

the Biomedical Model is the primary framework that shapes the evolution

of health care policy and the organization of health care organizations for most of the 20th Century in the United States. The Biomedical Model is responsible for the transformation of medicine in the United States. It promoted improvements in medical science and technology that corresponded with our increased ability to diagnose and treat disease. Its ability to help control infectious disease and reduce the number of people dying from coronary heart disease and stroke helped increase life expectancy in the United States.

Quality

one of the more widespread models to help define and measure quality in health care uses three domains in which health care quality should be examined: structure, process, and outcomes.

Causation implies that there is a connection between being exposed that leads from exposure to the identified determinant and the health outcome

our understanding of "why" some people become ill is based on identifying possible causes and the strength of the association between that cause and the health condition.

Much of what is currently happening with health reform today in the US is operating

out of Multiple-cause/Multiple-effect Frameworks and Social Models of Health. -The United States has recognized if we are to make continued gains in the improvement of health outcomes, it is necessary to address the broader determinants of health. However, it is not easy to transform a 2.7 trillion dollar industry that has been built up over the past century

Germany spends 56 percent of what the United States per capita on health care.

partly due to Germany's smaller medical technology infrastructure

Market justice

places the responsibility for the fair distribution of health care on the market forces in a free economy.

Direct causes are

proximal to health outcomes -In some cases, the association between health determinates and outcomes is positive and strong. Some would describe these cases as being "direct" cause of the health outcome

Multiple-Cause/ Multiple Effect Framework

recognizes that poor health outcomes are not the result of isolated cause(s), but rather they develop from a chain of causation in which each link is a result of a complex interaction of preceding events. one model used to describe the Multiple-cause/Multiple-effect Framework is the Casual Web of Health

Distal Determinants

social, economic, and environmental factors

All of the following are true about the Biomedical Model of Health EXCEPT for:

sometimes called the Find it and Fix it Model. choices It is based on John Snow's Study. It indicates that every disease has a single and observable cause. It likens the human body to a machine. It defines being healthy as having no signs or symptoms of disease.

To encourage employers to sponsor insurance, the federal government provides

tax subsidies for employment-based health insurance. These subsidies in 2018 were approximately 146 billion dollars.

The U.S. health care system is technology-driven and focusing on medical care meaning

that we have invested to create a hospital-centric system to take care of sick people, not necessarily to keep people healthy

The US healthcare system is described as pluralistic because

the U.S. system depends more on the private sector to deliver and pay for health care, it is more fragmented, and has large but not universal public insurance programs.

Multiple Levels of Health Policies

the United States does not have a centrally controlled system of health care delivery, but it does have a history of federal, state, and local government involvement in health care and health policy. Health policies are public policies enacted by the government. Public policies are authoritative decisions made in the legislative, executive, or judicial branches of government (either at the state or federal level) that are intended to direct or influence the actions, behaviors, or decisions of others.

Outcome

the effects or final results obtained from utilizing the structure and processes of health care delivery. They also suggest an overall improvement in health status through health promotion and disease prevention efforts and adequate access to health care services. On the other hand, negative outcomes suggest a problem with the structure, process, or both. Examples of outcome measures include: Life expectancy Average length of stay Mortality rates Surgical complication rates Hospital readmission rates Preterm birth and low birth weight rates Health care acquired infection (HAIs) rates

We spend more on health care than

the entire Gross Domestic Product of 190 countries

In the NHS

the government both finances a tax-supported national health insurance program AND also manages the infrastructure for the delivery of medical care.

The distribution of health care in Great Britain does not rely on a private market

the government operates most of the medical institutions. Most health care providers, such as physicians, are either government employees or are tightly organized in a publicly managed infrastructure.

The government is subsidiary to the private sector meaning

the government provides resources to support or improve the private sectors ability to provide and distribute health care. The United States has preferred to limit the government's overt involvement in health care

Health Policy to Healthy Policies

the growing recognition of Social Models of Health and Multiple-cause/Multiple-effect Frameworks are prompting the system to transform itself—away from being a system that focuses only on treating the sick, to one that promotes health. Some advocates use the Health Vulnerability Model and the Healthy People 2020 to urge the United States to move away from "health policies" to having "health in all policies."

The greater control state governments have,

the harder it is for a national strategy to be coordinated

Determinants of Health:

the range of personal, social, economic, and environmental factors that influence health status

The few exceptions of where the government has an overt role include providing insurance are:

to the very poor, the old, and the direct provision of health care to veterans.

Most industrialized countries have achieved universal (or near-universal) public insurance coverage of health care costs

which usually include consultations with doctors and specialists, tests and examinations, and surgical and therapeutic procedures.