HCM Chapter 1 PDF

CHAPTER 1 INTRODUCTION LEARNING OBJECTIVES After completing this chapter, students will be able to: Describe the elements common to all health care systems. Define health and identify and describe the determinants of health. Discuss the influence of basic demographic characteristics on mort...

CHAPTER 1 INTRODUCTION LEARNING OBJECTIVES After completing this chapter, students will be able to: Describe the elements common to all health care systems. Define health and identify and describe the determinants of health. Discuss the influence of basic demographic characteristics on mortality and morbidity. Define and describe the differences between primary, secondary, and tertiary preven- tion and primary, secondary, and tertiary health care. Identify the components of the U.S. health care system and describe how it is organized. Identify and define Aday’s criteria for evaluating health care system performance. System: A set of connected parts or components that function together to form a complex whole. A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mecha- nism; a well-trained and adequately paid workforce; reliable informa- tion on which to base decisions and policies; well-maintained facilities and logistics to deliver quality medicines and technologies. (European Patients’ Academy on Therapeutic Innovation, 2024, para. 1) Each nation has a health care system, but as a knowledgeable colleague said, “When you’ve seen one health care system, you’ve seen one health care system. No two are exactly the same.” Every country’s health care system is organized to provide the diagnosis and treatment of individuals’ health prob- lems and consists of a health care workforce, practice setting, and organizations responsible for workforce training, research, and system oversight. However, there is enormous variation in how this important societal function is actually realized. The variation arises from differences in fundamental beliefs about what constitutes a health problem, who are legitimate health care providers, what are fitting and effective methods of diagnosis and treatment, what are suitable settings for the provision of health care, how health care should be financed, and what constitutes appropriate oversight and evaluation of health 3 4 I: U.S. Health Care System: Present State care providers and the health care system. Differences also result from variation in national resources, which differentiate nations’ health care systems even if their fundamental beliefs about health and health care are similar. In general, all societies designate some persons or positions as legitimate providers of health care. These designated providers are empowered in their society to identify health problems, determine their causes, and provide alleviation or cure. Some providers are des- ignated as dominant or vie with others for dominance. There is also a defined role for the recipients of health care services: for example, the “sick role,” as defined by Parsons (1951), which posits the rights and obligations of sick persons in Western societies. The sum of all the institutions and processes that support the work of diagnosis and healing can be called the health care system of that society. These systems are organized to facilitate the diagnosis and treatment of legitimate patients by legitimized providers using approved tools in appropriate settings. We also recognize that conditions defined as health problems may differ from society to society and over time. In the United States today, people who are obese are considered in poor health, and they are treated with everything from diet to bariatric surgery. In other societies, obesity is a desirable trait, emulated if possible by those who are thin. Diagno- sis and treatment models may differ between societies. The social position, training, and authority of healers may differ. The organization of the system and the expected outcomes may differ among countries and among cultures. For example, “Greek historian Herodotus stated that every Babylonian was an amateur physician, since it was the custom to lay the sick in the street so that anyone passing by might offer advice” (Underwood et al., 2023, para. 8). But let us consider an example, still being practiced, of fundamental differences in beliefs about what constitutes a health problem, a legitimate provider, and appropriate methods of treatment of health problems. Traditional Chinese medicine (Liu, 1988) offers an entirely different perspective on health and health care than the model developed in the Western European countries. Written records about the origins of traditional Chinese medicine can be traced back further than 200 BCE. According to Chinese medicine, the human body must maintain homeostasis in order to maintain a state of health, that is, an internal, bodily balance between two inseparable and opposing forces of nature: yin and yang. Yin represents the cold, or passive, principle, whereas yang represents the hot, or active, principle. Any imbal- ance of these two forces can lead to a blockage of flow in the qi (vital energy) or in the blood, both of which run along interconnected channels in the body called meridians. When there is a disturbance in the energy flow, the appropriate type of treatment is selected to unblock the flow through the meridians: materia medica (herbology), acupuncture, bodywork (massage and manipulation), or health-benefiting exercises (exercising the body–mind connection). This is quite different from the Western approach to understanding health problems and their treatment. Western medicine perceives the human body as a collection of intercon- nected health systems—heart, circulatory, endocrine, reproductive, and so forth—each with a set of functions and normal operating processes. Health problems result from dysfunction in a system or systems, resulting from injury, infection, toxic exposure, or other causes. They are treated with surgery and/or medication to restore normal functioning (cure), if possible, or to interrupt a downward spiral and provide rehabilitation, stabilization, or comfort care.  1: Introduction 5 The focus of this book is the U.S. health care system, with some comparisons to certain peer industrialized countries, including Western European nations, Canada, Australia, and Japan. The United States shares with these nations (as well as many others around the globe) the same basic understanding of health and health care, including what consti- tutes a health problem; what are legitimate and effective diagnostic and treatment theories, methods, and tools; and which persons should be designated as health care providers, with physicians dominant among them. This set of beliefs about health and health care, which originated and developed over a period of centuries in Western Europe, is gener- ally referred to as “Western medicine.” Western medicine is also called allopathic medicine after the medical faction (allopath) that gained dominance in the 19th century over groups of healers, including homeopaths, chiropractors, and osteopaths (Starr, 1982). Among the countries in which Western medicine is the primary means of dealing with the problems of health and disease, there are also certain similarities in the basic structures and organi- zation used to deliver health care. Moreover, the United States and its peer nations have similar economies and abilities to finance their health care systems. However, as discussed, there are very real differences between the United States and its peer nations relating to the methods of paying for health care, the equity and efficiency of health care as provided, and population health outcomes. These differences make the U.S. health care system unique, even among its peer nations. HEALTH AND HEALTH CARE What Is Health? The most famous and influential definition of health is the one developed by the World Health Organization (WHO): “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It was adopted in 1946 and has not been amended since 1948 (WHO, 1948, p. 100). Many subsequent definitions have taken an equally broad view of health, including: A state characterized by anatomical, physiological and psychological integrity; ability to perform personally valued family, work and community roles; ability to deal with physical, biological, psychological and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death. (Porta, 2014, p. 128) Both definitions exemplify the tendency over the second half of the 20th century to enlarge the definition of health beyond morbidity, mortality, and disability to include sense of well-being, ability to adapt to change, and social functioning. However, in prac- tice, the more limited view of health usually guides the provision of health services and efforts to improve health status. As Young (1998) wrote: “Indeed, the WHO definition is ‘honored in repetition, rarely in application.’ Health may become so inclusive that virtu- ally all human endeavors, including the pursuit of happiness, are considered within its domain” (p. 2). Determinants of Health Individual and population health are determined by many factors, only one of which is health care. It is generally accepted that the determinants of health include genetic inher- itance, the physical environment—natural and built—the social environment, and health 6 I: U.S. Health Care System: Present State behaviors. The impact of these factors on health is mediated by an individual’s response to them, both behavioral and biologic. This concept is argued well by Evans and Stoddart (1994) and more recently in Marmot and Wilkinson’s (2006) Social Determinants of Health. Note that, although we talk about the “determinants of health,” they are usually discussed in terms of how they are related to poor health. A brief overview of the determinants of health follows. Genetic Inheritance Our knowledge about the effects of genetic inheritance on health is growing rapidly. It is understood that, with few exceptions, disease processes are … determined both by environmental and by genetic factors. These often inter- act, and individuals with a particular set of genes may be either more or less likely, if exposed, to be at risk of developing a particular disease. These effects can be measured by showing that the relative risk of exposure to the environ- mental factor is significantly greater (or lesser) for the subgroup with the abnor- mal gene, than the risk in those without. (Pencheon et al., 2001, p. 544) The advancements in genomic research and the application of genomic technology have great potential to improve health. Nevertheless, the current ability to do so is incomplete and much research is needed to help maximize the potential benefits of genomic medicine while minimizing possible harm. As Horton and Lucassen (2019) write: Our current response to the outcomes from genomic tests is often reactive and ad hoc, partly because we are still learning how to interpret genomic variation and are often unable to gain a consensus on whether genetic variants are clin- ically significant or not. This situation is exacerbated by the different routes in which genomic information is now accessible—rapid tests to establish diag- nosis or plan treatment for patients are now a reality in the real-life clinical setting, but healthy people also have increasing access to commercial tests that claim to provide genetic information to improve health and life planning. This raises particular challenges in the context of a public discourse about genomics that tends to present it as far more predictive and certain than it actually is. (Horton & Lucassen, 2019, p. 705) Physical Environment The physical environment includes both the natural and built environments. The natural environment is defined by the features of an area that include its topography, weather, soil, water, animal life, and other such attributes. The built environment is defined by the struc- tures that people have created for housing, commerce, transportation, government, rec- reation, and so forth. Health threats arise from both the physical and built environments. The built environment refers to the presence of (and proximity to) health-relevant resources as well as to aspects of the ways in which neighborhoods are designed and built (including land use patterns, transportation systems, and urban plan- ning and design features). (National Research Council, 2013, pp. 194–195) Health threats from the built environment include exposure to toxins and unsafe con- ditions, particularly in occupational and residential settings where people spend most of their time. The built environment includes all of the physical constructions in which we  1: Introduction 7 live, recreate, and work (e.g., homes, buildings, streets, open spaces, and infrastructure). The built environment influences health in a variety of ways. For example, an individual’s level of physical activity is affected by the built environment. Inaccessible or nonexistent sidewalks and bicycle or walking paths contribute to sedentary habits. These habits lead to poor health outcomes such as obesity, cardiovascular disease, diabetes, and some types of cancer. Occupational settings often expose workers to disease-causing substances, high risk of injury, and other physical risks. For example, the greatest health threats to U.S. farm workers are injuries from farm machinery and falls that result in sprains, strains, frac- tures, and abrasions (Myers, 2001; National Institute for Occupational Safety and Health [NIOSH], 2023). In addition, they are “at high risk for fatalities and injuries, work-related lung diseases, noise-induced hearing loss, skin diseases, and certain cancers associated with chemical use and prolonged sun exposure” (Occupational Safety and Health Admin- istration [OSHA], 2023, para. 2). There are well-documented health threats to office workers from indoor air pollution, found by research beginning in the 1970s, including passive exposure to tobacco smoke, nitrogen dioxide from gas-fueled cooking stoves, formaldehyde exposure, “radon daughter” exposure, and other health problems encountered in sealed office buildings (Samet et al., 1987; U.S. Environmental Protection Agency [EPA], n.d.). In addition, An understanding of the influence of occupational hazards has gradually shifted to include appreciation of complex interactions between an individ- ual’s personal and occupational risk factors. Epidemiologists now link work attributes such as access to healthy food, opportunity for physical activity, shift work, and occupational stress to health problems with multifactorial origins not yet considered as work related by most insurance systems. Adverse health effects associated with these work characteristics include unhealthy lifestyles, substance use and mental health disorders, psychological distress, metabolic syndrome, cancer, and chronic disease. (McLellan, 2017, pp. 206–207) In residential settings, exposure to pollutants from nearby industrial facilities, power plants, toxic waste sites, or a high volume of traffic presents hazards for many (Organ- isation for Economic Co-operation and Development [OECD], 2012). In the United States, these threats are increasingly known to have a disproportionately heavy impact on low-income and minority communities (Centers for Disease Control and Prevention [CDC], 2003; Institute of Medicine [IOM], 1999). “Environmental health disparities exist when communities exposed to a combination of poor environmental quality and social inequities have more sickness and disease than wealthier, less polluted communities” (National Institute of Environmental Health Sciences, 2023, para. 2). Common health threats from the natural environment include weather-related disas- ters such as tornados, hurricanes, earthquakes, wildfires, droughts, and extreme heat, as well as exposure to infectious disease agents that are endemic in a region, such as Plasmo- dium falciparum, the microbe that causes malaria and is endemic in Africa. However, it is increasingly evident that human activity increases the frequency and intensity of natural environment threats. For example, climate change brought about by use of fossil fuels, over- population, and deforestation is resulting in heatwaves, droughts, and floods that exceed plant and animal tolerance thresholds and are impacting food and water security in much of the world, but especially Africa, Asia, and Central and South America (Intergovern- mental Panel on Climate Change [IPCC], 2022). This is an accelerating problem that has 8 I: U.S. Health Care System: Present State been noted by scientists for many years (e.g., Tilman & Lehman, 2001), but to which we have not responded adequately. These conditions are having an enormous negative effect on human health in the United States and the world. The health effects of the built environ- ment are increasingly linked to those of the natural environment. Both the natural and built environments impact the health of individuals living within them—for better or worse. Social Environment The social environment, as the name implies, is the context defined by our relationships with other people—our social relationships. These relationships occur at all levels of social interaction from societal, to community, to familial, to occupation, and so forth. The formal and informal “rules” that govern our social interactions at each level reflect the values, beliefs, and norms of the group—be it societal, community, family, occupation, or other. These formal and informal rules—and the values, beliefs, and norms they reflect—have historical roots, and they affect how individuals live and behave; their relationships with others; and what resources and opportunities individuals have (see Figure 1.1). FIGURE 1.1 Social determinants of health. Neighborhood Community Economic Health Care and Physical Education Food and Social Stability System Environment Context Employment Housing Literacy Hunger Social Health integration coverage Income Transportation Language Access to healthy Support Provider Expenses Safety Early childhood options systems availability education Debt Parks Community Provider Vocational engagement linguistic and Medical bills Playgrounds training cultural Support Walkability Discrimination competency Higher Zip code/ education Stress Quality of care geography Health Outcomes Mortality, morbidity, life expectancy, health care expenditures, health status, functional limitations SOURCE: Artiga, S., & Hinton, E. (2018, May 10). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief /beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity  1: Introduction 9 Some people are systematically disadvantaged because of their place in the social envi- ronment. In a social setting that values certain characteristics, people with those character- istics are advantaged (e.g., paid more, have greater access to resources, have higher status) compared to those without them. Of particular importance to health professionals is the role of the social environment in affecting health status and producing health disparities. The CDC define health disparities as follows: Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. (CDC, 2020, para. 1) Aa Islam writes: Ideally, the socio-politico-economic conditions in a society should be such that its citizens enjoy a favorable set of social resources, and that these resources are distributed fairly. The quality, quantity, and distribution of these resources, together, to a large extent, determine citizen’s health and well-being. (Islam, 2019, p. 11) In 2008, WHO (2008) released a major report on the social determinants of health: Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. The premise and evidence of the report are that “Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others” (p. iii). Areas studied include early child development, globalization, urbanization, employment con- ditions, social exclusion, priority public health conditions, and women and gender equity. Socioeconomic Status Socioeconomic status—an attribute conferred on individuals within a social context— provides an example of the social environment effect on health. In the United States and other Western countries, this aspect is often indicated by a combination of education, occupation, and income/wealth. Persistent and substantial health differences exist be- tween groups defined by socioeconomic status. Socioeconomic status is associated with significant variations in health status and risk for health problems for those with lower status compared to higher status individuals. There is a large literature demonstrating the relationship between socioeconomic status and health, including a gradient in which the higher the socioeconomic status, the better the health (e.g., Lynch & Kaplan, 2000; Mar- mot, 2005; Petrovic et al., 2018). The famous Whitehall Study of English civil servants in the 1970s was one of the first and most influential studies to demonstrate this relationship: The Whitehall Study consists of a group of people of relatively uniform ethnic background, all employed in stable office-based jobs and not subject to indus- trial hazards, unemployment, or extremes of poverty or affluence; all live and work in Greater London and adjoining areas. Yet in this relative homogeneous population, we observed a gradient in mortality—each group experiencing a higher mortality than the one above it in the hierarchy. The difference in mortality between the highest and lowest grades was threefold. (Marmot et al., 1995, p. 173) 10 I: U.S. Health Care System: Present State Race and Ethnicity Similarly, much research indicates that disparities in health status exist between racial and ethnic groups in the United States. Minority Americans, including Black Americans, His- panic/Latino Americans, Native Americans, and Pacific Islanders, generally have poorer health outcomes than do White Americans. The preventable and treatable conditions for which disparities between majority and minority Americans have been shown include di- abetes, hypertension, obesity, asthma, and heart disease (CDC, 2011, 2023a). Racial dispar- ities in health are linked to racism and the policies and practices within the social environ- ment that express it. These policies and practices prevent or inhibit racial equity in health (Krieger, 2000; Mays et al., 2007). The CDC explains it this way: Racism is a system—consisting of structures, policies, practices, and norms— that assigns value and determines opportunity based on the way people look or the color of their skin. This results in conditions that unfairly advantage some and disadvantage others throughout society. Racism—both interpersonal and structural—negatively affects the mental and physical health of millions of people, preventing them from attaining their highest level of health, and consequently, affecting the health of our nation. (CDC, 2023a, para. 1–2) Occupational Health Nonphysical occupational factors also affect health. For example, a great deal of research demonstrates the relationship between poor health outcomes and the psychosocial work environment. The demand–control model is one well-known theory, hypothesizing that employees with the highest psychologic demands and the lowest decision-making latitude are at the highest risk for poor health outcomes (Karasek et al., 1981, 1998; Theorell, 2000). In addition, job loss and threat of job loss also have a negative impact on health. Evidence suggests that transitions from employment to unemployment adversely affect physical health and psychologic well-being among working-age persons (Dooley et al., 1996; Kasl 1998; Kasl & Jones, 2000). Social Integration, Social Networks, and Social Support Another large body of research on the social environment and health focuses on social in- tegration, social networks, and social support (e.g., Berkman & Glass, 2000; Uchino, 2009; Uchino et al., 2018). Numerous studies over the past 20 years have found that people who are isolated or disengaged from others have a higher risk of premature death. In addition, research has found that survival of cardiovascular disease events and stroke is higher among people with close ties to others, particularly emotional ties. Social relations have been found to predict compliance with medical care recommendations, adaptation to adverse life events such as death of a loved one or natural disaster, and coping with long- term difficulties such as caring for a dependent parent or a child with disabilities. A great deal of research in the area of social support was conducted during the 1960s and 1970s. A seminal review article published in 1977 by Kaplan and colleagues identified methodological issues that needed to be addressed. Since then, there has been further specification of the relationship between social support and health to explain the rela- tionship. For example, Cohen (2004) discusses three factors that indicate different aspects of social relationships: social integration, negative interaction, and social support, each  1: Introduction 11 influencing health through different mechanisms. Thoits (1982) reanalyzed data to test the hypothesis that disadvantaged sociodemographic groups such as low-income women are more vulnerable to the effects of life events because they experience more negative events and have fewer psychologic resources to cope with them. Although the relation- ship between social support and health is still not well understood, it is found over and over again in health studies. The social environment encompasses the full range of social relationships from the societal level to the interpersonal, and its effect is structured by the “rules” that govern social relationships, both formal and informal. Health Behavior The term health behavior can refer to behaviors that are beneficial to health, but the term is generally used in the negative to reference behaviors that harm health, including smoking, abusing alcohol or other substances, failing to use seat belts or other poor safety behaviors, making unhealthy food choices, and not engaging in adequate physical activity. The effect of health behaviors on health status has been widely studied and found to be an important determinant of health. Looking at the cause of death by major contributing cause of the disease to which the death was attributed rather than by the disease itself—in the first study of its kind—McGinnis and Foege (1993) showed that, as of 1990, the lead- ing factors were tobacco use, dietary patterns, sedentary lifestyle, alcohol consumption, microbial agents, toxic agents, firearms, sexual behavior, misuse of motor vehicles, and use of illicit drugs. As of 2002, the situation remained the same (McGinnis et al., 2002). Thus, improving health behaviors is viewed as critical to reducing the major causes of mortality, morbidity, and disability including diseases of the heart; malignant neoplasms (cancer); chronic lower respiratory diseases; injuries, both intentional and unintentional; diabetes mellitus; and renal disease. “Health behaviors are conceptually and practically pivotal in research on health. Conceptually, they are recognized as key mediating mechanisms between more distal structural and ideological environments and individual health outcomes” (Short & Molborn, 2015, pp. 78–79). Even though there is widespread agreement that health status is a response to the physical and social environments in which the individual lives and is influenced by the individual’s genetic inheritance, health behaviors have been previously viewed as pri- marily under the control of the individual. Recent advances in reducing adverse health behaviors link them instead to the social determinants of health. As Short and Molborn (2015) write: This approach shifts the lens from individual attribution and responsibility to societal organization and the myriad institutions, structures, inequalities, and 12 I: U.S. Health Care System: Present State ideologies undergirding health behaviors. Recent scholarship integrates a social determinants perspective with biosocial approaches to health behavior dynam- ics. (Short & Molborn, 2015, p. 78) Importantly, this change has been reflected in the emphases of Healthy People 2010 and Healthy People 2020 (U.S. Department of Health and Human Services [DHHS], 2000, 2010), the U.S. nationwide health-promotion and disease-prevention agendas. The leading health indicators cited in Healthy People 2010 are level of physical activity, overweight and obe- sity, tobacco use, substance abuse, responsible sexual behavior, mental health, exposure to injury and violence, environmental quality, immunization status, and access to health care. Only the environmental quality indicator deals substantively with factors other than per- sonal behavioral change or the availability of medical care. However, Healthy People 2020 (DHHS, 2010) acknowledges the narrow focus of the past and has expanded its approach for improving population health: Because significant and dynamic inter-relationships exist among (these) dif- ferent levels of health determinants, interventions are most likely to be effec- tive when they address determinants at all levels. Historically, many health fields have focused on individual-level health determinants and interventions. Healthy People 2020 should therefore expand its focus to emphasize health-en- hancing social and physical environments. (DHHS, 2010, p. 2) Health Care as a Determinant of Health The central focus of health care is to restore health or prevent exacerbation of health prob- lems. If we argue that health is the product of multiple factors, including genetic inher- itance, the physical environment, and the social environment, as well as an individual’s behavioral and biologic response to these factors, we see that health care has an impact late in the causal chain leading to disease, illness, and infirmity. Often by the time the in- dividual interacts with the health care system, the determinants of health have had their impact on their health status, for better or worse. Thus, the need for health care may be seen as a failure to prevent the determinants of health from adversely affecting the indi- vidual patient. As examples, consider the health care required for treating lung disease among miners and smokers. The failure of the coal industry to protect coal miners from regular inhala- tion of airborne dust had resulted, by 1970, in coal workers’ pneumoconiosis in 33% of miners with 25 years or more in the mines, 20% with 20 to 24 years, and nearly 15% with 15 to 19 years’ tenure (NIOSH, 2019). Our failure at many levels—parents, schools, public health—to prevent adolescents from beginning to smoke results in three out of four teens who smoke cigarettes in high school smoking as adults. People who begin smoking early are more likely to develop a severe nicotine addiction than those who begin at a later age (American Lung Association, 2019; SmokeFree.gov, 2019). In both cases, failure to address the determinants of health results in increased need for health care. What Is Health Care? Health care can be categorized in terms of its relationship to prevention—primary, sec- ondary, and tertiary. Fos and Fine (2000) define these terms as follows: “Primary pre- vention is concerned with eliminating risk factors for a disease. Secondary prevention  1: Introduction 13 focuses on early detection and treatment of disease (subclinical and clinical). Tertiary pre- vention attempts to eliminate or moderate disability associated with advanced disease” (pp. 108–109). Primary prevention intends to prevent the development of disease or injury before it occurs in individuals, and thus to reduce the incidence of disease in the population. Exam- ples of primary prevention include the use of automobile seat belts, condom use, skin pro- tection from ultraviolet light, and tobacco-use cessation programs. Secondary prevention is concerned with reducing the burden of existing disease after it has developed; early detection is emphasized. Secondary prevention activities are intended to identify the exis- tence of disease early so treatments that might not be as effective when applied later can be of benefit. Tertiary prevention focuses on the optimum treatment of clinically apparent, clearly identified disease so as to reduce the incidence of later complications to the greatest possible degree. In cases where disease has been associated with adverse effects, tertiary prevention involves rehabilitation and limitation of disability. Health care is primarily concerned with secondary and tertiary prevention: (a) early detection, diagnosis, and treatment of conditions that can be cured or limited in their con- sequences (secondary prevention); and (b) treatment of chronic diseases and other con- ditions to prevent exacerbation, stabilize conditions, and minimize future complications (tertiary prevention). The health care system undoubtedly has its smallest impact on primary preven- tion—that group of interventions that focus on stopping the development of disease and illness, and the occurrence of injury. And as Evans and Stoddart (1994) argue, other than for immunization, the major focus of the health care system’s primary prevention activities is on the behavioral determinants of health, rather than the physical and social environments: The focus on individual risk factors and specific diseases has tended to lead not away from but back to the health care system itself. Interventions, particularly those addressing personal lifestyles, are offered in the form of “provider coun- seling” for smoking cessation, seatbelt use, or dietary modification. These in turn are subsumed under a more general and rapidly growing set of interven- tions attempting to modify risk factors through transactions between clinicians and individual patients. The “product line” of the health care system is thus extended to deal with a more broadly defined set of “diseases”: unhealthy behaviors. The boundary becomes blurred between, e.g., heart disease as manifest in symptoms, or in elevated serum cholesterol measurements, or in excessive consumption of fats. All are “diseases” and represent a “need” for health care intervention …. The behavior of large and powerful organizations, or the effects of economic and social policies, public and private, [are] not brought under scrutiny. (pp. 43–44) The success of any health care system is also affected by the other determinants of health. Genetic predisposition to breast cancer may limit the long-term success rates of cancer treatment. Continued exposure to toxins in the environment or at work may decrease the likelihood that the physician can stabilize an individual with allergies. Health behaviors, such as smoking or substance abuse, may stymie the best health care system when treating an individual with lung disease. The lack of support at home for changes in 14 I: U.S. Health Care System: Present State behaviors or adherence to medical regimens may undermine the ability of the health care system to treat an individual with diabetes successfully. Poverty, race, and ethnicity often limit access to health care, as well as the ability of physicians to diagnose and treat health problems effectively (IOM, 2003). We recognize that health, as well as health care, exist within a biologic, physical, and social context, and all of these factors influence the health care system’s probability of success. THE POPULATION SERVED The determinants of health lead to the health problems that are diagnosed and treated in the health care system. It can be argued that those people who use the health care system have as great an influence on the system as those who provide health care. What are some of the major characteristics of the U.S. population—the aggregate user of health care— that influence the health care system? Thus, we ask: What are America’s major health problems and what factors influence who is beset by these problems? The demographic characteristics of any population have an enormous impact on health and, therefore, on the health care system. They differentiate people’s risk of mortality and causes of morbid- ity, as well as their health behaviors. In this section, we provide a brief discussion of the health conditions that result in utilization of health care, as well as the principal demo- graphic characteristics—age, sex, race and ethnicity, and poverty—and their relationship to mortality, morbidity, and health behaviors in the population. America is the third largest country in the world, following India and China, both of which have populations exceeding 1 billion. The U.S. population was 331,449,520 in 2020, following a steady increase throughout the 20th and 21st centuries, beginning in 1900 with 76.3 million people. We have a heterogeneous population, racially and ethnically. In 2020, 58.9% of the U.S. population was non-Hispanic White, 19.1% was Hispanic or Latino, 13.6% was Black or African American, 6,3% was Asian, 1.3% Amer- ican Indian or Alaska Native, and 3.3% was some other race or two or more races. As a percentage of total population, every racial and ethnic group increased between 2000 and 2020 except for non-Hispanic White individuals. This diversity is reflected in the languages spoken. In about 22% of households, a language other than English is spo- ken (U.S. Census Bureau, 2023). Age structure also affects the U.S. health care system, and it is changing. The percent of the population that is 0 to 4 years old decreased from 6.5% in 2010 to 5.7% in 2021. The population 5 to 19 decreased slightly. The percent of the population that is 65 and older increased from 13.1% in 2010 to 16.8% in 2021. These changes have been predicted. In 2010, for example, the population forecast for 2020 foreshadowed major changes to the system as the Baby Boomer generation ages. As a result, health care consumption patterns that had remained fairly constant over time have moved unevenly in the direction of elder care. Physicians spend more time providing services for older adults (Bureau of Health Profes- sions, Health Resources and Services Administration, 2013). Poverty adversely affects the ability to access health care, health behaviors, health con- ditions, and length of life. However, there are large income differentials in the United States that are becoming wider over time (IOM, 2003; Reich, 1998; Stein, 2006; Thurow, 1995). This is true in 2021, especially for children. “The national poverty rate was 12.8% in 2021, but was significantly different for the nation’s oldest and youngest populations.... The child  1: Introduction 15 poverty rate (for people under age 18) was 16.9% in 2021, 4.2 percentage points higher than the national rate, while poverty for those ages 65 and over was 10.3%, 2.5 percentage points lower than the national rate” (Benson, 2022, paras. 1–2). Mortality Older adults use far more health care than younger people, and the last 6 months of life are a time of intense health care utilization. As one study found: “In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ven- tilation” (Hill et al., 2019, pp. 308–310). Thus, age and death are decidedly related to health care utilization, and the mortality figures are instructive on the magnitude of the population in need of medical care. There were 3.5 million deaths in the United States in 2021. Most deaths occurred among people 65 and older (72%). People 45 to 64 years old accounted for 20% of all deaths, and each younger age group accounted for a smaller percentage of total deaths than the one preceding it except for children less than 1 year old. The crude death rate for each 10-year age group differed dramatically. In 2021, infants had a death rate of 558.8/100,000, which dropped to 25/100,000 for children 1 to 4 years old and to 14.3/100,000 for children 5 to 14 years old. The rate rose steadily in each succeeding age group (see Table 1.1). TABLE 1.1 Crude Death Rates for Underlying Cause of Death, by Age, 2021 10-Year Age Group Population Deaths Crude Rate/100,000