Guidelines in Developing a Group ProposalAPA StyleIntroduction.docx

Guidelines in Developing a Group Proposal
APA Style
Introduction Part: Literature review of a minimum of 5 articles
· Why is there a need for such a group?
· What type of group are you forming?
· For whom is the group intended? Identify the specific
population. What do you know about the needs for this
population?
· Most importantly your rationale for this group needs or be
clear and convincing, remember you might have to convince an
audience about why there is a need for your group.
· State your goals or what you expect to achieve?
Objectives:
· How many members in your group? Is there a specific age
group?
· Are you planning to conduct any pre-group interviewing or
pre-screening candidates?
· Where will the group meet and how long will the sessions be?
· Will it be an open or closed group? Would there be any group
pre-selection or pre-screening?
· What topics will be explored in this group?
Final Part:
· This part should include how you see your initial goals
achieved, or what you expect your group members to
accomplish after attending your group.
· If you are administering a pre-screening tool what do you
expect to see as you complete the group as far as changes in the
scores.

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R e v i e w
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/RMHP.S70173
Barriers to health care for undocumented
immigrants: a literature review

Karen Hacker1,2
Maria Anies2
Barbara L Folb2,3
Leah Zallman4–6
1Allegheny County Health
Department, Pittsburgh, PA,
USA; 2Graduate School of Public
Health, 3Health Sciences Library
System, University of Pittsburgh,
Pittsburgh, PA, USA; 4institute for
Community Health, Cambridge, MA,
USA; 5Cambridge Health Alliance,
Cambridge, MA, USA; 6Harvard School
of Medicine, Boston, MA, USA
Correspondence: Karen Hacker
Allegheny County Health Department,
542 4th Street, Pittsburgh,
PA 15219, USA
Tel +1 412 578 8008
Fax +1 412 578 8325
email [email protected]
Abstract: With the unprecedented international migration seen
in recent years, policies that
limit health care access have become prevalent. Barriers to
health care for undocumented
immigrants go beyond policy and range from financial
limitations, to discrimination and fear
of deportation. This paper is aimed at reviewing the literature

on barriers to health care for
undocumented immigrants and identifying strategies that have
or could be used to address these
barriers. To address study questions, we conducted a literature
review of published articles from
the last 10 years in PubMed using three main concepts:
immigrants, undocumented, and access
to health care. The search yielded 341 articles of which 66 met
study criteria. With regard to
barriers, we identified barriers in the policy arena focused on
issues related to law and policy
including limitations to access and type of health care. These
varied widely across countries but
ultimately impacted the type and amount of health care any
undocumented immigrant could
receive. Within the health system, barriers included
bureaucratic obstacles including paperwork
and registration systems. The alternative care available (safety
net) was generally limited and
overwhelmed. Finally, there was evidence of widespread
discriminatory practices within the
health care system itself. The individual level focused on the
immigrant’s fear of deportation,
stigma, and lack of capital (both social and financial) to obtain

services. Recommendations
identified in the papers reviewed included advocating for policy
change to increase access
to health care for undocumented immigrants, providing novel
insurance options, expanding
safety net services, training providers to better care for
immigrant populations, and educating
undocumented immigrants on navigating the system. There are
numerous barriers to health care
for undocumented immigrants. These vary by country and
frequently change. Despite concerns
that access to health care attracts immigrants, data demonstrates
that people generally do not
migrate to obtain health care.
Solution
s are needed that provide for noncitizens’ health care.
Keywords: undocumented immigrants, health care, access,
deportation, immigration and
migration
Background

Over the last decade, international migration has continued to
rise despite the efforts
of many countries to tighten their borders.1 Factors such as
conflict, discrimination,
and the lack of employment opportunities in countries of origin
contribute to migration
patterns. Today, countries have used a variety of strategies to
dissuade immigrants from
crossing their borders ranging from border patrol to identity
checks, detention, and
deportation.2,3 With the unprecedented rates of migration,
policies that disincentivize
migration have spread to health care. Internationally, many
countries, including the US,
European nations, Scandinavia, Canada, and Costa Rica, have
promulgated a range of
policies that limit access to health services.4–8 In the US for

example, the Affordable
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mailto:[email protected]
Risk Management and Healthcare Policy 2015:8
Articles identified in PubMed
search
(N=341)
Records screened (N=123)
Full articles assessed for eligibility
(N=74)
Excluded (N=8)
Excluded (N=54)

Excluded (N=218)
Studies included in qualitative
synthesis
(N=66)
Figure 1 Flow chart of review process.
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176
Hacker et al
Care Act excludes undocumented immigrants from access-
ing health insurance.9 In the European Union, policies that
limit undocumented immigrants’ access to health care are

widespread and vary substantially. These policies range from
denying all access to providing limited access to emergency
and preventive care.4
Throughout the literature, undocumented immigrants/
migrants, also referred to as illegal, irregular, and noncitizen,
are seen as underutilizing the health care system.10–12 This
underutilization not only puts their health at risk, as is the case
with infectious diseases, but may also put the general public’s
health at risk.13–15 Many papers examine the sequelae of
undocumented immigrants’ limited access to health care.16,17
This includes the lack of follow-up for tuberculosis and HIV/
AIDS, low immunization rates, and untreated mental health
issues.14,15 A number of factors are presumed to exacerbate

undocumented immigrants’ limited access to health care.
These include their lack of knowledge, bureaucratic issues,
confusion about rules and regulations, and discrimination.18 To
date, however, we have not encountered a review focused spe-
cifically on the variety of barriers to health care beyond legal
regulations that undocumented immigrants currently face. Nor
have we found a review of strategies that have been used or
might be used to alleviate these barriers. Therefore, this paper
is aimed at reviewing the literature on barriers to health care
for undocumented immigrants and identifying strategies that
have or could be used to address these barriers.
Methods
To address our main study aim we conducted a literature

review using a systematic approach to examine peer-
reviewed literature related to barriers to health care faced by
undocumented immigrants. We also identified recommended
strategies for solutions within the literature reviewed.
Search strategy
Our literature search was conducted using PubMed by one
author (BF) to capture our three main concepts: immigrants,
undocumented, and access to health care. We limited our
search to articles written in English over the last 10 years. Var-
ious terms for immigrants were used, including immigrants,
foreigners, aliens, and migrants. In addition, a variety of
search terms for undocumented were used, including undocu-
mented, illegal, irregular, and noncitizen. The full search

strategy is provided in the “PubMed search strategy” section
of Supplementary materials. The search was designed to
retrieve articles on a wide range of subtopics within the main
topic but without being exhaustive, as would be required for
a complete systematic review. By incorporating systematic
review methods into the search, this study occupies a middle
ground between traditional narrative reviews, which do not
require documentation of search methods or defined crite-
ria in their choice of articles for inclusion, and systematic
reviews. We applied our search criteria on April 8, 2015 and
identified 341 journal article records (Figure 1). All records
were exported to an EndNote database for inclusion/exclu-

sion evaluation.
Article selection
We conducted a three-stage screening process starting with
a title review followed by an abstract review and ending
with a full-text article review. Articles were included if
they addressed barriers to health care for undocumented
immigrants and/or recommendations for strategies to solve
problems of access. For the purposes of this search, editorials
and opinion pieces were excluded.
In our title review stage, three authors (KH, MA, LZ)
independently reviewed the journal article titles to determine
whether they were relevant or irrelevant. Based on this title
review, 123 articles were included for review and 218 were

excluded. In our second stage, the authors independently
screened the abstracts of the remaining 123 articles and
determined that 74 initially met eligibility. Three reviewers
examined full-text articles for eligibility. Seven articles were
excluded as they were deemed to be opinion pieces and one
article was deemed irrelevant. After excluding these articles,
66 articles were included in the qualitative analysis that fol-
lowed (see Table S1; reviewed articles).
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177
Barriers to health care for undocumented immigrants
Abstraction
The reviewers then developed a data abstraction form and
independently applied it to three eligible articles. They then
reviewed their findings and developed an initial list of cat-
egories of barriers (eg, fear of deportation and insurance).
They independently abstracted information from 10 to
12 articles each and met to review the tool, finalizing the
list of categories of barriers. At this stage, one category was
removed and four were added, yielding the finalized abstrac-
tion tool. Authors were instructed to highlight any themes

that were not captured by the abstraction tool; however, no
further key themes emerged. Once abstraction was complete,
two authors (KH, LZ) met to review all of the data and
consolidate the themes into categories for both barriers and
recommendations.
Results
Barriers
The final categories for barriers identified from the literature
represent the multiple levels where the barriers to health
care for undocumented immigrants exist. These categories
include barriers experienced in the policy arena, in the health
care system, and at the individual level (Table 1). The policy
arena focused on issues related to both law and policy includ-
ing access to insurance for undocumented populations and

limitations to the type of health care that they could utilize.
The health care system focused on bureaucracy, capacity,
and the discriminatory practices that were present. The
individual level focused on the undocumented immigrants’
fears, stigma, and lack of capital (both social and financial)
that, in turn, created barriers to health care.
Table 1 Barriers to health care experienced by undocumented
immigrants
Category Subcategory Description Number (%)
of articles
References
Policy arena Law/insurance Legal barriers including barred
access
to insurance by law

50 (76) 1,4–8,13,16,20,22–62
Need for documentation
to get services/
unauthorized parents
Requirements that individuals show
documentation to get health care services,
often leading unauthorized parents to avoid
care for authorized children
18 (27) 1,2,6,13,36,38,43–45,51,
56–58,63,64
Health system external resource
constraints
Constraints beyond individual’s ability to pay
for services including work conflicts, lack of
transportation, and limited health care capacity
(such as lack of translation services, cultural
competency, and funding cuts)
24 (36) 1,2,6,13,36–38,40,43–45,49,
51,56–58,63,64

Discrimination Discrimination on the basis of documentation
status resulting in stigma experienced by
undocumented immigrants
22 (33) 2,5–7,19,20,23,29–32,
34,35,41,42,45,47,50,57,59,
61,63–65
Bureaucracy Complex paperwork or systems required
to gain access to health care
17 (26) 1,2,8,16,19,20,24,36–38,40,41,
44,45,48,49,54,57,63–66
individual level Fear of deportation Concerns about being
reported to authorities
if they utilized services or provided their
documentation
43 (65) 2,4–8,13,16,20,23–25,29,
31,33,34,36–38,40,41,43–46,
49–51,53,56,57,59,60,62–70
Communication ability Not speaking or understanding the

dominant
language to communicate with health care
providers. Also cultural challenges to
understanding the nuances of another culture
and expressing one’s problems so that they
are understood and not ignored
24 (36) 7,19,24,27,28,29,31,34,
36–38,41,42,44,47,53,
56,59–61,63,64,65,67
Financial resources Lack of personal financial resources to
pay for services
30 (45) 1,6,8,13,22,23,26,27,29,
30,33,36–38,41,44–48,53,
57,60,62,63,65,67,71,72
Shame/stigma Not wanting to be a burden to society or
experiencing shame when seeking services
and concerns about being stigmatized when
seeking services
7 (11) 19,36,38,41,45,62,64

Knowledge of the health
care system
Little knowledge about how the “system”
works, what rights to health care exist, and how
to navigate the health care system at all levels
22 (33) 7–9,26,28,31,33,34,37,41,
44,47,53,54,57,58,60,62,
63,66,72,73
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Hacker et al
Policy

National policies excluding undocumented immigrants from
receiving health care were the most commonly cited barriers
to health care. Three quarters of the articles described legal
barriers including denying access to insurance. In some
nations, active surveillance of providers led to the denial
of care as providers feared losing their medical licenses
or criminal procedures. A commonly cited mechanism
for excluding undocumented immigrants from health care
was laws limiting access to insurance. Because insurance
was generally required for affordable care or required to
receive services at all, these laws effectively barred access
to care. The fact that medical repatriation was allowed in
many countries – that is, repatriation of a sick individual

to the country of origin against an individual’s will for the
purposes of medical care (which is often insufficient in the
country of origin) – led to avoidance of care. In addition,
27% of articles described requirements that individuals show
documentation to get health care services as major barriers to
care. Often, this need for documentation “spilled over” and
affected authorized children of unauthorized parents, who
did not seek care for their children because of the inability
to provide documentation for themselves.
Health system
Health system barriers included external resource constraints,
costs to the individual, discrimination, and high bureaucratic
requirements. External resource constraints – or constraints

such as work conflicts (eg, health care offered during work
hours and fear of losing job due to time off seeking care),
lack of transportation, and limited health care capacity (eg,
lack of translation services, cultural competency, and funding
cuts) – were identified in 36% of articles. One area where
there was particularly limited capacity was in mental health
care for undocumented immigrants. One third of articles
discussed discrimination on the basis of nativity status; for
some subpopulations, discrimination on the basis of nativity
intersected with other forms of discrimination such as sexual
discrimination, placing subpopulations at particularly high-
risk of not receiving care. Finally, complicated bureaucracies

created insurmountable barriers for not only undocumented
immigrants but also providers wanting to provide care to
immigrants; 26% of articles described this issue. Often
bureaucratic regulations led to extensive paperwork require-
ments that were too complicated and costly to complete.
individual
Individual barriers included fear of deportation, commu-
nication ability, financial resources, shame/stigma, and
knowledge about the health care system. Fear of deportation,
whether real or imagined, was identified as a barrier in 65%
of articles. Undocumented immigrants reported avoiding
health care and waiting until health issues were critical to
seek services because of their concerns of being reported to

authorities. This was seen in countries as diverse as France,
the US, and Denmark. A second barrier – noted in 36% of
articles – was communication, which not only included the
inability to speak the language of the dominant culture but
also included cultural discomfort with the way in which the
dominant culture communicated. It was noted that undocu-
mented immigrants were unable to communicate their
health concerns to care providers or were misunderstood by
those providers. For example, in one article, undocumented
immigrants felt that the emergency room physicians did not
fully believe their symptoms.19 Lack of financial resources
was also a significant barrier, as noted in 45% of articles,
and was particularly true in countries where undocumented

immigrants were excluded from all health care services or
had no access to insurance (the UK and Denmark). Eleven
percent of papers reported the issue of shame and/or stigma
as a barrier for accessing health care. Undocumented immi-
grants did not want to “be a burden on the system” or felt
that they would be stigmatized if they sought services even
in countries where services were available. Lastly, the final
individual barrier that was identified was a lack of knowledge
of the system itself. Undocumented immigrants often did
not know what services were available to them nor what
their rights to health care were. In addition, immigrants
often did not know how to utilize the health care system,

particularly when additional requirements were needed (ie,
France’s requirement to obtain authorization prior to access-
ing services).20 This was identified as a barrier in 33% of
the reviewed articles.
Recommendations
We identified five major categories of recommendations in
the reviewed papers relevant to addressing barriers to health
care for undocumented immigrants (Table 2). These cat-
egories are related to advocacy for policy change, insurance
options, expansion of the safety net, training of providers
to better care for immigrant populations, and education of
undocumented immigrants on navigating the system.
Advocacy for policy change included a range of possible

legislation to allow either full access to health care or varying
levels of access such as public health services. Insurance
options included special insurance programs through the
state available to undocumented immigrants and/or full
insurance benefits to employees regardless of their status.
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Table 2 Recommendations for improving barriers
Category Description Number (%)
of articles
References
Advocacy/legal change expand health care access to all
regardless of status,
delay deportation for those in care until the course of

treatment is completed, make undocumented immigrants
documented and give full rights to health care
31 (47) 1,2,8,16,22,24,25,29,31,
35,37–41,45,48–51,53,
57–59,61,65,66,71,73,74
insurance Allow all residents to have access to state-funded
limited network health plan, “paid” or subsidized
insurance options, or provide insurance to all
workers regardless of status
9 (14) 1,8,23,44–46,48,58,59
expansion of the
safety net
Expand the capacity of public, nonprofit and free clinics
to render care to the population, especially for public
health services such as communicable diseases, maternal
and child health, and preventive care
Provide health and education in nonprofit social
service or faith-based organizations
enhance support for safety net providers through
state-funded vehicle

18 (27) 7,8,31,32,34–37,
40,44,60,63,64,66,
68,71,73,75
Training providers Train providers to better understand the
needs of their
immigrant patients and utilize interpretation services
Train providers and update them on legal
mandates within the country
10 (15) 8,13,16,19,33,37,41,56,64,68
education and outreach to
undocumented immigrants
Outreach to specific immigrant communities to
educate on the current laws and the system,
especially education regarding rights to health care
Provide culturally appropriate navigators in health
care environments to help undocumented immigrants’
access services
15 (23) 2,19,28,34,36,37,40,41,44,
46,47,59,60,69,72

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Expansion of the safety net focused on increasing the
capacity of safety net providers (free clinics, state clinics,
federally qualified health centers and public hospitals, and
public health clinics) to service the population and receive
reimbursement. In addition, strategies to employ sliding
fee scales to accommodate low-income individuals and the
use of voluntary organizations were mentioned. Training

of providers included both training in the legal mandates of
the individual country and training in cultural competency.
Education for immigrants included providing specialized
linguistically appropriate information on how to navigate
the health care system and on what rights were afforded to
undocumented immigrants. Authors also suggested using
navigators to help undocumented immigrants maneuver
through the health care system.
Advocacy/legal change
A variety of advocacy recommendations to change the
existing laws were suggested in the majority of the papers
reviewed (47%). These included not only changing laws to
provide full access to care regardless of citizenship but also

promoting legislation that would allow delayed deporta-
tion until treatment was completed. Others recommended
major immigration reform that would grant legal status to
undocumented immigrants after some period of time, thus
making health care exclusion laws irrelevant.
insurance options
Several papers suggested newly configured insurance options
to support undocumented immigrants’ access to health care.
These included a range of options from a state-funded insur-
ance plan to a low-cost insurance plan with a limited network.
Most of the insurance strategies recommended required
undocumented immigrants to financially contribute at some
level in order to access care. Fourteen percent of papers

recommended changes in insurance options.
expansion of the safety net
Twenty-seven percent of papers identified the need to expand
the existing safety net to accommodate the needs of undocu-
mented immigrants. This included expanding public and free
clinics and hospitals, particularly for conditions that put the
public’s health at risk (ie, tuberculosis [TB], and sexually
transmitted diseases) or those related to maternal and child
health (obstetrics and preventive care). They also noted that
current voluntary organizations such as food banks could be
important health care providers, particularly for prevention
and health education. Many papers noted that the safety net
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Hacker et al
system did not currently have capacity to take on this role
and called for increased state support to do so.
Training of providers
A number of papers (15%) noted that providers them-
selves needed additional training to appropriately care for
undocumented immigrants. A focus on cultural competency
was needed to improve existing services as well as any
new services. In some of the papers, it was also noted that

providers did not adequately understand the current policies
on access and might turn undocumented immigrants away
based on false information. Therefore, a number of papers
recommended additional training to keep providers up to
date on changing legislation related to access.
education and outreach
Lastly, a number of papers (23%) argued for education and
specialized outreach to the undocumented immigrant com-
munity to facilitate their utilization of the health care system
and their understanding of the policies relevant to them in
the specific country. Several papers also recommended the
use of navigators or cultural ambassadors to help undocu-
mented immigrants maneuver through the bureaucracy and

obtain needed care.
Discussion
In this literature review, we identified 66 peer-reviewed
articles in the medical literature addressing barriers to
health care among undocumented immigrants. These articles
described multiple policy, health system, and individual
barriers to care for this population. Policy-level barriers
centered on legal barriers, particularly barred access to
insurance, and the need to show documentation to get
services. Health system barriers included external resource
constraints (such as lack of transportation), discrimination
within the health care system, and complex bureaucracies.
Finally, individual-level barriers identified included fear

of deportation, communication ability, lack of financial
resources, and experience of shame or stigma.
The barriers to health care for undocumented immigrants
are extensive and vary by country. Even in countries with more
lenient health care access laws for undocumented immigrants,
bureaucratic obstacles can be complex and have similar
effects to limiting care. The literature suggests that the legal
obstacles are not the only bureaucratic obstacles that undocu-
mented immigrants face; undocumented immigrants deal with
challenges that revolve around understanding the health care
system, shame, and fear of deportation. Tying access to health
care to deportation is perhaps the largest barrier to obtaining

services even in countries that offer access. It is well known
that
immigrants overall and undocumented immigrants in particular
are underutilizing the health care system. The ramifications of
such obstacles might include a risk to the public’s health when
communicable diseases are involved or a risk for more serious
issues when health care is deferred.
Given the extent of immigration now and potentially in
the future, countries will continue to grapple with developing
strategies that serve the public’s health. Many of the recom-
mendations that we identified in the reviewed articles have not
been tested so it is difficult to ascertain whether or not they
would be deemed successful. Recommendations mentioned

frequently involved changing legislation to provide full health
coverage regardless of status. Other recommendations sug-
gested providing health care that was limited (by disease),
only preventive in nature, or of low-cost. Many countries
already have such systems in place.4,7,44
These secondary systems of health care for noncitizens
have restricted access to care and require complex and costly
bureaucracies to administer. Some of the recommendations
we encountered suggested that a thoughtfully constructed
(inclusive of preventive, acute, and secondary care) and
controlled (limited networks), system might offer a low-cost
alternative to full access.
Studies have documented that people migrate to flee

violence or persecution or for economic opportunities rather
than to obtain health care.21 It is therefore possible that
despite concerns that access to health care attracts undocu-
mented immigrants, integration of a noncitizens’ health care
option into national systems may not increase immigration.
However, more research is needed to better understand the
impact of the various recommendations we identified on
undocumented immigration, costs, and health outcomes.
Limitations
The literature search was limited to English language articles
from the last 10 years and run using PubMed. It is likely that
relevant articles are missing from this review that were pub-
lished in other languages, and indexed in databases besides

PubMed (such as PsycINFO and Embase, etc). Inclusion of
those missing articles could have added more information
on barriers and options for recommendations addressing
undocumented immigrants’ access to health care.
In addition, this review was designed to answer
a specif ic question about barriers to health care for
undocumented immigrants. Recommendations examined
were limited to those identified in the articles retrieved
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181
for our review of barriers. We did not carry out a separate
review of strategies to address the provision of health care for
undocumented immigrants, and a literature review focused on
polices or strategies to address health care for this population
might provide additional evidence not mentioned in this
paper. Another review examining the impact of various health
services for undocumented immigrants would be needed.
Because the review aimed to examine barriers in general
rather than compare barriers by country, we are unable to
present comparisons across countries. Further research would

be needed to answer this question. Lastly, we were strictly
focused on undocumented immigrants and are unable to com-
ment on barriers to care for documented (legal) immigrants.
Conclusion
There are numerous and wide-ranging barriers to receipt of
health care for undocumented immigrants. These barriers are
not only legal in nature but also encompass challenges inher-
ent in “undocumented” or illegal status. They include policy
limitations, the fear of disclosure, and the lack of both social
and financial assets. Given the current level of undocumented
immigrants worldwide, these barriers will continue to impact
human health. Additional research is needed to determine
the effect of implemented health policies on undocumented

immigrant health and decisions to immigrate.
Disclosure
The authors report no conflicts of interest in this work.
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Publication Info 2: Nimber of times reviewed:
H E A LTH 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 polic y issues, health polic y 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, Universit y of Southern California

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Shi (2238) FM.indd 1 7/9/13 9:03 AM
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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.
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00_Shi (2238).indb 4 7/3/13 8:34 AM
mailto:[email protected]
http://www.copyright
I dedicate this book to my wife, Ruoxian,
and my children, Sylvia, Jennifer, and Victor Shi.
00_Shi (2238).indb 5 7/3/13 8:34 AM

00_Shi (2238).indb 6 7/3/13 8:34 AM
v i i
B R I E F C O N T E N T S
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
00_Shi (2238).indb 7 7/3/13 8:34 AM
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
00_Shi (2238).indb 8 7/3/13 8:34 AM
P r e f a c e i x

D E T A I L E D C O N T E N T S
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

00_Shi (2238).indb 9 7/3/13 8:34 AM
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
.............................................................................................3
1
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
..........................................................................................49
For Discussion
...............................................................................................
......49
References
............................................................................... ................
.............50
Additional Resources
............................................................................................5
1
Chapter 3 Health Policymaking at the State and
Local Levels and in the Private Sector
...............................................53
Learning Objectives
.............................................................................................5
3
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
..........................................................................................68
For Discussion
...............................................................................................
......68
References
...............................................................................................
.............69
Chapter 4 International Health Policymaking
...................................................74

Learning Objectives
.............................................................................................7
4
Case Study: China’s Healthcare Reform
...............................................................75
World Health Organization
.................................................................................76
Health Policymaking from Selected Countries
.....................................................79
Key Points
...............................................................................................
.............90
..........................................................................................91
For Discussion
...............................................................................................
......91
References
...............................................................................................
.............91
............................................................................................9
5
00_Shi (2238).indb 10 7/3/13 8:34 AM

D e t a i l e d C o n t e n t s x i
PART III Health Policy Issues
..........................................................................97
Chapter 5 Health Policy Related to Financing and Delivery
.............................99
Learning Objectives
.............................................................................................9
9
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
........................................................................................114
For Discussion
...............................................................................................
....114
References
...............................................................................................
...........115
Chapter 6 Health Policy for Diverse Populations
............................................118
Learning Objectives
...........................................................................................11
8
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
...........................................................................................15
0
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

........................................................................................173
For Discussion
...............................................................................................
....173
References
...............................................................................................
...........174
PART IV Health Policy Research
...................................................................183
Chapter 8 Overview of Health Policy Research
..............................................185
Learning Objectives
...........................................................................................18
5
Case Study: The RAND Health Insurance Experiment
......................................186
00_Shi (2238).indb 11 7/3/13 8:34 AM
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
........................................................................................212
For Discussion
...............................................................................................
....212
References
...............................................................................................
...........212
Chapter 9 Health Policy Research Methods
....................................................216
Learning Objectives
...........................................................................................21
6

Case Study: Health Centers and the Fight Against
Health Disparities in the United States
..........................................................217
Quantitative Methods
........................................................................................218
Qualitative Methods
..........................................................................................23
4
Key Points
...............................................................................................
...........242
Case Study Assignment
......................................................................................243
For Discussion
...............................................................................................
....243
References
...............................................................................................
...........243
..........................................................................................25
3
Chapter 10 An Example of Health Policy Research

...........................................255
by Sarika Rane Parasuraman
Learning Objectives
...........................................................................................25
5
Questions for Policy Analysis
.............................................................................256
Policy Analysis: Responses to Exam Questions
...................................................257
References
...............................................................................................
...........284
Glossary
...............................................................................................
................295
Index
...............................................................................................
......................303
About the Author
..............................................................................................
320

00_Shi (2238).indb 12 7/3/13 8:34 AM
x i i i
P R E F A C E
F
or 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
00_Shi (2238).indb 13 7/3/13 8:34 AM
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
00_Shi (2238).indb 14 7/3/13 8:34 AM
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
00_Shi (2238).indb 15 7/3/13 8:34 AM
00_Shi (2238).indb 16 7/3/13 8:34 AM
1
PA R T I
I N T R O D u C T I O N
T
he 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.
00_Shi (2238).indb 1 7/3/13 8:34 AM
00_Shi (2238).indb 2 7/3/13 8:34 AM
3
L e a r n i n g O b j e c t i v e s
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
O v E R v I E w
O F H E A LT H P O L I C y
I have never had a policy. I have simply tried to do what
seemed best each
day, as each day came.
— Abraham Lincoln
00_Shi (2238).indb 3 7/3/13 8:34 AM

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
C A S E S T u D y
HE A LT H C A R E RE F O R M: HI L L A Ry CL I N T O N A
N D BA R A C K OB A M A
Two➤major➤healthcare➤reform➤initiatives➤have➤played➤out
➤on➤the➤US➤political➤landscape➤in➤the➤
last➤two➤decades:➤the➤Health➤Security➤Act,➤developed➤b
y➤the➤Clinton➤administration➤in➤the➤
1990s➤and➤spearheaded➤by➤then➤First➤Lady➤Hillary➤Clint
on,➤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➤co

verage➤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➤employe
r➤costs➤and➤subsidies➤for➤small➤busi-
nesses.➤Competition➤among➤private➤health➤plans➤and➤a➤c
ap➤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➤healt
h➤insurance➤market,➤extending➤
insurance➤coverage➤to➤the➤uninsured,➤providing➤better➤co
verage➤for➤those➤with➤preexisting➤

conditions,➤improving➤prescription➤drug➤coverage➤in➤Med
icare,➤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➤t
anning➤services➤(KFF➤2011);➤and➤
other➤offsets➤(provisions➤of➤the➤law➤that➤reduce➤the➤ov
erall➤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➤Democrat
ic➤Party,➤both➤chambers➤of➤the➤US➤

Congress➤were➤controlled➤by➤Democrats,➤and➤national➤op
inion➤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➤follo
w-
ing➤that➤failed➤effort➤helped➤Republicans➤gain➤control➤o
f➤the➤House➤of➤Representatives➤and➤
Senate➤in➤the➤1994➤election➤(Trafford➤2010).➤
00_Shi (2238).indb 4 7/3/13 8:34 AM

➤ 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
A
t 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.
HE A LT H D E F I N E D
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.
00_Shi (2238).indb 5 7/3/13 8:34 AM
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.
P H y S I C A L H E A LT H
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➤availabl
e➤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➤fin
ancial➤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➤Med
icaid➤program.➤Both➤programs➤were➤

created➤in➤1965➤under➤the➤Great➤Society➤reforms➤of➤Pr
esident➤Lyndon➤Johnson➤in➤an➤era➤
when➤civil➤rights➤and➤social➤justice➤had➤taken➤central➤s
tage➤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➤Insu
rance➤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➤re
sulted➤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.
•
00_Shi (2238).indb 6 7/3/13 8:34 AM
l i c y ➤ 7
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.
M E N TA L H E A LT H
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).
S O C I A L W E L L -B E I N G
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
00_Shi (2238).indb 7 7/3/13 8:34 AM

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.
P u B L I C H E A LT H D E F I N E D
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➤populati
on➤within➤a➤specified➤period)➤of➤
specific➤diseases
•➤
➤Prevalence➤(number➤of➤instances➤in➤a➤defined➤populati
on➤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,➤eati
ng)
•➤
➤Limitations➤in➤performing➤instrumental➤activities➤of➤dai
ly➤living➤(i.e.,➤doing➤housework➤
and➤chores,➤grocery➤shopping,➤preparing➤food,➤using➤the
➤phone,➤traveling➤locally,➤tak-
ing➤medicine)
*

00_Shi (2238).indb 8 7/3/13 8:34 AM
l i c y ➤ 9
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

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