Health Essays. Health And Wellness Essay Paper Moreover, There Is Nothing Mor...Amanda Harris
Essay on Health Health Essay for Students and Children in English - A .... Essay on Health Education Health Education Essay for Students and .... Health Essay Sample Telegraph. PDF How to improve healthcare improvement - An essay by Mary Dixon-Woods. argumentative essay about universal healthcare. health essays. Paper article essay about health. Argumentative Essay About Universal Healthcare. Essay on the Importance of Health Social Group Public Health. Impressive Health Care Essay Thatsnotus. Essay About Medical And Health. Health essay writing,Essay 123 Help. Essays about sports and health, IELTS Sample Essay - Sports and health. Essay on health Order Custom Essays at littlechums.com.. Essay on Health amp; Hygiene 10 Lines amp; Short Essay for Students. Research paper: Essay about good health. Essay Samples PDF Medical School Preventive Healthcare. Medical School Essays Medical School Preventive Healthcare. Example Of Article Essay About Health - Essay On Health Canada Type .... Narrative Essay: Health essays. Technology in Healthcare Free Essay Example. Healthy Lifestyle Essay Introduction - Help Health. Short Essay on the Importance of Mental Health. Write an essay on Preservation of Health Essay Writing English .... Essays on health care issues. Health essay - 24/7 Homework Help.. Improved More Efficient And Affordable Health Care Health Care Essay .... Health care essay. Health And Wellness Essay Paper Moreover, There Is Nothing More .... Public Health Essay Public Health Preventive Healthcare Health Essays Health Essays. Health And Wellness Essay Paper Moreover, There Is Nothing More ...
Discuss three (3) ways that large organizations are increasingly eng.docxrhetttrevannion
Discuss three (3) ways that large organizations are increasingly engaging in social entrepreneurship and the importance of stakeholder relationships in this effort.
Describe the concept of ‘Third Sector’ innovation and reflect on the motive of non-profit entrepreneurial organizations to service these social needs. Next explain how the concept of uneven global distribution of innovation influences this sector. Provide examples to support your rationale.
I am adding a web link for you to review, here are a few web links on Social Entrepreneurship
1. From Forbes.com here is a list of several young social entrepreneurs.
http://www.forbes.com/special-report/2012/30-under-30/30-under-30_social.html
2.
From Stanford University:
Social Entrepreneurship: the case for Definition.
http://ssir.org/articles/entry/social_entrepreneurship_the_case_for_definition
.
Discuss this week’s objectives with your team sharing related rese.docxrhetttrevannion
Discuss
this week’s objectives with your team sharing related research, connections and applications made by individual team members.
Prepare
a 350- to 1,050- word Reflection from the learning that took place in your team forum with:
·
An introduction
·
A body that uses the objectives as headings (2.1, 2.2, 2.3, & 2.4 spelled out). After commenting on or defining the objectives (no names) include a couple of individual team member’s specific connections and/or applications by name.
·
A conclusion that highlights a few specifics from the body of the Reflection.
·
A reference page that lists the e-text plus at least two other sources.
.
Discuss theoretical considerations or assumptions relevant to yo.docxrhetttrevannion
Discuss theoretical considerations or assumptions relevant to your issue. To determine these, consider the research hypothesis you developed in earlier units. What theory or theories (e.g., social learning theory, critical theory, constructivism theory, human behavioral theory, network theory, routine activities theory, etc.) would help to explain the relationship you hypothesize exists between your independent and dependent variables?
.
Health Essays. Health And Wellness Essay Paper Moreover, There Is Nothing Mor...Amanda Harris
Essay on Health Health Essay for Students and Children in English - A .... Essay on Health Education Health Education Essay for Students and .... Health Essay Sample Telegraph. PDF How to improve healthcare improvement - An essay by Mary Dixon-Woods. argumentative essay about universal healthcare. health essays. Paper article essay about health. Argumentative Essay About Universal Healthcare. Essay on the Importance of Health Social Group Public Health. Impressive Health Care Essay Thatsnotus. Essay About Medical And Health. Health essay writing,Essay 123 Help. Essays about sports and health, IELTS Sample Essay - Sports and health. Essay on health Order Custom Essays at littlechums.com.. Essay on Health amp; Hygiene 10 Lines amp; Short Essay for Students. Research paper: Essay about good health. Essay Samples PDF Medical School Preventive Healthcare. Medical School Essays Medical School Preventive Healthcare. Example Of Article Essay About Health - Essay On Health Canada Type .... Narrative Essay: Health essays. Technology in Healthcare Free Essay Example. Healthy Lifestyle Essay Introduction - Help Health. Short Essay on the Importance of Mental Health. Write an essay on Preservation of Health Essay Writing English .... Essays on health care issues. Health essay - 24/7 Homework Help.. Improved More Efficient And Affordable Health Care Health Care Essay .... Health care essay. Health And Wellness Essay Paper Moreover, There Is Nothing More .... Public Health Essay Public Health Preventive Healthcare Health Essays Health Essays. Health And Wellness Essay Paper Moreover, There Is Nothing More ...
Discuss three (3) ways that large organizations are increasingly eng.docxrhetttrevannion
Discuss three (3) ways that large organizations are increasingly engaging in social entrepreneurship and the importance of stakeholder relationships in this effort.
Describe the concept of ‘Third Sector’ innovation and reflect on the motive of non-profit entrepreneurial organizations to service these social needs. Next explain how the concept of uneven global distribution of innovation influences this sector. Provide examples to support your rationale.
I am adding a web link for you to review, here are a few web links on Social Entrepreneurship
1. From Forbes.com here is a list of several young social entrepreneurs.
http://www.forbes.com/special-report/2012/30-under-30/30-under-30_social.html
2.
From Stanford University:
Social Entrepreneurship: the case for Definition.
http://ssir.org/articles/entry/social_entrepreneurship_the_case_for_definition
.
Discuss this week’s objectives with your team sharing related rese.docxrhetttrevannion
Discuss
this week’s objectives with your team sharing related research, connections and applications made by individual team members.
Prepare
a 350- to 1,050- word Reflection from the learning that took place in your team forum with:
·
An introduction
·
A body that uses the objectives as headings (2.1, 2.2, 2.3, & 2.4 spelled out). After commenting on or defining the objectives (no names) include a couple of individual team member’s specific connections and/or applications by name.
·
A conclusion that highlights a few specifics from the body of the Reflection.
·
A reference page that lists the e-text plus at least two other sources.
.
Discuss theoretical considerations or assumptions relevant to yo.docxrhetttrevannion
Discuss theoretical considerations or assumptions relevant to your issue. To determine these, consider the research hypothesis you developed in earlier units. What theory or theories (e.g., social learning theory, critical theory, constructivism theory, human behavioral theory, network theory, routine activities theory, etc.) would help to explain the relationship you hypothesize exists between your independent and dependent variables?
.
Discuss theprinciple events of PROCESS AND THREAD used in both t.docxrhetttrevannion
Discuss the
principle events of PROCESS AND THREAD used in both the hosting OS and the OS management of the appropriate QUEUES. OS may only include Linux, Windows, Unix, ROS, RTOS, and Mainframe.
Initial Discussion - 300 words
2 Responses - each 250 words.
.
Discuss the Windows Registry System Hive1) What information.docxrhetttrevannion
Discuss the Windows Registry System Hive:
1) What information is retained in the hive?
2) Specifically, what security incident information could be extracted from the System Hive?
1) It should be a minimum of 400 Words not including references
2) APA Format and scholarly References needed
.
Discuss the way the idea of heroism develops from Gilgamesh th.docxrhetttrevannion
Discuss the way the idea of heroism develops from
Gilgamesh
through
The Iliad
/
The Odyssey
, and
The Aeneid.
Focus your discussion of heroism in each text around both the connection between heroic action and divine will and the relationship between the hero and his people. THREE PARAGRAPHS
Compare the role of vengeance in
Agamemnon
,
Medea
, and
Beowulf
. In what ways does the avenger stand for justice? In what ways does the avenger pose a threat to the continuance of society? What does each text lead you to conclude about the viability of revenge in a civilized society? THREE PARAGRAPHS
Compare the depiction of love in
The Aeneid
,
Sir Gawain and the Green Knight
, and the Wife of Bath's Prologue and Tale. What place does love have in society in each text? What problems does it pose? How, if at all, are those problems resolved? THREE PARAGRAPHS
1 PAGE
.
Discuss the ways in which the history of the U.S. was presented in t.docxrhetttrevannion
Discuss the ways in which the history of the U.S. was presented in the stock certificate for the 1876 Centennial International Exhibition in Philadelphia by F. O. C. Darley and S. J. Ferris. Compare it with the overall narrative of nationhood contained in the early 19th century relief sculptures above the doorways in the Capitol Rotunda in Washington, D. C. Be sure to comment on the ways in which these images would have been influenced by the locations in which they were viewed.
200-300 words, work sited
.
Discuss the value of Lean Systems Engineering to systems develop.docxrhetttrevannion
Discuss the value of Lean Systems Engineering to systems development (1 – 2 pages).
This assignment will be graded on two factors: 1.) the degree to which the response depicts clear and comprehensive understanding of the topic/material (80 points); and 2.) the degree to which the response is well thought through and clearly articulated (20 points).
.
discuss the various pathways interest groups use to influence politi.docxrhetttrevannion
discuss the various pathways interest groups use to influence politics and policy in the U.S. Discuss three way interest groups influence government. What are these methods, how do they work, and why are they effective at influencing government.
discuss the three components of political parties. Discuss party-in-the-electorate, party organization, and party-in-government. Briefly describe who makes up each component and what each component does.
.
Discuss the various tools and techniques used by an HCO to incre.docxrhetttrevannion
Discuss the various tools and techniques used by an HCO to increase logistical efficiency. Why would an organization need to measure the capacity (throughput) of the various resources (x-ray equipment, exam rooms, length of stay, etc.)? How does capacity utilization support decision making? PLEASE INCLUDE IN-TEXT CITATIONAND REFERENCE
.
Discuss the various means by which slaves resisted the slave system..docxrhetttrevannion
Discuss the various means by which slaves resisted the slave system. How widespread was such resistance? What were the most common and effective tactics? What does the prevalence of resistance reveal not only about slaves’ attitude toward slavery but also their ability to shape the conditions under which they lived and worked?
one page, doubled spaced, in Times New Roman font, with standard
1 inch margins on all sides
.
Discuss the typica l clinical presentation of the diagnosis , Hip Os.docxrhetttrevannion
Discuss the typica l clinical presentation of the diagnosis , Hip Osteoarthritis(OA), included possible therapeutic exercise treatment intervention, also recommendations for the management of the condition.
Introduction: First about OA and then write about Hip OA
Describe the pathophysiology of the diagnosis and the expected clinical presentation anticipated. If it varies, them describe common variations.
Discuss
etiology
and
demographics
related to the diagnosis(I.e., is this dx more common in men than women, what age, group ect)
Very important only use the articles provides, not citation work submitted via turnitin!!!!
.
Discuss the types of resources, tools, and methods that are availabl.docxrhetttrevannion
Discuss the types of resources, tools, and methods that are available to leaders for data collection and analysis, including organization assessments such as Baldrige, SWOT, and others. What techniques does your organization utilize to make decisions?
You can use US Navy for the organization.
.
Discuss the types of items that should be examined in a firewall log.docxrhetttrevannion
Discuss the types of items that should be examined in a firewall log:
a. IP addresses that are being rejected and dropped
b. Probes to ports that have no application services running on them
c. Source-routed packets
d. Suspicious outbound connections
e. Unsuccessful logins
.
Discuss the types of property, providing an example of each an.docxrhetttrevannion
Discuss the types of property, providing an example of each and why each falls into its classification.
Provide an instance of when you have seen eminent domain in action in your community. If you have not seen this situation, create an example of how this may occur.
.
Discuss the type of personality it takes to become a police officer..docxrhetttrevannion
Discuss the type of personality it takes to become a police officer. Why is this type of individual personality required for police work? What are the dangers to having this type of individual in police work?
Be sure to support your position with a very detailed explanation or a source citation.
.
Discuss the two major sources of crime statistics for the United Sta.docxrhetttrevannion
Discuss the two major sources of crime statistics for the United States. Uniform Crime Report (UCR), National Crime Victim Survey (NCVS), and the National Incident-Based Reporting System (NIBRS), including
but not limited to
: the Part I and II offenses, UCR terminology, how the UCR and NCVS collect crime data, types of information collected and not collected by the NCVS, accuracy issues with the UCR and NCVS, and the role and purpose of the NIBRS
.
Discuss the two most prominent theories related to the stage of adul.docxrhetttrevannion
Discuss the two most prominent theories related to the stage of adulthood: Erikson’s Stage of Generativity vs. Stagnation and Levinson’s Season’s of a Man’s Life. Describe how theory conceptualizes middle adulthood and explain the growth of development changes that occur during this stage. Using Figure 16.7 as your reference, describe the impact of daily hassles and daily uplifts on the midlife stage of adulthood. In your post, please address the role of stress and personal control on life satisfaction and happiness during midlife development.
.
Discuss the two elements required for the consent defense. In ad.docxrhetttrevannion
Discuss the two elements required for the consent defense. In addition, please identify three situations where consent can operate as a legal defense.
The paper must be 1-2 pages.
Use proper APA formatting and citations, including ‘in-text’ citations.
Reference at least 2 outside credible resources.
DUE SUNDAY MORNING STAND PACIFIC TIME
.
Discuss the Truth in Lending Act and what role it places in financia.docxrhetttrevannion
Discuss the Truth in Lending Act and what role it places in financial and regulatory reports requirements in regards to funds acquisition strategies. What are various important terms which must be disclosed and their meaning?
Rose, P.S., & Marquis, M.H., chap. 4, 17, & 21
Due Date:
7/13/2014 11:59:59 PM (5 Days)
Total Pts:
125
Points Earned:
n/a
Deliverable Length:
600-800 words
Assignment Type:
Individual Project
.
Discuss the traits, behaviors, and leadership style you would expect.docxrhetttrevannion
Discuss the traits, behaviors, and leadership style you would expect to see in a person who identifies as a servant leader. In your response, include discussion about the following:
In what ways can servant leadership be considered a calling?
When people commit to being servant leaders, what does that mean about the types of behaviors they exhibit and prohibit personally and within the organizations they are leading?
How does servant leadership differ from traditional forms of leadership?
.
Discuss the three main forces that have been responsible for hospita.docxrhetttrevannion
Discuss the three main forces that have been responsible for hospital downsizing: changes in reimbursement, growth in managed care, and hospital closures. How has each of these forces been responsible for the decline in inpatient hospital utilization?
Make sure your paper is at least two pages in length, double spaced, font 12, Times New Roman.
.
Discuss the threats and vulnerabilities to Access Control and what b.docxrhetttrevannion
Discuss the threats and vulnerabilities to Access Control and what business must do to be protected.
Length, 2 – 3 pages.
All paper are written in APA formatting, include title and references pages (not counted). Must use at least two references and citations.
All paper are checked for plagiarism using SafeAssign, you can review your score.
.
Discuss theprinciple events of PROCESS AND THREAD used in both t.docxrhetttrevannion
Discuss the
principle events of PROCESS AND THREAD used in both the hosting OS and the OS management of the appropriate QUEUES. OS may only include Linux, Windows, Unix, ROS, RTOS, and Mainframe.
Initial Discussion - 300 words
2 Responses - each 250 words.
.
Discuss the Windows Registry System Hive1) What information.docxrhetttrevannion
Discuss the Windows Registry System Hive:
1) What information is retained in the hive?
2) Specifically, what security incident information could be extracted from the System Hive?
1) It should be a minimum of 400 Words not including references
2) APA Format and scholarly References needed
.
Discuss the way the idea of heroism develops from Gilgamesh th.docxrhetttrevannion
Discuss the way the idea of heroism develops from
Gilgamesh
through
The Iliad
/
The Odyssey
, and
The Aeneid.
Focus your discussion of heroism in each text around both the connection between heroic action and divine will and the relationship between the hero and his people. THREE PARAGRAPHS
Compare the role of vengeance in
Agamemnon
,
Medea
, and
Beowulf
. In what ways does the avenger stand for justice? In what ways does the avenger pose a threat to the continuance of society? What does each text lead you to conclude about the viability of revenge in a civilized society? THREE PARAGRAPHS
Compare the depiction of love in
The Aeneid
,
Sir Gawain and the Green Knight
, and the Wife of Bath's Prologue and Tale. What place does love have in society in each text? What problems does it pose? How, if at all, are those problems resolved? THREE PARAGRAPHS
1 PAGE
.
Discuss the ways in which the history of the U.S. was presented in t.docxrhetttrevannion
Discuss the ways in which the history of the U.S. was presented in the stock certificate for the 1876 Centennial International Exhibition in Philadelphia by F. O. C. Darley and S. J. Ferris. Compare it with the overall narrative of nationhood contained in the early 19th century relief sculptures above the doorways in the Capitol Rotunda in Washington, D. C. Be sure to comment on the ways in which these images would have been influenced by the locations in which they were viewed.
200-300 words, work sited
.
Discuss the value of Lean Systems Engineering to systems develop.docxrhetttrevannion
Discuss the value of Lean Systems Engineering to systems development (1 – 2 pages).
This assignment will be graded on two factors: 1.) the degree to which the response depicts clear and comprehensive understanding of the topic/material (80 points); and 2.) the degree to which the response is well thought through and clearly articulated (20 points).
.
discuss the various pathways interest groups use to influence politi.docxrhetttrevannion
discuss the various pathways interest groups use to influence politics and policy in the U.S. Discuss three way interest groups influence government. What are these methods, how do they work, and why are they effective at influencing government.
discuss the three components of political parties. Discuss party-in-the-electorate, party organization, and party-in-government. Briefly describe who makes up each component and what each component does.
.
Discuss the various tools and techniques used by an HCO to incre.docxrhetttrevannion
Discuss the various tools and techniques used by an HCO to increase logistical efficiency. Why would an organization need to measure the capacity (throughput) of the various resources (x-ray equipment, exam rooms, length of stay, etc.)? How does capacity utilization support decision making? PLEASE INCLUDE IN-TEXT CITATIONAND REFERENCE
.
Discuss the various means by which slaves resisted the slave system..docxrhetttrevannion
Discuss the various means by which slaves resisted the slave system. How widespread was such resistance? What were the most common and effective tactics? What does the prevalence of resistance reveal not only about slaves’ attitude toward slavery but also their ability to shape the conditions under which they lived and worked?
one page, doubled spaced, in Times New Roman font, with standard
1 inch margins on all sides
.
Discuss the typica l clinical presentation of the diagnosis , Hip Os.docxrhetttrevannion
Discuss the typica l clinical presentation of the diagnosis , Hip Osteoarthritis(OA), included possible therapeutic exercise treatment intervention, also recommendations for the management of the condition.
Introduction: First about OA and then write about Hip OA
Describe the pathophysiology of the diagnosis and the expected clinical presentation anticipated. If it varies, them describe common variations.
Discuss
etiology
and
demographics
related to the diagnosis(I.e., is this dx more common in men than women, what age, group ect)
Very important only use the articles provides, not citation work submitted via turnitin!!!!
.
Discuss the types of resources, tools, and methods that are availabl.docxrhetttrevannion
Discuss the types of resources, tools, and methods that are available to leaders for data collection and analysis, including organization assessments such as Baldrige, SWOT, and others. What techniques does your organization utilize to make decisions?
You can use US Navy for the organization.
.
Discuss the types of items that should be examined in a firewall log.docxrhetttrevannion
Discuss the types of items that should be examined in a firewall log:
a. IP addresses that are being rejected and dropped
b. Probes to ports that have no application services running on them
c. Source-routed packets
d. Suspicious outbound connections
e. Unsuccessful logins
.
Discuss the types of property, providing an example of each an.docxrhetttrevannion
Discuss the types of property, providing an example of each and why each falls into its classification.
Provide an instance of when you have seen eminent domain in action in your community. If you have not seen this situation, create an example of how this may occur.
.
Discuss the type of personality it takes to become a police officer..docxrhetttrevannion
Discuss the type of personality it takes to become a police officer. Why is this type of individual personality required for police work? What are the dangers to having this type of individual in police work?
Be sure to support your position with a very detailed explanation or a source citation.
.
Discuss the two major sources of crime statistics for the United Sta.docxrhetttrevannion
Discuss the two major sources of crime statistics for the United States. Uniform Crime Report (UCR), National Crime Victim Survey (NCVS), and the National Incident-Based Reporting System (NIBRS), including
but not limited to
: the Part I and II offenses, UCR terminology, how the UCR and NCVS collect crime data, types of information collected and not collected by the NCVS, accuracy issues with the UCR and NCVS, and the role and purpose of the NIBRS
.
Discuss the two most prominent theories related to the stage of adul.docxrhetttrevannion
Discuss the two most prominent theories related to the stage of adulthood: Erikson’s Stage of Generativity vs. Stagnation and Levinson’s Season’s of a Man’s Life. Describe how theory conceptualizes middle adulthood and explain the growth of development changes that occur during this stage. Using Figure 16.7 as your reference, describe the impact of daily hassles and daily uplifts on the midlife stage of adulthood. In your post, please address the role of stress and personal control on life satisfaction and happiness during midlife development.
.
Discuss the two elements required for the consent defense. In ad.docxrhetttrevannion
Discuss the two elements required for the consent defense. In addition, please identify three situations where consent can operate as a legal defense.
The paper must be 1-2 pages.
Use proper APA formatting and citations, including ‘in-text’ citations.
Reference at least 2 outside credible resources.
DUE SUNDAY MORNING STAND PACIFIC TIME
.
Discuss the Truth in Lending Act and what role it places in financia.docxrhetttrevannion
Discuss the Truth in Lending Act and what role it places in financial and regulatory reports requirements in regards to funds acquisition strategies. What are various important terms which must be disclosed and their meaning?
Rose, P.S., & Marquis, M.H., chap. 4, 17, & 21
Due Date:
7/13/2014 11:59:59 PM (5 Days)
Total Pts:
125
Points Earned:
n/a
Deliverable Length:
600-800 words
Assignment Type:
Individual Project
.
Discuss the traits, behaviors, and leadership style you would expect.docxrhetttrevannion
Discuss the traits, behaviors, and leadership style you would expect to see in a person who identifies as a servant leader. In your response, include discussion about the following:
In what ways can servant leadership be considered a calling?
When people commit to being servant leaders, what does that mean about the types of behaviors they exhibit and prohibit personally and within the organizations they are leading?
How does servant leadership differ from traditional forms of leadership?
.
Discuss the three main forces that have been responsible for hospita.docxrhetttrevannion
Discuss the three main forces that have been responsible for hospital downsizing: changes in reimbursement, growth in managed care, and hospital closures. How has each of these forces been responsible for the decline in inpatient hospital utilization?
Make sure your paper is at least two pages in length, double spaced, font 12, Times New Roman.
.
Discuss the threats and vulnerabilities to Access Control and what b.docxrhetttrevannion
Discuss the threats and vulnerabilities to Access Control and what business must do to be protected.
Length, 2 – 3 pages.
All paper are written in APA formatting, include title and references pages (not counted). Must use at least two references and citations.
All paper are checked for plagiarism using SafeAssign, you can review your score.
.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
2. Additional Public Health FiguresAppendix B
Spotlight on Public Health Figures:
Clara Barton (1821–1912)
Who is Clara Barton?
Clara Barton was born in Massachusetts in 1821.
She originally worked at the U.S. Patent Office and
became an independent nurse during the Civil
War. She is primarily known for collecting and
distributing supplies for the Union Army during
the Civil War. She was nicknamed “the angel of
the battlefield” because of her willingness to walk
onto the field to aid the soldiers.
What was the political climate at
the time?
Barton lived during the Civil War. Before the
Civil War, the nation had already philosophically
divided into the anti-slavery North and pro-
slavery South. There were significant political
battles between the two major political parties:
Whigs and Democrats. The Missouri Compromise,
which consisted of laws that allowed each state to
determine slavery issues, was passed in 1850. It
ended slavery in the northern states, but it wasn’t
until the passage of the 1854 Kansas–Nebraska
Act repealing the Missouri Compromise that
the slavery dispute blew up into a major war. The Kansas–
Nebraska Act also prompted the
founding of the anti-slavery political party now known as
Republicans.
What was her contribution to public health?
She was one of the earliest health educators in the public health
3. realm, focusing on nursing
and creating positive outcomes for population health. She was
also the founder of the
American Red Cross, one of the most famous quasi-
governmental agencies working to
improve the health of the nation.
What motivated her?
Barton was reportedly a very shy child, but she found her
calling when her brother David
was injured during a farming accident. At age 11, she became
David’s primary caretaker. For
2 years, she stayed home from school to care for her brother,
who did eventually recover. It
was during that time that she realized she felt a calling to care
for the sick and injured.
Sources: Biography.com. (2018a). Clara Barton biography.
Retrieved from https://www.biography.com/people/clara-barton-
9200960
Clara Barton Birthplace Museum. (2017). Clara’s family.
Retrieved from http://www.clarabartonbirthplace.org/claras-
life/claras
-family/
Ourdocuments.gov. (n.d.). Kansas–Nebraska Act (1854).
Retrieved from https://www.ourdocuments.gov/doc.php?f
lash=false&doc=28
University of North Carolina. (n.d.). Civil War era NC.
Retrieved from
https://cwnc.omeka.chass.ncsu.edu/exhibits/show/benjamin
-hedrick/polticalclimate
Photos.com/Photos.com/Thinkstock
Clara Barton founded the American
Red Cross based on her interactions
with the Swiss-inspired Red Cross
5. What was the political climate at
the time?
Italy did not become a state until the country’s
unification in 1861. Before this, the country
struggled for unity and political autonomy. The
Crimean War (1853–1856) was fought between
the French and Russian military over the rights of
Christian minorities in the Holy Land (currently
known as Israel). The French promoted the rights
of Roman Catholics, while Russia fought for the
Eastern Orthodox. Italy joined its European allies,
which led to Nightingale’s involvement.
What was her contribution to public health?
Like her American counterpart, Clara Barton, Nightingale was a
pioneer in the nursing field.
She had a significant impact on 19th- and 20th-century policies
about proper medical care.
She was a solid philanthropist, volunteering her time and skills
to the poor in her community.
She served as a nurse during the Crimean War, in which she saw
deplorable conditions in
military medical facilities. Based on this experience, she
proposed policy reforms for military
hospitals on sanitation in an 1858 publication called “Notes on
Matters Affecting the Health,
Efficiency and Hospital Administration of the British Army.”
What motivated her?
Nightingale, born to very wealthy parents, believed she had a
“divine” calling to help the
poor. Her parents were not pleased with her decision and
actually forbade her from pursuing
the education needed to become a nurse. At the time, taking a
job as a nurse was considered
by the upper class to be menial labor. She ignored the
7. Additional Public Health FiguresAppendix B
Spotlight on Public Health Figures:
Thomas Francis Jr. (1900–1969)
Who is Thomas Francis Jr.?
Thomas Francis Jr. was an American physician
and epidemiologist who grew up in New
Castle, Pennsylvania, and earned his medical
degree from Yale University in 1905. He
initially focused on vaccinations for bacterial
pneumonia but eventually became the first
person to isolate the influenza virus. He also
proved there were various strains of influenza
and participated in the successful development
of influenza vaccinations. One of his students
was the famous Jonas Salk, who ultimately
developed the polio vaccine.
What was the political climate at
the time?
Francis lived and worked during a time of war.
World War II (1939–1945) escalated the issue
of disease prevention and treatment. Historically, disease had
killed more soldiers than
battle scars had, so controlling influenza was a priority going
into World War II. There was
a fear of another pandemic like the influenza outbreak of 1918,
so the U.S. Army organized
a commission to develop a vaccine against influenza. This
support from the military and
federal government allowed a commission, led by Francis, to
develop and obtain Food and
Drug Administration approval for a vaccine in less than two
years. Frankly, for Francis, there
11. resale or redistribution.
320
Additional Public Health FiguresAppendix B
Spotlight on Public Health Figures:
Camille Guérin (1872–1961)
Who is Camille Guérin?
Born in France, Guérin studied veterinary
medicine but eventually devoted his career to
finding a cure for tuberculosis. His father died
of the disease in 1882, and his wife succumbed
to it in 1918. In 1905, he discovered that the
bovine tuberculosis bacillus could immunize
animals against tuberculosis without giving
them the disease. After that success, he and
Calmette worked toward a human version of
the inoculation.
What was the political climate at
the time?
Research in bacteria was just beginning, and
people still did not understand the mechanisms
of disease transmission. The focus was on
developing safe vaccines and treatments.
What was his contribution to
public health?
His contribution, along with that of his
colleague, Calmette, was the successful
development of a vaccine to prevent
tuberculosis. Despite several setbacks, the
13. Who is Ignaz Semmelweis?
Semmelweis was born in Hungary in 1818. The
child of a well-off tradesman, Ignaz attended law
school at the University of Vienna. After a year,
he switched to medicine for reasons that are not
known, and he earned a doctorate in 1844. He
specialized in obstetrics.
What was the political climate at
the time?
When Semmelweis worked as a physician, little was
known about the benefits of handwashing—even in
the medical community. At the obstetrics hospital
where he worked as an assistant, Semmelweis
claimed there was one cause of puerperal fever, a
bacterial infection of the female reproductive tract
following childbirth or miscarriage. He believed
that if medical workers washed their hands in a
chlorine and lime solution, it would significantly
reduce, if not eliminate, infections. He even called
his colleagues “irresponsible murderers” for not
washing their hands before treating patients.
The members of the Medical Society of Vienna at
the time not only did not believe his theory but
harassed him over it and suggested that he was
losing his mind. He was eventually committed to an
asylum, where he died 14 days later.
What was his contribution to public health?
He hypothesized that cleanliness could ward off disease. He was
credited for introducing the
idea of handwashing with chlorinated lime solutions to prevent
diseases. While working as
an assistant in the Vienna General Hospital in Austria, he
introduced the concept of washing
hands to reduce childbed fever. His suggested handwashing
14. practice was never accepted
during his lifetime. It wasn’t until Louis Pasteur developed the
germ theory of disease that
the medical community finally understood the theoretical basis
for Semmelweis’s claims.
What motivated him?
There is no solid record of what motivated Semmelweis’s
actions. He originally attended law
school and then transferred to medical school, and there is no
record of why he decided to
focus on medicine and obstetrics. However, some speculate that
he cared deeply about the
lives of those he treated and actually became fixated on the
issue, which perhaps led to his
admission to an asylum and eventual death. He was right that
handwashing is a solid means
of preventing the spread of diseases.
Sources: Clark, L. (2015, January 15). The doctor who
introduced the virtues of hand washing died of an infection.
Smithsonian.com. Retrieved
from https://www.smithsonianmag.com/smart-news/doctor-who-
introduced-virtues-hand-washing-died-infection-180953901/
Semmelweis Society International. (2009). Dr. Semmelweis’
biography. Retrieved from http://semmelweis.org/about/dr-
semmelweis-biography/
Photos.com/Photos.com/Thinkstock
Ignaz Semmelweis believed that
handwashing with chlorinated
lime solutions would help prevent
the spread of disease during
medical procedures. His colleagues,
however, did not agree with his
cleanliness theory.
16. A special section is devoted to health care funding in the United
States and includes an out-
line of the Affordable Care Act. How these systems of funding
function and how public health
supports these efforts also is explored. Lastly, Appendix A
details the responsibilities and
accountability of the U.S. public health system, especially those
of the seven specific agencies
that function as part of the health care realm and public health.
A.1 Linking Public Health to the U.S. Health Care System
The link between the U.S. health care system and the public
health realm can be understood
by examining how the system first started.
A Tradition of Giving
The U.S. method of caring for the sick, poor, aged, and
mentally ill historically was grounded in
churches and religious orders and was later expanded on by
charitable organizations such as
the Catholic sisters’ work during war times and epidemics
(Stepsis & Liptak, 1989). The con-
cept that people need to take care of people became rooted in a
system of giving, and it was
through this system that social services assistance such as
Medicare and Medicaid developed.
Indeed, federal and state laws were born from the idea that
health is a partnership between
those who can provide services and those who need them. After
the passage of An Act for the
Relief of Sick and Disabled Seamen in 1798, the nation began to
view health care as a right
and a necessary part of human existence. It became part of the
public realm and thus forged
the link between health care and public health. Table A.1 shows
18. 1890 Public Health Service Commissioned Corps legislation
1902 Marine Hospital Service renamed, becomes Public Health
and Marine Hospital Service
1906 Pure Food and Drugs Act passed (eventually became part
of the FDA)
1912 Public Health and Marine Hospital Service shortened to
Public Health Service
1921 Bureau of Indian Affairs Health Division created
(forerunner of the Indian Health Service)
1929 Baylor University began to offer a “sickness” insurance
plan for teachers that would
become the model for Blue Cross plans
The Great Depression began; few people covered by health
insurance
1932 Blue Cross established
1935 President Roosevelt signed into law the landmark Social
Security Act of 1935, a major
turning point in American history; initiated a system of elderly
benefits for workers,
workers’ benefits resulting from industrial accidents,
unemployment insurance, aid for
dependent mothers and children, and benefits for the blind and
the disabled supported
by taxes on individual and employer payrolls
1939 The Federal Security Agency created, merging fields of
health, education, and social
insurance
20. Section A.1 Linking Public Health to the U.S. Health Care
System
Forces Shaping the Current System
World wars, the Great Depression, economic issues, social and
health policy, and the gradual
acceptance of the concept of “sickness” and health insurance
further shaped the nature of
the U.S. health care system. These transitional factors
eventually pushed the responsibility of
health care from the individual to the employer, diminishing the
role of individual responsi-
bility and lifestyle choices. See A Closer Look for more details
on the beginnings of employer-
based health insurance.
Year Event/landmark
1965 Medicare and Medicaid passed; federal government
became the largest single purchaser
of health care
1970 National Health Service Corps created
1973 Health Maintenance Organizations (HMO) Act addressed
rising health care costs
1979 Department of Education Organization Act removed the
education duties from the HEW
1980 HEW became the Department of Health and Human
Services
1983 Prospective payment system (PPS) legislation assigned
diagnostic-related groups (DRGs)
for hospital payment, directed to control inflationary hospital
21. costs
1988 McKinney Act passed to provide health care to the
homeless
1992 Resource-Based Relative Value Scale (RBRVS) created a
relative value affecting
reimbursement for physicians in family practice, internal
medicine, and obstetrics and
lower fees for surgeons and radiologists; resulted in a shortage
of physicians in some
areas of medical practice
1995 Social Security Administration became an independent
agency
1996 Welfare reform passed under the Personal Responsibility
and Work Opportunity
Reconciliation Act
Health Insurance Portability and Accountability Act passed
1997 State Children’s Health Insurance Program (SCHIP)
created
2002 Landmark study by the Institute of Medicine: The Future
of the Public’s Health in the
Twenty-First Century
Office of Public Health Emergency Preparedness created
2003 Medicare Prescription Drug Improvement and
Modernization Act enacted, the most
significant expansion of Medicare with a prescription drug
benefit
2010 Affordable Care Act passed
23. of government into the practices of businesses, which was
against the democratic system
developed in the United States (Roberts, 2009). The progressive
movement in the early
20th century, a period of widespread activism and political
reform, sought to make health
insurance a national priority, arguing that it would “stabilize the
income of workers, relieving
poverty caused by sickness, and healthier workers would be
more efficient” (Roberts, 2009,
p. 8). However, the demands of World War I halted the push to
create compulsory health
insurance.
During the industrial and technological growth of the 1920s,
newly available diagnostic
tools and treatments were expensive, and they increased the
costs of health care to the
point where most people simply could not afford it. Because of
this, the notion of national
health insurance again became a focal point. Most people in the
medical community did not
want government interference into their work and considered
the possibility radical. In fact,
President Franklin D. Roosevelt had originally planned to
include voluntary health insurance
in his New Deal reforms, but the concept was removed due to
negative reactions from the
medical community.
During the Great Depression, Baylor Hospital in Dallas, Texas,
was facing the dilemma of
choosing between empty beds or patients who could not pay
their bills. To combat this, the
hospital developed a plan where schoolteachers could pay 50
cents per month to the hospital
25. resale or redistribution.
https://www.ache.org/pubs/Morrisey2253_Chapter_1.pdf
293
Section A.1 Linking Public Health to the U.S. Health Care
System
As the industrial revolution struck the United States, so did the
need for health care. But for-
malized health care could not keep up with the growing demand
for health care services, so
the American health system implemented quick and temporary
solutions often called “stop-
gap measures.” Unfortunately, these multiple stopgap measures
resulted in a complex, redun-
dant, and fragmented health care system. Broad forces shaping
the evolving system included
• economic incentives fueled by government-enacted programs;
• political expediency;
• compromises on a Cadillac tax (a 40% excise tax on employer
plans that exceed
$10,200 per year for individuals and $27,500 for families) in
exchange for conces-
sions to limit its scope;
• development of diagnostic tools and technology-driven
interventions;
• escalation of increasing efficacy of pharmaceutical
interventions;
• increases in hospital beds and medical manpower linked with
the further enhance-
26. ment of the need to be able to pay for these services; and
• multiple funding sources from governmental entitlements,
grants, and categorical
programs for similar or the same services.
The appetite of the American consumer for health care services
in conjunction with limited
consumer economic consequences meant that as more people
used health care, the more
expensive it became. Most Americans didn’t realize that the
cost of these consumer-driven
consumption patterns would trigger major economic issues in
the future (National Acade-
mies of Sciences, Engineering, and Medicine, 2017a).
Public Health and Health Care
Working Together
The realization that public health services and the
U.S. health care system are inextricably linked is
an unfolding perspective. By examining the overall
health status in the United States and the perfor-
mance of these two interlocking systems, it is clear
that U.S. spending for health care services is high
and will likely continue to rise (Darzi et al., 2012).
The Public Health Service is responsible for guid-
ing health care in the United States. According to
the Institute of Medicine (IOM), which conducts
an ongoing analysis of public health services and
the U.S. health care system, the first critical step
to a fully functional system is to set a national target for the
health system performance on
two key measures: longevity and per capita health, which is the
28. millions of dollars into treatment
and illness, the national focus should be on wellness and
prevention (National Committee on
Public Health Strategies, 2012).
While it may seem obvious that the national health care system
should be linked to pub-
lic health, there are other models that are structured differently.
The next section outlines
the different health care models and describes the elements that
pertain to the existing U.S.
model.
A.2 Health Care Systems
The successful provision of health care services requires strong
collaboration among pro-
viders, services, institutions, and resources in a goal-focused
model. Three basic models
for health care systems have evolved based upon the funding
mechanism of private, public,
blended, and limitation of services. All of the models have
coverage for those with limited
resources, but access to this support has many barriers,
including limitations as to what can
be covered. None of the publicly nationalized health system
models, other than that of the
private–public United States model, offers the scientific,
medical diagnostics, and interven-
tion technology developed by the private sector component of
the U.S. health care system.
Table A.2 compares the three major health system models,
representative countries, funding,
and providers.
Table A.2: Basic health system models
30. Health care is an economic function providing health care
services. The model for the U.S.
health care system is market driven. It is a complex system with
multiple funding resources
and navigation issues. The major stakeholders in the U.S. health
care system model include
consumers (insured and uninsured), providers, employers,
government agencies, insurance
companies, managed care organizations, manufacturers of
pharmaceuticals, medical suppli-
ers, and professional organizations—essentially the consumers
and suppliers of direct and
indirect patient/client services.
National Insurance Model
The U.S. health care system primarily aligns with the national
insurance model. Taiwan’s
health care system is also based on the national insurance
model. However, the U.S. system
is quite different, as it is a blend of the fragmented public–
private partnership model. In fact,
the current health care system in the United States is made up of
small elements from vari-
ous national health care systems fused into a larger system. This
blending of private–public
resources results in a health care system with a unique structure
and funding mechanisms.
Further complicating this organizational structure is the
movement of individuals into and
out of both the private model and the public model. The public
model is considered categori-
cal health care for the poor, elderly, disabled, and mentally ill.
But individuals can fall between
the two systems and fail to receive services.
The number of Americans under 65 years of age covered by
31. employer-sponsored health
insurance declined slightly from 58.6% in 2010 to 58.3% in
2011; this is attributable to the
impact of unemployment during the most recent recession
(Gould, 2012). Individuals with-
out employer-sponsored insurance can purchase insurance from
a private insurance com-
pany, pay out of pocket, or access public funds. These public
funds are usually distributed
categorically by age and other criteria. This type of additional
insurance purchase is known
as a “safety net” system. All Americans can access the public
sector for health services as long
as they meet the service’s qualifying guidelines. The public
component provides health care
services for the vulnerable populations of the elderly, the
disabled, the poor, and children
through programs such as Medicare, Medicaid, Title V Maternal
and Child Health Services,
the Children’s Health Insurance Program (CHIP), State Health
Insurance Programs (SHIPs),
school health programs, supplemental food programs for
children and the elderly, public
health immunization and health services, federally qualified
health care providers, and Indian
Health Services (U.S. Department of Health and Human
Services, 2017).
The U.S. health care system attempts to link services between
providers such as hospitals
to skilled long-term care facilities, residential services,
rehabilitation, in-home services, and
mental health facilities. Within the larger hospitals and
facilities, there may be specialized
services targeting specific patient care needs such as mental
health care, intensive care, pedi-
33. vices and social assistance organizations, driven initially by
insurance companies and public
entities. Social Services, in collaboration with physicians,
provide a gatekeeping function for
publicly funded programs and insurance companies. Case
management is a system of man-
aging integrated health and human services for a defined group
of patients or clients. The
patients or clients may be high risk for hospitalization or
special care needs, or they may be
clients with various publicly funded community-home waivers
for Medicaid and long-term
care, mental health, and rehabilitation services. Case
management services are organized to
support the patient or client with wraparound services,
community-based interventions that
provide a multitude of needs for children and their families that
typically involve some level
of mental health needs, and to enhance independence. Some
insurance plans/providers have
case management services and health maintenance organizations
to manage access and costs.
State public health agencies have oversight responsibility for
safe practices of health care
service using a system of licensure/credentialing requirements,
inspections, and specific
monitoring for health care and human service providers and
institutions. While licensed
practitioners have state and professional organizations
overseeing the practice guidelines
and standards, the state department of public health or one of its
branches is generally the
licensing body.
Health Care Workforce
34. The United States Labor Occupational Handbook identifies 41
categories of health care work-
ers (U.S. Bureau of Labor Statistics, 2018b). The health care
workforce is diverse, drawn from
fields such as the life sciences, social science, and information
technology (financial, eco-
nomic, and educational areas). Professional schools provide the
skills and knowledge needed
to fulfill these roles. According to the Bureau of Labor
Statistics (2018a), there will be 2.4
million new health care jobs by 2026, a projected expansion rate
of 18%.
• Physicians provide diagnostic and treatment interventions as
well as a first point
of contact into the health care system for patients. From
selected national stud-
ies concerning physician resources, Young, Chaudhry, Rhyne,
and Dugan (2010)
reported that there were 850,085 physicians in 2010 with an
active license to prac-
tice medicine in the United States. By studying the complexity
of physician supply
and demand and referencing multiple government and
professional organizations’
research studies, Dill and Salsberg (2008) projected that by the
year 2025, there
may be a physician shortage as high as 130,000 physicians.
• Registered nurses (RNs) make up the bulk of the health care
occupation workforce.
RNs provide and coordinate patient care, educate patients and
the public, and pro-
vide case management and emotional support to patients and
their family members.
Practicing requires an associate, bachelor’s, and/or master’s
36. therapist may also supervise a physical therapy technician or
assistant. Academic
preparation is advancing from the master’s degree to doctorial
preparation. Physical
therapists are licensed.
• Occupational therapists treat patients with injuries, illnesses,
and/or disabilities
facilitating the resumption of activities of daily living.
Occupational therapists
supervise occupational technicians and occupational assistants;
entry into the field
requires a master’s degree licensure.
• Medical and clinical laboratory technologists and technicians
vary in occupational
preparation based upon future practice area. Academic
preparation also varies
and may include certification and associate’s, bachelor’s, and/or
graduate degrees.
Licensure and/or certification consistent with legislated practice
standards is
required in each state.
• Health care managerial/administration occupations are another
health care job
area projected to expand. As Americans are experiencing an
increased incidence of
chronic conditions combined with lon-
ger lives, the demand for health care will
require additional workers to provide
health care services and access into the
system for recipients of categorical pro-
grams such as Medicaid and other sources
of welfare funding. Integration of these
health and social services will be increas-
38. Other health care personnel positions expected to experience
increases include the following
ancillary personnel (U.S. Bureau of Labor Statistics, 2018a):
• emergency medical technicians
• paramedics
• medical sonographers
• medical records personnel
• medical transcriptionists
• health information technologists
• nursing assistants and medical assistants
Health Institutions and Agencies
There are many institutional health care organizations. They
include inpatient care facilities
such as hospitals, long-term care facilities such as nursing
homes and assisted living, and out-
patient clinics. Classification is based upon function and type,
such as government (federal,
state, community, city, military), specialty service focused,
community organizations, and fis-
cal profiles. In this section, health care institutions are profiled
and categorized as inpatient,
outpatient, or community providers.
• Inpatient health care facilities employ the largest number of
health care providers.
The CDC discovered that in 2014 (the most recent data
available), hospitals were
about 63% full with an average length of stay being 5.5 days
(CDC, 2016d). Any facil-
ity allowing for overnight stays is considered an inpatient
facility; however, most
hospitals allow for a stay of no more than 25 nights
(Medicare.gov, 2017).
40. 299
Section A.2 Health Care Systems
The U.S. health care system is financed through a complex
private–public system. Health care
consumes a large part of the gross domestic product (GDP) and
is growing faster than the
national income—which is a source of significant concern. The
GDP is a measurement of the
economic health of a nation. It consists of the monetary value of
all goods and services pro-
duced within a nation (Investopedia, 2018). Both the private and
the public sectors are reel-
ing under the increased costs of funding employee health
benefits and retirement health ben-
efits. States concerned with the increasing costs of Medicaid
and other federal programs are
changing guidelines to limit coverage. The private sector has
sought to control bottom-line
costs by limiting dependent coverage and by implementing
larger copays and deductibles.
Thus, both the public and private sectors are passing along the
growing costs of health care
to the beneficiaries.
The Debate Over Health Care Financing
Several major viewpoints drive the health care financing debate,
such as the role of per-
sonal responsibility for health, social justice, utilitarian
concepts, and economic and political
theories.
• Philosophical: From a social justice perspective, the question
41. is basic: Is health care
a right or a privilege? Is it the responsibility of citizens to pay
for the health services
of others, even though they can afford to purchase health
insurance, and even for
individuals maintaining unhealthy lifestyle choices?
• Economic: Does health care enhance a utilitarian function
such as “healthy” status,
in which an individual is able to work and purchase economic
goods? Or is it an
economic incentive? This viewpoint can be observed in the
historical economies in
which merchant seamen were provided with health services to
ensure the transport
of trade goods.
• Political: More recently, the view has turned political, where
funding can be a means
of gaining favor with selected population groups or causes.
Table A.3: Major funding sources for health care services
Capitation A system whereby the funder reimburses the provider
based upon a set cost for a population. Capitation is used
in some grant-funded programs, in experimental projects
such as Medicaid, in health care management organizations,
and in grant funding with a designated population/sample.
Capitation minimizes risk to the funder.
Managed care A program/service providing coordination,
utilization, and
cost containment for a group of designated clients or patients
Health care management organization An organization that
manages a system of integrated health
43. approach.
In the market-based approach, private entities fund health care,
and the government may
cover designated vulnerable populations. In the market-based
model, consumer demands
fuel the second driver of increased health care costs, which is
the health care industry itself.
Innovative technologies, treatments, and pharmaceuticals
supporting interventions that
were not possible in previous times (such as heart transplants or
knee replacement surgery)
also feed this cycle.
Private enterprises have implemented various cost management
strategies, including man-
aged care, provider networks, and health care management
services. These actions tend to
decrease how often people use higher-cost services such as
emergency department visits
and hospitalization. Private financing insurance funding
generally includes some deductibles,
copays, and waiting periods to reduce costs to the insurance
agency and to discourage unnec-
essary use. Some individuals elect to pay out of pocket for
health care services, and that puts
them at risk for exorbitant health care expenses.
In the government-driven approach, or the public system
approach, the government finances
health care expenses through funds allocated by taxes.
Examples of this are Medicaid,
Medicare, military health care (Veterans Administration), and
specific funding for targeted
populations.
45. out-of-pocket expenses, clini-
cal services, and physician services. Hospital usage was also
projected to increase over the
next decade, but at a much slower rate than other services.
Dimensions of the U.S. Public Health System
The National Academies of Sciences, Engineering, and
Medicine (NASEM) (2017a) reported
that if the United States is to achieve a higher level of quality
of prevention and treatment ser-
vices, then the fundamental concepts that have molded the
system will need to be assessed,
evaluated, and developed into reliable affordable health care
services. Citing administrative
waste, inadequate funding for public health, and failure to
utilize public health in reforming
U.S. health care, NASEM (2017b) sent a strong message to the
secretary of the Department of
Health and Human Services recognizing the enormity of the
lack of emphasis on prevention
and declaring that the system needed to be fundamentally
assessed and reevaluated.
While health care costs will continue to expand, so will the role
of the public health system
within the realm of health services. The current public health
model was shaped through
the integrated patterns of population growth, global economics,
wars, depressions, and sci-
entific technology-fueled revolutionary growth in medical
science, disease prevention, and
intervention.
Continued growth in scientific knowledge about health and
disease and the importance
of health resulted in the merging of the U.S. Department of
47. tion of policy and program activities is found at both the local
and state levels.
State health departments’ activities are administrated by a
public health official along with
a medical officer. The same structure is applied to smaller
populations at the local, county,
or city public health organizations, generally termed boards of
health. Duties of the state
and local boards of health include implementing public health
programs, monitoring and
assessing health status, and coordinating fiduciary concerns,
including funding allocations.
The state and local boards funnel federal funds into state and
local health programs. These
programs include Title V Maternal and Child Health Services
and administrative needs for
implementing the Department of Agriculture’s Women, Infants,
and Children (WIC) program.
Also, size and characteristics of a population determine the
extent of public health activities.
Figure A.1: The 10 regional health offices
Each regional office is responsible for assessment, policy
development, and assurance for the states
within its region.
Source: Adapted from “Regional Offices,” by U.S. Department
of Health and Human Services, 2014
(https://www.hhs.gov/about/agencies
/iea/regional-offices/index.html).
PR
Boston
50. ognize the connection to the community. Community health is
part of the public health sys-
tem when it comes to assessing, evaluating, and implementing
activities that improve the
health of a target population. It could be considered the smaller
segment of public health in
a specific community. As one example, public health would
emphasize population well-being
within the state of Nebraska, while community health efforts
would focus on the population
of Omaha—one community within the state. To break that down
further, the city of Omaha
could be segmented by municipalities, each one having its own
community health focus.
Regardless of the size of the community, community health
services monitor the health status/
characteristics of the people residing within specified
geographical areas. Community health
professionals perform their functions best—to assess, evaluate,
and implement actions to
improve the health of a specific population—in an environment
fostering collaboration. They
work with local agencies, professional organizations, and
nongovernment organizations to
implement and monitor the Healthy People 2020 goals and
action plans (CDC, n.d.-c). The
Healthy People initiative just began its third decade of
providing goals and objectives focused
on improving the nation’s health. It is a collaborative effort
among the United States Depart-
ment of Health and Human Services, the Centers for Disease
Control and Prevention, and the
National Center for Health Statistics (CDC, n.d.-c). Within the
publication, the leading health
indicators are stipulated under 42 focus areas and 1,200
52. Attempting to address cost, quality, and access concerns in the
U.S. health care system, and
taking inspiration from the successes of health care plans of
other countries, the United States
passed the Affordable Care Act of 2010. Also known as the
Patient Protection and Afford-
able Care Act, it combined the concepts of cost,
quality, and access to health care for the Ameri-
can people. This landmark legislation focused on
providing health coverage for every citizen in the
United States. It is not national health care—which
provides free health care—but it is a step toward
a national health care plan. This particular act
brought in two very different perspectives that
were not originally part of health insurance pro-
grams in the past: Prevention services were now
fully covered, and every individual was mandated
to purchase some type of health insurance.
Under the Affordable Care Act, new guidelines
for access to care, financial resources, and access
to health care insurance were enhanced. Limits
on cost sharing for covered benefits and new rules for private
health insurance, health care
exchanges, a decrease in reimbursement for health care
providers, rationing, and review
panels were some of the primary factors initiating the prominent
Congressional discussions.
These discussions included additional issues such as the extent
to which the legislation would
reduce the cost for low-income consumers, addressing the
shortage of critical health provid-
ers and reducing reimbursement of providers and the total cost
of the legislation (Kaiser
Family Foundation, 2012). A major argument in favor of the
health care act was the access to
53. preventive care with no additional costs.
The Affordable Care Act was passed with limited vetting by the
legislators. The fiscal and eco-
nomic case for the pending legislative agenda was based on the
assumption that the continu-
ing fiscal shortfall in the U.S. economy was due to excessive
health care cost inflation—and
that comprehensive health care reform would fix the fiscal
issue. This continues to be a major
subject of debate.
Prior to the ACA’s passage, critics suggested that the law would
eventually betray the nation’s
commitment to care for its vulnerable populations, meaning
these individuals would not be
able to receive the same standards of care as other consumers
(Aaron, 2009).
The Affordable Care Act is a complex piece of legislation. The
passage of this act has differing
pros and cons, depending on the evaluator. The law has three
main goals:
1. Make affordable health insurance available to more people
2. Expand the Medicaid program to cover all adults with income
levels below 138% of
the federal poverty level
3. Support innovative medical care delivery methods designed
to lower all health care
costs (Healthcare.gov, n.d.-a)
monkeybusinessimages/iStock/Thinkstock
Prevention services, such as annual
55. 32nd president of the United States, serving the
country during one of the most difficult periods
in American history. His passion for reform
and improvements won over the hearts of the
nation. He was diagnosed with polio, for which
there was no cure or vaccine. He died in 1945 of
a cerebral hemorrhage, just before World War
II ended.
What was the political climate at the time?
Roosevelt’s tenure in office occurred during what many
historians consider one of the
most difficult periods in American history. Roosevelt served as
president during the Great
Depression, built a new nation through his New Deal program,
and saw the nation through
World War II. His leadership, including his reforms and public
programs, helped shape the
nation into a stronger world power.
What was his contribution to public health?
While the New Deal was a significant contribution to the
nation’s overall well-being,
Roosevelt’s main contribution to public health was the
development of a national health care
plan. Roosevelt proposed within the Social Security Bill of
1935 his first draft of a national
health insurance plan. Due to significant opposition, especially
from the American Medical
Association, the health insurance plan was left out of the bill.
The second and last attempt
at national health care in the United States occurred only 4
years later. The Wagner Bill
included the National Health Act of 1939. Sen. Robert Wagner
introduced the bill, which
granted states the right to establish compulsory health
57. through a private insurer. Purchasing additional health care is a
benefit provided through the
purchase agreement or through an employer if the individual is
still working. There are also
programs funded directly through public health and other
government agencies.
Medicare
A federal health insurance program for people age 65 and older,
Medicare has been in exis-
tence since 1965. It also provides health insurance for some
younger people with disabilities
and those with permanent kidney failure. It contains four parts:
A, B, C, and D.
Spotlight on Public Health Figures:
Franklin D. Roosevelt (1882–1945) (continued)
support of such legislation, which would have been funded by
federal grants given to
the states for the establishment of health insurance programs.
Strong opposition from
the American Medical Association again forced the bill to die in
committee. Although
Roosevelt’s efforts seemed to die with him, President Barack
Obama’s administration passed
the Affordable Care Act in 2010—an act that gave the nation
exactly what Roosevelt had
envisioned in 1935.
What motivated him?
Roosevelt was a peacemaker who believed that nations should
be able to cohabitate without
fighting. He devoted a significant amount of his time to
planning the United Nations, a
coalition that he thought would help build international
59. http://www.pnhp.org/facts/a-brief-history-universal-health-care-
efforts-in-the-us
http://www.pnhp.org/facts/a-brief-history-universal-health-care-
efforts-in-the-us
http://76478895.weebly.com/wagner-bills.html
307
Section A.3 Funding the U.S. Health System
• Medicare Part A covers hospitalizations, nursing home care,
hospice, and some
home health care services.
• Medicare Part B is the medical insurance section, which
covers prevention services,
screenings, doctor visits, and medical supplies such as insulin
for diabetes.
• Medicare Part C is an advantage plan, which consists of
Medicare parts A and B
together under one policy. This plan is mainly offered through
private companies
under Medicare contracts and may include health maintenance
organizations
(HMOs), preferred provider organizations (PPOs), private fee-
for-service plans,
special needs plans, and savings account plans. In addition,
most Part C plans cover
prescriptions.
• Medicare Part D is more commonly referred to as the
Prescription Drug Plan. It cov-
ers medications that might be prescribed by physicians,
hospitals, or other health
60. care providers (Centers for Medicare and Medicaid Services,
n.d.).
Medicaid
Medicaid is a state-run operation that provides health care
coverage for low-income people
of any age. Eligibility varies from state to state, but most offer
coverage for a base income
rate near the poverty level. Beginning in 2014, all people under
age 65 with incomes up to
$15,000 per year became eligible for Medicaid. Those age 65
and over qualify for Medicare
(Healthcare.gov, n.d.-b).
Title V
Title V is a portion of the Maternal and Child Health (MCH)
Services Block Grant, which pro-
vides services for mothers and their children. Title V was
created in 1935 as part of the Social
Security Act and provides programs for mothers, infants, and
children, including those with
congenital disabilities. Today, Title V is the only federal
program that focuses solely on the
health of mothers and children. It makes a special effort to help
communities deliver various
services such as care coordination, transportation, home visits,
and nutrition counseling. It
provides prenatal services for more than 2 million women and
primary prevention services
to more than 17 million children, 1 million of whom have
special needs. Title V receives nearly
85% of the MCH funding, which is allocated to the states. From
there, the states distribute the
funds to the various local and county programs (Health
Resource and Services Administra-
tion, n.d.).
62. CHIP
All 50 states operate a Children’s Health Insurance Program
(CHIP), which is a public offer-
ing of free or low-cost health insurance for those under age 18
(Healthcare.gov, n.d.-c). This
coverage pays for pediatrician visits, medications,
hospitalizations, and other needed health
care. The program is similar to Medicaid but is jointly funded
by both federal and state gov-
ernments. In 2009, Congress passed the Children’s Health
Insurance Program Reauthoriza-
tion Act (CHIPRA), which provided additional funds for CHIP,
some of which were to be used
for a new program to reach eligible children who were not
enrolled.
A.4 Responsibility and Accountability of the U.S. Public
Health System
The United States Public Health Service is a large department
of the United States Department
of Health and Human Services. It has far-reaching
responsibilities. This vast array of respon-
sibilities and accountabilities is communicated downward
through the state and county or
city levels of public health. These functional entities include
approximately 3,000 county and
city health departments and local boards of health; 59 state,
territorial, and island nation
health departments; more than 160,000 public and private
laboratories, hospitals, and other
private-sector health care providers; and volunteer
organizations such as the American Red
Cross and American Diabetes Association (Lister, 2005).
64. Seven primary agencies deliver public health services. Given
this broad array of responsibil-
ity, the United States Department of Public Health’s overall
charge was set forth in a landmark
study by the Institute of Medicine (1988), which named the core
functions of the national
public health service: assessment, policy development, and
service assurance. These three
core functions have been used to organize and adapt the
department to meet the challenges
of emerging threats and environmental hazards, allocation of
resources, and service provi-
sion to meet the population’s needs. Table A.4 outlines the
responsibilities and accountabili-
ties of these seven agencies. More details on each agency can be
found in Chapter 1.
Table A.4: U.S. public health system organizational chart
Agency Primary services Extended services
National Institutes
of Health (NIH)
Medical research Includes 27 separate health institutes
and centers
Food and Drug
Administration
(FDA)
Ensures safety of food and
cosmetics and safety and efficacy of
pharmaceuticals, biological products,
and medical devices
65. Products represent 24 cents out of
every U.S. consumer dollar spent
Centers for Disease
Control and
Prevention (CDC)
Health surveillance; monitors and
prevents disease outbreaks; implements
disease prevention strategies and
maintains national health statistics;
immunization services, workplace
safety and environmental disease
prevention; includes the Agency for
Toxic Substances and Disease Registry
Maintains personnel in more than 25
foreign countries, guarding against
international disease transmission;
prevents exposure to hazardous
substances from waste sites on the
EPA’s national priorities list
Indian Health
Service (IHS)
Works to provide health services 46 hospitals, 324 health
centers, 309
health stations, and 34 urban Indian
health programs
Health Resources
and Services
Administration
(HRSA)
66. Provides access to essential health care
services for low-income people, the
uninsured, or those who live in rural
areas or urban areas where health care
is scarce; maintains the National Health
Service Corps
Provided medical care to nearly 17
million patients and more than 4,000
sites nationwide in fiscal year 2009;
helps to build the health care workforce,
administers programs to improve the
health of mothers and children (Title V,
WIC Program), serves people living with
HIV/AIDS through the Ryan White CARE
Act, and oversees the nation’s organ
transplantation system
Substance Abuse
and Mental
Health Services
Administration
(SAMHSA)
Ensures quality and availability of
education, prevention, and treatment
for addiction services and mental health
services
Monitors prevalence and incidence of
substance abuse and provides funding
through block grants to states to
support substance abuse and mental
health services
Agency for Health
68. Government Ethics, n.d.).
According to the Office of Government Ethics (n.d.), the OGE
is responsible for six key elements:
1. Maintaining enforceable standards of ethical conduct
2. Overseeing a financial disclosure system
3. Ensuring that executive branch ethics programs are in
compliance with laws and
regulations
4. Providing education and training to the more than 5,700
ethics officials, as well as
executive branch employees
5. Conducting outreach to the general public
6. Sharing good practices with, and providing technical
assistance to, state, local, and
foreign governments and international organizations
The OGE has no jurisdiction within state or local governments,
nor does it conduct investiga-
tions of individuals. It is meant solely for the executive branch
of government.
Ethics are applied and enforced through the laws that have had
an impact on the nation’s
health. Table A.5 is a brief synopsis of health care laws that
have undergone significant ethical
considerations prior to approval.
Table A.5: Laws with strong ties to ethical concerns
Law/act Explanation
General public policies These are principles that state laws
69. should not be made to injure the
public or go against the public good.
Sherman Trust Act of 1890 Conspiracy to restrain trade among
certain states is illegal, including such
health issues as market competition, price fixing, and preferred
provider
agreements. In other words, it limits the creation of monopolies.
Civil Rights Act of 1964 All individuals, regardless of race,
color, or national origin, living in the
United States will have equal rights, including admission to a
medical
facility for treatment.
Privacy Act of 1974 All individual privacies are protected from
the misuse of federal records,
which includes those under Medicare, Medicaid, and other
government
health care services.
Emergency Medical Treatment
and Active Labor Act of 1986
Any individual seeking medical treatment in the event of an
emergency
will receive it regardless of the ability to pay or means of
payment.
Ethics in Patient Referrals Act
of 1989
Doctors are prohibited from requiring the use of specific
laboratories for
testing based upon a prior financial arrangement.
71. responsibility will continue to present
a challenge.
Social Changes and Personal Responsibility
Social changes affect how the people of a nation view health.
The World Health Organization
has defined health as “a state of complete physical, mental, and
social well-being and not
merely the absence of disease or infirmity” (Grad, 2002, p.
984). With Americans participat-
ing in fewer physical activities, the nation has become
overweight and obese—issues that
have been linked to chronic diseases such as heart disease,
diabetes, and stroke. As a whole,
the people of this nation do not believe that their poor habits
(sedentary lifestyle and over-
eating) are unhealthy. This has become a new culture that will
likely strain the health care
system if the trend isn’t reversed. Unless each individual takes
responsibility for his or her
own health, chronic diseases will become the norm, draining the
resources of the existing
health care system.
Organizational Issues
Considering that some health researchers believe that the health
care system is fragmented,
duplicated, and lacking in the coordination of services, it likely
will not be able to handle the
potential increase in health needs (Bipartisan Policy Center,
2012). Others complain that the
system is rife with administrative cost, waste, and fraud, which
could become another con-
cern in the future (Bipartisan Policy Center, 2012). To combat
this, public health professionals
are focusing their attention on prevention to reverse the trend of
73. and children, the elderly, low-
income citizens, and the disabled. The U.S. public health
system, through encompassing ser-
vice outreach programs, targets at-risk populations in an
approach that is not significantly
different from that of socialized medical systems. With a
private–public partnership such
as the one that now exists, the United States’ model does not
differ significantly in opera-
tional aspects from other national models. The differentiating
factor is the emphasis on the
employer-sponsored health care function.
The U.S. health care system is in constant flux, partly
predicated on the cost, quality, and
access issues and the implementation of the Affordable Care
Act. From a health care system
perspective (private and public), major challenges appear to
reside in supply and demand in
caring for vulnerable populations, such as the uninsured, the
poor, the chronically diseased,
the aging, and the mentally ill. The problem involves high
demand with limited supply (i.e.,
availability) of health care workers. Perhaps, the answer could
lie in developing a collabora-
tion of health care services between both public and private
domains to provide seamless and
easy access to health care services.
Controlling Costs
In its report What Is Driving U.S. Health Care Spending?, the
Bipartisan Policy Center (2012)
reported four factors driving the growth in health care costs:
1. Prices
2. Population
74. 3. Use
4. Intensity
The key areas that will drive spending further are the following:
• fee-for-service reimbursement
• fragmentation in care delivery
• administrative burden on providers, payers, and patients
• populations aging, rising rates of chronic disease and
comorbidities, as well as life-
style factors and personal health choices
• advances in medical technology
• tax treatment of health insurance
• insurance benefit design
• lack of transparency about cost and quality, compounded by
limited data, to inform
consumer choice
• cultural biases that influence care utilization
• changing trends in health care market consolidation and
competition for providers
and insurers
• high unit prices of medical services
• the health care legal and regulatory environment, including
current medical mal-
practice and fraud and abuse laws
• structure and supply of the health professional workforce,
including scope of prac-
tice restrictions, trends in clinical specialization, and patient
access to providers
(Bipartisan Policy Center, 2012, pp. 6–7)
76. experienced in expanding access to health care through lower-
cost insurance and eliminate
the public health fund.
Summary & Resources
Chapter Summary
A health care system did not exist for many years in the United
States, but it eventually became
a nation of health insurance holders—most of whom received
such insurance through their
place of employment. The current public health system was
shaped through the integrated
patterns of population growth, global economics, wars,
depressions, and scientific technology-
fueled revolutionary growth in medicine, disease prevention,
and interventions. There are
different models of health care throughout the world, including
Bismarck (premium funded
and mandated), Beveridge (universal health coverage), and
national insurance (public and
privately funded).
There are several key funding areas for the nation’s people—
especially those who do not have
employer-sponsored health insurance plans. This includes the
expansions made through the
ACA as well as Medicaid and Medicare. Title V, WIC, SHIP,
and CHIP also provide a vast array
of health services to vulnerable populations such as children
and senior citizens.
The overarching body that handles public health aspects is the
U.S. Department of Health and
Human Services. While the structure of public health was
outlined in depth in Chapter 1, this
80. Seattle, Washington, might struggle more with mental
health/depression. The study of how,
when, and why disease occurs focuses on the health of
populations, and, in this respect, it dif-
fers from clinical medicine’s involvement with individual
patients.
In fact, epidemiology provides a method-
ological foundation for the entire public
health field by embracing a spectrum of
tools for studying health and illness. These
methodologies include natural experiments,
descriptive and analytic study designs (e.g.,
cross-sectional, case-control, cohort, and
experimental), and mapping technologies.
Epidemiologic research findings help develop
hypotheses that can be applied to the health
of the community and the study of potential
causal relationships.
Epidemiologic research is likened to detective
work because the causes of many diseases—
especially when they first appear—are
unknown. Some examples are hantavirus in national parks,
periodic episodes of foodborne
illnesses, West Nile virus, and the resurgence of whooping
cough (pertussis). This chapter
presents epidemiologic procedures and methodologies that aid
in unraveling the causes of
mysterious disease outbreaks and health conditions that can
afflict community members.
6.1 What Is Epidemiology?
Epidemiology is the study of the occurrence and distribution of
illnesses, injuries, and dis-