Chapter 1Major Characteristics of U.S.Health Care Delive.docx

Chapter 1
Major Characteristics of U.S.
Health Care Delivery
INTRODUCTION
The United States has a unique system of health care delivery.
For the
purposes of this discussion, “health care delivery” and “health
services
delivery” can have slightly different meanings, but in a broad
sense, both
terms refer to the major components of the system and the
processes that
enable people to receive health care. In a more restricted sense,
the terms
refer to the act of providing health care services to patients. The
reader can
identify which meaning is intended by paying attention to
context.
In contrast to the United States, most developed countries have
national
health insurance programs that are run by the government and
financed
through general taxes. Almost all of the citizens in such
countries are enti-
tled to receive health care services that include routine and
basic health
care. These countries have what is commonly referred to as
universal

access. All American citizens, on the other hand, are not
entitled to routine
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DISTRIBUTION.
2 Chapter 1 • Major Characteristics of U.S. Health Care
Delivery
and basic health care services. Although the U.S. health care
delivery sys-
tem has evolved in response to concerns about cost, access, and
quality, the
system has been unable to provide universally a basic package
of health
care at an affordable cost. One barrier to universal coverage is
the unneces-
sary fragmentation of the U.S. delivery system, which is
perhaps its central
feature (Shortell et al., 1996); however, the enormous challenge
of expand-
ing access to health care while containing overall costs and
maintaining
expected levels of quality continues to intrigue academics,
policy makers,
and politicians.
To make learning the structural and conceptual bases for the
delivery of
health services easier, this book is organized by the systems
framework,
which is presented at the end of this chapter. One of the main

objectives of
Chapter 1 is to provide a broad understanding of how health
care is deliv-
ered in the United States.
The following overview introduces the reader to several
concepts that
are treated more extensively in later chapters. The U.S. health
care delivery
system is complex and massive. Interestingly, it is not actually
a system in
the true sense, although it is called a system when its various
features, com-
ponents, and services are referenced. Hence, it may be
somewhat mislead-
ing to talk about the American health care delivery “system”
(Wolinsky,
1988, p. 54), but the term will nevertheless be used throughout
this book.
Organizations and individuals involved in health care range
from edu-
cational and research institutions, medical suppliers, insurers,
payers, and
claims processors to health care providers. Total employment in
various
health delivery settings is almost 14.4 million, including
professionally
active doctors of medicine (MDs), doctors of osteopathy (DOs),
active
nurses, dentists, pharmacists, and administrators.
Approximately 382,000
physical, occupational, and speech therapists provide
rehabilitation services.
The vast array of institutions includes 5,700 hospitals, 15,900
nursing

homes, almost 2,900 inpatient mental health facilities, and
11,000 home
health agencies and hospices. Close to 800 programs include
basic health
services for migrant workers and the homeless, community
health centers,
black lung clinics, human immunodeficiency virus (HIV) early
interven-
tion services, and integrated primary care and substance abuse
treatment
programs. Various types of health care professionals are trained
in
144 medical and osteopathic schools, 56 dental schools, 109
schools of
pharmacy, and more than 1,500 nursing programs located
throughout the
country.
DISTRIBUTION.
Subsystems of U.S. Health Care Delivery 3
There are 201.7 million Americans with private health insurance
coverage, 40.3 million Medicare beneficiaries, and 38.3 million
Medicaid recipients. Health insurance can be purchased from
approxi-
mately 1,000 health insurance companies and 70 Blue
Cross/Blue Shield
plans. The managed care sector includes approximately 405
licensed
health maintenance organizations (HMOs) and 925 preferred

provider
organizations (PPOs). A multitude of government agencies are
involved
with the financing of health care, medical and health services
research,
and regulatory oversight of the various aspects of the health
care deliv-
ery system (Aventis Pharmaceuticals, 2002; Bureau of Primary
Health
Care, 1999; National Center for Health Statistics, 2007; U.S.
Bureau of
the Census, 1998; U.S. Census Bureau, 2007; Bureau of Labor
Statistics,
2008).
SUBSYSTEMS OF U.S. HEALTH CARE DELIVERY
The United States does not have a universal health care delivery
system
enjoyed by everyone. Instead, multiple subsystems have
developed, either
through market forces or the need to take care of certain
population seg-
ments. Discussion of the major subsystems follows.
Managed Care
Managed care is a system of health care delivery that (1) seeks
to
achieve efficiency by integrating the basic functions of health
care delivery,
(2) employs mechanisms to control (manage) utilization of
medical services,
and (3) determines the price at which the services are purchased
and, conse-
quently, how much the providers get paid. It is the most

dominant health care
delivery system in the United States today and is available to
most Americans
(for more details on managed care, please refer to Chapter 9).
The employer or government is the primary financier of the
managed
care system. Instead of purchasing coverage from a traditional
insurance
company, the financier contracts with a managed care
organization (MCO),
such as an HMO or a PPO, to offer a selected health plan to
employees. In
this case, the MCO functions like an insurance company and
promises to
provide health care services contracted under the health plan to
the
enrollees of the plan.
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Delivery
The term enrollee (member) refers to the individual covered
under the
plan. The contractual arrangement between the MCO and the
enrollee—
including the collective array of covered health services that the
enrollee is
entitled to—is referred to as the health plan (or “plan” for

short). The
health plan uses selected providers from whom the enrollees can
choose to
receive routine services. Primary care providers or general
practitioners
typically manage routine services and determine appropriate
referrals for
higher level or specialty services, often earning them the name
of gate-
keeper. The choice of major service providers, such as
hospitals, is also
limited. Some of the services may be delivered through the
plans own hired
physicians, but most are delivered through contracts with
providers such as
physicians, hospitals, and diagnostic clinics.
Although the employer finances the care by purchasing a plan
from an
MCO, the MCO is then responsible for negotiating with
providers.
Providers are typically paid either through a capitation (per
head) arrange-
ment, in which providers receive a fixed payment for each
patient or
employee under their care, or a discounted fee. Providers are
willing to dis-
count their services for MCO patients in exchange for being
included in the
MCO network and being guaranteed a patient population. Health
plans rely
on the expected cost of health care utilization, which always
runs the risk
of costing more than the premiums collected. By underwriting
this risk, the
plan assumes the role of insurer.

Figure 1.1 illustrates the basic functions and mechanisms that
are nec-
essary for the delivery of health services within managed care.
The key
functions of financing, insurance, delivery, and payment make
up the quad-
function model. Managed care arrangements integrate the four
functions to
varying degrees.
Military
The military medical care system is available free of charge to
active-
duty military personnel of the U.S. Army, Navy, Air Force, and
Coast
Guard and also to certain uniformed nonmilitary services such
as the
Public Health Service and the National Oceanographic and
Atmospheric
Association (NOAA). It is a well-organized, highly integrated
system. It is
comprehensive and covers preventive as well as treatment
services that are
provided by salaried health care personnel, many of whom are
themselves
in the military or uniformed services. This system combines
public health
DISTRIBUTION.

with medical services. Routine ambulatory care is provided
close to the
military personnel’s place of work at the dispensary, sick bay,
first-aid sta-
tion, or medical station. Routine hospital services are provided
at base dis-
pensaries, in sick bays aboard ship, and at base hospitals.
Complicated
hospital services are provided in regional military hospitals.
Long-term
care is provided through Veterans Administration (VA)
facilities to certain
retired military personnel. Although patients have little choice
regarding
how services are provided, in general, the military medical care
system
provides high-quality health care.
Families and dependents of active-duty or retired career
military per-
sonnel are either treated at the hospitals or dispensaries or are
covered by
Employers
Government–Medicare, Medicaid
Individual self-funding
FINANCING
Insurance companies
Blue Cross/Blue Shield
Self-insurance

INSURANCE
Insurance companies
Blue Cross/Blue Shield
Third-party claims processors
PAYMENT
Physicians
Hospitals
Nursing homes
Diagnostic centers
Medical equipment vendors
Community health centers
DELIVERY (Providers)
Access
Risk
underwriting
Capitation
or
discounts
Utilization
controls
Integration of functions through managed care (HMOs, PPOs)
Figure 1.1 Managed Care: Integration of Functions

DISTRIBUTION.
Delivery
TRICARE, a program that is financed by the military. This
insurance plan
permits the beneficiaries to receive care from private medical
care facilities
as well as military ones.
The VA health care system is available to retired veterans of
previous
military service, with priority given to those who are disabled.
The VA sys-
tem focuses on hospital care, mental health services, and long-
term care. It
is one of the largest and oldest (1946) formally organized health
care sys-
tems in the world. Its mission is to provide medical care,
education and
training, research, contingency support, and emergency
management for
the Department of Defense medical care system. It provides
health care to
more than 5.5 million persons at over 1,100 sites, including 153
hospitals,
732 ambulatory and community-based clinics, 135 nursing
homes, 209
counseling centers, 47 domiciliaries (residential care facilities),
73 home
health care programs, and various contract care programs. The
VA budget

is over $30 billion, and it employs a staff of 263,350 as of 2007
(National
Center for Veterans Analysis and Statistics, 2007). The entire
VA system is
organized into 22 geographically distributed Veterans
Integrated Service
Networks (VISNs). Each VISN is responsible for coordinating
the activi-
ties of the hospitals, outpatient clinics, nursing homes, and
other facilities
located within its jurisdiction. Each VISN receives an allocation
of federal
funds and is responsible for equitable distribution of those
funds among its
hospitals and other providers. VISNs are also responsible for
improving
efficiency by reducing unnecessarily duplicative services, by
emphasizing
preventive services, and by shifting services from costly
inpatient care to
less costly outpatient care.
Subsystem for Vulnerable Populations
Vulnerable populations, particularly those who are poor and
uninsured
or of minority and immigrant status, live in geographically or
economically
disadvantaged communities and receive care from “safety net”
providers.
These providers include health centers, physicians’ offices, and
hospital
outpatient and emergency departments; of these, health centers
are
expressly designed to serve the underserved. Consistent with
their unique

role and mission, safety net providers offer comprehensive
medical and
enabling (e.g., language translation, transportation, outreach,
nutrition and
health education, social support services, case management, and
child care)
services targeted to the needs of vulnerable populations.
DISTRIBUTION.
For example, for over 30 years, federally funded health centers
have pro-
vided primary and preventive health services to rural and urban
underserved
populations. The Bureau of Primary Health Care (BPHC),
located in the
Health Resources and Services Administration in the
Department of Health
and Human Services (DHHS), provides federal support for
community-
based health centers that include programs for migrant and
seasonal farm
workers and their families, homeless persons, public housing
residents, and
school-aged children. These services facilitate regular access to
care for
patients who are predominantly minority, low-income,
uninsured, or receiv-
ing Medicaid. By the end of calendar year 2002, the nationwide

network of
843 reporting health centers delivered essential primary and
preventive care
at more than 3,500 sites, serving more than one fifth (more than
11 million)
of the nation’s 50 million underserved persons (Bureau of
Primary Health
Care, 2002). Health centers have contributed to significant
improvements in
health outcomes for the uninsured and Medicaid populations and
have
reduced disparities in health care and health status across
socioeconomic and
racial/ethnic groups (Politzer et al., 2003; Shi et al., 2001).
In addition to health centers, government health insurance
programs,
such as Medicare, Medicaid, and State Children’s Health
Insurance
Program (SCHIP), provide vulnerable populations with access
to health
care services.
Medicare is one of the largest sources of health insurance in the
coun-
try, serving nearly 39 million people, who are either 65 years
old or older
and who are suffering from certain disabilities or are diagnosed
with end-
stage renal disease. Managed by the Health Care Financing
Administration
(HCFA), another division within the DHHS, Medicare is
composed of
three parts, Part A, Part B, and most recently Part D. Part A and
Part B were
the original divisions of the Medicare program. Part A covers

health care
received in hospitals, nursing facilities, hospice care, and some
home
health care with no monthly premiums, while Part B covers
doctors’ ser-
vices and other outpatient care not included in Part A with an
additional
monthly premium, which in 2008 cost about $96.40 per month.
Part D, or
the Medicare Prescription Drug Plan, provides coverage for
brand-name
and generic prescription drugs at pharmacies involved in the
program. The
program is designed to protect those in Medicare burdened with
very high
drug costs or unexpected prescription bills in the future.
In addition, Medicaid, the third largest source of health
insurance in
the country, provides coverage for low-income women,
children, elderly
DISTRIBUTION.
Delivery
people, and individuals with disabilities, covering 12% of the
U.S. popula-
tion. The program offers these vulnerable populations health
insurance and

long-term care for older Americans and individuals with
disabilities and
also provides additional coverage for low-income Medicare
recipients for
services not provided in the Medicare Part A Plan, such as
outpatient care
and prescription drugs.
Finally, with the growing uninsured population, the government
has
taken the initiative to provide insurance to children in uninsured
families
through SCHIP. Established in 1997, it expands coverage to
children in
families who do not qualify for Medicaid but who have a
modest income,
although each state has its own rules of eligibility. For little or
no cost, the
insurance pays for the child’s physician visits, immunizations,
hospitaliza-
tions, and emergency room visits.
America’s safety net, however, is by no means secure, and the
avail-
ability of safety net providers varies from community to
community.
Vulnerable populations residing in communities without safety
net
providers have to forego care or seek care from hospital
emergency depart-
ments if one is nearby. Safety net providers face enormous
pressure from
the increasing number of uninsured and poor in their
communities. The
inability to shift costs for uncompensated care onto private
insurance has

become a significant problem as revenues from Medicaid, the
primary
source of third-party financing for core safety net providers, are
restricted.
Integrated Delivery
Over the last decade, the hallmark of the U.S. health care
industry has
been organizational integration to form integrated delivery
systems (IDSs)
or networks. An IDS represents various forms of ownership and
other
strategic linkages among hospitals, physicians, and insurers. Its
objective is
to have one health care organization deliver a range of services.
An IDS can
be defined as a network of organizations that provides or
arranges to pro-
vide a coordinated continuum of services to a defined
population and that
is willing to be held clinically and fiscally accountable for the
outcomes
and health status of the population. From the standpoint of
integration, the
major participants or players in the health care delivery system
are physi-
cians, hospitals, and insurers. The key strategic position that
physicians,
hospitals, and insurers hold gives rise to different forms of IDSs
(see
Chapter 9).

DISTRIBUTION.
Characteristics of the U.S. Health Care System 9
CHARACTERISTICS OF THE U.S. HEALTH CARE SYSTEM
The health care system of a nation is influenced by external
factors,
including the political climate, stage of economic development,
techno-
logic progress, social and cultural values, the physical
environment, and
population characteristics such as demographic and health
trends. It fol-
lows, then, that the combined interaction of these environmental
forces
influences the course of health care delivery in the United
States. This sec-
tion summarizes the basic characteristics that differentiate the
U.S. health
care delivery system from that of other countries. There are
eight main
areas of distinction (see Exhibit 1.1).
No Central Governing Agency; Little Integration and
Coordination
The U.S. health care system stands in conspicuous contrast to
the
health care systems of other developed countries. The centrally
controlled
universal health care system that most developed countries have
authorizes
the financing, payment, and delivery of health care to all

residents. The
U.S. system, however, is not centrally controlled and therefore
has a variety
of payment, insurance, and delivery mechanisms, and health
care is
financed both publicly and privately. Private financing, which is
predomi-
nantly through employers, accounts for approximately 55% of
total health
care expenditures; the government finances the remaining 45%
(National
Center for Health Statistics, 2002).
Exhibit 1.1 Main Characteristics of the U.S. Health Care System
• No central governing agency and little
integration and coordination
• Technology-driven delivery system focusing
on acute care
• High on cost, unequal in access, average in
outcome
• Delivery of health care under imperfect
market condition
• Legal risks influence practice behaviors
• Government as subsidiary to the private sector
• Market justice vs. social justice: conflict
throughout health care
• Multiple players and balance of power
• Quest for integration and accountability
• Access to health care services is selectively

based on insurance coverage
DISTRIBUTION.
Delivery
Centrally controlled health care systems are less complex. They
are
also less costly because they can manage total expenditures
through global
budgets and can govern the availability and utilization of
services. Because
the United States has such a large private system of financing as
well as
delivery, the majority of hospitals and physician clinics are
private busi-
nesses, independent of the government. Nevertheless, the
federal and state
governments in the United States play an important role in
health care
delivery. They determine public sector expenditures and
reimbursement
rates for services provided to Medicaid and Medicare patients.
The govern-
ment also formulates standards of participation through health
policy and
regulation, which means that providers must comply with the
standards
established by the government in order to deliver care to
Medicaid and

Medicare patients. Certification standards are also regarded as
minimum
standards of quality in most sectors of the health care industry.
Technology Driven and Focusing on Acute Care
The United States has been the hotbed of research and
innovation in
new medical technology. Growth in science and technology
often creates a
demand for new services despite shrinking resources to finance
sophisti-
cated care. Other factors contribute to increased demand for
expensive
technological care: Patients assume that current technologies
offer the best
care; physicians want to try the latest gadgets. Even hospitals
compete on
the basis of having the most modern equipment and are often
under pres-
sure to recoup capital investments made in technology by using
it. Legal
risks for providers and health plans alike may also play a role in
the reluc-
tance to deny new technology.
Although technology has ushered in a new generation of
successful
interventions, the negative outcomes resulting from its overuse
are many.
For example, the cost of highly technical interventions adds to
the rising
costs of health care, making it more difficult for employers to
extend insur-
ance to part-time workers or for insurance companies to lower
their premi-

ums. Because there are limited resources to invest in the
American health
care system, it is essential to think twice before assuming that
the best solu-
tion always involves technology. Considering the broad benefits
of primary
care in preventing acute conditions that ultimately require
technological
intervention, it seems essential to strive for a balanced
investment in both
high- and low-technology medicine.
DISTRIBUTION.
High on Cost, Unequal in Access, and Average in Outcome
The United States spends more than any other developed
country on
health care (primarily medical care), and costs continue to rise
at an alarm-
ing rate. Despite spending such a high percentage (13%) of the
nation’s
gross domestic product on health care, many U.S. residents have
limited
access to even the most basic care (Anderson et al., 2003).
Access means the ability of an individual to obtain health care
services when needed. In the United States, access is restricted
to those

who (1) have health insurance through their employers, (2) are
covered
under a government health care program, (3) can afford to buy
insurance
out of their own private funds, and (4) are able to pay for
services pri-
vately. Health insurance is the primary means for ensuring
access. In
2000, the number of uninsured Americans—those without
private or pub-
lic health insurance coverage—was estimated to be 40.5 million
or 16.8%
of the U.S. population (National Center for Health Statistics,
2002). For
consistent basic and routine care, commonly referred to as
primary care,
the uninsured are unable to see a physician unless they can pay
the physi-
cian’s fees. Those who cannot afford to pay generally wait until
health
problems develop, at which point they may be able to receive
services
free of charge in a hospital emergency department. Uninsured
Ameri-
cans therefore are able to obtain medical care for acute illness.
Hence,
one can say that the United States does have a form of universal
cata-
strophic health insurance even for the uninsured (Altman &
Reinhardt,
1996, p. xxvi).
It is well acknowledged that the absence of insurance inhibits
the
patient’s ability to receive well-directed, coordinated, and
continuous

health care through access to primary care services and, when
needed,
referral to specialty services. Experts generally believe that the
inadequate
access to basic and routine primary care services is the main
reason that the
United States, in spite of being the most economically advanced
country,
lags behind other developed nations in measures of population
health such
as infant mortality and overall life expectancy.
Imperfect Market Conditions
Under national health care programs, patients have varying
degrees of
choice in selecting their providers; however, true economic
market forces
DISTRIBUTION.
Delivery
are virtually nonexistent. In the United States, even though the
delivery of
services is largely in private hands, health care is only partially
governed
by free market forces. The delivery and consumption of health
care in the
United States do not quite meet the basic tests of a free market.

Hence, the
system is best described as a quasi-market or an imperfect
market. The fol-
lowing key characteristics of free markets help explain why
U.S. health
care is not a true free market.
In a free market, multiple patients (buyers) and providers
(sellers) act
independently. In a free market, patients should be able to
choose their
provider based on price and quality of services. If it were this
simple,
patient choice would determine prices by the unencumbered
interaction of
supply and demand. Theoretically, at least, prices are negotiated
between
payers and providers; however, in many cases, the payer is not
the patient
but an MCO, Medicare, or Medicaid. Because prices are set by
agencies
external to the market, they are not freely governed by the
forces of supply
and demand.
For the health care market to be free, unrestrained competition
must
occur among providers on the basis of price and quality.
Generally speak-
ing, free competition exists among health care providers in the
United
States. The consolidation of buying power into the hands of
private health
plans, however, is forcing providers to form alliances and IDSs
on the sup-
ply side. As explained earlier, IDSs are networks that offer a

range of health
care services. In certain geographic sectors of the country, a
single giant
medical system has taken over as the sole provider of major
health care
services, restricting competition. As the health care system
continues to
move in this direction, it appears that only in large metropolitan
areas will
there be more than one large integrated system competing to get
the busi-
ness of the health plans.
A free market requires that patients have information about the
avail-
ability of various services. Free markets operate best when
consumers are
educated about the products they are using, but patients are not
always well
informed about the decisions that need to be made regarding
their care.
Choices involving sophisticated technology, diagnostic
methods, interven-
tions, and pharmaceuticals can be difficult and often require
physician
input. Acting as an advocate, primary care providers can reduce
this infor-
mation gap for patients. Recently, health care consumers have
taken the ini-
tiative to educate themselves with the use of Internet resources
for
DISTRIBUTION.

gathering medical information. Pharmaceutical product
advertising is also
having an impact on consumer expectations and increasing
awareness of
available medications.
In a free market, patients have information on price and quality
for
each provider. Current pricing methods for health care services
further con-
found free market mechanisms. Hidden costs make it difficult
for patients
to gauge the full expense of services ahead of time. Item-based
pricing, for
example, refers to the costs of ancillary services that often
accompany
major procedures such as surgery. Patients are usually informed
of the
surgery’s cost ahead of time but cannot anticipate the cost of
anesthesiolo-
gists and pathologists or hospital supplies and facilities, thus
making it
extremely difficult to ascertain the total price before services
have actually
been received. Package pricing and capitated fees can help
overcome these
drawbacks by providing a bundled fee for a package of related
services.
Package pricing covers services bundled together for one
episode of care,
which is less encompassing than capitation. Capitation covers

all services
an enrollee may need during an entire year.
In recent years, the quality of care has received much attention.
Performance rating of health plans has met with some success;
however,
apart from sporadic news stories, the public generally has scant
informa-
tion on the quality of health care providers.
In a free market, patients must directly bear the cost of services
received. The purpose of insurance is to protect against the risk
of unfore-
seen major events. Because the fundamental purpose of
insurance is to
meet major expenses when unlikely events occur, having
insurance for
basic and routine health care undermines the principle of
insurance. Health
insurance coverage for minor services such as colds, coughs,
and earaches
amounts to prepayment for such services. There is a moral
hazard that after
enrollees have purchased health insurance they will use health
care services
to a greater extent than if they were without health insurance.
Even certain
referrals to higher level services may be foregone if the patient
has to bear
the full cost of these services.
In a free market for health care, patients as consumers make
decisions
about the purchase of health care services. The main factors that
severely
limit the patient’s ability to make health care purchasing

decisions have
already been discussed. At least two additional factors limit the
ability of
patients to make decisions. First, decisions about the utilization
of health
DISTRIBUTION.
Delivery
care are often determined by need rather than price-based
demand. Need
has generally been defined as the amount of medical care that
medical
experts believe a person should have to remain or become
healthy
(Feldstein, 1993, p. 74–75). Second, the delivery of health care
can result
in creation of demand. This follows from self-assessed need
that, coupled
with moral hazard, leads to greater utilization. This creates an
artificial
demand because prices are not taken into consideration.
Practitioners who
have a financial interest in additional treatments also create
artificial
demand (Hemenway & Fallon, 1985), commonly referred to as
provider-
induced demand.

Government as Subsidiary to the Private Sector
In most other developed countries, the government plays a
central
role in the provision of health care. In the United States,
however, the pri-
vate sector plays the dominant role. This can be explained to
some degree
by the American tradition of reliance on individual
responsibility and a
commitment to limiting the power of the national government.
As a result,
government spending for health care has been largely confined
to filling
in the gaps left open by the private sector. These gaps include
environ-
mental protections, support for research and training, and care
of vulnera-
ble populations.
Market Justice versus Social Justice: Conflict Throughout
Health Care
Market justice and social justice are two contrasting theories
that gov-
ern the production and distribution of health care services in the
United
States. The principle of market justice places the responsibility
for the fair
distribution of health care on the market forces in a free
economy. Medical
care and its benefits are distributed on the basis of people’s
willingness and
ability to pay (Santerre & Neun, 1996, p. 7). In contrast, social
justice
emphasizes the well-being of the community over that of the

individual;
thus, the inability to obtain medical services because of a lack
of financial
resources would be considered unjust. A just distribution of
benefits must
be based on need, not simply one’s ability to purchase them in
the market-
place. In a partial public and private health care system, the two
theories
often work well hand in hand, contributing ideals from both
theories; how-
ever, market justice principles tend to prevail. As mentioned
before,
Americans generally prefer market solutions to government
intervention in
DISTRIBUTION.
health care financing and delivery. Unfortunately, market
justice results in
the unequal allocation of health care services, neglecting
critical human
concerns that are not confined to the individual but have
broader, negative
impacts on society (see Chapter 2 for contrast between market
and social
justice).
Multiple Players and Balance of Power

The U.S. health services system involves multiple players. The
key
players in the system have been physicians, administrators of
health
service institutions, insurance companies, large employers, and
the gov-
ernment. Big business, labor, insurance companies, physicians,
and hos-
pitals make up the powerful and politically active special
interest groups
represented before lawmakers by high-priced lobbyists. Each
player has
a different economic interest to protect. The problem is that the
self-
interests of each player are often at odds. For example,
providers seek to
maximize government reimbursement for services delivered to
Medicare
and Medicaid patients, but the government wants to contain cost
increases.
The fragmented self-interests of the various players produce
counteract-
ing forces within the system. One positive effect of these
opposing
forces is that they prevent any single entity from dominating the
system.
In an environment that is rife with motivations to protect
conflicting
self-interests, achieving comprehensive system-wide reforms is
next to
impossible, and cost containment remains a major challenge.
Conse-
quently, the approach to health care reform in the United States
is char-
acterized as incremental or piecemeal and is sometimes

regressive when
administrations change followed by its ripple effect on
government
health agencies.
Quest for Integration and Accountability
Currently in the United States, there is a drive to use primary
care as
the organizing hub for continuous and coordinated health
services.
Although this model gained popularity with the expansion of
managed
care, the model’s development stalled before reaching its full
potential. The
envisioned role for primary care would include integrated health
care by
offering comprehensive, coordinated, and continuous services
with a seam-
less delivery. Furthermore, the model emphasizes the
importance of the
patient–provider relationship and how it can best function to
improve the
DISTRIBUTION.
Delivery
health of each individual and thus strengthen the population.
Integral to

the relationship is the concept of accountability. Accountability
on the
provider’s behalf means ethically providing quality health care
in an effi-
cient manner. On the patient’s behalf, it means safeguarding
one’s own
health and using available resources sensibly.
Access to Health Care Services Is Selectively Based on
Insurance Coverage
Unlike countries with national health plans providing universal
access,
the United States’ access to health care services is limited.
Access is
granted only to individuals who (1) have health insurance
through their
employers, (2) are covered under a government health care
program, (3)
can afford to buy insurance with their own private funds, and
(4) can pay
for services privately. Although the United States offers some
of the best
medical care in the world, this care is often available only to
individuals
with health insurance plans that provide adequate coverage or
sufficient
resources to pay for the procedures themselves.
In addition, there is a relatively large population of uninsured in
the
country. In 2006, 47 million people (15.8% of the population)
were unin-
sured, meaning they were not covered by any type of insurance
program,
public nor private (DeNavas-Walt et al., 2006). This statistic

does not
include individuals in the population who are underinsured or
only inter-
mittently insured in a given year.
The uninsured have limited options when seeking medical care.
They can either (1) pay physicians out of pocket that are
typically at
higher rates than those paid by insurance plans, (2) access
federally
funded health centers, or (3) obtain treatment for acute illnesses
at a hos-
pital emergency department for which hospitals do not receive
direct
payments unless patients have the ability to pay. The
Emergency Medical
Treatment and Labor Act of 1986 requires screening and
evaluation of
every patient, necessary stabilizing treatment, and admitting
when nec-
essary, regardless of ability to pay. Unfortunately, the
inappropriate use
of emergency departments results in cost-shifting, where
patients able to
pay for services, privately insured individuals, employers, and
the gov-
ernment ultimately cover the costs provided to the uninsured in
the emer-
gency room. Also, the lack of insurance restricts the patients’
capability
DISTRIBUTION.

Health Care Systems of Other Developed Countries 17
to receive well-directed, coordinated, and continuous health
care through
access to primary care services, and when necessary, referral to
specialty
services.
Legal Risks Influence Practice Behaviors
Americans as a society are quick to engage in lawsuits.
Motivated by
prospects of enormous jury awards, people are easily prompted
to drag
alleged offenders into the courtroom because of the slightest
perceptions of
incurred harm. Because private health care providers are
increasingly
becoming more susceptible to litigations, risk of malpractice
lawsuits is a
serious consideration in the practice of medicine. As a form of
protection,
most providers engage in what is known as defensive medicine
by prescrib-
ing additional diagnostic tests, scheduling checkup
appointments, and
maintaining abundant documentation on cases. Many of these
efforts are
unnecessary and only drive up costs and inefficiency.
HEALTH CARE SYSTEMS OF OTHER DEVELOPED
COUNTRIES
Most Western European countries have national health care
programs

that provide universal access. There are three basic models for
structuring
national health care systems. In a system under National Health
Insurance,
such as Canada, the government finances health care through
general taxes,
but the actual care is delivered by private providers. In the
context of the
quad-function model (see Figure 1.1), National Health
Insurance requires a
tighter consolidation of the financing, insurance, and payment
functions,
which are coordinated by the government. Delivery is
characterized by
detached private arrangements.
In a national health system, such as the one in Great Britain, in
addition
to financing a tax-supported national health insurance program,
the govern-
ment also manages the infrastructure for the delivery of medical
care.
Under such a system, most of the medical institutions are
operated by the
government. Most health care providers, such as physicians, are
either gov-
ernment employees or are tightly organized in a publicly
managed infra-
structure. In the context of the quad-function model, a National
Health
System requires a tighter consolidation of all four functions,
typically by
the government.

DISTRIBUTION.
Delivery
In a socialized health insurance system, such as in Germany,
health
care is financed through government-mandated contributions by
employers and employees. Health care is delivered by private
providers.
Private not-for-profit insurance companies, called sickness
funds, are
responsible for collecting the contributions and paying
physicians and
hospitals (Santerre & Neun, 1996, p. 134). In a socialized health
insur-
ance system, insurance and payment functions are closely
integrated,
and the financing function is better coordinated with the
insurance and
payment functions than it is in the United States. Delivery is
character-
ized by independent private arrangements. The government
exercises
overall control.
Canada
Canada’s National Health Insurance system, referred to as
Medicare,
was initially established in the Medical Care Act of 1966,
providing 50/50

cost sharing for provincial or territorial medical insurance
plans. The sys-
tem provides universal coverage with free care at the point of
contact and is
publicly funded through taxes, although it is privately run. Most
doctors are
private practitioners who are paid fee-for-service and submit
service claims
directly to the health insurance plan for payment. The federal
government
is responsible for establishing the constitution that determines
how health
care is run, whereas provincial and territorial governments
administer and
deliver heath care services and health insurance plans. In 1984,
the addition
of the Canadian Health Act solidified and defined five
principles and crite-
ria for territorial and provincial governments to meet in order to
receive full
funding for health insurance plans. Care must be (1) available to
all eligible
residents of Canada, (2) comprehensive in coverage, (3)
accessible without
financial and other barriers, (4) portable within the country and
while trav-
eling abroad, and (5) publicly administered. Canada’s health
care system
relies heavily on primary care physicians, who account for 51%
of active
physicians in the country. These physicians serve two key
functions. First,
they provide first contact health care services, and second, they
coordinate
patient health care services across the system to ensure
continuity. Primary

physicians arrange patient access to specialists, hospital
admissions, and
diagnostic testing and prescription drug therapy.
DISTRIBUTION.
Health Care Systems of Other Developed Countries 19
Great Britain
In Great Britain, universal health coverage is provided by the
National
Health Service (NHS), which is publicly funded and run, relying
on the
belief that every citizen is entitled to health care. Through this
system, all
basic services, visits to primary care physicians and specialists,
inpatient
care, or x-ray and pathology services are free, whereas other
costs are cov-
ered by the patient in full or subsidized by the government.
Additionally, the
purchase of private health insurance is also a choice for
individuals with 7
million, or 12%, of the population covered by these plans. The
system comes
with serious problems that vary in severity across the region
involving fund-
ing, service, and staff. One of the largest concerns plaguing the
NHS is
referred to as “health tourism,” which is when individuals go

into the country
to get treated, escaping monetary fees and costing the agency
almost £200
million each year. There are also long wait times for care,
especially elective
procedures, with 41.2% reporting a wait period of 12 or more
weeks to see a
specialist or receive surgical care, and much of the equipment
used is out-
dated, as there is little funding directed towards technological
innovations.
Germany
Germany follows the Socialized Health Insurance system with
the
statutory health insurance (GKV) providing organizational
framework for
the delivery of public health care. Employees and employers are
required to
provide 50/50 contributions toward the system if the employed
earns below
a specific level of income (40,500 Euros per year in 2004). The
health plan
also covers the spouse and children (until a certain age) of the
employee. If
income is above the limit, the individual is given a choice
between private
health insurance or the state insurance. Over 90% of the
population is cov-
ered by the national health insurance—the remainder is insured
privately.
Although this system prevents the growth of an uninsured
population, it is
met with mixed opinions. In 2003, the German health ministry
concluded

that the system suffers from lack of competition, superfluous,
insufficient,
or inappropriate care, and shrinking revenue, and an aging
population.
Table 1.1 presents selected features of the national health care
pro-
grams in Canada, Germany, and Great Britain and compares
them with
those in the United States.
DISTRIBUTION.
Delivery
Ta
bl
e
1.
1
He
alt
h
Ca
re

S
ys
te
m
s o
f S
ele
cte
d
In
du
str
ial
ize
d
Co
un
tri
es
Un
ite
d
St
at

es
Ca
na
da
Gr
ea
t B
rit
ai
n
Ge
rm
an
y
Ty
pe
Ow
ne
rsh
ip
Fin
an
cin
g

Re
im
bu
rse
m
en
t
(h
os
pit
al)
Re
im
bu
rse
m
en
t
(p
hy
sic
ian
s)

Co
ns
um
er
C
op
ay
m
en
t
Plu
ra
lis
itic
Pr
iva
te
Vo
lun
ta
ry,
m
ult
ipa

ye
r
sy
ste
m
(p
re
m
ium
s o
r
ge
ne
ra
l t
ax
es
)
Va
rie
s (
DR
Gs
,

ne
go
tia
te
d
fe
e-f
or
-
se
rv
ice
, p
er
d
iem
,
ca
pit
at
ion
)
RB
RV

S,
fe
e-f
or
-se
rv
ice
Sm
all
to
si
gn
ific
an
t
Na
tio
na
l h
ea
lth
ins
ur

an
ce
Pu
bli
c/
Pr
iva
te
Si
ng
le-
pa
ye
r (
ge
ne
ra
l
ta
xe
s)
Gl
ob
al

bu
dg
et
s
Ne
go
tia
te
d
fe
e-f
or
-
se
rv
ice
Ne
gli
gib
le
Na
tio
na
l h

ea
lth
sy
ste
m
Pu
bli
c
Si
ng
le-
pa
ye
r (
ge
ne
ra
l
ta
xe
s)
Gl
ob

al
bu
dg
et
s
Sa
lar
ies
a
nd
ca
pit
at
ion
p
ay
m
en
ts
Ne
gli
gib
le

So
cia
liz
ed
h
ea
lth
ins
ur
an
ce
Pr
iva
te
Em
plo
ye
r–
em
plo
ye
e
(m

an
da
te
d
pa
yr
oll
co
nt
rib
ut
ion
s,
an
d
ge
ne
ra
l t
ax
es
)
Pe

r d
iem
p
ay
m
en
ts
Ne
go
tia
te
d
fe
e-f
or
-se
rv
ice
Ne
gli
gib
le
No

te
:D
RG
s,
dia
gn
os
is-
re
lat
ed
g
ro
up
s;
RB
RV
S,
re
so
ur
ce
-ba
se

d
re
lat
ive
va
lue
sc
ale
.
DISTRIBUTION.
Systems Framework 21
SYSTEMS FRAMEWORK
A system consists of a set of interrelated and interdependent
compo-
nents designed to achieve some common goals. The components
are logi-
cally coordinated. Even though the various functional
components of the
health services delivery structure in the United States are at best
only
loosely coordinated, the main components can be identified with
a systems
model. The systems framework used here helps one understand

that the
structure of health care services in the United States is based on
some foun-
dations, provides a logical arrangement of the various
components, and
demonstrates a progression from inputs to outputs. The main
elements of
this arrangement are system inputs (resources), system
structure, system
processes, and system outputs (outcomes). In addition, system
outlook
(future directions) is a necessary element of a dynamic system.
This sys-
tems framework has been used as the conceptual base for
organizing later
chapters in this book (see Figure 1.2).
System Foundations
The current health care system is not an accident. Historical,
cultural,
social, and economic factors explain its current structure. These
factors
also affect forces that shape new trends and developments and
those that
impede change. Chapters 2 and 3 provide a discussion of the
system
foundations.
System Resources
No mechanism for the delivery of health services can fulfill its
primary
objective without the necessary human and nonhuman resources.
Human
resources consist of the various types and categories of workers

directly
engaged in the delivery of health services to patients. Such
personnel—
including physicians, nurses, dentists, pharmacists, other
professionals
trained at the doctoral level, and numerous categories of allied
health pro-
fessionals—usually have direct contact with patients. Numerous
ancillary
workers, such as those involved in billing and collection,
marketing and
public relations, and building maintenance, often play an
important but
indirect supportive role in the delivery of health care. Health
care managers
are needed to manage and coordinate various types of health
care services.
This book discusses primarily the personnel engaged in the
direct delivery
DISTRIBUTION.
Delivery
of health care services (Chapter 4). The nonhuman resources
include med-
ical technology (Chapter 5) and health services financing
(Chapter 6).
Resources are closely intertwined with access to health care.

For
instance, in certain rural areas of the United States, access is
restricted
because of a shortage of certain categories of health
professionals.
Development and diffusion of technology also determine the
caliber of
health care to which people may have access.
II. SYSTEM RESOURCES
Human Resources
“Health Care Providers
and Professionals”
(Chapter 4)
Nonhuman Resources
“Technology and Its Effect”
(Chapter 5)
“Financing and Reimbursement
Methods”
(Chapter 6)
IV. SYSTEM OUTCOMES
Issues and Concerns
“Health Care Cost, Access, and Quality”
(Chapter 12)
Change and Reform
“Policy Issues in Health Care Delivery”
(Chapter 13)
III. SYSTEM PROCESSES
The Continuum of Care
“Outpatient Services and Primary Care”
(Chapter 7)
“Inpatient Facilities and Services”

(Chapter 8)
“Managed Care and Health Networks”
(Chapter 9)
Special Populations
“Long-Term Care Services”
(Chapter 10)
“Medically Underserved Groups”
(Chapter 11)
V. SYSTEM OUTLOOK
“Health Care Delivery in the Future”
(Chapter 14)
E
N
V
I
R
O
N
M
E
N
T
T
R
E
N
D
S
F
U
T

U
R
E
I. SYSTEM FOUNDATIONS
Cultural Beliefs and Values, Historical Developments
“Foundation of US Health Care Delivery”
(Chapter 2)
“Historical Overview of US Health Care Delivery”
(Chapter 3)
System Features
Figure 1.2 Systems Framework
DISTRIBUTION.
Systems Framework 23
System Processes
The system resources influence the development and change in
physi-
cal structures, such as hospitals, clinics, and nursing homes.
These struc-
tures are associated with distinct processes of health services
delivery, and
the processes are associated with distinct health conditions.
Most health
care services are delivered in noninstitutional settings, which

are mainly
associated with processes referred to as outpatient care (Chapter
7).
Institutional health services (inpatient care) are predominantly
associated
with acute care hospitals (Chapter 8). Managed care and
integrated systems
(Chapter 9) represent a fundamental change in the financing
(including
payment and insurance) and delivery of health care. Even
though managed
care represents an integration of the resource and process
elements of the
systems model, it is discussed as a process for the sake of
clarity and conti-
nuity of the discussions. Special institutional and community-
based set-
tings have been developed for long-term care (Chapter 10) and
mental
health (Chapter 11).
System Outcomes
System outcomes refer to the critical issues and concerns
surrounding
what the health services system has been able to accomplish, or
not accom-
plish, in relationship to its primary objective. The primary
objective of any
health care delivery system is to provide to an entire nation
cost-effective
health services that meet certain established standards of
quality. The previ-
ous three elements of the systems model (foundations,
resources, and
processes) play a critical role in fulfilling this objective.

Access, cost, and
quality are the main outcome criteria for evaluating the success
of a health
care delivery system (Chapter 12). Issues and concerns
regarding these cri-
teria trigger broad initiatives for reforming the system through
health pol-
icy (Chapter 13).
System Outlook
A dynamic health care system must look forward. In essence, it
must
project into the future the accomplishment of desired system
outcomes in
view of anticipated social, cultural, and economic changes.
Chapter 14 dis-
cusses these future perspectives.
DISTRIBUTION.
Delivery
CONCLUSION
The United States has a unique system of health care delivery,
but the
system lacks universal access; therefore, continuous and
comprehensive
health care is not enjoyed by all Americans. Health care

delivery in the
United States is characterized by a patchwork of subsystems
developed
either through market forces or the need to take care of certain
population
segments. These include managed care, the military and VA
systems, the
system for vulnerable populations, and the emerging IDSs.
No country in the world has a perfect system. Most nations with
a
national health care program have a private sector that varies in
size. The
systems framework provides an organized approach to an
understanding of
the various components of the U.S. health care delivery system.
REFERENCES
Altman, S. H., and U. E. Reinhardt. 1996. Introduction: Where
does health care
reform go from here? An uncharted odyssey. In S. H. Altman
and U. E.
Reinhardt (eds.). Strategic Choices for a Changing Health Care
System (pp.
xxi–xxxii). Chicago: Health Administration Press.
Anderson, G. F., et al. 2003. It’s the prices, stupid: Why the
United States is so
different from other countries. Health Affairs 22 (3):89–105.
Aventis Pharmaceuticals. 2002. HMO-PPO Digest: Managed
Care Digest Series.
Bridgewater, NJ: Aventis Pharmaceuticals.
Bureau of Labor Statistics. March 12, 2008. Health Care. U.S.

Department of
Labor. Retrieved July 11, 2008, from
http://www.bls.gov/oco/cg/cgs035.htm.
Bureau of Primary Health Care. 1999. Primary Care Programs
Directory.
McLean, VA: National Clearinghouse for Primary Care
Information.
Bureau of Primary Health Care. 2002. BPHC-UDS Annual
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MD: Bureau of Primary Health Care, Health Resources and
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National Center for Health Statistics. 2002. Health, United
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Hyattsville, MD: Department of Health and Human Services.
National Center for Health Statistics. 2007. Health, United
States, 2007.
Hyattsville, MD: Department of Health and Human Services.
National Center for Veterans Analysis and Statistics. 2007.
FY07 VA Information
Pamphlet. Washington, DC: Department of Veterans Affairs.
DISTRIBUTION.
References 25

Politzer, R. M., et al. 2003. The future role of health centers in
improving national
health. Journal of Public Health Policy 24 (3):296–306.
Santerre, R. E., and S. P. Neun. 1996. Health Economics:
Theories, Insights, and
Industry Studies. Chicago: Irwin.
Shi, L., et al. 2001. The impact of managed care on vulnerable
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by community health centers. Journal of Ambulatory Care
Management 24
(1):51–66.
Shortell, S. M., et al. 1996. Remaking health care in America:
Building organized
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U.S. Bureau of the Census. 1998. Statistical Abstract of the
United States: 1998,
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U.S. Census Bureau. 2007. Current Populations Report (pp. 60–
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2006.
Washington, DC: Government Printing Office.
Wolinsky, F. D. 1988. The Sociology of Health: Principles,
Practitioners, and
Issues, 2nd ed. Belmont, CA: Wadsworth Publishing Company.

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Faculty Contact
Cary Stanger [email protected]
Course Description
Prerequisite: A writing course. Recommended: WRTG 291. An
investigation of U.S. history from the end of World
War II to the events of September 11, 2001. The goal is to
identify events, individuals, movements, and
technological developments; synthesize primary and secondary
resources; and analyze the significance of social,
cultural, and political events. Topics include social turmoil, the
Cultural Revolution, the role of the United States
in the world, economic trends, military conflicts, consumerism,
political and public scandals, and globalization.
Course Introduction
World War II profoundly changed the United States. It
contributed to ending the Great Depression and made the
United States a global power with worldwide interests and
commitments. This course investigates the United
States during its development into a prosperous and powerful
nation in the years following 1945. Issues such as
the cold war, Vietnam, and the civil rights movement will be
addressed with both primary and secondary source
readings.
Course Outcomes
After completing this course, you should be able to
• identify key events, individuals, movements, and
technological developments to formulate and effectively
communicate an integrated historical perspective

• synthesize multi-modal primary and secondary resources to
articulate the complexity of historical concepts
and viewpoints
• comprehend and evaluate the significance of historical context
to interpret the development of the United
States in the post-World War II era
• comprehend and analyze the significance of the social,
cultural, and political events of the post-World War II
era in the United States to interpret current issues
Course Materials
Click to access your course materials information
(http://webapps.umuc.edu/UgcmBook/BPage.cfm?
C=HIST%20365&S=6380&Sem=2188)
Grading Information
You are responsible for the following graded items:
Weekly Discussions 35%
University of Maryland University College • Adelphi • Syllabus
•
HIST 365 6380 RECENT AMERICA: 1945 TO THE
PRESENT (2188) HIST-365
Fall 2018 Section 6380 3 Credits 08/20/2018 to 10/14/2018

http://webapps.umuc.edu/UgcmBook/BPage.cfm?C=HIST
365&S=6380&Sem=2188
Research Project - Paper Topic &
Proposal
10%
Research Project - Annotated
Bibliography
20%
Research Project - Final Paper 35%
TOTAL 100%
Late Policy - No late work will be accepted in this class.
Extra Credit Policy - No extra credit will be offered in this
class.
Please note: Submitting proof of successful completion of the
plagiarism prevention tutorial no later than the
first week of the term (23:59 E.S.T. Saturday August 25th) will
entitle you to a bonus point. That will result in
your calculated grade being advanced a single point in your
adjusted grade total which is often enough to result
in a letter grade change. Credit will not be retroactive.
Project Descriptions
I. Discussion Participation (35% of final grade) - See schedule
of assignments
There will be weekly discussions except for the final week of

the semester. Each discussions
takes place in two parts, a preliminary response in the form of a
coherent, integrated essay of one
to two typed pages taking into account all facets of the
discussion question. Remember to write a
literate, documented essay. Bullet point memorandum will be
denied all credit. History takes into
account evidence from multiple sources and reflects evidence of
different points of view. Your
initial response is due no later than Wednesday at 23:59 E.S.T.
and your follow up posting is due no
later than Saturday at 23:59 E.S.T. On Thursday, I award three
points for timely completion of part
I. On Sunday I add the two final points for providing a
response to a previous posting by any
member of the class. This prevents adding two simultaneous
postings at the end of the week. To
complete this class successfully, students are expected to be
engaged on an ongoing basis. Each
completed discussion is valued at up to five points.
II. Research Project (65% of final grade)
The research paper assignment makes up a total of 65% of the
final grade and consists of three sections:
topic/thesis, annotated bibliography, and final paper. Each
section of this assignment builds on the previous
ones and will assist you in completing the final paper which is
to be submitted by the end of week 8 in place of a
final examination.
A. Paper Topic and Proposal (10% of final grade) - Due Week 2
With written approval from the instructor, select a topic from
within the historical parameters of this course (the
United States during the period of 1945 to 2001) that is relevant

to the course outcomes. During the first
week of the term you should send an individual e-message
indicating the topic you are interested
in. Your topic cannot be too broad such as the Vietnam War.
Approval will assist you to define a
manageable but original research topic. Without written
authorization, anything subsequently
submitted will not receive credit. You will perform preliminary
research and create a working thesis
statement with the understanding that it may be slightly
modified later in the research process. Your
topic/thesis is due by the end of week 2 and must show that
you've done some preliminary
research. A proposal is tantamount to a thesis is what you
intend to prove or disprove by your
research. It is not a recitation of events but a meaningful
analysis. The proposal must be in the
form of a written statement from which it is clearly evident that
you have begun your research and
developed a framework for the entire project. Do not provide
this in outline form. Historians are
devoted to lucid articulation, not scanning a column of numbers
or crossword puzzle clues.
B. Annotated Bibliography (20% of final grade) - Due Week 5
Write an annotated bibliography. This will list and describe a
minimum of 10 primary and secondary sources,
with specific requirements detailed below, that you may use in
your paper.

The annotated bibliography should involve a variety of primary
and secondary sources, including at
least two primary sources and articles from at least two
academic journals; it should not include
encyclopedias of any kind, printed or electronic (especially
including Wikipedia), dictionaries, or
non-professional websites. A non-professional web site includes
commercial information or
information designed for a general public. Government
depositories and academic journals (check
the UMUC library web page) are expected in all circumstances.
Each annotation should include a
full, properly formatted Chicago style citation, 1-2 paragraphs
detailing the basic argument of the
work, the type of evidence used to prove the thesis, and an
explanation of the value of the
information to your paper. Professional historians always
utilize the University of Chicago
graduate school citation standards first associated with Kate
Turabian (A Manual for Writers...) This
very detailed form of documenting research enables the whoever
reads your work can find the exact
reference(s) upon which your original conclusions are based.
You can type Chicago style citation into your url
and numerous websites will provide information and examples.
C. Final Paper (35% of final grade) - Due Week 8
Submit a finished paper that includes a title page, endnotes
pages (if used) and bibliography (without
annotations). This paper will be 7-8 double-spaced pages
(excluding the title page, endnotes pages, and the
bibliography), with one-inch margins, times new roman font
size 12, and either footnotes or endnotes (Chicago
Style). Do not use parenthetical notes. If you're not sure about
what this means, ask your

instructor.
The finished paper will use both primary and secondary sources
to increase the plausibility of the
clearly stated, analytical thesis. It will be carefully structured,
composed, and proofread, with all
required components included in the correct order. You need a
minimum of 7 sources to be eligible
for a grade of C; 10 sources to be eligible for an A. Note the
specific requirements for primary and
secondary sources.
Please note that the History Department places great
importance on individual research in upper level
classes. There is no final examination. Your term project
takes the place of a final examination and is
due no later than Sunday October 14, 2018 at 23:59 E.S.T.
Academic Policies
Academic Policies and Guidelines
ACADEMIC INTEGRITY
As a member of the University of Maryland University College
(UMUC) academic community that honors integrity
and respect for others you are expected to maintain a high level
of personal integrity in your academic work at
all times. Your work should be original and must not be reused
in other courses.
CLASSROOM CIVILITY
Students are expected to work together cooperatively, and treat
fellow students and faculty with respect,
showing professionalism and courtesy in all interactions.
Please review the Code of Civility for more guidance on
interacting in UMUC classrooms:

https://www.umuc.edu/students/support/studentlife/conduct/cod
e.cfm
(https://www.umuc.edu/students/support/studentlife/conduct/cod
e.cfm).
POLICIES AND PROCEDURES
https://www.umuc.edu/students/support/studentlife/conduct/cod
e.cfm
UMUC is committed to ensuring that all individuals are treated
equally according to Policy 040.30 Affirmative
Action, Equal Opportunity, and Sexual Harassment
(https://www.umuc.edu/policies/adminpolicies/admin04030.cfm
).
Students with disabilities who need accommodations in a course
are encouraged to contact the Office of
Accessibility Services (OAS) at [email protected]
(mailto:[email protected]), or call
800-888-UMUC (8682) or 240-684-2287.
The following academic policies and procedures apply to this
course and your studies at UMUC.
150.25 Academic Dishonesty and Plagiarism
(https://www.umuc.edu/policies/academicpolicies/aa15025.cfm)
– UMUC defines academic
dishonesty as the failure to maintain academic integrity. All
charges of academic dishonesty
will be brought in accordance with this Policy.
Note: In this course, your instructor has access to use
Turnitin.com, a tool that helps to
evaluate the originality of student work. Your instructor may
use Turnitin or other resources to
check the authenticity of your work and the accuracy of your

use of sources. To learn more
about Turnitin, the feedback it provides, and your options
regarding the storage of your work
in the Turnitin database go to the UMUC guides at
umuc.edu/library/libresources/turnitin-
students.cfm
(https://www.umuc.edu/library/libresources/turnitin.cfm) and
http://sites.umuc.edu/library/libresources/turnitin.cfm#studentco
pyright
(http://sites.umuc.edu/library/libresources/turnitin.cfm). If you
have questions about academic
integrity or how to cite your sources go to the UMUC Academic
Integrity Resources page at
http://www.umuc.edu/current-students/learning-
resources/academic-integrity/resources.cfm
(http://www.umuc.edu/current-%20students/learning-
resources/academic-
integrity/resources.cfm).
151.00 Code of Student Conduct
(https://www.umuc.edu/policies/studentpolicies/stud15100.cfm)
170.40
170.41
170.42
The following policies describe the requirements for the award
of each degree:
Degree Completion Requirements for the Graduate School
Degree Completion Requirements for a Bachelor’s Degree
Degree Completion Requirements for an Associate’s Degree
170.71 Policy on Grade of Incomplete

- The mark of I is exceptional and considered only for certain
courses. Students who have
completed 60% of their coursework with a grade of B or better
for graduate courses or C or
better for undergraduate courses and request an I before the end
of the term. The mark of I is
not available for noncredit courses.
170.72 Course Withdrawal Policy
-
Students must follow drop and withdrawal procedures and
deadlines available at
https://www.umuc.edu/ (https://www.umuc.edu/) under
Academic Calendar.
130.80 Procedures for Review of Alleged Arbitrary and
Capricious Grading
– appeals may be made on
final course grades as described herein.
205.06 Calculation Of Grade-Point Average (GPA) for Inclusion
on Transcripts and Transcript Requests
– Note: Undergraduate and
Graduate Schools have different Grading Policies (i.e. The
Graduate School does not award
the grade of D). See Course Syllabus for Grading Policies.
https://www.umuc.edu/policies/adminpolicies/admin04030.cfm
mailto:[email protected]
https://www.umuc.edu/policies/academicpolicies/aa15025.cfm
https://www.umuc.edu/library/libresources/turnitin.cfm
http://sites.umuc.edu/library/libresources/turnitin.cfm

http://www.umuc.edu/current- students/learning-
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Week/Dates Assignments Due Date
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Topic: WWII to Cold War
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Week 8
10/7-10/14
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due
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11:59 pm ET
HIST 365 6380 Recent America: 1945 to the Present (2188)
HIST-365Faculty ContactCourse DescriptionCourse
IntroductionCourse OutcomesCourse MaterialsGrading
InformationProject DescriptionsAcademic PoliciesClass &
Assignment Schedule
Name: Adedotun Adereti
Course : HIIT 102
Date: September 14, 2018

The healthcare delivery system in the United States is unique
and complex, when compared to other developed countries that
has national healthcare for their citizens. In these countries, the
government provides the citizens with access to routine and
basic health care (Shi, 2019) while that is not available in the
U.S. There are so many factors that influence the U.S healthcare
delivery system, some of these factors are political climate,
stage of economy development, technological advancement,
social and cultural influence. There are major characteristics of
the U.S healthcare delivery system which are as follows;
No central governing agency and little integration and
coordination
The healthcare system in the United states is complex because
there is no centralized control system. Lack of centralization in
the United states health care system makes health care to be
expensive as it can not be managed by global budget. Due to the
large private sector involvement in the US health care system,
most of the Doctor’s office and hospitals are privately owned
and independent of the government. The federal and state
government have huge impact in the US healthcare delivery
system, public sector expenses and reimbursement for Medicaid
and Medicare patients are determined by both federal and state
government. In contrast to the US healthcare system, other
developed countries have a centralized Healthcare system that
makes financing and delivery of health care available to all
citizens.
Technology-driven delivery system focusing on acute care
The United States has been the most advanced in medical
technology. Progress in science and technology generates a
demand for new services though there is a shrink in the
resources to finance healthcare (Shi, 2019). There are other
factors that contributes to increase in the demand for expensive
care in the US health care system; Some patients believe that
modern technologies offer better care, some physician office

would want to try new technology and some medical institution
like hospital believe that having the latest technology allows
them to compete in the healthcare market. These factors hike up
the cost of care because hospitals, physician office are now
pressured to recover the capital invested in obtaining the
technologies thereby leading to increase in the cost of
healthcare. Advance medical technology has ushered in new and
successful medical interventions but there are consequences
linked to these advanced technologies being over used. For
instance, the high cost of medical intervention has caused
inflation in the cost of healthcare, which has made it difficult
for employers to offer part-time workers insurance benefit (Shi,
2019).
High on Cost, Unequal in Access, and Average in Outcome
The United States spend 13% of gross domestic product (GDP)
on healthcare which is mostly medical care which is not the
case in other developed countries. Not everyone in the US has
access to healthcare when in need of preventive care. Healthcare
is only available to those who have health care benefits through
their employers, covered by government healthcare programs
such as Medicaid and Medicare, those who can afford to pay out
of personal funds and those who can pay for the care and
services they obtained. The only way to get access to healthcare
is by buying an health insurance out of pocket or getting one
through your employer and this leads to the high cost of
healthcare, uninsured people do not have access to routine and
basic care which is also known as primary care except they pay
the fee charged by the physician and those that cannot afford it,
have to wait till the health challenges gets worse at which point
they can obtain free care. In the absence of insurance, patients
are unable to receive adequate care that is needed which has led
to increase in mortality rate in the US, though the US is one of
the most advanced economies, they are behind in the healthcare
provided for her citizens. (Shi, 2019)
Imperfect Market Condition:
The US healthcare delivery is mostly in private hands but is

partially governed by free market forces (Shi, 2019). There are
key characteristics of a free market which prove that the US
healthcare market is not free.In a freemarket, many patient
(buyers) and providers(sellers) act autonomously, Patient should
be able to choose their provider with price and services
rendered being the determinant. For free healthcare market,
there must be unrestricted competition among providers based
on their prices and the quality service they render. Free market
works well when information about care services and products
are made available to patients which is not the case in the US;
Patient don’t have information about other expense that comes
with the care obtained. For instance, the of recovery care and
anesthesiology is not made available to patient who is about to
undergo a procedure.
Government as Subsidiary to the private Sector:
In the US health care market, the private sector dominates
unlike other countries where government provides the health
care for residents. The gaps left opened by the private sector in
the US healthcare market is covered up by the government. (Shi,
2019)
Market Justice versus Social Justice: Conflict throughout Health
Care
There are two opposite theories that controls production and
distribution of health care in the US. The market justice’s
principle puts the responsibility of reasonable distribution of
health care on market forces in a free market (Shi, 2019). In
market justice, medical care and its benefit are made available
based on the ability of people to pay out of their personal funds.
In the just distribution principle, the distribution of health care
is based on the need of the health care not the ability to pay.
Multiple Players and Balance of power
There are numerous key players in the healthcare system of the
United States. Insurance companies, labor, physicians, big
businesses and hospital consist of the powerful group that are
represented by high price lobbyist before law makers. Conflicts
arises when interest of each player contradicts the other. For

Chapter 1Major Characteristics of U.S.Health Care Delive.docx

Chapter 1Major Characteristics of U.S.Health Care Delive.docx

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