Community Health in Context
- Describe how health maintenance is linked to long-term health outcomes like premature death.
- Explain Maslow's Hierarchy of Needs and its relevance to understanding individual health and well-being.
- Outline the challenges and issues faced by the US healthcare system, including complexity, cost, coverage, and consequences.
- Identify the goals of the Triple Aim in population health initiatives and the shift towards value-based healthcare reimbursement models.
- Define social care and list the 5 A's of social care activities.
Introduction
Community health workers (CHWs) help people in their community access and use the healthcare system. They work together with medical professionals to make it easier for community members to get the care they need.
This lesson covers important foundational knowledge for understanding the systems that influence the health and quality of life of the diverse communities you will be working with as a CHW.
Which type of car owner are you?
Imagine two car owners. One regularly changes the oil and rotates the tires. The other neglects maintenance — they don't have the time, the money, or they just let it go. The first spends more up front. The second ends up with a broken engine and a much bigger bill, and the car never quite recovers.
Taking care of your health works the same way. Ignoring problems can cost more — and be more dangerous — in the long run.
What resources do people need to be healthy and reach their potential?
What does it mean to take care of your health? What does maintenance look like?
How can doctors, nurses, and other professionals help meet those needs?
Should individuals be responsible for knowing what their own health needs are?
Top risk factors for premature death
Top risk factors for premature death
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Maslow's Hierarchy of Needs
One framework for understanding what people want and need is psychologist Abraham Maslow's hierarchy. Click each tier to explore it.
Maslow's Hierarchy of Needs
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Self-Actualization
Morality, creativity, spontaneity, problem-solving, lack of prejudice, acceptance of facts.
Maslow suggested that lower-tier needs (physiological, safety) must be satisfied before someone can fully focus on higher needs. He also emphasized this isn't rigid — even people in poverty can find fulfillment in love, belonging, and self-actualization.
According to Maslow's hierarchy, why does it matter that CHWs often work with patients facing food insecurity or housing instability?
An overview of the US healthcare system
The United States healthcare system includes both how and where care is given, and how it's paid for.
Healthcare delivery settings
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Issue 1: Complexity
Most developed countries have national health insurance programs run by government and funded by taxes. The US works very differently.
Countries with government-funded health insurance
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In the US, healthcare is delivered and paid for in a more fragmented way. Most insured Americans get private commercial insurance through their job or via the Marketplace. Government programs (Medicare, Medicaid, military/veteran care) cover the rest.
Health Insurance Coverage Sources Among Insured Americans (2020)
- Private; Through employer54.4 (51.9%)
- Private; Bought on marketplace10.5 (10%)
- Public; Medicare18.4 (17.6%)
- Public; Medicaid17.8 (17%)
- Public; Military/veterans care3.7 (3.5%)
Issue 2: Cost
In 2020, the US spent nearly 19% of its GDP on healthcare — over $11,700 per person for the nearly 330 million US citizens. Other developed nations spend 8–13% of GDP and have similar or even better outcomes.
Health Expenditure as a % of GDP (2020)
Why so expensive?
- High administrative costs
- For-profit companies throughout the system
- No government negotiation of pharmaceutical prices
- Defensive medicine — overtreating to avoid lawsuits
- Fee-for-service reimbursement — more services billed = more revenue
Healthcare providers are often paid based on the number of services they provide, known as the "fee-for-service" model. Some examples of billable healthcare services:
Examples of healthcare services
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Issue 3: Coverage
Even with all those different insurance sources cobbled together, there are significant cracks. In 2020, 28 million Americans — 8.6% of the population — had no healthcare coverage at all.
For those who do have insurance, many plans restrict coverage to certain doctors or hospitals, and charge more for out-of-network providers. The result: confusion and unexpected bills that become a major financial burden.
Issue 4: Consequences
Despite spending more on healthcare than any other country, Americans don't enjoy better health. Preventable illnesses and manageable chronic diseases drive more hospital visits and a shorter life expectancy than other advanced nations.
Healthcare Spend per Capita vs. Life Expectancy
The US spends far more on healthcare than comparable countries, but life expectancy is similar to (or lower than) nations that invest a fraction of what the US does. Despite the spending, the US falls short on actual citizen wellbeing.
Which best describes the relationship between US healthcare spending and outcomes?
The Triple Aim
Positive changes are being made. These changes are being made to improve the healthcare system and ensure better access for any underserved individuals. Population health improvement initiatives strive for three central goals:
- Improve the well-being of entire communities
- Enhance people's healthcare experiences
- Reduce overall costs
These goals are often referred to as the "Triple Aim" of population health.
Value-based reimbursement
Unlike fee-for-service, value-based models reward providers for quality over quantity — for working together, preventing chronic disease, and helping patients live healthier lives. The two most common forms:
Bundled Payments
Social Determinants of Health and Social Care
Value-based care recognizes that addressing social determinants of health (SDOH) is essential to improving outcomes and reducing costs. SDOH are conditions outside the healthcare system that influence health: housing, education, employment, nutrition, social support, transportation.
Social care refers to the support and services that address these determinants — utility bill assistance, home-delivered meals, caregiver respite, and so on. Common activities that integrate social care into healthcare are the 5 A's:
The 5 A's of social care
The role of social care in value-based health care
Because SDOH play a vital role in determining health outcomes, value-based initiatives are now including social care activities. Payers such as insurance companies and Medicare make both financial and wellness-based arguments to support them:
- Social care can reduce future costs by preventing needs from getting worse.
- Social care can boost future revenue by improving appointment attendance rates and satisfaction with care.
- Social care can enhance health outcomes by addressing basic needs and helping people better manage their health conditions.
Promoting Health Equity
Throughout this lesson we've explored healthcare system challenges and how social care helps. Running through it all is the realization that certain groups consistently experience worse outcomes.
But here's the exciting part: we have the power to make things better. It starts with understanding the concepts of equality and equity.
Equality vs. Equity
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We can work toward not just equality, but equity. CHWs build strong relationships with patients, listen, and understand each person's unique needs. They become champions, connecting people with the right resources to improve their health. By linking individuals with social care and providing personalized assistance, CHWs play a vital role in improving patient outcomes, reducing healthcare costs, and repairing a broken system.
Match each of the 5 A's of social care to the activity it describes.
🌟 Lesson Takeaways
Health outcomes are shaped by maintenance, access, and social factors. The US healthcare system is more complex, more expensive, less universal, and produces worse outcomes than peer nations. The Triple Aim and value-based care are trying to fix this — and addressing social determinants of health (via the 5 A's) is central to that work. CHWs are uniquely positioned to bridge clinical care and the social factors that determine health by building trust, staying in regular contact, and providing social care support.
Great work! At the end of this module, you'll join a live discussion with your cohort and an instructor. We'll see you there.