the who, healthcare systems can most improve health equality when institutions are organized to provide universal coverage, where everyone receives the same quality healthcare regardless of ability to pay, as well as a primary healthcare system rather than emergency center assistance. these structural problems result in worse healthcare and therefore worse health outcomes for impoverished populations. health care costs can pose absolutely serious threats to impoverished populations, especially in countries without proper social provisions. according to us hhs, "in 2009, children 6–17 years of age were more likely to be uninsured than younger children, and children with a family income below 200% of the poverty level were more likely to be uninsured than children in higher-income families." in elderly populations, individuals below 400% of the poverty line were between 3 and 5 times more likely to lack insurance. children below 200% of the poverty line were also less likely to have insurance than wealthier families. also, in 2009 in the us, 20% of adults (ages 18–64) below 200% of the poverty line did not receive their necessary drugs because of cost, compared to only 4% of those above 400% of the poverty line. increasing healthcare costs (including higher premiums) imposed a burden on consumers. in 2010, president obama introduced the patient protection and affordable care act (aca), expanding health care to many that lacked coverage. the u.s. had the highest rate of uninsured people, and the highest health care costs, of all industrialized nations at the time. the aca helped 20 million americans get coverage and decreased the rates of uninsured from 16% in 2010 to 8.6% in 2016. the aca brought coverage to people who had had downgrades in employee insurance programs, by providing a health insurance marketplace, giving them access to private insurance plans along with income-based government subsidies. this can be seen in other nations, where in asia, payments for healthcare pushed almost 3% of the population of 11 countries below 1 us$ per day. however, under the current u.s. administration, there have been shifts in how federal funding is allocated to social service programs. although, initiatives like the national prevention council have been established to address prevention, there have also been some drawbacks. because of this political shift, entities that address the social determinants of health in poverty, like social service programs, are threatened under these new policies. these policies reallocate funding away from public social service programs, causing resources that promote prevention and public health to be limited. the problem most present with state provisioned resources like public social service programs that aim to alleviate health disparities are the ever changing political spheres that either propel or block communities from access to effective health care resources and interventions. despite the strength of political influences, it has been shown that, globally, shifting attention to addressing social needs like healthcare access has dramatically affected the health of impoverished communities. societal psychological influences in impoverished communities, different social norms and stressors exist than in other populations, which can greatly affect health outcomes in disadvantaged populations. according to the national institutes of health, "low socioeconomic status may result in poor physical and/or mental health ... through various psychosocial mechanisms such as poor or "risky" health-related behaviors, social exclusion, prolonged and/ or heightened stress, loss of sense of control, and low self-esteem as well as through differential access to proper nutrition and to health and social services (national institutes of health 1998)." these stressors can cause physiological alterations including increased cortisol, changed blood-pressure, and reduced immunity which increases their risks for poor health. structural violence underlying social structures that propagate and perpetuate poverty and suffering- structural violence- majorly determine health outcomes of impoverished populations. poor and unequal living conditions result from deeper structural conditions, including "poor social policies and programs, unfair economic arrangements, and bad politics," that determine the way societies are organized. the structure of the global system causes inequality and systematically higher death rates, which is caused by inequity in distribution of opportunities and resources, which is termed structural violence. definition structural violence is a term devised by johan galtung and liberation theologians during the 1960s to describe economic, political, legal, religious, and cultural social structures that harm and inhibit individuals, groups, and societies from reaching their full potential. structural violence is structural because the causes of misery are "embedded in the political and economic organization of our social world; they are violent because they cause injury to people." structural violence is different from personal or behavioral violence because it exclusively refers to preventable harm done to people by no one clear individual, but arises from unequal distribution of power and resources, pre-built into social structure. structural violence broadly includes all kinds of violations of human dignity: absolute and relative poverty, social inequalities like gender inequality and racism, and outright displays of human rights violations. the idea of structural violence is as old as the study of conflict and violence, and so it can also be understood as related to social injustice and oppression. effects structural violence is often embedded in longstanding social structures, ubiquitous throughout the globe, that are regularized by persistent institutions and regular experience with them. these social structures seem so normal in our understanding of the world that they are almost invisible, but inequality in resource access, political power, education, healthcare, and legal standing are all possible perpetrators of structural violence. non citizens do not have access to medical insurance and healthcare and must seek care in clinics and outpatient departments. structural violence occurs "whenever persons are harmed, maimed, or killed by poverty and unjust social, political, and economic institutions, systems, or structures" structural violence can contribute to worse health outcomes through either harming or killing victims, just like armed violence can have these effects. this type of unintended harm perpetuated by structural violence progressively promotes misery and hunger that eventually results in death, among other effects. ehrlich and ehrlich reported in 1970 that between 10 and 20 million of the 60 million annual deaths across the globe result from starvation and malnutrition. their report also estimated that structural violence was responsible for the end of one billion lives between 1948 and 1967 in the third world. structural violence connection to health inequality in daily living conditions stem from unseen social structures and practices. this systematic inequality is produced by social norms, policies, and practices that promote the unfair distribution of power, wealth, and other social resources, such as healthcare. "the poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally." first, structural violence is often a major determinant of the distribution and outcome of disease. it has been known for decades that epidemic disease is caused by structural forces. structural violence can affect disease progression, such as in hiv, where harmful social structures profoundly affect diagnosis, staging, and treatment of hiv and associated illnesses. the determinants of disease and their outcome are set by the social factors, usually rampant with structural violence, that determine risk to be infected with the disease. understanding how structural violence is embodied at the community, individual, and microbial levels is vital to understanding the dynamics of disease. the consequences of structural violence is post pronounced in the world's poorest countries and greatly affects the provision of clinical services in these countries. elements of structural violence such as "social upheaval, poverty, and gender inequality decrease the effectiveness of distal services and of prevention efforts" presents barriers to medical care in countries like rwanda and haiti due to structural violence, there exists a growing outcome gap where some countries have access to interventions and treatment, and countries in poverty who are neglected. with the power of improved distal interventions, the only way to close this outcome gap between countries who do and do not have access to effective treatment, lies on proximal interventions to reduce the factors contributing to health problems that arise from structural violence.