Professor Marshall

LESSON 19: Health and Medicine

Lesson 19

Target Competencies (Outcomes)

Explain the social construction of health in America

Understand global health concerns

Characterize different forms of health care delivery

You will demonstrate your competence by:

Completing the learning activities in this Learning Plan

Your performance will be successful when:

You can explain social construction in the context of health

You can articulate the impacts of illness on nations of varying wealth

You can characterize disparities in the health care system in America

You can classify the different forms of available health care in the United States

You can analyze problems in health care via major sociological perspectives


Learning Activities

1. If you have not yet done so, READ Chapter 19 of your text.

2. COMPLETE the lesson below.


This lesson takes a detour from the information in your text and concetrates on two issues that are of importance to Americans today:

  1. the high costs of health care
  2. AIDS and its impact on society.

Caduceus

 

What are the positive and negative aspects of the US Health Care System?

For the last few decades in the US, there has been a national debate about the efficiency of our health care system. On one side of the debate is the reluctance of most Americans to pay additional taxes to fund a public health care system that would (or, at least, could) meet the basic needs of all Americans. On the other side of the debate are micro and macro level problems associated with a pay-for-care, profit making health care system. 

No matter the political debate, our system is flawed and is in serious need of an overhaul. Hospitals, health care facilities, and health care providers generally charge a set amount for their services. For patients with insurance, the cost of that care will automatically be billed to their insurance company--but with this condition: their insurance company has already determined what it (the insurance company) considers is a reasonable price for that service, and it will not pay more than this amount to facilities and providers. In other words, set prices or not, facilities and providers agree to accept the amount for services that the insurance company deems reasonable and has agreed to pay.

If you are uninsured, things are different. You will just be billed the caregiver's original set amount, without any downward adjustments being driven by what an insurance company deems reasonable. So, because of this lack of adjustment, an uninsured person in the U.S. may actually end up paying more for a procedure than would their neighbor who has insurance (and who might be more financially secure). Many facilities won't even see uninsured people who aren't first willing and able to pay up front.

Using sociology to examine the system allows us to pivot around the debate and seek to find the positive and the negative aspects of the system how it is today, and of the system under current mandated changes that are happening under President Obama's Affordable Care Act.

This module is not intended to examine the POLITICS of health care. It is intended to examine ACCESS to health care from a sociological perspective. Sociologists are concerned with what actually happens in a society and to people and groups--with regard to health care access, sociologists want to know what the consequences are when significant members of that society are uninsured, such as in the United States.

Why is it that we would consider health care (access to care and absence of disease) a social problem? Using Joel Charon's 4 Questions Approach allows us to answer:

  1. What is the problem?: It is easy to look at problems related to health as personal issues, but when many individuals in society are impacted by personal issues of health, health care, and absence/presence of disease, it is easy to frame the issue as a social concern. We have to however, when answering this question, consider the values of a majority of citizens. Do significant numbers Americans today agree that we have a failing health care system? If we look at the popularity of President Obama's ACA, we can see that many Americans might agree that we have a systemic issue which is contributing to the illness of many Americans. Among the failures of the current system are prohibitive costs (of insurance policies, premiums, copays, and other related expenses), denial of services and claims (for pre-exisiting conditions, or for other administrative reasons), and a general lack of accessibility within the system with regards to the elderly and the working poor. Is there evidence that these problems will impact society? Certainly we can point to myriad studies which show the hours of lost productivity (calling in sick, missing work due to ill children at home, losing a job due to chronic, untreated illness). We can also point to many peer reviewed studies which show that the uninsured cost tax payers greatly as they rely on emergency rooms to seek care, and usually wait until a health problem is acute before seeking care. More than 50 million people in America are currently uninsured (Kendall 2013).
  2. What makes it a social problem?: Research suggests that this is a social problem due to the lack of affordable care for poorer Americans. Significant numbers of the poor die each year and research suggests that the lack of affordable heath care is a major contributor to many of these deaths. With increasing numbers of Americans being impacted by issues related to the ailing health care system, society as a whole beings to suffer. While solutions to the ailing system are myriad, one thing is sure: most Americans now agree that there need to be significant changes to the current system in order for it to work better for most people.
  3. What causes the problem?: Certainly personal choices contribute to the overall issues of high costs of health care, but we also have to view this as a structural issue. Not all people who are poor/lack health insurance have done something to cause their illness or condition--most will fall ill due to no fault of their own. If personal behavior was the only contributor to illness, then we would not necessarily view access to health care as a social problem. Social problems become social problems when our culture and our social structure work together to create the conditions under which Americans begin (and continue) to suffer. In this case, we have had a majority culture which strongly suggested that health care costs should be borne by the individual and not by the government. We have also had a structure which supported good care for those who could afford it, while not denying care to many (but not all) of those who could not afford it (via government programs such as Medicaid and Medicare). In recent years however there has been a shift in the way access to health care is perceived in America. Prior to this shift, access to health care was viewed as a benefit earned through hard work and effort. The shift in thinking has begun to move us toward thinking that access to good health (via access to the health care system) is a human right.This shift in thinking has caused us to begin the social construction of the problems related to access to health care.
  4. What can be done about the problem?: Today, we are working toward one possible solution which would potentially ease the problems associated with limited access--the ACA (see above). While we cannot solve problems related to individual behaviors and illness, we can work to guarantee that, from infancy, every American is afforded a minimum level of care which will encourage them to practice healthy behaviors throughout their lifecourse. There will never be 100% consensus about access to health care--some will continue to see this as a privilege, while others will continue to view it as a right. We also will never have complete consensus about the solutions to the problem. One thing is certain: if we do nothing, many Americans will continue to go about their lives without seeing doctors for routine care, and will potentially suffer the consequences of poor heath throughout their lives.

Why is There a Health Care Crisis?

Costs spiraling out of control, high unemployment/underemployment and increasing rates of poverty have contributed to the crises related to health care in the US. We are beginning to implement the ACA, President Obama's change to our health care system, which is designed to try to get costs under control while widening the net of Americans who can afford to see a doctor when ill. View THIS TIMELINE of the schedule of changes under the ACA. As you can see, the ACA is a measure which attempts to bring costs under control while also bringing affordable insurance to many more people in the US. The ACA is modeled after other industrialized nations' own systems, which are commonly referred to as universal health care systems.

There is a bit of discussion among Americans about these types of system--much of the information we hear is incorrect. For example, we often hear that a system such as the Canadians have would not work for for the US. Research suggests that overall, Canadians have better acess to doctors, make more trips to see doctors, have longer hospitalization stays, and have higher immunization rates among their citizenry. Canadians also live longer, have lower infant mortality rates, and enjoy overall better health than do Americans. While there is also research which shows that there are longer waits in Canada for services, the benefits seem to outweigh the costs. In the United Kingdom, most people are covered by the National Health System (NHS). Again, long waits seem to be the biggest problem, and the British government is working toward implementing changes to the system which might help in this regard. Sweden, another universal type of system, has a system which covers everyone who lives there--regardless of their citizenship status. Sweden also faces the same issues as do Canada and the United Kingdom--lines and waits are long for services and physicians are not motivated to see extra patients due to the way their paychecks are structured by the government.

Only time will tell if the US can engage a program which will work for Americans. But since the percentage of uninsured Americans has increased steadity over the last few decades, the system is in need of major overhauls. When we drill down to view who the uninsured are, we see a clearer picture of who has access to health care and who does not:

Uninsured Dempgraphics

As we can see, race, class, and age all play important parts with regard to access to health care. For example, while whites make up 72% of the population in the US, only 12% of whites lack health coverage. Conversely, Hispanics, who comprise 17% of our overall population have a 32% rate of non-coverage. Poor children also suffer a higher percentage of non-coverage than do all children without health care in the US. In all families in the US, nearly 27% of those who have incomes of less than 25,000 annually have no insurance. When we have a major health crisis, these groups suffer more than those who have insurance and who have the financial ability to see a doctor when they need to. The hope of the ACA is that the discrepancies in the above chart will be eased by a program which eventually hopes to insure all Americans regardless of their socio-economic situations.

Mortality

There are several major illnesses and health conditions which are mortality factors in the US. The ten leading causes of death are (CDC, 2009):

  • Heart disease: 599,413
  • Cancer: 567,628
  • Chronic lower respiratory diseases: 137,353
  • Stroke (cerebrovascular diseases): 128,842
  • Accidents (unintentional injuries): 118,021
  • Alzheimer's disease: 79,003
  • Diabetes: 68,705
  • Influenza and Pneumonia: 53,692
  • Nephritis, nephrotic syndrome, and nephrosis: 48,935
  • Intentional self-harm (suicide): 36,909

While not listed on the above, the mortality rate for persons in the US identified to be HIV+ is approximately 22,000 per year. It is important to note that this figure may be underreported--the data on AIDS related deaths is from CDC estimates calculated from a confidential name-based HIV reporting tool, and thus, only captures those who are known to be infected and who died in a given years' time. This means that the statistic may be considered somewhat "volatile" and that it is likely (as with all data collected about private matters such as health status, income, sexual orientation, illicit drug use, etc.) underrepresented.

The AIDS Crisis

By the early 1990s, AIDS had become a health care issue labeled a "crisis" here in the US (and in many countries around the world). Most of us are now familiar with the basics of the disorder (how one is infected, etc.) Each year in the US, over 50,000 new cases of AIDS are diagnosed. Men are the majority of these cases (about 75%), and although African Americans make up only about 15% of our total US population, nearly HALF of all new diganoses come from this group. Hispanics/Latinos are also disproportionately affected. Over half a million Americans have died from AIDS-related complications over the past few decades, and while deaths have begun to slow down due to advances in medical research, this is still very much a fatal disease. People do not die of AIDS however; rather death is attributed to the HIV (human immunodeficiency virus) which destroys white blood cells and makes the individual succeptible to diseases (tuberculosis, pneumonia, etc.) These diseases eventually become too much for the ill person to overcome.

AIDS is not evenly distributed with regard to race, class or gender. It is also not geographically evenly distributed:

AIDS by Geographic Region

Because the HIV epidemic is not evenly distributed across the country, CDC uses a strategy called High-Impact Prevention that invests its HIV prevention resources in the places and populations most affected by HIV and encourages the use of programs that will be most effective in those jurisdictions.

Examples of CDC's targeted approach to HIV prevention:

  • The Enhanced Comprehensive HIV Prevention Planning Project (ECHPP) is a 3-year project intended to maximize the impact of HIV prevention in the 12 metropolitan statistical areas with the highest AIDS prevalence in the United States. Each site creates a tailored HIV prevention plan using HIV interventions that should be most effective in their specific region.
  • The Expanded Testing Initiative (ETI) is a large-scale HIV testing program intended for populations disproportionately affected by HIV. During the first 3 years of the program, CDC invested more than $100 million in ETI to test 2.7 million persons for HIV, resulting in 0.7% with newly identified HIV diagnoses and averting an estimated 3,381 new HIV infections. Importantly, ETI achieved a return of $1.95 for every dollar invested—showing that an investment in HIV testing can save money over time. Research shows that once people learn of their HIV infection, they are likely to take steps to protect their partners from becoming infected.
  • Funding for state and local health departments is CDC's most significant HIV investment. CDC allocates its HIV and AIDS funding for health departments to closely align with the geographic areas and populations most affected by the epidemic. These programs channel more resources to the areas that need them the most, while still ensuring that all persons in the United States have a basic understanding of HIV, know how to protect themselves from becoming infected, know where to get an HIV test, and understand the importance of treatment. Therefore, all states receive a basic level of HIV funding to achieve these goals.

Relationships Between HIV/AIDS and Access to Health Care

People in the US who get appropriate treatment do respond well to drug protocols and do extend their lives significantly. So, how does one who does not have early and regular access to health care (via an employer or some other government sponsored health care) fare?

In theory and until the ACA is fully recognized, every American citizen is "covered" by either private insurance (through an employer or union), a government program (such as Medicaid or Medicare), or a individually purchased private health insurance policy. However we do know that nearly 50 million Americans are not covered by any type of health insurance protection. For those living with HIV, access to health care is more limited--less than 20% of those living with HIV in the US have private insurance, and 33% do not have any health care coverage at all. This makes HIV/AIDS not only a health care problem, but also a social problem.

The ACA will address this issue by prohibiting insurers from denying coverage to children living with AIDS/HIV. The ACA will also prohibit rescinding/cancelling policies of HIV/AIDS infected adults. In addition, in general the ACA prohibits the imposition of lifetime caps on benefits (drug protocols for the treatment of HIV/AIDS is very expensive).

Many people living with AIDS/HIV are on a low income, which contributes to the amount of stress the individual experiences. In general as supported by research, those who do not have or cannot afford to purchase health care insurance are less likely to seek preventative health care, and are more likely to wait to seek care when they are ill (usually this is due to the costs related to seeing a doctor or other health care professional). According to the National HIV/AIDS Strategy report, nearly one third of all people in the US living with HIV are not in care. The changes that will be implemented under the ACA hope to expand care to those who cannot afford it today.

Theory

Helath Care Theory

Conclusion

While it can not be argued that most Americans have access to top-notch health care, through our examination of the AIDS epidemic, it is easy to see how some groups are disadvantaged. As in other areas, sociologists are concerned about the unequal access to health care that is the primary driver of poor health outcomes for minority groups. We have touched upon some of the more obvious connections between race, gender, sexual orientation, class and so on, with regard to health in this lesson. You are encouraged to continue to investigate this social problem and to ponder what some of the solutions to these problems may be.