Health and Illness

Health Care in the United States

Health Care and Insurance

In the United States, the health insurance system includes private companies and publicly funded programs.
In the United States, access to health care is linked to numerous factors, including where people live, what kind of job they have, whether or not they have insurance, and the type of insurance they have. Many rural areas have few doctors and hospitals, while major urban areas have a range of providers that people can choose from. Private, employer-sponsored health insurance developed in the early 20th century. By the 1960s, most large employers offered some type of health insurance, although the costs and types of coverage of these plans vary widely. In 1965 the federal Medicare and Medicaid programs were created. Medicare is a health insurance system for Americans aged 65 and older, while Medicaid is a program for low-income Americans. CHIP, or Children's Health Insurance Program, covers eligible children through both Medicaid and separate, state-run CHIP programs. The federal Veterans Health Administration (VA) provides health care to veterans.
Percentages of Americans Covered under Different Types of Insurance Plans
Employer-sponsored plans 49%
Privately purchased plans 7%
Medicare 14%
Medicaid, including CHIP 19%
Other 2%
Uninsured 9%

In the last half of the 20th century, the concept of managed care emerged. Managed care refers to a health insurance system that creates contracts with networks of health care providers and approves or denies care. Patients agree to receive care only from approved providers, and health insurance companies monitor costs and treatments. Doctors and other providers agree to be paid set fees for each type of service they provide. Medicare, Medicaid, and the VA use this approach, as do many private health insurance companies.

Many Americans lack health insurance. Those who do not qualify for Medicaid or Medicare or who do not have employers who provide affordable coverage often go without insurance and without treatment. In 2010 the federal government passed the Patient Protection and Affordable Care Act, often referred to as Obamacare or the Affordable Care Act (ACA). The Patient Protection and Affordable Care Act (PPACA) is legislation that seeks to extend health insurance coverage to more Americans and includes numerous provisions, such as prohibiting denial of coverage based on preexisting health conditions, as well as subsidies (funding) to help some people pay for coverage. Prior to the passage of the PPACA, over 45 million people in the United States—about 15 percent of the population—had no health insurance. By the end of 2016 this number was cut to about 28 million people, about 9 percent of the population. It is notable that among wealthy countries, the United States is an outlier in that it does not provide universal health care coverage to all citizens. Age, occupation, socioeconomic status, and race are important factors related to who has health insurance in the United States. Lack of health insurance is higher for African Americans, Hispanics, and Native Americans. This is in part because these groups have statistically lower levels of income and wealth, as well as higher levels of unemployment and employment in lower-paying occupations. Individuals who belong to these groups may not have income, wealth, insurance, or employment that align with these patterns of employment and wealth. But average levels of income and wealth for these groups reflect broad patterns of inequality. These factors of social stratification contribute to lack of health insurance and a corresponding lack of access to health care and treatment.

Percentage of Uninsured Americans under Age 65 by Race/Ethnicity, 2016

One example of racial and ethnic stratification in the United States can be seen in rates of uninsured individuals. African Americans, Hispanics, and Native Americans have consistently higher rates of lack of health insurance, in part because of higher unemployment rates and higher rates of working in occupations that do not provide affordable health insurance. These groups had the greatest gains in insurance coverage after the passage of the Affordable Care Act, but disparities still persist.

Health Maintenance Organizations

Health maintenance organizations focus on keeping the cost of medical care down, while shaping decisions about what treatments are considered necessary.

Health care in the United States is often delivered through health maintenance organizations. A health maintenance organization (HMO) is an organization that delivers medicine through prepaid contracts and negotiated fees. HMOs developed as a way to control medical expenses by discouraging doctors from prescribing unnecessary medications and performing unnecessary procedures. HMOs use the concept of managed care, a system of approving or denying treatments, medications, and consultations with primary care doctors and specialists. Many hospitals maintain a chargemaster, a comprehensive list of medical services and their costs, which is used for negotiating with HMOs. To strengthen the hospital's negotiating position, this list may inflate fees for some procedures, and some services might be denied because of their cost. The United States has the highest per capita health care costs in the world, leading some analysts to criticize the ways that these prices are set and negotiated.

Managed care has been criticized for denial of care. Medicines and treatments that a doctor prefers might be denied by an insurance company, forcing the patient to turn to a cheaper, suboptimal treatment. A social issue around managed care and HMOs is the question of who has the power to define treatment as necessary or unnecessary. In systems where health care is managed by a for-profit business, power is mostly in the hands of administrators whose job is to keep costs down for the business. This can increase the social power of corporations and decrease the power of doctors and patients.

Sociologists study the social implications of HMOs on the U.S. health system. HMOs are both market-based systems and bureaucratic systems. Sociologists consider how bureaucracies function as social institutions. On the one hand, they can promote the use of rational, evidence-based decision making. This can help remove bias from the health care system of a society. However, sociologists also consider how bureaucracies can be impersonal and inflexible. This can contribute to disparities in the health care system. Researchers point to longstanding disparities in health and health care linked to race, ethnicity, and gender. Addressing such disparities may require a more personalized and flexible approach to health care.

Hospitals

Most U.S. hospitals are managed by nonmedical professionals and earn huge profits; doctor-run hospitals tend to rank higher in terms of quality.

In the United States large hospitals serve as facilities for researching disease and medicine, training new doctors, and treating patients. Smaller, community hospitals focus exclusively on patient care. Hospitals are complex bureaucracies, and running them effectively while distributing medical care equitably throughout a society can be challenging. In the United States hospitals face doctor and nurse shortages, although the distribution of the problem is not even. Rural areas and hospital emergency rooms suffer the most acute shortages. Both of these areas offer lower pay. This partly contributes to another issue for hospitals—lack of sleep among physicians. Doctors often work long hours, even surpassing 24 hours straight on a shift. Numerous studies have shown that doctors who do not get proper sleep are more likely to make mistakes. Issues facing hospitals are connected to society at large. In the United States a free-market approach to health care that results in big profits for many hospitals is heavily favored. This approach is linked to high health care costs and difficult working conditions, although health outcomes in the United States are worse than in other high-income countries.

In the United States some hospitals are run by doctors, but most are run by administrators with a background in business. Sociologists look at data related to hospital management and relevant social, economic, and political issues. Over 90 percent of U.S. hospitals are led by CEOs with no medical training. However, many of the best hospitals are among the small minority that is managed by physicians. A 2011 study of hospital quality found that doctor-run hospitals scored 25 percent higher on quality measures than hospitals run by CEOs. American hospitals earn huge profits, including nonprofit hospitals. A study of hospital profits from 2003–13 found that profitable hospitals succeeded by raising costs and excluding uninsured patients or those with Medicare and Medicaid (public insurance). Investor-owned hospitals had the highest profit margins. Unprofitable hospitals treated a disproportionate share of Medicare, Medicaid, and uninsured patients. In social terms, this research shows a trend of placing profits over people in U.S. health care. Much sociological research on U.S. hospitals analyzes the social forces behind this trend, as well as the impacts on different social groups.

Health Care Costs

U.S. health care costs per capita are the highest in the world.
Sociologists study the social implications of the role of huge profits in medicine, including how different social groups are affected by this approach and the impact on society at large. Numerous studies show that U.S. per capita health care costs—how much is spent per person, per year—are by far the highest in the world. However, health outcomes in the United States are inferior to those in other high-income countries. A 2018 study of health care spending in high-income countries confirmed the disparity between the United States and its peer countries, such as Canada, Australia, Japan, and France. The study notes that high prices characterize every facet of American health care. The high price of care and the emphasis placed on profit shape the American health care system and divert money from other parts of society, such as education and transportation. These factors also increase the likelihood that health care and good health are more accessible to individuals and groups with higher incomes. In hospital settings, more privileged patients are more likely to get care from more experienced, less stressed providers. Patients who lack insurance are more likely to go to hospital emergency rooms for conditions that could have been treated in a nonemergency setting. These patterns impact doctors, nurses, and medical assistants working in hospitals, as well as patients.