Health Care and Insurance
|Percentages of Americans Covered under Different Types of Insurance Plans|
|Privately purchased plans||7%|
|Medicaid, including CHIP||19%|
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
Health Maintenance Organizations
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.
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.