SOC101: Introduction to Sociology

There are broad, structural differences among the healthcare systems of different countries. In core nations, those differences might arise in the administration of healthcare, while the care itself is similar. In peripheral and semi-peripheral countries, a lack of basic healthcare administration can be the defining feature of the system.

Most countries rely on some combination of modern and traditional medicine. In core countries with large investments in technology, research, and equipment, the focus is usually on modern medicine, with traditional (also called alternative or complementary) medicine playing a secondary role. In the United States, for instance, the American Medical Association (AMA) resolved to support the incorporation of complementary and alternative medicine in medical education. In developing countries, even quickly modernizing ones like China, traditional medicine (often understood as "complementary" by the Western world) may still play a larger role.

U.S. Healthcare

U.S. healthcare coverage can broadly be divided into two main categories: public healthcare (government-funded) and private healthcare (privately funded).

The two main publicly funded healthcare programs are Medicare, which provides health services to people over 65 years old and people who meet other standards for disability, and Medicaid, which provides services to people with very low incomes who meet other eligibility requirements. Other government-funded programs include service agencies focused on Native Americans (the Indian Health Service), Veterans (the Veterans Health Administration), and children (the Children's Health Insurance Program).

Private insurance is typically categorized as either employment-based insurance or direct-purchase insurance. Employment-based insurance is health plan coverage that is provided in whole or in part by an employer or union; it can cover just the employee or the employee and their family. Direct purchase insurance is coverage that an individual buys directly from a private company.

Even with all these options, a sizable portion of the U.S. population remains uninsured. In 2019, about 26 million people, or eight percent of U.S. residents, had no health insurance. 2020 saw that number go up to 31 million. Several more million had health insurance for part of the year. Uninsured people are at risk of both severe illness and chronic illnesses that develop over time. Fewer uninsured people engage in regular check-ups or preventative medicine and rely on urgent care for a range of acute health issues.

The number of uninsured people is far lower than in previous decades. In 2013 and in many of the years preceding it, the number of uninsured people was in the 40 million range, or roughly 18 percent of the population. The Affordable Care Act, which came into full force in 2014, allowed more people to get affordable insurance. The uninsured number reached its lowest point in 2016 before beginning to climb again.

People with some insurance may mask the fact that they could be underinsured; that is, people who pay at least 10 percent of their income on healthcare costs not covered by insurance or, for low-income adults, those whose medical expenses or deductibles are at least five percent.

Why are so many people uninsured or underinsured? Skyrocketing healthcare costs are part of the issue. While most people get their insurance through their employer, not all employers offer it, especially retail companies or small businesses where many workers may be part-time. Finally, for many years, insurers could deny coverage to people with pre-existing conditions – previous illnesses or chronic diseases.

The Patient Protection and Affordable Care Act (often abbreviated ACA or nicknamed Obamacare) was a landmark change in U.S. healthcare. Passed in 2010 and fully implemented in 2014, it increased eligibility for programs like Medicaid, helped guarantee insurance coverage for people with pre-existing conditions, and established regulations to ensure that the premium funds collected by insurers and care providers go directly to medical care.

It also included an individual mandate requiring everyone to have insurance coverage by 2014 or pay a penalty. A series of provisions, including significant subsidies, are intended to address the discrepancies in income that are currently contributing to high rates of uninsurance and underinsurance. In 2012, the U.S. Supreme Court upheld the constitutionality of the ACA's individual mandate. 29 million people in the United States have gained health insurance under ACA.

Figure 19.7 The Affordable Care Act has been a savior for some and a target for others. As Congress and various state governments sought to have it overturned with laws or to have it diminished by the courts, supporters took to the streets to express its importance to them.

The ACA remains contentious. The Supreme Court ruled in the case of National Federation of Independent Businesses v. Sebelius in 2012 that states cannot be forced to participate in the PPACA's Medicaid expansion. This ruling opened the door to further challenges to the ACA in Congress and the Federal courts, some state governments, conservative groups, and independent businesses. The ACA has been a driving factor in elections and public opinion. In 2010 and 2014, many Republican gains in Congressional seats were related to fierce concern about Obamacare. However, once the law covered millions of people and the economy continued to improve public sentiment and elections swung the other way. Healthcare was the top issue for voters, and the desire to preserve the law was credited for many of the Democratic gains in the election, which carried over to 2020.

Healthcare Elsewhere

Clearly, healthcare in the United States has some areas for improvement. But how does it compare to healthcare in other countries? Many people in the United States are fond of saying that this country has the best healthcare in the world. While it is true that the United States has a higher quality of care available than many peripheral or semi-peripheral nations, it is not necessarily the "best in the world." In a report on how U.S. healthcare compares to that of other countries, researchers found that the United States does "relatively well in some areas – such as cancer care – and less well in others – such as mortality from conditions amenable to prevention and treatment."

One critique of the Patient Protection and Affordable Care Act is that it will create a system of socialized medicine. For many Americans, this term has negative connotations lingering from the Cold War era and earlier. Under a socialized medicine system, the government owns and runs the system. It employs doctors, nurses, and other staff and owns and runs the hospitals. Great Britain offers the best example of socialized medicine, where the National Health System (NHS) gives free healthcare to all its residents. Despite the knee-jerk reaction some Americans have to healthcare changes that hint at socialism, the Veterans Health Administration is a socialized system.

It is important to distinguish between socialized medicine, where the government owns the healthcare system, and universal healthcare, which guarantees healthcare coverage for everyone. Germany, Singapore, and Canada have universal healthcare. People often consider Canada's universal healthcare system, Medicare, a model. In Canada, healthcare is publicly funded and administered by separate provincial and territorial governments. However, the care itself comes from private providers. This is the main difference between universal healthcare and socialized medicine. The Canada Health Act of 1970 required that all health insurance plans must be "available to all eligible Canadian residents, comprehensive in coverage, accessible, portable among provinces, and publicly administered."

Heated discussions about the socialization of medicine and managed-care options seem frivolous when compared with the issues of healthcare systems in developing or underdeveloped countries. In many countries, per capita income is so low, and governments are so fractured that healthcare as we know it is virtually non-existent. Care that people in developed countries take for granted – like hospitals, healthcare workers, immunizations, antibiotics and other medications, and even sanitary water for drinking and washing – is unavailable to much of the population. Organizations like Doctors Without Borders, UNICEF, and the World Health Organization have played an important role in helping these countries meet their most basic health needs.

Figure 19.8 This map shows the countries where malaria is known to occur. In low-income countries, malaria is still a common cause of death.

The World Health Organization (WHO), the health arm of the United Nations, set eight Millennium Development Goals (MDGs) in 2000 with the aim of reaching these goals by 2015. Some of the goals deal more broadly with the socioeconomic factors that influence health. Still, MDGs 4, 5, and 6 all relate specifically to large-scale health concerns, the likes of which most people in the United States will never contemplate. MDG 4 aims to reduce child mortality, MDG 5 aims to improve maternal health, and MDG 6 strives to combat HIV/AIDS, malaria, and other diseases. The goals may not seem particularly dramatic, but the numbers behind them show how serious they are.

For MDG 4, the WHO reports that 2009 infant mortality rates in "children under five years old in the WHO African Region (127 per 1000 live births) and in low-income countries (117 per 1000 live births) [had dropped], but they were still higher than the 1990 global level of 89 per 1000 live births" (World Health Organization 2011). The fact that these deaths could have been avoided through appropriate medicine and clean drinking water shows the importance of healthcare.

Much progress has been made on MDG 5, with maternal deaths decreasing by 34 percent. However, almost all maternal deaths occurred in developing countries, with the African region still experiencing high numbers.

On MDG 6, the WHO is seeing some decreases in per capita incidence rates of malaria, tuberculosis, HIV/AIDS, and other diseases. However, population increases often offset the decreases (World Health Organization 2011). Again, the lowest-income countries, especially in the African region, experience the worst problems with disease. An important component of disease prevention and control is epidemiology, or the study of the incidence, distribution, and possible control of diseases. Fear of Ebola contamination, primarily in Western Africa but also to a smaller degree in the United States, became national news in the summer and fall of 2014.

Source: Tonja R. Conerly, Kathleen Holmes, Asha Lal Tamang; OpenStax, https://openstax.org/books/introduction-sociology-3e/pages/19-4-comparative-health-and-medicine
This work is licensed under a Creative Commons Attribution 4.0 License.