Access to Health Care in the U.S

Access to health care in the United States is a complex and contentious issue, primarily characterized by the absence of universal coverage. Unlike many developed nations, the U.S. operates on a fee-for-service model, resulting in significant disparities in access to medical care based on socioeconomic status, race, and ethnicity. Vulnerable populations, including low-income individuals, immigrants, children, and people of color, often face substantial barriers, leading to higher rates of uninsured individuals, with millions lacking adequate health care coverage.

The Affordable Care Act (ACA) of 2010 sought to address these inequalities by expanding health insurance access and regulations aimed at improving care quality. Programs like Medicaid and the Children's Health Insurance Program (CHIP) provide essential coverage for low-income Americans, particularly children and seniors. However, challenges persist, including cultural and linguistic barriers that hinder access for many immigrants, as well as ongoing issues related to the quality and availability of care.

The broader context of social inequality exacerbates these health care access issues, raising questions about the U.S. system's ability to provide equitable care for all its citizens. The debate over health care reform continues to evoke strong opinions among the public and policymakers, reflecting the multifaceted nature of the issue.

Published in: 2021

By: Mandel, Ilanna

Subject Terms

Access to Health Care in the U.S.

Abstract

The United States is one of few developed nations without universal access to health care. Instead, the system has functioned as a fee for service system, which means some people are able to afford access to health care and while others are not. The American health care system and access to it has been a key social issue for many decades. It continues to divide the American public and policy makers.

The United States faces another reality that is intrinsically bound with the health care issue—social inequality. Some suggest that social inequalities are based primarily on socioeconomic status, while others suggest they are based on race and/or gender. President Barack Obama’s Affordable Care Act of 2010 attempts to address these issues and level the playing field by equalizing access to health insurance.

Overview

The United States is one of the few developed countries without universal access to health care, and since access to health care is inextricably tied to access to affordable health insurance, many see the system as failing the American people. Historically there have been disparities in availability of health care for people from various income levels, and the care that is available is not of consistent quality. Immigrants, the poor, and the homeless seem to be most affected by inaccessibility to health care, and seniors and children are also vulnerable.

There has long been a concern that people of color and ethnic communities continue to represent a majority of the uninsured in America. New immigrants often experience difficulties with accessing and understanding the system. There are Americans who are homeless and their ability to access health care is severely limited. Ironically, the US continues to be one of the wealthiest countries in the world with some of the most advanced medical technologies. Regardless of this reality, the question remains whether or not the United States can successfully reform its own system so that no one is denied access to proper health care.

Social Stratification & the US Health Care System. The primary theory of stratification is that historical inequities have translated into creating socioeconomic strata in society. The lower a person or group may be on the strata, the greater the likelihood that person or group will always live in poverty and the harder it is to improve the socioeconomic state in life. Such social strata are directly tied to social inequalities, and "social inequalities in access to health care persist in the US health care delivery system. Lower social classes, minority racial/ethnic groups, and those without health insurance continue to experience barriers to care" (Pappas, Hadden, Kozak, & Fisher, 1997, p. 811). In other words, historically there has been one system in the United States for those who can afford health insurance, and thus quality health care, and another system, often of lesser quality, for those without insurance.

The Affordable Care Act. The Patient Protection and Affordable Care Act (PPACA) of 2010—commonly called the Affordable Care Act (ACA) or Obamacare after its major backer US president Barack Obama—sought to reform a number of aspects of the US health insurance industry as well as improve access to and quality of health care services. After the passage of ACA, insurers were required to cover preventive services without a deductible, copayment, or other out-of-pocket expense; extend coverage to children with existing medical conditions; cover young-adult children up to age twenty-six on their parents’ plans; spend most of their premiums on benefits to consumers rather than on administrative costs; and provide justification for rate increases. Starting in 2014, insurers were no longer allowed to set annual dollar limits on coverage, reject anyone based on preexisting medical conditions, or restrict or deny coverage to those who participate in clinical trials. ACA also expands Medicare coverage through the state governments (US Department of Health & Human Services, 2013).

At the time of its passage, the Affordable Care Act was the most substantial overhaul of the US healthcare system since the passage of Medicare and Medicaid during the Johnson administration in the mid-1960s. Although it has encountered intense opposition from the general public, medical professionals, and various public officials and has had numerous problems and glitches in its start-up, the ACA promised to dramatically improve the affordability of and access to health insurance. By 2019, political divide over the Affordable Care Act remained high, with some groups continueously calling for it to be overturned.

Public Health Coverage: Medicaid & Medicare. Medicaid is a federal program that provides health insurance coverage to qualifying very low-income Americans, particularly among those over age sixty-five and children under eighteen. Medicare is the program that provides people over sixty-five with medical care. It also provides support for persons with certain disabilities and people of all ages who have end-stage renal disease (kidney failure). Medicare has become far more complicated than it was in its original form. There are four sections to Medicare: A, B, C, and D. Respectively, they cover hospital insurance, medical insurance, advantage plans, and prescription drug coverage. One of the ongoing problems for the Medicare program has been to continue to provide the health insurance required by seniors and persons with disabilities at the same time as trying to contain costs. Like Medicaid, Medicare also has variations in practice among states, which also leads to some confusion over and frustration with the program.

Public Health Coverage: Health Care for Children. There is perhaps no issue as salient and distressing as that of the millions of Americans who are uninsured. In 2018, an estimated 28.56 million Americans were uninsured, 4.3 million of them were children under eighteen (Berchick, Edward R., et al., 2019). According to DeVoe (2007), "children from lower socioeconomic backgrounds have poorer health outcomes. These health disparities are due, in part, to barriers in accessing medical care and utilizing primary care services" (DeVoe, et al., 2007, p. 511). Libby (2006) further explains that "one specific vulnerable and often low-income population is children and adolescents involved with child welfare. Children in contact with child welfare systems have been shown to be particularly vulnerable to health and mental health problems…" (Libby, 2006, p. 40).

The Children’s Health Insurance Program (CHIP) is a health program that emerged in 1997 from the collapse of the Clinton administration's efforts at health care reform in 1994. CHIP is part of Medicaid and provides health insurance to many children below the age of nineteen. States have a great deal of leeway in deciding how to administer the program. Prior to the Affordable Care Act, very few programs besides CHIP and Medicaid provided health insurance to very poor or uninsured children. Problems arose with these programs, however, from inadequate state funding for CHIP, and children on Medicaid were reported to have to wait longer for appointments than were children with private pay insurance. Physician access for children on Medicaid was also poor (Roy, 2011; Grady, 2011). The Affordable Care Act as it was passed in 2010 proposed to expand Medicaid coverage and benefits and address the issues of substandard health care for children by increasing Medicaid payment rates to health care providers to help ensure access to primary care providers for more low-income children. Children will also no longer be denied coverage for preexisting conditions and will no longer have annual or lifetime caps placed on their health insurance. For very poor or uninsured families, ACA provides tax credits and vouchers to help with quality health insurance coverage (Children’s Defense Fund, 2012). Additionally, ACA allows parents to keep their children on their policy until age twenty-six.

Public Health Coverage: Health Care for Seniors. Senior citizens are living longer than ever before. "Two factors—longer life spans and aging baby boomers—will combine to double the population of Americans aged sixty-five and older during the next twenty-five years" (Centers for Disease Control, 2007, p. III). Seniors also tend to be far more independent into their later years than at any time in history. In addition, the senior population is swelling and with it is the need to provide adequate geriatric health care. Health care for seniors is provided more and more on an out-patient basis. Far fewer seniors are going into long-term care, and when they do, they tend to go into care at an older age than in the past.

Historically, healthcare benefits for older persons were not uniform. Medicare beneficiaries enrolled in health plans, for instance, might receive essential services (such as case management) that are not covered for those enrolled in fee-for-service Medicare. Community-based alternatives to long-term care (such as the Program for All-inclusive Care of the Elderly) were essentially out of reach financially for older persons who are not dually insured by Medicare and Medicaid (Racz, 2005, p. 248).

The Affordable Care Act attempted to address these issues and has among other provisions included additional preventative care benefits through Medicare. The law also lowers the cost of prescription drugs and provides incentives to physicians who treat Medicare patients or who provide primary care in regional areas with doctor shortages. In prior years, seniors did not have consistent access to quality health care and services (Centers for Disease Control, 2007). To further address this issue, the Affordable Care Act increased the number of checks and balances to ensure best practices in nursing homes so that seniors and their family members can feel more assured of quality care.

The Working Poor. Prior to the passing of the Affordable Care Act, the working poor have had difficulty accessing affordable health insurance. Many employers do not provide health insurance for their employees as a cost cutting measure. Therefore, many of the uninsured are not necessarily homeless or unemployed. A study in California revealed that the majority of the working poor in the state are immigrants. In a state where almost one third of the population is comprised of immigrants, this means that almost a third of Californians go without medical coverage. "Among immigrant working poor families, the disproportionate number of parents whose employers do not offer health benefits coupled with limited eligibility for public health insurance coverage have contributed to decreased access to care" (Guendelman, Angulo, Wier, & Oman, 2005, p. 352). There is no doubt that an inextricable link exists between poverty and lack of access to health care in America.

Cultural Barriers & American Health Care. The United States is comprised of many immigrant cultures, and many newly immigrated do not speak English as a first language and also bring with them their cultural heritage and customs. The process of acculturation, or adjustment to a new culture, implies that people become accustomed the norms, values, and ways of life in their new home. While the term may imply a sense of adjustment, it does not mean that people lose their own heritage or cultural identity. However, the American health care system is not based on the principle of multiculturalism. According to Yu, et al., “This suggests cultural and linguistic barriers in the health care system that discourages access despite eligibility. Immigrant children who are not naturalized citizens clearly face substantial barriers to seeking and receiving health care (2004, p. 106).

Further Insights

The Failures of the American Health Care System. Many sociologists and others blame the structure of the health care system for creating inequities. While they do not deny that racism and prejudice exist, they suggest that any inability to access the system should be blamed on the fact that a fee for service system cannot easily be changed and regulations often lead to further inequality of access. “Despite the extraordinary increase in health expenditures . . . and the rise in government financing through Medicare and Medicaid, . . . millions of Americans either have no health insurance . . . or are inadequately protected by limited and intermittent coverage. Millions still live in geographical regions that have been officially designated as "medically underserved" (Bayer, et al., 1988, p. 583).

Viewpoints

History of Reform Efforts. While one can easily become cynical over the state of American health care, it is important to present a balanced picture. Prior to the Affordable Care Act of 2010, there have been notable efforts to try and change or reform the system. During his two-term presidency (1993–2001), former president Bill Clinton and his wife Hillary Rodham Clinton worked to bring universal health care to the United States. Even before this, there were significant attempts to try and reform the system.

During the first two decades of the twentieth century, labor unions attempted to reform the American health care. Since there was no requirement for employers to provide health care to their workers, workers would lose wages if they missed work due to illness and would have to pay for medical care out of pocket. This dual problem often left workers with huge debts. According to Hoffman (2003), "In 1915, progressive reformers proposed a system of compulsory health insurance to protect workers against both wage loss and medical costs during sickness" (p. 76).

In the 1960s, President Lyndon Johnson attempted reform by enacting Medicare, which is a federal program that provides health insurance coverage to qualifying very low-income Americans, particularly among those over age sixty-five and children under eighteen. By creating Medicare, the most vulnerable in society would be provided for. However, today, Medicare has become another huge bureaucratic structure which only adds to the complexity of the current problems facing the health care system.

Throughout the 1960s and 1970s, Massachusetts Senator Edward Kennedy (1932–2009) was at the forefront of trying to create universal health care in America. He is famous for being a health care advocate and many believe this was his greatest legacy as a politician. Yet, despite his best efforts, and his popularity in the Senate, he was unable to provide a bill that would truly reform American health care (Hoffman, 2003).

The history of health care reform would be incomplete without mentioning grassroots movements. In the 1970s, returning war veterans from the Vietnam came home with permanent disabilities. They lobbied hard and long for their own needs and for health care reform. Their demonstrations and constant efforts were rewarded with the development of The Rehabilitation Act of 1974 - Bill 504. Disabled Rights Activists worked together again and pushed President George H. W. Bush to gain passage of the Americans with Disabilities Act in 1990.

Yet even before then, groups of Americans were fighting for their health care rights. For example, "The women's health movement has greatly influenced campaigns for national health care. In the early 1970s, the labor-led Committee for National Health Insurance held the first conference on women and universal health care" (Hoffman, 2003, p. 81).

In 1991, Representative Marty Russo of Illinois and Senate Majority Leader George Mitchell of Maine sponsored the Universal Health Care Act of 1991. This was a follow-up to the Pepper Commission Report on Access to Health Care and Long-Term Care for All Americans in 1990 (Scuka, 1994). The Pepper Commission and the Universal Health Care Act of 1991 differed in their approaches, but they both attempted to bring long-term reform to health care. The Russo Bill, as it was also called, went the furthest by recommending an end to co-payments, deductibles, and annual out-of-pocket payments (Scuka, 1994).

When President Bill Clinton was elected in 1992 the time seemed right for health care reform. He appointed his wife Hillary as the head of the Clinton Health Care Task Force. During the debates among the Democratic contenders for the 2008 presidential nomination, Senator Clinton admitted that despite her best effort, she could not bring about universal health care. According to Hoffman, "Clinton, fearful of business and insurance company opposition, proposed a dauntingly complex system of ‘health alliances’ that would preserve both employer-based coverage and the commercial insurance industry" (2003, p. 78).

No group in American history has possibly fought as long and hard for health care reform than have HIV/AIDS activists. Since the early 1980s, these activists have been organized and determined. They have advocated for research, proper care, medication trials, and insurance reform for people living with HIV and AIDS. "The activism of people with AIDS and HIV fighting for their very lives led to unprecedented changes in the health care system" (Hoffman, 2003, p. 80).

Conclusion

A 2004 report from the Agency for Healthcare Research and Quality stated that “despite the high quality of the US health care delivery system, many Americans do not get all the health care that they need" (Agency for Healthcare Research and Quality. 2005). Many in poor socioeconomic circumstances are less likely to access quality health care, or, in some cases, any health care at all. Some large cities such as Los Angeles, California, have free medical facilities, but the waiting list is very long.

Poor or near poor women are more likely than high income women to report fair or poor overall health and limitations of activity; they are also more likely to report anxiety, depression, arthritis, asthma, diabetes, hypertension, obesity, and osteoporosis (Agency for Healthcare Research and Quality, 2005).

DeVoe, et al. (2007) also report on the dire situation for people in low socioeconomic circumstances. Many American children go without health care because their families cannot afford it. For those families who are able to secure public funding, they discover that many doctors do not accept their coverage. Even lower and middle income families have coverage difficulties: "Finally, there is a growing number of low- and middle-income families with private health insurance who gain access to most services, but the high deductibles and co-pays prevent them from getting necessary care" (DeVoe, et al., 2007, p. 6). By 2020, 11.4 million people had signed up for private insurance using the Health Insurance Marketplace established by the Affordable Care Act. Additionally, the CHIP and Medicaid programs saw three million more enrollees between the opening of the marketplaces under the ACA and February 2014.

Terms & Concepts

Acculturation: Refers to the process by which two or more distinct cultural groups come into contact with each other and although they may influence each other, they do not lose their own unique, cultural identities.

Corporatization: A term that is sometimes used interchangeably with privatization. It refers to the process by which a formerly publicly owned business or enterprise is sold into corporate hands.

Cultural Competence: Usually referred to as the ability to interact effectively with people from a broad range of cultures. With respect to health care it has a much broader connotation which implies that health care professionals will be trained in working and communicating about health care with people from a broad range of cultures.

Medical Necessity: Used to define the relative appropriateness of a medical procedure. A medically necessary service is clinically appropriate, in accordance with generally accepted standards of practice and not for primarily the convenience of the patient.

Monopoly: Economic control is in the hands of a few corporations that dominate the ways in which a specific area of business is conducted. It creates an imbalance in socioeconomic conditions as the monopoly is in control of access to economic power and reduces the power of the individual consumer.

Social Stratification: Refers a society is divided into different strata according to ethnicity, socioeconomic status, race class, and/or disability. People are often treated different and access various structures of society according to the strata of society in which they exist. In some societies there is greater social mobility than in others. Stratification will become the foundation for the society's structure and important aspects of society such as health care reflect those divisions.

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