Health Care by Age, Gender, and Class

Abstract

Historically, access to health care for US citizens has been a challenge. There are, for instance, disparities in availability of health care for people of various income levels, and the care that is available is of lower quality. Children and older adults are two of the most vulnerable groups of people in any society. Their health care needs are high, but not all children and older adults have equal access to the same quality of health care. Those of particular vulnerability are the children of the poor, immigrant, or those experiencing homelessness. Health care for women is also a concern, and many women endure various gender-related conditions without adequate health care.

Overview

Health Care by Age, Gender, & Class. One of the primary concerns in the United States is the lack of adequate health care for every citizen. In particular, people who are poor, experiencing homelessness, or newly arrived tend to be without health care insurance. Additionally, some of the people most deeply affected are women, children, and older adults. The class structure in the United States is very much evident in the health care system. Historically, those with wealth, high-paying jobs, or secure employment have excellent health care plans and therefore have access to better facilities. This is not the case for people with partial insurance or no insurance at all, who, in turn, have limited access to quality health care, which then leads to poor health and additional barriers to success in life.

Further Insights

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 several aspects of the US health insurance industry, as well as improve the access to and quality of health care services. Since the passage of ACA, insurers have been 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, discriminate against women, 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 health care system since the passage of Medicare and Medicaid during the Johnson administration in the mid-1960s. Although it has encountered intense opposition from the public, medical professionals, and various public officials, and has had numerous problems and glitches in its start-up, the ACA promises to dramatically improve the affordability of and access to health insurance. During the COVID-19 pandemic, the American Rescue Plan Act extended coverage for poor families to ensure their health and safety. Many experts noted this likely saved many lives. In a 2021 executive order, President Biden assigned federal agencies to tackle several issues in health care which act as barriers for many Americans—policies which undermine the Health Insurance Marketplace, enrollment challenges, policies on preexisting conditions, and general affordable access. Later, in 2022, the Inflation Reduction Act was signed, which extended the ACA's funding through 2025 (Kenton, 2022).

Health Care for Children. There is perhaps no issue as salient and distressing as that of the millions of Americans who are uninsured. In 2013, an estimated 41 million Americans were uninsured, including 9.8 percent of children below the poverty line and 7 percent of children above it. In 2015, after the first year of major implementation of the ACA, the number of uninsured people of all ages in the United States had dropped from 36 million in 2013 to 28.5 million (Cohen & Martinez, 2015; Henry J. Kaiser Family Foundation, 2016). By 2022, the number of uninsured individuals in the US reached an all-time low of 8 percent. This indicated that between 2020 and 2022, 5.2 million people gained health insurance. One million of these individuals were children (Lee et al., 2023). 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 ("Children’s Health Insurance Program," 2022). 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). As of 2022, CHIP was funded through the year 2027, after which, it will require an extension or reform ("Children’s Health Insurance Program," 2022).

Resources for Mental Health Care and Substance Use Disorder. Primarily due to the stigma associated with mental health disorders and addiction, the United States has for generations suffered from a lack of access to and adequate provision for services for mental health issues and often concurrent substance use disorder, especially for children and adolescents. "Children's mental health needs [have been] underserved, poorly served or completely unmet . . . with untenable waiting lists for services and uneven geographic availability of services and providers. Those children with the most severe, chronic mental illnesses have the fewest options for care” (Jellinek et al., 2005, pp. 31–32). The Affordable Care Act of 2010 extends coverage and accessibility for children and adolescents as well as adults by requiring all health plans to include mental health and substance use disorder services and expanding the 2008 Mental Health Parity and Addiction Equity Act, which prohibits differences in treatment limits, cost sharing, and in- and out-of-network coverage between mental and physical health care, from employer-provided large group health plans to small business and individually purchased health plans. In addition, increased funding will be provided for school-based health centers that will provide mental health services in addition to medical care. Medicaid was also marked for improvement in that it would cover chronic conditions that would include mental illness and substance use disorder.

Mental health and substance use disorder insurance coverage has been inadequate for much of the nation. Prior to the implementation of the Affordable Care Act, approximately one-third of individuals with private insurance did not have mental health benefits and close to 20 percent did not have any coverage to treat addiction. An estimated 60 percent of Medicare Advantage enrollees in 2022 were not covered for out-of-network outpatient mental health or substance abuse services, and those who were covered typically paid about half of the total bill in the end (Freed et al., 2023). An estimated 3.7 million Americans in need of mental health coverage have been left uncovered because the states in which they live have opted not to expand Medicaid programs under the APA (Ollove, 2014). In 2022, an estimated 20 percent of adults over sixty-five reported mental health symptoms, most of whom could not afford the care they needed (Freed et al., 2023).

Health Care for Older Adults. Medicare is a federal health care 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 older adults and persons with disabilities while also containing costs. Like Medicaid, Medicare also has variations in practice among states, which has led to some confusion over and frustration with the program.

People 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). Older adults also tend to be far more independent in their later years than at any time in history. In addition, the older adult population is swelling in the twenty-first century and with it is the need to provide adequate geriatric health care. Health care for older adults is provided more and more on an outpatient basis. Far fewer older adults 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, health care benefits for older persons were not uniform. Medicare beneficiaries enrolled in health plans, for instance, may 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, older adults 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 older adults and their family members can feel more assured of quality care.

Health Care for Women. Just as health care for older adults is changing, so is it for women. Women’s health care includes a wide range of medical needs and specialties including conception counseling, pre- and post-natal care, and menopausal care. There are also several recommended preventive procedures that test for potentially fatal diseases such as cervical and breast cancer. Early diagnosis and treatment of these cancers have dramatically increased life expectancy among women, yet many forgo these relatively simple tests due to lack of adequate health coverage and insurance. Implementation of the Affordable Care Act has promised that all women will have access to preventative care by no longer requiring out-of-pocket expenses for immunizations, mammograms, and screenings for certain cancers. Women will also not be denied coverage for preexisting conditions such as breast cancer or diabetes.

Women & AIDS. One of the most serious health problems is that of the increasing number of individuals who have acquired or are at risk for acquiring HIV/AIDS. According to a 2003 report prepared for the Kaiser Foundation, women accounted for 7 percent of the reported AIDS cases in 1986. Women and girls were approximately 25 percent of all HIV/AIDS diagnoses in the United States in 2014 (Centers for Disease Control and Prevention, 2016). In 2021, women accounted for 18 percent of the new HIV diagnoses, but women of color were disproportionately affected ("Diagnoses of HIV infection," 2023).

Quality health care and health services are of primary importance for any individual living with HIV and AIDS. Acquiring affordable and secure health insurance is equally important but historically has been difficult to obtain. Fewer than 20 percent of Americans living with HIV had private health insurance and nearly one-third had no coverage whatsoever (Centers for Disease Control and Prevention, 2015). The majority of those with insurance are covered by Medicare or Medicaid, and ACA helps those living with HIV to secure affordable care and medications. For instance, as with every other American, those with HIV or AIDS cannot be denied coverage, nor can their coverage be canceled or rescinded. The ACA promise of no lifetime limits on health benefits for HIV or AIDS patients further advances equal health care for all.

Conclusion

A report from the Agency for Health care 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" (Women's Health Care, 2004, p. 1). Many in poor socioeconomic circumstances are less likely to access quality health care, or, in some cases, any health care at all (Long et al., 2021). 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 (Women's Health Care, 2004, p. 1).

Health Care Reform. The United States will always be in a quandary about how to address these issues until the system undergoes radical change. Even though the particular health concerns for women, older adults, children, and others may vary according to their unique special needs, there is really only one overall issue: How can the United States create a system that will meet the needs of hundreds of millions of people? The Affordable Care Act was an attempt to put all Americans on a level playing field with insurance companies.

Health care in the United States continues to be a controversial subject primarily because many people have difficulty accessing and using the system. It is a complicated system that can provide access to brilliant medical treatments, surgeries, and the most modern technologies available. However, it is also a system of great disparity. People of various ethnic minorities, the poor, and the disenfranchised experience the greatest problems accessing and using the health care system. Time will tell whether ACA is the answer to the US health care problems.

Terms & Concepts

Contraceptive Management: The term for the various ways in which individuals practice birth control.

Geriatric Medicine: The practice of medicine for older adults.

Hepatitis C: An incurable viral condition of the liver. Hepatitis C is treatable and long-term management is available but there is no cure. Untreated, it can lead to permanent liver damage and liver failure.

Infertility: The inability to conceive a child.

Post-Traumatic Stress Disorder (PTSD): A psychological condition that results from stress, shock, and/or trauma. A person's coping abilities are significantly hindered and a broad range of symptoms such as panic or anxiety attacks and/or depression are experienced.

Primary Care Services: Generally a term used for the primary doctor or first medical contact in the American medical system. Once called General or Family Practitioners.

Traumatic Brain Injury (TBI): Also known as a head injury, it is the result of a serious trauma or blow to the head. There are various parts of the brain that can be damaged, and the results can be mild to severe and can include problems with memory, cognition, and behavior. TBI can also lead to permanent disability.

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Suggested Reading

Armstrong, P. Armstrong, H., & Scott-Dixon, K. (2016). Critical to care: The invisible women in health services. University of Toronto Press.

Bartlett, D.A. (2005). Critical condition: How health care in America became big business—and bad medicine. Broadway Books.

Cassel, C.K. (2005). Medicare matters: What geriatric medicine can teach American health care. University of California Press.

Committee on Evaluation of Children's Health, National Research Council. (2004). Children's Health, the Nation's Wealth: Assessing and Improving Child Health. National Academies Press.

Dhingra, S. S., Zack, M. M., Strine, T. W., Druss, B. G., & Simoes, E. (2013). Change in health insurance coverage in Massachusetts and other New England states by perceived health status: Potential impact of health reform. American Journal of Public Health, 103, e107–e114. Retrieved November 15, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=87069057&site=ehost-live

Hegenauer, C. L. (2016). Are we covered? Health insurance disparities in the Affordable Care Act era. Michigan Sociological Review, 3093-3108. Retrieved December 22, 2016, from EBSCO online database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=119711117&site=ehost-live&scope=site

Khanlou, N., & Pilkington, F. B. (2015). Women's mental health: Resistance and resilience in community and society. Springer.

Nover, C. (2013). Mental health in primary care: Perceptions of augmented care for individuals with serious mental illness. Social Work in Health Care, 52, 656–668. Retrieved November 15, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=89770771&site=ehost-live

Patel, K., & Rushefsky, M.E. (2015). Health care politics and policy in America. Routledge

Reyes, A. M., & Hardy, M. (2014). Another health insurance gap: Gaining and losing coverage among natives and immigrants at older ages. Social Science Research, 43, 145–156. Retrieved January 12, 2015, from EBSCO online database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=92592132&site=ehost-live&scope=site