The chapter discusses the US healthcare system and issues of access, costs, and reform efforts. It covers:
1) The high costs of US healthcare without corresponding health outcomes benefits compared to other wealthy nations. Defensive medicine and profit motives contribute to inefficiency.
2) Historical shifts from physician-centered to managed care and consequences like "medlining". Unequal access based on social class, race, gender.
3) Alternative models like Bismarck (Germany), Beveridge (UK), and National Health Insurance (Canada) show cost-effective options.
3. Learning Objectives
17.1 Understand the extent of the healthcare crisis in
the United States.
17.2 Explain how the healthcare system has shifted
from physician-centered care to managed care,
and the consequences of this shift.
17.3 Explain how access to healthcare varies by
social class, race, and gender.
17.4 Compare and contrast the Bismarck, the
Beveridge, and the National Health Insurance
models of healthcare.
17.5 Discuss some alternatives to improve the
healthcare delivery system in the United States.
4. 17.1 - Crises in Healthcare: Cost,
Coverage, and Consequences
• Rising Healthcare Costs
• Does the High Cost of Healthcare
Translate into Good Health
Consequences?
5. LO 17.1 - Rising Healthcare Costs
• In 2010, Americans spent $2.6 trillion on
healthcare
• Why is American healthcare so expensive?
– Profit driven
– Inefficiency
– Defensive medicine
– Malpractice lawsuits
– Development of new technology
6. LO 17.1 - Does the High Cost Mean Good
Health Consequences?
• The U.S. spends 50 percent more per capita
on healthcare than any other country
• The U.S. ranks 47th in average life
expectancy
• The U.S. ranks last among 23 wealthy
countries in its infant mortality rate
• The U.S. ranks 54th out of 191 countries in
terms of the fairness of its healthcare system.
7. LO 17.1
Doctors practice __________ medicine;
;they order unnecessary tests to avoid
lawsuits.
A. malpractice
B. defensive
C. efficient
D. technological
8. LO 17.1
Doctors practice __________ medicine;
;they order unnecessary tests to avoid
lawsuits.
A. malpractice
B. defensive
C. efficient
D. technological
9. LO 17.1
The high cost of the U.S. healthcare system
translates into better health outcomes than
those of other wealthy nations.
A. True
B. False
10. LO 17.1
The high cost of the U.S. healthcare system
translates into better health outcomes than
those of other wealthy nations.
A. True
B. False
11. 17.2 - The Healthcare System in the
United States Prior to 2010 Reform
• Different Plans for Different Categories
• Private Insurance
• For-Profit Hospitals
• Managed Care Networks
12. LO 17.2 - Different Plans for Different
Categories
• Workers
• Native Americans, Military Personnel, and
Veterans
• Those 65 and Over
• The Uninsured
13. LO 17.2 - Private Insurance
• Health insurance firms are for-profit
– Try to enhance profits through
• Raising rates
• Hiring adjusters
• Rescissioning
• Not covering preexisting conditions
• Health insurance is crucial
– Many Americans have inadequate coverage
15. LO 17.2 - For-Profit Hospitals
• Traditionally, hospitals were run by
churches, universities, and municipalities
• Since the 1960s, for-profit hospitals and
chains have emerged
16. LO 17.2 - Managed Care Networks
• Doctors used to practice alone
– Today, 93 percent of medical school
graduates will work in a hospital system,
clinic, or other large setting
• Implications for doctor-patient relationship
– medlining
17. LO 17.2
In order to increase profits, for-profit
hospitals may eliminate __________
departments.
A. maternity
B. intensive care
C. cardiac
D. emergency
18. LO 17.2
In order to increase profits, for-profit
hospitals may eliminate __________
departments.
A. maternity
B. intensive care
C. cardiac
D. emergency
19. LO 17.2
Insurance companies are designed to help
the sick, not the well.
A. True
B. False
20. LO 17.2
Insurance companies are designed to help
the sick, not the well.
A. True
B. False
21. 17.3 - Unequal Access to Healthcare
• Social Class
• Race/Ethnicity
• Gender
• HIV/AIDS: The Intersection of Class,
Race, and Gender
22. LO 17.3 - Explorer Activity: Health and
Healthcare: Social Context and Healthcare
http://www.socialexplorer.com/pearson/plink.aspx?Please log into MySocLab with your
username and password before accessing
this link.
23. LO 17.3 - Social Class
• Wealth = Health
– Disease
– Diet/nutrition
– Shelter
– Sanitation
– Economic stress
– Access to medicine
– Insurance (Medicaid)
25. LO 17.3
The infant mortality rate in the United States is more than
twice as high as the rate in the countries with the lowest rate.
26. LO 17.3 - Race
• Life expectancy
• Infant mortality
• Maternal mortality
• Prenatal care
• Low birth weight
• Cancer and other diseases
27. LO 17.3 - Gender
• Women:
– Health advantages over men
• biological and social
– less likely to have health insurance than men
– left out of medical research
– Doctor-patient interaction is different
28. LO 17.3 - HIV/AIDS: Class, Race and
Gender
• Blacks account for about one-half of all the
people in the U.S. who live with HIV
• The number of HIV cases per 100,000
population was
– 15.3 for Whites,
– 44.7 for Latinos
– 116.0 for African Americans
• Two-thirds of new infections among women
occur in Black women
30. LO 17.3
According to the textbook, one of the best
predictors of health status is __________.
A. gender
B. race
C. social class
D. religion
31. LO 17.3
According to the textbook, one of the best
predictors of health status is __________.
A. gender
B. race
C. social class
D. religion
32. LO 17.3
Women have health advantages over men,
but women are also more likely to face
discrimination in the healthcare system.
A. True
B. False
33. LO 17.3
Women have health advantages over men,
but women are also more likely to face
discrimination in the healthcare system.
A. True
B. False
34. 17.4 - Models for National Healthcare:
Lessons From Other Societies
• The Bismarck Model
• The Beveridge Model
• The National Health Insurance Model
35. LO 17.4 - The Bismarck Model
• Germany, Japan, France, Belgium, and
Switzerland
– Private insurance with no profit
– Covers everyone
– Government regulation of fees
36. LO 17.4 - The Beveridge Model
• Great Britain, Italy, Spain, Cuba,
Scandinavia
– Medical treatment is a public service
– No bills
– Government-owned hospitals
– Doctors are government employees
37. LO 17.4 - The National Health Insurance
Model
• Canada, Taiwan, South Korea
– Single-payer plan
– Doctors/hospitals are private
– Government run insurance
39. LO 17.4
Examining alternative plans for healthcare,
we learn that __________.
A. socialized medicine is a burden
B. there are many cost-effective
alternatives
C. changing plans would be
detrimental to our health status
D. private insurance plans are the
best
40. LO 17.4
Examining alternative plans for healthcare,
we learn that __________.
A. socialized medicine is a burden
B. there are many cost-effective
alternatives
C. changing plans would be
detrimental to our health status
D. private insurance plans are the
best
41. LO 17.4
Countries utilizing single-payer healthcare
plans spend more of their GDP on
healthcare.
A. True
B. False
42. LO 17.4
Countries utilizing single-payer healthcare
plans spend more of their GDP on
healthcare.
A. True
B. False
43. 17.5 - Reforming the Healthcare
System of the United States
• The Politics of Health Reform
• The Obama Plan
• The Supreme Court and the Affordable
Healthcare Act
• The Future of the Affordable Healthcare
Act
44. LO 17.5 - The Politics of Health Reform
• Efforts to oppose reform include:
– Influencing the Public
– Influencing Congress
– Legislative Blockage by the Minority
46. LO 17.5 - The Obama Plan
• Changes to the status quo:
– Everyone must have insurance.
– Government will subsidize those with low
income.
– Individuals may keep their current plan.
– Private plans will compete for business.
– Individuals cannot be denied for a preexisting
medical condition.
– 31 million uninsured will become insured.
48. LO 17.5 - Video: Obama Healthcare Plan
http://abavtooldev.pearsoncmg.com/sbx_videoplayer_
49. LO 17.5 - The Supreme Court and the
Affordable Health Care Act
• Challenged as unconstitutional
– Supreme Court upheld the act
• The Big Picture
• The Ingredients of the Affordable Health
Care Act
50. LO 17.5
In 2012 the Supreme Court ruled by a 5–4 vote to uphold the
constitutionality of the individual mandate and most of the
provisions of the Affordable Health Care Act.
51. LO 17.5 - The Future of the Affordable
Health Care Act
• The plan is not perfect
– Both sides see problems
– Costs need to be contained
• But it is a start
52. LO 17.5
Conservatives oppose the Affordable Health
Care Act because __________.
A. the system remains private
B. the government has too much
control
C. private insurers will turn a larger
profit
D. the underinsured will still suffer
53. LO 17.5
Conservatives oppose the Affordable Health
Care Act because __________.
A. the system remains private
B. the government has too much
control
C. private insurers will turn a larger
profit
D. the underinsured will still suffer
54. LO 17.5
The Affordable Health Care Act is basically
a socialist healthcare plan.
A. True
B. False
55. LO 17.5
The Affordable Health Care Act is basically
a socialist healthcare plan.
A. True
B. False
56. LO 17.5
Question for Discussion
Compare and contrast the conservative and
progressive views on healthcare reform.
Editor's Notes
This chapter is devoted to analyzing the system of healthcare in the United States.
How does the current system work?
Who benefits and who does not from the current system?
Is reform needed?
What reforms, if any, emerged from the Obama and Democratic Party initiatives?
17.8 percent of GDP, more than any other modern nation.
The U.S. healthcare system is profit driven. Hospitals, insurance companies, and medical equipment companies are looking for greater returns on their investments.
There is a lot of paper. People are hired to process all the paperwork. 31 percent of the money spent on healthcare goes for paperwork and administration.
Tests and procedures doctors perform are primarily to protect themselves from lawsuits. One-third of the healthcare performed is unnecessary.
Lawsuits account for 4 percent of healthcare costs.
Because health insurers pay doctors and clinical facilities most of what they charge, there are financial incentives to use new and expensive technologies. Related to this, many physicians, to increase their incomes, install expensive equipment in their offices (ultrasound, magnetic resonance imaging, etc.).
It seems reasonable to expect that Americans would be the healthiest people on Earth, yet Americans do not fare as well as those in Western Europe, Scandinavia, Canada, and Japan.
The U.S. healthcare system has unique characteristics
For most workers, healthcare is linked to employment. Workers and employers share premiums for health insurance. Employers have cut back on the amount they pay for insurance and coverage for part-time workers. The other problem with employer health coverage is a person (or family) is no longer covered if they lose their job.
Certain categories of people receive healthcare coverage from the government.
Medicare covers 45 million elderly and disabled individuals. Payroll tax covers Medicare. When you are old enough you qualify.
The uninsured have access to medical care if they can pay the bills out-of-pocket at the time of treatment. The other alternative is to go to the emergency room in a public hospital. Public hospitals are required to attend to the medical needs of the indigent.
The healthcare system for most Americans depends on the health insurance industry. Health insurance is a necessity.
However, 49.9 million people—16.3 percent of the population—were uninsured in 2010, which means that they were essentially left outside the healthcare system
Health insurance companies want to make money. They try to turn a profit.
They do this through raising rates.
They hire adjusters to investigate and deny claims.
They practice “rescission,” which means they cancel the insurance after a large claim is made.
They will not cover people with preexisting conditions or they refuse to cover people who need their services the most.
Many Americans have inadequate coverage and face bankruptcy when something goes wrong and they need medical care.
Characteristics of the uninsured.
Healthcare coverage clearly is a resource available to some groups, but not others.
For profit-systems buy up hospitals and run networks of healthcare systems.
In order to turn profit, they tend to settle in areas that have adequate health insurance coverage, not near low-income areas.
They build hospitals without emergency departments, neonatal units, and burn departments because these lose money.
They have a special interest in minimizing the care for emergency patients because emergency facilities attract Medicaid and charity cases.
Patient dumping includes helping those who can afford services and leaving behind all others.
They also purchase all the not-for-profit hospitals in the area and create a monopoly.
To summarize, proponents of for-profit hospitals argue that they are more efficient than nonprofits. Critics counter that they charge more, provide less charitable care, and have lower personnel costs because of lower patient-staff ratios.
The shift to managed care systems in the 1970s changed the relationship between patients and doctors.
Patient care is depersonalized.
Out of the hands of doctors and into the hands of other personnel who handle paperwork.
Managed care networks, as in other profit-oriented medical entities, seek to enhance the bottom line by maximizing the number of healthy and insured patients while restrict the number who are sick.
Medlining is the practice of avoiding the sick and uninsured to help the bottom line.
Glaring inequities result in some categories of people being less healthy than others.
The structural inequity focuses on the three fundamental structures of inequality—class, race, and gender—which are key determinants of health (i.e., the distribution of health and disease) and healthcare delivery (i.e., the distribution of treatment).
These structures of inequality make a difference, not surprisingly, with the already advantaged being advantaged even more and the already disadvantaged being disadvantaged further.
Being poor puts a person at risk for many health-related problems.
Because of lifestyle differences in diet, shelter, sanitation, and stress, the poor are at a greater risk for disease.
Since the poor do not have access to medicine in the same way as the more affluent, when they get sick they suffer longer.
Not all doctors or hospitals accept Medicaid, so even when the poor are covered, access is usually inferior to that of the wealthy.
As strong as the case is for providing equal access to medical care to all people, it is not the most fruitful approach to correcting the differences in health by socioeconomic class.
The answer, most fundamentally, is to reduce the inequalities of class (and race and gender) that perpetuate poor health among the disadvantaged.
Living in poverty has negative health outcomes. The outcomes can also compound on each other.
The reason for our higher infant mortality rate in the United State: the pockets of poverty where pregnant women do not have access to prenatal and preventative medicine.
To examine health outcomes by race implies that there are biological differences among the races.
The differences in health outcomes by race are, almost entirely, a consequence of disproportionate poverty and discriminatory treatment.
The life expectancy for African American males in 2008 was 5.4 years less than for White males, and for Black females it is 3.7 years less than for White females. The discrepancy is even wider for Native Americans, who have the poorest health of any racial category in the United States, with a life expectancy ten years below that of the nation as a whole.
The Black infant mortality rate in 2009 (13.3 per 1,000 live births) was almost twice that of the White rate (6.7 per 1,000).
Statistics reveal that the death rate of African American women due to complications during birth is more than triple the rate for White mothers. The main reason for this racial disparity is that Black women are less likely to receive prenatal care.
Nine of ten White mothers receive prenatal care, compared to about three of four Latino and African American mothers.
African Americans are twice as likely to be born with a low birth weight than are White children. This differential by race has remained about the same since 1960.
Heart disease in all its forms is the nation's leading cause of death. Overall, the national death rate from heart disease for African American men is 841 per 100,000 compared to 666 White men. A study of a national sample of 237,000 Medicare patients from 1999 through 2005 found that Black patients are less likely to receive implantable heart devices than White patients
The death rate from cancer is about three and one-half times greater for Black males than for White males. The rate for Black women is also higher than it is for White women. The problem, generally, is that African Americans (and Latinos) are more likely to be diagnosed with cancer in its later stages, making survival less likely.
According to the Alzheimer's Association, African Americans are almost twice as likely as Whites to have Alzheimer's and other forms of dementia, and Latinos are about one and a half times more likely to be affected. Some forms of dementia are associated with diabetes and heart disease.
African American adults are nearly twice as likely as Whites to be legally blind or vision impaired. Latinos are more likely than Whites to be blind, primarily because of complications from diabetes, a disease they are three times more likely than Whites to have.
The diseases especially found among the poor (e.g., influenza, pneumonia, and tuberculosis) are disproportionately found among non-Whites because they are disproportionately poor.
Biological differences
During early childhood, girls have biological benefits over boys, as exhibited by their greater resistance to infectious and chronic diseases.
As adults, women in the past were more protected than were men, at least until menopause, especially from heart disease and hypertension, because of the hormone estrogen.
Social differences
Males are more likely to be assertive and daring.
This leads to increased risk for accidents. Increased use of drugs and alcohol (with its problems). Greater likelihood of smoking,
Women are more likely to seek preventative care.
Women are more likely to suffer from anorexia/bulimia due to societal pressures,
When ill, men receive better care because they are more likely to have health insurance.
Women have also, until recently, been left out of medical research. In most cases, a drug proved effective in men is also effective for women. But the differences in hormone proportions and the menstrual cycle can be important.
The interaction for women with their male physicians can be sexist and degrading.
Since 1981, when AIDS emerged, the worldwide death toll has reached 30 million people.
The statistics reflect differences in race/ethnicity in the United States.
Men who have sex with other men and intravenous drug users are most at risk.
Among women, new infections are more likely to occur in Black women.
Here are the subpopulations of those diagnosed with HIV/AIDS in 2007. You can see there are differences in race/gender.
The United States, as we have stated, spends much more for healthcare, both in total dollars and as a percentage of its gross national product, than any other nation. Yet, all major indicators of national health show that other nations are getting more for their health dollars than does the United States.
The Bismarck model was developed by Otto von Bismarck.
This model has private insurance (like the U.S.) but is covers everyone.
The insurance companies do not profit and the government strictly regulates fees and services to contain cost.
In this model of healthcare the patient receives no bills because it is run by the government.
Most hospitals are government owned and doctors are employees.
Some doctors/hospitals are private, but they are reimbursed by the government.
The U.S. Veterans Affairs is an example of the Beveridge Model.
Costs stay down in a single-payer plan because there is no need for marketing and underwriting.
By cutting out the for-profit insurance companies the countries using this spend much less on healthcare costs.
The health outcomes in the Canadian single-payer plan are much better.
The United States is the only developed nation without some form of universal healthcare.
There have been attempts to reform the U.S. healthcare system going back to 1912, but they have all failed.
The main questions asked of healthcare reform :
Should the government be involved in the healthcare system? (Democrats)
Should the marketplace dictate the healthcare system? (Republicans)
Interest groups spent more than $210 million on television ads to influence the public.
Conservative talk show hosts claimed Obama and Democrats were leading the country down the wrong path where the new system would be the death of the elderly, subsidize abortion, and create “death panels.”
The public was swayed and opposed healthcare reform.
In 2009 there were 3,098 health-sector lobbyists. That is six for every member of Congress.
Their efforts were intended to either block reform legislation or to shape the resulting legislation to maintain their advantage
They also funneled money to campaigns of key people.
The Republicans, as the minority party in both houses of Congress, agreed on a strategy of total opposition to health reform. For example, when the Senate voted on a crucial healthcare bill on Christmas Eve 2009, not a single Republican voted in favor.
Those who opposed healthcare reform worked hard to influence the public through scare tactics.
The Democrats controlled the House and Senate so a bill passed. It was not a single-payer system as many progressives desired, but it did place greater control in the government.
The new system is not socialism. It did not hurt insurance companies. It is not run but regulated by the government. There is no public option in the plan, which would have allowed the government to compete with private health insurance companies.
The new health plan is still predominantly a private system.
The Republican minority in Congress agreed on a total opposition to any healthcare reform.
Challenges were filed against the Affordable Healthcare Act with the Supreme Court—most particularly to the constitutionality of its centerpiece—the individual mandate that everyone buy some kind of health insurance or face penalties.
The constitutionality of the individual mandate and most of the provisions upheld (5-4 decision).
The Court's decision moved the United States closer to the other advanced industrial societies that guarantee health insurance to their citizens.
20 million will still be left uninsured.
It affirmed the high value that Americans have for equality of opportunity as it did do much to help the disadvantaged.
The Ingredients
Some parts of the act, already in effect, remained so.
Young adults could stay on their parents' health insurance up to age 26 (affecting 3.1 million young adults).
Insurers could not deny coverage to children with preexisting health problems.
Insurers could no longer limit how much policies would pay out to each person annually and over a lifetime (affecting 105 million).
Seniors and people with disabilities could save money through improved Medicare prescription benefits (affecting 5.3 million).
New pieces by 2014:
Almost everyone would be required to have insurance or pay a fine.
Businesses employing more than fifty employees would face fines if they did not offer coverage for their employees.
Newly created insurance markets would make it easier for individuals and small businesses to purchase affordable coverage.
Insurance companies were now limited to spending no more than 15 cents out of every dollar on nonmedical costs (overhead).
Insurers would be prohibited from denying adults and children coverage or from charging them more if they had preexisting health problems.
Health insurance was expanded to include psychiatric disorders.
The Medicaid system would be expanded to include all people within 133 percent of the poverty line.
Chapter 17, Activity 1
The Politics of Healthcare Reform
Assign the students the following task: Either before they come to class (or, if you have Internet in your classroom you could do this in class) they need to find one article on the healthcare reform bill that they feel sensationalizes or distorts the issue in some way.* They should break into groups and discuss their article with the group, and select one to share with the class. They should think about:
1) Who wrote (or is being quoted in) the article? What political party do they represent?
2) What issue is being distorted or blown up in the article?
3) How does their article compare to what they read in their textbook?
4) How influential is the media in swaying public opinion? Would this article influence their opinion if they did not know the facts?
*An Alternative Assignment: Have your students find one article representing the Democrats' position and one article representing the Republicans' position on healthcare and have them debate the two sides.
The Court's decision moved the United States closer to other advanced industrial societies that guarantee health insurance to their citizens.
Progressives believe it did not go far enough because healthcare is still private.
Conservatives do not like the government control of the system.
Items need to be addressed to control costs. The remaining uninsured need to be included.
But, it is a step towards a better healthcare system for ALL, not just for those who can afford it.
