Medical Sociology. Twelfth Edition William C. Cockerham. Chapter 15 Health Care Reform and Social Policy in the United States

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1 Medical Sociology Twelfth Edition William C. Cockerham Chapter 15 Health Care Reform and Social Policy in the United States

2 Introduction Major issues in the public debate about health care delivery in the United States: 1) Rising costs 2) Equity 3) Geographic distribution of services Recent health reforms address some of these issues Promotes better access to health insurance

3 Introduction Importance of access to health insurance: Previously uninsured persons had worse health and used more services when they became eligible for Medicare coverage at age 65 Uninsured more likely to hesitate before seeking treatment, even in emergencies

4 Rising Costs Per capita health care expenditures in the U.S. are the highest in the world 1980 per capita expenditures: $1, per capita expenditures: $7,681 Costs influenced by a number of factors: Aging of the population Increases in hospital expenses and doctors fees Increased cost of health insurance Increased use of and advertising for prescription drugs

5 The Road to Health Care Reform: Initial Federal Efforts During the 20 th century, several U.S. presidents have attempted or recognized the need for health care reforms Only Johnson s establishment of Medicare and Medicaid in 1965 was successful Public resistance and the opposition of the AMA have hampered efforts at reform

6 The Road to Health Care Reform: Initial Federal Efforts Addition of Medicare and Medicaid to the Social Security Act in 1965 marked a new level of involvement in U.S. health care by the federal government Medicare and Medicaid have provided needed health services for the old and those in poverty where these services were not previously available

7 The Road to Health Care Reform: Medicare Initial Federal Efforts Federally administered program Provides hospital and medical insurance for people aged 65 years or older, regardless of financial resources Includes disabled people under the age of 65 who receive cash benefits from Social Security 2006 added prescription coverage to benefits Covers 14.8% of the population

8 The Road to Health Care Reform: Initial Federal Efforts Medicaid Welfare program operated by individual states States and the federal government share the cost of health care for the poor Each state is required to cover all needy persons receiving cash assistance May also include the medically needy, the aged, blind, and disabled poor as well as their dependent children and families Covers 15.5% of the population

9 The Road to Health Care Reform: Clinton President Clinton proposed a plan of national health insurance in 1994 Plan failed due to: Anti-insurance lobbying efforts Lack of consensus between the Democrats and Republicans in Congress Growing public uncertainty Highlighted the need for reform Resulted in the reorganization of American health care into a delivery system in which managed care is now the dominant approach in the private sector

10 The Road to Health Care Reform: Managed Care In the early to mid-1990s, private health care shifted away from a largely office-based, fee-forservice system to an increasingly group- or organization-based managed care system Emerged indirectly as a response to the government imposed DRGs for Medicare services Diagnostic related groups (DRGs) Schedules of fees placing a ceiling on how much the government will pay for specific services rendered to Medicare patients by hospitals and doctors

11 The Road to Health Care Reform: Managed Care Managed care organizations Control the cost of health care by monitoring the work of doctors and hospitals, limiting visits to specialists within a particular managed care network and to all physicians outside it, and requiring prior authorization for hospitalization Capitation fees Financing system employed by managed care organizations A fixed monthly sum is paid by the subscriber and his or her employer that guarantees care to that person and the person s immediate family, with little or no additional cost Discourages inefficient and unnecessary treatment

12 The Road to Health Care Reform: Managed Care Initially kept rising costs in check Pressure by physicians, the media, and politicians responding to patients helped dilute cost controls Especially the requirement to obtain approval from a primary care physician before seeing a specialist in many managed care programs

13 The Road to Health Care Reform: State Efforts Some individual states have implemented their own plans in order to increase coverage: Hawaii In 1974 required all employers to contribute to health insurance Tennessee Converted Medicaid into the TennCare managed care program Vermont, Illinois, Washington Provide health care for children, with subsidies for premiums Massachusetts Requires all residents to have health insurance

14 The Road to Health Care Reform: 2010 Reforms Despite widespread opposition and concern from various interest groups, politicians, and the general public, President Obama passed significant health reforms in 2010 Patient Protection and Affordable Care Act Will take effect in 2014 Estimated that 95% of Americans will be covered by health insurance by 2019 Few changes for people who already have insurance

15 The Road to Health Care Reform: 2010 Reforms Changes introduced by the Patient Protection and Affordable Care Act: 1) Persons with preexisting medical conditions can no longer be denied coverage because of those conditions 2) A minimum level of benefits to be set by the federal government must be provided in all health insurance plans 3) State insurance exchanges will be established that will offer a range of competitive health care plans at affordable prices 4) Persons not covered by their employer will be able to purchase coverage through the state exchanges 5) Persons under the age of 65 who already have health insurance may also purchase plans from the exchanges and those who earn up to four times the federal poverty line about $88,200 for a family of four in 2010 will receive government subsidies to help pay the cost

16 The Road to Health Care Reform: 2010 Reforms Changes introduced by the Patient Protection and Affordable Care Act: 6) Low-income persons under the age of 65 earning below 133 percent of the federal poverty line about $14,000 for an individual and $29,327 for a family of four in 2010 will be covered by an expanded Medicaid program 7) Small businesses can buy insurance for their employees through the exchanges and get tax credits 8) Children may remain on their parent s health insurance plan until age 26 9) Most Americans (American Indians and religious objectors would be exempt) would be required by law to purchase health insurance or pay a fine, while employers with more than 50 workers who do not provide coverage will also pay fines

17 The Road to Health Care Reform: 2010 Reforms Several states have joined in a lawsuit to challenge the federal law requiring Americans to have health insurance Claim it is unconstitutional and unprecedented to require people to buy any commercial good or service as a condition of lawful residence in the United States

18 Equity in Health Services Problem of equity in health services lessened with health care reform but still remains a problem in American society Especially true for individuals dependent on public health care, those without health insurance, and both the urban and rural poor since health care may simply not be available where they live

19 Geographic Distribution of Services A major factor in obtaining adequate medical care for some people is the numerical shortage of physicians serving patients in rural areas and urban slums Most physicians prefer to practice in urbanized settings One out of every 20 counties in the U.S. lacks physicians More than half of all counties do not have a pediatrician There are a few signs that the distribution of physicians is beginning to improve

20 Geographic Distribution of Services Another factor in the maldistribution of physicians is that of overspecialization Has reduced the number of doctors engaged as general practitioners in primary care and family practice Medical students often prefer to specialize because: Can focus on a narrower and more manageable body of knowledge Increased prestige and income afforded to specialists

21 Overview of Health Care Delivery The existing health care delivery system in the United States is a conglomerate of health practitioners, agencies, and organizations, all of which operate more or less independently Greatest portion of all patient services is provided in offices and clinics by physicians who sell their services on a fee-for-service or per capita fee basis in a managed care network Followed by services provided by hospitals

22 Overview of Health Care Delivery Official agencies Public organizations supported by tax funds Support and conduct research, develop educational materials, protect the nation s health, and provide services designed to minimize public health problems Voluntary agencies Charitable organizations who solicit funds from the general public and use them to support medical research and to provide services for disease victims

23 Overview of Health Care Delivery Health maintenance organizations (HMOs) Managed care prepaid group practices Individual pays a monthly premium for comprehensive health care services Preferred provider organizations (PPOs) Relatively new form of managed care health organization Employers who purchase group health insurance agree to send their employees to particular hospitals or doctors in return for discounts Allied health enterprises Manufacturers of pharmaceuticals and medical supplies and equipment, which play a major role in research, development, and distribution of medical goods

24 Overview of Health Care Delivery Traditional fee-for-service system is modeled on the principle of the open market High-quality services and affordable prices are supposed to result from competition among providers This system is not a good example of a competitive marketplace Fundamental law states that when the supply of a product exceeds the demand for it, prices should drop Does not apply to medicine since doctors and hospitals effectively create their own demand and provide services at prices they set

25 Health Care: A Right or a Privilege? Conflict theory Sociological perspective which takes the position that social inequality leads to conflict, which leads to change Has its origins in the work of Karl Marx and Max Weber Modern focus is not just on class conflict but also on competition between interest groups, as they maneuver for advantages in democratic political systems

26 Health Care: A Right or a Privilege? Modern societies are characterized by conflict between: Democratic principles Emphasize equality and universal rights The organization of economic services Involving the production, exchange, and consumption of goods and services Features inequality Health reform is really about whether medical care is a right of all Americans or a privilege

27 Health Care: A Right or a Privilege? As a privilege: Medical care is a commodity Doctors entitled to high incomes because of difficulty and high value placed on obtaining necessary skills Generalized opposition to the welfare state The best way to help the poor is to provide them with jobs so that they can buy medical care like everybody else

28 Health Care: A Right or a Privilege? As a right: Health care should be an opportunity Emphasizes its special importance to society in relieving suffering, preventing premature death, and restoring the ability to function to the people who live in it Society has an ethical obligation to provide health care

29 Health Care: A Right or a Privilege? Movement toward conceptualizing and establishing health care as a right in the capitalist economy of the United States Consistent with other measures associated with being a welfare state Individual rights of citizenship, not ownership and control of property, serve as the basis for political representation and entitlement to public programs

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