The Structure & Cost of US Health Care: Crash Course Sociology #44


The health care system in America is…complicated. Doctors, hospitals, insurance
and drug companies – it can be hard to navigate all the moving
parts of healthcare, and it’s even harder if you’re
trying to do it when you’re sick. Theory and statistics can give us a broad
understanding of the social and cultural forces
that affect health. But for the average American making choices
about healthcare, the questions that matter
most are the practical ones. After all, when you’re running a fever,
the most important question is where can you
find a doctor to make you better. And then after the fever has gone down and
you get the bill, your question might become,
“How do I pay for this? And why does giving me an aspirin count as
a separate thing that I get charged for?” It’s easier to answer these questions once you
understand how the US structures and finances
its health care system. So, let’s do it. [Theme Music] Let’s start with the basic structure of
the healthcare system in the United States. Health care is split into different sectors –
the private, the public, and the voluntary sectors. Private and public sectors supply insurance
and care to most Americans. In the private sector, 56% of patients pay
for their health care with insurance that they
get primarily through their employer. There are also public health insurance
plans for vulnerable groups – like Medicare, which covers elderly Americans,
and Medicaid, which covers Americans below a
certain poverty threshold. The government also provides healthcare through
things like VA hospitals and the Bureau of Indian Affairs, and it has a legal mandate to provide
healthcare for people in federal prison. But the voluntary sector is different, in that it includes
charitable organizations that do health research and
provide free or low-cost health services, like the American Cancer Association or
the March of Dimes. So, with all of these options available, what
determines how easy or hard it might be to
get access to health care? In this context, access refers to entry into,
or use of, the health care system. In 1981, two professors of Public Health at
the University of Michigan – Roy Penchansky
and J. William Thomas – came up with what they called the Five A’s of
health care access: availability, accessibility,
accommodation, acceptability, and affordability. So, the first “a” asks: Does the person
live where the health services they need are
readily available? If you live in a major city, you might take it for
granted that finding a doctor or a 24-hour clinic
on short notice is just a google search away. Urban areas have more doctors, specialists,
and hospitals – all of which means that a wider
variety of services are available. By contrast, rural areas are more likely to
experience shortages of healthcare workers. Urban areas have twice as many doctors per
person as rural areas! Rural areas also tend to have issues with
the second “a”, accessibility. Accessibility here refers to a person’s
literal ability to get to facilities and keep
appointments. Transportation to appointments can be much
more difficult in rural places, where providers
tend to be farther away. This is especially hard for people with chronic
illnesses or disabilities that make it impossible
for them to drive by themselves. Time can also be a limiting factor. Doctor’s appointments are usually during
business hours, so patients may have to miss
work to get the care they need. Low-income and blue collar workers are more
likely to have jobs that don’t offer paid sick leave – and they may even be fired
if they miss work due to illness. Sociocultural factors can also impact the
accessibility. And so can the accommodations provided by
health services. Accommodations are the ways that services are
organized to accept clients, like the hours that they’re
open or the ways that they communicate with patients. Language barriers can make it especially hard
for non-English speaking patients in the US. So accommodations like translators or multilingual
information packets, can help mitigate the disparities. And finding the ‘right’ accommodations
for different populations can be difficult, too. For example, Hmong Americans, who primarily immigrated as refugees from Southeast Asia in the wake of the Vietnam war, have higher mortality rates than native-born Americans. Providing medical information can be hard,
because no written form of the Hmong language
existed until the 1960s, meaning that many Hmong people can’t read
or write in their own language, and dialects vary,
making it hard to find the right translator. Once you get past all those other obstacles, there’s still the matter of whether the doctor and patient have similar ideas about how the whole doctor-patient relationship should work. Some people want a doctor who gives them the
information they need to make decisions themselves. But others just want to leave all the decision-making
to the doctor and just be told what pills to take. How satisfied a patient is with their healthcare tends to depend on the match between their preferences and their doctor’s style of care, or the doctor-patient congruence. A patient’s satisfaction with a provider
will determine if they return. So the next “a”, acceptability, is based on
whether a doctor meets the patient’s preferences – both in terms of their professional
abilities and in their personal traits, like
gender, race, or age. For example, many people feel more comfortable
with a doctor of the same gender as themselves, so if none are available, they may not find
that health care experience acceptable. The last A of the five A’s is a pretty important
one, particularly in the United States: affordability. How people pay for health care in the US, and more importantly if people can pay for health care, is closely linked to how we financially structure the healthcare system. The US has what’s known as a ‘fee-for-service’
healthcare system, where services are unbundled
and paid for separately. So if you go in for a check up and the doctor
orders a blood test and an x-ray, the charges
on the bill will be separated into three parts: the x-ray, the lab test for the blood, and
the cost of the doctor’s time. There are pros and cons to a system like this. It incentivizes doctors to do a lot of tests,
because they’ll get a separate fee for every test. Which can be good – you want your doctor
to be thorough when you’re not feeling well. But a fee-for-service system also incentivizes
overtreatment, and this drives up the cost of care. The US also relies on a third-party payer
system, which means that medical costs are
paid through a third party, like a commercial insurance company
that’s responsible for paying the doctor on
behalf of the patient. Third-party payer systems often rely on cost-sharing,
where the insured patient pays a little each month,
whether they need care or not. This helps limit the overall costs to the
insurance provider. An insurance premium is the amount you pay
to the insurance company each month so that
you can keep your coverage. A deductible is the portion of the health
care costs that you’re responsible for yourself
before your insurance kicks in. Most insurers offer lower monthly premiums if you
accept a higher deductible – so it’s kind of a trade off: do you want to pay more per month and not
have to worry about meeting the deductible, or would you rather pay less per month and worry
later when faced with more expensive medical bills? Health insurance exists to protect us
from health uncertainty. We don’t know if we’ll get sick or how
expensive being sick will be, making it pretty much impossible to save
enough money against the possibility of a very
costly illness. So let’s go to the Thought Bubble one last time,
to discuss how health insurance helps us manage
financial risk in the face of a health crisis. Suppose there’s a 1 in 50 chance that you’ll
break your leg and have to pay $7,500 to get
an x-ray, a cast, and some therapy. You might not be able to dig up that much
money. But what if you have 49 other people who also
are worried about breaking their leg? If you all agree to chip in $150 dollars to
a pool that will go to whichever one of you
breaks their leg, you all can rest easy knowing that you won’t have
to empty your bank account if you fall out of a tree. This is a simple example of a risk pool – a
group of individuals who are covered under
one insurance plan. An insurance company decides how to set their
premiums and deductibles based on how likely the ‘risk’
is that they’ll have to pay out an insurance benefit. Take our broken leg example. What if some of those fifty people were really
into extreme sports and actually had a 50%
chance breaking their leg? If the insurance company knows that,
they might increase the price that you have to
pay into the pool, because there’s a greater likelihood that more people
will need them to shell out $7500 for a broken leg. Some insurance plans set prices using community
rating in which everyone in the risk pool is charged the
same price to buy into the insurance plan. But in the US, insurance plans typically use
experience rating, where different groups that
have higher or lower risks pay different prices. For example, smokers are at a higher risk for
heart disease and lung cancer, so an insurer might
charge you higher premiums if you smoke. Thanks Thought Bubble. Hopefully, that helps you better understand
how insurance plans work. Access to affordable insurance can make
a huge difference in the quality of health care
that a person receives. People without insurance use preventative services
less often, are more likely to postpone medical care, and are more likely to move between different
doctors, resulting in worse continuity of care. As a result, being uninsured is associated
with a greater need for more expensive and
more urgent medical procedures. The high costs of medical care in the US and the
high number of uninsured people are big parts of what
spurred the passage of the Affordable Care Act and kicked off the national debate about
the best way to deal with these twin problems
in the US health system. Of course, what we’ve covered here today,
is only one understanding of how healthcare
works in the US. There’s so much more to consider and explore
in this topic and, quite frankly, with everything else
that we’ve discussed throughout this course. But even though Crash Course Sociology
has to come to an end, the number of questions that remain unanswered
about how societies work is never ending. Hopefully this course has given you some helpful
tools and perspectives to use as you analyze and
participate in the social world. Thanks for joining me and don’t forget to
be awesome. Today, we talked about what the health care
system in the US looks like, the five A’s of health care accessibility,
and a couple of contributing factors to the
affordability of health care: Fee for service care and the structure of our health
insurance system which encourage higher spending. Crash Course Sociology is filmed in the Dr.
Cheryl C. Kinney Studio in Missoula, MT, and it’s
made with the help of all of these nice people. Our animation team is Thought Cafe and Crash
Course is made with Adobe Creative Cloud. If you’d like to keep Crash Course free for
everyone, forever, you can support the series
at Patreon, a crowdfunding platform that allows
you to support the content you love. Thank you to all of our patrons for making
Crash Course possible with their continued
support.

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