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TH

MEDICAL
SOCIOLOGY,
13
EDITION
Chapter x

William C. Cockerham

Chapter 15
Health Care Reform and Social
Policy in the United States

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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

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Rising Costs
Per capita health care expenditures in the
U.S. are the highest in the world
1980 per capita expenditures: $1,100
2012 per capita expenditures: $8,900

Costs influenced by a number of factors:


Aging of the population
Increases in hospital expenses and doctors
fees
Increased cost of health insurance
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Rising Costs
Increased use of and advertising for
prescription drugs

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The Road to Health Care Reform:


Initial Federal Efforts
During the 20th century, several U.S.
presidents have attempted or recognized
the need for health care reforms
Only Johnsons establishment of Medicare
and Medicaid in 1965 was successful
Public resistance and the opposition of the
AMA have hampered efforts at reform

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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
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The Road to Health Care Reform:


Initial Federal Efforts
Medicare
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
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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
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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


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The Road to Health Care Reform:


Clinton
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

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The Road to Health Care Reform:


Managed Care
In the early to mid-1990s, private health
care shifted away from a largely officebased, fee-for-service 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)
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The Road to Health Care Reform:


Managed Care
Schedules of fees placing a ceiling on how much the
government will pay for specific services rendered to
Medicare patients by hospitals and doctors

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

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The Road to Health Care Reform:


Managed Care
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 persons immediate family, with
little or no additional cost
Discourages inefficient and unnecessary
treatment

Initially kept rising costs in check


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The Road to Health Care Reform:


Managed Care
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

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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
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The Road to Health Care Reform:


State Efforts
Vermont, Illinois, Washington
Provide health care for children, with subsidies for
premiums

Massachusetts
Requires all residents to have health insurance

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Enactment of the Affordable Care Act


(ACA)
Obama put health care reform at the top
of the domestic agenda
Those opposed cited these concerns:
prohibitive costs
higher taxes
cuts in Medicare benefits
expanded federal funding for abortion
services
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Enactment of the Affordable Care Act


(ACA)
government-controlled health care delivery would
be too bureaucratic and unresponsive to
individual needs

There were several legal challenges to the


Affordable Care Act concerning
Religious exemptions
the mandate for employers to provide health
insurance, and the legality of paying subsidies
giving tax credits to low- and middle-income
Americans
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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
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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
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Geographic Distribution of Services


There are a few signs that the distribution
of physicians is beginning to improve
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

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Geographic Distribution of Services


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

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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
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Overview of Health Care Delivery


Followed by services provided by hospitals

Official agencies
Public organizations supported by tax funds
Support and conduct research, develop
educational materials, protect the nations
health, and provide services designed to
minimize public health problems

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Overview of Health Care Delivery


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

Health maintenance organizations (HMOs)


Managed care prepaid group practices
Individual pays a monthly premium for
comprehensive health care services
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Overview of Health Care Delivery


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

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Overview of Health Care Delivery


Allied health enterprises
Manufacturers of pharmaceuticals and
medical supplies and equipment, which play a
major role in research, development, and
distribution of medical goods

Traditional fee-for-service system is


modeled on the principle of the open
market
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Overview of Health Care Delivery


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

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Overview of Health Care Delivery


Does not apply to medicine since doctors and
hospitals effectively create their own demand
and provide services at prices they set

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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
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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

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Health Care: A Right or a Privilege?


Health reform is really about whether
medical care is a right of all Americans 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

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Health Care: A Right or a Privilege?


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

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
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Health Care: A Right or a Privilege?


Society has an ethical obligation to provide
health care

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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