Health Care Through the Social Problem Lense

The lack of health insurance has serious consequences for the uninsured and under insured, far beyond its impact on their physical health alone. A study, using the World Health Organization's measure for the quality of life, shows uninsured have:

• higher depression scores;
  
• lower physical quality of life scores;
  
• lower psychological quality of life scores;
  
• lower social quality of life scores;
  
• Lower environmental quality of life measures.
  

As one would expect, the uninsured are also less satisfied with their health and their access to health care services. (W.H.O., 2009)

The phenomemon of lack of health insurance not only hinders the quality of life and general overall health of those living without it, but also adversely affects those who do have access to insurance. When people who are uninsured are seen in an Emergency Room and are unable to pay their bill, the hospital may write off that charge, however, the hospital's insurance in turn eventually increases the cost of care in order to recover the monies lost from such write-offs. This increase is passed down the line to the consumers of individual and group health benefits, causing them to pay higher premiums and deductibles, leaving less money in their pockets for life's necessities.

Many politicians and health care companies have proclaimed for years that the US has the best health care system in the world. Still, there are many people who do not agree with this assertion, especially the 42.6 million people in the US without health insurance. The rising costs of health care and the lack of access to health care creates a myriad of social problems, and many health care professionals have begun to voice their concerns about a potential future crisis in the US health care system (Massachusetts Medical Society House of Delegates Report 207, A-99).

How does a society know when a health care system is "good"? The World Health Organization (WHO) released a report in 2000, in which it outlined three goals for a "good" health care system:

1. It should make the health status of the entire population as good as possible across the whole country.
   
2. It should respond to people's expectations of respectful treatment and client orientation by the health care providers.
   
3. It should ensure financial protection for everyone, with costs distributed according to one's ability to pay (WHO, 200).
   

In making their comparison of "good" health care systems, several basic facts emerged: the United States has, by far, the most expensive health care system in the world, based on health expenditures per capita and on total expenditures as a percentage of GDP. The United States spent $4178 per capita on health care in 1998, more than twice the median, and far more than its closest competitor, Switzerland, who spent $2470 (WHO, 2000).

In addition, the US is the only country in the developed world, except for South Africa, that does not provide health care for all of its citizens (Ayres, 1996). Instead, private insurance is used, coverage by which depends mostly on employment, along with public insurance coverage for the elderly (Medicare), the military, veterans, the poor, and also for the disabled (Medicaid – which varies greatly in its implementation across states). Such a system creates serious gaps in health care coverage, which coupled with the high cost of insurance, means that often employers are forced to either drop the insurance benefits, or to raise premiums and pass this on to their employees (Massachusetts Medical Society House of Delegates Report 207, A-99).

According to recent figures, 42.6 million people in the US were uninsured in 1999. This is an embarrassment to politicians, but a matter of life or death to many of these 42.6 million people. As Martin Luther King Jr. said "Of all the forms of inequality, injustice in health care is the most shocking and inhumane". People without health insurance tend to live sicker and die younger than people with health insurance. 80% of those uninsured are in working families, which has detrimental repercussions for the US economy as a whole.

In addition, the WHO report found that the US ranked 26th among industrialized countries for infant mortality rates (WHO, 2000), at 7.2 infant deaths per 1000. These figures are the highest among the OECD countries, and also mask a general disparity in infant mortality among racial groups, which is based in large part on economic differences (Massachusetts Medical Society House of Delegates Report 207, A-99). The US Department of Health and Human Services estimates that the infant mortality rate for black children in the US is 14.3 per 1000, which is more than twice that for white children (at 6.0 infant deaths per 1000). Most health care professionals consider these figures to be a shocking indictment of the living conditions for certain segments of the population of the richest country on earth.

The WHO report also showed that the US ranks very low, at 24^th, on the disability-adjusted life expectancy (DALE) among high-income OECD countries. The US also has a highly skewed distribution of DALE, particularly among males. This should perhaps not come as a surprise: with a great proportion of the US population lacking access to health care, particularly preventive care, it should be expected that some of these people live their lives with a higher frequency of, and more years of, disability (Massachusetts Medical Society House of Delegates Report 207, A-99).

The same WHO report looked at the degree to which financial contributions to health systems are distributed fairly across the population, and it was found that the US was the least fair of all the OECD countries. This unfair system of financing has implications for much of the population, but especially for those who are uninsured, or underinsured. As the WHO stated "the impact of failures in health care systems is most severe on the poor everywhere, who are driven deeper into poverty by lack of financial protection against ill-health" (WHO, 2000, cited in Massachusetts Medical Society House of Delegates Report 207, A-99).

In evaluating the world's health care systems using the above noted criteria, the WHO also ranked the world's countries based on overall attainment of their health care system, and the performance of their health care system. It was found that the US health care system ranked 15th in the world for overall attainment, and 37th in the world for performance (WHO, 2000, cited in (Massachusetts Medical Society House of Delegates Report 207, A-99). The same study found that only 40% of Americans are satisfied with the health care system in the US.

Further studies by other organizations have uncovered similar depressing statistics. In 1999, the United States Congress commissioned the Institute of Medicine (IoM) to study the issues of racial and ethnic disparities in health care (Betancourt, 2002). The IoM study found that minority Americans suffer disproportionately from preventable and treatable conditions - cardiovascular disease, asthma, cancer etc. - and attributed this to a lack of access to medical care. The IoM also found disparities in the quality of care for those from the ethnic minority communities with access to medical care (Byrd, 1990). The IoM report stated that "whereas racial/ethnic disparities in health were deemed to be "unacceptable yet understandable" given the persistent racial and socioeconomic inequalities in the US today, the racial/ethnic disparities in health care highlighted by this research seemed unconscionable" (cited in Betancourt, 2002). Possible solutions put forward by IoM included: raising the awareness of these issues with health care professionals; making legal, regulatory and policy interventions; providing interpreter services in health care settings; providing cross-cultural education as part of the curriculum for all health care professionals.

A paper by Mangalore (2002), attempts to provide some sort of solution to this crisis of inequality in the US health care system. The paper starts with the premise that as long as command over health-production inputs are dictated by the ability to pay for them, health inequality will persist within and among countries. A globally-acceptable definition of equality therefore needs to be defined, says Mangalore, and to be adopted practically.

Mangalore then goes on to provide a definition of equity, as the equal probability of reaching a desired end. He argues that an equitable health policy will then ensure that everyone belonging to a particular age group will have an equal probability of reaching a certain desirable health status (Mangalore, 2002). This, however, has to be coupled with two crucial conditions, in order for the objective of equitable health care to be achieved: equality of access to care, and care in proportion to the need (Mangalore, 2002). He argues that many of the current problems in the US health care system have arisen because conflicts have arisen between equity and efficiency, with the correct definition of equality of access (the freedom and ability to make use of relevant health medical care for those in need) being largely ignored in the efficient (and therefore not equitable) delivery of health care in the US.

Mangalore concludes by saying that a new definition of heath equity demands an equal probability of achieving a desirable target level of health. Medical care, he says, should be of primary importance, and should be available to all in an equitable manner. Equality of care, and of access, are therefore, essential conditions for this equity (Mangalore, 2002).

As we have seen, then, the US health care system ranks very low on many indices used by the WHO in their comparisons of health care provision worldwide. The inequalities that arise from the poor health care provision in the US have many repercussions, for the poor, for the disabled, for the elderly, and for those from ethnic minorities who tend to be disproportionately poor, in the US. These problems are now being recognized by health care professionals in the US, and now the discussion of how to solve these problems is opening up in health care journals, as we have seen, from the studies by Betancourt and Mangalore presented here. This, however, will not be an easy task, and will take a concerted "bottom-up" effort from health care workers, to influence policy-makers, who in turn will have to influence politicians and law-makers.

Those powerful words of Martin Luther King Jr. should ring in our minds as we ponder the question of inequality in health care provision in the US, and the plight of the 46.2 million people in the US should be changed for the better.

References

Ayres, S.M. (1996). Health Care in the United States: The Facts and Choices. Chicago and London: American Library Association.

Betancourt, J. (2002). "Unequal treatment: the Institute of Medicine's findings and recommendations on health care disparities". Health Policy Review. 3(2): 6-9.

Budrys, Grace.(2003) Unequal Health: How Inequality Contributes to Health or Illness.

Byrd, W.M. (1990). "Race, biology and health care: reassessing a relationship". Journal of Healthcare for the Poor and Underserved. 1: 278-296.

Evidence from the Philippines. University of California, Berkley. Retrieved from http://faculty.haas.berkeley.edu/gertler/working_papers/gertler-solon%20philippines%20hopsital%20paper%203-1-02.pdf on 06/01/2009.

Mangalore, R. (2002). "Forging a new definition of health equity". Health Policy Review. 3(2):15-18.

Massachusetts Medical Society House of Delegates Report 207, A-99 (2001). "The US health care system: best in the world, or just the most expensive?"

Morris, Robert. Journal of Health Politics, Policy and Law. Aging Devolution and Aging Policy. 29.2 (2004) 335-337

WHO (2000). The World Health Report 2000 – Health Care Systems: Improving Performanc