.The United States is one of few developed nations without universal access to health care, Instead, the system has functioned as a fee for service system, which means some people are able to afford access to health care and many more are not. The American health care system and access to it has been a key social issue for many decades. It continues to divide the American public and policy makers.
The United States faces another reality that is intrinsically bound with the health care issue—social inequality. Some suggest that social inequalities are based primarily on socioeconomic status, while others suggest they are based on race and/or gender. President Barack Obama’s Affordable Care Act of 2010 attempts to address these issues and level the playing field by equalizing access to health insurance.
Keywords Acculturation; Corporatization; Cultural Competence; Medical Necessity; Monopoly; Social Stratification
Access to Health Care in the US
The United States is one of the few developed countries without universal access to health care, and since access to health care is inextricably tied to access to affordable health insurance, many see the system as failing the American people. Historically there have been disparities in availability of health care for people from various income levels, and the care that is available is not of consistent quality. Immigrants, the poor, and the homeless seem to be most affected by inaccessibility to health care, and seniors and children are also vulnerable.
There has long been a concern that people of color and ethnic communities continue to represent a majority of the uninsured in America. New immigrants often experience difficulties with accessing and understanding the system. There are Americans who are homeless and their ability to access health care is severely limited. Ironically, the US continues to be one of the wealthiest countries in the world with some of the most advanced medical technologies. Regardless of this reality, the question remains whether or not the United States can successfully reform its own system so that no one is denied access to proper health care.
The primary theory of stratification is that historical inequities have translated into creating socioeconomic strata in society. The lower a person or group may be on the strata, the greater the likelihood that person or group will always live in poverty and the harder it is to improve the socioeconomic state in life. Such social strata are directly tied to social inequalities, and "social inequalities in access to health care persist in the US health care delivery system. Lower social classes, minority racial/ethnic groups, and those without health insurance continue to experience barriers to care" (Pappas, Hadden, Kozak, & Fisher, 1997, p. 811). In other words, historically there has been one system in the United States for those who can afford health insurance, and thus quality health care, and another system, often of lesser quality, for those without insurance.
The Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) of 2010—commonly called the Affordable Care Act (ACA) or Obamacare after its major backer US president Barack Obama—sought to reform a number of aspects of the US health insurance industry as well as improve access to and quality of health care services. Since the passage of ACA, insurers have been required to cover preventive services without a deductible, copayment, or other out-of-pocket expense; extend coverage to children with existing medical conditions; cover young-adult children up to age twenty-six on their parents’ plans; spend most of their premiums on benefits to consumers rather than on administrative costs; and provide justification for rate increases. Starting in 2014, insurers will no longer be allowed to set annual dollar limits on coverage, reject anyone based on preexisting medical conditions, or restrict or deny coverage to those who participate in clinical trials. ACA also expands Medicare coverage through the state governments (US Department of Health & Human Services, 2013).
At the time of its passage, the Affordable Care Act was the most substantial overhaul of the US healthcare system since the passage of Medicare and Medicaid during the Johnson administration in the mid-1960s. Although it has encountered intense opposition from the general public, medical professionals, and various public officials and has had numerous problems and glitches in its start-up, the ACA promises to dramatically improve the affordability of and access to health insurance.
Public Health Coverage
Medicaid is a federal program that provides health insurance coverage to qualifying very low-income Americans, particularly among those over age sixty-five and children under eighteen. Medicare is the program that provides people over sixty-five with medical care. It also provides support for persons with certain disabilities and people of all ages who have end-stage renal disease (kidney failure). Medicare has become far more complicated than it was in its original form. There are four sections to Medicare: A, B, C, and D. Respectively, they cover hospital insurance, medical insurance, advantage plans, and prescription drug coverage. One of the ongoing problems for the Medicare program has been to continue to provide the health insurance required by seniors and persons with disabilities at the same time as trying to contain costs. Like Medicaid, Medicare also has variations in practice among states, which also leads to some confusion over and frustration with the program.
Health Care for Children
There is perhaps no issue as salient and distressing as that of the millions of Americans who are uninsured. In 2012, an estimated 48 million Americans were uninsured, 7 million of them were children under eighteen (DeNavas-Walt, Proctor & Smith, 2013). According to DeVoe (2007), "children from lower socioeconomic backgrounds have poorer health outcomes. These health disparities are due, in part, to barriers in accessing medical care and utilizing primary care services" (DeVoe, et al., 2007, p. 511). Libby (2006) further explains that "one specific vulnerable and often low-income population is children and adolescents involved with child welfare. Children in contact with child welfare systems have been shown to be particularly vulnerable to health and mental health problems…" (Libby, 2006, p. 40).
The Children’s Health Insurance Program (CHIP) is a health program that emerged in 1997 from the collapse of the Clinton administration's efforts at health care reform in 1994. CHIP is part of Medicaid and provides health insurance to many children below the age of nineteen. States have a great deal of leeway in deciding how to administer the program. Prior to the Affordable Care Act, very few programs besides CHIP and Medicaid provided health insurance to very poor or uninsured children. Problems arose with these programs, however, from inadequate state funding for CHIP, and children on Medicaid were reported to have to wait longer for appointments than were children with private pay insurance. Physician access for children on Medicaid was also poor (Roy, 2011; Grady, 2011). The Affordable Care Act as it was passed in 2010 proposed to expand Medicaid coverage and benefits and address the issues of substandard health care for children by increasing Medicaid payment rates to health care providers to help ensure access to primary care providers for more low-income children. Children will also no longer be denied coverage for preexisting conditions and will no longer have annual or lifetime caps placed on their health insurance. For very poor or uninsured families, ACA provides tax credits and vouchers to help with quality health insurance coverage (Children’s Defense Fund, 2012). Additionally, ACA allows parents to keep their children on their policy until age twenty-six.
Health Care for Seniors
Senior citizens are living longer than ever before. "Two factors—longer life spans and aging baby boomers—will combine to double the population of Americans aged sixty-five and older during the next twenty-five years" (Centers for Disease Control, 2007, p. III). Seniors also tend to be far more independent into their later years than at any time in history. In addition, the senior population is swelling and with it is the need to provide adequate geriatric health care. Health care for seniors is provided more and more on an out-patient basis. Far fewer seniors are going into long-term care, and when they do, they tend to go into care at an older age than in the past.
Historically, healthcare benefits for older persons were not uniform. Medicare beneficiaries enrolled in health plans, for instance, might receive essential services (such as case management) that are not covered for those enrolled in fee-for-service Medicare. Community-based alternatives to long-term care (such as the Program for All-inclusive Care of the Elderly) were essentially out of reach financially for older persons who are not dually insured by Medicare and Medicaid (Racz, 2005, p. 248).
The Affordable Care Act has attempted to address these issues and has among other provisions included additional preventative care benefits through Medicare. The law also lowers the cost of prescription drugs and provides incentives to physicians who treat Medicare patients or who provide primary care in regional areas with doctor shortages. In prior years, seniors did not have consistent access to quality health care and services (Centers for Disease Control, 2007). To further address this issue, the Affordable Care Act increased the number of checks and balances to ensure best practices in nursing homes so that seniors and their family members can feel more assured of quality care.
The Working Poor
Prior to the passing of the Affordable Care Act, the working poor have had difficulty accessing affordable health insurance. Many employers do not provide health insurance for their employees as a cost cutting measure. Therefore, many of the...
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