As we examine the social structures of health and healthcare in the U.S. and around the world, we see that governments, in their functions of law and policy, influence health outcomes. In this policymaking step of the natural history of social problems, governments decide who gets insurance, how people have access to clean water, or whether to fund initiatives related to reproductive health. We’ll see that laws, policies, and practices related to health care and health access affect the social problem of health.

7.5.1 U.S. Healthcare

U.S. healthcare coverage can broadly be divided into two main categories: public healthcare, which is funded by the government, and private healthcare, which a person buys from a private insurance company. The two main publicly funded healthcare programs are Medicare, which provides health services to people over sixty-five years old as well as people who meet other standards for disability, and Medicaid, which provides services to people with very low incomes who meet other eligibility requirements. Other government-funded programs include The Indian Health Service which serves Native Americans, Veterans Health Administration, which serves veterans, and the Children’s Health Insurance Program (CHIP).

Private insurance is typically categorized as either employment-based insurance or direct-purchase insurance. Employment-based insurance is health plan coverage that is provided in whole or in part by an employer or union; it can cover just the employee, or the employee and their family. Direct purchase insurance is coverage that an individual buys directly from a private company.

Even with all these options, a sizable portion of the U.S. population remains uninsured. In 2019, about 26 million people, or eight percent of U.S. residents, had no health insurance. That number increased to 31 million in 2020 (Keith 2020). Several more million had health insurance for part of the year (Keisler-Starkey 2020). Uninsured people are at risk of both severe illness and also chronic illnesses that develop over time. Fewer uninsured people engage in regular check-ups or preventative medicine and rely on urgent care for a range of acute health issues.

The number of uninsured people is far lower than in previous decades, but that doesn’t mean everyone has the healthcare they need. In 2013, and many of the years preceding it, the number of uninsured people was in the 40 million range, or roughly 18 percent of the population. The Patient Protection and Affordable Care Act (ACA), which was implemented in 2014, allowed more people to get affordable insurance. The uninsured number reached its lowest point in 2016, before beginning to climb again (Garfield 2019). People having some insurance may mask the fact that they could be underinsured; that is, people who pay at least 10 percent of their income on healthcare costs not covered by insurance or, for low-income adults, those whose medical expenses or deductibles are at least five percent of their income (Schoen et al. 2011).

Why are so many people uninsured or underinsured? Skyrocketing healthcare costs are part of the issue. While most people get their insurance through their employer, not all employers offer it, especially retail companies or small businesses in which many of the workers may be part-time. Finally, for many years insurers could deny coverage to people with pre-existing conditions–previous illnesses or chronic diseases.

The Affordable Care Act (ACA), also referred to as Obamacare, was a landmark change in U.S. healthcare. Passed in 2010 and fully implemented in 2014, it increased eligibility to programs like Medicaid, helped guarantee insurance coverage for people with pre-existing conditions, and established regulations to ensure insurance premiums collected by insurers and care providers went directly to medical care (as opposed to administrative costs). It also included an individual mandate, which required anyone filing for a tax return to either acquire insurance coverage by 2014 or pay a penalty of several hundred dollars. Other provisions, including government subsidies, are intended to make insurance coverage more affordable, reducing the number of underinsured or uninsured people.

In 2012, the U.S. Supreme Court upheld the constitutionality of the ACA’s individual mandate. 29 million people in the United States have gained health insurance under ACA (Economic Policy Institute 2021).

Figure 7.18 The Affordable Care Act has been a savior for some and a target for others. As Congress and various state governments sought to have it overturned with laws or to have it diminished by the courts, supporters took to the streets to express its importance to them. (Credit: Molly Adams)

The ACA remained contentious for several years. The Supreme Court ruled in the case of National Federation of Independent Businesses v. Sebelius in 2012, that states cannot be forced to participate in the ACA’s Medicaid expansion. This ruling opened the door to further challenges to the ACA in Congress and the Federal courts, some state governments, conservative groups, and private businesses. The ACA has been a driving factor in elections and public opinion. In 2010 and 2014, the election of many Republicans to Congress came out of concerns about the ACA. However, once millions of previously uninsured people received coverage through the law, public sentiment and elections shifted dramatically. Healthcare was the top issue for voters going into the 2020 election cycle, and the desire to preserve the law led to Democratic gains in the election (just a short time before COVID-19 began to spread globally). The ACA, with its passage, response, subsequent changes, and new policies, demonstrates the interplay between policymaking, social problems work, and policy outcomes, the last step of the claims-making process.

7.5.2 Healthcare In Other Nations

Clearly, healthcare in the United States has some areas for improvement. But how does it compare to healthcare in other countries? Many people in the United States are fond of saying that this country has the best healthcare in the world, and while it is true that the United States has a higher quality of care available than many nations in the Global South, it is not necessarily the best in the world. In a report on how U.S. healthcare compares to that of other countries, researchers found that the United States does relatively well in some areas—such as cancer care—and less well in others—such as mortality from conditions amenable to prevention and treatment” (Docteur & Berenson 2009). This conflict between values and outcomes is another example of the conditions of a social problem – that values and outcomes do not match.

Some consider the Patient Protection and Affordable Care Act (ACA) to be a slippery slope that could lead to socialized medicine, a term that for many people in the United States has negative connotations lingering from the Cold War era and earlier. Under a socialized medicine system, all medical facilities and expenses are covered through a public insurance plan that is administered by the federal government. It employs the doctors, nurses, and other staff, and it owns and runs the hospitals (Klein, 2009). The best example of socialized medicine is in Great Britain, where the National Health System (NHS) covers the cost of healthcare for all residents. Despite some U.S. citizens’ knee-jerk reaction to policy changes that hint at socialism, the United States Veterans Health Administration (VA) is administered in a similar way to socialized medicine in other countries.

It is important to distinguish between socialized medicine, in which the government owns the healthcare system, and universal healthcare, which is simply a system that guarantees healthcare coverage for everyone. Germany, Singapore, and Canada all have universal healthcare. People often look to Canada’s universal healthcare system, Medicare, as a model for the system. In Canada, healthcare is publicly funded and is administered by the separate provincial and territorial governments. However, the care itself comes from private providers. This is the main difference between universal healthcare and socialized medicine. The Canada Health Act of 1970 required that all health insurance plans must be “available to all eligible Canadian residents, comprehensive in coverage, accessible, portable among provinces, and publicly administered” (International Health Systems Canada, 2010).

Heated discussions about the socialization of medicine and managed-care options seem frivolous when compared with the issues of healthcare systems in developing or underdeveloped countries. In countries with low incomes, meeting basic health care needs is difficult. Care that people in wealthy countries take for granted—like hospitals, healthcare workers, immunizations, antibiotics, other medications, and even sanitary water for drinking and washing—are unavailable to much of the population. Organizations like Doctors Without Borders, UNICEF, and the World Health Organization have played an important role in helping these countries get their most basic health needs met.

Figure 7.19 Malaria, a life-threatening blood-borne disease transmitted by mosquitoes and other insects, affects different regions of the world at different rates. This map shows which nations are impacted the most by malaria infections. Malaria is most common in tropical and subtropical regions near the equator.

The United Nations set goals in 2016 with the goal of transforming our world. Some of these goals reflect familiar descriptions of social location, such as Goal 5. Gender Equality, Goal 11 Sustainable Cities and Communities, and Goal 4, Quality Education.

Figure 7.20. United Nations Global Sustainability Goals, Figure 7.20 Image Description

Many of these goals relate more directly to health outcomes, like Goal 3 itself, Good Health and Wellbeing, Goal 6 Clean Water and Sanitation, and Goal 2, Zero Hunger.

Prior to COVID-19 infant mortality rates and maternal deaths were decreasing worldwide. However, the World Health Organization reports that ”Children in sub-Saharan Africa are more than 15 times more likely to die before the age of five than children in high-income countries.” (World Health Organization, 2020). Most of these deaths could be prevented by access to sufficient food, clean water, and regular immunizations. The United Nations also reports that 94 15 times more likely to die before the age of percent of all maternal deaths occur in low and lower-middle-income countries. (Unicef, 2019). With COVID-19, over 6 million people have died of COVID-19 worldwide. The resources that are being used to contain the virus are limiting access to other health services, particularly in areas of high poverty. The response to the virus will resonate as we look at health and health outcomes for decades to come.