Chapter 16

1. Chapter 16 Health and Health Care

2. Chapter Outline • Using the Sociological Imagination • Health Care as a Social Institution • Theoretical Perspectives and the Health-Care System • Health in the United States • The Changing Health-Care System • Health-Care Reform in the United States

3. The American Health-Care System • Americans spent $1.2 trillion on health care in 1999, up from $75 billion in 1970. • Since 1980, total health expenditures increased nearly 400 %. • Health-care expenditures account for about 14% of the GDP; the comparable figure in 1970 was about 7%.

4. Components of the Health-care System • Physicians • Nurses • Hospitals • patients

5. Rising Health-Care Expenditures in the U.S.

6. The Sick Role • The sick are permitted to withdraw temporarily from other roles or at least reduce their involvement in them. • It is assumed that the sick cannot simply will the sickness away.

7. The Sick Role • The sick are expected to define their condition as undesirable. • The sick are expected to seek and to follow the advice of competent health-care providers.

8. Theoretical Perspectives: Health Care in the U.S.

9. Theoretical Perspectives: Health Care in the U.S.

10. Infant Mortality According to Race/Ethnicity of Mother

11. Higher Incidence of Mental Illness Among the Poor: Explanations • Genetic explanation • A biological tendency to mental illness within the lower social class. • Social stress explanation • Lower class is more susceptible to mental disorders because of the extra stress of deprivation.

12. Higher Incidence of Mental Illness Among the Poor: Explanations • Social selection explanation • Individuals with mental disorders in other social classes tend to end up in the lower class. • The mentally healthy born into the lower class move up to higher social classes.

13. Characteristics of Managed Care Systems • Delivery of a comprehensive set of health services for a prepaid premium. • Utilization and quality controls that providers agree to accept.

14. Characteristics of Managed Care Systems • Financial incentives for patients to use the provider’s facilities or designated physicians only. • Assumption of some financial risk by doctors to motivate them to balance patients’ needs against the need for cost control.

15. Negative Aspects of HMOs • Coverage is restricted: • Patients have to use doctors who are members of the HMO. • Physicians may turn patients away because of the quota for subscribers. • Physicians limit enrollment because HMO reimbursements are below other forms of insurance.

16. Negative Aspects of HMOs • Co-payment requirements discourage subscribers from visiting doctors. • HMOs control referrals to more costly specialists: • The primary care doctors divide referral money left over at the end of the year. • Primary care doctors who fail to limit referrals are more likely to be released by HMOs.

17. Negative Aspects of HMOs • HMOs encourage doctors to keep costs low: • They pay the physicians a predetermined amount annually for each patient they have. • Because doctors can keep the difference between their total allocation and the actual costs of patient care, they have an incentive to under treat.

18. Health-Care Reform • The United States is the only highly developed country in the world without health insurance for all citizens. • Health insurance in the United States is a privilege enjoyed, with the exception of the elderly, by those who have full-time jobs with well-established firms.

19. Health-care Reform: Economic Motivation • In 1999, health care accounted for 13% of America’s GDP ($1.2 trillion). • If current trends continue, health-care spending is expected to reach 18% of GDP early in the 21st century.

20. Health-care Reform: Access to Medical Care • Even with Medicaid, 1/2 of America’s poor are without medical coverage. • In 2001, 60% of the uninsured were employed. • Nearly 1/2 of uninsured children live with parents who are insured. • Nearly 10% of children in the United States were without health insurance in 2001.

21. Americans without Health Insurance, 2001

22. Health-Care Reform Options • The “modified competitiveness” option • Based on market principles such as consumer cost sharing. • Depends on universal health coverage as a precondition to health-care reform.

23. Health-Care Reform Options • Managed competition • A combination of free-market forces and government regulation. • Health care would be structured around plans modeled after HMOs.

24. Health-Care Reform Options • Single payer approach, like the Canadian model. • Government finances medical services. • Canadians choose their doctors and hospitals and bill the government according to a fee structure. • This approach engenders higher levels of satisfaction with patient services, and is regarded much more favorably than the U.S. system.

25. Health-Care Reform Options • Play or pay mechanism based primarily on the German model • Universal coverage is provided by employers who either offer health coverage (play) or pay into a fund for covering the uninsured. • Access to medical care in Germany, considered among the best in the world, is guaranteed for life.