By Symone Welch
Jonathan Oberlander, a professor of health policy and management, said it best: “U.S. health policy has also been an abject failure, having produced an inequitable, inefficient, and irrational non system that is the most expensive in the world and that leaves about one in ten Americans uninsured” (Oberlander). Within the United States citizens can be insured under a variety of systems yet, a significant amount of the population remains without insurance or underinsured. Health insurance is a complicated and multifaceted concept for both patients and physicians to grasp. However, it is easy to see that there is a large equity gap financially in access to insurance and health care that is largely influenced by the insurance system.
Fundamentally, insurance can be provided in two ways: private or public. Private insurance is available through a multitude of ways including: private plan through license agent, federal marketplace, or group plan with an employer. Most citizens have private insurance through employer coverage. These plans must abide by the federal health benefits requirements of the Affordable Care Act (Lalley). On the other hand, public insurance is provided through the government and includes Medicare, Medicaid, and Children’s health insurance program (CHIP). Public insurance differs from private due to the eligibility criteria needed for coverage.
Medicare “ensures a universal right to health care for persons age 65 and older. Eligible populations and the range of benefits covered have gradually expanded”. The system is four parts that includes hospital insurance (Part A), medical insurance, such as doctor’s visits (Part B), private health maintenance organization (Part C), drug coverage option (Part D). Medicaid is a “state based medical program that receives federal funding meant for low-income families and those with disabilities” (Tikkanen). The eligibility of the insurance varies, and you must re-enroll annually. While Medicaid provides coverage to visit a physician, patients often fall within the cracks.
The structure of insurance policy within the U.S makes having insurance a privilege rather than a basic necessity. If you have good insurance; in which you have a consistent primary care doctor, you will receive better care than the state appointed Medicaid doctor. For patients and families in households with low-incomes, unstable employment, or underserved areas, their access to care is limited. Crystal Deshazor:
“noticed this a long time ago when I would take my daughter to the doctor, because she would have Medicaid and she would go to a doctor’s office, and they had maybe four baby doctors in there, and she would see somebody different every time she would go, as opposed to a person that may have a different insurance, they’re going to see that one doctor and one care. So I noticed that early on, and I ended up having to switch her primary care provider as a baby, her pediatrician” (Deshazor 26:58).
When Deshazor began taking her baby to a primary physician she noticed an immediate change in the quality of care received, and her daughter’s health. For those who cannot afford an insurance plan that allows a regular provider their treatment is at the hands of different doctors with often conflicting advice. With frequent changes in providers patient care becomes inconsistent, resulting in limited treatment progress. Health disparities for those on Medicaid often start as small manageable issues, but worsen over time due to the lack of information, access to consistent care, and policy changes.
As said by Oberlander, “health insurance should be a source of security and reassurance. The U.S. insurance non system is too often a source of suffering, anxiety, economic insecurity, and frustration.” Oberlander is discussing another challenge with Medicaid or government insurance due to the eligibility criteria and re-enrollment process. Insurance and receiving healthcare often becomes an anxious and frustrating process due to the challenges of the system. Patients and families are already going through an emotional toll further complicated by worries of insurance and cost factors.
When Christine Tabb’s daughter had a major stroke and was on life support, social worker’s informed her she was eligible for Medicaid. Her million dollar bill from treatment and hospital stay was covered by Medicaid, but when she was released the care she needed did not continue. Tabb felt there was no one she could look to for help:
“we didn’t qualify, didn’t qualify for a nurse, we didn’t qualify for a CNA, we didn’t qualify for a caregiver. We didn’t qualify for nothing. […] It all comes down to politics and it all comes down to income again. I was three dollars over the limit to get help. Three dollars” (Tabb 20:01, 21:31).
Tabb, felt disappointed and frustrated with the healthcare system especially being born and raised in Germany where insurance is more universal.
On the surface, the German system of healthcare can be comparable to the United States. Like the United States, German citizens are required to belong to a sickness fund, a public insurance that covers many of the citizens. However, these funds have mandated coverage which provides medication and procedures. Whereas in the U.S, the cost is split between employers and patients. For unemployed and children, the government assumes this responsibility. This key difference makes German health care more cost effective compared to the United States.
Many Americans, like Tabb, fall into the “Medicaid gap” in which they “make too much to qualify for the state’s existing Medicaid program, yet too little to qualify for the federal government’s subsidies to buy health insurance on the new exchanges. This gap displays the socioeconomic differences in access to care and health. This can be directly correlated to poorer , rural and often communities of color experiencing more health problems than richer more affluent areas. Germany’s insurance system addresses this by making insurance premiums a percentage of your income. Those making 90,000 or 30,000 a year, each would have insurance co-pays to reflect their income. This model allows for a more equitable quality of care across the nation for all. Furthermore, the pay out system takes the cost factor out of the patient-doctor relation. A patient just shows their insurance card and receives care and later the doctor will be paid from the sickness fund. The German doctors’ associations negotiate their fees directly with all of the sickness funds in each state resulting in providers and care costs to be cheaper and more uniformed. This allows lower cost, for example an appendectomy costs $3,093 in Germany, but $13,000 in the U.S (Khazan).
The high cost factor for many with low incomes leads to many choosing to self-treat before visiting a physician and using insurance. Angela Salamanca:
“remembers visiting the emergency room when I had really bad cramps and I had been sick for a while. They made me stay for about two days and I had about a three thousand dollar bill for that. I mean this was a long time ago. So what I learned is that I don’t need to go to the doctor and I need to just take care of myself” (Salamanca 11:18).
Angela’s experience with cost has caused her to employ home remedies to treat herself to avoid visiting a hospital or physician unless necessary. While home remedies can help cure issues like fever or stomach bugs, it can also cause a false sense of reality in which patients are withholding care in hopes their more cost effective way works.
Angela, a native of Colombia states how healthcare in her country is based on:
“the money you have and the more people that you know the better access you are going to have to better care. If you don’t have health insurance, or health insurance that you can afford, then the access to clinics you have is not the best facility. Overcrowded, you know things like that” (14:41).
Angela explains the system is similar to that of the U.S in which economic gaps often correlate to healthcare gaps.
There seems to be hope for the inequalities of healthcare in the United States. The need for change has been seen through some areas of the U.S moving towards a single-payer system or medicare for all, in efforts to provide more accessible healthcare to all. An example of this is North Carolina implementing prepaid health plans, in which through Medicaid “provider groups offering primary care service to take on care management for a group with month payment directly” (McClellan et al). This action will direct the burden of cost away from the patient to the hands of the physician and establishment to provide good care, to receive pay. This initiative will also provide more inclusive care including behavioral health, physical health, and pharmacy. Additionally, the initiative will also provide funding to address social determinants like food insecurity and lack of transportation that coincide with limited access to healthcare. The shift to these reforms will result in a better focus on patient care through physician monetary incentives, while also improving the nation’s health and cost effectiveness.
Overall, healthcare policies must allow for better access to physicians for more consistent and equitable care across all income and family types. Implementing policies, like Germany that are less concerned with payment cost, will result in better access to care. The priority is to make health insurance more economically friendly for all financial situations. However, health insurance changes must also go beyond policy to actively alleviate the large gap of health disparities seen within low-income, rural, and underserved populations.
DeShazor, Crystal. Interview with Ina Dixon. 22 October 2018 (Y-0087). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Khazan, Olga. “What American Healthcare Can Learn From Germany.” The Atlantic, Atlantic Media Company, 8 Apr. 2014, www.theatlantic.com/health/archive/2014/04/what-american-healthcare-can-learn-from-germany/360133/.
Lalley, Colin. “What Is Private Health Insurance?” Health Insurance.org, Policygenius, 13 Mar. 2021, www.healthinsurance.org/glossary/private-health-insurance/.
McClellan Mark B., et al. “North Carolina: The New Frontier For Health Care Transformation:” Health Affairs, Project HOPE, 7 Feb. 2019, www.healthaffairs.org/do/10.1377/hblog20190206.576299/full/.
Oberlander, Jonathan. “Unfinished Journey — A Century of Health Care Reform in the United States.” New England Journal of Medicine, vol. 367, no. 7, 2012, pp. 585–590., doi:10.1056/nejmp1202111.
Salamanca, Ángela. Interview with Adriann Bennett. 30 June 2015 (Y-0820). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Tabb, Christine. Interview with Joanna Ramirez. 27 June 2018 (Y-0053). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Tikkanen, Roosa, et al. “International Health Care System Profiles United States.” Commonwealth Fund , The CommonWealth Fund, www.commonwealthfund.org/international-health-policy-center/countries/united-states.