The Structure & Cost of US Health Care: Crash Course Sociology #44


The health care system in America is…complicated. Doctors, hospitals, insurance
and drug companies – it can be hard to navigate all the moving
parts of healthcare, and it’s even harder if you’re
trying to do it when you’re sick. Theory and statistics can give us a broad
understanding of the social and cultural forces
that affect health. But for the average American making choices
about healthcare, the questions that matter
most are the practical ones. After all, when you’re running a fever,
the most important question is where can you
find a doctor to make you better. And then after the fever has gone down and
you get the bill, your question might become,
“How do I pay for this? And why does giving me an aspirin count as
a separate thing that I get charged for?” It’s easier to answer these questions once you
understand how the US structures and finances
its health care system. So, let’s do it. [Theme Music] Let’s start with the basic structure of
the healthcare system in the United States. Health care is split into different sectors –
the private, the public, and the voluntary sectors. Private and public sectors supply insurance
and care to most Americans. In the private sector, 56% of patients pay
for their health care with insurance that they
get primarily through their employer. There are also public health insurance
plans for vulnerable groups – like Medicare, which covers elderly Americans,
and Medicaid, which covers Americans below a
certain poverty threshold. The government also provides healthcare through
things like VA hospitals and the Bureau of Indian Affairs, and it has a legal mandate to provide
healthcare for people in federal prison. But the voluntary sector is different, in that it includes
charitable organizations that do health research and
provide free or low-cost health services, like the American Cancer Association or
the March of Dimes. So, with all of these options available, what
determines how easy or hard it might be to
get access to health care? In this context, access refers to entry into,
or use of, the health care system. In 1981, two professors of Public Health at
the University of Michigan – Roy Penchansky
and J. William Thomas – came up with what they called the Five A’s of
health care access: availability, accessibility,
accommodation, acceptability, and affordability. So, the first “a” asks: Does the person
live where the health services they need are
readily available? If you live in a major city, you might take it for
granted that finding a doctor or a 24-hour clinic
on short notice is just a google search away. Urban areas have more doctors, specialists,
and hospitals – all of which means that a wider
variety of services are available. By contrast, rural areas are more likely to
experience shortages of healthcare workers. Urban areas have twice as many doctors per
person as rural areas! Rural areas also tend to have issues with
the second “a”, accessibility. Accessibility here refers to a person’s
literal ability to get to facilities and keep
appointments. Transportation to appointments can be much
more difficult in rural places, where providers
tend to be farther away. This is especially hard for people with chronic
illnesses or disabilities that make it impossible
for them to drive by themselves. Time can also be a limiting factor. Doctor’s appointments are usually during
business hours, so patients may have to miss
work to get the care they need. Low-income and blue collar workers are more
likely to have jobs that don’t offer paid sick leave – and they may even be fired
if they miss work due to illness. Sociocultural factors can also impact the
accessibility. And so can the accommodations provided by
health services. Accommodations are the ways that services are
organized to accept clients, like the hours that they’re
open or the ways that they communicate with patients. Language barriers can make it especially hard
for non-English speaking patients in the US. So accommodations like translators or multilingual
information packets, can help mitigate the disparities. And finding the ‘right’ accommodations
for different populations can be difficult, too. For example, Hmong Americans, who primarily immigrated as refugees from Southeast Asia in the wake of the Vietnam war, have higher mortality rates than native-born Americans. Providing medical information can be hard,
because no written form of the Hmong language
existed until the 1960s, meaning that many Hmong people can’t read
or write in their own language, and dialects vary,
making it hard to find the right translator. Once you get past all those other obstacles, there’s still the matter of whether the doctor and patient have similar ideas about how the whole doctor-patient relationship should work. Some people want a doctor who gives them the
information they need to make decisions themselves. But others just want to leave all the decision-making
to the doctor and just be told what pills to take. How satisfied a patient is with their healthcare tends to depend on the match between their preferences and their doctor’s style of care, or the doctor-patient congruence. A patient’s satisfaction with a provider
will determine if they return. So the next “a”, acceptability, is based on
whether a doctor meets the patient’s preferences – both in terms of their professional
abilities and in their personal traits, like
gender, race, or age. For example, many people feel more comfortable
with a doctor of the same gender as themselves, so if none are available, they may not find
that health care experience acceptable. The last A of the five A’s is a pretty important
one, particularly in the United States: affordability. How people pay for health care in the US, and more importantly if people can pay for health care, is closely linked to how we financially structure the healthcare system. The US has what’s known as a ‘fee-for-service’
healthcare system, where services are unbundled
and paid for separately. So if you go in for a check up and the doctor
orders a blood test and an x-ray, the charges
on the bill will be separated into three parts: the x-ray, the lab test for the blood, and
the cost of the doctor’s time. There are pros and cons to a system like this. It incentivizes doctors to do a lot of tests,
because they’ll get a separate fee for every test. Which can be good – you want your doctor
to be thorough when you’re not feeling well. But a fee-for-service system also incentivizes
overtreatment, and this drives up the cost of care. The US also relies on a third-party payer
system, which means that medical costs are
paid through a third party, like a commercial insurance company
that’s responsible for paying the doctor on
behalf of the patient. Third-party payer systems often rely on cost-sharing,
where the insured patient pays a little each month,
whether they need care or not. This helps limit the overall costs to the
insurance provider. An insurance premium is the amount you pay
to the insurance company each month so that
you can keep your coverage. A deductible is the portion of the health
care costs that you’re responsible for yourself
before your insurance kicks in. Most insurers offer lower monthly premiums if you
accept a higher deductible – so it’s kind of a trade off: do you want to pay more per month and not
have to worry about meeting the deductible, or would you rather pay less per month and worry
later when faced with more expensive medical bills? Health insurance exists to protect us
from health uncertainty. We don’t know if we’ll get sick or how
expensive being sick will be, making it pretty much impossible to save
enough money against the possibility of a very
costly illness. So let’s go to the Thought Bubble one last time,
to discuss how health insurance helps us manage
financial risk in the face of a health crisis. Suppose there’s a 1 in 50 chance that you’ll
break your leg and have to pay $7,500 to get
an x-ray, a cast, and some therapy. You might not be able to dig up that much
money. But what if you have 49 other people who also
are worried about breaking their leg? If you all agree to chip in $150 dollars to
a pool that will go to whichever one of you
breaks their leg, you all can rest easy knowing that you won’t have
to empty your bank account if you fall out of a tree. This is a simple example of a risk pool – a
group of individuals who are covered under
one insurance plan. An insurance company decides how to set their
premiums and deductibles based on how likely the ‘risk’
is that they’ll have to pay out an insurance benefit. Take our broken leg example. What if some of those fifty people were really
into extreme sports and actually had a 50%
chance breaking their leg? If the insurance company knows that,
they might increase the price that you have to
pay into the pool, because there’s a greater likelihood that more people
will need them to shell out $7500 for a broken leg. Some insurance plans set prices using community
rating in which everyone in the risk pool is charged the
same price to buy into the insurance plan. But in the US, insurance plans typically use
experience rating, where different groups that
have higher or lower risks pay different prices. For example, smokers are at a higher risk for
heart disease and lung cancer, so an insurer might
charge you higher premiums if you smoke. Thanks Thought Bubble. Hopefully, that helps you better understand
how insurance plans work. Access to affordable insurance can make
a huge difference in the quality of health care
that a person receives. People without insurance use preventative services
less often, are more likely to postpone medical care, and are more likely to move between different
doctors, resulting in worse continuity of care. As a result, being uninsured is associated
with a greater need for more expensive and
more urgent medical procedures. The high costs of medical care in the US and the
high number of uninsured people are big parts of what
spurred the passage of the Affordable Care Act and kicked off the national debate about
the best way to deal with these twin problems
in the US health system. Of course, what we’ve covered here today,
is only one understanding of how healthcare
works in the US. There’s so much more to consider and explore
in this topic and, quite frankly, with everything else
that we’ve discussed throughout this course. But even though Crash Course Sociology
has to come to an end, the number of questions that remain unanswered
about how societies work is never ending. Hopefully this course has given you some helpful
tools and perspectives to use as you analyze and
participate in the social world. Thanks for joining me and don’t forget to
be awesome. Today, we talked about what the health care
system in the US looks like, the five A’s of health care accessibility,
and a couple of contributing factors to the
affordability of health care: Fee for service care and the structure of our health
insurance system which encourage higher spending. Crash Course Sociology is filmed in the Dr.
Cheryl C. Kinney Studio in Missoula, MT, and it’s
made with the help of all of these nice people. Our animation team is Thought Cafe and Crash
Course is made with Adobe Creative Cloud. If you’d like to keep Crash Course free for
everyone, forever, you can support the series
at Patreon, a crowdfunding platform that allows
you to support the content you love. Thank you to all of our patrons for making
Crash Course possible with their continued
support.

63 Replies to “The Structure & Cost of US Health Care: Crash Course Sociology #44”

  1. Thanks for this course… I know this has not bin the most popular show, the was a bit of a drop out over the course. But i found it interesting. Especially the more general topics with a lesser focus on the US.

  2. I’ve learned from this series that apparently all white people are racist and everyone who technically belongs with a particular group acts exactly like the members of their group and humans have no individuality or control over their lives

  3. I work at a restaurant and last summer I had an eye-opening experience. A family came in and it was very obvious that at least half of them were deaf. I did not know any sign language, so I got nervous while giving them menus that it would be hard when it came to taking their order. Luckily for me, they must have been used to everybody in every type of restaurant, grocery store, gas station, etc. not knowing sign language. They had one of them who was not deaf order for everybody else. I personally believe that it is sad that someone cannot so much as order for themselves in a restaurant just because they are deaf and the rest of the world refuses to learn sign language.

    My friends and I love watching CrashCourse, and we are also trying to learn sign language. I think that it would be a great thing if CrashCourse could start a series on learning ASL (the standard sign language throughout North America). Not only would it help my friends and I learn sign language, but it would also spread awareness of the cause.

    Thank you for your time!

  4. I LOVE YOU NICOLE!!!. I learned so much… Will you have my babies?? Hell, Ill have your babies lol

  5. Complexity of the system is inversely related to the role of third party payers. When docs and patients had a direct contract for payment, the system was much simpler.

  6. Meanwhile, Israel has state-funded basic healthcare for all citizens. By "basic" I mean "Covers most common drugs and procedures with very small participation fee".

    A visit to your physician is literally free of charge. Seeing an expert in a specific field is around 6$.
    A visit to the ER costs around 40$ if you decide to go on your own, or completely free of charge if a doctor sends you there/if you end up needing to get hospitalized/have a time-sensitive kind of condition, such as a stroke or heart attack.
    Dental care is free under 18, and basic dental care is fairly inexpensive [prices of more complicated or cosmetic stuff can skyrocket, though].
    The burden on the taxpayer is pretty tiny, and most people rely on the public healthcare system.
    It's far from perfect, obviously. But it works pretty well for the most part.

    [And for the record, Israel's economy in the last 20 years is mostly neo-liberal and hyper-capitalistic. And yet nobody seriously suggests taking the healthcare system down.]

  7. Man I am disappointed that you ended this here. Why? This course has been exclusively America-centric (not counting the theories, which were mostly a history lesson). Isn't there some place I can get sociology information on, say, European, Asian, or African countries? Knowing about the inner workings of other societies is extremely important when confronting issues with ours.

  8. Great course! Thank to Nicole, all the writers and the rest of the team. You never forget being awesome!

  9. I had a ton of fun reinforcing what i learned in my introduction to sociology class through watching this series, thanks!

  10. If I've learned one thing in this whole series, it's that it's hard to be a non-white non-male in society.

    (but yes, I've learned a lot of other things, too. This was a great series!)

  11. When your house is burning, you don't need insurance to afford fire fighters to put down the flames. When crime occurs, you don't need insurance to afford police officers to show up. Nor should you if you require urgent care! Hospitals should be entirely government regulated and free! We pay taxes for a reason…… US healthcare system as of now is PURE greed and another reason why America is on the decline! The patient should matter not MONEY! Reason why it costs you $7500 for a broken leg treatment is because of administrative parasites, inflated salaries to sustain their lavish lifestyles and pharmaceutical companies spending more on their marketing budgets than their R&D (essentially price gouging medication and tech). If you're at the bottom of the totem poll and require urgent care, you're pretty much soft killed or going to be crippled for life. Health care is not for everyone, and that is a travesty in a 1st world nation such as ours. Greed is a bottomless pit which undermines any civilization following it in an endless effort to satisfy the need without ever reaching satisfaction.

  12. It's funny how as soon as people are educated on how health care operates in the U.S. and other countries, they are immediately all for public healthcare… sips tea

  13. IN AMERICA, THE GREATEST AND RICHEST COUNTRY IN THE WORLD, FORGET PRE-EXISTING CONDITIONS THAT'S A LAME TERM.MEDICAL HEALTHCARE SHOULD BE 100% COVERAGE FOR A AMERICAN CITIZENS. YOU PAY PREMIUMS FOR THE HEALTH INSURANCE SO YOU SHOULD BE COVERED 100% REGARDLESS. THIS IS WHY WE PAY FOR HEALTH INSURANCE. FORGET DEDUCTIBLES, JUST ANOTHER OBSTACLE TO RIGG THE SYSTEM. DID YOU HEAR THAT MR. PRESIDENT ? LET'S ACT ON THIS PROBLEM. OBAMACARE IS OUT, TRUMPCARE IS IN.EVERYBODY GETS PAID FOR SERVICES RENDERED…

  14. Can someone tell me whats the average medical bill to visit a doctor for fever and get paracetemol? Asking from Singapore

  15. somehow i know less about the US healthcare system after watching this video than i did when i started watching it. nice job writers.

  16. I just wonder what to expect in terms of changes in the healthcare systems (if any)

  17. 8:06 "As a result, being uninsured is associated with the greater need for more expensive and more urgent medical procedures" Check yourself, friends… not everything adds up here

  18. Thank you for this series, learned a whole ton of stuff! Also as I was trying to se the little bubbles of comments in the intro section so I slowed the video by half and Nicole sounds high as hell 😂😂😂

  19. the first problem is that the U.S has a healthcare system. It's not the job of the federal government to run healthcare. It should be states doing it, or better yet local governments. Healthcare was much less expensive before the federal gov. got involved. There isnt anything liberals dont want federalized except immigration. Where are the liberal run states with government funded healthcare? There aren't any because liberals are hypocrits.
    the dumbest thing is that I have to pay more for healthcare out of network. The other is insurance company's funding all healthcare. Who's the idiot who came up with that idea? Insurance should only pay for catastrophic healthcare bills. If people can't afford a physical or basic treatment or even insurance then they should be allowed to pay over time, as long as they pay something. We do that with a lot of other things like mortgages, college loans, credit cards and car payments. Most healthcare is NOT unaffordable anyway. It is expensive not unaffordable. There's a difference. Liberals never want to address the things that cause it to be so expensive.

  20. This is indoctrination. If you are unfortunate to come down with a horrible disease, you can't be treated in the rest of the world. Why? You're too espensive so the goal is to waitlist you in hopes that you will die on the list-just like our VA. There is no innovation. You don't have the density of biologists, chemists, geneticists, etc doing research. They can only bandaid you in the UK. Lines & waitlists are the foundation in places like the UK. There are not enough specialists. Your point here is that you think people who work in healthcare should work for $15/hr-after all that medical school. You also don't get the equipment, the robotic arms, # of MRI-PET-CAT scan machines.

  21. Thanks a lot for this wonderful series. You've tackled loaded subjects and have done it with class. It was really interesting.

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