Equal Access to Medical Care
Since the early 20th century, huge advancements in medicine and the dissemination of germ theory have made medical care far more beneficial and integral to people’s lives. But unfortunately, not everyone has been able to reap the benefits of the high quality medical care now available.
Barriers to access are numerous and prolific and delve into a variety of systemic issues far more complicated than this article can practically examine. However, the major areas of discrimination in health care access are rooted in classism and racism. We’ll cover these briefly and address what can be done in vivo in hospitals and clinics to make discriminatory practices less of a concern for marginalized patients in healthcare systems.
By far the largest barricade to medical service access, affecting nearly every demographic, is the initial economic hurdle of healthcare. Even with insurance subsidizing costs, the average American spent upwards of 10,000 dollars out-of-pocket per person annually on healthcare services, according to the U.S. Government’s National Health 2017 Expenditures Highlights. For most people, 10,000 dollars is not a trivial amount of money, especially with the median household income in the country resting just below 60,000 dollars, according to the U.S. Census Bureau. But this is especially concerning for the 18.5 million people who fall below the national poverty line and who are, naturally, unable to pay for this level of care.
So what is causing medical care to cost so much? As it turns out, it’s a multifaceted issue.
People in the United States pay more for medical care than anywhere else in the world, even when factoring in the government payments of countries that have implemented universal health care systems. In the United States, medicine is commercialized, and in a lot of ways, behaves very much as a business, rather than as a public service, as it is seen in most other places worldwide. According to Frank Pasquale in his article published in the Annals of Health Law, “the reallocative effects of higher spending on healthcare by the wealthiest can cascade down the distribution ladder” and raise medical care prices for everyone. High spending in concierge medicine practices, single specialty hospitals, and cosmetic surgery centers also contribute to a payment system where resources are allocated to those who are paying top dollar, and are, by definition, not universally accessible for people.
There is also an issue of surplus. Sometimes, too much medicine can be too much.
Physicians might be pressured to over-prescribe medications to patients by pharmaceutical companies, hospital finance overseers, and insurance agencies looking for ways to expand their bottom lines. Examples of over-treatment can include proton pump inhibitors for ulcers, arthroscopic knee surgery for arthritis, hormone replacement therapy for menopause, and high-dose chemotherapy for breast cancer. These treatments have also been shown to be largely unnecessary for most people, ineffective in their ability to treat the diseases they are prescribed for, and can be, in some circumstances, more endangering to a patient’s life than the disease they intend to treat. Unnecessary prescriptions and treatments again raise medical costs for everyone and not just for those specifically receiving the care.
When looking at class restrictions that prevent equal opportunity access to healthcare services, it’s important to note that relative poverty rather than absolute poverty is what is most useful to look at. For example, poverty in the United States looks very different than poverty in countries that are in the middle of industrializing, and in this case, possession of more liquid currency might not be indicative of how far that money will go day-to-day, nor in a healthcare environment. The rising costs of healthcare in the United States have led to increasing rates of medical tourism, where American citizens essentially take a vacation to another country in order to find cheaper healthcare abroad. Medical tourism is actually quite harmful to the countries where these tourists are flocking to because it reduces medical supply for residents and leads to instances of price gouging, making it so that endemic medical care becomes unaffordable for the people living there.
Lastly, with regards to instances of barred access to medical services, people with lower incomes generally have less time to spend outside of work. Typically, they will have less job flexibility and will not be able to take time off work for a doctor’s appointment. Additionally, they will have less access to a reliable means of transportation to go to and from a healthcare provider. Then there is also the matter of affording professional childcare--people living in poverty generally do not have the ability to pay for extraneous childcare in order to focus on their personal medical needs. At every point in the system, people living in poverty find these roadblocks constructed that limit access to healthcare services.
Race and class intersect in many ways when it comes to health care access, but there are also inherent biases structured into the healthcare system that disproportionately target people of color.
Prejudice between hospital staff and patients breaks down in a variety of ways. In one of the most egregious examples of racial discrimination, highly reproducible studies done by William F. Owen, Jr., MD, Lynda A. Szczech, MD, MSC,t and Diane L. Frankenfield, DrPH, there is a huge disparity in the proportion of white patients versus black patients who are waitlisted and ultimately go on to receive a kidney transplant. Physicians carry their unconscious biases with them wherever there go, and that does not automatically stop when they set foot in the doctor’s office. They may find patients of color to present symptoms differently than expected from a history of white patients and overlook a disease diagnosis entirely. Or they may not have experience working with people from different cultural backgrounds and be unable to properly meet their patient’s needs.
Regardless, the onus is on the physician and their medical staff to step up to the plate and make corrective interventions in their clinical space. By holding healthcare providers accountable for their actions and creating a performance profile to monitor subconscious or conscious behavior in need of modification, healthcare staff can go a long way towards ensuring clinics and hospitals are equitable, welcoming environments for everyone.
But the future is bright! There are many social, political, and healthcare advocates working on these endemic social issues today. In addressing both untenable upfront costs to care and racial discrimination in clinical settings, the healthcare industry will be able to better serve people--all people--and foster stronger community wellness and cohesion in the process.
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Access to Medicine in an Era of Fractal Inequality: http://lawecommons.luc.edu/cgi/viewcontent.cgi?article=1056&context=annals
Income, Inequality, and Social Cohesion: https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.87.9.1504
National Mortality Rates: The Impact of Inequality?: https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.82.8.1082
Does Income Inequality Harm Health?: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.984.9309&rep=rep1&type=pdf
Income Inequality and Health: A Critical Review of the Literature: https://bit.ly/2WCUhTF
Women, Inequality, and the Burden of HIV: http://www.ph.ucla.edu/epi/faculty/detels/Epi227/reader/Detels_WomenHIV_NEJM2005.pdf
Disadvantage, Inequality, and Social Policy: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.21.2.48