64 Health Disparities and Inequalities

Health Disparity

Despite prevention efforts, some groups of people are affected by HIV/AIDS, viral hepatitis, STDs, and TB more than other groups of people. The occurrence of these diseases at greater levels among certain population groups more than among others is often referred to as a health disparity. Differences may occur by gender, race or ethnicity, education, income, disability, geographic location and sexual orientation among others. Social determinants of health like poverty, unequal access to health care, lack of education, stigma, and racism are linked to health disparities.

Health in the United States is a complex and often contradictory issue. One the one hand, as one of the wealthiest nations, the United States fares well in health comparisons with the rest of the world. However, the United States also lags behind almost every industrialized country in terms of providing care to all its citizens. The following sections look at different aspects of health in America.

Health by Race and Ethnicity

When looking at the social epidemiology of the United States, it is hard to miss the disparities among races. The discrepancy between black and white Americans shows the gap clearly; in 2008, the average life expectancy for white males was approximately five years longer than for black males: 75.9 compared to 70.9. An even stronger disparity was found in 2007: the infant mortality rate for blacks was nearly twice that of whites at 13.2 compared to 5.6 per 1,000 live births (U.S. Census Bureau 2011). According to a report from the Henry J. Kaiser Foundation (2007), African Americans also have higher incidence of several other diseases and causes of mortality, from cancer to heart disease to diabetes. In a similar vein, it is important to note that ethnic minorities, including Mexican Americans and Native Americans, also have higher rates of these diseases and causes of mortality than whites. Lisa Berkman (2009) notes that this gap started to narrow during the Civil Rights movement in the 1960s, but it began widening again in the early 1980s.

What accounts for these perpetual disparities in health among different ethnic groups? Much of the answer lies in the level of health care that these groups receive. The National Healthcare Disparities Report (2010) shows that even after adjusting for insurance differences, racial and ethnic minority groups receive poorer quality of care and less access to care than dominant groups. The Report identified these racial inequalities in care: Black Americans, American Indians, and Alaskan Natives received inferior care than Caucasian Americans for about 40 percent of measures Asian ethnicities received inferior care for about 20 percent of measures Among whites, Hispanic whites received 60 percent inferior care of measures compared to non-Hispanic whites (Agency for Health Research and Quality 2010). When considering access to care, the figures were comparable.

Health by Socioeconomic Status

Discussions of health by race and ethnicity often overlap with discussions of health by socioeconomic status, since the two concepts are intertwined in the United States. As the Agency for Health Research and Quality (2010) notes, “racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor,” so many of the data pertaining to subordinate groups is also likely to be pertinent to low socioeconomic groups. Marilyn Winkleby and her research associates (1992) state that “one of the strongest and most consistent predictors of a person’s morbidity and mortality experience is that person’s socioeconomic status (SES). This finding persists across all diseases with few exceptions, continues throughout the entire lifespan, and extends across numerous risk factors for disease.”It is important to remember that economics are only part of the SES picture; research suggests that education also plays an important role. Phelan and Link (2003) note that many behavior-influenced diseases like lung cancer (from smoking), coronary artery disease (from poor eating and exercise habits), and AIDS initially were widespread across SES groups. However, once information linking habits to disease was disseminated, these diseases decreased in high SES groups and increased in low SES groups. This illustrates the important role of education initiatives regarding a given disease, as well as possible inequalities in how those initiatives effectively reach different SES groups.

Health by Gender

Women are affected adversely both by unequal access to and institutionalized sexism in the health care industry. According a recent report from the Kaiser Family Foundation, women experienced a decline in their ability to see needed specialists between 2001 and 2008. In 2008, one quarter of females questioned the quality of her health care (Ranji and Salganico 2011). In this report, we also see the explanatory value of intersection theory. Feminist sociologist Patricia Hill Collins developed this theory, which suggests we cannot separate the effects of race, class, gender, sexual orientation, and other attributes. Further examination of the lack of confidence in the health care system by women, as identified in the Kaiser study, found, for example, women categorized as low income were more likely (32 percent compared to 23 percent) to express concerns about health care quality, illustrating the multiple layers of disadvantage caused by race and sex.

We can see an example of institutionalized sexism in the way that women are more likely than men to be diagnosed with certain kinds of mental disorders. Psychologist Dana Becker notes that 75 percent of all diagnoses of Borderline Personality Disorder (BPD) are for women according to the Diagnostic Statistical Manual of Mental Disorders. This diagnosis is characterized by instability of identity, of mood, and of behavior, and Becker argues that it has been used as a catch-all diagnosis for too many women. She further decries the pejorative connotation of the diagnosis, saying that it predisposes many people, both within and outside of the profession of psychotherapy, against women who have been so diagnosed (Becker).

Many critics also point to the medicalization of women’s issues as an example of institutionalized sexism. Medicalization refers to the process by which previously normal aspects of life are redefined as deviant and needing medical attention to remedy. Historically and contemporaneously, many aspects of women’s lives have been medicalized, including menstruation, pre-menstrual syndrome, pregnancy, childbirth, and menopause.

The medicalization of pregnancy and childbirth has been particularly contentious in recent decades, with many women opting against the medical process and choosing a more natural childbirth. Fox and Worts (1999) find that all women experience pain and anxiety during the birth process, but that social support relieves both as effectively as medical support. In other words, medical interventions are no more effective than social ones at helping with the difficulties of pain and childbirth. Fox and Worts further found that women with supportive partners ended up with less medical intervention and fewer cases of postpartum depression. Of course, access to quality birth care outside of the standard medical models may not be readily available to women of all social classes.

How to Define and Measure Health Disparities

Healthy People 2010 is a statement of objectives published by the United States Department of Health and Human Services. Recognized as one of the most important public health documents in the nation, it states the overarching national goals for public health to be achieved by the year 2010.

The first goal is “to help individuals of all ages increase life expectancy and improve their quality of life.

The second goal is “to eliminate health disparities among segments of the population, including differences according to gender, race or ethnicity, education or income, disability, geographic location or sexual orientation.”
In other words, there would be no health disparity between or among groups within these social categories of gender, race/ethnicity, education, income, disability, geography or sexual orientation. So as you can see, health disparities are high on the public health agenda.

• How do we know a disparity exists?
• How can disparity be depicted?

As another example, here we see infant mortality rates among African-Americans and whites across regions of the U.S.

There is a black/white difference in infant mortality in the U.S. Additionally, the difference varies by region of the country, so both a race/ethnic and geographic disparity exist.

Recently, efforts to monitor health disparities have grown significantly. We have already talked about the Healthy People 2010 goals, but there are others worth noting. The National Center for Health Statistics is currently producing a handbook to measure health disparities. There are also various initiatives across the National Institutes of Health. The National Cancer Institute, in particular, has a major initiative on health disparities.

The Health Resources and Services Administration, the Institute of Medicine, and many other bodies have produced documents and sponsored conferences and workshops focused on reducing or eliminating health disparities in the U.S. In addition to these, there are many Healthy People 2010 efforts at the state level, such as Michigan’s task force on health disparities.

The language of health disparities is varied, and different terms are used in different parts of the world. In the United States we usually talk about “disparities.” In England they sometimes use the word “variations” Throughout Europe they talk about “inequalities” in health. You will also see the term “inequities” being used; specifically, you will hear it in the phrase: “inequities in health.” We can think about disparities, variations and inequalities as being very similar terms; whereas, the term “inequity” implies something different. We’ll explore that distinction in a moment. But for now, you can think about inequalities, variations, or disparities or inequities in health according to gender, race/ethnicity, socioeconomic position, and geography. Note that these are some of the social categories that are reflected in HP 2010 Goal #2.

Now let’s consider the word “disparity.”

The dictionary defines disparity as a difference, which means two quantities are not equal. We have a mathematical symbol for that. It is very easy to decide when two things are not equal. We can easily say that a rate in Group A is not the same as—or is not equal to—a rate in Group B. This provides a workable definition of health disparity that we will use from this point forward. According to this simple definition, a disparity is just a difference. In this sense, the word disparity has the same meaning as the word inequality— two quantities are not equal.

Now that we’ve defined disparity, let’s move on to the next step—understanding what the inequalities in health are based upon. Inequalities in health are based on observed differences or disparities in health. For example to conclude whether “poor people die younger than rich people,” we simply compare death rates in the two groups and we find out whether they are the same. If they are different, then an inequality exists—a disparity exists. Infants born into a low social class have lower birth weight. Smokers get more lung cancer than non-smokers. Women live longer than men. These statements can be made from simple, unambiguous observations of the relevant data.

When we begin to discuss inequities in health, things get a little more complicated. Deciding if something is an “inequity” means we have to make an ethical judgment about the fairness of the health differences we observe. This extends beyond recognizing that things are different. You need to get to the point of thinking,

• “It is true poor people die younger than rich people, but should they—is it fair?
• Should infants born into a low social class have a lower birth weight?
• Should smokers get more lung cancer?
• Should women live longer than men?”

Here are questions for you to think about:

• Are all health inequalities, also health inequities?
• In other words, are all the observed health differences among social groups unfair?
• Are health inequalities always health inequities?

Public health scientists can measure differences or inequalities or disparities in health. We can measure differences in health status between groups. However, as you have just seen, we require some process of social and political discourse to assess which disparities—which differences—are unjust and intolerable in our society. Which disparities are unfair and thus require priority policy attention? As you will see, one of the challenges in addressing health disparities lies in moving beyond the drawing board. Different endeavors to reduce health disparities have frameworks and approaches that complicate interpretation. Next we will discuss some examples of how the conceptualization of health disparity differs.

• …the National Institutes of Health (NIH) Strategic Plan to Reduce and Ultimately Eliminate Health Disparities—the plan that guides NIH research—defines health disparities in this way: It says, “health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” Note that this definition is very similar to the one we agreed upon earlier—a disparity is a difference.
• By contrast, the Act that actually set up some of these research endeavors—the Minority Health and Health Disparities Research and Education Act of 2000—states: “A population is a health disparity population if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population.”

Comparing the two definitions for disparity, you may note that the first one just says that disparity is a difference, without indicating from where the difference should be measured. The second definition, on the other hand, says that a disparity has to be significant when compared to the general population.

Former U.S. Surgeon General, David Satcher, has written about the importance of disparities, and he offers a third perspective. He argues that we must eliminate disparities in health. The central part of his statement is the aim “to eliminate, not just reduce, some of the health disparities between majority and minority populations.”

How does this statement differ from the earlier definitions?

Dr. Satcher explains that the disparity of concern exists between the majority and the minority populations. The previous definition we saw stated that differences should be compared to the general population, not to the majority population.

As you can see, differences in language reflect different understandings about 1) which elements are most important in assessing the extent of health disparity and 2) which groups are of concern.

The Culture of Poverty

Socio-economic status influences most aspects of health, but the nature of that influence is complex and varied. Nonetheless, there are some consistencies that may be relevant for the clinician to note. The term culture of poverty describes certain characteristics of behavior and outlook that may be seen among people who are living in socially disadvantaged conditions. Here are some thoughts to bear in mind when communicating with people living in poverty:

1. People lower in the social hierarchy have the same diseases as anyone else, but tend to have more of them.
2. When you are poor and sick the future looks bleak, and so you try to ignore it, to live in the present, and plan only in the short term.
3. When a person with few choices is trying to survive from day to day, long-term health is less of a priority than getting through today.
4. Behaviors that may seem irresponsible to people who are not members of the culture often have a different meaning to people in marginal situations. For instance, adolescent pregnancy may offer a route to self-esteem. Substance abuse may be an antidote to reality. Both, ultimately, serve to maintain poverty, but recognize item 3, above.
5. A person living in poverty may not be able to follow the doctor’s advice; he may not have the time, the money, or the opportunities that the doctor probably takes for granted. A poor person may not have a drug plan, so may not be able to afford the antibiotic you just prescribed.
6. Do not confuse schooling with intelligence. Many people with little formal schooling have no difficulty understanding new concepts when they are properly explained.

California Profile

California has some of the lowest rates of death due to various causes including deaths from cancer and deaths due to unintentional injuries. The state ranks among those with the highest rates of deaths due to influenza and pneumonia, and diabetes-related causes, with substantially higher rates of diabetes-related deaths among the black and Hispanic populations. Rates of high blood pressure and obesity are higher for the black, Hispanic and American Indian/Alaskan Native (AI/AN) populations in the state as compared with the white and Asian/Pacific Islander populations. It is one of the states in which all population groups have achieved the Healthy People 2020 target for percentages of population with no leisure-time physical activity.

California ranks among the states with low proportions of current smokers and high percentages of residents who eat five or more fruits and vegetables per day. California ranks in the lower range of states for health insurance coverage, and the rate of coverage for the state’s large Hispanic population is notably lower than for other population groups.

Income and Life Expectancy

If you are curious about the relationship between income and life expectancy, take a look at a video clip of a BBC documentary about Income and Life Expectancy. What does it Tell Us About Us:

Determinants of Human Behavior in Health

Before identifying the various determinants of human behavior, you should consider the following four types of assessment: social diagnosis, epidemiological diagnosis, educational diagnosis, and environmental and behavioral diagnosis. Below is a brief description of each of these phases of assessment.

Social diagnosis

The focus of social diagnosis is to identify and evaluate the social problems which impact on the quality of life within your population. Doing a ‘social diagnosis’ will help you to gain an understanding of the social problems which affect the quality of life of people in your community, and how local people see those problems. This understanding is followed by the establishment of a link between the social problems and specific health problems that will become the focus of your health education activities.

Methods used for social diagnosis may be one or more of the following: community forums, focus groups, surveys and interviews.

An example of a social diagnosis would be that in a community the quality of life of the people may be very low as a result of poverty, malnutrition and the poor quality of drinking water.

Epidemiological diagnosis

Epidemiological diagnosis will help you to determine the specific health issues that affect the people in your community. The focus of this phase is to identify both the health problems and the non-health factors which are associated with a poor quality of life. Describing these health problems can help establish a relationship between health problems and the quality of life. It can also lead to the setting of priorities which will guide your health education programs and show you how to best use your resources.

An example would be that in your community the specific health problems that have resulted in poor quality of life. These may be malaria, HIV/AIDS, TB, malnutrition and others. At this phase you will identify which ones are the most important ones.

Educational diagnosis

This phase of assessment pinpoints the factors that must be changed to initiate and maintain behavioral change. Educational diagnosis looks at the specific features that hinder or promote behavior related to the health issues that are important in your community. An example would be to identify why people are behaving in a way that is dangerous to their life? As you will see later in the study session there are a number of ways of examining these sorts of questions as they relate to predisposing, enabling and reinforcing factors.

Environmental and behavioral diagnosis

Environmental diagnosis is a parallel analysis of factors in the social and physical environment that could be linked to health problems.

Behavioral diagnosis is the analysis of behavioral links to the health problems that are identified in the epidemiological or social diagnosis.

This phase focuses on the systematic identification of health practices or behaviors which cause health problems in your community. If you take the example of HIV/AIDS, once you reach this stage your focus will be to examine why people in your community are highly affected by HIV/AIDS. Is it because of their behaviors —or is it due to other environmental factors such as lack of HIV prevention and counseling services? At this stage you need to be able to identify the factors—and as in many societies the most important factor responsible for higher level of HIV/AIDS in your community may be high-risk sexual behaviors.

• Read again the list of different diagnoses that precede and underpin preventive health education work. Of these various processes which one do you think you are most likely to need to consult with other health colleagues over?
• As a health worker you are likely to undertake social diagnosis, behavioral diagnosis and education diagnosis yourself. You will also collect some statistical data yourself, from your own community. But you are likely to depend at least as much if not more on statistics from other colleagues. The reason for this is that epidemiological data has to be collected from large numbers of people in order to be able to see trends, and looking at a small sample from your community may not enable to you understand what happens at the level of a whole population.

Factors affecting behavior

Predisposing factors are those characteristics of a person or population that motivate behavior before the occurrence of that behavior. Peoples’ knowledge, beliefs, values and attitudes are predisposing factors and always affect the way they behave. Predisposing factors are motivational factors subject to change through direct communication or education. All of these can be seen as targets for change in health promotion or other public health interventions. We will look at each of them in turn.

Knowledge

Knowledge is usually needed but is not enough on its own for individuals or groups to change their behavior. At least some awareness of health needs and behavior that would address that need is required. Usually, however, for behavior change some additional motivation is required.

Beliefs

Beliefs are convictions that something is real or true. Statements of belief about health include such negative comments as, ‘I don’t believe that exercising daily will improve my health.’ More positive health beliefs might include statements such as, ‘If I use an insecticide treated bed net at night I will probably not get malaria.’
Often a potent motivator related to beliefs is fear. Fear combines an element of belief with an element of anxiety. The anxiety results from beliefs about the severity of the health threat and one’s susceptibility to it, along with a feeling of hopelessness or helplessness to do anything about the threat.

Values

Values are the moral and ethical reasons or justifications that people use to justify their actions. They determine whether people consider various health-related behaviors to be right or wrong. Similar values tend to be held by people who share generation, geography, history or ethnicity. Values are considered to be more entrenched and thus less open to change than beliefs or attitudes. Of interest is the fact that people often hold conflicting values. For example, a teenage male may place a high value on living a long life; at the same time, he may engage in risky behaviors such as drinking alcohol. Health promotion programs often seek to help people see the conflicts in their values, or between their values and their behavior.

Attitudes

Attitudes are relatively constant feelings directed toward something or someone that contains a judgment about whether that something or someone is good or bad. Attitudes can always be categorized as positive or negative. For example, a woman may feel that using contraception is unacceptable. Attitudes differ from beliefs in that they always include some evaluation of the person, object or action.

Self-efficacy

The most important predisposing factor for self-regulating one’s behavior is seen to be self-efficacy, that is the person’s perception of how successful he or she can be in performing a particular behavior. Self-efficacy is learning why particular behaviors are harmful or helpful. It includes learning how to modify one’s behavior, which is a prerequisite for being able to undertake or maintain behaviors that are good for your health. Health education and behavioral change programs help a person to bring the performance of a particular behavior under his or her self-control.

• Make a list of some health beliefs that you think that some people in your own community have which affect the way they behave—in other words beliefs which pre-dispose them to have certain health behaviors.
• Of course beliefs can cover a huge range. They could equally be ‘I don’t believe that smoking harms my health’ through to ‘I do believe that smoking harms my health.’ The same may be true of people’s beliefs about exercise, alcohol, and so on. The important thing is that beliefs don’t always coincide with facts. For example the evidence is that smoking does harm health. But many people believe that it doesn’t affect their health.

Enabling factors

Enabling factors are factors that make it possible (or easier) for individuals or populations to change their behavior or their environment. Enabling factors include resources, conditions of living, social support and the development of certain skills.

Among the factors that influence use of health services are two categories of enabling resources: community-enabling resources (health personnel and facilities must be available), and personal or family-enabling resources (people must know how to access and use the services and have the means to get to them).

Enabling factors refer to characteristics of the environment that facilitate or impede healthy behavior. They also include the skills and resources required to attain a behavior. For example enabling factors for a mother to give oral rehydration salts to her child with diarrhea include having time, a suitable container and the salt solution itself.

Skills

A person or population may need to employ a number of skills to carry out all the tasks involved in changing their behavior. For some positive health behaviors it might be necessary to learn new skills. For example if a breast feeding mother is not well trained on positioning and attachment of her baby she may have difficulty in properly breastfeeding her child. Similarly, if the mother is not well trained at a later stage on the preparation of complementary feeding, the child may not get the nutrition they require

Healthcare resources

A number of healthcare resources may also need to be in place if an individual or population is to make and sustain a particular health-related behavior change. The availability, accessibility and affordability of these resources may either enable or hinder undertaking a particular behavior. For example, in a given health post the lack of availability of the family planning method of choice for a mother may discourage her from utilization of the service in the future.

Changing behavior may also be easier if other aspects of one’s environment are supportive of that change. For example policy initiatives or even laws might be in place that create a positive atmosphere for change.

• From your experience as an educator or receiver of health education make a list of some of the enabling skills and enabling resources you have seen or experienced that support health education.
• Enabling factors make it possible (or easier) for individuals or populations to change their health-related behavior. Enabling skills, of course, include making sure people know how to do things.

Reinforcing Factors

Reinforcing factors are the positive or negative influences or feedback from others that encourage or discourage health-related behavior change. The most important reinforcing factors are usually related to social influences from family, peers, teachers or employers.

Social influence

Social influence is the positive or negative influence from those influential people around us that might encourage or discourage us from performing certain health-related behaviors. For example a mother who is planning to start family planning (FP) might be influenced by negative attitudes from her peer group and think, ‘Most of my friends do not use FP methods and I may lose friends in the neighborhood if I use the methods.’ She might also be influenced by her family: ‘My family members do not all support the idea of using FP methods, especially my husband and my mother-in-law. They would really be mad at me if I use FP.’ She may also be aware that her community society or culture generally may not be supportive: ‘Everyone in our community is against FP and it is seen as a sin in our society.’

An individual’s behavior and health-related decision making—such as choice of diet, condom use, quitting smoking and drinking, etc.—might very well be dependent on the social networks and organizations they relate to. Peer group, family, school and workplace are all important influences when people make up their minds about their individual health-related behavior.

• Choose either smoking or alcohol use among young men and think about some of the reinforcing factors, or reinforcing people, that might encourage them to stay smoking or give up smoking or alcohol.
• Reinforcing factors are the positive or negative influences or feedback from others that encourage or discourage the behavior change. The most important reinforcers in a given community include family, peers, teachers and employers. In the case of young men, their own peer group may be the strongest reinforcer to stay smoking or using alcohol. They may think they look grown up, or that others will think they look childish if they don’t smoke or drink a lot. But perhaps employers may say that it is not professional to smoke or teachers may say it is childish to smoke.

Medicalization of Sleeplessness

But is insomnia a disease that should be cured with medication?

How is your “sleep hygiene?” Sleep hygiene refers to the lifestyle and sleep habits that contribute to sleeplessness. Bad habits that can lead to sleeplessness include inconsistent bedtimes, lack of exercise, late-night employment, napping during the day, and sleep environments that include noise, lights, or screen time (National Institutes of Health 2011a).

According to the National Institute of Health, examining sleep hygiene is the first step in trying to solve a problem with sleeplessness.

For many Americans, however, making changes in sleep hygiene does not seem to be enough. According to a 2006 report from the Institute of Medicine, sleeplessness is an underrecognized public health problem affecting up to 70 million people. It is interesting to note that in the months (or years) after this report was released, advertising by the pharmaceutical companies behind Ambien, Lunesta, and Sepracor (three sleep aids) averaged $188 million weekly promoting these drugs (Gellene 2009).

According to a study in the American Journal of Public Health (2011), prescriptions for sleep medications increased dramatically from 1993 to 2007. While complaints of sleeplessness during doctor’s office visits more than doubled during this time, insomnia diagnoses increased more than sevenfold, from about 840,000 to 6.1 million. The authors of the study conclude that sleeplessness has been medicalized as insomnia, and that “insomnia may be a public health concern, but potential overtreatment with marginally effective, expensive medications with nontrivial side effects raises definite population health concerns” (Moloney, Konrad, and Zimmer 2011). Indeed, a study published in 2004 in the Archives of Internal Medicine shows that cognitive behavioral therapy, not medication, was the most effective sleep intervention (Jacobs, Pace-Schott, Stickgold, and Otto 2004).

A century ago, people who couldn’t sleep were told to count sheep. Now, they pop a pill, and all those pills add up to a very lucrative market for the pharmaceutical industry.

• Is this industry behind the medicalization of sleeplessness, or are they just responding to a need?
• What else do we tend to medicalize?

American Health Care

United States health care coverage can broadly be divided into two main categories: public health care (government-funded) and private health care (privately funded). The two main publicly funded health care programs are Medicare, which provides health services to people over 65 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 service agencies focused on Native Americans (the Indian Health Service), Veterans (the Veterans Health Administration), and children (the Children’s Health Insurance Program).

A controversial issue in 2011 was a proposed constitutional amendment requiring a balanced federal budget, which would almost certainly require billions of dollars in cuts to these programs. As discussed below, the United States already has a significant problem with lack of health care coverage for many individuals; if these budget cuts pass, the already heavily burdened programs are sure to suffer, and so are the people they serve (Kogan 2011).The U.S. Census (2011) divides private insurance into employment-based insurance and 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 his or her family. Direct purchase insurance is coverage that an individual buys directly from a private company.With all these insurance options, insurance coverage must be almost universal, right? Unfortunately, the U.S. Census Current Population Survey of 2010 and 2011 shows that 16 percent of Americans have no health insurance at all. Equally alarming, a study by the Commonwealth Fund shows that in 2010, 81 million adults were either uninsured or underinsured; that is, people who pay at least ten percent of their income on health care 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, Doty, Robertson, and Collins 2011).

The Commonwealth study further reports that while underinsurance has historically been an issue that low-income families faced, today it is affecting middle-income families more and more.Why are so many people uninsured or underinsured? Skyrocketing health care costs are part of the issue. Many people cannot afford private health insurance, but their income level is not low enough to meet eligibility standards for government supported insurance. Further, even for those who are eligible for Medicaid, the program is less than perfect. Many physicians refuse to accept Medicaid patients, citing low payments and extensive paperwork (Washington University Center for Health Policy N.d.)

Health care in the United States is a complex issue, and it will only get more so with the continued enactment of the Patient Protection and Affordable Care Act (PPACA) of 2010. This Act, sometimes called “ObamaCare” for its most noted advocate, President Barack Obama, represents large-scale federal reform of the United States’ health care system. Most of the provisions of the Act will take effect by 2014, but some were effective immediately on passage. The PPACA aims to address some of the biggest flaws of the current health care system. It expands eligibility to programs like Medicaid and CHIP, helps guarantee insurance coverage for people with pre-existing conditions, and establishes regulations to make sure that the premium funds collected by insurers and care providers go directly to medical care. It also includes an individual mandate, which requires everyone to have insurance coverage by 2014 or pay a penalty. A series of provisions, including significant subsidies, are intended to address the discrepancies in income that are currently contributing to high rates of uninsurance and underinsurance. Many Americans worry that governmental oversight of health care represents a federal overstepping of constitutional guarantees of individual freedom. Others welcome a program that they believe will make health care accessible and affordable to everyone.

The PPACA has been incredibly contentious. Private insurance companies have been among the strongest opponents of the law. But many Americans are also concerned that the PPACA will actually result in their medical bills increasing. In particular, some people oppose the individual mandate on the grounds that the federal government should not require them to have health care. A coalition of 26 states and the National Federation of Independent Businesses brought suit against the federal government, citing a violation of state sovereignty and concerns about costs of administering the program.