Equity in Health Services

The problem of equity with respect to health services is and remains a serious problem in American society. In a free market system lacking national health insurance, those personswho are economically disadvantaged are also medically disadvantaged when it comes to obtaining quality services. The United States has a two-track system of health-care delivery divided into a private track and a public track. The public track is a system of welfare medicine supported by public health insurance, especially Medicaid (for the poor) but also Medicare (for the elderly).

Public health insurance has provided access to the American health-care delivery system for the poor, but the character of the services rendered – that of welfare medicine – has not changed dramatically. The urban poor have historically been dependent on public hospitals rift gold and clinics rather than private hospitals and practitioners for providing patient care. And that is still the case today for many of the poor and near-poor as physicians, pharmacists, and hospitals have joined banks, supermarkets, and department stores in migrating out of inner-city areas where the poor are concentrated. Vladeck (1983: 9) describes a pattern that has remained unchanged for years: Apart from whatever esthetic differences such a pattern might imply, the fact remains that the poor – and to an even greater extent, the near-poor, who lack even the limited access to private physicians Medicaid provides – have no continuing relationship with individual physicians. This means that access to other services resides in the hands of bureaucratic strangers. The poor and nearpoor are more likely to be admitted to hospitals through emergency rooms than a scheduled admission, and more likely to be sicker when they are admitted. They are more likely to be treated by a foreign medical graduate, or a house staff physician still in training (or both) than a fully trained American graduate. Their drug prescriptions are written by physicians with less personal knowledge and understanding of the patients’ characteristics and problems, and they are likely to be seen on a follow-up visit by a physician other than the one who treated them originally.

The rural poor likewise have problems of access to health care as medical facilities and health practitioners may not be available locally. And the rural poor (as other people living in rural areas) also may be more likely to be treated by foreign medical school graduates. This situation is brought on by the doctor shortage in these areas caused by a reluctance of many American-trained physicians to work in small communities. Another segment of society particularly affected by problems of equity is the large number of Americans – over 16% of the population – who do not have health insurance. The largest proportion of persons (about 70%) without health insurance in 2003 were those whose family income was $50 000 or less. Most individuals and families without health insurance make too much money to qualify for Medicaid but still struggle financially. Many of them work for small businesses that cannot afford to offer health insurance to their employees. Not only does not having health insurance prevent or delay getting care for immediate health problems, but a lack of insurance over time has a strong negative cumulative effect on a person’s health (Quesnel-Valle´e, 2004). Without health insurance or available cash, people can be rift gold and are turned away from hospitals and sent elsewhere. Ultimately, they may be sent to ‘hospitals of last resort,’ which are generally public hospitals under the jurisdiction of city, county, or state governments. These hospitals are the ones that accept patients other hospitals refuse to treat because of an inability to pay for services.