Healthcare Disparities Based on Socioeconomic Status

By Dalal Abiaad / Winter 2020

A social problem that is noticeably present in modern American society today is  access to healthcare, as well as proper medical facilities and medication, for various groups of people in society, based on their socioeconomic status. Something I am really passionate about is helping people through healthcare and being a pharmacy technician for the last three years has really allowed me to recognize how having proper care plays a significant role in improving your overall health, especially when needing such resources determines whether you get through a health issue and in due time. The fundamental causes of disease creates a link between inequality and health outcomes, acknowledging that social conditions are tied to whether or not you have access to proper healthcare and if you can afford it. We must consider the divide in access to flexible resources among patients that influences not only the risk factors particular groups face, but also the varying disease outcomes such social elements reflect. In order to look deeper at this problem we need to understand these elements, qualifications and restrictions on insurance coverage, the health services available in certain areas of society, and the notion of timeliness as the ability in which care for particular needs is provided within a sufficient time frame once conditions are recognized.

Before we discuss healthcare disparities and factors that limit proper medical care, we must explore the concept of health insurance and how it plays into ensuring that patients receive treatment or conversely choose not to seek medical assistance because such resources are expensive or don’t provide for the needs of the individual. In order for consumers to purchase prescription drugs as well as affordably and regularly use medical facilities, they must rely on health insurances to contribute to the costs. Working in a pharmacy for the last three years and having to deal with many insurance situations I have learned a lot about the struggles patients are faced with, in particular with the concept of a formulary. Health insurance formularies are a list of drugs, both generic and brand, that are covered by your corresponding insurance plan. Many of my patients have been sent to the pharmacy with a new prescription to drop off just to find that it isn’t covered by their plan because of its formulary not including it. Whenever I’m in the position of dealing with a customer’s medication that isn’t covered, most of the time this includes certain inhalers, specific brand names, all over-the-counter drugs, and some suspensions or drops, I look for other options to help reduce the costs or even send a request to the doctor to change the medication to something on the formulary or fill out a prior authorization. A prior authorization is a request that pharmacies send to doctors, in which the doctors are asked to see if they can get permission from the insurer in order to bypass their restrictions on coverage. Although this sounds like it fixes the problem, more often than not, the patients are left with no medication for quite some time, in the case of waiting on their doctor to get approval, or end up paying high out of pocket prices when in need of the prescription and have no other choice but to buy it. Dealing with either circumstance ends up putting a strain on the patients, leaving them frustrated and often with high levels of anxiety. I have seen multiple examples of this, especially with patients who have underlying health conditions, who take various medications and are afraid to be left without one that could have a drastic effect on their health.

Now that we have discussed the problem with insurance formularies, we can consider the particular drug coverages that are the most prevalent in the United States. In general, most elderly in the United States population are covered by Medicare health insurance; a federal or government program that pays some of the expenses for patients who are 65 years of age or older. However, many prescriptions that are still quite expensive, leading elders to also have private insurance, known as Medicaid, a welfare program that is often used to pay for the remaining or a portion of the remaining expenses not covered by Medicare (Hall, McCue). Although this form of medical assistance may seem to be completely advantageous, we can still see unbeneficial aspects to it. Within the federal health insurance program, there are subgroups that play different roles in providing health coverage, the first being Medicare Part B and the second Part D. Medicare Part B covers necessary supplies and services that are needed for detecting and preventing illnesses first hand. When consumers invest in this form of health insurance, their providers (outpatient hospitals or physician offices) who are purchasing these services through manufacturers or wholesalers, are actually negotiating prices privately and aside from Medicare, which gives the providers an incentive to, as if in a cycle, negotiate for low prices in these Part B qualified drugs (Antos, Capretta). This in itself is a representation of the concept of neoliberal “common sense”, capitalization of goods for the benefit of companies in which quality isn’t the primary focus and because this is a focal point for healthcare, affecting life expectancy and more vulnerable communities. Moreover, Medicare Part D presents a complication towards those who rely on its coverage, one that is colloquially referred to as the “donut hole” or being required to pay the full costs of drugs the consumer has purchased through Medicare Part D, out of pocket, because of surpassing the deductible and reaching the total payment of $3,750 (Blum). With this coverage gap involved in Medicare Part D, beneficiaries face a set amount of expenses that they may have not been prepared for and are therefore unable to afford. According to the American Association of Retired Persons (AARP), the range in which this “donut hole” occurs has been narrowing since the Affordable Care Act that was passed in 2010, but there is still room for improvement in the years to come (Bunis). Within all of these health insurance concepts arises a prominent feature in current health care payments recognized as the “play or pay” reform. Essentially this further explains a rule for employers, where healthcare workers must also be receiving their own health insurance through the company, as part of their compensation benefits (Herring, Pauly). With this “play or pay” proposal in place there is an additional method at hand that conversely arises a disadvantage towards controlling medical costs, resulting in a regression and the chance of government subsidies as a consequence (Brown). While healthcare insurance brings forth both advantages and not so beneficial aspects, those who are uninsured face a considerably larger barrier, due to not being able to access and afford necessary and appropriate medical care (Institute of Medicine).

Now that we’ve examined qualifications on coverage, we can consider another topic in terms of healthcare, one in which people do not have access to such coverage through their jobs or being part of a low income family, which results in unaffordable medical bills when having to resort to preventive care. According to the global media company, Forbes, as of May 2018 the amount of Americans without health insurance has risen to 15.5% in comparison to 2016 when it was at 12.7% (Cohen). Among all of these details health insurance in and of itself is a paradoxical entity, due to the fact that it is meant to allow for coverage for medical expenses, but is very often unaffordable for communities who are faced with low-income wages, high household budgets, subjective perceptions of social status, living environments and overall financial security. These obstacles influencing attainment, and in turn prolonged possession of health insurance, has a significant role in whether or not someone will have a usual and regular source of care as needed. The New York Academy of Sciences stated that in 2005 about 97% of both privately and publicly insured children had that usual source of care in response to being insured, in contrast to 72% of insured children who didn’t implement those facilities regularly due to medical costs restricting them and their families (Hoffman). From all of this information on insurance as a means of both acquiring medication at a reasonable price (if eligible) and choosing to not treat your conditions because of unmanageable prices, it is clear that healthcare has become a big business that favors the rich over the poor and vulnerable populations. 

Another prevalent influence, and arguably the most contributing to this social problem, is disparities between access to healthcare through social determinants of health and how this becomes an obstacle in attaining proper care. This topic of health disparities very much connects to elements this class has implemented firstly through the overarching theme of systemic analysis, in which situations are understood as more than surface level in order to gain a comprehensive understanding of the way in which social structures function and the fundamental aspects, such as economic stability, education, social and community contexts, that make up this national problem. I also would argue that this topic relates to the concept of social hierarchies being that as discussed in lecture, social hierarchies create a divide between various groups of people in society in which their socioeconomic status separates them from others in relation to experiences they face and access they have. This notion of social hierarchies can be seen as a contradiction to one of the liberties discussed in the Second Bill of Rights, “the right to adequate medical care and the opportunity to achieve and enjoy good health.” Being that social hierarchies have inevitably been present in society throughout multiple stages in history, this aspect of the Second Bill of Rights where equality is meant to be provided in the field of medical care, contradicts what is written and proclaimed.

Lastly, in terms of timeliness, I have seen this with family members who have at one point needed to go to the doctor and the availability of appointments restricted them from accessing that right away as well as having to resort to the emergency room for such care and being left with waiting hours to receive any medical attention. I think the aspect of waiting endlessly in an emergency room as a last resort especially for medical issues like diabetes or cancer that requires consistent care, is on it’s own a perfect representation of access to health care shaping an individual’s life and the way they live it, due to the increased emotional distress and higher treatment costs they most often face as a result. Being that the focus of these disparities lies in socioeconomic status and the factors that constitute that, the main obstacle that is preventing us, as a society, from solving this problem lies in the reality that vulnerable communities are more likely to face issues with resources and even strategies to handle particular care. I think it is important to analyze how it has become “common sense” for healthcare to be treated as a commodity, something that is bought, rather than a right, as the Second Bill of Rights makes it out to be. Based on all the disparities discussed thus far, it is clear that this healthcare system that we are all too used to has managed to continue because of hegemony within medicine, in which the biomedical model dominates as an obstacle in addressing the problem. According to the International Journal of Complementary and Alternative Medicine, “Medical hegemony is the dominance of the biomedical model, the active suppression of alternatives as well as the corporatization of personal, clinical medicine into pharmaceutical and hospital centered treatment” (Weber). This point becomes clear when we examine that medicine has become an economic commodity in itself, pioneering the reality of for-profit medical care as an industry, a condition that has allowed healthcare to thrive in this way hegemonically. Along with hegemony within the realm of medicine, the neoliberal mentality compliments efforts of allowing this problem to prevail. The neoliberal mentality, as discussed throughout this course, implements this illusion of reality where people who are unable to afford health insurance or have trouble with access to healthcare, are at fault of a personal problem. This mentality creates this idea that such people are the reason they are in that position in the first place and that if they want to change it they have the power to do so through hard work. This mentality is inequitable and demoralizing, it is just not right to blame a person individually for such a huge problem that has multiple elements outside of their control. 

Now that we see the depths of this problem, we can consider how to embrace a few ethical principles to help us overcome these obstacles, beginning with, establishing networks or local groups for putting together a system in which members of that community apply for grants to help obtain necessary resources as well as hospital-community partnerships where addressing specific prevalent health issues within that population can be done. In addition to these resources a significant ethical principle that I believe needs to be applied is society making it a norm to recognize the truth of these social determinants of health so that people will work to reshape them through research and as a result, change hegemonic norms of such details being inevitable. All together these values cannot be instilled unless we as a nation acknowledge what was addressed in the Second Bill of Rights, that healthcare is a right that everyone is entitled for. If we move forward and educate this value as imperative and have politicians who are guided by this principle, naturally new policies that abide by such beliefs will be put into place. One particular change in our healthcare system that could reflect this idea is Medicare for All. Adapting Medicare for All would alter the way healthcare disparities currently take place, and create universal healthcare that is accessible to everyone through a better system of quality care. With universal care there is a higher chance that populations will reflect healthier individuals who are as a result happier because there won’t be restrictions that get in the way of patients having the same standard of service rather than the current structure that targets wealthier individuals because of its for-profit framework. I think it is important to look at this design of healthcare and compare it to what we currently have. Canada, as the closest example to contrast, inhabits Medicare for All in which consumers are able to access any health services necessary and pay nothing for health insurance. In comparison to the system we have here in the United States, Medicare for All does not include all the problematic elements listed throughout this paper. Meaning that a patient in Canada does not have to deal with the very regular issues we face here such as co-pays, deductibles, and pre-authorizations. This concept of free healthcare is publicly funded and in the case of Canada only requires being a tax-paying Canadian. I would argue, as a person who deals with all of those problems at work, this seems very advantageous in the sense that it could very possibly cut out all the stress from both the patient and also someone like me who has to navigate through much of this regularly. Based on all of these details, I believe this style of healthcare will lead to people feeling as though healthcare is being treated as an actual right (as it should be) and as a result they will feel more obligated to stand up for injustice in this field rather than leave it to its hegemonic and neoliberal frame of mind.

All in all, it is vital that individually and collectively as a nation we put first these details of healthcare disparities when it comes to recognizing their faults as well as acknowledging that it is a problem that we should all be concerned with. If we leave the healthcare system the way it is without questioning the corporations that profit off of it or admitting that we are allowing for medical hegemony to persist, there will be no change evident among all the components described as part of our current healthcare system. Therefore, I urge you to get involved, to stand up for qualities of healthcare that puts citizens first, by following those who stand for such beliefs in politics as well as participating in activist movements or allowing your voice to be heard through writing, voting, creating groups, and pushing for change.

Works Cited 

Antos, Joseph, and James C. Capretta. "Prescription Drug Pricing: An Overview of the Legal, Regulatory, and Market Environment." AEI Paper & Studies, American Enterprise Institute, 2018, p. 1+. General OneFile. Accessed 12 Sept. 2018.

Blum, Jonathan. “What Is the Donut Hole?” The Medicare Blog, 10 Aug. 2010. 

Brown, E. Richard. “Problems of Health Insurance Coverage and Health Care in the United States: Public and Private Solution Strategies.” Química Nova, SBQ.

Bunis, Dena. “Medicare Part D 'Donut Hole' Will Close in 2019.” AARP, 9 Feb. 2018,

Cohen, Joshua. “Troublesome News: Numbers Of Uninsured On The Rise.” Forbes, Forbes Magazine, 6 July 2018.

Hall, Mark A., and Michael J. McCue. “Financial Performance of Health Insurers: State-Run Versus Federal-Run Exchanges.” Commonwealth Fund, 1 May 2017.

Herring, Bradley, and Mark V. Pauly. “‘Play-or-Pay’ Insurance Reforms for Employers — Confusion and Inequity.” New England Journal of Medicine, 14 Jan. 2010.

Hoffman, Catherine and Paradise Julia. “Health Insurance and Access to Health Care in The United States.” The New York Academy of Sciences, 25 July 2008.

Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. “The Health Care Delivery System.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine.

Weber, Daniel. “Medical Hegemony.” International Journal of Complementary &  Alternative Medicine, 8 January 2016.