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

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



  • Philip Hawkins

    Man, I’m so glad I live in the UK where we have the NHS.

    Now we just to stop the Tories selling it off to companies that care more about profit than patient care.

  • Benjamin Abruzzo

    When it comes right down to it, you can only have two of the following three: Affordability, Universality, and Quality. Like a balloon, if you squeeze to try to get too much one one, you tend to strain the other two. You can find a balance or you can choose to sacrifice in one area to get better in another one, but expecting all three to the highest is going to end up in disappointment.

    This is not to say it's wrong to want all three and it is wrong to try and achieve the best balance. But it's not for a group of politicians in a far-away city to choose for an individual.

  • Amy G


  • Aaron H

    Pharmaceutical companies are absolutely ruthless, and the best way to deal with them is to unite as a single buyer.

    I live in a country with universal healthcare. A government purchasing body buys our drugs from the pharmas, then sells them to the public. Almost everything is US$3 per prescription – from aspirin to HIV medicine (but not cosmetic things). And the pharmaceutical companies aren't coerced, they sell voluntarily. Turns out they still make a profit at lower prices. They charge more in the US cos they can.

    The US could go half-way to a proper public healthcare by keeping private doctors and private hospitals, but establishing a govt purchasing body to deal with the pharmas. Cos I hear hospitals in the US will charge you guys like $4 for a single tylenol! And all this happens because of corrupt legislators and corrupt think tanks that pump out propaganda that flies in the face of all other developed nations.

  • Funky Sagan Cat

    I will miss you

  • Kase 317

    Get Government out of healthcare.

  • Rory O'Kane

    “After the fever has gone and you get the bill…”
    The rest of the civilised world would find this funny if healthcare as a commodity wasn’t so intrinsically horrific.

  • rubin

    I want more sociology! I absolutely loved this crash course. Thank you, crash course team. You guys are awesome

  • Thom Holland

    I hope you expand on this subject.  I would like to see a comparison of healthcare costs between western countries, i.e. Britain, France, Germany & Denmark.

  • Xin Ye

    Thank you so much for this wonderful course! Hope to see more when possible.

  • zolacnomiko

    These videos are interesting and educational, but also I'm frequently distracted by a) how fabulous Nicole always looks and b) how every single item in her wardrobe coordinates with her purple glasses which wow seems like a lot of work???

  • Lloyd Duran

    Just a minor error with the message: almost everyone will eventually get sick and need healthcare unless they die instantly.

  • morenauer

    It's sad and, frankly, absolutely pathetic that you guys, the richest and by far most powerful nation on earth, have one of the worst if not the worst healthcare system… I pity you.

  • Flaming Basketball Club

    I truly enjoyed learning about Sociology with this series. Unfortunately, Crash Course Sociology comes to an end after one whole year. This series actually inspired me to learn more about this subject. Thank you so much Nicole Sweeney!

  • Arnaldo Castro

    well, if the number of questions that remain unanswered is unending you might as well continue the show

  • sankimalu

    Nicole always helped me start the week right… How will I cope? Wait, Crash Course Statistics! You have big shoes to fill!

  • Filipe Almeida

    Ah yes… US Health Care, or the art of how to spend twice as much as everyone else and get worse health stats in return.

  • A. B.


  • Asclepius


  • Nate Weinand

    A really good series! I learned a lot!

  • Peter Fiala

    thanks for teaching us nicole!

  • Jesus Osegueda

    Thank you so much! Thanks 😀

  • Laura

    As an aspiring cultural anthropologist I really enjoyed this course! Cultural anthropology and sociology really do have a lot in common, so it was really cool to hear about some of the same things we've discussed in my classes. Crash course always makes every subject very interesting and thought-provoking!

  • Nelson Swanberg

    tramp is about to solve the health care quagmire by introducing the single prayer system.

  • Allon Vorlete

    Can you lie when getting insurance? Like, can you be a smoker and say you don't smoke so your premium doesn't go up?
    Like, legally. Not ethically.
    How can they prove these things besides having a doctor do invasive tests? Is there a repercussion for lying when getting insurance? Thanks for any help that anyone can offer these questions.

  • Felix Iaccarino

    cant belive your country needs a course to explain how to do single payer system…. and stop making money inmoraly with… healthcare : / what a sick country

  • Shawn Ravenfire

    We put our money in a risk pool, and as soon as you break your leg, your insurance company tells you that you didn't sign the proper form that no one told you about, but it was on display in a cellar with no light or stairs in a locked filing cabinet in an unused lavatory with a sign saying "beware of the leopard." And you don't find out they're not going to pay their share of the bill until AFTER the unpaid portion of the doctor's bill has been forwarded to a collection agency whose only purpose it to bother people to pay mystery bills like an overaggressive televangelist who has your home phone number. Meanwhile, your leg isn't getting any better, but you're still expected to buy health insurance, like a con that turns into a robbery halfway through. At the same time, the doctors aren't worried about their patients not being able to pay their bills, because some money is going to eventually show up from somewhere, so what's the risk to them if they charge a zillion dollars for the air that you breathed in the waiting room, and… you know what? Maybe it would be simpler if they just came up to me with a gun and demanded my wallet every time I felt a little sick.

  • Merveesh Auchoybur

    nice video – quite an eye opener in healthcare

  • GuldorPhotography

    I have visited the USA for the first time and was amazed how bad the whole healthcare system is. I wear contact lenses and to get them in there costs way more and I needed a +150dollars eye doctors-note in stead of just buying them cheap in many stores like I can in the Netherlands. I had type of aspirin with me what also seemed to be a task to just buy there. heard personal health horror stories like a girl who could not go the the hospital when our plane got canceled because it would cost her tons of money instead of just going to the hospital for free in her own country. Just because the plane had a delay so she had to risk it. I also was amazed by the amount of different laxatives in stores and that I could buy. Or diabetic equipment at wallmart what I do need to get from a pharmacy. And the questionable medicine commercials on tv for things that are as far as I know clearly are not a thing like "stress sweat" or other problems I never even heard about, and that all seemed to be able to kill you if your unlucky with the side effects. Other then that, I had a great trip!

  • Malcolm Pagett

    Great Video. Now to the comment section where all the European countries are screaming about their love of having free healthcare. (I am doing banter).

  • Athula Bandara


  • Harri Kirik

    Great course, this turned out to be a lot more interesting and engaging than I initially anticipated, I leaned a lot. Thanks! 🙂

  • ashvic2

    The US healthcare is crazy!! Here in Malaysia a "third world country" we have universal healthcare. i broke my hand when i was 18. i went to a government hospital and they charged me RM1 (about 25 cents US).

  • rbmaserang

    its a bunch of fascists

  • Marv Farstar

    this channel deserves more views

  • Güber McSanchez

    Good watch. Thanks.

  • Sinpay

    A sincere thank you to the crash course sociology team!!

  • poisonedfrog

    I adored this cc series!! VERY informative and useful.

  • Petch85

    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.

  • Alfonso Paredes

    So LONG….Thanks a lot for the clarity and effort. Greetings from Mexico.

  • A

    Thank you CC Sociology!

  • joshua byrne

    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

  • IceNixie0102

    LOVE LOVE LOVE your purple sweater!! Where did you get it??

  • Nory-Chan

    Final? What? Nooo!

  • shiny x

    Oh no…need more warning when shows end! 🙁

  • Margony

    Thank you so much for this series! 😀

  • Ayush Gupta

    thank you

  • Nursery of life

    Thank you so much for the series / i loved it.

  • Emma Williamson

    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!

  • Jeremai Yo-Antoine Burke

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

  • Kathy Fausett

    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.

  • Abdullah


  • Ropsana Khanom

    Wow your healthcare sucks

  • thedoanzone

    I feel bad for her. She didn't have access to orthodontia.

  • Ashley

    …why is Sansa on the Iron Throne?

  • l60449

    Thank you so much for this great series!!

  • Tyrone Gil

    Please make a crash course anthropology 😊

  • T. Vinters

    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.]

  • Windy3s

    Am not from US so not sure this is a good topic for me. Could be more general 😏

  • Fabby Marmol

    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.

  • Talismanhex

    Thank you Nicole Sweeney. You’re amazing! I learned a lot!

  • Broccoli Caulifer

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

  • Thomas Kee

    Great course! I watched all of it and loved it. Im going to watch all the other crash courses now!

  • Ieva Kazaka

    A big THANK YOU for this course! Really, really enjoyable! 🙂

  • AKM pullingoo

    I need contact details mam please provide

  • Sinnum

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

  • GabriellaMZ

    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!)

  • Raghad Abo

    I need Arabic translation

  • Szkojani Charlatans

    Can you pls do a antropology crash course?

  • Quenton Plumlee Q plums

    Study to be a nurse and you don’t need to go to the doctor that much.

  • Ravener Alpha

    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.

  • Jansen Huang

    Amazing US HealthCare. Likely Donald only like Canada because of the money that universal healthcare saved him

  • Taco The Cat

    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

  • Mohammed Sabri

    if you can be add languag arabic i would be present this courses in my university because is so good plz

  • Chris Scovitch


  • Yogesh Gosavi

    It's awesome 😉

  • Jim Feaster

    United health care
    And aarp are not
    For seniors ….

  • Sopek cs

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

  • 1MinuteFlipDoc

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

  • YouTube Channel

    Thanks Nicole!

  • Conner Fields

    What is the nature of Social Alienation?

  • Hira Khan

    Thank you Nicole for this amazing series:-)

  • Timoha

    Thankyou for the course !

  • Let's Talk Money Channel

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

  • Emma Selby


  • Caleb Keller

    I'm sorry you are gonna need to dumb it down tonto.

  • Haru Hana

    thank you!

  • ReeAmor

    Thank you….well explained!

  • Cary Morris

    Thank you for this course! You all did such a great job!

  • William Kibler

    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

  • IAmNoOne

    The US healthcare is a racket for rich people.

  • william Dark

    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 😂😂😂

  • William Penn jr.

    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.

  • Ariel Currá

    This was a great crash course

  • Kim Libera

    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.

  • Ralf Vlogs

    Did you ever know Russia provides ALL its citizens with FREE HEALTHCARE?Checkout my experience on my channel 👌

  • Kamila kozioł

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

  • David Hill

    Here in Australia we pay a 2% levy on our wages (people who earn less than 20k don't pay it ) that pays for our healthcare system for that we get subsidised drugs , subsidised doctor visits and no cost hospital treatment .

  • Avantika Sharma

    Nicole you have been awesome throughout the whole series. Thank you very much.

  • Sumit K. Singh.

    Thanks Nicole And The Crash course Team!.🎀🎇🎆

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