The US healthcare system, despite recent healthcare reform legislation and medical advances, still has a long way to go before affordable and high-quality health care is available to all. This inequity makes healthcare a social justice issue. How might we achieve this goal?
We have seen throughout this chapter that social class, race, gender, sexuality, and other areas of social location all play a profound role in the quality of health and healthcare. For instance, people from low-income backgrounds have higher rates of physical and mental illness because of the stress and other factors associated with living with little money and also because of their lack of access to adequate health care. Partly because they tend to be poorer and partly because of the discrimination they experience in their daily lives and in the health-care system, people of color also have higher rates of physical and mental illness.
To improve health and health care in the US then, the importance of social location must be addressed. Efforts that reduce poverty and social inequality outlined in earlier chapters should also improve the physical and mental health of those currently at risk because of their marginalized identities, as public health experts recognize (Bradley & Taylor 2011). At the same time, special efforts must be made to ensure that these millions of individuals receive the best health care possible within the existing system of social inequality.
A National Health Care System
US healthcare coverage can broadly be divided into two main categories: Public healthcare, which is funded by the government, and private healthcare, which a person buys from a private insurance company or is offered such through their employer. The two main publicly funded healthcare programs are Medicare, which provides health services to people over 65 years old and people who meet other standards for disability, and Medicaid, which provides services to people with low incomes who meet other eligibility requirements. Other government-funded programs include The Indian Health Service, which serves Native Americans; the Veterans Health Administration, which serves veterans; and the Children’s Health Insurance Program (CHIP), which serves children.
Private insurance is typically categorized as either employment-based insurance or direct-purchase insurance. Employment-based insurance is health plan coverage provided in whole or in part by an employer or union. It covers only the employee or the employee and their family. Direct purchase insurance is coverage that an individual buys directly from a private company.
The number of uninsured people – those who lack health care coverage – is far lower now than in previous decades, but that doesn’t mean everyone has the healthcare they need. In 2013, and in many years preceding it, the number of uninsured people was in the 40 million range, or roughly 18% of the population. The Patient Protection and Affordable Care Act (ACA, aka 'Obamacare') allowed more people to obtain affordable insurance (Patient Protection and Affordable Care Act Glossary N.d.), reducing the number of uninsured individuals and families, though many remain uninsured today.
With the Affordable Care Act (ACA), the percent of uninsured people dropped by nearly half. What else might protect Americans in regards to accessing health care?
See photo credit above
The ACA was a landmark change in US healthcare. Passed in 2010 and fully implemented in 2014, it increased eligibility to programs like Medicaid, helped guarantee insurance coverage for people with pre-existing conditions, and established regulations to ensure insurance premiums collected by insurers and care providers went directly to medical care (as opposed to administrative costs). It also included an individual mandate, which required anyone filing for a tax return to either acquire insurance coverage by 2014 or pay a penalty of several hundred dollars. Other provisions, including government subsidies, are intended to make insurance coverage more affordable, reducing the number of underinsured or uninsured people.
The uninsured number reached its lowest point in 2016, before beginning to climb again (Garfield, Orgera, and Damico 2019). People having some insurance may mask the fact that they could be underinsured – that is, people who pay at least 10% of their income on healthcare costs not covered by insurance or, for low-income adults, those whose medical expenses or deductibles are at least 5% of their income (Schoen et al. 2011).
Even with all these options, a sizable portion of the US population remains uninsured. In 2020, about 31 million people had no health insurance (Keith 2020). People don’t have health insurance for many reasons. Many small businesses can’t afford to provide insurance to their employees. Many employees are part time, so they don’t qualify for insurance benefits from their employers. Some people only have health insurance for part of a year (Keisler-Starkey and Bunch 2020). In addition, all states except for California and recently Oregon make it illegal for undocumented immigrants to receive Medicaid services through the ACA. Other states, such as Texas, are pushing to stop the spread of Medicaid to low-income citizens. So, what else can be done?
Canada and other wealthy nations have national health-care systems that provide models for the United States to follow.
Samuel Auguste – Au Canada – CC BY-NC-ND 2.0
The national health-care and health insurance systems of Canada, the United Kingdom, and many other Western nations provide other successful models for the US. As discussed in this chapter, these nations provide better health care to their citizens in many ways and at a lower cost than that incurred under the US model of private insurance. Their models are not perfect, but a government-funded single-payer system shows great promise for improving the health and health care of all Americans. This option has been called “Medicare for all,” as it would cover all citizens.
We in effect have single-payer government-funded systems for police, firefighters, education, public libraries, and even the postal service, proponents of national health insurance say, and they add that the government program Medicare is largely successful (Kristof 2009). As mentioned above, the US government also runs a preventive care and hospital system for military veterans through the Department of Veteran Affairs (VA), which has been called "one of the best-performing and most cost-effective elements in the American medical establishment." According to a study by the Rand Corporation, "If other health care providers followed the V.A.’s lead, it would be a major step toward improving the quality of care across the U.S. health care system" (Kristof 2009).
These models all indicate that national health insurance and the single-payer system for health care found in many other democracies could also succeed in the US. As one single-payer proponent observed, "A public role in health care shouldn’t be any scarier or more repugnant than a public fire department" (Kristof 2009).
People Making a Difference
Physicians in Favor of National Health Insurance
Physicians for a National Health Program (PNHP) is a national organization of some 18,000 physicians who support a single-payer system of national health insurance in the United States. They advocate for this goal through the PNHP’s website and through a variety of advocacy efforts. These efforts include writing articles for medical and public health journal; writing op-ed columns for newspapers; and making educational materials available to members of the public who wish to contact their members of Congress. PNHP members also appear on local and national television news shows and coordinate and speak at public health forums. PNHP has local chapters and allied groups in more than forty states and the District of Columbia.
According to PNHP, a single-payer system would greatly reduce the billing, paperwork, and other administrative costs of the private insurance model that now dominates the US health care system. These costs, PNHP says, account for one-third of US health expenditures; if the United States were to adopt a national single-payer system, administrative costs would be reduced by $400 billion. PNHP also emphasizes that more than 50 million Americans are now uninsured and many others are underinsured. A national single-payer system would cover virtually the entire population.
An important reason for the high administrative costs of US health care, PNHP explains, is the fact that private insurance companies are for-profit companies. Because their goal is to make a profit, they advertise and engage in various marketing activities, and their CEOs and other executives receive extremely high salaries and other compensation. A single-payer system would eliminate all these problems.
By calling attention to the many problems in the current US health model and by advocating for a national single-payer system, Physicians for a National Health Program is helping to make a difference. For more information, visit http://www.pnhp.org.
In this discussion, it is important to distinguish between socialized medicine and universal healthcare. Under a socialized medicine system, the government owns and runs the healthcare system. All medical facilities and expenses are covered through a public insurance plan that is administered by the federal government. It employs doctors, nurses, and other staff and owns and runs the hospitals (Klein 2009). The best example of socialized medicine is in Great Britain, where the National Health System (NHS) covers the cost of healthcare for all residents. Despite some U.S. citizens’ reaction to policy changes that hint at socialism, the Veterans Health Administration (VA) is administered in a similar way to socialized medicine in other countries.
Germany, Singapore, and Canada all have universal healthcare, which is simply a system that guarantees healthcare coverage for everyone. People often look to Canada’s universal healthcare system, Medicare, as a model for the system. In Canada, healthcare is publicly funded and administered by separate provincial and territorial governments. However, the care itself comes from private providers. This is the main difference between universal healthcare and socialized medicine. The Canada Health Act of 1970 required that all health insurance plans must be "available to all eligible Canadian residents, comprehensive in coverage, accessible, portable among provinces, and publicly administered" (Kaiser Family Foundation 2010).
A Focus on Care
Short of adopting national health insurance, other efforts to improve health and health care are certainly essential. One such effort would include an expansion of measures that fall broadly into what the field of public health calls preventive care. This approach recognizes that the best approach to health and health care is to prevent illness and disease before they begin. One facet of this approach focuses on the unhealthy behaviors and lifestyles, including lack of exercise and smoking, characteristic of millions of Americans. Although the US has public education campaigns and other initiatives on these risk factors, more could still be done.
An additional facet of this approach focuses on early childhood in general but especially on early childhood among low-income families. As this chapter has emphasized, many health problems begin very early in childhood and even in the womb. Home visitation and nutrition assistance programs must be expanded across the country to address these problems.
Another strategy that would reduce health care costs would be the adoption of integrated care, also called 'high touch medicine' (Emanuel 2011). In this model, teams of health care professionals (nurses, pharmacists, physicians) coordinate care for the chronically ill patients (10% of the population) who account for two-thirds of all health care costs. This integrated care involves extensive communication among the members of a patient’s team with the patient and any caregivers, home visits by nurses to check on the patient, and other components. The goal is to help the patients take better care of themselves so that they do not become sicker and need (additional) hospital or emergency room care. Because hospital and emergency room care is so expensive, the prevention of hospital and emergency room visits through integrated care yields a significant savings in health care costs. If integrated care became the norm around the country, it is estimated that its adoption would save more than $80 billion annually.
Lessons from Other Societies
Aging Policy and Programs in the Netherlands and Sweden
A few years ago, AARP assessed quality-of-life issues for older people and the larger society in sixteen wealthy democracies (the nations of North America and Western Europe, along with Australia and Japan). Each nation was rated (on a scale of 1–5, with 5 being the highest score) on seventeen criteria, including life expectancy, health care for the elderly, pension coverage, and age-discrimination laws. Of the sixteen nations, the Netherlands ranked first, with a total score of 64, while Italy ranked last, with a score of 48; the United States was thirteenth, with a score of 50. Despite its immense wealth, then, the United States lagged behind most other democracies. Because a “perfect” score would have been 85 (17×5), even the Netherlands fell short of an ideal quality of life as measured by the AARP indicators.
Why did the United States not rank higher? The experience of the Netherlands and Sweden, both of which have longer life expectancies than the United States, points to some possible answers. In the Netherlands, everyone at age 65 receives a full pension that does not depend on how much money they earned while they were working, and everyone thus gets the same amount. This amount is larger than the average American gets, because Social Security does depend on earnings and many people earned fairly low amounts during their working years. As a result, Dutch elderly are much less likely than their American counterparts to be poor. The Dutch elderly (and also the nonelderly) have generous government insurance for medical problems and for nursing home care; this financial help is much higher than older Americans obtain through Medicare.
As one example, the AARP article mentioned an elderly Dutch woman who had cancer surgery and thirty-two chemotherapy treatments, for which she paid nothing. In the United States, the chemotherapy treatments would have cost at least $30,000. Medicare would have covered only 80 percent of this amount, leaving a patient to pay $6,000.
The Netherlands also helps its elderly in other ways. One example is that about one-fourth of that nation’s elderly receive regular government-subsidized home visits by health-care professionals and/or housekeepers; this practice enables the elderly to remain independent and avoid having to enter a nursing home. In another example, the elderly also receive seven days of free riding on the nation’s rail system.
Sweden has a home-care visitation program that is similar to the Netherlands’ program. Many elderly are visited twice a day by a care assistant who helps them bathe and dress in the morning and go to bed at night. The care assistant also regularly cleans their residence and takes them out for exercise. The Swedish government pays about 80 percent of the costs of this assistance and subsidizes the remaining cost for elderly who cannot afford it. Like the Netherlands’ program, Sweden’s program helps the elderly to remain independent and live at home rather than enter a nursing institution.
Compared to the US, then, other democracies generally provide their elderly less expensive or free health care, greater financial support during their retirement, and home visits by health-care professionals and other assistants. In these and other ways, these other governments encourage “active aging.” Adoption of similar policies in the US would improve the lives of older Americans and perhaps prolong their life spans.
Sources: Edwards 2004; Hartlapp & Schmid 2008; Ney 2005
Programs can also be developed to provide care to those with specific health needs, such as mental illness. For instance, the Crisis Assistance Helping Out On The Streets (CAHOOTS) program in Eugene, Oregon, addresses mental health and drug-related issues. It is integrated into 911 emergency services systems, and is operated jointly by the White Bird Clinic and the Eugene police.
CAHOOTS began as an offshoot of the counterculture movement in Eugene. The organization provided volunteer-operated mental health services to the community. It also presented periodic role-playing seminars to the Eugene police related to managing and defusing mental health-related situations in policing. In the 1980s, the police department began taking advantage of this community initiative, informally referring mental health cases to the CAHOOTS organization to reduce the direct involvement of police in non-crime scenarios. CAHOOTS volunteers still offer crisis response services and access to other community services to persons experiencing mental health or drug-related issues.
The people in this picture are working together in the CAHOOTS program to create solutions for mental health problems.
“White Bird/CAHOOTS Photo” from “Best Programs for the Homeless” © Todd Cooper, Eugene Weekly is all rights reserved and included with permission
In response to a lawsuit against the city for excessive use of force and racial discrimination in a fatal shooting of a veteran with PTSD by the Eugene police, the Eugene city council committed $225,000 of the city police budget to fund 24/7 availability of the CAHOOTS services and access to the 911 dispatch system. As the CAHOOTS organization began to respond to calls, delays in response time decreased significantly. CAHOOTS estimates that in 2021, roughly 17% of the calls to 911 in Eugene resulted in a dispatch of a CAHOOTS team, reducing the involvement of the official police significantly. Chris Skinner, the Eugene chief of police, commented before the pandemic hit that increasing the number of CAHOOTS teams is a benefit of probability: "The less time I put police officers in conflict with people, the less time those conflicts go bad."
If you would like to learn more, listen to ‘CAHOOTS’: How Social Workers And Police Share Responsibilities In Eugene, Oregon.
Organization Profile
The Loveland Foundation was established in 2018 by Rache Cargle, a writer, entrepreneur, and philanthropist, in response to a fundraiser for therapy support for Black women and girls. The Loveland Foundation now assists with mental health resources in communities of color in a number of locations nationwide, including Texas, Georgia, California, Ohio, and New York.
The organization partners with organizations providing culturally-competent therapy resources for Black women and nonbinary people in the areas where they operate. Through their Therapy Fund, the organization funds all or part of the costs of access to therapy. They also provide residency programs, fellowships, educational spaces, a resource directory, listening tours, and more. For instance, the organization operates workshops for therapy providers to educate about eating disorders among Black women and girls, in partnership with the Renfrew Center for Eating Disorders. The workshops are a six-part series focusing on providing the historical context, etiology, intergenerational trauma, and its impact on body image, assessment, and treatment.
One unusual feature is their approach to building future therapy support resources for people of color. According to the American Psychological Association, only 17% of therapists in the US identify as people of color, and only 3% identify as Black or African American. The Loveland Foundation is investing significant scholarship funding in enabling undergraduate and graduate education for BIPOC people (Black, Indigenous, and other People of Color) intending to offer therapy to the BIPOC community, including addressing the use of unpaid internships and the lack of dependable mentors to provide support resources to students wishing to address this need.
The foundation explains, "Black women and nonbinary folks deserve access to healing, and that healing will impact generations. ... We believe if we reimagine a mental health care system accessible to Black women, we can create a system that benefits everyone."
If you would like to learn more about the services of the Loveland Foundation, check out their site The Loveland Foundation.
Other Policies and Practices
Examples of other policies and practices include addressing the high cose of healthcare in the US and increasing global aid to help reduce poor health in other nations, which are social justice concerns as low-income people often cannot afford care or do not have access to it.
We saw earlier that the US fee-for-service model, in which hospitals and physicians largely set the prices for their services, contributes greatly to the high cost of health care in the US. Related to this model, physicians are paid for each patient they see, rather than receiving a set salary, as teachers, firefighters, police officers, and most other occupations that service large numbers of people receive. Yet there are some outstanding hospitals, such as the Mayo Clinic in Minnesota and the Cleveland Clinic in Ohio, where physicians do work on salary rather than charging for each patient or for each surgery. Costs per patient at these hospitals tend to be lower (Gawande, Berwick, Fisher, & McClellan 2009). Moving toward this model would help lower healthcare costs. The elimination of many diagnostic tests and medical procedures and surgeries that research has shown to be unnecessary and that may cost at least $200 billion annually woudl also help reduce costs (Weinberger 2011).
What can be done to improve world health? Because the poorest nations have the poorest health, it is essential that the wealthy nations provide them the training, equipment, and other resources they need to improve their health and healthcare. The residents of these nations also need to be given the resources they need to undertake proper sanitation and other good health practices. In this regard, organizations like the World Health Organization (WHO) have been instrumental in documenting the dire status of health in the poor nations and in promoting efforts to help them, and groups like Doctors Without Borders have been instrumental in bringing healthcare professionals and medical care to poor nations.
Another US government organization, U.S.A.I.D., has saved lives and improved health across the globe, including for issues such as malaria, HIV, tuberculosis, and more. In fact, one study estimates that the program saved over 90 million lives over the two decades before 2025 (Cavalcanti et al. 2025). Moreover, aid from the US has been estimated to save over 3 million lives worldwide annually: "We suggest the number of lives saved per year may range between 2.3 to 5.6 million with our preferred number resting on gross estimates of 3.3 million" (Kenny and Sandefur 2025). With the massive cuts in funding to U.S.A.I.D. under the second Trump administration, an estimated 14 million lives may be lost (Cavalcanti et al. 2025). For an average of 18 cents per day, US taxpayers could help save millions of lives worldwide (Lambert 2025). From sociological and social justice perspectives, we must strengthen rather than cut funding for U.S.A.I.D. This is a matter of life or death for millions worldwide.
Individual Agency and Collective Action
We have already discussed some examples of individuals using their own agency and engaging in collective action to help reduce problems in health and medicine. For instance, the CAHOOTS volunteers described above who provide community-based mental health services used their agency to decide to take action. In the remainder of this section, we will focus on issues related to reproductive health and pregnancy, which are problems of health and medicine. If we are concerned about social justice and health, a model framework for addressing health inequities is that of the reproductive justice movement.
Women have always shared information about health, but this work became more focused with the 1970s women’s movement. A women’s collective wrote Our Bodies Ourselves (pictured below) to share concrete practical information about women’s health. In their work, they told each other stories about how they learned about menstruation and experienced their first periods. Generally, information about menstruation at the time had been shrouded in mystery and shame. The book challenged this mystery and shame related to women’s health, offering women clear, accessible information about health, information that wasn’t generally accessible at the time. This collective is still going strong today (Our Bodies Ourselves Today 2023).
The Boston Women’s Health Book Collective published Our Bodies Ourselves to educate women about women’s health. How might information like this increase reproductive justice?
“Cover of the 1973 edition of ‘Our Bodies, Ourselves’” by The Boston Women’s Health Book Collective is included under fair use
Women’s commitment to reproductive justice didn’t stop with writing books and education. Feminists, including women, men, and nonbinary people, continue to work for reproductive justice. These efforts include supporting the 1973 Roe v. Wade decision, which protected the right to have an abortion. More recently, this social movement generated several Women’s Marches on Washington D.C. and protests related to reproductive rights. The song “I Can’t Keep Quiet” became one of the anthems of recent women’s marches – feel free to listen if you’d like.
Feminist activists continue to advocate for reproductive justice. In the Boston Women’s March in 2017, a protester carries a sign that says ”Stop The War On Women.”
“Boston Women’s March 02” by Carly Hagins is licensed under CC BY 2.0
Beyond education, writing, and protesting, many organizations provide reproductive justice through healthcare services. SisterSong, the women of color reproductive justice coalition was formed in 1997 by 16 organizations of women of color. They write, "SisterSong’s mission is to strengthen and amplify the collective voices of indigenous women and women of color to achieve reproductive justice by eradicating reproductive oppression and securing human rights" (SisterSong 2023).
They connect issues of gender, sexuality, class, and race to create a national multi-ethnic movement to support reproductive justice, which includes not only access to safe abortion, but access to contraception, and freedom from forced sterilization. The organization collects funds and distributes them to birthing people of color and queer people who need birth support (Sistersong 2023).
These collective actions were in part inspired by an individual who used her agency to organize the reproductive justice movement. Loretta J. Ross is a scholar-activist who helped found the movement and has worked tirelessly to advance social justice regarding reproductive health issues. She explains:
"I joined the women's movement in 1978 by working at the first rape crisis center in the country and learned about women's human rights, reproductive justice, white supremacy, and women of color organizing. I also researched and fought hate groups such as the KKK in the 1990s, and I founded a national center for teaching people about their human rights, and co-founded SisterSong. I want to share what I've experienced with emerging activists in hopes that you will join the transformative human rights movement that has changed the world."
Ross has participated in or produced a variety of resources related to reproductive health, antiracism, and other social justice projects. You may learn more about her at her website: Loretta J. Ross: Activist. Public Intellectual. Professor.
Finally, midwives and birth doulas are offering options to ensure reproductive justice. Black Doulas, for example, help Black birthing people to have babies safely. This alternative is important to combat the racism in reproductive care, in which Black women are three times more likely to die than white women from pregnancy-related causes.
A birth doula provides emotional and physical support to a pregnant person before, during, and after the birth. This culturally specific care improves outcomes for pregnant people: "As doula care is a proven, cost-effective means of reducing racial disparities in maternal health and improving overall health outcomes, policy advocates, legislators, and other stakeholders should undertake efforts to increase Medicaid and private insurance coverage of doula services" (Robles-Fradet and Greenwald 2022).
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When we consider mental and physical health and well-being, we notice interdependent solutions supporting social justice. Each of us has agency in our own health and the health of our friends and families. We can care for ourselves and each other. At the same time, we experience different rates of adverse health outcomes as well as trauma, stigma, prejudice, and discrimination. We need equity in health resources and treatment options. Organizations and programs like those described on this page work to address the systemic inequities in health experiences. Working together we can weave interdependent solutions for health resilience and social justice.
