Many factors affect an individual’s access to healthcare; urban planning methods determine the location of hospitals, and cultural factors can deter an individual from allopathic medicine. Structural barriers within the healthcare system can disrupt patient access to care too. If a patient has an unknown heart condition, but there are no cardiologists close to them, how would they receive a diagnosis? Diagnosis is a privilege. Outside of the United States, many developing countries experience a healthcare shortage, where patients do not receive a diagnosis for the issues they face. Some regions within the US actually experience a shortage of general practitioners too. Many structural barriers within the healthcare system reveal the privilege behind diagnoses and having a structured healthcare system. Fortunately, many of these issues have viable solutions.
Personal Anecdote
During my years in high school, I had an opportunity to shadow a doctor at a pain management office. At the office, lumbar and thoracic epidural procedures, joint aspirations, cortisone injections, and a variety of other services are carried out by the head practitioner, in addition to general checkups.
I will never forget one patient interaction that shifted my perspective on healthcare (vague details and minimal identification details are included because of HIPAA protection). With a firm grip on her cane but a strong stride, she entered the office. Her chart included x-ray imaging of her spine that revealed severe lateral curvature of her spine or scoliosis.
I stood there in awe at the degree of curvature I had observed, and turned to the doctor and asked, “does she have a congenital disorder?” I could not fathom the development of such severe scoliosis throughout a lifetime from lifestyle or environmental factors. What I could not imagine is what exactly had happened to this woman. The doctor explained that she was likely born with scoliosis, and the absence of proper medical treatment only worsened her scoliosis.
Diagnoses are a Privilege
I knew that this patient was from abroad, considering that English was not her native language. At the time, it had not occurred to me that the availability of doctors varies in every region of the world. I understood that neglecting treatment early on can prevent effective care later on for some disorders after this patient encounter. And, I learned that diagnoses are a privilege that not everyone has. Aside from urban planning and cultural factors, below are some of the structural barriers that limit access to healthcare having to do with the healthcare system.
Laws and Ordinances as a Structural Barrier in Healthcare
Traditionally, new medical school graduates had to adhere to the Hippocratic Oath, known for its condemnation of harming patients. Condemnation of harming patients is common among schools that have their own variation of this oath. The Imperial College School of Medicine has a declaration that all doctors must promise that they will serve humanity to the best of their ability (Sritharan, K. et al., 2001). Hence, part of the declaration means that new doctors will not consider demographic, religious, and political information (Sritharan, K. et al., 2001). Yet, this information is essential to the holistic way of medicine, and then some. Doctors promise to care for humanity, but structural barriers in the form of laws and ordinances stand in the way of this promise.
Trends in the Migrant Population
As of 2007, 15% of the United States population was foreign-born, and this number continues to grow (Edward, J., 2014). The foreign-born population disproportionally experience higher levels of poverty, lower levels of education, lack healthcare coverage, and receives fewer healthcare services than the rest of the United States population (Edward, J., 2014). Disparities of migrant populations are comparable to lower-income families. However, immigrants face laws barring them from healthcare eligibility.
Structural Barriers Faced by the Migrant Population
Many people have depicted the migrant population as a socio-cultural, economic, and political issue. As a result, issues prompted the passage of laws that limit their right to care. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, PRWORA, restricted immigrants from accessing Medicaid (Edward, J. 2014). The Patient Protection and Affordable Care Act (PPACA) of 2010 required that all citizens and legal immigrants have health insurance coverage (Edward, J., 2014).
The Patient Protection and Affordable Care Act of 2010 attempted to open up healthcare privileges to the migrant population. However, the requirement for insurance diminishes any progress that the ordinance intended to make. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 restricted immigrant access to federally funded healthcare, and restrictions continued through 2010 since many immigrants still did not have insurance coverage.
Why Structural Barriers Still Stand for the Migrant Population
Note that the PPACA applied to legal immigrants and citizens of the United States. And, according to astho.org, there are no laws that should prevent an immigrant (lawful or unlawful) from accessing healthcare. Yet, undocumented immigrants are still reluctant to seek care because of immigration laws. United States laws require that immigrants that enter the country outside of a designated time to avoid inspection by an immigration officer or attempt to obtain entry into the United States under false or misleading representation will face legal consequences. These consequences include a fine and six months of imprisonment. Subsequent commissions threaten migrants with two years of imprisonment and fines.
Reluctancy to seek healthcare has much to do with immigration laws. As a result, fear can drive an immigrant away from a healthcare professional. They may fear that physicians will report their immigration status to the authorities. Many medical forms require immigration status and the social security number of the patient. Patients in a mixed-status family, family members of an undocumented immigrant might still fear seeking medical care since their undocumented relatives still face the risk of deportation. Medical forms sometimes require the social security number of family members. Undocumented immigrants only have a social security number if they apply for a non-citizen social security number. However, a non-citizen social security number requires a visa.
Lack of Doctors as a Structural Barrier in Healthcare
Researchers compiled a range of demographic data in America as coronavirus ravaged the country. They were able to draw connections between communities and how they were affected by the virus. They were able to discern why these communities were affected a certain way. Areas of a lower socioeconomic status experienced more cases and more fatalities because of various social issues. However, one of the reasons for this disparity is a shortage of doctors for areas in need. The Association of American Medical Colleges (AAMC) projects that the United States will face a shortage of between 54,000 and 139,000 physicians by 2033. This pandemic has especially revealed the effects of the physician shortage.
The AAMC’s demographic data contribute to the projection that there will be a shortage of physicians. Within the next ten years, the number of people over 65 will increase up to 45.1%. This population cohort, in particular, generally requires more care. In addition, more physicians will reach retirement age, considering 2 of 5 active physicians tend to retire around 65 years old.
The Shortage of Primary Care Physicians
The lack of doctors is most apparent in primary care. According to the New England Journal of Medicine, only a third of American doctors are in primary care. Therefore, fewer available primary care physicians mean that they are less accessible to the population. In developed nations, on average, half of the doctors are primary care physicians. Scholarships and other incentives have been offered to medical school students to entice them towards a primary care career, but these methods have only been successful to an extent.
Will the Shortage of Doctors Always be a Structural Barrier?
There is a shortage of primary care physicians, despite a large portion of the population that does not have a usual source of care. So, what if there are enough physicians to accommodate the current populace in need (that actively seeks regular primary care)? The Association of American Medical Colleges predicts that more primary care physicians will drive more people to seek primary healthcare. If more people seek care, there will still be the same shortage of physicians faced by more of the population.
The shortage of general practitioners is a structural barrier in the healthcare system. Besides structural barriers outside of the healthcare system, the scarcity of doctors can deter individuals from seeking care. Doctor scarcity may be apparent when patients face difficulties while scheduling an appointment. If a doctor has a large book of patients, they might have a large volume of appointments, and walk-in appointments may be hard to come by for a patient. The scarcity of doctors extends beyond general practitioners. For example, if there are no specialists nearby for a patient, the patient is less likely to travel to seek care for a specific condition. The unavailability of a specialist can be because there are not many specialists who can treat the given health condition.
Limited Research as a Structural Barrier in Healthcare
Limited research may also be a structural barrier in the healthcare system. Health research holds great importance for society as well as the healthcare system. Health research can reveal data that assesses trends, risk factors, outcomes, patterns of care, and health care cost and use (Nass, S. J., et al., 2009). Clinical trials are a vital part of health research. They provide relevant information regarding the efficacy of medical treatments and any possible adverse effects (Nass, S, J., et al., 2009). Thus, any research gathered is of great importance to the public. In a Harris poll, 80% of respondents were interested in health research findings, and in a 2007 survey, 76% of respondents reported that science plays a principal role in health (Nass, S. J., et al., 2009).
The Special Case of the Tuskegee Syphilis Experiment
In the past, there were situations where health care research has acted as a structural barrier. For example, during the Tuskegee Syphilis Experiment, African Americans were withheld from proper care to see the possible outcomes of their conditions. The Tuskegee Experiment has undeniably violated some medical ethical values. Despite medical ethics violations, the experiment did produce information valuable to health research in subsequent studies.
Results of Narrow Diversity in Clinical Trials
Medical research has great value. Because of its great value, there is no question that limited research can act as a structural barrier. Historically, women and people of color were underrepresented in clinical trials and studies. From being underrepresented in clinical trials and studies, many people of color and women reluctantly seek a given treatment. More recently, this exact scenario occurred with the new coronavirus vaccines. Because of pertinent information, many people are wary about receiving the coronavirus vaccine.
A patient has the legal right to refuse to take a prescription due to factors such as drug prices. Patients can also refuse treatment because of the underrepresentation of a demographic category they have in scientific studies.
Limited Access to Data from Clinical Trials
Medical professionals should publish the results of clinical research in the best interest of the public. However, they do not always publish their results. Researchers may use a patient’s files in a research study, but the patient is often not informed about the relevance of those results (Nass, S. J., et al., 2009). The public usually does not have access to the databases that hold the results of many research studies. Research studies seldom have observational data (Nass, S. J., et al., 2009). Public information can eliminate biases and might even encourage voluntary citizen participation in research.
Structural Barriers in Relation to Anthropology
Structural barriers in the healthcare system of the United States extend beyond the few laws, shortage of doctors, and underrepresentation I have discussed. To combat disparities as a result of structural barriers, the United States must make resources available to individuals. Laws must not prevent access to healthcare for migrant groups, and resources must be expanded to students for more students to pursue a career in primary care. Also, representation should be equitable in clinical trials, and data should be released to the public from clinical trials. That way, individuals can have access to scientific data for medical decision-making.
Structural barriers have much to do with the societal aspect of anthropology. Elimination or minimization of these barriers can help create a more uniform and structured healthcare system eventually. Also, this can improve public health conditions in America. For now, measures must be taken by providers to create equity for patients. That way, diagnoses are not just a privilege for those that are the most represented in the healthcare system.
Referenced Materials
Sritharan, K., Russell, G., Fritz, Z., Wong, D., Rollin, M., Dunning, J., Morgan, P., & Sheehan, C. (2001). Medical oaths and declarations. BMJ (Clinical research ed.), 323(7327), 1440–1441. https://doi.org/10.1136/bmj.323.7327.1440
Edward, J. (2014). Undocumented Immigrants and Access to Health Care: Making a Case for Policy Reform – Jean Edward, 2014. SAGE Journals. https://journals.sagepub.com
https://www.law.cornell.edu/uscode/text/8/1325
https://www.aamc.org/news-insights/us-physician-shortage-growing
https://www.bu.edu/articles/2011/what-happens-if-we-run-out-of-doctors/
Institute of Medicine (US) Committee on Health Research and the Privacy of Health Information: The HIPAA Privacy Rule; Nass, S. J., Levit, L. A., Gostin, L. O., editors. Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research. Washington (DC): National Academies Press (US); 2009. 3, The Value, Importance, and Oversight of Health Research.
