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United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territo ...
far outspends any other nation on
health care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profes ...
, measured both in ''per capita'' spending and as a percentage of GDP. Despite this, the country has significantly worse healthcare outcomes when compared to peer nations. The United States is the only developed nation without a system of
universal health care Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
, with a large proportion of its population not carrying health insurance, a substantial factor in the country's
excess mortality Excess may refer to: * Angle excess, in spherical trigonometry * Insurance excess, similar to a deductible * Excess, in chemistry, a reagent that is not the limiting reagent * "Excess", a song by Tricky from the album '' Blowback'' * ''Excess' ...
. Healthcare is provided by many distinct organizations, made up of insurance companies, healthcare providers, hospital systems, and independent providers. Health care facilities are largely owned and operated by
private sector The private sector is the part of the economy, sometimes referred to as the citizen sector, which is owned by private groups, usually as a means of establishment for profit or non profit, rather than being owned by the government. Employment The p ...
businesses. 58% of community hospitals in the United States are
non-profit A nonprofit organization (NPO) or non-profit organisation, also known as a non-business entity, not-for-profit organization, or nonprofit institution, is a legal entity organized and operated for a collective, public or social benefit, in co ...
, 21% are government-owned, and 21% are for-profit. According to the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO), the United States spent $9,403 on health care per capita, and 17.9% on health care as percentage of its
GDP Gross domestic product (GDP) is a monetary measure of the market value of all the final goods and services produced and sold (not resold) in a specific time period by countries. Due to its complex and subjective nature this measure is ofte ...
in 2014. Healthcare coverage is provided through a combination of private health insurance and public health coverage (e.g., Medicare,
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
). In 2013, 64% of health spending was paid for by the government, and funded via programs such as Medicare,
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
, the
Children's Health Insurance Program The Children's Health Insurance Program (CHIP) – formerly known as the State Children's Health Insurance Program (SCHIP) – is a program administered by the United States Department of Health and Human Services that provides matching funds to ...
,
Tricare Tricare (styled TRICARE) is a health care program of the United States Department of Defense Military Health System. Tricare provides civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, in ...
, and the
Veterans Health Administration The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the healthcare program of the VA through a nationa ...
. People aged under 65 acquire insurance via their or a family member's employer, by purchasing health insurance on their own, getting government and/or other assistance based on income or another condition, or are uninsured.
Health insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...
for
public sector The public sector, also called the state sector, is the part of the economy composed of both public services and public enterprises. Public sectors include the public goods and governmental services such as the military, law enforcement, infra ...
employees is primarily provided by the government in its role as employer.
Managed care The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("man ...
, where payers use various techniques intended to improve quality and limit cost, has become ubiquitous. The United States
life expectancy Life expectancy is a statistical measure of the average time an organism is expected to live, based on the year of its birth, current age, and other demographic factors like sex. The most commonly used measure is life expectancy at birth ...
is 78.6 years at birth, up from 75.2 years in 1990; this ranks 42nd among 224 nations, and 22nd out of the 35 industrialized
OECD The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate e ...
countries, down from 20th in 1990. In 2016 and 2017 life expectancy in the United States dropped for the first time since 1993. Of 17 high-income countries studied by the
National Institutes of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late 1 ...
, the United States in 2013 had the highest or near-highest prevalence of obesity, car accidents,
infant mortality Infant mortality is the death of young children under the age of 1. This death toll is measured by the infant mortality rate (IMR), which is the probability of deaths of children under one year of age per 1000 live births. The under-five morta ...
, heart and lung disease, sexually transmitted infections, adolescent pregnancies, injuries, and homicides.National Research Council and Institute of Medicine. (2013
"U.S. Health in International Perspective: Shorter Lives, Poorer Health"
Panel on Understanding Cross-National Health Differences Among High-Income Countries, Steven H. Woolf and Laudan Aron, Eds. Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: The National Academies Press.
A 2017 survey of the healthcare systems of 11 developed countries found the US healthcare system to be the most expensive and worst-performing in terms of health access, efficiency, and equity. In a 2018 study, the USA ranked 29th in healthcare access and quality. The rate of adults uninsured for health care peaked at 18.0% in 2013 prior to the ACA mandate, fell to 10.9% in the third quarter of 2016, and stood at 13.7% in the fourth quarter of 2018, based on surveys by the Gallup organization beginning in 2008. At over 27 million, the number of people without
health insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...
coverage in the United States is one of the primary concerns raised by advocates of
health care reform Health care reform is for the most part governmental policy that affects health care delivery in a given place. Health care reform typically attempts to: * Broaden the population that receives health care coverage through either public sector insu ...
. A 2009 study done at Harvard Medical School with Cambridge Health Alliance by co-founders of
Physicians for a National Health Program Physicians for a National Health Program (PNHP) is an advocacy organization of more than 20,000 American physicians, medical students, and health professionals that supports a universal, comprehensive single-payer national health insurance program. ...
, a pro-single payer lobbying group, showed that nearly 45,000 annual deaths are associated with a lack of patient health insurance. The study also found that uninsured, working Americans have an approximately 40% higher mortality risk compared to privately insured working Americans. In 2010, the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
(formally known as the "Patient Protection and Affordable Care Act", and commonly known as "Obamacare") became law, enacting major changes in health insurance. The
Supreme Court of the United States The Supreme Court of the United States (SCOTUS) is the highest court in the federal judiciary of the United States. It has ultimate appellate jurisdiction over all U.S. Federal tribunals in the United States, federal court cases, and over Stat ...
upheld the constitutionality of most of the law in June 2012 and affirmed insurance exchange subsidies in all states in June 2015. The Human Rights Measurement Initiative finds that the US is achieving 81.3% of what should be possible at their income level for fulfilling the right to health.


History

In the United States, dissimilar to the European nationalized health insurance plans, the market created a private employment-based system. Following the Stabilisation Act of 1942, employers, unable to provide higher salaries to attract or retain employees, began to offer
insurance Insurance is a means of protection from financial loss in which, in exchange for a fee, a party agrees to compensate another party in the event of a certain loss, damage, or injury. It is a form of risk management, primarily used to hedge ...
plans, including health care packages, as a fringe benefit, thereby beginning the practice of employer-sponsored health insurance.


Statistics


Hospitalizations

According to a statistical brief by the
Healthcare Cost and Utilization Project The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products from the United States that is developed through a Federal-State-Industry partnership and sponsored b ...
(HCUP), there were 35.7 million
hospital A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emergency ...
izations in 2016, a significant decrease from the 38.6 million in 2011. For every 1,000 in the population, there was an average of 104.2 stays and each stay averaged $11,700, an increase from the $10,400 cost per stay in 2012. 7.6% of the population had overnight stays in 2017, each stay lasting an average of 4.6 days. A study by the
National Institutes of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late 1 ...
reported that the lifetime per capita expenditure at birth, using the year 2000 dollars, showed a large difference between the health care costs of females ($361,192) and males ($268,679). A large portion of this cost difference is in the shorter lifespan of men, but even after adjustment for age (assuming men live as long as women), there still is a 20% difference in lifetime health care expenditures.


Health insurance and accessibility

Unlike most
developed nations A developed country (or industrialized country, high-income country, more economically developed country (MEDC), advanced country) is a sovereign state that has a high quality of life, developed economy and advanced technological infrastruct ...
, the US health system does not provide health care to the country's entire population. Instead, most citizens are covered by a combination of private insurance and various federal and state programs. As of 2017, health insurance was most commonly acquired through a
group plan A group is a number of persons or things that are located, gathered, or classed together. Groups of people * Cultural group, a group whose members share the same cultural identity * Ethnic group, a group whose members share the same ethnic iden ...
tied to an employer, covering 150 million people. Other major sources include Medicaid, covering 70 million, Medicare, 50 million, and
health insurance marketplace In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
s created by the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
(ACA) covering around 17 million. In 2017, a study found that 73% of plans on ACA marketplaces had narrow networks, limiting access and choice in providers. Measures of accessibility and affordability tracked by national health surveys include: percent of population with insurance, having a usual source of medical care, visiting the dentist yearly, rates of preventable hospitalizations, reported difficulty seeing a specialist, delaying care due to cost, and rates of health insurance coverage. In 2004, an OECD report noted that "all OECD countries xcept Mexico, Turkey, and the United Stateshad achieved universal or near-universal (at least 98.4% insured) coverage of their populations by 1990". The 2004 IOM report also observed that "lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States." The Gallup organization tracks the percent of adult Americans who are uninsured for health care, beginning in 2008. The rate of uninsured peaked at 18.0% in 2013 prior to the ACA mandate, fell to 10.9% in the third quarter of 2016, and stood at 13.7% in the fourth quarter of 2018. "The 2.8-percentage-point increase since that low represents a net increase of about seven million adults without health insurance." The
U.S. Census Bureau The United States Census Bureau (USCB), officially the Bureau of the Census, is a principal agency of the U.S. Federal Statistical System, responsible for producing data about the American people and economy. The Census Bureau is part of the ...
reported that 28.5 million people (8.8%) did not have health insurance in 2017, down from 49.9 million (16.3%) in 2010. * * * * * Between 2004 and 2013 a trend of high rates of underinsurance and
wage stagnation Real wages are wages adjusted for inflation, or, equivalently, wages in terms of the amount of goods and services that can be bought. This term is used in contrast to nominal wages or unadjusted wages. Because it has been adjusted to account f ...
contributed to a health-care consumption decline for low-income Americans. This trend was reversed after the implementation of the major provisions of the ACA in 2014. As of 2017, the possibility that the ACA may be repealed or replaced has intensified interest in the questions of whether and how health insurance coverage affects health and mortality. Several studies have indicated that there is an association with expansion of the ACA and factors associated with better health outcomes such as having a regular source of care and the ability to afford care. A 2016 study concluded that an approximately 60% increased ability to afford care can be attributed to Medicaid expansion provisions enacted by the Patient Protection and Affordable Care Act. Additionally, an analysis of changes in mortality post Medicaid expansion suggests that Medicaid saves lives at a relatively more cost effective rate of a societal cost of $327,000 - 867,000 per life saved compared to other public policies which cost an average of $7.6 million per life. A 2009 study in five states found that
medical debt Medical debt refers to debt incurred by individuals due to health care costs and related expenses. Medical debt is different from other forms of debt, because it is usually incurred accidentally or faultlessly. People do not plan to fall ill or ...
contributed to 46.2% of all personal bankruptcies, and 62.1% of bankruptcy filers claimed high medical expenses in 2007. Since then, health costs and the numbers of uninsured and underinsured have increased. A 2013 study found that about 25% of all senior citizens declare bankruptcy due to medical expenses. In practice, the uninsured are often treated, but the cost is covered through taxes and other fees which shift the cost. Forgone medical care due to extensive cost sharing may ultimately increase costs due to downstream medical issues; this dynamic may play a part in United States' international ranking as having the highest health-care expenditures despite significant patient cost-sharing. Those who are insured may be underinsured such that they cannot afford adequate medical care. A 2003 study estimated that 16 million United States adults were underinsured, disproportionately affecting those with lower incomes – 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level. Lack of insurance or higher cost sharing (user fees for the patient with insurance) create barriers to accessing health care: use of care declines with increasing patient cost-sharing obligation. Before the ACA passed in 2014, 39% of below-average income Americans reported forgoing seeing a doctor for a medical issue (whereas 7% of low-income Canadians and 1% of low-income British citizens reported the same).


Health in the United States in global context

In 2019, the under-five child mortality rate was 6.5 deaths per 1000 live births, placing the United States 33rd of 37 OECD countries. In 2010-2012, more than 57,000 infants (52%) and children under 18 years died in the United States. While not as high in 2015 (14) as in 2013 (18.5), maternal deaths related to childbirth have shown recent increases; in 1987, the mortality ratio was 7.2 per 100,000. As of 2015, the American rate is double the maternal mortality rate in Belgium or Canada, and more than triple the rate in the Finland as well as several other Western European countries. Life expectancy at birth for a child born in the United States in 2015 is 81.2 (females) or 76.3 (males) years. According to the World Health Organization,
life expectancy Life expectancy is a statistical measure of the average time an organism is expected to live, based on the year of its birth, current age, and other demographic factors like sex. The most commonly used measure is life expectancy at birth ...
in the United States is 31st in the world (out of 183 countries) as of 2015. The United States' average life expectancy (both sexes) is just over 79. Japan ranks first with an average life expectancy of nearly 84 years. The United States ranks lower (36th) when considering health-adjusted life expectancy (HALE) at just over 69 years. Another source, the Central Intelligence Agency, indicates life expectancy at birth in the United States is 79.8, ranking it 42nd in the world. Monaco is first on this list of 224, with an average life expectancy of 89.5. A 2013 National Research Council study stated that, when considered as one of 17
high-income countries A high-income economy is defined by the World Bank as a nation with a gross national income per capita of US$12,696 or more in 2020, calculated using the Atlas method. While the term "high-income" is often used interchangeably with "First World" a ...
, the United States was at or near the top in infant mortality,
heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to ...
and
lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
disease,
sexually transmitted infection Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs) and the older term venereal diseases, are infections that are spread by sexual activity, especially vaginal intercourse, anal sex, and oral s ...
s, adolescent pregnancies, injuries, homicides, and rates of
disability Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be cognitive, developmental, intellectual, mental, physical, ...
. Together, such issues place the United States at the bottom of the list for life expectancy in high-income countries. Females born in the United States in 2015 have a life expectancy of 81.6 years, and males 76.9 years; more than 3 years less and as much as over 5 years less than people born in Switzerland (85.3 F, 81.3 M) or Japan (86.8 F, 80.5 M) in 2015.


Causes of mortality in the United States

The top three causes of death among both sexes and all ages in the United States have consistently remained cardiovascular diseases (ranked 1st), neoplasms (2nd) and neurological disorders (3rd), since the 1990s. In 2015, the total number of deaths by heart disease was 633,842, by cancer it was 595,930, and from chronic lower respiratory disease it was 155,041. In 2015, 267.18 deaths per 100,000 people were caused by cardiovascular diseases, 204.63 by neoplasms and 100.66 by neurological disorders. Diarrhea, lower respiratory and other common infections were ranked sixth overall, but had the highest rate of infectious disease mortality in the United States at 31.65 deaths per 100,000 people. There is evidence, however, that a large proportion of health outcomes and early mortality can be attributed to factors other than communicable or non-communicable disease. As a 2013 National Research Council study concluded, more than half the men who die before the age of 50 die due to murder (19%), traffic accidents (18%), and other accidents (16%). For women, the percentages are different: 53% of women who die before the age of 50 die due to disease, whereas 38% die due to accidents, homicide, and suicide.
Diseases of despair The diseases of despair are three classes of behavior-related medical conditions that increase in groups of people who experience despair due to a sense that their long-term social and economic prospects are bleak. The three disease types are dr ...
(drug overdoses, alcoholic liver disease and suicide), which started increasing in the early 1990s, kill roughly 158,000 Americans a year as of 2018. Since 2020, the CDC reports that the life expectancy for the U.S. population was 77.0 years, a decrease of 1.8 years from 2019.


Providers

Health care provider A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices. Health care providers often receive ...
s in the United States encompass individual health care personnel, health care facilities and medical products.


Facilities

In the United States, ownership of the healthcare system is mainly in private hands, though federal, state, county, and city governments also own certain facilities. As of 2018, there were 5,534 registered hospitals in the United States. There were 4,840 community hospitals, which are defined as nonfederal, short-term general, or specialty hospitals. The
non-profit hospital A non-profit hospital is a hospital that does not make profits for owners of the hospital from the funds collected for patient services. The owners of non-profit hospitals are often a charitable organization or non-profit corporations. Fees for s ...
s share of total hospital capacity has remained relatively stable (about 70%) for decades. There are also privately owned for-profit hospitals as well as government hospitals in some locations, mainly owned by county and city governments. The Hill-Burton Act was passed in 1946, which provided federal funding for hospitals in exchange for treating poor patients. The largest hospital system in 2016 by revenue was
HCA Healthcare HCA Healthcare is an American for-profit operator of health care facilities that was founded in 1968. It is based in Nashville, Tennessee, and, as of May 2020, owns and operates 186 hospitals and approximately 2,000 sites of care, including sur ...
; in 2019, Dignity Health and Catholic Health Initiatives merged into
CommonSpirit Health CommonSpirit Health is the largest Catholic health system, and the second-largest nonprofit hospital chain, in the United States (as of 2019). It operates more than 700 care sites and 142 hospitals in 21 states. Founded in 2019 by the merger of D ...
to create the largest by revenue, spanning 21 states.
Integrated delivery system An integrated delivery system (IDS), also known as integrated delivery network (IDN), is a health system with a goal of logical integration of the delivery (provision) of health care as opposed to a fragmented system or a disorganized lack of syste ...
s, where the provider and the insurer share the risk in an attempt to provide value-based healthcare, have grown in popularity. Regional areas have separate healthcare markets, and in some markets competition is limited as the demand from the local population cannot support multiple hospitals. About two-thirds of doctors practice in small offices with less than seven physicians, with over 80% owned by physicians; these sometimes join groups such as
independent practice association In the United States, an independent practice association (IPA) is an association of independent physicians, or other organizations that contracts with independent care delivery organizations, and provides services to managed care organizations on ...
s to increase bargaining power. There is no nationwide system of government-owned medical facilities open to the general public but there are local government-owned medical facilities open to the general public. The
U.S. Department of Defense The United States Department of Defense (DoD, USDOD or DOD) is an executive branch department of the federal government charged with coordinating and supervising all agencies and functions of the government directly related to national secur ...
operates field hospitals as well as permanent hospitals via the
Military Health System The Military Health System (MHS) is a form of nationalized health care operated within the United States Department of Defense that provides health care to active duty, Reserve component and retired U.S. Military personnel and their dependents. ...
to provide military-funded care to active military personnel. The federal
Veterans Health Administration The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the healthcare program of the VA through a nationa ...
operates VA hospitals open only to veterans, though veterans who seek medical care for conditions they did not receive while serving in the military are charged for services. The
Indian Health Service The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing direct medical and public health services to members of federally-recognized Nativ ...
(IHS) operates facilities open only to Native Americans from recognized tribes. These facilities, plus tribal facilities and privately contracted services funded by IHS to increase system capacity and capabilities, provide medical care to tribespeople beyond what can be paid for by any private insurance or other government programs.
Hospital A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emergency ...
s provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital
emergency department An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pat ...
s and
urgent care An urgent care center (UCC), also known as an urgent treatment centre in the United Kingdom, is a type of walk-in clinic focused on the delivery of urgent ambulatory care in a dedicated medical facility outside of a traditional emergency department ...
centers are sources of sporadic problem-focused care. Surgicenters are examples of specialty clinics.
Hospice Hospice care is a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life. Hospice care prioritizes comfort and quality of life by ...
services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal,
family planning Family planning is the consideration of the number of children a person wishes to have, including the choice to have no children, and the age at which they wish to have them. Things that may play a role on family planning decisions include marita ...
, and
dysplasia Dysplasia is any of various types of abnormal growth or development of cells (microscopic scale) or organs (macroscopic scale), and the abnormal histology or anatomical structure(s) resulting from such growth. Dysplasias on a mainly microscopic ...
clinics are government-funded
obstetric Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgic ...
and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners. Services, particularly urgent-care services, may also be delivered remotely via telemedicine by providers such as Teladoc. Besides government and private health care facilities, there are also 355 registered free clinics in the United States that provide limited medical services. They are considered to be part of the
social safety net The social safety net (SSN) consists of non-contributory assistance existing to improve lives of vulnerable families and individuals experiencing poverty and destitution. Examples of SSNs are previously-contributory social pensions, in-kind and fo ...
for those who lack health insurance. Their services may range from more acute care (i.e. STDs, injuries, respiratory diseases) to long term care (i.e. dentistry, counseling). Another component of the healthcare safety net would be federally funded community health centers. Other health care facilities include long-term housing facilities which as of 2019, there were 15,600 nursing homes across the United States, with a large portion of that number being for-profit (69.3%) In 2022 19 hospitals filed for bankruptcy, closed or announced plans to close.


Physicians (M.D. and D.O.)

Physicians in the U.S. include those trained by the U.S. medical education system, and those that are
international medical graduate An international medical graduate (IMG), earlier known as a foreign medical graduate (FMG), is a physician who has graduated from a medical school outside of the country where he or she intends to practice. The term non-local medical graduate may b ...
s who have progressed through the necessary steps to acquire a
medical license A medical license is an occupational license that permits a person to legally practice medicine. In most countries, a person must have a medical license bestowed either by a specified government-approved professional association or a governm ...
to practice in a state. This includes going through the three steps of the
United States Medical Licensing Examination The United States Medical Licensing Examination (USMLE) is a three-step examination program for medical licensure in the United States sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Ph ...
(USMLE). The first step of the USMLE tests whether medical students both understand and are capable of applying the basic scientific foundations to medicine after the second year of medical school. The topics include: anatomy, biochemistry,
microbiology Microbiology () is the scientific study of microorganisms, those being unicellular (single cell), multicellular (cell colony), or acellular (lacking cells). Microbiology encompasses numerous sub-disciplines including virology, bacteriology, p ...
, pathology, pharmacology, physiology,
behavioral sciences Behavioral sciences explore the cognitive processes within organisms and the behavioral interactions between organisms in the natural world. It involves the systematic analysis and investigation of human and animal behavior through naturalistic o ...
, nutrition,
genetics Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinian friar working i ...
, and aging. The second step is designed to test whether medical students can apply their medical skills and knowledge to actual clinical practice during students' fourth year of medical school. The third step is done after the first year of residency. It tests whether students can apply medical knowledge to the unsupervised practice of medicine. The
American College of Physicians The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults.Sokanu "What is an Internist?" Retrieved October 20, 2014 With 161,000 members, ACP is the largest ...
, uses the term "physician" to describe all medical practitioners holding a professional
medical degree A medical degree is a professional degree admitted to those who have passed coursework in the fields of medicine and/or surgery from an accredited medical school. Obtaining a degree in medicine allows for the recipient to continue on into special ...
. In the U.S., the vast majority of physicians have a
Doctor of Medicine Doctor of Medicine (abbreviated M.D., from the Latin ''Medicinae Doctor'') is a medical degree, the meaning of which varies between different jurisdictions. In the United States, and some other countries, the M.D. denotes a professional degree. T ...
(M.D.) degree. Those with
Doctor of Osteopathic Medicine Doctor of Osteopathic Medicine (DO or D.O., or in Australia DO USA) is a medical degree conferred by the 38 osteopathic medical schools in the United States. DO and Doctor of Medicine (MD) degrees are equivalent: a DO graduate may become licens ...
(D.O.) degrees get similar training and go through the same MLE steps as MD's and so are also allowed to use the title "physician".


Medical products, research and development

As in most other countries, the manufacture and production of
pharmaceuticals A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy (pharmacotherapy) is an important part of the medical field and r ...
and
medical devices A medical device is any device intended to be used for medical purposes. Significant potential for hazards are inherent when using a device for medical purposes and thus medical devices must be proved safe and effective with reasonable assura ...
is carried out by private companies. The research and development of medical devices and pharmaceuticals is supported by both public and private sources of funding. In 2003, research and development expenditures were approximately $95 billion with $40 billion coming from public sources and $55 billion coming from private sources.Medical Research Spending Doubled Over Past Decade
Neil Osterweil, MedPage Today, September 20, 2005
These investments into medical research have made the United States the leader in medical innovation, measured either in terms of revenue or the number of new drugs and devices introduced.Stats from 2007 Europ.Fed.of Pharm.Indust.and Assoc. Retrieved June 17, 2009, fro

/ref> In 2016 the research and development spending by pharmaceutical companies in the U.S. was estimated to be around 59 billion dollars. In 2006, the United States accounted for three quarters of the world's biotechnology revenues and 82% of world R&D spending in biotechnology. According to multiple international
pharmaceutical A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy (pharmacotherapy) is an important part of the medical field and ...
trade groups, the high cost of patented drugs in the U.S. has encouraged substantial reinvestment in such research and development. Though the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
will force industry to sell medicine at a cheaper price. Due to this, it is possible budget cuts will be made on research and development of human health and medicine in America.


Healthcare provider employment in the United States

A major impending demographic shift in the United States will require the healthcare system to provide more care, as the older population is predicted to increase medical expenses by 5% or more in North America due to the "baby boomers" reaching retirement age. The overall spending on health care has increased since the late 1990s, and not just due to general price raises as the rate of spending is growing faster than the rate of inflation. Moreover, the expenditure on health services for people over 45 years old is 8.3 times the maximum of that of those under 45 years old.


Alternative medicine

Other methods of
medical treatment A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis. As a rule, each therapy has indications and contraindications. There are many different ...
are being practiced more frequently than before. This field is labeled
Complementary and Alternative Medicine Alternative medicine is any practice that aims to achieve the healing effects of medicine despite lacking biological plausibility, testability, repeatability, or evidence from clinical trials. Complementary medicine (CM), complementary and alt ...
(CAM) and are defined as therapies generally not taught in
medical school A medical school is a tertiary educational institution, or part of such an institution, that teaches medicine, and awards a professional degree for physicians. Such medical degrees include the Bachelor of Medicine, Bachelor of Surgery (MBBS, MB ...
nor available in hospitals. They include
herbs In general use, herbs are a widely distributed and widespread group of plants, excluding vegetables and other plants consumed for macronutrients, with savory or aromatic properties that are used for flavoring and garnishing food, for medicinal ...
, massages, energy healing,
homeopathy Homeopathy or homoeopathy is a pseudoscientific system of alternative medicine. It was conceived in 1796 by the German physician Samuel Hahnemann. Its practitioners, called homeopaths, believe that a substance that causes symptoms of a dise ...
,
faith healing Faith healing is the practice of prayer and gestures (such as laying on of hands) that are believed by some to elicit divine intervention in spiritual and physical healing, especially the Christian practice. Believers assert that the healing ...
, and, more recently popularized,
cryotherapy Cryotherapy, sometimes known as cold therapy, is the local or general use of low temperatures in medical therapy. Cryotherapy may be used to treat a variety of tissue lesions. The most prominent use of the term refers to the surgical treatment, ...
, cupping, and
Transcranial Magnetic Stimulation Transcranial magnetic stimulation (TMS) is a noninvasive form of brain stimulation in which a changing magnetic field is used to induce an electric current at a specific area of the brain through electromagnetic induction. An electric pulse gener ...
or TMS. Providers of these CAM treatments are sometimes legally considered healthcare providers in the US. Common reasons for seeking these alternative approaches included improving their well-being, engaging in a transformational experience, gaining more control over their own health, or finding a better way to relieve symptoms caused by chronic disease. They aim to treat not just physical illness but fix its underlying nutritional, social, emotional, and spiritual causes. In a 2008 survey, it was found that 37% of hospitals in the U.S. offer at least one form of CAM treatment, the main reason being patient demand (84% of hospitals). Costs for CAM treatments average $33.9 with two-thirds being out-of-pocket, according to a 2007 statistical analysis. Moreover, CAM treatments covered 11.2% of total out-of-pocket payments on health care. During 2002 to 2008, spending on CAM was on the rise, but usage has since plateaued to about 40% of adults in the U.S.


Spending

The U.S. spends more as a percentage of GDP than similar countries, and this can be explained either through higher prices for services themselves, higher costs to administer the system, or more utilization of these services, or to a combination of these elements.Free full-text
Health care costs rising far faster than inflation have been a major driver for
health care reform in the United States Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordab ...
. As of 2016, the US spent $3.3 trillion (17.9% of GDP), or $10,438 per person; major categories included 32% on hospital care, 20% on physician and clinical services, and 10% on prescription drugs. In comparison, the UK spent $3,749 per person. In 2018, an analysis concluded that prices and administrative costs were largely the cause of the high costs, including prices for labor, pharmaceuticals, and diagnostics. The combination of high prices and high volume can cause particular expense; in the U.S., high-margin high-volume procedures include angioplasties, c-sections,
knee replacement Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources a ...
s, and CT and MRI scans; CT and MRI scans also showed higher utilization in the United States. Aggregate U.S. hospital costs were $387.3 billion in 2011 – a 63% increase since 1997 (inflation adjusted). Costs per stay increased 47% since 1997, averaging $10,000 in 2011.Pfuntner A., Wier L.M., Elixhauser A. Overview of Hospital Stays in the United States, 2011. HCUP Statistical Brief #166. November 2013. Agency for Healthcare Research and Quality, Rockville, MD

.
As of 2008, public spending accounts for between 45% and 56% of U.S. health care spending.Thomas M. Selden and Merrile Sing
"The Distribution Of Public Spending For Health Care In The United States, 2002,"
Health Affairs ''Health Affairs'' is a monthly peer-reviewed healthcare journal established in 1981 by John K. Iglehart; since 2014, the editor-in-chief is Alan Weil. It was described by ''The Washington Post'' as "the bible of health policy". Abstracting a ...
27, no. 5 (2008): w349–59 (published online July 29, 2008)
Surgical, injury, and maternal and neonatal health hospital visit costs increased by more than 2% each year from 2003–2011. Further, while average hospital discharges remained stable, hospital costs rose from $9,100 in 2003 to $10,600 in 2011, and were projected to be $11,000 by 2013. According to the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO), total health care spending in the U.S. was 18% of its
GDP Gross domestic product (GDP) is a monetary measure of the market value of all the final goods and services produced and sold (not resold) in a specific time period by countries. Due to its complex and subjective nature this measure is ofte ...
in 2011, the highest in the world. The Health and Human Services Department expects that the health share of GDP will continue its historical upward trend, reaching 19% of GDP by 2017."National Health Expenditure Data: NHE Fact Sheet,"
Centers for Medicare and Medicaid Services The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
, referenced February 26, 2008
Of each dollar spent on health care in the United States, 31% goes to hospital care, 21% goes to physician/clinical services, 10% to pharmaceuticals, 4% to dental, 6% to
nursing home A nursing home is a facility for the residential care of elderly or disabled people. Nursing homes may also be referred to as skilled nursing facility (SNF) or long-term care facilities. Often, these terms have slightly different meanings to in ...
s and 3% to home health care, 3% for other retail products, 3% for government public health activities, 7% to administrative costs, 7% to investment, and 6% to other professional services (physical therapists, optometrists, etc.). In 2017, a study estimated that nearly half of hospital-associated care resulted from
emergency department An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pat ...
visits. As of 2017, data from 2009-2011 showed that
end-of-life care End-of-life care (EoLC) refers to health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotio ...
in the last year of life accounted for about 8.5%, and the last three years of life about 16.7%. As of 2013, administration of health care constituted 30 percent of U.S. health-care costs. Free-market advocates claim that the health care system is "dysfunctional" because the system of third-party payments from insurers removes the patient as a major participant in the financial and medical choices that affect costs. The Cato Institute claims that because government intervention has expanded insurance availability through programs such as Medicare and Medicaid, this has exacerbated the problem. According to a study paid for by
America's Health Insurance Plans AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual m ...
(a Washington lobbyist for the health insurance industry) and carried out by PriceWaterhouseCoopers, increased utilization is the primary driver of rising health care costs in the U.S.The Factors Fueling Rising Healthcare Costs 2006
, PriceWaterhouseCoopers for America's Health Insurance Plans, 2006. Retrieved October 8, 2007.
The study cites numerous causes of increased utilization, including rising consumer demand, new treatments, more intensive diagnostic testing, lifestyle factors, the movement to broader-access plans, and higher-priced technologies. The study also mentions cost-shifting from government programs to private payers. Low reimbursement rates for Medicare and Medicaid have increased cost-shifting pressures on hospitals and doctors, who charge higher rates for the same services to private payers, which eventually affects health insurance rates. In March 2010, Massachusetts released a report on the cost drivers which it called "unique in the nation".Health Care Cost Trends
Massachusetts Office of Health and Human Services. Se
Appendix B: Preliminary Report of the Massachusetts Attorney General (PDF)
pp. 1–2, for quote and summary.
The report noted that providers and insurers negotiate privately, and therefore the prices can vary between providers and insurers for the same services, and it found that the variation in prices did not vary based on quality of care but rather on market leverage; the report also found that price increases rather than increased utilization explained the spending increases in the past several years. Economists Eric Helland and Alex Tabarrok speculate that the increase in costs of healthcare in the United States are largely a result of the Baumol effect. Since healthcare is relatively labor intensive, and productivity in the service sector has lagged that in the goods-producing sector, the costs of those services will rise relative to goods.


Regulation and oversight


Involved organizations and institutions

Healthcare is subject to extensive regulation at both the federal and the state level, much of which "arose haphazardly". Under this system, the federal government cedes primary responsibility to the states under the McCarran-Ferguson Act. Essential regulation includes the
licensure Licensure means a restricted practice or a restriction on the use of an occupational title, requiring a license. A license created under a "practice act" requires a license before performing a certain activity, such as driving a car on public roa ...
of
health care provider A health care provider is an individual health professional or a health facility organization licensed to provide health care diagnosis and treatment services including medication, surgery and medical devices. Health care providers often receive ...
s at the state level and the testing and approval of pharmaceuticals and medical devices by the
U.S. Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food s ...
(FDA), and laboratory testing. These regulations are designed to protect consumers from ineffective or fraudulent healthcare. Additionally, states regulate the health insurance market and they often have laws which require that health insurance companies cover certain procedures,Victoria Craig Bunce and JP Wieske
"Health Insurance Mandates in the States 2008"
The Council for Affordable Health Insurance, 2008
although state mandates generally do not apply to the
self-funded health care Self-funded health care, also known as Administrative Services Only (ASO), is a self insurance arrangement in the United States whereby an employer provides health or disability benefits to employees using the company's own funds.About.com > What ...
plans offered by large employers, which exempt from state laws under preemption clause of the
Employee Retirement Income Security Act The Employee Retirement Income Security Act of 1974 (ERISA) (, codified in part at ) is a U.S. federal tax and labor law that establishes minimum standards for pension plans in private industry. It contains rules on the federal income tax ef ...
. In 2010, the Affordable Care Act was signed by President
Barack Obama Barack Hussein Obama II ( ; born August 4, 1961) is an American politician who served as the 44th president of the United States from 2009 to 2017. A member of the Democratic Party, Obama was the first African-American president of the U ...
and includes various new regulations, with one of the most notable being a
health insurance mandate A health insurance mandate is either an employer or individual mandate to obtain private health insurance instead of (or in addition to) a national health insurance plan.D. Andrew Austin, Thomas L. Hungerford (2010). Market Structure of the He ...
which requires all citizens to purchase health insurance. While not regulation per se, the federal government also has a major influence on the healthcare market through its payments to providers under Medicare and Medicaid, which in some cases are used as a reference point in the negotiations between medical providers and insurance companies. At the federal level,
U.S. Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government created to protect the health of all Americans and providing essential human services. Its motto is ...
oversees the various federal agencies involved in health care. The health agencies are a part of the
U.S. Public Health Service The United States Public Health Service (USPHS or PHS) is a collection of agencies of the Department of Health and Human Services concerned with public health, containing nine out of the department's twelve operating divisions. The Assistant ...
, and include the Food and Drug Administration, which certifies the safety of food, effectiveness of drugs and medical products, the Centers for Disease Prevention, which prevents disease, premature death, and disability, the Agency of Health Care Research and Quality, the Agency Toxic Substances and Disease Registry, which regulates hazardous spills of toxic substances, and the National Institutes of Health, which conducts
medical research Medical research (or biomedical research), also known as experimental medicine, encompasses a wide array of research, extending from " basic research" (also called ''bench science'' or ''bench research''), – involving fundamental scienti ...
.
State governments A state government is the government that controls a subdivision of a country in a federal form of government, which shares political power with the federal or national government. A state government may have some level of political autonomy, o ...
maintain state health departments, and
local governments Local government is a generic term for the lowest tiers of public administration within a particular sovereign state. This particular usage of the word government refers specifically to a level of administration that is both geographically-l ...
( counties and
municipalities A municipality is usually a single administrative division having corporate status and powers of self-government or jurisdiction as granted by national and regional laws to which it is subordinate. The term ''municipality'' may also mean the go ...
) often have their own health departments, usually branches of the state health department. Regulations of a state board may have executive and police strength to enforce state health laws. In some states, all members of state boards must be health care professionals. Members of state boards may be assigned by the governor or elected by the state committee. Members of local boards may be elected by the mayor council. The McCarran–Ferguson Act, which cedes regulation to the states, does not itself regulate insurance, nor does it mandate that states regulate insurance. "Acts of Congress" that do not expressly purport to regulate the "business of insurance" will not preempt state laws or regulations that regulate the "business of insurance." The Act also provides that federal anti-trust laws will not apply to the "business of insurance" as long as the state regulates in that area, but federal anti-trust laws will apply in cases of boycott, coercion, and intimidation. By contrast, most other federal laws will not apply to insurance whether the states regulate in that area or not. Self-policing of providers by providers is a major part of oversight. Many health care organizations also voluntarily submit to inspection and certification by the
Joint Commission The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majorit ...
on Accreditation of Hospital Organizations, JCAHO. Providers also undergo testing to obtain
board certification Board certification is the process by which a physician or other professional demonstrates a mastery of advanced knowledge and skills through written, practical, or simulator-based testing. Certification bodies There are more than 25 boards that ...
attesting to their skills. A report issued by
Public Citizen Public Citizen is a non-profit, progressive consumer rights advocacy group and think tank based in Washington, D.C., United States, with a branch in Austin, Texas. Lobbying efforts Public Citizen advocates before all three branches of the United ...
in April 2008 found that, for the third year in a row, the number of serious disciplinary actions against physicians by state medical boards declined from 2006 to 2007, and called for more oversight of the boards. The federal
Centers for Medicare and Medicaid Services The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
(CMS) publishes an on-line searchable database of performance data on
nursing homes A nursing home is a facility for the residential care of elderly or disabled people. Nursing homes may also be referred to as skilled nursing facility (SNF) or long-term care facilities. Often, these terms have slightly different meanings to in ...
. In 2004, libertarian think tank
Cato Institute The Cato Institute is an American libertarian think tank headquartered in Washington, D.C. It was founded in 1977 by Ed Crane, Murray Rothbard, and Charles Koch, chairman of the board and chief executive officer of Koch Industries.Koch Indus ...
published a study which concluded that regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion. The study concluded that the majority of the cost differential arises from
medical malpractice Medical malpractice is a legal cause of action that occurs when a medical or health care professional, through a negligent act or omission, deviates from standards in their profession, thereby causing injury or death to a patient. The negligen ...
, FDA regulations, and facilities regulations.


"Certificates of need" for hospitals

In 1978, the federal government required that all states implement Certificate of Need (CON) programs for cardiac care, meaning that hospitals had to apply and receive certificates prior to implementing the program; the intent was to reduce cost by reducing duplicate investments in facilities. It has been observed that these certificates could be used to increase costs through weakened competition.Improving Health Care: A Dose of Competition
Report by the Federal Trade Commission and the Department of Justice, 2004
Many states removed the CON programs after the federal requirement expired in 1986, but some states still have these programs. Empirical research looking at the costs in areas where these programs have been discontinued have not found a clear effect on costs, and the CON programs could decrease costs because of reduced facility construction or increase costs due to reduced competition.


Licensing of providers

The
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's st ...
(AMA) has lobbied the government to highly limit physician education since 1910, currently at 100,000 doctors per year, which has led to a shortage of doctors. An even bigger problem may be that the doctors are paid for procedures instead of results.Sending Back the Doctor's Bill
''The New York Times'' July 29, 2007
The AMA has also aggressively lobbied for many restrictions that require doctors to carry out operations that might be carried out by cheaper workforce. For example, in 1995, 36 states banned or restricted midwifery even though it delivers equally safe care to that by doctors. The regulation lobbied by the AMA has decreased the amount and quality of health care, according to the consensus of economist: the restrictions do not add to quality, they decrease the supply of care. Moreover, psychologists, nurses and pharmacists are not allowed to prescribe medicines. Previously nurses were not even allowed to vaccinate the patients without direct supervision by doctors. 36 states require that healthcare workers undergo criminal background checks.


Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured, but established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. More than half of all emergency care in the U.S. now goes uncompensated.The Uninsured: Access to Medical Care
, American College of Emergency Physicians. Retrieved October 30, 2007.
According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the
Institute of Medicine The National Academy of Medicine (NAM), formerly called the Institute of Medicine (IoM) until 2015, is an American nonprofit, non-governmental organization. The National Academy of Medicine is a part of the National Academies of Sciences, Eng ...
, between 1993 and 2003, emergency room visits in the U.S. grew by 26%, while in the same period, the number of emergency departments declined by 425.Fact Sheet: The Future of Emergency Care: Key Findings and Recommendations
, Institute of Medicine, 2006. Retrieved October 7, 2007.
Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, mentally ill patients who enter emergency rooms are evaluated for emergency medical conditions. Once mentally ill patients are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated as to whether they are a danger to themselves or others. Those meeting this criterion are admitted to a mental health facility to be further evaluated by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is required.


Quality assurance

Health care quality assurance consists of the "activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps." Private companies such as
Grand Rounds Grand rounds are a methodology of medical education and inpatient care, consisting of presenting the medical problems and treatment of a particular patient to an audience consisting of doctors, pharmacists, residents, and medical students. It wa ...
also release quality information and offer services to employers and plans to map quality within their networks. One innovation in encouraging quality of health care is the public reporting of the performance of hospitals, health professionals or providers, and healthcare organizations. However, there is "no consistent evidence that the public release of performance data changes consumer behaviour or improves care."


Overall system effectiveness


Measures of effectiveness

The US health care delivery system unevenly provides medical care of varying quality to its population. In a highly effective health care system, individuals would receive reliable care that meets their needs and is based on the best scientific knowledge available. In order to monitor and evaluate system effectiveness, researchers and policy makers track system measures and trends over time. The
US Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government created to protect the health of all Americans and providing essential human services. Its motto is " ...
(HHS) populates a publicly available dashboard called the Health System Measurement Project (healthmeasures.aspe.hhs.gov), to ensure a robust monitoring system. The dashboard captures the access, quality and cost of care; overall population health; and health system dynamics (e.g., workforce, innovation, health information technology). Included measures align with other system performance measuring activities including the HHS Strategic Plan, the
Government Performance and Results Act The Government Performance and Results Act of 1993 (GPRA) () is a United States law enacted in 1993,Congress, U. S., and An Act. "Government Performance and Results Act of 1993." In ''103rd Congress. Congressional Record''. 1993. one of a series o ...
, Healthy People 2020, and the National Strategies for Quality and Prevention.


Waiting times

Waiting times in American health care are usually short, but are not usually 0 for non-urgent care at least. Also, a minority of American patients wait longer than is perceived. In a 2010 Commonwealth Fund survey, most Americans self-reported waiting less than four weeks for their most recent specialist appointment and less than one month for elective surgery. However, about 30% of patients reported waiting longer than one month for elective surgery, and about 20% longer than four weeks for their most recent specialist appointment. These percentages were smaller than in France, the U.K., New Zealand and Canada, but not better than Germany and Switzerland (although waits shorter than four weeks/one month may not be equally long across these three countries). The number of respondents may not be enough to be fully representative. In a study in 1994 comparing Ontario to three regions of the U.S., self-reported mean wait times to see an orthopedic surgeon were two weeks in those parts of the U.S., and four weeks in Canada. Mean waits for the knee or hip surgery were self-reported as three weeks in those parts of the U.S. and eight weeks in Ontario. However, current waits in both countries' regions may have changed since then (certainly in Canada waiting times went up later). More recently, at one Michigan hospital, the waiting time for the elective surgical operation open carpel tunnel release was an average of 27 days, most ranging from 17-37 days (an average of almost 4 weeks, ranging from about 2.4 weeks to 5.3 weeks). This appears to be short compared with Canada's waiting time, but may compare less favorably to countries like Germany, the Netherlands (where the goal was 5 weeks), and Switzerland. It is unclear how many of the patients waiting longer have to. Some may be by choice, because they wish to go to a well-known specialist or clinic that many people wish to attend, and are willing to wait to do so. Waiting times may also vary by region. One experiment reported that uninsured patients experienced longer waits; patients with poor insurance coverage probably face a disproportionate number of long waits. American health care tends to rely on
rationing Rationing is the controlled distribution of scarce resources, goods, services, or an artificial restriction of demand. Rationing controls the size of the ration, which is one's allowed portion of the resources being distributed on a particular ...
by exclusion (uninsured and underinsured), out-of-pocket costs for the insured, fixed payments per case to hospitals (resulting in very short stays), and contracts that manage demand instead.


Population health: quality, prevention, vulnerable populations

The health of the population is also viewed as a measure of the overall effectiveness of the healthcare system. The extent to which the population lives longer healthier lives signals an effective system. * While life expectancy is one measure,
United States Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government created to protect the health of all Americans and providing essential human services. Its motto is ...
uses a composite health measure that estimates not only the average length of life, but also, the part of life expectancy that is expected to be "in good or better health, as well as free of activity limitations." Between 1997 and 2010, the number of expected high quality life years increased from 61.1 to 63.2 years for newborns. * The underutilization of preventative measures, rates of preventable illness and prevalence of chronic disease suggest that the US healthcare system does not sufficiently promote wellness. Over the past decade rates of teen pregnancy and low birth rates have come down significantly, but not disappeared. Rates of obesity, heart disease (high blood pressure, controlled high cholesterol), and type 2 diabetes are areas of major concern. While chronic disease and multiple co-morbidities became increasingly common among a population of elderly Americans who were living longer, the public health system has also found itself fending off a rise of chronically ill younger generation. According to the US Surgeon General "The prevalence of obesity in the U.S. more than doubled (from 15% to 34%) among adults and more than tripled (from 5% to 17%) among children and adolescents from 1980 to 2008." * A concern for the health system is that the health gains do not accrue equally to the entire population. In the United States, disparities in health care and health outcomes are widespread. Minorities are more likely to develop serious illnesses (e.g., type 2 diabetes, heart disease and colon cancer) and less likely to have access to quality health care, including preventative services. Efforts are underway to close the gap and to provide a more equitable system of care.


Innovation: workforce, healthcare IT, R&D

Finally, the United States tracks investment in the healthcare system in terms of a skilled healthcare workforce, meaningful use of healthcare IT, and R&D output. This aspect of the healthcare system performance dashboard is important to consider when evaluating cost of care in America. That is because in much of the policy debate around the high cost of US healthcare, proponents of highly specialized and cutting-edge technologies point to innovation as a marker of an effective health care system.


Compared to other countries

A 2014 study by the private American foundation
The Commonwealth Fund The Commonwealth Fund is a private U.S. foundation whose stated purpose is to "promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, includ ...
found that although the U.S. health care system is the most expensive in the world, it ranks last on most dimensions of performance when compared with Australia, Canada, France, Germany, the Netherlands,
New Zealand New Zealand ( mi, Aotearoa ) is an island country in the southwestern Pacific Ocean. It consists of two main landmasses—the North Island () and the South Island ()—and over 700 smaller islands. It is the sixth-largest island country ...
,
Norway Norway, officially the Kingdom of Norway, is a Nordic country in Northern Europe, the mainland territory of which comprises the western and northernmost portion of the Scandinavian Peninsula. The remote Arctic island of Jan Mayen and th ...
,
Sweden Sweden, formally the Kingdom of Sweden,The United Nations Group of Experts on Geographical Names states that the country's formal name is the Kingdom of SwedenUNGEGN World Geographical Names, Sweden./ref> is a Nordic country located on ...
,
Switzerland ). Swiss law does not designate a ''capital'' as such, but the federal parliament and government are installed in Bern, while other federal institutions, such as the federal courts, are in other cities (Bellinzona, Lausanne, Luzern, Neuchâtel ...
and the
United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and Nor ...
. The study found that the United States failed to achieve better outcomes than other countries, and is last or near last in terms of access, efficiency and equity. Study data came from international surveys of patients and
primary care physicians Primary or primaries may refer to: Arts, entertainment, and media Music Groups and labels * Primary (band), from Australia * Primary (musician), hip hop musician and record producer from South Korea * Primary Music, Israeli record label Work ...
, as well as information on health care outcomes from The Commonwealth Fund, the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
, and the
Organisation for Economic Co-operation and Development The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate e ...
. As of 2017, the U.S. stands 43rd in the world with a life expectancy of 80.00 years. The
CIA World Factbook ''The World Factbook'', also known as the ''CIA World Factbook'', is a reference resource produced by the Central Intelligence Agency (CIA) with almanac-style information about the countries of the world. The official print version is availabl ...
ranked the United States 170th worst (out of 225) – meaning 55th best – in the world for infant mortality rate (5.80/1,000 live births). Americans also undergo cancer screenings at significantly higher rates than people in other developed countries, and access
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
and CT scans at the highest rate of any OECD nation. A study found that between 1997 and 2003, preventable deaths declined more slowly in the United States than in 18 other industrialized nations. A 2008 study found that 101,000 people a year die in the U.S. that would not if the health care system were as effective as that of France, Japan, or Australia. A 2020 study by the economists
Anne Case Anne Catherine Case, Lady Deaton, (born July 27, 1958) is an American economist who is currently the Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus, at Princeton University. Early life and career She graduated from ...
and
Angus Deaton Sir Angus Stewart Deaton (born 19 October 1945) is a British economist and academic. Deaton is currently a Senior Scholar and the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at the Princeton School of Public ...
argues that the United States "spends huge sums of money for some of the worst health outcomes in the Western world." The
Organisation for Economic Co-operation and Development The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate e ...
(OECD) found that the U.S. ranked poorly in terms of
years of potential life lost Years of potential life lost (YPLL) or potential years of life lost (PYLL), is an estimate of the average years a person would have lived if they had not died prematurely. It is, therefore, a measure of premature mortality. As an alternative to de ...
(YPLL), a statistical measure of years of life lost under the age of 70 that were amenable to being saved by health care. Among OECD nations for which data are available, the United States ranked third last for the health care of women (after Mexico and Hungary) and fifth last for men (Slovakia and Poland also ranked worse). Recent studies find growing gaps in life expectancy based on income and geography. In 2008, a government-sponsored study found that life expectancy declined from 1983 to 1999 for women in 180 counties, and for men in 11 counties, with most of the life expectancy declines occurring in the Deep South, Appalachia, along the Mississippi River, in the Southern Plains and in Texas. The difference is as high as three years for men, six years for women. The gap is growing between rich and poor and by educational level, but narrowing between men and women and by race. Another study found that the mortality gap between the well-educated and the poorly educated widened significantly between 1993 and 2001 for adults ages 25 through 64; the authors speculated that risk factors such as smoking, obesity and high blood pressure may lie behind these disparities. In 2011 the
U.S. National Research Council The National Academies of Sciences, Engineering, and Medicine (also known as NASEM or the National Academies) are the collective scientific national academy of the United States. The name is used interchangeably in two senses: (1) as an umbrell ...
forecasted that deaths attributed to smoking, on the decline in the US, will drop dramatically, improving life expectancy; it also suggested that one-fifth to one-third of the life expectancy difference can be attributed to obesity which is the worst in the world and has been increasing. In an analysis of
breast cancer Breast cancer is cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a r ...
,
colorectal cancer Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel m ...
, and
prostate cancer Prostate cancer is cancer of the prostate. Prostate cancer is the second most common cancerous tumor worldwide and is the fifth leading cause of cancer-related mortality among men. The prostate is a gland in the male reproductive system that sur ...
diagnosed during 1990–1994 in 31 countries, the U.S. had the highest five-year relative survival rate for breast cancer and prostate cancer, although survival was systematically and substantially lower in black U.S. men and women. The debate about U.S. health care concerns questions of access, efficiency, and quality purchased by the high sums spent. The
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO) in 2000 ranked the U.S. health care system first in responsiveness, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).World Health Organization assesses the world's health system
Press Release WHO/44 21 June 2000.
The WHO study has been criticized by the free market advocate
David Gratzer David George Gratzer (born September 5, 1974) is a physician, columnist, author, Congressional expert witness; he was a senior fellow at both the Manhattan Institute and the Montreal Economic Institute. Though he has written essays on topics as div ...
because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment.
David Gratzer David George Gratzer (born September 5, 1974) is a physician, columnist, author, Congressional expert witness; he was a senior fellow at both the Manhattan Institute and the Montreal Economic Institute. Though he has written essays on topics as div ...

Why Isn't Government Health Care The Answer?
, ''Free Market Cure'', July 16, 2007
The WHO study has been criticized, in an article published in ''Health Affairs'', for its failure to include the satisfaction ratings of the general public.Robert J. Blendon, Minah Kim and John M. Benson
"The Public Versus The World Health Organization On Health System Performance,"
Health Affairs, May/June 2001
The study found that there was little correlation between the WHO rankings for health systems and the stated satisfaction of citizens using those systems. Countries such as Italy and Spain, which were given the highest ratings by WHO were ranked poorly by their citizens while other countries, such as Denmark and Finland, were given low scores by WHO but had the highest percentages of citizens reporting satisfaction with their health care systems. WHO staff, however, say that the WHO analysis does reflect system "responsiveness" and argue that this is a superior measure to consumer satisfaction, which is influenced by expectations. Furthermore, the relationship between patient satisfaction and health care utilization, expenditures, clinically meaningful measures, and the evaluation of outcomes is complex, not well defined, and only beginning to be explored. A report released in April 2008 by the
Foundation for Child Development The Foundation for Child Development is a United States-based non-profit organization which promotes good child development. History and name The organization began as a volunteer community project in 1899, then in 1908 was established as the As ...
, which studied the period from 1994 through 2006, found mixed results for the health of children in the U.S. Mortality rates for children ages 1 through 4 dropped by a third, and the percentage of children with elevated blood lead levels dropped by 84%. The percentage of mothers who smoked during pregnancy also declined. On the other hand, both obesity and the percentage of low-birth weight babies increased. The authors note that the increase in babies born with low birth weights can be attributed to women delaying childbearing and the increased use of fertility drugs. In a sample of 13 developed countries the US was third in its population weighted usage of medication in 14 classes in both 2009 and 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use. A critic of the U.S. health care system, British philanthropist
Stan Brock Stanley James Brock (born June 8, 1958) is a former American football player and coach. He played as a tackle at the University of Colorado at Boulder and in the National Football League for the New Orleans Saints and the San Diego Chargers. B ...
, whose charity
Remote Area Medical Remote Area Medical (RAM) is a non-profit provider of mobile medical clinics delivering free dental, vision, and medical care (as well as veterinary services when available) to under-served and uninsured individuals. Founded by British philanthro ...
has served over half a million uninsured Americans, stated, "You could be blindfolded and stick a pin on a map of America and you will find people in need." The charity has over 700 clinics and 80,000 volunteer doctors and nurses around the U.S. Simon Usborne of ''The Independent'' writes that in the UK "General practitioners are amazed to hear that poor Americans should need to rely on a charity that was originally conceived to treat people in the developing world."


System efficiency and equity

Variations in the efficiency of health care delivery can cause variations in outcomes. The Dartmouth Atlas Project, for instance, reported that, for over 20 years, marked variations in how medical resources are distributed and used in the United States were accompanied by marked variations in outcomes. The willingness of physicians to work in an area varies with the income of the area and the amenities it offers, a situation aggravated by a general shortage of doctors in the United States, particularly those who offer primary care. The Affordable Care Act is anticipated to produce an additional demand for services which the existing stable of primary care doctors will be unable to fill, particularly in economically depressed areas. Training additional physicians would require some years. Lean manufacturing techniques such as
value stream mapping Value-stream mapping, also known as "material- and information-flow mapping", is a lean-management method for analyzing the current state and designing a future state for the series of events that take a product or service from the beginning of ...
can help identify and subsequently mitigate waste associated with costs of healthcare. Other product engineering tools such as FMEA and Fish Bone Diagrams have been used to improve efficiencies in healthcare delivery. Since 2004 the Commonwealth Fund has produced reports comparing healthcare systems in high income countries using survey and administrative data from the
Organisation for Economic Co-operation and Development The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate e ...
and the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
which is analyzed under 5 themes: access to care, the care process, administrative efficiency, equity and health-care outcomes. The United States has been assessed as worst health-care system overall among 11 high-income countries in every report, even though it spends the highest proportion of its gross domestic product on health care. In 2021 Norway, the Netherlands and Australia were the top-performing countries. The United States spent 16.8% of GDP on health care in 2019; the next highest country on the list was Switzerland, at 11.3% of GDP. The lowest was New Zealand, which spent roughly 9% of its GDP on health care in 2019. It "consistently demonstrated the largest disparities between income groups" across indicators, apart from those related to preventive services and the safety of care.


Efficiency


Preventable deaths

In 2010, coronary artery disease,
lung cancer Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, malignan ...
,
stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop funct ...
,
chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce m ...
s, and traffic accidents caused the most years of life lost in the US. Low back pain, depression,
musculoskeletal disorder Musculoskeletal disorders (MSDs) are injuries or pain in the human musculoskeletal system, including the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back. MSDs can arise from a sudden exertion (e.g., li ...
s, neck pain, and
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
caused the most years lost to disability. The most deleterious
risk factor In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection. Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often us ...
s were poor diet, tobacco smoking, obesity,
high blood pressure Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high b ...
,
high blood sugar Hyperglycemia is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/L (200  mg/dL), but symptoms may not start to become noticeable until even ...
, physical inactivity, and alcohol use.
Alzheimer's disease Alzheimer's disease (AD) is a neurodegenerative disease that usually starts slowly and progressively worsens. It is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As ...
, drug abuse, kidney disease and cancer, and falls caused the most additional years of life lost over their age-adjusted 1990 per-capita rates. Between 1990 and 2010, among the 34 countries in the OECD, the US dropped from 18th to 27th in age-standardized death rate. The US dropped from 23rd to 28th for age-standardized years of life lost. It dropped from 20th to 27th in life expectancy at birth. It dropped from 14th to 26th for healthy life expectancy. According to a 2009 study conducted at
Harvard Medical School Harvard Medical School (HMS) is the graduate medical school of Harvard University and is located in the Longwood Medical and Academic Area, Longwood Medical Area of Boston, Massachusetts. Founded in 1782, HMS is one of the oldest medical schools ...
by co-founders of
Physicians for a National Health Program Physicians for a National Health Program (PNHP) is an advocacy organization of more than 20,000 American physicians, medical students, and health professionals that supports a universal, comprehensive single-payer national health insurance program. ...
, a pro-single payer lobbying group, and published by the ''
American Journal of Public Health The ''American Journal of Public Health'' is a monthly peer-reviewed public health journal published by the American Public Health Association that covers health policy and public health. The journal was established in 1911 and its stated missio ...
'', lack of health coverage is associated with nearly 45,000 excess preventable deaths annually. Since then, as the number of uninsured has risen from about 46 million in 2009 to 49 million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year. The group's methodology has been criticized by economist John C. Goodman for not looking at cause of death or tracking insurance status changes over time, including the time of death. A 2009 study by former Clinton policy adviser Richard Kronick published in the journal
Health Services Research Health services research (HSR) became a burgeoning field in North America in the 1960s, when scientific information and policy deliberation began to coalesce. Sometimes also referred to as health systems research or health policy and systems resear ...
found no increased mortality from being uninsured after certain risk factors were controlled for.


Value for money

A study of international health care spending levels published in the health policy journal ''
Health Affairs ''Health Affairs'' is a monthly peer-reviewed healthcare journal established in 1981 by John K. Iglehart; since 2014, the editor-in-chief is Alan Weil. It was described by ''The Washington Post'' as "the bible of health policy". Abstracting a ...
'' in the year 2000 found that the United States spends substantially more on health care than any other country in the
Organisation for Economic Co-operation and Development The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate e ...
(OECD), and that the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study conclude that the prices paid for health care services are much higher in the U.S. than elsewhere.Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey and Varduhi Petrosyan
"It's The Prices, Stupid: Why The United States Is So Different From Other Countries"
''Health Affairs'', Volume 22, Number 3, May/June 2003. Retrieved February 27, 2008.
While the 19 next most wealthy countries by GDP all pay less than half what the U.S. does for health care, they have all gained about six years of life expectancy more than the U.S. since 1970.


Delays in seeking care and increased use of emergency care

Uninsured Americans are less likely to have regular health care and use preventive services. They are more likely to delay seeking care, resulting in more medical crises, which are more expensive than ongoing treatment for such conditions as diabetes and high blood pressure. A 2007 study published in ''JAMA'' concluded that uninsured people were less likely than the insured to receive any medical care after an accidental injury or the onset of a new chronic condition. The uninsured with an injury were also twice as likely as those with insurance to have received none of the recommended follow-up care, and a similar pattern held for those with a new chronic condition. Uninsured patients are twice as likely to visit hospital emergency rooms as those with insurance; burdening a system meant for true emergencies with less-urgent care needs. In 2008 researchers with the
American Cancer Society The American Cancer Society (ACS) is a nationwide voluntary health organization dedicated to eliminating cancer. Established in 1913, the society is organized into six geographical regions of both medical and lay volunteers operating in more than ...
found that individuals who lacked private insurance (including those covered by Medicaid) were more likely to be diagnosed with late-stage cancer than those who had such insurance. Lay summary
Study Finds Cancer Diagnosis Linked to Insurance
''New York Times''.


Variations in provider practices

The treatment given to a patient can vary significantly depending on which health care providers they use. Research suggests that some cost-effective treatments are not used as often as they should be, while
overutilization Unnecessary health care (overutilization, overuse, or overtreatment) is health care provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overuse was the ...
occurs with other health care services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety. The use of prescription drugs varies significantly by geographic region. The overuse of medical benefits is known as
moral hazard In economics, a moral hazard is a situation where an economic actor has an incentive to increase its exposure to risk because it does not bear the full costs of that risk. For example, when a corporation is insured, it may take on higher ri ...
– individuals who are insured are then more inclined to consume health care. The way the health care system tries to eliminate this problem is through cost sharing tactics like co-pays and deductibles. If patients face more of the economic burden they will then only consume health care when they perceive it to be necessary. According to the RAND health insurance experiment, individuals with higher coinsurance rates consumed less health care than those with lower rates. The experiment concluded that with less consumption of care there was generally no loss in societal welfare but, for the poorer and sicker groups of people there were definitely negative effects. These patients were forced to forgo necessary preventative care measures in order to save money leading to late diagnosis of easily treated diseases and more expensive procedures later. With less preventative care, the patient is hurt financially with an increase in expensive visits to the ER. The health care costs in the US will also rise with these procedures as well. More expensive procedures lead to greater costs. One study has found significant geographic variations in Medicare spending for patients in the last two years of life. These spending levels are associated with the amount of hospital capacity available in each area. Higher spending did not result in patients living longer.John E. Wennberg, Elliott S. Fisher, David C. Goodman, and Jonathan S. Skinner
"Tracking the Care of Patients with Severe Chronic Illness: the Dartmouth Atlas of Health Care 2008."
The Dartmouth Institute for Health Policy and Clinical Practice The Dartmouth Institute for Health Policy and Clinical Practice (TDI) is an organization within Dartmouth College "dedicated to improving healthcare through education, research, policy reform, leadership improvement, and communication with patient ...
, May 2008,
Executive Summary
)


Care coordination

Primary care doctors are often the point of entry for most patients needing care, but in the fragmented health care system of the U.S., many patients and their providers experience problems with care coordination. For example, a Harris Interactive survey of California physicians found that: * Four of every ten physicians report that their patients have had problems with coordination of their care in the last 12 months. * More than 60% of doctors report that their patients "sometimes" or "often" experience long wait times for diagnostic tests. * Some 20% of doctors report having their patients repeat tests because of an inability to locate the results during a scheduled visit. According to an article in ''
The New York Times ''The New York Times'' (''the Times'', ''NYT'', or the Gray Lady) is a daily newspaper based in New York City with a worldwide readership reported in 2020 to comprise a declining 840,000 paid print subscribers, and a growing 6 million paid ...
'', the relationship between doctors and patients is deteriorating.Tare Parker-Pople
"Well: Doctor and Patient, Now at Odds,"
''
The New York Times ''The New York Times'' (''the Times'', ''NYT'', or the Gray Lady) is a daily newspaper based in New York City with a worldwide readership reported in 2020 to comprise a declining 840,000 paid print subscribers, and a growing 6 million paid ...
'', July 29, 2008
A study from
Johns Hopkins University Johns Hopkins University (Johns Hopkins, Hopkins, or JHU) is a private research university in Baltimore, Maryland. Founded in 1876, Johns Hopkins is the oldest research university in the United States and in the western hemisphere. It consiste ...
found that roughly one in four patients believe their doctors have exposed them to unnecessary risks, and anecdotal evidence such as self-help books and web postings suggest increasing patient frustration. Possible factors behind the deteriorating doctor/patient relationship include the current system for training physicians and differences in how doctors and patients view the practice of medicine. Doctors may focus on diagnosis and treatment, while patients may be more interested in wellness and being listened to by their doctors. Many primary care physicians no longer see their patients while they are in the hospital; instead,
hospitalist Hospital medicine is a medical specialty that exists in some countries as a branch of family medicine or internal medicine, dealing with the care of acutely ill hospitalized patients. Physicians whose primary professional focus is caring for hos ...
s are used. The use of hospitalists is sometimes mandated by health insurance companies as a cost-saving measure which is resented by some primary care physicians.


Administrative costs

As of 2017, there were 907 health insurance companies in the United States, although the top 10 account for about 53% of revenue and the top 100 account for 95% of revenue. The number of insurers contributes to administrative overhead in excess of that in nationalized, single-payer systems, such as that in Canada, where administrative overhead was estimated to be about half of the US. Insurance industry group
America's Health Insurance Plans AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual m ...
estimates that administrative costs have averaged approximately 12% of premiums over the last 40 years, with costs shifting away from adjudicating claims and towards medical management, nurse help lines, and negotiating discounted fees with health care providers. A 2003 study published by the
Blue Cross and Blue Shield Association Blue Cross Blue Shield Association (BCBS, BCBSA) is a federation, or supraorganization, of, in 2022, 34 independent and locally operated BCBSA companies that provide health insurance in the United States to more than 106 million people. It was ...
(BCBSA) also found that health insurer administrative costs were approximately 11% to 12% of premiums, with Blue Cross and Blue Shield plans reporting slightly lower administrative costs, on average, than commercial insurers. For the period 1998 through 2003, average insurer administrative costs declined from 13% to 12% of premiums. The largest increases in administrative costs were in customer service and information technology, and the largest decreases were in provider services and contracting and in general administration. The McKinsey Global Institute estimated that excess spending on "health administration and insurance" accounted for as much as 21% of the estimated total excess spending ($477 billion in 2003). According to a report published by the CBO in 2008, administrative costs for private insurance represent approximately 12% of premiums. Variations in administrative costs between private plans are largely attributable to economies of scale. Coverage for large employers has the lowest administrative costs. The percentage of premium attributable to administration increases for smaller firms, and is highest for individually purchased coverage. A 2009 study published by BCBSA found that the average administrative expense cost for all commercial health insurance products was represented 9.2% of premiums in 2008. Administrative costs were 11.1% of premiums for small group products and 16.4% in the individual market. One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20–22% of privately insured spending in California acute care settings.


Long-term Living Facilities

As of 2014, according to a report published the higher the skill of the RN the lower the cost of a financial burden on the facilities. With a growing elderly population, the number of patients in these long term facilities needing more care creates a jump in financial costs. Based on research done in 2010, annual out of pocket costs jumped 7.5% while the cost for Medicare grew 6.7% annually due to the increases. While Medicare pays for some of the care that the elderly populations receive, 40% of the patients staying in these facilities pay out of pocket.


Third-party payment problem and consumer-driven insurance

Most Americans pay for medical services largely through insurance, and this can distort the incentives of consumers since the consumer pays only a portion of the ultimate cost directly. The lack of price information on medical services can also distort incentives. The insurance which pays on behalf of insureds negotiate with medical providers, sometimes using government-established prices such as Medicaid billing rates as a reference point. This reasoning has led for calls to reform the insurance system to create a
consumer-driven health care Consumer-driven healthcare (CDHC), or consumer-driven health plans (CDHP) refers to a type of health insurance plan that allows employers and/or employees to utilize pretax money to help pay for medical expenses not covered by their health plan. ...
system whereby consumers pay more out-of-pocket. In 2003, the
Medicare Prescription Drug, Improvement, and Modernization Act The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health progr ...
was passed, which encourages consumers to have a
high-deductible health plan In the United States, a high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. It is intended to incentivize consumer-driven healthcare. Being covered by an HDHP i ...
and a
health savings account A health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal inc ...
. In October 2019, the state of Colorado proposed running public health care option through private insurers, which are to bear the brunt of the costs. Premiums under the public option are touted to be 9% to 18% cheaper by 2022.


Equity


Mental health

In 2020, 52.9 million adults were affected by mental illness, nearly one in five adults in the country. 44.7 million adults were affected in 2016. In 2006, mental disorders were ranked one of the top five most costly medical conditions, with expenditures of $57.5 billion. A lack of mental health coverage for Americans bears significant ramifications to the U.S. economy and social system. A report by the
U.S. Surgeon General The surgeon general of the United States is the operational head of the United States Public Health Service Commissioned Corps (PHSCC) and thus the leading spokesperson on matters of public health in the federal government of the United States. Th ...
found that mental illnesses are the second leading cause of
disability Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be cognitive, developmental, intellectual, mental, physical, ...
in the nation and affect 20% of all Americans. It is estimated that less than half of all people with mental illnesses receive treatment (or specifically, an ongoing, much needed, and managed care; where medication alone, cannot easily remove mental conditions) due to factors such as stigma and lack of access to care, including a shortage of mental health professionals. Treatment rates are understood to vary between different conditions; as an example, only 16% of adults with schizophrenia and 25% with bipolar disorder were estimated to be untreated with appropriate medication in 2007. The Paul Wellstone Mental Health and Addiction Equity Act of 2008 mandates that group health plans provide mental health and
substance-related disorder Substance-related disorders, also known as substance use disorders, can lead to large societal problems. It is found to be greatest in individuals ages 18–25, with a higher likelihood occurring in men compared to women, and urban residents compa ...
benefits that are at least equivalent to benefits offered for medical and surgical procedures. The legislation renews and expands provisions of the
Mental Health Parity Act The Mental Health Parity Act (MHPA) is legislation signed into United States law on September 26, 1996 that requires annual or lifetime dollar limits on mental health benefits to be no lower than any such dollar limits for medical and surgical be ...
of 1996. The law requires financial equity for annual and lifetime mental health benefits, and compels parity in treatment limits and expands all equity provisions to addiction services. Insurance companies and third-party disability administrators (most notably, Sedgwick CMS) used loopholes and, though providing financial equity, they often worked around the law by applying unequal co-payments or setting limits on the number of days spent in inpatient or outpatient treatment facilities.


Oral health

In the US, dental care is largely not recognized as healthcare, even though individuals visit a dentist more often than a general practitioner, and thus the field and its practices developed independently. In modern policy and practice, oral health is thus considered distinct from primary health, and dental insurance is separate from health insurance. Disparities in oral healthcare accessibility mean that many populations, including those without insurance, the low-income, uninsured, racial minorities, immigrants, and rural populations, have a higher probability of poor oral health at every age. While changes have been made to address these disparities for children, the oral
health disparity Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequitie ...
in adults of all previously listed populations has remained consistent or worsened. The magnitude of this health issue is surprising even in New York state, where the Medicaid program includes dental coverage and is one of the most impressive insurance programs in the nation. Seven out of ten older adults (aged >= 65) have periodontal disease, and one in four adults (aged > 65) has no teeth. This raises concern about the New York State Department of Health's rule, which prevents Medicaid coverage for the replacement of dentures within eight years of initial placement and a ban on coverage of dental implants. In addition, older adults are more likely than those in younger age groups to have medical conditions, such as diabetes and cardiovascular disease, that worsen their oral health.


Medical underwriting and the uninsurable

Prior to the Affordable Care Act, medical underwriting was common, but after the law came into effect in 2014 it became effectively prohibited.


Demographic differences

Health disparities Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequitie ...
are well documented in the U.S. in ethnic minorities such as
African Americans African Americans (also referred to as Black Americans and Afro-Americans) are an ethnic group consisting of Americans with partial or total ancestry from sub-Saharan Africa. The term "African American" generally denotes descendants of enslav ...
, Native Americans, and
Hispanics The term ''Hispanic'' ( es, hispano) refers to people, cultures, or countries related to Spain, the Spanish language, or Hispanidad. The term commonly applies to countries with a cultural and historical link to Spain and to viceroyalties forme ...
. When compared to
whites White is a racialized classification of people and a skin color specifier, generally used for people of European origin, although the definition can vary depending on context, nationality, and point of view. Description of populations as " ...
, these minority groups have higher incidence of chronic diseases, higher mortality, poorer health outcomes and poorer rates of diagnosis and treatment. Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 25% higher than among whites.American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004). In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes and have higher overall obesity rates. Minorities also have higher rates of
cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, h ...
and
HIV/AIDS Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual ma ...
than whites. In the U.S., Asian Americans live the longest (87.1 years), followed by Latinos (83.3 years), whites (78.9 years), Native Americans (76.9 years), and African Americans (75.4 years). A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education. Public spending is highly correlated with age; average per capita public spending for seniors was more than five times that for children ($6,921 versus $1,225). Average public spending for non-Hispanic blacks ($2,973) was slightly higher than that for whites ($2,675), while spending for Hispanics ($1,967) was significantly lower than the population average ($2,612). Total public spending is also strongly correlated with self-reported health status ($13,770 for those reporting "poor" health versus $1,279 for those reporting "excellent" health). Seniors comprise 13% of the population but take 1/3 of all prescription drugs. The average senior fills 38 prescriptions annually. A new study has also found that older men and women in the South are more often prescribed antibiotics than older Americans elsewhere, even though there is no evidence that the South has higher rates of diseases requiring antibiotics. There is considerable research into inequalities in health care. In some cases these inequalities are caused by income disparities that result in lack of health insurance and other barriers to receiving services. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. For example, minorities are not regularly screened for
colon cancer Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel m ...
and the death rate for colon cancer has increased among African Americans and Hispanic people. In other cases, inequalities in health care reflect a
systemic bias Systemic bias, also called institutional bias, and related to structural bias, is the inherent tendency of a process to support particular outcomes. The term generally refers to human systems such as institutions. Institutional bias and structur ...
in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times. Nancy Krieger wrote that racism underlies unexplained inequities in health care, including treatment for heart disease, renal failure, bladder cancer, and pneumonia. Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings were that black Americans received less health care than white Americans – particularly when the care involved expensive new technology. One recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.


Prescription drug issues


Drug efficiency and safety

The
Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food s ...
(FDA) is the primary institution tasked with the safety and effectiveness of human and veterinary drugs. It also is responsible for making sure drug information is accurately and informatively presented to the public. The FDA reviews and approves products and establishes drug labeling, drug standards, and medical device manufacturing standards. It sets performance standards for radiation and ultrasonic equipment. One of the more contentious issues related to drug safety is immunity from prosecution. In 2004, the FDA reversed a federal policy, arguing that FDA premarket approval overrides most claims for damages under state law for medical devices. In 2008 this was confirmed by the Supreme Court in Riegel v. Medtronic. On June 30, 2006, an FDA ruling went into effect extending protection from lawsuits to pharmaceutical manufacturers, even if it was found that they submitted fraudulent clinical trial data to the FDA in their quest for approval. This left consumers who experience serious health consequences from drug use with little recourse. In 2007, the House of Representatives expressed opposition to the FDA ruling, but the Senate took no action. On March 4, 2009, an important U.S. Supreme Court decision was handed down. In Wyeth v. Levine, the court asserted that state-level rights of action could not be pre-empted by federal immunity and could provide "appropriate relief for injured consumers." In June 2009, under the
Public Readiness and Emergency Preparedness Act The Public Readiness and Emergency Preparedness Act (PREPA), passed by the United States Congress and signed into law by President of the United States George W. Bush in December 2005 (as part of ), is a controversial tort liability shield int ...
,
Secretary of Health and Human Services The United States secretary of health and human services is the head of the United States Department of Health and Human Services, and serves as the principal advisor to the president of the United States on all health matters. The secretary is ...
Kathleen Sebelius Kathleen Sebelius (; née Gilligan, born May 15, 1948) is an American businesswoman and politician who served as the 21st United States secretary of Health and Human Services from 2009 until 2014. As Secretary of Health and Human Services, Sebeli ...
signed an order extending protection to vaccine makers and federal officials from prosecution during a declared health emergency related to the administration of the swine flu vaccine.


Prescription drug prices

During the 1990s, the price of
prescription drugs A prescription drug (also prescription medication or prescription medicine) is a pharmaceutical drug that legally requires a medical prescription to be dispensed. In contrast, over-the-counter drugs can be obtained without a prescription. The rea ...
became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. Per capita, the U.S. spends more on pharmaceuticals than any other country, although expenditures on pharmaceuticals accounts for a smaller share (13%) of total health care costs compared to an
OECD The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate e ...
average of 18% (2003 figures). Some 25% of out-of-pocket spending by individuals is for prescription drugs. Another study finds that between 1990 and 2016, prescription drug prices in the US increased by 277% while prescription drug prices increased by only 57% in the UK, 13 percent in Canada, and decreased in France and Japan. The U.S. government has taken the position (through the
Office of the United States Trade Representative The Office of the United States Trade Representative (USTR) is an agency of the Federal government of the United States, United States federal government responsible for developing and promoting Trade policy of the United States, American trade ...
) that U.S. drug prices are rising because U.S. consumers are effectively subsidizing costs which drug companies cannot recover from consumers in other countries (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices). The U.S. position (consistent with the primary lobbying position of the Pharmaceutical Research and Manufacturers of America) is that the governments of such countries are free riding on the backs of U.S. consumers. Such governments should either deregulate their markets, or raise their domestic taxes in order to fairly compensate U.S. consumers by directly remitting the difference (between what the companies would earn in an open market versus what they are earning now) to drug companies or to the U.S. government. In turn, pharmaceutical companies would be able to continue to produce innovative pharmaceuticals while lowering prices for U.S. consumers. Currently, the U.S., as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the Medicare program due to the
Medicare Prescription Drug, Improvement, and Modernization Act The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health progr ...
passed in 2003. Democrats have charged that the purpose of this provision is merely to allow the pharmaceutical industry to profiteer off of the Medicare program.


Impact of drug companies

The U.S., along with New Zealand, make up the only countries in the world that allows
direct-to-consumer advertising Direct-to-consumer advertising (DTCA) refers to the marketing and advertising of pharmaceutical products directly to consumers as patients, as opposed to specifically targeting health professionals. The term is synonymous primarily with the ad ...
of prescription drugs. In 2015, the
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's st ...
called for the banning of direct-to-consumer advertising because it is linked with increased drug prices. Still, other evidence cites that there are some benefits to direct-to-consumer advertising, such as encouraging patients to see the doctor, diagnosis of rare diseases, and the removal of stigma associated with the disease. When health care legislation was being written in 2009, the drug companies were asked to support the legislation in return for not allowing importation of drugs from foreign countries.


Healthcare reform debate

In 2008, prior to the major healthcare reform in 2010, Americans were divided in their views of the U.S. health system; 45% said that the U.S. system was best and 39% said that other countries' systems are better. Much of the historical debate around healthcare reform centered around
single-payer health care Single-payer healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system (hence "single-payer"). Single-payer systems may contract for healthcare services from p ...
, and particularly pointing to the hidden costs of treating the uninsured while free-market advocates point to freedom of choice in purchasing health insuranceCenter for Economic and Social Rights
"The Right to Health in the United States of America: What Does it Mean?"
October 29, 2004.
:Reproduced as and unintended consequences of government intervention, citing the Health Maintenance Organization Act of 1973. According to a 2020 study published in ''
The Lancet ''The Lancet'' is a weekly peer-reviewed general medical journal and one of the oldest of its kind. It is also the world's highest-impact academic journal. It was founded in England in 1823. The journal publishes original research articles, ...
'', a single-payer
universal healthcare Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
system could save 68,000 lives and $450 billion in national healthcare expenditure annually, while another 2022 study published in the ''
PNAS ''Proceedings of the National Academy of Sciences of the United States of America'' (often abbreviated ''PNAS'' or ''PNAS USA'') is a peer-reviewed multidisciplinary scientific journal. It is the official journal of the National Academy of Scien ...
'', estimated that a universal healthcare system could have saved more than 338,000 lives during the
COVID-19 pandemic in the United States The COVID-19 pandemic in the United States is a part of the worldwide pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the United States, it has resulted in confirme ...
from its start until March 2022. Ultimately, a single-payer health care, sometimes called "
socialized medicine Socialized medicine is a term used in the United States to describe and discuss systems of universal health care—medical and hospital care for all by means of government regulation of health care and subsidies derived from taxation. Because of ...
", was not adopted in the final Affordable Care Act.


Patient Protection and Affordable Care Act (2010)

The
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
(Public Law 111–148) is a health care reform bill that was signed into law in the
United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territo ...
by
President President most commonly refers to: *President (corporate title) *President (education), a leader of a college or university *President (government title) President may also refer to: Automobiles * Nissan President, a 1966–2010 Japanese ful ...
Barack Obama Barack Hussein Obama II ( ; born August 4, 1961) is an American politician who served as the 44th president of the United States from 2009 to 2017. A member of the Democratic Party, Obama was the first African-American president of the U ...
on March 23, 2010. The law includes a large number of health-related provisions, most of which took effect in 2014, including expanding
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
eligibility for people making up to 133% of FPL, subsidizing insurance premiums for individuals and families making up to 400% of FPL and capping expenses from 2% to 9.8% of annual income. For the first time, all health policies sold in the United States must cap an individual's (or family's) medical expenses out of pocket annually. Other provisions include providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing
health insurance exchange In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
s, prohibiting insurers from establishing annual spending caps and support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for high-income brackets, taxes on
indoor tanning Indoor tanning involves using a device that emits ultraviolet radiation to produce a cosmetic tan. Typically found in tanning salons, gyms, spas, hotels, and sporting facilities, and less often in private residences, the most common device is a h ...
, cuts to the
Medicare Advantage Medicare Advantage (Medicare Part C, MA) is a capitated program for providing Medicare benefits in the United States. Under Part C, Medicare pays a private-sector health insurer a fixed payment. The insurer then pays for the health care expense ...
program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies; there is also a tax penalty for citizens who do not obtain health insurance (unless they are exempt due to low income or other reasons). The
Congressional Budget Office The Congressional Budget Office (CBO) is a federal agency within the legislative branch of the United States government that provides budget and economic information to Congress. Inspired by California's Legislative Analyst's Office that manages ...
estimates that the net effect (including the reconciliation act) will be a reduction in the federal deficit by $143 billion over the first decade. However, two months later, the office subsequently acknowledged that there was an additional $115 billion in funds needed that were not originally included in the estimate. Additionally, the CBO estimated that although projected premiums in 2016 would be lower by $100 per person for small and large business health insurance plans with the Affordable Care Act than without, individual plans would be higher by $1,900 with the bill. The first open enrollment period of the Affordable Care Act began in October 2013. Prior to this period, access to healthcare and insurance coverage trends were worsening on a national level. A large, national survey of American adults found that after the act's first two enrollment periods, self-reported coverage, health, and access to care improved significantly. Furthermore, insurance coverage for low-income adults were significantly greater in states that expanded Medicaid in comparison with states that did not expand Medicaid. However, discrepancies do exist between those covered by Medicaid versus those covered by private insurance. Those insured by Medicaid tend to report fair or poor health, as opposed to excellent or very good health. On December 22, 2017, the
Tax Cuts and Jobs Act of 2017 The Act to provide for reconciliation pursuant to titles II and V of the concurrent resolution on the budget for fiscal year 2018, , is a congressional revenue act of the United States originally introduced in Congress as the Tax Cuts and Jobs A ...
was signed into law by
President Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who served as the 45th president of the United States from 2017 to 2021. Trump graduated from the Wharton School of the University of Pe ...
. Inside the final version of the bill was a repeal of the individual mandate in the Affordable Care Act, which required individuals and companies to get healthcare for themselves and their employees. It was this mandate which kept healthcare costs down under the PPACA by promoting cost sharing over a larger pool. Economists believe the repeal of the individual mandate will lead to higher premiums and lower enrollment in the current market though they do not agree with how much. In 2017, the new Republican healthcare bill known as the
American Health Care Act The American Health Care Act of 2017 (often shortened to the AHCA or nicknamed Trumpcare) was a bill in the 115th United States Congress. The bill, which was passed by the United States House of Representatives but not by the United States ...
was passed by the House of Representatives under President Donald Trump. Although the Affordable Care Act and the American Health Care Act both propose tax cuts in order to make insurance more affordable for Americans, each of these bills affected Americans in different ways. The people most affected by President Trump's plan are young people, individuals of a higher socioeconomic status, and people who live in urban areas. Young people because individuals between the age of 20 and 30 will see drops in the premiums they pay within their plans. Individuals with higher socioeconomic status because whereas under Obamacare individuals could only make up to $50,000 dollars annually and still receive tax breaks, now under Trump's plan that number has been increase so that individuals who make up to $115,000 annually can receive tax breaks. In addition, those in urban areas can also benefit from the plan because under Obamacare tax credits were designated also by the cost of local healthcare, but the American Health Care Act does not take this into consideration although rural healthcare is generally more expensive due to the lack of hospitals and available services.


Health insurance coverage for immigrants

Of the 26.2 million foreign immigrants living in the US in 1998, 62.9% were non-U.S. citizens. In 1997, 34.3% of non-U.S. citizens living in America did not have health insurance coverage opposed to the 14.2% of native-born Americans who do not have health insurance coverage. Among those immigrants who became citizens, 18.5% were uninsured, as opposed to noncitizens, who are 43.6% uninsured. In each age and income group, immigrants are less likely to have health insurance. With the recent healthcare changes, many legal immigrants with various immigration statuses now are able qualify for affordable health insurance. Undocumented immigrants within the United States do not have access to government funded health insurance. Although the Affordable Care Act allows immigrants to receive insurance at a discounted rate, the same does not go for those without US citizenship. While policies like the Patient Protection Act and Affordable Care Act have aimed at expanding health insurance coverage to also improve
refugee health in the United States Refugee health in the United States focuses on the health, treatment, and healthcare barriers of migrants to the United States who have relocated from their country of origin, often because of factors such as political instability, war, or natural ...
, different states have implemented their health insurance programs differently leading to healthcare access disparities between states. Undocumented immigrants in the US can seek medical help from community centers, or what is termed Safety Net Providers, and participate in fee for service medical assistance, but can only buy health insurance from private health insurers.


See also

* Biomedical research in the United States * Canadian and American health care systems compared * Centers for Disease Control and Prevention timeline *
Health Care and Education Reconciliation Act of 2010 The Health Care and Education Reconciliation Act of 2010 (, ) is a law that was enacted by the 111th United States Congress, by means of the reconciliation process, in order to amend the Affordable Care Act (ACA) (). The law includes the St ...
*
Health care compared Health, according to the World Health Organization, is "a state of complete physical, Mental health, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World H ...
– tabular comparisons of the US, Canada, and other countries not shown above. *
Health care industry The healthcare industry (also called the medical industry or health economy) is an aggregation and integration of sectors within the economic system that provides goods and services to treat patients with curative, preventive, rehabilitative, a ...
* Health care politics *
Health care systems Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organiza ...
(including comparisons) *
Health insurance cooperative A health insurance cooperative is a cooperative entity that has the goal of providing health insurance and is also owned by the people that the organization insures. It is a form of mutual insurance. United States In the debate over healthcare ...
*
Healthy People program Healthy People is a program of a nationwide health-promotion and disease-prevention goals set by the United States Department of Health and Human Services. The goals were first set in 1979 "in response to an emerging consensus among scientists and ...
* List of countries by health care expenditures *
List of healthcare accreditation organizations in the United States The following organizations survey and accredit hospitals and healthcare organizations in the US. Medicare and Medicaid deeming A number have deeming power for Medicare and Medicaid. *American Association for Accreditation of Ambulatory Surgery ...
*
Medical centers in the United States :''This article discusses the major medical centers in the U.S. For all hospitals, see List of hospitals in the United States. For a general discussion about U.S. health care see Health care in the United States''. Medical centers in the United S ...
*
Medical debt Medical debt refers to debt incurred by individuals due to health care costs and related expenses. Medical debt is different from other forms of debt, because it is usually incurred accidentally or faultlessly. People do not plan to fall ill or ...
*
Medical education in the United States Medical education in the United States includes educational activities involved in the education and training of physicians in the country, with the overall process going from entry-level training efforts through to the continuing education o ...
*
Medicare for All Act The Medicare for All Act, aka the Expanded and Improved Medicare for All Act or United States National Health Care Act, is a bill first introduced in the United States House of Representatives by Representative John Conyers (D-MI) in 2003, with ...
* Medicare Rights Center *
Medicare Sustainable Growth Rate The Medicare Sustainable Growth Rate (SGR) was a method used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control spending by Medicare on physician services. President Barack Obama signed a bill into law on Apr ...
*
Military Health System The Military Health System (MHS) is a form of nationalized health care operated within the United States Department of Defense that provides health care to active duty, Reserve component and retired U.S. Military personnel and their dependents. ...
*
Osteopathic medicine in the United States Osteopathic medicine is a branch of the medical profession in the United States that promotes the practice of allopathic medicine with a set of philosophy and principles set by its earlier form, osteopathy. Osteopathic physicians (DOs) are lice ...
*
School health services School-based health and nutrition services are provided through the school system to improve the health and well-being of children and in some cases whole families and the broader community. These services have been developed in different ways ar ...
*
Universal Health Care Foundation of Connecticut Universal Health Care Foundation of Connecticut is an independent, nonprofit organization with offices in Meriden, Connecticut. The foundation supports the mission of its parent organization, CHART (Connecticut Health Advancement and Research T ...
*
Visitor health insurance Visitor health insurance, also known as visitor medical insurance, is a form of short-term travel medical insurance policy that visitors to any country purchase to obtain coverage protection for accidental injury or sickness or illness that occurs ...


References


Further reading

* * * A standard comprehensive scholarly history * * * * * * * * McBride, David. (2018) ''Caring for Equality: A History of African American Health and Healthcare.'' Lanham, MD: Rowman and Littlefield. * * * *


External links


National Center for Health Statistics
from
Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georg ...
(CDC)
National Health Expenditure Data (U.S.)
from
United States Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government created to protect the health of all Americans and providing essential human services. Its motto is ...
(DHHS)
United States
profile from the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...

And Pharma Market Research Report
* {{Authority control Medicare and Medicaid (United States) Public services of the United States