Healthcare in the United States
Healthcare in the United States is largely provided by private sector healthcare facilities, and paid for by a combination of public programs, county indigent health care programs, private insurance, and out-of-pocket payments. The U.S. is the only developed country without a system of universal healthcare, and a significant proportion of its population lacks health insurance. The United States spends more on healthcare than any other country, both in absolute terms and as a percentage of GDP; however, this expenditure does not necessarily translate into better overall health outcomes compared to other developed nations. In 2022, the United States spent approximately 17.8% of its Gross Domestic Product on healthcare, significantly higher than the average of 11.5% among other high-income countries. Coverage varies widely across the population, with certain groups, such as the elderly, disabled and low-income individuals receiving more comprehensive care through government programs such as Medicaid and Medicare.
The U.S. healthcare system has been the subject of significant political debate and reform efforts, particularly in the areas of healthcare costs, insurance coverage, and the quality of care. Legislation such as the Affordable Care Act of 2010 has sought to address some of these issues, though challenges remain. Uninsured rates have fluctuated over time, and disparities in access to care exist based on factors such as income, race, and geographical location. The private insurance model predominates, and employer-sponsored insurance is a common way for individuals to obtain coverage.
The complex nature of the system, as well as its high costs, has led to ongoing discussions about the future of healthcare in the United States. At the same time, the United States is a global leader in medical innovation, measured either in terms of revenue or the number of new drugs and medical devices introduced. The Foundation for Research on Equal Opportunity concluded that the United States dominates science and technology, which "was on full display during the COVID-19 pandemic, as the U.S. government coronavirus vaccines far faster than anyone had ever done before", but lags behind in fiscal sustainability, with " spending... growing at an unsustainable rate".
In the early 20th century, advances in medical technology and a focus on public health contributed to a shift in healthcare. The American Medical Association worked to standardize medical education, and the introduction of employer-sponsored insurance plans marked the beginning of the modern health insurance system. More people were starting to get involved in healthcare like state actors, other professionals/practitioners, patients and clients, the judiciary, and business interests and employers. They had interest in medical regulations of professionals to ensure that services were provided by trained and educated people to minimize harm. The post–World War II era saw a significant expansion in healthcare where more opportunities were offered to increase accessibility of services. The passage of the Hill–Burton Act in 1946 provided federal funding for hospital construction, and Medicare and Medicaid were established in 1965 to provide healthcare coverage to the elderly and low-income populations, respectively.
History
The healthcare system in the United States can be traced back to the Colonial Era. Community-oriented care was typical, with families and neighbors providing assistance to the sick. During the 19th century, the practice of medicine began to professionalize, following the "Anglo-American model" where these new medical professionals were empowered by the state to govern their own affairs, leading to various collaborations to acquire status and win legislation granting them the power to self-regulate. The establishment of medical schools and professional organizations led to standardized training and certification processes for doctors. Despite this progress, healthcare services remained disparate, particularly between urban and rural areas. The concept of hospitals as institutions for the sick began to take root, leading to the foundation of many public and private hospitals.File:Bellevue_Psychiatric_Hospital_old_building.jpg|thumb|right|250px|Bellevue Hospital is one of the oldest public hospitals in the United States. It is located in Manhattan.
The latter part of the 20th century saw continued evolution in healthcare policy, technology, and delivery. Following the Stabilization Act of 1942, employers, unable to provide higher salaries to attract or retain employees, began to offer insurance plans, including healthcare packages, as a benefit in kind, thereby beginning the practice of employer-sponsored health insurance, a practice that is cemented into the work culture of today. The Health Maintenance Organization Act of 1973 encouraged the development of managed care, while advances in medical technology revolutionized treatment. In the 21st century, the Affordable Care Act was passed in 2010, extending healthcare coverage to millions of uninsured Americans and implementing reforms aimed at improving quality and reducing costs.
Statistics
Hospitalizations
According to a statistical brief by the Healthcare Cost and Utilization Project, there were 35.7 million hospitalizations 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. Approximately 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 reported that the lifetime per capita expenditure at birth, using the year 2000 dollars, showed a large difference between the healthcare costs of females and males. A large portion of this cost difference is in the shorter lifespan of men, but, even after adjustment for age, there still is a 20% difference in lifetime healthcare expenditures.
Health insurance and accessibility
Unlike most developed nations, the US health system does not provide healthcare to the country's entire population. In 1977, the United States was said to be the only industrialized country not to have some form of national health insurance or direct healthcare provision to citizens through a nationalized healthcare system. A 1978 study argued that "Today every government in the world – including Red China with its squadrons of semi-trained 'barefoot doctors' – realizes it has a responsibility to keep its citizens in good physical and mental health. Unlike the U.S., nations like Scandinavia, the U.K., Ireland, Japan and others have opted for a universal health care system in which the state pays everyone's medical bills." Instead, most citizens are covered by a combination of private insurance and various federal and state programs., health insurance was most commonly acquired through a group plan tied to an employer, covering 150 million people. Other major sources include Medicaid, covering 70 million, Medicare, 50 million, and health insurance marketplaces created by the 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.Healthcare coverage is provided through a combination of private health insurance and public health coverage. In 2013, 64% of health spending was paid for by the government, and funded via programs such as Medicare, Medicaid, the Children's Health Insurance Program, Tricare, and the Veterans Health Administration. 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 for public sector employees is primarily provided by the government in its role as employer. Managed care, where payers use various techniques intended to improve quality and limit cost, has become ubiquitous.
File:MayoClinicPlummerBldg16floor.JPG|thumb|left|250px|Mayo Clinic is renowned for its patient-centered approach to care and its commitment to accessibility. In Rochester, Minnesota.
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 had achieved universal or near-universal 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 US". A 2009 study done at Harvard Medical School with Cambridge Health Alliance by cofounders of Physicians for a National Health 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.
The Gallup organization tracks the percent of adult Americans who are uninsured for healthcare, 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 US Census Bureau reported that 28.5 million people did not have health insurance in 2017, down from 49.9 million in 2010. Between 2004 and 2013, a trend of high rates of underinsurance and wage stagnation contributed to a healthcare consumption decline for low-income Americans. This trend was reversed after the implementation of the major provisions of the ACA in 2014.
, 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. An estimated 13 million people gained coverage through Medicaid expansion, and 76 million people gained eligibility for free preventative services. 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 to $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 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 US's international ranking as having the highest healthcare 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 US 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 create barriers to accessing healthcare: 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.