Health System in the US

Abstract

This analysis of the US health system reviews its organization and governance, health financing, health-care provision, health reforms, and health system performance. The US health system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce, a wide range of high-quality medical specialists as well as secondary and tertiary institutions, and a robust health research program and, for selected services, has among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditure levels per person far exceeding all other countries, poor health indicators on many objective and subjective measures of quality and outcomes, an unequal distribution of resources and outcomes across the country and among different population groups, and lagging efforts to introduce health information technology. It is difficult to determine the extent to which deficiencies are health system related, though it seems that at least some of the problems are a result of poor access to care. Because of the adoption of the Affordable Care Act (ACA) in 2010, the USA is facing a period of enormous potential change. The major provisions of the ACA were implemented in 2014, although judicial setbacks, delays, and legislative repeals to its core provisions have reduced its overall impact. Improving coverage was a central aim, envisaged through mandates that certain individuals purchase, and employers offer, private health insurance as well as subsidies for lower-income uninsured citizens to purchase private insurance. However, in late 2017, the individual mandate to purchase insurance was repealed by Congress, with an effective date of January 2019. Eligibility for Medicaid, which provides public coverage for low-income individuals and families, is also expanded, and greater protections for insured persons have been instituted. Furthermore, primary care and public health are receiving increased funding, and improving quality and controlling expenditures are addressed through a range of policies. Early assessments of the ACA suggest coverage rates have expanded, particularly for low-income adults in some states. Whether the ACA will be effective in addressing the US health-care system’s historic challenges can only be determined over time.

The material used in this chapter was adapted or taken directly from our book on the US health-care system – Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, van Ginneken E, Health Syst Transit 15(3):1–431, 2013.