This chapter first provides the two main theoretical perspectives related to the U.S. health system: the “market-based” view and the “socially sensitive” argument. The second main section discusses important facts and highlights related to the national health situation of the United States compared with other advanced OECD countries. Taking these facts and highlights into consideration, the final sections of the contribution critically examine the merits and demerits of contrasting approaches to implementing a comprehensive national health and insurance scheme in the United States, and offer concrete policy considerations. Some brief conclusions end the chapter.
TopIntroduction
Healthcare in the United States is provided through a combination of private health insurance and public health coverage (e.g., Medicare, Medicaid). Based on latest statistics, around 45 percent of health spending is paid for by the government at either the federal or state and local level. According to the Centers for Medicare & Medicaid Services (CMS Program Statistics, 2018), in 2017, the U.S. health spending reached $3,492.1 billion or approximately $10,740 per capita, and accounted for 17.9 percent of the nation’s Gross Domestic Product (see Figure 1: CMS, 2018). U.S. hospitals are largely owned and operated by private sector institutions with 3.3 percent being federal and 15.7 percent being state and local government or community hospitals (Figure 2: American Hospital Association, 2019). Further, 47.8 percent are nongovernment not-for-profit, 21.3 percent are for-profit, and 11.9 percent are non-federal psychiatric and “other” hospitals. Although nearly 45 percent of healthcare spending and close to 18 percent of acute care facilities are government-supported (CMS, 2018), the U.S. does not have a universal healthcare system. This contributes to health disparities when the U.S. is compared to other advanced industrial countries (OECD, 2018).
Moreover, the United States life expectancy is 78.6 years at birth, up from 75.2 years in 1990; this ranks 22nd out of the 35 industrialized OECD countries, down from 20th in 1990 (OECD, 2018, 2020). A relatively recent CDC statement (Nov 15, 2019), however, indicates U.S. life expectancy has been reduced by drug overdoses and suicides over the past several years. Of 17 high-income countries studied by the National Institutes of Health, in 2018, the United States had the highest or near-highest prevalence of obesity, car accidents, infant mortality, heart and lung disease, sexually transmitted infections, adolescent pregnancies, homicides, and injuries (NIH, 2019). A 2018 survey of the healthcare systems of 11 developed countries found that the U.S. healthcare system to be the most expensive and worst-performing in terms of health access, efficiency, and equity (OECD, Health Statistics 2019). While real incomes remained almost stagnant during the last two decades, health expenses have increased enormously.
What’s more, in 2018, there were nearly 41 million people and around 28 million families living in poverty in the United States with blacks and Hispanics experiencing the highest poverty rates. Prohibitively high cost is the primary reason Americans have problems accessing healthcare . Based on statistics by the U.S. Census Bureau and the Gallup organization, around 29 million did not have health insurance in 2018 (U.S. Census Bureau, Annual Social and Economic Supplements, 2018, 2019). Such a large number of people without health insurance coverage in the United States is one of the primary concerns raised by advocates of healthcare reform.