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{{Use American English|date=May 2015}}
{{Use mdy dates|date=November 2017}}
{{Health care in the United States}}
{{Health care reform 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, [[private insurance]], and [[Out-of-pocket expense|out-of-pocket payments]]. The U.S. is the only [[developed country]] without a system of [[universal health care|universal healthcare]], and a significant proportion of its population [[Health insurance coverage in the United States|lacks health insurance]].<ref name="USC Price"/><ref>{{Cite journal |last=Vladeck |first=Bruce |date=January 2003 |title=Universal Health Insurance in the United States: Reflections on the Past, the Present, and the Future |journal=American Journal of Public Health |volume=93 |issue=1 |pages=16–19 |doi=10.2105/AJPH.93.1.16 |issn=0090-0036 |pmc=1447684 |pmid=12511377}}</ref><ref>{{cite web|url=https://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/|title=Here's a Map of the Countries That Provide Universal Health Care (America's Still Not on It)|last=Fisher|first=Max|website=[[The Atlantic]]| name-list-style = vanc |date=2012-06-28}}</ref><ref name="dpeaflcio.org">{{cite web|url=http://dpeaflcio.org/programs-publications/issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/|title=The U.S. Health Care System: An International Perspective - DPEAFLCIO|website=dpeaflcio.org|date=August 15, 2016 }}</ref>

The United States [[List of countries by total health expenditure per capita|spends more]] on healthcare than any other country, both in absolute terms and as a percentage of GDP.<ref name="USC Price">{{cite web |author=<!--Staff writer(s); no by-line.--> |date=2023 |title=How to Improve Access to Health Care: Issues & Potential Solutions |url=https://healthadministrationdegree.usc.edu/blog/how-to-improve-access-to-health-care/ |url-status=live |website=healthadministrationdegree.usc.edu |location=[[Los Angeles]] and [[Sacramento, California]] |publisher=[[USC Price School of Public Policy]], [[University of Southern California]] |archive-url=https://web.archive.org/web/20230421051321/https://healthadministrationdegree.usc.edu/blog/how-to-improve-access-to-health-care/ |archive-date=21 April 2023 |access-date=12 May 2023}}</ref> However, this expenditure does not necessarily translate into better overall health outcomes compared to other developed nations.<ref>{{cite journal |vauthors=Fullman N, Yearwood J, Abay SM, Abbafati C, Abd-Allah F, Abdela J |display-authors=etal |collaboration=GBD 2016 Healthcare Access and Quality Collaborators |title=Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016 | language = en |journal=Lancet |volume=391 |issue=10136 |pages=2236–2271 |date=June 2018 |pmid=29893224 |pmc=5986687 |doi=10.1016/S0140-6736(18)30994-2}}</ref> Coverage varies widely across the population, with certain groups, such as the elderly and low-income individuals, receiving more comprehensive care through government programs such as [[Medicaid]] and [[Medicare (United States)|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 health in the United States|race]], and geographical location.<ref name="Black-HIV/AIDS">{{cite journal |last1=Murdock |first1=Christopher J. |last2=Laurencin |first2=Lynne |last3=Christensen |first3=Donna M. |last4=Laurencin |first4=Cato T. |date=June 2018 |title=HIV/AIDS and the African-American Community 2018: A Decade Call To Action |journal=Journal of Racial and Ethnic Health Disparities |publisher=[[Springer Nature]] |volume=5 |issue=3 |pages=449–458 |doi=10.1007/s40615-018-0491-0 |pmc=8224540 |pmid=29869005 |issn=2196-8837}}</ref><ref name="Latino HIV Crisis">{{cite journal |last1=Guilamo-Ramos |first1=V |last2=Thimm-Kaiser |first2=M |last3=Benzekri |first3=A |last4=Chacón |first4=G |last5=Rios |first5=E |last6=Scaccabarrozzi |first6=L |date=January 2020 |title=The Invisible US Hispanic/Latino HIV Crisis: Addressing Gaps in the National Response |journal=[[American Journal of Public Health]] |publisher=[[American Public Health Association]] |volume=110 |issue=1 |pages=27–31 |doi=10.2105/AJPH.2019.305309 |pmc=6893335 |pmid=31725313 |issn=0090-0036}}</ref><ref name="Am. J. Health Behav.">{{cite journal |last1=Lee |first1=S. |last2=Martinez |first2=G. |last3=Ma |first3=G. |last4=Hsu |first4=C. E. |last5=Robinson |first5=E. S. |last6=Bawa |first6=J. |last7=Juon |first7=H.-S. |date=January–February 2010 |title=Barriers to Health Care Access in 13 Asian American Communities |editor-last=Glover |editor-first=Elbert D. |editor-link=Elbert Glover |journal=[[American Journal of Health Behavior]] |publisher=PNG Publications and Scientific Research Limited |volume=34 |issue=1 |pages=21–30 |doi=10.5993/AJHB.34.1.3 |issn=1945-7359 |pmc=6628721 |pmid=19663748 |s2cid=31669071}}</ref><ref name="Med. Care">{{cite journal |last1=Armstrong |first1=Katrina |last2=Putt |first2=Mary |last3=Halbert |first3=Chanita H. |last4=Grande |first4=David |last5=Schwartz |first5=Jerome Sanford |last6=Liao |first6=Kaijun |last7=Marcus |first7=Noora |last8=Demeter |first8=Mirar B. |last9=Shea |first9=Judy A. |date=February 2013 |title=Prior Experiences of Racial Discrimination and Racial Differences in Health Care System Distrust |journal=[[Medical Care (journal)|Medical Care]] |publisher=[[Lippincott Williams & Wilkins]] on behalf of the [[American Public Health Association]] |volume=51 |issue=2 |pages=144–150 |doi=10.1097/mlr.0b013e31827310a1 |issn=0025-7079 |pmc=3552105 |pmid=23222499 |s2cid=46125799}}</ref> The private insurance model predominates, and employer-sponsored insurance is a common way for individuals to obtain coverage.<ref name="USC Price"/><ref name="NYT-20210822">{{cite news |last1=Kliff |first1=Sarah |last2=Katz |first2=Josh |title=Hospitals and Insurers Didn't Want You to See These Prices. Here's Why. |url=https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html |access-date=18 July 2022 |work=[[The New York Times]] |date =22 August 2021| department = The Upshot | issn = 0362-4331 | eissn = 1553-8095 | oclc =1645522 |archive-url=https://web.archive.org/web/20211231205650/https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html |archive-date=31 December 2021}}</ref><ref name="NYT-20131221">{{cite news |last=Rosenthal |first=Elisabeth | name-list-style = vanc |title=News Analysis – Health Care's Road to Ruin |url=https://www.nytimes.com/2013/12/22/sunday-review/health-cares-road-to-ruin.html |date=December 21, 2013 |work=[[New York Times]] |access-date=December 22, 2013}}</ref> 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 devices introduced.<ref name="EFPIA">{{cite web|url=http://www.efpia.org/content/Default.asp?PageID=388|title=Improving Europe's competitiveness|publisher=[[European Federation of Pharmaceutical Industries and Associations|EFPIA]]|access-date=November 6, 2016|archive-url=https://web.archive.org/web/20090823030103/http://www.efpia.org/content/Default.asp?PageID=388|archive-date=August 23, 2009}}</ref><ref name="Europe">Stats from 2007 Europ.Fed.of Pharm.Indust.and Assoc. Retrieved June 17, 2009, from [http://212.3.246.100/Objects/2/Files/infigures2007.pdf]{{dead link|date=October 2017|bot=InternetArchiveBot|fix-attempted=yes}}</ref> The Foundation for Research on Equal Opportunity concluded that the United States dominates science & technology, which "was on full display during the [[COVID-19 pandemic]], as the U.S. government [delivered] coronavirus vaccines far faster than anyone had ever done before," but lags behind in fiscal sustainability, with "[government] spending [...] growing at an unsustainable rate."<ref>{{cite web|url=https://freopp.org/united-states-11-in-the-2022-world-index-of-healthcare-innovation-7175b47ab5d7|title=United States: #11 in the 2022 World Index of Healthcare Innovation. America's runaway leadership in science and technology is marred by a fiscally unsustainable system of costly health care.|website=freopp.org|author=Grant Rigney|date=March 3, 2023|access-date=April 27, 2023}}</ref>

== History ==
{{Main|History of medicine in the United States}}

The healthcare system in the United States can be traced back to the [[Colonial history of the United States|Colonial Era]].<ref>Carl Bridenbaugh, ''Cities in the Wilderness: The First Century of Urban Life in America 1625-1742'' (1938) p 401</ref> Community-oriented care was typical, with families and neighbors providing assistance to the sick.<ref name="Robinson, Martha 2005">Robinson, Martha. 2005. New Worlds, New Medicines: Indian Remedies and English Medicine in Early America. Early American Studies (Spring): 94-110.</ref><ref>Jacob Ernest Cooke, ed. ''Encyclopedia of the North American colonies'' (3 vol 1992) 1:214</ref>

During the 19th century, the practice of medicine began to professionalize. The establishment of [[medical schools]] and professional organizations led to standardized training and certification processes for doctors.<ref>Richard Morris ''Encyclopedia of American History'' (1976) p 806.</ref> 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.<ref>{{Cite book |last1=Breslaw |first1=Elaine G. |title=Lotions, Potions, Pills, and Magic: Health Care in Early America |date=March 2014 |publisher=NYU Press |isbn=978-1479807048}}</ref>  

[[File:Salk-child-Karsh.jpg|thumb|right|[[Polio vaccine]] was invented in the US by [[Hilary Koprowski]] and [[Jonas Salk]] ''(above, right)''.]]

In the early 20th century, advances in medical technology and a focus on public health contributed to a shift in healthcare.<ref>{{Cite book |last=Health |first=Institute of Medicine (US) Committee for the Study of the Future of Public |url=https://www.ncbi.nlm.nih.gov/books/NBK218224/ |title=A History of the Public Health System |date=1988 |publisher=National Academies Press (US)}}</ref> The [[American Medical Association]] (AMA) worked to standardize medical education, and the introduction of employer-sponsored insurance plans marked the beginning of the modern health insurance system.<ref>{{cite web |url = http://www.ama-assn.org/ama/pub/about-ama/our-history.shtml |title =AMA (AMA History) 1847 to 1899 |publisher = American Medical Association |access-date = 2009-02-16| archive-url= https://web.archive.org/web/20090209162032/http://www.ama-assn.org/ama/pub/about-ama/our-history.shtml| archive-date= 9 February 2009 | url-status= live}}</ref>

The post–World War II era saw a significant expansion in healthcare. 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.<ref>{{Cite book |last1=Shi |title=Delivering health care in America : a systems approach |last2=Singh |publisher=Jones & Bartlett Learning |year=2019 |edition=7th}}</ref><ref>Raffel, M. W. (1980). ''The U.S. health system : origins and functions''. New York : Wiley.</ref>

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 [[Health insurance|healthcare packages]], as a [[Employee benefits|benefit in kind]], thereby beginning the practice of employer-sponsored health insurance.<ref>{{cite journal |last=Thomasson |first=Melissa A. | name-list-style = vanc |date= July 2002 |title=From Sickness to Health: The Twentieth-Century Development of U.S. Health Insurance|journal=Explorations in Economic History|language=en|volume=39|issue=3|pages=233–253|doi=10.1006/exeh.2002.0788|s2cid=30393803 }}</ref> 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]] (ACA) was passed in 2010, extending healthcare coverage to millions of uninsured Americans and implementing reforms aimed at improving quality and reducing costs.<ref>{{cite journal |last1=Gruber |first1=Jonathan |title=The Impacts of the Affordable Care Act: How Reasonable Are the Projections? |journal=National Tax Journal |date=2011 |volume=64 |issue=3 |pages=893–908 |url=https://economics.mit.edu/files/11416 |archive-url=https://web.archive.org/web/20160620124250/http://economics.mit.edu/files/11416 |url-status=dead |archive-date=2016-06-20 |access-date=July 23, 2017 |doi=10.17310/ntj.2011.3.06 |hdl=1721.1/72971 |s2cid=232213290 }}</ref>

== Statistics ==
=== Hospitalizations ===
According to a statistical brief by the [[Healthcare Cost and Utilization Project]] (HCUP), there were 35.7&nbsp;million [[hospital]]izations in 2016,<ref name=":03">{{Cite web|url=https://www.hcup-us.ahrq.gov/reports/statbriefs/sb246-Geographic-Variation-Hospital-Stays.jsp|title=Overview of U.S. Hospital Stays in 2016: Variation by Geographic Region #246|website=www.hcup-us.ahrq.gov|access-date=2019-11-10}}</ref> a significant decrease from the 38.6&nbsp;million in 2011.<ref>{{Cite web|url=https://www.hcup-us.ahrq.gov/reports/statbriefs/sb166.jsp|title=Overview of Hospital Stays in the United States, 2011 - Statistical Brief #166|website=www.hcup-us.ahrq.gov|access-date=2019-11-10}}</ref> For every 1,000 in the population, there was an average of 104.2&nbsp;stays and each stay averaged $11,700 (equivalent to ${{Formatprice|{{inflation|US|11700|2016}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}),<ref name=":03" /> an increase from the $10,400 (equivalent to ${{Formatprice|{{inflation|US|10400|2012}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) cost per stay in 2012.<ref>{{cite book |vauthors=Weiss AJ, Elixhauser A |chapter=Overview of Hospital Stays in the United States, 2012: Statistical Brief #180 |date=2006 |pmid=25506966 |chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK259100/ |access-date=2019-11-10 |publisher=Agency for Healthcare Research and Quality (US) |title=Healthcare Cost and Utilization Project (HCUP) Statistical Briefs }}</ref> 7.6% of the population had overnight stays in 2017,<ref>{{Cite web|url=https://www.cdc.gov/nchs/fastats/hospital.htm|title=FastStats|date=2019-09-04|website=www.cdc.gov|language=en-us|access-date=2019-11-10}}</ref> each stay lasting an average of 4.6&nbsp;days.<ref name=":03" />

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 ($361,192, equivalent to ${{Formatprice|{{inflation|US|361192|2000}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) and males ($268,679, equivalent to ${{Formatprice|{{inflation|US|268679|2000}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}). 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 healthcare expenditures.<ref>{{cite journal |vauthors=Alemayehu B, Warner KE |title=The lifetime distribution of health care costs |journal=Health Services Research |volume=39 |issue=3 |pages=627–642 |date=June 2004 |pmid=15149482 |pmc=1361028 |doi=10.1111/j.1475-6773.2004.00248.x}}</ref>

=== Health insurance and accessibility ===
{{Main|Health insurance coverage in the United States|Health insurance in the United States}}
[[File:U.S. Uninsured and Uninsured Rate (1987 to 2008).JPG|thumb|upright=1.6|The numbers of uninsured Americans and the uninsured rate from 1987 to 2008]]Unlike most [[Developed country|developed nations]], the US health system does not provide healthcare to the country's entire population.<ref name="IOM 2004">{{cite book |url=https://archive.org/details/insuringamericas00inst/page/25|title=Insuring America's health: principles and recommendations|author=Institute of Medicine. Committee on the Consequences of Uninsurance|date=January 13, 2004 |publisher=National Academies Press|isbn=978-0-309-52826-9|location=Washington, DC|page=[https://archive.org/details/insuringamericas00inst/page/25 25]}}</ref> 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.<ref>[https://www.google.co.uk/books/edition/Health_Care_Problems_in_Rural_and_Small/yA0QzViGaeAC?hl=en&gbpv=1&dq=Health+Security+Act,+S.+3,+is+the+legislation+best+able+to+provide+adequate+health+care+to+all+Americans&pg=PA126&printsec=frontcover Health Care Problems in Rural and Small Communities (Macon, Ga., and Atlanta, Ga.) Joint Hearings Before the Subcommittee on Health of the Committee on Finance and Committee on Governmental Affairs, United States Senate, Ninety-fifth Congress, First Session, August 16 and 18, 1977 By United States. Congress, Senate, Committee on Finance, Subcommittee on Health, 1978, P.126]</ref> 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.”<ref>The Book of Numbers, compiled by the Editors of Heron House, 1978, P.231</ref>Instead, most citizens are covered by a combination of private insurance and various federal and state programs.<ref>Access to health care in America. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Millman M, editor. Washington: National Academies Press; 1993.</ref> {{As of|2017}}, health insurance was most commonly acquired through a [[Group insurance|group plan]] tied to an employer, covering 150&nbsp;million people.<ref name=":11">{{Cite journal |url=https://www.commonwealthfund.org/blog/2017/decline-employer-sponsored-health-insurance|title=The Decline of Employer-Sponsored Health Insurance|website=commonwealthfund.org|year=2017|doi=10.26099/dnqz-4g48|language=en |access-date=2018-11-25|last1=Blumenthal|first1=David}}</ref> Other major sources include Medicaid, covering 70&nbsp;million, Medicare, 50&nbsp;million, and [[health insurance marketplace]]s created by the [[Affordable Care Act|ACA]] covering around 17&nbsp;million.<ref name=":11" /> In 2017, a study found that 73% of plans on ACA marketplaces had narrow networks, limiting access and choice in providers.<ref name=":11" />

Healthcare coverage is provided through a combination of private health insurance and public health coverage (e.g., Medicare, Medicaid). In 2013, 64% of health spending was paid for by the government,<ref>{{cite journal | vauthors = Himmelstein DU, Woolhandler S | title = The Current and Projected Taxpayer Shares of US Health Costs | journal = American Journal of Public Health | volume = 106 | issue = 3 | pages = 449–52 | date = March 2016 | pmid = 26794173 | pmc = 4880216 | doi = 10.2105/AJPH.2015.302997 | quote = Government's share of overall health spending was 64% of national health expenditures in 2013 }}</ref><ref>{{cite magazine|last=Leonard|first=Kimberly| name-list-style = vanc |date=January 22, 2016|title=Could Universal Health Care Save U.S. Taxpayers Money?|url=https://www.usnews.com/news/blogs/data-mine/2016/01/22/could-universal-health-care-save-us-taxpayers-money|magazine=U.S. News & World Report|access-date=July 12, 2016}}</ref> and funded via programs such as [[Medicare (United States)|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 in the United States|Health insurance]] for [[public sector]] employees is primarily provided by the government in its role as employer.<ref>{{Cite news|url=http://www.fedweek.com/retirement-financial-planning/fehb-relates-government-health-insurance/|title=How FEHB Relates to Other Government Health Insurance|date=May 25, 2017|work=FEDweek|access-date=May 26, 2017|language=en-US}}</ref> [[Managed care]], where payers use various techniques intended to improve quality and limit cost, has become ubiquitous.

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.<ref>{{cite web|url=https://www.cdc.gov/nchs/nhis.htm|title=National Center for Health Statistics|website=Cdc.gov|access-date=December 1, 2016}}</ref> In 2004, an OECD report noted that "all [[Organisation for Economic Co-operation and Development#Member countries|OECD countries]] [except Mexico, Turkey, and the US] had achieved universal or near-universal (at least 98.4% insured) coverage of their populations by 1990".<ref name="Docteur 2004">{{cite book |chapter-url= https://books.google.com/books?id=r6MLakbHnEQC&pg=PA74 |title=Towards high-performing health systems: policy studies |last1=Docteur |first1=Elizabeth |last2=Oxley |first2=Howard | name-list-style = vanc |date=October 19, 2004 |publisher=OECD |isbn=978-92-64-01559-3 |series=The OECD health project |location=Paris |pages=25, 74 |chapter=Health-system reform: lessons from experience}}</ref> The 2004 IOM report also observed that "lack of health insurance causes roughly 18,000 unnecessary deaths every year in the US".<ref name="IOM 2004" /> 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.<ref>{{Cite news|url=https://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-linked-to-lack-of-health-coverage/|title=New study finds 45,000 deaths annually linked to lack of health coverage|date=2009-09-17|work=Harvard Gazette|access-date=2018-02-28|language=en-US}}</ref> 

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.<ref name=WittersJan2019>{{cite news |url=https://news.gallup.com/poll/246134/uninsured-rate-rises-four-year-high.aspx |title=U.S. Uninsured Rate Rises to Four-Year High |first=Dan |last=Witters | name-list-style = vanc |date=January 23, 2019 |newspaper=Gallup News: Well-being |access-date=August 13, 2019}}</ref> "The 2.8-percentage-point increase since that low represents a net increase of about seven million adults without health insurance."<ref name=WittersJan2019 />

The [[United States Census Bureau|US Census Bureau]] reported that 28.5&nbsp;million people (8.8%) did not have health insurance in 2017,<ref>{{Cite web|url=https://www.census.gov/library/publications/2018/demo/p60-264.html|title=Health Insurance Coverage in the United States: 2017|last=Bureau|first=US Census|website=census.gov|language=en-US|access-date=2018-11-25}}</ref> down from 49.9&nbsp;million (16.3%) in 2010.<ref name="DeNavas-Walt 2011">{{cite book|url=https://www.census.gov/prod/2011pubs/p60-239.pdf|title=Income, poverty, and health insurance coverage in the United States: 2010|last1=DeNavas-Walt|first1=Carmen|last2=Proctor|first2=Bernadette D.|last3=Smith|first3=Jessica C. | name-list-style = vanc |date=September 13, 2011|publisher=U.S. Government Printing Office|series=U.S. Census Bureau: Current Population Reports, P60-239|location=Washington, DC}}</ref><ref name="uninsured 2009">{{cite news|url=https://www.wsj.com/articles/SB10001424052748704394704575496093363948142|title=Recession swells number of uninsured to 50.7 million|author=Johnson, Avery|date=September 17, 2010|newspaper=The Wall Street Journal|access-date=November 21, 2010|page=A4}}

* {{cite news|url=https://www.usatoday.com/news/nation/2010-09-17-uninsured17_ST_N.htm|title=Number of uninsured Americans rises to 50.7 million| last = Wolf | first = Richard | name-list-style = vanc |date=September 17, 2010|newspaper=USA Today|access-date=November 21, 2010|page=8A}}
* {{cite web|url=https://www.census.gov/prod/2010pubs/p60-238.pdf|title=Income, poverty, and health insurance coverage in the United States: 2009| last1 = DeNavas-Walt | first1 = Carmen | last2 = Proctor | first2 = Bernadette D. | name-list-style = vanc |date=September 16, 2010|publisher=U.S. Census Bureau|location=Washington, D.C.|access-date=November 21, 2010|author3=Smith, Jessica C.}}
* {{cite web|url=http://meps.ahrq.gov/mepsweb/data_files/publications/st291/stat291.pdf|title=The uninsured in America, first half of 2009: estimates for the United States civilian noninstitutionalized population under age 65. Medical Expenditure Panel Survey, Statistical Brief #291| last1 = Roberts | first1 = Michelle | last2 =Rhoades | first2 = Jeffrey A. | name-list-style = vanc |date=August 19, 2010|publisher=Agency for Healthcare Research and Quality (AHRQ)|location=Rockville, Md.|access-date=November 21, 2010}}
* {{cite web|url=https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201009.pdf|title=Health insurance coverage: early release of estimates from the National Health Interview Survey, January–March 2010| last1 = Cohen | first1 = Robin A. | last2 = Martinez | first2 = Michael A. | name-list-style = vanc |date=September 22, 2010|publisher=National Center for Health Statistics (NCHS)|location=Hyattsville, Md.|access-date=November 21, 2010}}
* {{cite web|url=http://www.shadac.org/files/RWJF_CompareSurveysIB_Aug2008.pdf|title=Comparing federal government surveys that count uninsured people in America|date=August 26, 2008|publisher=State Health Access Data Assistance Center, School of Public Health, University of Minnesota|location=Minneapolis, Minn.|access-date=November 21, 2010}}</ref> Between 2004 and 2013, a trend of high rates of underinsurance and [[wage stagnation]] contributed to a healthcare consumption decline for low-income Americans.<ref>{{cite journal | vauthors = Dickman SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU | title = Health Spending For Low-, Middle-, And High-Income Americans, 1963-2012 | journal = Health Affairs | volume = 35 | issue = 7 | pages = 1189–96 | date = July 2016 | pmid = 27385233 | doi = 10.1377/hlthaff.2015.1024 | url = https://dash.harvard.edu/bitstream/handle/1/27007724/DICKMAN-DOCTOROFMEDICINETHESIS-2016.pdf?sequence=3&isAllowed=y | doi-access = free | url-access =  | url-status =  | archive-url =  | archive-date =  }}</ref> This trend was reversed after the implementation of the major provisions of the ACA in 2014.<ref name=":0">{{cite journal | vauthors = Dickman SL, Himmelstein DU, Woolhandler S | title = Inequality and the health-care system in the USA | journal = Lancet | volume = 389 | issue = 10077 | pages = 1431–1441 | date = April 2017 | pmid = 28402825 | doi = 10.1016/s0140-6736(17)30398-7 | s2cid = 13654086 }}</ref>

[[File:Medicaid expansion map of US. Affordable Care Act.svg|thumb|upright=1.35|[[Medicaid coverage gap#Medicaid expansion|ACA Medicaid expansion]] by state.<ref name="KFF-Medicaid">{{cite web |title=Status of State Medicaid Expansion Decisions: Interactive Map |url=https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map |publisher=[[Kaiser Family Foundation|KFF]]. Map is updated as changes occur. Click on states for details.}}</ref>
{{legend|#2b83ba|Not adopted}}
{{legend|#89CC7F|Adopted}}
{{legend|#FECDAC|Implemented}}]]
{{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.<ref name=":1">{{cite journal | vauthors = Sommers BD, Gawande AA, Baicker K | title = Health Insurance Coverage and Health - What the Recent Evidence Tells Us | language = EN | journal = The New England Journal of Medicine | volume = 377 | issue = 6 | pages = 586–593 | date = August 2017 | pmid = 28636831 | doi = 10.1056/nejmsb1706645 | s2cid = 2653858 }}</ref> 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.<ref name=":1" /> 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.<ref>{{cite journal | vauthors = Frean M, Gruber J, Sommers BD | title = Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act | journal = Journal of Health Economics | volume = 53 | pages = 72–86 | date = May 2017 | pmid = 28319791 | doi = 10.1016/j.jhealeco.2017.02.004 | hdl = 1721.1/129483 | s2cid = 3759121 | url = http://www.nber.org/papers/w22213.pdf | hdl-access = free }}</ref> 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 (equivalent to ${{Formatprice|{{inflation|US|327000|2016}}}} to ${{Formatprice|{{inflation|US|867000|2016}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) per life saved compared to other public policies which cost an average of $7.6&nbsp;million (equivalent to ${{Formatprice|{{inflation|US|7600000|2016}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) per life.<ref>{{Cite journal|last=Sommers |first=Benjamin D.|name-list-style=vanc|date=May 11, 2017 |title=State Medicaid Expansions and Mortality, Revisited: A Cost-Benefit Analysis|journal=American Journal of Health Economics|volume=3|issue=3|pages=392–421|doi=10.1162/ajhe_a_00080|s2cid=53488456|issn=2332-3493 |url=https://dash.harvard.edu/bitstream/1/27305958/1/Mcaid%20Mortality%20Revisited%20DASH%20Version.pdf|url-access=|url-status=|archive-url=|archive-date=}}</ref>

A 2009 study in five states found that [[medical debt]] contributed to 46.2% of all [[Bankruptcy in the United States|personal bankruptcies]], and 62.1% of bankruptcy filers claimed high medical expenses in 2007.<ref>{{cite news|url=http://www.cbsnews.com/stories/2009/06/05/earlyshow/health/main5064981.shtml |title=Medical Debt Huge Bankruptcy Culprit – Study: It's Behind Six-In-Ten Personal Filings|date=June 5, 2009|access-date=June 22, 2009 |publisher=CBS}}</ref><!--refuted by Todd Zywicki's paper on the subject. See http://mason.gmu.edu/~tzywick2/Bankruptcy%20Crisis%20Final.pdf and http://judiciary.house.gov/hearings/July2007/Zywicki070717.pdf--> Since then, health costs and the numbers of uninsured and underinsured have increased.<ref>{{cite news|url=https://money.cnn.com/2009/03/05/news/economy/healthcare_underinsured/|title=Underinsured Americans: Cost to you|last=Kavilanz |first=Parija B.|name-list-style=vanc |date=March 5, 2009|work=CNN}}</ref> A 2013 study found that about 25% of all senior citizens declare bankruptcy due to medical expenses.<ref name="kelley2013">{{cite journal | vauthors = Kelley AS, McGarry K, Fahle S, Marshall SM, Du Q, Skinner JS | title = Out-of-pocket spending in the last five years of life | journal = Journal of General Internal Medicine | volume = 28 | issue = 2 | pages = 304–9 | date = February 2013 | pmid = 22948931 | pmc = 3614143 | doi = 10.1007/s11606-012-2199-x }}</ref>

In practice, the uninsured are often treated, but the cost is covered through taxes and other fees which shift the cost.<ref>{{Cite web|last=Groman|first=Rachel|name-list-style=vanc|date=2004|title=The Cost of Lack of Health Insurance|website=American College of Physicians|access-date=22 October 2017 |url=https://www.acponline.org/acp_policy/policies/cost_of_lack_of_health_insurance_1999.pdf|archive-url=https://web.archive.org/web/20160707030157/https://www.acponline.org/acp_policy/policies/cost_of_lack_of_health_insurance_1999.pdf|archive-date=July 7, 2016|url-status=dead}}</ref> 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.<ref name=":0" />

Those who are insured may be underinsured such that they cannot afford adequate medical care. A 2003 study estimated that 16&nbsp;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.<ref>{{cite journal |vauthors=Schoen C, Doty MM, Collins SR, Holmgren AL |title=Insured but not protected: how many adults are underinsured? |journal=Health Affairs |volume=24 |issue=Suppl 1 Web Exclusives |pages=W5-289-W5-302 |date=June 14, 2005 |pmid=15956055 |doi=10.1377/hlthaff.w5.289}}</ref> Lack of insurance or higher cost sharing (user fees for the patient with insurance) create barriers to accessing healthcare: use of care declines with increasing patient cost-sharing obligation.<ref name=":0" /> 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).<ref>{{cite journal |vauthors=Davis K, Ballreich J |title=Equitable access to care--how the United States ranks internationally |language=EN |journal=The New England Journal of Medicine |volume=371 |issue=17 |pages=1567–1570 |date=October 2014 |pmid=25337745 |doi=10.1056/nejmp1406707 |s2cid=205110579 }}</ref>

=== Health in the US in global context ===
[[File:Life expectancy vs healthcare spending.jpg|thumb|upright=1.6|Life expectancy vs healthcare spending of rich OECD countries. [[List of countries by total health expenditure per capita|US average of $10,447 in 2018]].<ref name=life>[https://ourworldindata.org/the-link-between-life-expectancy-and-health-spending-us-focus Link between health spending and life expectancy: US is an outlier]. May 26, 2017. By [[Max Roser]] at [[Our World in Data]]. Click the sources tab under the chart for info on the countries, healthcare expenditures, and data sources. See the later version of the chart [https://ourworldindata.org/us-life-expectancy-low here].</ref><ref name=Kenworthy2011>{{cite web |last= Kenworthy |first= Lane | name-list-style = vanc |date= July 10, 2011 |title= America's inefficient health-care system: another look | work = Consider the Evidence (blog) |url= http://lanekenworthy.net/2011/07/10/americas-inefficient-health-care-system-another-look/ |access-date= September 11, 2012}}</ref>]]
[[File:Life expectancy by WBG -USA -diff.png|thumb|upright=1.3|Timeline of US life expectancy by gender and overall. Also, a timeline of the gender gap.]]

The US [[life expectancy]] in 2010 was 78.6 years at birth, up from 75.2 years in 1990; this ranks 42nd among 224 nations, and 22nd out of the 35 [[OECD]] countries, down from 20th in 1990.<ref name=factbook-life-expenctancy>{{cite web |url=https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html |title=Country Comparison: Life Expectancy at Birth |publisher=CIA |work=The World Factbook |access-date=April 22, 2017 |archive-date=January 2, 2018 |archive-url=https://web.archive.org/web/20180102233121/https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html |url-status=dead }}</ref><ref name="Murray2013" /> In 2021, US life expectancy fell to 76.4 years, the shortest in roughly two decades. Drivers for this drop in life expectancy include accidents, [[Opioid epidemic in the United States|drug overdoses]], heart and liver disease, [[Suicide in the United States|suicides]] and the [[COVID-19 pandemic in the United States|COVID-19 pandemic]].<ref>{{cite news |last=Noguchi|first=Yuki |date=December 22, 2022 |title=American life expectancy is now at its lowest in nearly two decades|url=https://www.npr.org/sections/health-shots/2022/12/22/1144864971/american-life-expectancy-is-now-at-its-lowest-in-nearly-two-decades|work=[[NPR]] |location= |access-date=June 22, 2023}}</ref> 

In 2019, the under-five child mortality rate was 6.5&nbsp;deaths per 1000 live births, placing the US 33rd of 37 OECD countries.<ref>[http://databank.worldbank.org/data/reports.aspx?source=2&series=SH.DYN.MORT&country= Mortality rate, under-5 (per 1,000 live births)]. [[World Bank]] Data. [[World Development Indicators]]. World DataBank.</ref>

While not as high in 2015 (14)<ref name=":3">{{cite web|url=http://apps.who.int/gho/data/node.sdg.3-1-viz?lang=en|title=Global Health Observatory (GHO) data: Maternal mortality ratio (per 100 000 live births), by WHO region, 2015|website=World Health Organization|language=en-GB|access-date=September 5, 2017}}</ref> 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.<ref name=":4">{{cite news|url=https://www.washingtonpost.com/local/maternal-deaths-in-childbirth-rise-in-the-us/2014/05/02/abf7df96-d229-11e3-9e25-188ebe1fa93b_story.html|title=Maternal deaths in childbirth rise in the U.S.|last=Morello|first=Carol| name-list-style = vanc |date=May 2, 2014|access-date=May 5, 2015|newspaper=Washington Post}}</ref> {{As of|2015}}, the US 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.<ref name=":3" /> In 2019, [[Black maternal mortality in the United States|Black maternal health]] advocate and ''[[Parents (magazine)|Parents]]'' writer [[Christine Michel Carter]] interviewed Vice President [[Kamala Harris]]. As a senator, in 2019 Harris reintroduced the [https://www.congress.gov/bill/116th-congress/senate-bill/1600 Maternal Care Access and Reducing Emergencies (CARE) Act] which aimed to address the maternal mortality disparity faced by women of color by training providers on recognizing implicit racial bias and its impact on care. Harris stated:

<blockquote>We need to speak the uncomfortable truth that women—and especially Black women—are too often not listened to or taken seriously by the health care system, and therefore they are denied the dignity that they deserve. And we need to speak this truth because today, the United States is 1 of only 13 countries in the world where the rate of maternal mortality is worse than it was 25 years ago. That risk is even higher for Black women, who are three to four times more likely than white women to die from pregnancy-related causes. These numbers are simply outrageous.</blockquote>

[[Life expectancy at birth]] for a child born in the US in 2015 is 81.2 (females) or 76.3 (males) years.<ref name=":5">{{cite web|url=http://apps.who.int/gho/data/view.main.SDG2016LEXv?lang=en|title=Global Health Observatory (GHO) data: Life expectancy data by country |publisher=World Health Organization|language=en-GB|access-date=September 5, 2017}}</ref> According to the WHO, life expectancy in the US is [[List of countries by life expectancy|31st in the world]] (out of 183&nbsp;countries) {{As of|2015|lc=y}}.<ref name=":6">{{cite web|url=https://www.who.int/gho/publications/world_health_statistics/2016/EN_WHS2016_AnnexB.pdf?ua=1|title=World Health Statistics 2016 Monitoring health for the SDGs: Annex B, Tables of health statistics by country, WHO region, and globally|website=World Health Organization|language=en-GB|access-date=September 5, 2017}}</ref> The US's average life expectancy (both sexes) is just over 79.<ref name=":6" /> Japan ranks first with an average life expectancy of nearly 84&nbsp;years. The US ranks lower (36th) when considering health-adjusted life expectancy (HALE) at just over 69&nbsp;years.<ref name=":6" /> Another source, the Central Intelligence Agency, indicates life expectancy at birth in the US 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.<ref name=factbook-life-expenctancy/>

A 2013 [[National Academies of Sciences, Engineering, and Medicine|National Research Council]] study stated that, when considered as one of 17 [[World Bank high-income economy|high-income countries]], the US was at or near the top in infant mortality, [[Cardiovascular disease|heart]] and [[Respiratory disease|lung]] disease, [[sexually transmitted infection]]s, [[Teenage pregnancy|adolescent pregnancies]], injuries, homicides, and rates of [[disability]]. Together, such issues place the US at the bottom of the list for life expectancy in high-income countries.<ref name="nihbph">National Research Council and Institute of Medicine. (2013) [http://books.nap.edu/openbook.php?record_id=13497 "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.</ref> Females born in the US in 2015 have a life expectancy of 81.6&nbsp;years, and males 76.9&nbsp;years; more than three years less and as much as over five years less than people born in Switzerland (85.3 F, 81.3 M) or Japan (86.8 F, 80.5 M) in 2015.<ref name=":5" />

{{Anchor|Causes_of_mortality_in_the_U.S.}}

=== Causes of mortality in the US ===
{{See also|List of causes of death by rate#United States}}

The top three causes of death among both sexes and all ages in the US have consistently remained cardiovascular diseases (ranked 1st), neoplasms (2nd) and neurological disorders (3rd), since the 1990s.<ref name=":7">{{cite web|url=http://ihmeuw.org/46l6|title=Institute for Health Metrics and Evaluation: United States both sexes, all ages, deaths per 100,000|website=healthdata.org|language=en|access-date=September 5, 2017}}</ref> 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.<ref>{{cite web|url=https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm|title=FastStats|date=2017-08-03|website=cdc.gov|language=en-us|access-date=2018-02-28}}</ref> In 2015, 267.18 deaths per 100,000 people were caused by cardiovascular diseases, 204.63 by neoplasms and 100.66 by neurological disorders.<ref name=":7" /> Diarrhea, lower respiratory, and other common infections were ranked sixth overall, but had the highest rate of infectious disease mortality in the US at 31.65&nbsp;deaths per 100,000&nbsp;people.<ref name=":7" /> 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.<ref>{{cite web| url= https://www.npr.org/blogs/health/2013/01/09/168976602/u-s-ranks-below-16-other-rich-countries-in-health-report |title=U.S. Ranks Below 16 Other Rich Countries In Health Report |website=Npr.org |date=January 9, 2013 |access-date=December 1, 2016}}</ref> [[Diseases of despair]] (drug overdoses, alcoholic liver disease, and suicide), which started increasing in the early 1990s, kill roughly 158,000&nbsp;Americans a year {{As of|2018|lc=y}}.<ref>{{cite book |last1= Case |first1=Anne |last2= Deaton |first2=Angus|author-link1=Anne Case |author-link2=Angus Deaton |date=2021 |title=Deaths of Despair and the Future of Capitalism |url=https://books.google.com/books?id=-l37DwAAQBAJ&pg=PR9 |publisher=[[Princeton University Press]]|page=ix |isbn=978-0691217079}}</ref> [[Suicide in the United States|Suicides]] reached record levels in the United States in 2022, with nearly 49,500 suicide deaths. Since 2011, around 540,000 people in the U.S. have died by suicide.<ref>{{cite news |author=<!--not stated--> |date=August 10, 2023 |title=Suicides in the U.S. reached all-time high in 2022, CDC data shows|url=https://www.nbcnews.com/health/mental-health/cdc-data-finds-suicides-reached-time-high-2022-rcna99327|work=[[NBC News]] |location= |access-date=August 15, 2023}}</ref><ref>{{cite news |last=Mateus|first=Benjamin |date=August 11, 2023 |title=Deaths of despair and suicides in the US at historic levels|url=https://www.wsws.org/en/articles/2023/08/12/suou-a12.html|work=[[World Socialist Web Site]]|location= |access-date=August 15, 2023}}</ref> Cumulative [[Poverty in the United States|poverty]] of ten years or more is the fourth leading risk factor for mortality in the United States annually.<ref>{{cite news |last=Danelski |first=David |date=April 17, 2023|title=Poverty is the 4th greatest cause of U.S. deaths|url=https://news.ucr.edu/articles/2023/04/17/poverty-4th-greatest-cause-us-deaths|work=news.ucr.edu|location= |access-date=June 23, 2023}}</ref><ref>{{cite journal |last1=Brady|first1=David |last2=Kohler|first2=Ulrich|last3=Zheng|first3=Hui |date=2023|title=Novel Estimates of Mortality Associated With Poverty in the US|url= |journal=The Journal of the American Medical Association|volume=183 |issue=6 |pages=504–628|doi=10.1001/jamainternmed.2023.0276|pmid=37067817 |pmc=10111231 |access-date= |pmc-embargo-date=April 17, 2024 }}</ref><ref>{{cite news |last=Murez|first=Cara |date=April 18, 2023|title=America's 4th Leading Cause of Death: Poverty|url=https://www.usnews.com/news/health-news/articles/2023-04-18/americas-4th-leading-cause-of-death-poverty|work=[[U.S. News & World Report]]|location= |access-date=August 15, 2023}}</ref><ref>{{cite news |last=Jarow|first=Oshan |date=July 14, 2023|title=Poverty is a major public health crisis. Let's treat it like one.|url=https://www.vox.com/future-perfect/23792854/poverty-mortality-study-public-health-antipoverty-america-deaths-poor-life-expectancy|work=Vox  |location= |access-date=August 24, 2023}}</ref>

[[File:Life expectancy post-COVID.png|thumb|Post-COVID life expectancy in the US, UK, Netherlands, and Austria]]

Since 2020, the [[Centers for Disease Control and Prevention]] (CDC) reports that the life expectancy for the US population was 77.0 years, a decrease of 1.8 years from 2019.<ref>{{Cite journal |date=2021-12-21 |title=Products - Data Briefs - Number 427 - December 2021 |url=https://www.cdc.gov/nchs/products/databriefs/db427.htm |access-date=2022-03-03 |website=www.cdc.gov |doi=10.15620/cdc:112079 |s2cid=54466506 |language=en-us}}</ref> Life expectancy fell again in 2021 to 76.4&nbsp;years, which has been attributed to [[COVID-19]] and rising death rates from suicide, drug overdoses and liver disease.<ref>{{cite news |last=Noguchi|first=Yuki |date=December 22, 2022 |title=American life expectancy is now at its lowest in nearly two decades|url=https://www.npr.org/sections/health-shots/2022/12/22/1144864971/american-life-expectancy-is-now-at-its-lowest-in-nearly-two-decades|work=[[NPR]] |location= |access-date=December 27, 2022|quote=The new numbers also speak to the acute mental health crisis that's run parallel to the pandemic: Deaths from drug overdoses reached over 106,000 last year — another major factor reducing life expectancy, according to the second CDC analysis released on Thursday. Deaths by suicide and from liver disease, or cirrhosis, caused by alcohol also increased — shortening the average American life span.}}</ref> As of 2023, U.S. life expectancy has increased slightly following the COVID-19 pandemic, but still trails behind peer and rival countries including Canada, China and Germany.<ref>{{cite news |last=Diamond|first=Dan|date=December 28, 2023|title=America has a life expectancy crisis. But it’s not a political priority.|url=https://www.washingtonpost.com/health/2023/12/28/life-expectancy-no-political-response/|work=The Washington Post |location= |access-date=December 29, 2023|quote=While recent federal data suggests that life expectancy ticked up in 2022, a partial rebound from the ravages of the coronavirus pandemic, no national strategy exists to reverse a years-long slide that has left the United States trailing peers, such as Canada and Germany, and rivals, such as China.}}</ref> Death certificate data from the CDC reveals that mortality rates among children and adolescents increased by 11% for the years 2019 and 2020 and a further 8% for 2020 and 2021, with injuries being a driving factor, along with homicide, suicide, drug overdoses and motor vehicle accidents impacting those aged 10 to 19.<ref>{{cite web |url=https://news.vcu.edu/article/2023/03/child-and-teen-mortality-in-the-us-experiences-largest-increase-in-decades|title=Child and teen mortality in the U.S. experiences largest increase in decades|last=Trani|first=Olivia |date=March 13, 2023 |website=[[Virginia Commonwealth University|VCU News]]|publisher= |access-date=June 15, 2023 |quote=}}</ref><ref>{{cite news |last=de Visé|first=Daniel |date=March 22, 2023 |title=Child mortality is rising at the fastest rate in 50 years|url=https://thehill.com/policy/healthcare/3910940-child-mortality-is-rising-at-the-fastest-rate-in-50-years/|work=[[The Hill (newspaper)|The Hill]] |location= |access-date=June 15, 2023}}</ref>

== Providers ==
[[Health care provider|Healthcare provider]]s in the US encompass individual healthcare personnel, healthcare facilities, and medical products.

=== Facilities ===
{{Main|Medical centers in the United States|Category:Hospital networks in the United States}}
[[File:Aerial-Picture-of-Jackson-e1445995779731.jpg|thumb|upright=1.2|[[Jackson Memorial Hospital]] in [[Miami]], the primary teaching hospital of the [[University of Miami]]'s [[Leonard M. Miller School of Medicine]] and the largest hospital in the US with 1,547 beds<ref>[https://www.beckershospitalreview.com/100-of-the-largest-hospitals-and-health-systems-in-america-2021.html "100 of the largest hospitals and health systems in America"], ''Becker's Hospital Review''</ref>]]

In the US, 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 US. There were 4,840 community hospitals, which are defined as nonfederal, short-term general, or specialty hospitals.<ref>{{cite web|url=https://www.aha.org/statistics/fast-facts-us-hospitals|title=Fast Facts on U.S. Hospitals, 2018 {{!}} AHA|website=American Hospital Association|language=en|access-date=2018-02-28}}</ref> The [[nonprofit hospital]]s share of total hospital capacity has remained relatively stable (about 70%) for decades.<ref>{{cite web|title=The Convergence between For-Profit and Nonprofit Hospitals in the United States|last=David|first=Guy| name-list-style = vanc |date=May 2005 |url=http://www.aeaweb.org/annual_mtg_papers/2006/0106_0800_0204.pdf|archive-url=https://web.archive.org/web/20060226133139/http://www.aeaweb.org/annual_mtg_papers/2006/0106_0800_0204.pdf|url-status=dead|archive-date=2006-02-26}}</ref> There are also [[For-profit hospital|privately owned for-profit hospitals]] as well as [[public hospital|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.<ref>{{cite web |url=http://congress.indiana.edu/hill%E2%80%93burton-act |title=The Hill–Burton Act &#124; The Center On Congress at Indiana University |website=Congress.indiana.edu |access-date=December 1, 2016 |archive-url=https://web.archive.org/web/20141103062317/http://congress.indiana.edu/hill%E2%80%93burton-act |archive-date=November 3, 2014 |url-status=dead}}</ref> The largest hospital system in 2016 by revenue was [[HCA Healthcare]];<ref>{{Cite web|url=https://www.beckershospitalreview.com/lists/15-largest-health-systems-in-the-u-s-june15.html|title=15 largest health systems in the U.S.|website=beckershospitalreview.com|date=June 15, 2016 |access-date=2019-05-17}}</ref> in 2019, Dignity Health and Catholic Health Initiatives merged into [[CommonSpirit Health]] to create the largest by revenue, spanning 21&nbsp;states.<ref>{{Cite web|url=https://www.healthcaredive.com/news/dignity-chi-merger-creates-largest-nonprofit-health-system-by-revenue/547451/|title=Dignity-CHI merger creates largest nonprofit health system by revenue|website=Healthcare Dive|language=en-US|access-date=2019-05-17}}</ref>

[[Integrated delivery system]]s, where the provider and the insurer share the risk in an attempt to provide [[Pay for performance (healthcare)|value-based healthcare]], have grown in popularity.<ref>{{cite journal | vauthors = Cohen GR, Jones DJ, Heeringa J, Barrett K, Furukawa MF, Miller D, Mutti A, Reschovsky JD, Machta R, Shortell SM, Fraze T, Rich E | display-authors = 6 | title = Leveraging Diverse Data Sources to Identify and Describe U.S. Health Care Delivery Systems | journal = eGEMs | volume = 5 | issue = 3 | pages = 9 | date = December 2017 | pmid = 29881758 | pmc = 5983023 | doi = 10.5334/egems.200 | doi-access = free }}</ref> Regional areas have separate healthcare markets, and in some markets competition is limited as the demand from the local population cannot support multiple hospitals.<ref>{{Cite web|url=https://www.statnews.com/2017/09/20/hospitals-competition-health-care/|title=Boosting competition among hospitals, health systems will improve health care|date=2017-09-20|website=STAT|language=en-US|access-date=2019-05-22}}</ref><ref>{{Cite web|url=http://politi.co/2zs8SI0|title=A nation of McHospitals?|last=Diamond|first=Dan| name-list-style = vanc |website=The Agenda|date=November 8, 2017 |language=en|access-date=2019-05-24}}</ref>

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]]s to increase bargaining power.<ref>{{cite journal | vauthors = Casalino LP, Pesko MF, Ryan AM, Mendelsohn JL, Copeland KR, Ramsay PP, Sun X, Rittenhouse DR, Shortell SM | display-authors = 6 | title = Small primary care physician practices have low rates of preventable hospital admissions | journal = Health Affairs | volume = 33 | issue = 9 | pages = 1680–8 | date = September 2014 | pmid = 25122562 | doi = 10.1377/hlthaff.2014.0434 | doi-access = free }}</ref>
[[File:US Department of Veterans Affairs vertical logo.svg|thumb|upright|US Department of Veterans Affairs vertical logo]]
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 [[United States Department of Defense|US Department of Defense]] operates field hospitals as well as permanent hospitals via the [[Military Health System]] to provide military-funded care to active military personnel.<ref>{{Cite web|title=About the Military Health System|url=https://health.mil/About-MHS|access-date=2021-03-08|website=Military Health System|language=en}}</ref>

The federal [[Veterans Health Administration]] operates [[List of Veterans Affairs medical facilities|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]] (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]]s provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital [[emergency department]]s and [[urgent care]] centers are sources of sporadic problem-focused care. [[Surgicenter]]s are examples of specialty clinics. [[Hospice]] 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]], and [[dysplasia]] clinics are government-funded [[obstetric]] and [[gynecologic]] specialty clinics respectively, and are usually staffed by nurse practitioners.{{citation needed|date=September 2016}} Services, particularly urgent-care services, may also be delivered remotely via [[telemedicine]] by providers such as [[Teladoc]].

Besides government and private healthcare facilities, there are also 355 registered [[free clinics]] in the US that provide limited medical services. They are considered to be part of the [[social safety net]] for those who lack health insurance. Their services may range from more acute care (i.e., STIs, injuries, respiratory diseases) to long term care (i.e. dentistry, counseling).<ref name=":22">{{cite journal | vauthors = Nadkarni MM, Philbrick JT | title = Free clinics: a national survey | journal = The American Journal of the Medical Sciences | volume = 330 | issue = 1 | pages = 25–31 | date = July 2005 | pmid = 16020996 | doi = 10.1097/00000441-200507000-00005 | s2cid = 20380812 }}</ref> Another component of the healthcare safety net would be federally funded [[Community health centers in the United States|community health centers]].

Other healthcare facilities include long-term housing facilities which, {{As of|2019|lc=y}}, there were 15,600 nursing homes across the US, with a large portion of that number being for-profit (69.3%)<ref>{{cite web|title=FastStats: Nursing Home Care|url=https://www.cdc.gov/nchs/fastats/nursing-home-care.htm|website=National Center for Health Statistics (U.S.)|date=March 2021}}</ref>

In 2022, 19&nbsp;hospitals filed for bankruptcy, closed, or announced plans to close.<ref>{{cite news |title=19 hospital closures, bankruptcies in 2022 |url=https://www.beckershospitalreview.com/finance/19-hospital-closures-bankruptcies-in-2022.html?origin=BHRSUN&oly_enc_id=3981D2277256E2X |access-date=14 November 2022 |publisher=Beckers Hospital Review |date=11 November 2022}}</ref>

=== Physicians (M.D. and D.O.) ===
{{Main|Physicians in the United States}}

Physicians in the US include those trained by the [[Medical education in the United States|US medical education]] system, and those that are [[international medical graduate]]s who have progressed through the necessary steps to acquire a [[medical license]] to practice in a state.{{citation needed|date=September 2016}} This includes going through the three steps of the [[US Medical Licensing Examination]] (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]], pathology, pharmacology, physiology, [[Behavioural sciences|behavioral sciences]], nutrition, [[genetics]], 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.<ref name="doctorsthatdo.org|title=Home">{{cite web|url=http://doctorsthatdo.org|title=Home - Doctors That DO {{!}} Doctors of Osteopathic Medicine|website=Doctors That DO {{!}} Doctors of Osteopathic Medicine|language=en-US|access-date=2018-02-28}}</ref>{{Unreliable source?|date=March 2018}}

The [[American College of Physicians]], uses the term "physician" to describe all medical practitioners holding a professional [[medical degree]]. In the US, the vast majority of physicians have a [[Doctor of Medicine]] (M.D.) degree.<ref>{{Cite journal | vauthors = Young A, Chaudhry HJ, Pei X, Arnhart K, Dugan M, Snyder GB | title = A census of actively licensed physicians in the United States, 2016. | journal = Journal of Medical Regulation | date = 2017 | volume = 103 | issue = 2 | pages = 7–21 |url= https://www.fsmb.org/Media/Default/PDF/Census/2016census.pdf | doi = 10.30770/2572-1852-103.2.7 | doi-access = free }}</ref> Those with [[Doctor of Osteopathic Medicine]] (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 [[Medication|pharmaceuticals]] and [[medical devices]] 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&nbsp;billion (equivalent to ${{Formatprice|{{inflation|US-GDP|95000000000|2003}}}} in {{Inflation/year|index=US-GDP}}{{Inflation/fn|index=US-GDP}}) with $40&nbsp;billion (equivalent to ${{Formatprice|{{inflation|US-GDP|40000000000|2003}}}} in {{Inflation/year|index=US-GDP}}{{Inflation/fn|index=US-GDP}}) coming from public sources and $55&nbsp;billion (equivalent to ${{Formatprice|{{inflation|US-GDP|55000000000|2003}}}} in {{Inflation/year|index=US-GDP}}{{Inflation/fn|index=US-GDP}}) coming from private sources.<ref>{{cite web|url=http://www.csic.es/vri/otros-programas/esf/EMRC_Whitepaper.pdf|title=(Open using Adobe reader) p. 16|url-status=dead|archive-url=https://web.archive.org/web/20091004085517/http://www.csic.es/vri/otros-programas/esf/EMRC_Whitepaper.pdf|archive-date=October 4, 2009}}</ref><ref name="Medical Research Spending Doubled Over Past Decade">[http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/tb/1767 Medical Research Spending Doubled Over Past Decade], Neil Osterweil, MedPage Today, September 20, 2005</ref> These investments into medical research have made the US the leader in medical innovation, measured either in terms of revenue or the number of new drugs and devices introduced.<ref name="EFPIA"/><ref name="Europe"/> In 2016, the research and development spending by pharmaceutical companies in the US was estimated to be around $59&nbsp;billion (equivalent to ${{Formatprice|{{inflation|US-GDP|59000000000|2016}}}} in {{Inflation/year|index=US-GDP}}{{Inflation/fn|index=US-GDP}}).<ref>{{cite web|url=https://www.statista.com/statistics/265085/research-and-development-expenditure-us-pharmaceutical-industry/#0|title=U.S. pharmaceutical R&D expenditure 1995-2015 {{!}} Statistic|website=Statista|language=en|access-date=2018-02-28}}</ref> In 2006, the US accounted for three quarters of the world's biotechnology revenues and 82% of world R&D spending in biotechnology.<ref name="EFPIA" /><ref name="Europe" /> According to multiple international [[pharmaceutical]] trade groups, the high cost of patented drugs in the US has encouraged substantial reinvestment in such research and development.<ref name="EFPIA" /><ref name="Europe" /><ref name="PHRMA">{{cite web|url=http://www.phrma.org/files/PhRMA_annualreportFianl.pdf |title=2008 Annual Report |access-date=June 20, 2009 |work=PHRMA |url-status=dead |archive-url=https://web.archive.org/web/20081230124209/http://www.phrma.org/files/PhRMA_annualreportFianl.pdf |archive-date=December 30, 2008 }}</ref> Though, the [[Affordable Care Act|ACA]] will force industry to sell medicine at a cheaper price.<ref name="Houlton 2012 23">{{cite journal|last=Houlton|first=Sarah| name-list-style = vanc |title=Debating Obamacare|journal=Chemistry and Industry|date=September 2012|volume=76|page=23|doi=10.1002/cind.7609_5.x|issue=9}}</ref> Due to this, it is possible budget cuts will be made on research and development of human health and medicine in the US.<ref name="Houlton 2012 23" />
In 2022, the United States had 10,265 drugs in the works, more than twice as many as China and the European Union, and four times as many as the United Kingdom.<ref>{{cite news |title=The world will need to stop piggybacking on US pharma |url=https://www.ft.com/content/0c20c518-60a8-4dd0-87be-f03adc8ec0e1 |agency=Financial Times |date=2023}}</ref>

=== Healthcare provider employment in the US ===
A major impending demographic shift in the US 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<ref>{{Cite news|url=https://www.economist.com/news/2014/11/13/health-care?zid=318&ah=ac379c09c1c3fb67e0e8fd1964d5247f|title=Health Care|date=2014-11-13|newspaper=The Economist|access-date=2019-11-10|issn=0013-0613}}</ref> due to the "baby boomers" reaching retirement age.<ref>{{Cite news|url=https://www.washingtonpost.com/news/fact-checker/wp/2014/07/24/do-10000-baby-boomers-retire-every-day/|title=Do 10,000 baby boomers retire every day?|last=Kessler|first=Glenn| name-list-style = vanc |date=2014-07-24|newspaper=Washington Post|access-date=2019-11-10|language=en-US|issn=0190-8286}}</ref> The overall spending on healthcare 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.<ref>{{Cite web|url=https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/|title=How has U.S. spending on healthcare changed over time?|website=Peterson-Kaiser Health System Tracker|language=en-US|access-date=2019-11-11}}</ref> Moreover, the expenditure on health services for people over 45&nbsp;years old is 8.3&nbsp;times the maximum of that of those under 45&nbsp;years old.<ref>{{Cite journal| vauthors = Prowle MJ, Araali NA |title= Meeting The Escalating Demands For Health And Social Care Services Of Elderly Populations In Developing Countries: A Strategic Perspective |journal=American Journal of Medical Research|language=en-gb|volume=4|issue=2|pages=127 |doi=10.22381/ajmr4220175|year=2017 |url=http://eprints.glos.ac.uk/4723/1/costs%20of%20ageing.pdf }}</ref>

=== Alternative medicine ===
Other methods of [[Therapy|medical treatment]] are being practiced more frequently than before.{{when|reason=Before when?|date=June 2021}} This field is labeled [[Alternative medicine|Complementary and Alternative Medicine]] (CAM) and are defined as therapies generally not taught in [[Medical school in the United States|medical school]] nor available in hospitals. They include [[Herbal medicine|herbs]], massages, energy healing, [[homeopathy]], [[faith healing]], and, more recently popularized, [[cryotherapy]], [[Cupping therapy|cupping]], and [[Transcranial magnetic stimulation|Transcranial Magnetic Stimulation]] or TMS.<ref>{{Cite web|url=https://www.thespectrum.com/story/news/2019/10/06/cryotherapy-cupping-new-alternative-medicine-now-st-george/3450970002/|title=Cryotherapy, cupping and TMS: New forms of alternative medicine treatment in St. George|last=Wilkins|first=Terell| name-list-style = vanc |website=The Spectrum & Daily News|language=en|access-date=2019-11-11}}</ref> Providers of these CAM treatments are sometimes legally considered healthcare providers in the US.<ref>{{Cite web|title=29 CFR § 825.125 - Definition of health care provider.|url=https://www.law.cornell.edu/cfr/text/29/825.125|access-date=2020-11-13|website=LII / Legal Information Institute|language=en}}</ref> 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 US offer at least one form of CAM treatment, the main reason being patient demand (84% of hospitals).<ref>{{Cite web|url=http://www.aha.org/presscenter/pressrel/2008/080915-pr-cam.shtml|title=Latest Survey Shows More Hospitals Offering Complementary and Alternative Medicine Services|date=2012-09-02|access-date=2019-11-11|archive-url=https://web.archive.org/web/20120902072431/http://www.aha.org/presscenter/pressrel/2008/080915-pr-cam.shtml|archive-date=September 2, 2012}}</ref> Costs for CAM treatments average $33.9 (equivalent to ${{Formatprice|{{inflation|US|33.90|2007|r=2}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) with two-thirds being out-of-pocket, according to a 2007 statistical analysis.<ref name=":13">{{cite web |url= https://nccih.nih.gov/news/camstats/costs/costdatafs.htm |title=The Use of Complementary and Alternative Medicine in the United States: Cost Data |website=NCCIH |language=en |access-date=2019-11-11 }}</ref> Moreover, CAM treatments covered 11.2% of total out-of-pocket payments on healthcare.<ref name=":13" /> During 2002 to 2008, spending on CAM was on the rise, but usage has since plateaued to about 40% of adults in the US<ref>{{cite journal | vauthors = Davis MA, Martin BI, Coulter ID, Weeks WB | title = US spending on complementary and alternative medicine during 2002-08 plateaued, suggesting role in reformed health system | journal = Health Affairs | volume = 32 | issue = 1 | pages = 45–52 | date = January 2013 | pmid = 23297270 | pmc = 3644505 | doi = 10.1377/hlthaff.2011.0321 }}</ref>

== Spending ==
{{Main|Health care finance in the United States|Health care prices in the United States}}
[[File:US Healthcare Expenditure, OWID.svg |thumb |US healthcare expenditure as share of GDP, 1929–2013<ref>{{cite web |title=US Healthcare Expenditure |url=https://ourworldindata.org/grapher/us-healthcare-expenditure |website=Our World in Data |access-date=6 March 2020}}</ref>]]
[[File:20231204 Life expectancy vs. healthcare spending - by country.svg |thumb |Though the U.S. healthcare system tends to produce more innovation, it has a lower level of regulation, and almost every form of its healthcare costs more than other high-income countries.<ref name=NYTimes_20231204>{{cite news |last1=Leonhardt |first1=David |title=Big Profits in Caring for the Elderly |url=https://www.nytimes.com/2023/12/04/briefing/health-care.html |newspaper=The New York Times |date=December 4, 2023 |archive-url=https://web.archive.org/web/20231204131609/https://www.nytimes.com/2023/12/04/briefing/health-care.html |archive-date=December 4, 2023 |url-status=live }}</ref>]]

The US 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.<ref name="Marmoretal2009">{{cite journal | vauthors = Marmor T, Oberlander J, White J | title = The Obama administration's options for health care cost control: hope versus reality | journal = Annals of Internal Medicine | volume = 150 | issue = 7 | pages = 485–9 | date = April 2009 | pmid = 19258549 | doi = 10.7326/0003-4819-150-7-200904070-00114 | doi-access = free }}[http://www.annals.org/content/150/7/485.full Free full-text].</ref> Healthcare costs rising far faster than inflation have been a major driver for [[health care reform in the United States|healthcare reform in the US]]. {{As of|2016}}, the US spent $3.3 trillion (equivalent to ${{Formatprice|{{inflation|US-GDP|3300000000000|2016}}}} in {{Inflation/year|index=US-GDP}};{{Inflation/fn|index=US-GDP}} 17.9% of GDP), or $10,438 (equivalent to ${{Formatprice|{{inflation|US|10438|2016}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) per person; major categories included 32% on hospital care, 20% on physician and clinical services, and 10% on prescription drugs.<ref>{{cite web|url=https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf|title=National Health Expenditures 2016 Highlights}}</ref> In comparison, the [[United Kingdom]] spent $3,749 (equivalent to ${{Formatprice|{{inflation|US|3749|2016}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) per person.<ref>{{Cite news|url=https://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-country-spends-the-most-and-least-on-health-care-per-person|title=What Country Spends The Most (And Least) On Health Care Per Person?|work=NPR.org|access-date=2018-02-28|language=en}}</ref>

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.<ref>{{cite journal | vauthors = Papanicolas I, Woskie LR, Jha AK | title = Health Care Spending in the United States and Other High-Income Countries | journal = JAMA | volume = 319 | issue = 10 | pages = 1024–1039 | date = March 2018 | pmid = 29536101 | doi = 10.1001/jama.2018.1150 | s2cid = 4293977 | url = http://eprints.lse.ac.uk/87362/2/jama_Papanicolas_2018_sc_180001_3_.pdf}}</ref><ref>{{cite web|title = Why Are U.S. Health Costs The World's Highest? Study Affirms 'It's The Prices, Stupid'|
 url = http://www.wbur.org/commonhealth/2018/03/13/us-health-costs-high-jha | work = WBUR }}</ref> The combination of high prices and high volume can cause particular expense; in the US, high-margin high-volume procedures include [[Angioplasty|angioplasties]], [[Caesarean section|C-sections]], [[knee replacement]]s, and CT and MRI scans; CT and MRI scans also showed higher utilization in the US.<ref>{{cite journal | vauthors = Emanuel EJ | title = The Real Cost of the US Health Care System | journal = JAMA | volume = 319 | issue = 10 | pages = 983–985 | date = March 2018 | pmid = 29536081 | doi = 10.1001/jama.2018.1151 }}</ref>

Aggregate US 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 (equivalent to ${{Formatprice|{{inflation|US|10000|2011}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}).<ref name="hcup-us.ahrq.gov">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. [http://www.hcup-us.ahrq.gov/reports/statbriefs/sb166.jsp] {{Webarchive|url=https://web.archive.org/web/20191110230344/https://www.hcup-us.ahrq.gov/reports/statbriefs/sb166.jsp|date=November 10, 2019}}.</ref> {{As of|2008}}, public spending accounts for between 45% and 56% of US healthcare spending.<ref name="content.healthaffairs.org">Thomas M. Selden and Merrile Sing, [http://content.healthaffairs.org/cgi/reprint/hlthaff.27.5.w349v1 "The Distribution Of Public Spending For Health Care In The United States, 2002,"] [[Health Affairs]] 27, no. 5 (2008): w349–59 (published online July 29, 2008)</ref> 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 (equivalent to ${{Formatprice|{{inflation|US|9100|2003}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) to $10,600 in 2011 (equivalent to ${{Formatprice|{{inflation|US|10600|2011}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) and were projected to be $11,000 by 2013 (equivalent to ${{Formatprice|{{inflation|US|11000|2013}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}).<ref>{{cite journal|url=https://www.hcup-us.ahrq.gov/reports/statbriefs/sb175-Hospital-Cost-Utilization-Projections-2013.jsp|title=Trends and Projections in Inpatient Hospital Costs and Utilization, 2003–2013|date=July 2014|journal=HCUP Statistical Brief #175|publisher=Agency for Healthcare Research and Quality|location=Rockville, MD|vauthors=Weiss AJ, Barrett ML, Steiner CA|pmid=25165806 }}</ref>

According to the [[World Health Organization|WHO]], total healthcare spending in the US was 18% of its [[gross domestic product|GDP]] in 2011, the [[List of countries by total health expenditure (PPP) per capita|highest]] in the world.<ref name="WHO 2011">{{cite book|url=https://www.who.int/gho/publications/world_health_statistics/2011/en/index.html|archive-url=https://web.archive.org/web/20111022222941/http://www.who.int/gho/publications/world_health_statistics/2011/en/index.html|url-status=dead|archive-date=October 22, 2011|title=World health statistics 2011|author=WHO|publisher=World Health Organization|year=2011|isbn=978-92-4-156419-9|location=Geneva}}</ref> 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.<ref name="NHE Fact Sheet">[http://www.cms.hhs.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage "National Health Expenditure Data: NHE Fact Sheet,"] [[Centers for Medicare and Medicaid Services]], referenced February 26, 2008</ref><ref>Sean Keehan, Andrea Sisko, Christopher Truffer, Sheila Smith, Cathy Cowan, John Poisal, M. Kent Clemens, and the National Health Expenditure Accounts Projections Team, [http://content.healthaffairs.org/cgi/reprint/hlthaff.27.2.w145v1 "Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming To Medicare"], ''Health Affairs'' Web Exclusive, February 26, 2008. Retrieved February 27, 2008.</ref> Of each dollar spent on healthcare in the US, 31% goes to hospital care, 21% goes to physician/clinical services, 10% to pharmaceuticals, 4% to dental, 6% to [[nursing home]]s and 3% to home healthcare, 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.).<ref>{{cite web |url=http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx#How%20is%20the%20U.S.%20health%20care%20dollar%20spent |title=Health Costs |publisher=The Henry J. Kaiser Family Foundation |website=Kaiseredu.org |date=October 3, 2016 |access-date=December 1, 2016 |archive-date=September 10, 2013 |archive-url=https://web.archive.org/web/20130910181724/http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx#How%20is%20the%20U.S.%20health%20care%20dollar%20spent |url-status=dead }}</ref>

In 2017, a study estimated that nearly half of hospital-associated care resulted from [[emergency department]] visits.<ref>{{cite journal | vauthors = Marcozzi D, Carr B, Liferidge A, Baehr N, Browne B | title = Trends in the Contribution of Emergency Departments to the Provision of Hospital-Associated Health Care in the USA | journal = International Journal of Health Services | volume = 48 | issue = 2 | pages = 267–288 | date = April 2018 | pmid = 29039720 | doi = 10.1177/0020731417734498 | s2cid = 206411788 | url = https://www.sciencedaily.com/releases/2017/10/171017091849.htm }}</ref> {{As of|2017}}, data from 2009–2011 showed that [[end-of-life care]] in the last year of life accounted for about 8.5%, and the last three years of life about 16.7%.<ref>{{cite journal | vauthors = French EB, McCauley J, Aragon M, Bakx P, Chalkley M, Chen SH, Christensen BJ, Chuang H, Côté-Sergent A, De Nardi M, Fan E, Échevin D, Geoffard PY, Gastaldi-Ménager C, Gørtz M, Ibuka Y, Jones JB, Kallestrup-Lamb M, Karlsson M, Klein TJ, de Lagasnerie G, Michaud PC, O'Donnell O, Rice N, Skinner JS, van Doorslaer E, Ziebarth NR, Kelly E | display-authors = 6 | title = End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported | journal = Health Affairs | volume = 36 | issue = 7 | pages = 1211–1217 | date = July 2017 | pmid = 28679807 | doi = 10.1377/hlthaff.2017.0174 | url = http://discovery.ucl.ac.uk/1567490/1/De%20Nardi_French_etal_round3_v4.pdf | doi-access = free }}</ref>

{{As of|2013}}, administration of healthcare constituted 30% of US healthcare costs.<ref>{{cite news |last=Pfeffer |first=Jeffrey | name-list-style = vanc |title=The Reason Health Care Is So Expensive: Insurance Companies |url=https://www.bloomberg.com/bw/articles/2013-04-10/the-reason-health-care-is-so-expensive-insurance-companies |newspaper=[[Bloomberg News]] |date=April 10, 2013 |access-date=January 17, 2016 }}</ref>

Free-market advocates claim that the healthcare 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.<ref>Liebowitz, Stan [http://www.cato.org/pubs/pas/pa211.html Policy Analysis: Why Health Care Costs So Much], Cato Institute, June 23, 1994</ref> According to a study paid for by [[America's Health Insurance Plans]] (a Washington lobbyist for the health insurance industry) and carried out by PriceWaterhouseCoopers, increased utilization is the primary driver of rising healthcare costs in the US<ref name="PWC">[http://www.ahipbelieves.com/media/The%20Factors%20Fueling%20Rising%20Healthcare%20Costs.pdf The Factors Fueling Rising Healthcare Costs 2006] {{Webarchive|url=https://web.archive.org/web/20071127151147/http://www.ahipbelieves.com/media/The%20Factors%20Fueling%20Rising%20Healthcare%20Costs.pdf|date=November 27, 2007}}, PriceWaterhouseCoopers for America's Health Insurance Plans, 2006. Retrieved October 8, 2007.</ref> 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.<ref name="PWC" /> 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.<ref>{{cite web|url=http://www.managedcaremag.com/archives/0612/0612.costshift.html|title=Confronting The Medicare Cost Shift|work=Managed Care Magazine|access-date=June 28, 2007|date=December 2006}}</ref>

In March 2010, Massachusetts released a report on the cost drivers which it called "unique in the nation".<ref name="MassCostTrends">[http://www.mass.gov/dhcfp/costtrends Health Care Cost Trends]. Massachusetts Office of Health and Human Services. See [http://www.mass.gov/Eeohhs2/docs/dhcfp/cost_trend_docs/final_report_docs/appendix_b_ag_report.pdf Appendix B: Preliminary Report of the Massachusetts Attorney General (PDF)] {{Webarchive|url=https://web.archive.org/web/20100509003338/http://www.mass.gov/Eeohhs2/docs/dhcfp/cost_trend_docs/final_report_docs/appendix_b_ag_report.pdf |date=May 9, 2010 }}, pp. 1–2, for quote and summary.</ref> 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.<ref name="MassCostTrends" />

Economists Eric Helland and Alex Tabarrok speculate that the increase in costs of healthcare in the US are largely a result of [[Baumol's cost disease|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.<ref>{{cite web|url=https://www.mercatus.org/system/files/helland-tabarrok_why-are-the-prices-so-damn-high_v1.pdf|last1=Helland |first1=Eric |last2=Tabarrok |first2=Alex | name-list-style = vanc |title=Why Are the Prices So Damn High?|access-date=May 26, 2019|date=May 2019}}</ref>

== Regulation and oversight ==
{{Further|American Board of Medical Specialties|United States Medical Licensing Examination|National Association of Insurance Commissioners}}

=== Involved organizations and institutions ===
Healthcare is subject to extensive regulation at both the [[federal government of the United States|federal]] and the [[U.S. state|state level]], much of which "arose haphazardly".<ref name=just /> Under this system, the federal government cedes primary responsibility to the states under the [[McCarran–Ferguson Act]]. Essential regulation includes the [[licensure]] of [[health care provider|healthcare provider]]s at the state level and the testing and approval of pharmaceuticals and medical devices by the [[Food and Drug Administration]] (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,<ref name="Bunce&Wieske2008">Victoria Craig Bunce and JP Wieske, [http://www.cahi.org/cahi_contents/resources/pdf/HealthInsuranceMandates2008.pdf "Health Insurance Mandates in the States 2008"], The Council for Affordable Health Insurance, 2008</ref> although state mandates generally do not apply to the [[self-funded health care|self-funded healthcare]] plans offered by large employers, which exempt from state laws under preemption clause of the [[Employee Retirement Income Security Act]].

In 2010, the ACA was signed by President [[Barack Obama]] and includes various new regulations, with one of the most notable being a [[health insurance mandate]] 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.<ref name=just />

At the federal level, [[US Department of Health and Human Services]] (HHS) oversees the various federal agencies involved in healthcare, except for the [[Drug Enforcement Administration]], which has the final say over the FDA as it relates to controlled substance regulations. The health agencies are a part of the [[United States Public Health Service|US Public Health Service]], and include the FDA, which certifies the safety of food, effectiveness of drugs and medical products, the CDC, 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]].{{citation needed|date=September 2016}}

[[State governments of the United States|State governments]] maintain [[state health department]]s, and [[Local government in the United States|local governments]] ([[County (United States)|counties]] and [[Municipality|municipalities]]) 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 healthcare 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.{{citation needed|date=September 2016}}

[[Industry self-regulation|Self-policing]] of providers by providers is a major part of oversight. Many healthcare organizations also voluntarily submit to inspection and certification by the [[Joint Commission]] on Accreditation of Hospital Organizations (JCAHO). Providers also undergo testing to obtain [[board certification]] attesting to their skills. A report issued by [[Public Citizen]] 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.<ref>[http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=51710 "Coverage & Access: Disciplinary Action Against Physicians Dropped 6% From 2006 to 2007, Report Finds,"]{{dead link|date=October 2017 |bot=InternetArchiveBot |fix-attempted=yes }} Kaiser Daily Health Policy Report, [[Kaiser Family Foundation]], April 23, 2008. Original report: Sidney M. Wolfe and Kate Resnevic, [http://www.citizen.org/documents/medicalboardtable.pdf "Public Citizen's Health Research Group Ranking of the Rate of State Medical Boards' Serious Disciplinary Actions, 2005–2007,"] [[Public Citizen]], April 22, 2008</ref>

The federal [[Centers for Medicare and Medicaid Services]] (CMS) publishes an online searchable database of performance data on [[nursing homes]].<ref>[http://www.medicare.gov/NHCompare/Include/DataSection/Questions/SearchCriteria.asp?version=default&browser=IE%7C6%7CWinXP&language=English&defaultstatus=0&pagelist=Home&CookiesEnabledStatus=True Nursing Home Compare], [[Centers for Medicare and Medicaid Services]] (accessed April 24, 2008). Note, CMS also publishes a list of Special Focus Facilities – nursing homes with "a history of serious quality issues" at [http://www.cms.hhs.gov/CertificationandComplianc/Downloads/SFFList.pdf Special Focus Facility ("SFF") Initiative].</ref>

In 2004, libertarian think tank [[Cato Institute]] published a study which concluded that regulation provides benefits in the amount of $170&nbsp;billion but costs the public up to $340&nbsp;billion.<ref name="Cato2004">{{cite journal | title = Health Care Regulation: A $169 Billion Hidden Tax | first = Christopher J. | last = Conover | name-list-style = vanc | date = October 4, 2004 | journal = Cato Policy Analysis | volume = 527 | pages = 1–32 | url = http://www.cato.org/pubs/pas/pa527.pdf|access-date=February 19, 2014}}</ref> The study concluded that the majority of the cost differential arises from [[medical malpractice]], FDA regulations, and facilities regulations.<ref name="Cato2004" />

=== "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.<ref name="Hoetal2009" /> It has been observed that these certificates could be used to increase costs through weakened competition.<ref name=just>[https://www.justice.gov/atr/public/health_care/204694.pdf Improving Health Care: A Dose of Competition], Report by the Federal Trade Commission and the Department of Justice, 2004</ref> Many states removed the CON programs after the federal requirement expired in 1986, but some states still have these programs.<ref name="Hoetal2009">{{cite journal | vauthors = Ho V, Ku-Goto MH, Jollis JG | title = Certificate of Need (CON) for cardiac care: controversy over the contributions of CON | journal = Health Services Research | volume = 44 | issue = 2 Pt 1 | pages = 483–500 | date = April 2009 | pmid = 19207590 | pmc = 2677050 | doi = 10.1111/j.1475-6773.2008.00933.x }}</ref> 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.<ref name="Hoetal2009" />

=== Licensing of providers ===
The [[American Medical Association]] (AMA) has lobbied the government to highly limit physician education since 1910, currently at 100,000&nbsp;doctors per year,<ref name=evilama>{{cite magazine|url=https://www.forbes.com/2009/08/25/american-medical-association-opinions-columnists-shikha-dalmia.html|title=The Evil-Mongering of the American Medical Association|first=Shikha|last=Dalmia| name-list-style = vanc|date=August 26, 2009|magazine=Forbes|access-date=January 17, 2014}}</ref> which has led to a shortage of doctors.<ref>[https://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm Medical miscalculation creates doctor shortage], USA Today, March 2, 2005</ref>

An even bigger problem may be that the doctors are paid for procedures instead of results.<ref name=nytbill>[https://www.nytimes.com/2007/07/29/weekinreview/29berenson.html Sending Back the Doctor's Bill], ''The New York Times'' July 29, 2007</ref>

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&nbsp;states banned or restricted midwifery even though it delivers equally safe care to that by doctors.<ref name="evilama" /> The regulation lobbied by the AMA has decreased the amount and quality of healthcare, according to the consensus of economist: the restrictions do not add to quality, they decrease the supply of care.<ref name=evilama /> Moreover, psychologists, nurses and pharmacists are not allowed to prescribe medicines.{{Clarify||sentence intends to say "write formal prescriptions. Pharmacists can "suggest" OTC medication. Possibly the others can as well|date=August 2010}} Previously nurses were not even allowed to vaccinate the patients without direct supervision by doctors.

Thirty-six states require that healthcare workers undergo [[criminal background check]]s.<ref>Data from 2006, presented in: [http://www.medscape.com/viewarticle/746087?src=mp&spon=25 Criminal Background Checks for Entering Medical Students]{{registration required}} {{Webarchive|url=https://web.archive.org/web/20130515213412/http://www.medscape.com/viewarticle/746087?src=mp&spon=25 |date=May 15, 2013 }} by James Kleshinski, MD; Steven T. Case, PhD; Dwight Davis, MD; George F. Heinrich, MD; Robert A. Witzburg, MD. Posted: August 2, 2011; Academic Medicine. 2011;86(7):795–98.</ref>

==== Emergency Medical Treatment and Active Labor Act (EMTALA) ====
{{Main|Emergency Medical Treatment and Active Labor Act}}

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 US now goes uncompensated.<ref name="ACEP">[http://www.acep.org/patients.aspx?id=25932 The Uninsured: Access to Medical Care] {{Webarchive|url=https://web.archive.org/web/20100304211332/http://www.acep.org/patients.aspx?id=25932 |date=March 4, 2010 }}, American College of Emergency Physicians. Retrieved October 30, 2007.</ref> According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20&nbsp;years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the [[Institute of Medicine]], between 1993 and 2003, emergency room visits in the US grew by 26%, while in the same period, the number of emergency departments declined by 425.<ref name="IOM fact sheet">[http://www.iom.edu/~/media/Files/Report%20Files/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point/EmergencyCareFindingsandRecs.ashx Fact Sheet: The Future of Emergency Care: Key Findings and Recommendations] {{webarchive|url=https://web.archive.org/web/20110922075640/http://www.iom.edu/~/media/Files/Report%20Files/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point/EmergencyCareFindingsandRecs.ashx |date=September 22, 2011 }}, Institute of Medicine, 2006. Retrieved October 7, 2007.</ref>

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&nbsp;hours, after which a court order is required.

=== Quality assurance ===
{{See also|Hospital Quality Incentive Demonstration}}

Healthcare 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."<ref>{{cite web |url=https://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?mode=&term=Quality%20Assurance,%20Health%20Care|website=U.S. National Library of Medicine|title=National Library of Medicine – Medical Subject Headings, 2011 MeSH, MeSH Descriptor Data, Quality Assurance, Health Care|publisher=National Institutes of Health|location=Bethesda, MD |access-date=February 19, 2015}}</ref> Private companies such as [[Grand Rounds, Inc.|Grand Rounds]] also release quality information and offer services to employers and plans to map quality within their networks.<ref>{{Cite news|url=https://www.forbes.com/sites/matthewherper/2016/12/14/should-big-data-pick-your-next-doctor/|title=Should Big Data Pick Your Next Doctor?|last=Herper|first=Matthew| name-list-style = vanc|work=Forbes|access-date=May 26, 2017}}</ref>

One innovation in encouraging quality of healthcare 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".<ref>{{Cite journal|last1=Metcalfe|first1=David|last2=Rios Diaz|first2=Arturo J.|last3=Olufajo|first3=Olubode A.|last4=Massa|first4=M. Sofia|last5=Ketelaar|first5=Nicole Abm|last6=Flottorp|first6=Signe A.|last7=Perry|first7=Daniel C.|date=6 September 2018|title=Impact of public release of performance data on the behaviour of healthcare consumers and providers|journal=The Cochrane Database of Systematic Reviews|volume=2018|issue=9|pages=CD004538|doi=10.1002/14651858.CD004538.pub3|issn=1469-493X|pmc=6513271|pmid=30188566}}</ref>

== Overall system effectiveness ==
=== Measures of effectiveness ===
The US healthcare delivery system unevenly provides medical care of varying quality to its population.<ref>Corrigan, Janet M. "Crossing the quality chasm." Building a Better Delivery System (2005).</ref> In a highly effective healthcare 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 [[United States Department of Health and Human Services|HHS]] populates a publicly available dashboard called the Health System Measurement Project, 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,<ref>{{cite web|url=https://www.hhs.gov/strategic-plan/priorities.html|title=Strategic Plan and Priorities |website=HHS.gov|date=August 26, 2013|url-status=deviated|archive-url=https://web.archive.org/web/20130826222449/http://www.hhs.gov/strategic-plan/priorities.html|archive-date=August 26, 2013}}</ref> the [[Government Performance and Results Act]], [[Healthy People program|Healthy People 2020]], and the National Strategies for Quality and Prevention.<ref name=":10">{{cite web|url=https://www.surgeongeneral.gov/priorities/prevention/strategy/report.pdf|title=National Prevention Strategy|year=2011 |website=National Prevention Council|publisher=U.S. Department of Health and Human Services, Office of the Surgeon General|location=Washington, DC|access-date=October 22, 2017 |archive-date=April 12, 2019|archive-url=https://web.archive.org/web/20190412063906/https://www.surgeongeneral.gov/priorities/prevention/strategy/report.pdf|url-status=dead}}</ref><ref>{{cite web |url=https://healthmeasures.aspe.hhs.gov/about |title=About |date=January 13, 2013|url-status=dead |archive-date=January 13, 2013 |archive-url=https://web.archive.org/web/20130113042412/https://healthmeasures.aspe.hhs.gov/about}}</ref>

==== Waiting times ====
Waiting times in US healthcare are usually short, but are not usually 0 for non-urgent care at least. Also, a minority of US 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.<ref>{{cite web |publisher = The Commonwealth Fund|date = November 2010|title = Commonwealth Fund 2010 Health Policy Survey in 11 Countries |pages = 19–20 |url = http://www.commonwealthfund.org/~/media/files/publications/chartbook/2010/pdf_2010_ihp_survey_chartpack_full_12022010.pdf}}</ref> These percentages were smaller than in France, the UK, 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 US, self-reported mean wait times to see an orthopedic surgeon were two weeks in those parts of the US, and four weeks in Canada. Mean waits for the knee or hip surgery were self-reported as three weeks in those parts of the US and eight weeks in Ontario.<ref>{{cite journal | vauthors = Coyte PC, Wright JG, Hawker GA, Bombardier C, Dittus RS, Paul JE, Freund DA, Ho E | display-authors = 6 | title = Waiting times for knee-replacement surgery in the United States and Ontario | language = EN | journal = The New England Journal of Medicine | volume = 331 | issue = 16 | pages = 1068–71 | date = October 1994 | pmid = 8090168 | doi = 10.1056/nejm199410203311607 | doi-access = free }}</ref>

However, current waits in both countries' regions may have changed since then (certainly in Canada waiting times went up later).<ref>{{Cite web|url=https://www.hqontario.ca/System-Performance/Wait-Times-for-Surgeries-and-Procedures/Wait-Times-for-Orthopedic-Surgeries-including-Hip-Replacement-and-Knee-Replacement/Time-from-Decision-to-Having-Orthopedic-Surgery|title=Patient's Wait Time from Decision to Having Orthopedic Surgery – Health Quality Ontario|website=hqontario.ca|access-date=2019-06-13}}</ref> More recently, at one Michigan hospital, the waiting time for the elective surgical operation open carpel tunnel release was an average of 27&nbsp;days, most ranging from 17 to 37&nbsp;days (an average of almost four weeks, ranging from about 2.4&nbsp;weeks to 5.3&nbsp;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 five 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;{{citation needed|date=December 2018}} patients with poor insurance coverage probably face a disproportionate number of long waits.

US healthcare tends to rely on [[Healthcare rationing in the United States|rationing]] 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.{{citation needed|date=December 2018}}

==== 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.

{{Image frame 
 | caption={{legend-line|#318CE7 solid 3px|Life expectancy in the US<ref>{{Cite journal|url=https://ourworldindata.org/life-expectancy|title=Life Expectancy|journal=Our World in Data|date=May 23, 2013|last1=Roser|first1=Max|last2=Ortiz-Ospina|first2=Esteban|last3=Ritchie|first3=Hannah}}</ref>}} 
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 1921,1922,1923,1924,1925,1926,1927,1928,1929,1930,
 1931,1932,1933,1934,1935,1936,1937,1938,1939,1940,
 1941,1942,1943,1944,1945,1946,1947,1948,1949,1950,
 1951,1952,1953,1954,1955,1956,1957,1958,1959,1960,
 1961,1962,1963,1964,1965,1966,1967,1968,1969,1970,
 1971,1972,1973,1974,1975,1976,1977,1978,1979,1980,
 1981,1982,1983,1984,1985,1986,1987,1988,1989,1990,
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 | y=39.41,45.209999,
49.299999,50.5,50.599998,49.599998,50.299999,50.099998,50.200001,51.900002,52.799999,51.799999,
53.400002,54.099998,53.5,54.599998,55.099998,54.200001,54,47.200001,55.299999,55.400002,
58.200001,58.099998,57.5,58.5,58.5,57.900002,59.400002,58.299999,58.5,59.599998,
60.299999,61,60.880001,60.23,60.889999,60.349998,61.049999,62.389999,63.07,63.23,
63.799999,64.589996,64.300003,65.089996,65.580002,66.279999,66.690002,67.25,67.629997,68.202,
68.338,68.601,68.842,69.063,69.263,69.441,69.598,69.734,69.848,69.94,
70.011,70.064,70.106,70.144,70.188,70.247,70.328,70.44,70.586,70.777,
71.017,71.303,71.624,71.972,72.333,72.695,73.044,73.368,73.66,73.91,
74.118,74.289,74.432,74.554,74.662,74.765,74.87,74.983,75.107,75.246,
75.4,75.562,75.728,75.896,76.062,76.222,76.376,76.524,76.668,76.812,
76.962,77.124,77.299,77.486,77.685,77.892,78.101,78.303,78.49,78.652,
78.777,78.862,78.909,78.922,78.91,78.885,78.861,78.851,78.862,
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* While life expectancy is one measure, the [[United States Department of Health and Human Services|HHS]] 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&nbsp;years for newborns.<ref>{{cite web |url=https://healthmeasures.aspe.hhs.gov/measure/65 |title=Measure Details|date=February 15, 2013|url-status=dead|archive-date=February 15, 2013|archive-url=https://web.archive.org/web/20130215160734/https://healthmeasures.aspe.hhs.gov/measure/65}}</ref>
* 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.<ref name=":10" /> Over the past decade rates of teen pregnancy and low birth rates have come down significantly, but not disappeared.<ref>{{cite web|url=https://www.cdc.gov/nchs/data/hus/hus13.pdf |title=Health, United States, 2013 |website=Cdc.gov |access-date=December 1, 2016}}</ref> Rates of obesity, heart disease (high blood pressure, controlled high cholesterol), and type&nbsp;2 diabetes are areas of major concern. While chronic disease and multiple comorbidities 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 US 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."<ref>{{cite web|title=The Surgeon General's Vision for a Healthy and Fit Nation|location=Rockville, Maryland|publisher=U.S. Department of Health and Human Services, Office of the Surgeon General|date=January 2010|url=http://www.surgeongeneral.gov}}</ref>
* A concern for the health system is that the health gains do not accrue equally to the entire population. In the US, disparities in healthcare and health outcomes are widespread.<ref>IOM (Institute of Medicine). 2012. How far have we come in reducing health disparities?: Progress since 2000: Workshop summary. Washington, DC: The National Academies Press.</ref> Minorities are more likely to develop serious illnesses (e.g., type&nbsp;2 diabetes, heart disease and colon cancer) and less likely to have access to quality healthcare, including preventative services.<ref>{{cite web |url=https://healthmeasures.aspe.hhs.gov/topic/I|title=Topic Area|date=February 14, 2013|url-status=dead |archive-url=https://web.archive.org/web/20130214043644/https://healthmeasures.aspe.hhs.gov/topic/I |archive-date=February 14, 2013}}</ref> Efforts are underway to close the gap and to provide a more equitable system of care.

==== Innovation: workforce, healthcare IT, R&D ====
Finally, the US 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 the US. 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 healthcare system.<ref>{{cite web|author=ASPE |url=http://aspe.hhs.gov/sp/reports/2012/costandinnovation/ib.shtml |title=Health Care Cost Containment and Medical Innovation |website=Aspe.hhs.gov |date=July 23, 2012 |access-date=December 1, 2016}}</ref>

=== Compared to other countries ===
{{Further|Comparison of the healthcare systems in Canada and the United States}}
[[File:Health spending. OECD countries. US dollars per capita (using economy-wide PPPs).png|thumb|upright=1.4|[[List of countries by total health expenditure per capita|Total healthcare cost per person]]. Public and private spending. US dollars [[Purchasing power parity|PPP]]. $6,319 for Canada in 2022. $12,555 for the US in 2022.<ref name=OECD-barcharts/>]]
[[File:Health spending by country. Percent of GDP (Gross domestic product).png|thumb|right|upright=1.4|[[Health spending as a percent of GDP by country (gross domestic product)|Health spending by country]]. Percent of GDP ([[Gross domestic product]]). 11.2% for Canada in 2022. 16.6% for the United States in 2022.<ref name=OECD-barcharts>[[OECD]] Data. [https://data.oecd.org/healthres/health-spending.htm Health resources - Health spending]. {{doi|10.1787/8643de7e-en}}. 2 bar charts: For both: From bottom menus: Countries menu > choose OECD. Check box for "latest data available". Perspectives menu > Check box to "compare variables". Then check the boxes for government/compulsory, voluntary, and total. Click top tab for chart (bar chart). For GDP chart choose "% of GDP" from bottom menu. For per capita chart choose "US dollars/per capita". Click fullscreen button above chart. Click "print screen" key. Click top tab for table, to see data.</ref>]]
[[File:Total health expenditure per capita, US Dollars PPP.png|thumb|right|upright=1.4|Health spending per capita, in US$ [[Purchasing power parity|PPP-adjusted]], compared amongst various first world nations.]]

A 2014 study by the private US foundation [[Commonwealth Fund]] found that although the US healthcare system is the most expensive in the world, it ranks last on most dimensions of performance when compared with [[Australia health care system|Australia]], [[Canadian health care|Canada]], [[French healthcare system|France]], [[German health care system|Germany]], [[Netherlands health care system|the Netherlands]], [[New Zealand]], [[Norway]], [[Sweden]], [[Switzerland healthcare|Switzerland]], and the [[UK health care|UK]]. The study found that the US 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]], as well as information on healthcare outcomes from Commonwealth Fund, the [[World Health Organization|WHO]], and the [[Organisation for Economic Co-operation and Development|OECD]].<ref name=":12">{{Cite report|date=June 14, 2017|title=Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care|url=https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and|publisher=The Commonwealth Fund|doi=10.26099/0mh5-a632 |last1=Schneider |first1=Eric C. |last2=Sarnak |first2=Dana O. |last3=Squires |first3=David |last4=Shah |first4=Arnav |last5=Doty |first5=Michelle M.}}</ref><ref>{{Cite news |url=https://www.vox.com/2014/6/16/5812898/five-ways-the-american-health-care-system-is-literally-the-worst |title=Five ways the American health care system is literally the worst |last=Kliff |first=Sarah |name-list-style=vanc |date=June 16, 2014 |work=Vox |access-date=June 17, 2014}}</ref>

{{As of|2017}}, the US stands 43rd in the world with a life expectancy of 80.00&nbsp;years<ref name=factbook-life-expenctancy/> In 2007, the [[CIA World Factbook]] ranked the US 180th worst (out of 221)—meaning 42nd best—in the world for infant mortality rate (5.01/1,000 live births).<ref name="infant_mortality_by_country">{{cite web|url=https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html#us|archive-url=https://web.archive.org/web/20070613003931/https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html#us|url-status=dead|archive-date=June 13, 2007|work=The World Factbook|publisher = Cia.gov|access-date=December 14, 2018|title = Country Comparison: Infant Mortality Rate}}</ref> Americans also undergo cancer screenings at significantly higher rates than people in other developed countries, and access [[Magnetic resonance imaging|MRI]] and [[X-ray computed tomography|CT scans]] at the highest rate of any OECD nation.<ref name="Atlas">{{cite book|url=https://books.google.com/books?id=0qExi2-3m5IC |title=In excellent health: setting the record straight on America's health care and charting a path for future reform|first=Scott W. | last = Atlas | name-list-style = vanc |publisher=Hoover Institution Press, Stanford University|year=2011|isbn=978-0-8179-1444-8|location=Stanford, California|pages=199–205 }}</ref>

A study found that between 1997 and 2003, preventable deaths declined more slowly in the US than in 18 other industrialized nations.<ref>Ellen Nolte and C. Martin McKee, [http://content.healthaffairs.org/cgi/content/abstract/27/1/58?ijkey=05uD000683MNE&keytype=ref&siteid=healthaff "Measuring the Health of Nations: Updating an Earlier Analysis,"], [[Health Affairs]], January 8, 2008, Volume 98</ref> A 2008 study found that 101,000&nbsp;people a year die in the US that would not if the healthcare system were as effective as that of France, Japan, or Australia.<ref name="reuters1">{{cite news| title = France best, U.S. worst in preventable death ranking| first = Will| last = Dunham | name-list-style = vanc | url = https://www.reuters.com/article/us-deaths-rankings-idUSN0765165020080108| work = Reuters| date = January 8, 2008| access-date = April 3, 2012}}</ref> A 2020 study by the economists [[Anne Case]] and [[Angus Deaton]] argues that the US "spends huge sums of money for some of the worst health outcomes in the Western world".<ref>{{cite book |last1= Case |first1=Anne |last2= Deaton |first2=Angus |date=2020 |title=Deaths of Despair and the Future of Capitalism |url=https://books.google.com/books?id=bHK0DwAAQBAJ&pg=PA9|publisher= [[Princeton University Press]]|pages=9–10 |isbn=978-0691190785}}</ref>

The OECD found that the US ranked poorly in terms of [[years of potential life lost]] (YPLL), a statistical measure of years of life lost under the age of 70 that were amenable to being saved by healthcare. Among OECD nations for which data are available, the US ranked third last for the healthcare 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&nbsp;counties, and for men in 11&nbsp;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.<ref name="Ezzati2008">{{cite journal | vauthors = Ezzati M, Friedman AB, Kulkarni SC, Murray CJ | title = The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States | journal = PLOS Medicine | volume = 5 | issue = 4 | pages = e66 | date = April 2008 | pmid = 18433290 | pmc = 2323303 | doi = 10.1371/journal.pmed.0050066 | url = https://www.nytimes.com/2008/04/27/weekinreview/27sack.html | editor1-last = Novotny | editor1-first = Thomas | doi-access = free }}</ref> 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.<ref>{{cite journal | vauthors = Jemal A, Ward E, Anderson RN, Murray T, Thun MJ | title = Widening of socioeconomic inequalities in U.S. death rates, 1993-2001 | journal = PLOS ONE | volume = 3 | issue = 5 | pages = e2181 | date = May 2008 | pmid = 18478119 | pmc = 2367434 | doi = 10.1371/journal.pone.0002181 | bibcode = 2008PLoSO...3.2181J | doi-access = free }}</ref> In 2011 the [[United States National Research Council|US National Research Council]] 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.<ref>{{cite web |url= http://www.huffingtonpost.com/section/healthy-living |title=Healthy Living |work=The Huffington Post |access-date=December 1, 2016}}</ref> In an analysis of [[breast cancer]], [[colorectal cancer]], and [[prostate cancer]] diagnosed during 1990–1994 in 31&nbsp;countries, the US had the highest [[five-year survival rate|five-year relative survival rate]] for breast cancer and prostate cancer, although survival was systematically and substantially lower in Black US men and women.<ref>{{cite web |last=Doheny|first=Kathleen | name-list-style = vanc |date=July 16, 2008 |title=Cancer survival rates vary by country. Study shows U.S., Japan, and France have highest cancer survival rates |website=[[WebMD]] |url=http://www.webmd.com/cancer/news/20080716/cancer-survival-rates-vary-by-country}}<br />{{cite journal | vauthors = Coleman MP, Quaresma M, Berrino F, Lutz JM, De Angelis R, Capocaccia R, Baili P, Rachet B, Gatta G, Hakulinen T, Micheli A, Sant M, Weir HK, Elwood JM, Tsukuma H, Koifman S, E Silva GA, Francisci S, Santaquilani M, Verdecchia A, Storm HH, Young JL | display-authors = 6 | title = Cancer survival in five continents: a worldwide population-based study (CONCORD) | journal = The Lancet. Oncology | volume = 9 | issue = 8 | pages = 730–56 | date = August 2008 | pmid = 18639491 | doi = 10.1016/S1470-2045(08)70179-7 | doi-access = free | url = https://www.openaccessrepository.it/record/41552/files/fulltext.pdf }}<br />In the CONCORD study, [[Cuba]] had the highest five-year relative survival rates for breast cancer and for colorectal cancer in women, but problems with data quality might have led to over-estimations.</ref>

The debate about US healthcare concerns questions of access, efficiency, and quality purchased by the high sums spent. The WHO in 2000 ranked the US healthcare system first in responsiveness, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).<ref name="photius.com">[http://www.photius.com/rankings/who_world_health_ranks.html World Health Organization assesses the world's health system]. Press Release WHO/44 21 June 2000.</ref><ref name="who.int">{{cite web|url=https://www.who.int/whr/2000/en/annex01_en.pdf|title=The World Health Report 2000: Annex Table 1 Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997|website=Who.int|access-date=December 1, 2016}}</ref> The WHO study has been criticized by the free market advocate [[David Gratzer]] because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment.<ref name="fmc">[[David Gratzer]], [http://www.freemarketcure.com/whynotgovhc.php Why Isn't Government Health Care The Answer?] {{webarchive|url=https://web.archive.org/web/20090312071328/http://www.freemarketcure.com/whynotgovhc.php |date=March 12, 2009 }}, ''Free Market Cure'', July 16, 2007</ref> 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.<ref name="Blendon">Robert J. Blendon, Minah Kim and John M. Benson, [http://content.healthaffairs.org/cgi/reprint/20/3/10.pdf "The Public Versus The World Health Organization On Health System Performance,"] Health Affairs, May/June 2001</ref> The study found that there was little correlation between the WHO rankings for health systems and the stated satisfaction of citizens using those systems.<ref name="Blendon" /> 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 healthcare systems.<ref name="Blendon" /> 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.<ref>Christopher J.L. Murray, Kei Kawabata, and Nicole Valentine, [http://content.healthaffairs.org/cgi/reprint/20/3/21 "People's Experience Versus People's Expectations"], Health Affairs, May/June 2001</ref> Furthermore, the relationship between patient satisfaction and healthcare utilization, expenditures, clinically meaningful measures, and the evaluation of outcomes is complex, not well defined, and only beginning to be explored.<ref name=Fenton2012>{{cite journal | vauthors = Fenton JJ, Jerant AF, Bertakis KD, Franks P | title = The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality | journal = Archives of Internal Medicine | volume = 172 | issue = 5 | pages = 405–11 | date = March 2012 | pmid = 22331982 | doi = 10.1001/archinternmed.2011.1662 | url = http://archinte.jamanetwork.com/data/Journals/INTEMED/22610/iiq120001_405_411.pdf | doi-access = free }}</ref><ref>{{Cite journal|last1=Maratt|first1=Jennifer K.|last2=Kerr|first2=Eve A.|last3=Klamerus|first3=Mandi L.|last4=Lohman|first4=Shannon E.|last5=Froehlich|first5=Whit|last6=Bhatia|first6=R. Sacha|last7=Saini|first7=Sameer D.|date=2019|title=Measures Used to Assess the Impact of Interventions to Reduce Low-Value Care: a Systematic Review|url= |journal=Journal of General Internal Medicine|language=en|volume=34|issue=9|pages=1857–1864|doi=10.1007/s11606-019-05069-5|issn=0884-8734|pmc=6712188|pmid=31250366}}</ref>

A report released in April 2008 by the [[Foundation for Child Development]], which studied the period from 1994 through 2006, found mixed results for the health of children in the US 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.<ref>Donna St. George, [https://www.washingtonpost.com/wp-dyn/content/article/2008/04/23/AR2008042303666.html "For Children, a Better Beginning,"] ''The Washington Post'', April 24, 2008</ref><ref>Kenneth C. Land, Project Coordinator, [http://www.fcd-us.org/usr_doc/EarlyChildhoodWell-BeingReport.pdf "2008 Special Focus Report: Trends in Infancy/Early Childhood and Middle Childhood Well-Being, 1994–2006,"] The Foundation for Child Development Child and Youth Well-Being Index (CWI) Project, Foundation for Child Development (FCD), April 24, 2008</ref>

In a sample of 13 developed countries, the US was third in its population weighted usage of medication in 14&nbsp;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&nbsp;years. The study noted considerable difficulties in cross border comparison of medication use.<ref>{{cite web|last1=Office of health Economics|title=International Comparison of Medicines Usage: Quantitative Analysis |url=http://www.abpi.org.uk/our-work/library/industry/Documents/meds_usage.pdf|publisher=Association of the British Pharmaceutical Industry|access-date=July 2, 2015|archive-url=https://web.archive.org/web/20151111181650/http://www.abpi.org.uk/our-work/library/industry/Documents/meds_usage.pdf|archive-date=November 11, 2015|url-status=dead}}</ref>

A critic of the US healthcare system, British philanthropist [[Stan Brock (philanthropist)|Stan Brock]], whose charity [[Remote Area Medical]] 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."<ref name="Brock">{{cite news |title=Stan Brock: the British cowboy turned movie star who rescued millions of uninsured Americans |url=https://www.independent.co.uk/life-style/health-and-families/features/stan-brock-the-british-cowboy-turned-movie-star-who-rescued-millions-of-uninsured-americans-9604573.html |archive-url=https://ghostarchive.org/archive/20220509/https://www.independent.co.uk/life-style/health-and-families/features/stan-brock-the-british-cowboy-turned-movie-star-who-rescued-millions-of-uninsured-americans-9604573.html |archive-date=May 9, 2022 |url-access=subscription |url-status=live |access-date=May 19, 2019 |work=The Independent}}</ref> The charity has over 700&nbsp;clinics and 80,000&nbsp;volunteer doctors and nurses around the US 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."<ref name="Brock"/>

== System efficiency and equity ==
[[File:Maternal mortality rates per 100,000 births by state. US map.svg|thumb|right|upright=1.4|[[Maternal mortality in the United States|Maternal deaths per 100,000 births]]. From [[CDC]]: "Maternal deaths include deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."<ref name=CDC-NVSS>[https://www.cdc.gov/nchs/maternal-mortality/mmr-2018-2021-state-data.pdf Maternal deaths and mortality rates by state, 2018-2021]. Listed at [https://www.cdc.gov/nchs/maternal-mortality/data.htm Data Files and Resources]. [[National Vital Statistics System]] (NVSS). [[National Center for Health Statistics]]. [[Centers for Disease Control and Prevention]].</ref><ref name=CDC-table>[https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm#Table Maternal Mortality Rates in the United States, 2021]. Listed at [https://www.cdc.gov/nchs/maternal-mortality/data.htm Data Files and Resources]. [[US Center for Disease Control]]. [[National Center for Health Statistics]]. [[National Vital Statistics System|National Vital Statistics System, Natality and Mortality]]. {{doi|10.15620/cdc:124678}}.</ref>]]

Variations in the [[Health care efficiency|efficiency of healthcare delivery]] can cause variations in outcomes. The [[The Dartmouth Institute for Health Policy and Clinical Practice|Dartmouth Atlas Project]], for instance, reported that, for over 20&nbsp;years, marked variations in how medical resources are distributed and used in the US were accompanied by marked variations in outcomes.<ref>{{cite web|url=http://www.dartmouthatlas.org/index.shtm |title=Dartmouth Atlas of Health Care |website=Dartmouthatlas.org |date=December 30, 2015 |access-date=December 1, 2016}}</ref> 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 US, particularly those who offer primary care. The ACA 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.<ref name=NYT72812>{{cite news|title=Doctor Shortage Likely to Worsen With Health Law|url=https://www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-us-communities.html|access-date=July 29, 2012|newspaper=The New York Times|date=July 28, 2012|last1=Lowrey|first1=Annie|first2 = Robert | last2 = Pear | name-list-style = vanc }}</ref>

Lean manufacturing techniques such as [[value stream mapping]] can help identify and subsequently mitigate waste associated with costs of healthcare.{{citation needed|date=January 2022}} Other product engineering tools such as [[Failure mode and effects analysis|FMEA]] and [[Ishikawa diagram|Fish Bone Diagrams]] have been used to improve efficiencies in healthcare delivery.<ref name="MC_Gill2013">{{cite journal | vauthors = Gill PS |title=Five Product Engineering Methods That Can Be Applied to Health Care Management|journal=Managed Care |volume=3 |year=2013 |pages=21–26|url=http://www.managedcaremag.com/archives/1303/1303.engineering.html}}</ref>

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|OECD]] and [[World Health Organization|WHO]] which is analyzed under five themes: access to care, the care process, administrative efficiency, equity and healthcare outcomes. The US has been assessed as worst healthcare system overall among 11 high-income countries in every report, even though it spends the highest proportion of its gross domestic product on healthcare. In 2021 Norway, the Netherlands and Australia were the top-performing countries. The US spent 16.8% of GDP on healthcare 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 healthcare 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.<ref>{{cite news |title=U.S. health-care system ranks last among 11 high-income countries, researchers say |url=https://www.washingtonpost.com/world/2021/08/05/global-health-rankings/ |access-date=23 May 2022 |newspaper=Washington Post |date=5 August 2021}}</ref>

=== Efficiency ===
==== Preventable deaths ====
In 2010, [[coronary artery disease]], [[lung cancer]], [[stroke]], [[chronic obstructive pulmonary disease]]s, and traffic accidents caused the most years of life lost in the US. Low back pain, [[major depressive disorder|depression]], [[musculoskeletal disorder]]s, neck pain, and [[anxiety]] caused the most years lost to disability. The most deleterious [[risk factor]]s were poor diet, tobacco smoking, obesity, [[high blood pressure]], [[high blood sugar]], physical inactivity, and alcohol use. [[Alzheimer's disease]], drug abuse, kidney disease and cancer, and falls caused the most additional years of life lost over their age-adjusted 1990 per-capita rates.<ref name=Murray2013 />

Between 1990 and 2010, among the 34&nbsp;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.<ref name=Murray2013>{{cite journal | vauthors = Murray CJ, Atkinson C, Bhalla K, Birbeck G, Burstein R, Chou D, etal | title = The state of US health, 1990-2010: burden of diseases, injuries, and risk factors | journal = JAMA | volume = 310 | issue = 6 | pages = 591–608 | date = August 2013 | pmid = 23842577 | pmc = 5436627 | doi = 10.1001/jama.2013.13805 | url = http://jama.jamanetwork.com/data/Journals/JAMA/0/joi130037.pdf }}</ref>

According to a 2009 study conducted at [[Harvard Medical School]] by cofounders of [[Physicians for a National Health Program]], a pro-single payer lobbying group, and published by the ''[[American Journal of Public Health]]'', [[Health insurance coverage in the United States|lack of health coverage]] is associated with nearly 45,000 excess preventable deaths annually.<ref name="Harvard Gazette">{{cite news | first = David | last = Cecere | name-list-style = vanc | date = 17 September 2009 | url = http://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-linked-to-lack-of-health-coverage/ | title = New study finds 45,000 deaths annually linked to lack of health coverage | work = [[Harvard Gazette]] | access-date = 27 August 2013 }}</ref><ref name="Wilper 2009">{{cite journal | vauthors = Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU | title = Health insurance and mortality in US adults | journal = American Journal of Public Health | volume = 99 | issue = 12 | pages = 2289–95 | date = December 2009 | pmid = 19762659 | pmc = 2775760 | doi = 10.2105/AJPH.2008.157685 }}</ref> Since then, as the number of uninsured has risen from about 46&nbsp;million in 2009 to 49&nbsp;million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year.<ref name=uninsureddeaths>{{cite web | vauthors = Woolhandler S |date= September 12, 2012 |title= Despite slight drop in uninsured, last year's figure points to 48,000 preventable deaths |publisher= Physicians for a National Health Program |url= http://www.pnhp.org/news/2012/september/despite-slight-drop-in-uninsured-last-year%E2%80%99s-figure-points-to-48000-preventable- |access-date= September 26, 2012 |display-authors= etal |archive-url= https://web.archive.org/web/20120924021844/http://www.pnhp.org/news/2012/september/despite-slight-drop-in-uninsured-last-year%E2%80%99s-figure-points-to-48000-preventable- |archive-date= September 24, 2012 |url-status= dead}}</ref> 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.<ref name="Goodman">{{cite journal|title=Does Lack Of Insurance Cause Premature Death?|last=Goodman |first=John |name-list-style=vanc |date=September 21, 2009 |website=Health Affairs |doi=10.1377/forefront.20090921.002196|doi-access=free}}</ref>

A 2009 study by former [[Bill Clinton|Clinton]] policy adviser Richard Kronick published in the journal [[Health Services Research (journal)|Health Services Research]] found no increased mortality from being uninsured after certain risk factors were controlled for.<ref name="Kronick">{{cite journal|vauthors=Kronick R|date=August 2009|title=Health insurance coverage and mortality revisited|journal=Health Services Research|volume=44|issue=4 |pages=1211–31|doi=10.1111/j.1475-6773.2009.00973.x|pmc=2739025|pmid=19453392}}<!--|access-date=August 15, 2014--></ref>

==== Value for money ====
A study of international healthcare spending levels published in the health policy journal ''[[Health Affairs]]'' in the year 2000 found that the US spends substantially more on healthcare than any other country in the [[Organisation for Economic Co-operation and Development|OECD]] (OECD), and that the use of healthcare services in the US is below the OECD median by most measures. The authors of the study conclude that the prices paid for healthcare services are much higher in the US than elsewhere.<ref name="Prices Stupid">Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey and Varduhi Petrosyan, [http://content.healthaffairs.org/cgi/content/abstract/22/3/89 "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.</ref> While the 19 next most wealthy countries by GDP all pay less than half what the US does for healthcare, they have all gained about six years of life expectancy more than the US since 1970.<ref name=Kenworthy2011 />

==== Delays in seeking care and increased use of emergency care ====
Uninsured Americans are less likely to have regular healthcare 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.<ref name="pmid17356028">{{cite journal | vauthors = Hadley J | title = Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition | journal = JAMA | volume = 297 | issue = 10 | pages = 1073–84 | date = March 2007 | pmid = 17356028 | doi = 10.1001/jama.297.10.1073 | doi-access = free }}</ref> 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.<ref>{{cite web|url=https://www.cdc.gov/nchs/data/ad/ad388.pdf |title=Advance Data From Vital and Health Statistics No. 388 |website=Cdc.gov |date= June 28, 2007|access-date=December 1, 2016}}</ref>

In 2008 researchers with the [[American Cancer Society]] 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.<ref name="Halpern2008">{{cite journal | vauthors = Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY | title = Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis | journal = The Lancet. Oncology | volume = 9 | issue = 3 | pages = 222–31 | date = March 2008 | pmid = 18282806 | doi = 10.1016/S1470-2045(08)70032-9 }} Lay summary: [https://www.nytimes.com/2008/02/18/health/18cancer.html Study Finds Cancer Diagnosis Linked to Insurance], ''New York Times''.</ref>

==== Variations in provider practices ====
The treatment given to a patient can vary significantly depending on which healthcare providers they use. Research suggests that some cost-effective treatments are not used as often as they should be, while [[overutilization]] occurs with other healthcare services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety.<ref>{{cite web|first = Valerie |last =Ulene | name-list-style = vanc |url = http://www.latimes.com/features/printedition/health/la-he-themd5-2008may05,0,2608989.story |title =Care that goes too far|work = [[Los Angeles Times]]|date= May 5, 2008}}</ref> The use of prescription drugs varies significantly by geographic region.<ref>Emily Cox, Doug Mager, Ed Weisbart, [http://www.express-scripts.com/ourcompany/news/outcomesresearch/onlinepublications/study/geoVariationTrends.pdf "Geographic Variation Trends in Prescription Use: 2000 to 2006,"] [[Express Scripts]], January 2008 {{webarchive |url= https://web.archive.org/web/20080227072600/http://www.express-scripts.com/ourcompany/news/outcomesresearch/onlinepublications/study/geoVariationTrends.pdf |date=February 27, 2008 }}</ref> The overuse of medical benefits is known as [[moral hazard]]—individuals who are insured are then more inclined to consume healthcare. The way the healthcare system tries to eliminate this problem is through cost sharing tactics like copays and deductibles. If patients face more of the economic burden they will then only consume healthcare when they perceive it to be necessary. According to the RAND health insurance experiment, individuals with higher coinsurance rates consumed less healthcare 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 healthcare costs in the US will also rise with these procedures as well. More expensive procedures lead to greater costs.<ref>[http://www.dartmouthatlas.org/topics/effective_care.pdf "Effective Care,"] {{webarchive|url=https://web.archive.org/web/20080216012730/http://www.dartmouthatlas.org/topics/effective_care.pdf |date=February 16, 2008 }} The Dartmouth Atlas of Health Care, January 15, 2007</ref><ref>Laurence C. Baker, Elliott S. Fisher, and [[John Wennberg|John E. Wennberg]], [http://content.healthaffairs.org/cgi/reprint/hlthaff.27.2.w123v1 "Variations In Hospital Resource Use For Medicare And Privately Insured Populations In California,"] Health Affairs web exclusive, February 2008</ref>

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.<ref name=DartmouthAtlas2008>John E. Wennberg, Elliott S. Fisher, David C. Goodman, and Jonathan S. Skinner, [http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf "Tracking the Care of Patients with Severe Chronic Illness: the Dartmouth Atlas of Health Care 2008."] {{webarchive|url=https://web.archive.org/web/20081029000748/http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf |date=October 29, 2008 }} [[The Dartmouth Institute for Health Policy and Clinical Practice]], May 2008, {{ISBN|978-0-9815862-0-5}} ([http://www.dartmouthatlas.org/atlases/2008_Atlas_Exec_Summ.pdf Executive Summary] {{webarchive|url=https://web.archive.org/web/20080408231441/http://www.dartmouthatlas.org/atlases/2008_Atlas_Exec_Summ.pdf |date=April 8, 2008 }})</ref><ref>[http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=51385 "Medicare: End-of-Life Hospital Spending for Medicare Beneficiaries With Chronic Health Conditions Varies Widely, Study Finds,"]{{dead link|date=October 2017 |bot=InternetArchiveBot |fix-attempted=yes }} Kaiser Daily Health Policy Report, [[Kaiser Family Foundation]], April 7, 2008</ref>

==== Care coordination ====
Primary care doctors are often the point of entry for most patients needing care, but in the fragmented healthcare system of the US, 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&nbsp;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.<ref>California HealthCare Foundation, [http://www.chcf.org/topics/view.cfm?itemid=133466 "Uncoordinated Care: A Survey of Physician and Patient Experience"] {{Webarchive|url=https://web.archive.org/web/20080214013651/http://www.chcf.org/topics/view.cfm?itemid=133466 |date=February 14, 2008 }}, Harris Interactive. 2007. Retrieved March 20, 2008.</ref>

According to an article in ''[[The New York Times]]'', the relationship between doctors and patients is deteriorating.<ref name="NYTJuly2008">Tare Parker-Pople, [https://www.nytimes.com/2008/07/29/health/29well.html "Well: Doctor and Patient, Now at Odds,"] ''[[The New York Times]]'', July 29, 2008</ref> A study from [[Johns Hopkins University]] 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.<ref name="NYTJuly2008" />

Many primary care physicians no longer see their patients while they are in the hospital; instead, [[hospitalist]]s are used.<ref>Hospitalists and the family physician [http://www.aafp.org/afp/980800ap/edit.html] {{Webarchive|url=https://web.archive.org/web/20111026025031/http://www.aafp.org/afp/980800ap/edit.html|date=October 26, 2011}} by Bruce Bagley, M.D.; American Family Physician</ref> The use of hospitalists is sometimes mandated by health insurance companies as a cost-saving measure which is resented by some primary care physicians.<ref>{{cite web |url=http://www.acpinternist.org/archives/1999/05/hosps.htm |title=Use of mandatory hospitalists blasted, ACP Observer May 99 |website=Acpinternist.org |date=February 16, 1999 |access-date=December 1, 2016 |url-status=dead |archive-url=https://web.archive.org/web/20161019223115/http://www.acpinternist.org/archives/1999/05/hosps.htm |archive-date=October 19, 2016}}</ref>

==== Administrative costs ====
{{As of|2017}}, there were 907 health insurance companies in the US,<ref>{{Cite web|url=https://www.iii.org/fact-statistic/facts-statistics-industry-overview|title=Facts + Statistics: Industry overview {{!}} III|website=www.iii.org|access-date=2019-06-24}}</ref> although the top 10 account for about 53% of revenue and the top 100 account for 95% of revenue.<ref>{{Cite web|url=https://www.treasury.gov/initiatives/fio/reports-and-notices/Documents/2018_FIO_Annual_Report.pdf|title=Annual Report on the Insurance Industry (September 2018) | publisher=Federal Insurance Office, U.S. Department of the Treasury}}</ref>{{Rp|70}} 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.<ref>{{cite journal | vauthors = Woolhandler S, Campbell T, Himmelstein DU | title = Costs of health care administration in the United States and Canada | journal = The New England Journal of Medicine | volume = 349 | issue = 8 | pages = 768–75 | date = August 2003 | pmid = 12930930 | doi = 10.1056/NEJMsa022033 | s2cid = 2313231 | doi-access = free }}</ref>

Insurance industry group [[America's Health Insurance Plans]] estimates that administrative costs have averaged approximately 12% of premiums over the last 40&nbsp;years, with costs shifting away from adjudicating claims and towards medical management, nurse help lines, and negotiating discounted fees with healthcare providers.<ref>Jeff Lemieux, [http://www.ahipresearch.org/pdfs/Administrative_Costs_030705.pdf "Perspective: Administrative Costs of Private Health Insurance Plans"] {{Webarchive|url=https://web.archive.org/web/20071128170000/http://www.ahipresearch.org/pdfs/Administrative_Costs_030705.pdf |date=November 28, 2007 }}, [[America's Health Insurance Plans]], 2005</ref>

A 2003 study published by the [[Blue Cross and Blue Shield Association]] (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.<ref>[http://www.bcbs.com/betterknowledge/cost/Cost_Admin030703.pdf "Understanding Health Plan Administrative Costs"], [[Blue Cross and Blue Shield Association|Blue Cross Blue Shield Association]], 2003 {{webarchive |url=https://web.archive.org/web/20071026063247/http://www.bcbs.com/betterknowledge/cost/Cost_Admin030703.pdf |date=October 26, 2007 }}</ref> 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.<ref>{{cite report | first1 = Kent J. | last1 = Sacia | first2 = Robert H. | last2 = Dobson | name-list-style = vanc | title = Health Plan Administrative Cost Trends | publisher = [[Blue Cross and Blue Shield Association|BlueCross BlueShield Association]] | work = Milliman USA | date = 20 February 2003 }}</ref> 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&nbsp;billion in 2003).<ref>{{cite news| url=https://economix.blogs.nytimes.com/2008/11/21/why-does-us-health-care-cost-so-much-part-ii-indefensible-administrative-costs/ | work=The New York Times | title=Why Does U.S. Health Care Cost So Much? (Part II: Indefensible Administrative Costs) | first=Uwe E. | last=Reinhardt | name-list-style = vanc | date=November 21, 2008 | access-date=May 4, 2010}}</ref>

According to a report published by the [[Congressional Budget Office|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.<ref>[[Congressional Budget Office|U.S. Congressional Budget Office]], [http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/99xx/doc9924/12-18-keyissues.pdf ''Key Issues in Analyzing Major Health Insurance Proposals''], December 2008</ref> 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.<ref name="Sherlock 2009" /> Administrative costs were 11.1% of premiums for small group products and 16.4% in the individual market.<ref name="Sherlock 2009">{{cite web|first =Douglas B.|last = Sherlock | name-list-style = vanc |url = http://s3.amazonaws.com/zanran_storage/www.bcbs.com/ContentPages/25302966.pdf|title = Administrative Expenses of Health Plans|publisher= [[Blue Cross and Blue Shield Association|Blue Cross Blue Shield Association]]|date= 2009|via = s3.amazonaws.com}}</ref>

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.<ref name="pmid16284038">{{cite journal | vauthors = Kahn JG, Kronick R, Kreger M, Gans DN | title = The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals | journal = Health Affairs | volume = 24 | issue = 6 | pages = 1629–39 | year = 2005 | pmid = 16284038 | doi = 10.1377/hlthaff.24.6.1629 | doi-access = free }}</ref>

====Long-term living facilities====
As of 2014, according to a report published<ref>{{cite journal |pmc = 6376502|year = 2019|last1 = Weech-Maldonado|first1 = R.|last2 = Pradhan|first2 = R.|last3 = Dayama|first3 = N.|last4 = Lord|first4 = J.|last5 = Gupta|first5 = S.|title = Nursing Home Quality and Financial Performance: Is There a Business Case for Quality?|journal = Inquiry: A Journal of Medical Care Organization, Provision and Financing|volume = 56|pages = 0046958018825191|doi = 10.1177/0046958018825191|pmid = 30739511}}</ref> 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,<ref>{{cite journal|pmc = 2763425|year = 2009|last1 = Stewart|first1 = K. A.|last2 = Grabowski|first2 = D. C.|last3 = Lakdawalla|first3 = D. N.|title = Annual expenditures for nursing home care: Private and public payer price growth, 1977–2004|journal = Medical Care|volume = 47|issue = 3|pages = 295–301|doi = 10.1097/MLR.0b013e3181893f8e|pmid = 19194339}}</ref> 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.<ref>{{cite journal |pmc = 2763425|year = 2009|last1 = Stewart|first1 = K. A.|last2 = Grabowski|first2 = D. C.|last3 = Lakdawalla|first3 = D. N.|title = Annual expenditures for nursing home care: Private and public payer price growth, 1977–2004|journal = Medical Care|volume = 47|issue = 3|pages = 295–301|doi = 10.1097/MLR.0b013e3181893f8e|pmid = 19194339}}</ref>

=== 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.<ref name=just /> The lack of price information on medical services can also distort incentives.<ref name=just /> 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.<ref name=just /> This reasoning has led for calls to reform the insurance system to create a [[consumer-driven health care|consumer-driven healthcare]] system whereby consumers pay more out-of-pocket.<ref name="Scandlen2005">{{cite journal | vauthors = Scandlen G | title = Consumer-driven health care: just a tweak or a revolution? | journal = Health Affairs | volume = 24 | issue = 6 | pages = 1554–8 | year = 2005 | pmid = 16284028 | doi = 10.1377/hlthaff.24.6.1554 | doi-access = free }}</ref> In 2003, the [[Medicare Prescription Drug, Improvement, and Modernization Act]] was passed, which encourages consumers to have a [[high-deductible health plan]] and a [[health savings account]]. In October 2019, the state of Colorado proposed running public healthcare 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.<ref>{{Cite web|url=https://www.denverpost.com/2019/10/07/colorado-public-insurance-option-draft/|title=Colorado proposes running public health care option through private insurers|date=2019-10-07|website=The Denver Post|language=en-US|access-date=2019-11-21}}</ref>{{Update after|2022}}

=== Equity ===
[[File:Health Insurance Coverage in the U.S. 2016 - v1.png|thumb|right|upright=1.5|US health insurance coverage by source in 2016. CBO estimated ACA/Obamacare was responsible for 23&nbsp;million persons covered via exchanges and Medicaid expansion.<ref name="CBO_Subsidy2016">{{cite web|url=https://www.cbo.gov/publication/51385|title=Federal Subsidies for Health Insurance Coverage for People Under Age 65|publisher=CBO|date=March 24, 2016}}</ref>]]

==== Mental health ====
{{See also|Mental health#United States|Mentally ill prisoners in the United States}}

In 2020, 52.9&nbsp;million adults were affected by mental illness, nearly one in five adults in the country. 44.7&nbsp;million adults were affected in 2016.<ref>{{cite web|url=https://www.nimh.nih.gov/health/statistics/mental-illness.shtml|title=NIMH » Mental Illness|website=nimh.nih.gov|access-date=2018-02-28}}</ref> In 2006, mental disorders were ranked one of the top five most costly medical conditions, with expenditures of $57.5&nbsp;billion (equivalent to ${{Formatprice|{{inflation|US-GDP|57500000000|2006}}}} in {{Inflation/year|index=US-GDP}}{{Inflation/fn|index=US-GDP}}).<ref>{{cite web |title=Data on behavioral health in the United States |url=http://www.apa.org/helpcenter/data-behavioral-health.aspx |archive-url=https://web.archive.org/web/20190330035917/https://www.apa.org/helpcenter/data-behavioral-health |archive-date=30 March 2019 |access-date=2018-02-28 |website=apa.org}}</ref> A lack of mental health coverage for Americans bears significant ramifications to the [[Economy of the United States|US economy]] and social system. A report by the [[Surgeon General of the United States|US Surgeon General]] found that mental illnesses are the second leading cause of [[disability]] in the nation and affect 20% of all Americans.<ref name="SurGen">{{cite web |url=http://www.cartercenter.org/health/mental_health/index.html |title=The Carter Center Mental Health Program: Combating the Stigma of Mental Illness |access-date=July 30, 2008|publisher=The Carter Center}}</ref> 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,<ref name="WeissWP">{{cite news |first=Rick |last=Weiss | name-list-style = vanc |title=Study: U.S. Leads In Mental Illness, Lags in Treatment |url=https://www.washingtonpost.com/wp-dyn/content/article/2005/06/06/AR2005060601651.html |newspaper=The Washington Post |date=June 7, 2005 |access-date=July 30, 2008}}</ref> including a shortage of mental health professionals.<ref>{{Cite journal |last=Kuehn |first=Bridget M. |date=25 May 2022 |title=Clinician Shortage Exacerbates Pandemic-Fueled "Mental Health Crisis" |url=https://jamanetwork.com/journals/jama/fullarticle/2792853 |department=Medical News & Perspectives |journal=[[JAMA]] |volume=327 |issue=22 |pages=2179&ndash;81 |doi=10.1001/jama.2022.8661 |pmid=35612873 |doi-access=free}}</ref> 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.<ref>{{Cite journal |last1=Madden |first1=Jeanne M. |last2=Adams |first2=Alyce S. |last3=LeCates |first3=Robert F. |last4=Ross-Degnan |first4=Dennis |last5=Zhang |first5=Fang |last6=Huskamp |first6=Haiden A. |last7=Gilden |first7=Daniel M. |last8=Soumerai |first8=Stephen B. |date=2015-02-01 |title=Changes in Drug Coverage Generosity and Untreated Serious Mental Illness: Transitioning From Medicaid to Medicare Part D |journal=JAMA Psychiatry |language=en |volume=72 |issue=2 |pages=179–188 |doi=10.1001/jamapsychiatry.2014.1259 |issn=2168-622X |pmc=4505620 |pmid=25588123}}</ref> Some entities try to expand access to mental health services by providing access on a [[sliding-scale]] or reduced fee structure. Networks such as [[Open Path Collective]] are composed of professionals who offer their services to people who cannot otherwise find affordable treatment through insurance.<ref>{{cite web |url=https://psychcentral.com/reviews/affordable-therapy#_noHeaderPrefixedContent |title=8 Best Affordable Online Therapy Options for 2023 |author=<!--Not stated--> |date=16 November 2023 |website=PsychCentral |publisher= |access-date=22 November 2023|archive-url  = https://archive.today/i59GQ|archive-date = 24 November 2023  |quote=}}</ref>

The Paul Wellstone Mental Health and Addiction Equity Act of 2008 mandates that group health plans provide mental health and [[substance-related disorder]] 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]] 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 copayments or setting limits on the number of days spent in inpatient or outpatient treatment facilities.<ref>{{cite news |url=https://www.nytimes.com/2008/03/06/washington/06health.html |title=House Approves Bill on Mental Health Parity |access-date=July 29, 2009|work=The New York Times | first=Robert | last=Pear | name-list-style = vanc | date=March 6, 2008}}</ref><ref>{{YouTube|drSB2JPGh8Y|"Sedgwick Ignores Medical Records and Denies Disability Benefits"}}</ref>

====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,<ref>{{Cite journal|last1=Pinto|first1=Rita Del|last2=Monaco|first2=Annalisa|last3=Ortu|first3=Eleonora|last4=Czesnikiewicz-Guzik|first4=Marta|last5=Aguilera|first5=Eva Muñoz|last6=Giannoni|first6=Mario|last7=D'Aiuto|first7=Francesco|last8=Guzik|first8=Tomasz J.|last9=Ferri|first9=Claudio|last10=Pietropaoli|first10=Davide|date=2021-11-02|title=Access to dental care and blood pressure profiles in adults with high socioeconomic status|journal=Journal of Periodontology|volume=93 |issue=7 |pages=1060–1071 |doi=10.1002/JPER.21-0439|issn=1943-3670|pmid=34726790|pmc=9542004 |s2cid=240422102}}</ref> 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]] in adults of all previously listed populations has remained consistent or worsened.<ref>{{cite journal|doi=10.1146/annurev-publhealth-040119-094318|doi-access=free|title=Disparities in Access to Oral Health Care|year=2020|last1=Northridge|first1=Mary E.|last2=Kumar|first2=Anjali|last3=Kaur|first3=Raghbir|journal=Annual Review of Public Health|volume=41|pages=513–535|pmid=31900100|pmc=7125002}}</ref>

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.<ref>{{Cite journal |last=Committee |first=U.S. Department of Health and Human Services Oral Health Coordinating |date=March 2016 |title=U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014–2017 |journal=Public Health Reports |language=en |volume=131 |issue=2|pages=242–257 |doi=10.1177/003335491613100208 |pmid=26957659 |pmc=4765973 }}</ref> 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.<ref>{{Cite web |date=February 1, 2022 |title=New York State Medicaid program - dental policy and procedure code manual |url=https://www.emedny.org/ProviderManuals/Dental/PDFS/Dental_Policy_and_Procedure_Manual.pdf |access-date=October 23, 2022 |website=www.emedny.org/}}</ref> 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 ACA, [[medical underwriting]] was common, but, after the law came into effect in 2014, it became effectively prohibited.<ref>{{cite web|url=http://kff.org/health-reform/perspective/how-buying-insurance-will-change-under-obamacare/|title=How Buying Insurance Will Change Under Obamacare|date=September 24, 2013|website=Kff.org|publisher=The Henry J. Kaiser Family Foundation|access-date=December 1, 2016}}</ref>

==== Demographic differences ====
{{Main|Race and health in the United States|Poverty and health in the United States}}
[[File:CDC TB graphic on minority groups being impacted by TB.jpg|thumb|A [[Centers for Disease Control and Prevention|CDC]] image depicting racial health disparities in the US for [[tuberculosis]]]]

[[Health disparities]] are well documented in the US in ethnic minorities such as [[African Americans]], [[Native Americans in the United States|Native Americans]], and [[Hispanics in the United States|Hispanics]].<ref>Goldberg, J., Hayes, W., and Huntley, J. [http://www.healthpolicyohio.org/publications/healthdisparities.html "Understanding Health Disparities."] {{webarchive|url=https://web.archive.org/web/20080515210412/http://www.healthpolicyohio.org/publications/healthdisparities.html |date=May 15, 2008 }} Health Policy Institute of Ohio (November 2004), p. 3.</ref> When compared to [[White American|whites]], these minority groups have higher incidence of chronic diseases, higher mortality, poorer health outcomes and poorer rates of diagnosis and treatment.<ref>{{Cite book |last1=Smedley |first1=Brian D. |url=http://worldcat.org/oclc/853283904 |title=Unequal treatment: confronting racial and ethnic disparities in health care |last2=Stith |first2=Adrienne Y. |last3=Nelson |first3=Alan R. |date=2003 |publisher=National Academy Press |isbn=978-0-309-21582-4 |oclc=853283904}}</ref><ref>{{Cite journal |last1=Atdjian |first1=Sylvia |last2=Vega |first2=William A. |date=December 2005 |title=Disparities in Mental Health Treatment in U.S. Racial and Ethnic Minority Groups: Implications for Psychiatrists |url=http://psychiatryonline.org/doi/abs/10.1176/appi.ps.56.12.1600 |journal=Psychiatric Services |language=en |volume=56 |issue=12 |pages=1600–1602 |doi=10.1176/appi.ps.56.12.1600 |pmid=16339626 |issn=1075-2730}}</ref> Among the disease-specific examples of racial and ethnic disparities in the US is the cancer incidence rate among African Americans, which is 25% higher than among whites.<ref name="APHA">American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).</ref> In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes and have higher overall obesity rates.<ref>{{cite web|last=Campanile |first=Carl | name-list-style = vanc |url=http://www.nypost.com/p/news/national/we_regoing_wide_UBV52r2Rl9hejdZDaGTgNM |title=Americans are getting fatter: poll |publisher= New York Post |website=Nypost.com |date=November 23, 2012 |access-date=December 1, 2016}}</ref> Minorities also have higher rates of [[cardiovascular disease]] and [[HIV/AIDS]] than whites.<ref name="APHA" /> In the US, Asian Americans live the longest (87.1&nbsp;years), followed by Latinos (83.3&nbsp;years), whites (78.9&nbsp;years), Native Americans (76.9&nbsp;years), and African Americans (75.4&nbsp;years).<ref>Sarah Burd-Sharps and Kristen Lewis. ''[http://www.measureofamerica.org/congressional-districts-2015/ Geographies of Opportunity: Ranking Well-Being by Congressional District]''. 2015. [[Measure of America]] of the Social Science Research Council.</ref> A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.<ref>''[http://cat.inist.fr/?aModele=afficheN&cpsidt=1050427 Trends in healthy life expectancy in the united states, 1970–1990: gender, racial, and educational differences] {{Webarchive|url=https://web.archive.org/web/20100317145539/http://cat.inist.fr/?aModele=afficheN&cpsidt=1050427 |date=March 17, 2010 }}''</ref>

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, equivalent to ${{Formatprice|{{inflation|US|6921|2002}}}} versus ${{Formatprice|{{inflation|US|1225|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}). Average public spending for non-Hispanic blacks ($2,973, equivalent to ${{Formatprice|{{inflation|US|2973|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) was slightly higher than that for whites ($2,675, equivalent to ${{Formatprice|{{inflation|US|2675|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}), while spending for Hispanics ($1,967, equivalent to ${{Formatprice|{{inflation|US|1967|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}) was significantly lower than the population average ($2,612, equivalent to ${{Formatprice|{{inflation|US|2612|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}})). Total public spending is also strongly correlated with self-reported health status ($13,770 [equivalent to ${{Formatprice|{{inflation|US|13770|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}] for those reporting "poor" health versus $1,279 [equivalent to ${{Formatprice|{{inflation|US|1279|2002}}}} in {{Inflation/year|index=US}}{{Inflation/fn|index=US}}] for those reporting "excellent" health).<ref name="content.healthaffairs.org" /> Seniors make up 13% of the population but take one-third of all prescription drugs. The average senior fills 38&nbsp;prescriptions annually.<ref>{{cite news | first=Pamela | last=Tronetti | name-list-style = vanc | title=Senior consult:Check drugs supplements to avoid interactions | url=http://www.floridatoday.com/article/20110111/LIFE01/101110310/Dr-Pamela-TronettiI-Check-drugs-supplements-to-avoid-interactions| newspaper=Florida Today | location=Melbourne, Florida | page= 1D | date=January 11, 2011 }}</ref> 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.<ref>{{cite news |url=http://well.blogs.nytimes.com/2012/09/25/antibiotic-prescription-it-may-depend-on-where-you-live/?emc=rss |title=Well: Antibiotic Prescription? It May Depend on Where You Live | work=The New York Times | first=Anahad |last=O'Connor | name-list-style = vanc |date=September 25, 2012}}</ref>

There is considerable research into inequalities in healthcare. In some cases, these inequalities are caused by income disparities that result in lack of health insurance and other barriers, such as medical equipment, to receiving services.<ref>[http://www.kff.org/uninsured/7705.cfm "How Trends in the Health Care System Affect Low-Income Adults: Identifying Access Problems and Financial Burdens"], Issue Brief: Kaiser Commission on Medicaid and the Uninsured, December 21, 2007. Retrieved February 26, 2008.</ref> According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive [[preventive medicine|preventive services]] in healthcare.<ref>{{cite journal | vauthors = Habib JL | year = 2010 | title = Progress lags in infection prevention and health disparities | url = http://dbt.consultantlive.com/display/article/1145628/1582744 | journal = Drug Benefit Trends | volume = 22 | issue = 4 | page = 112 | access-date = June 11, 2010 | archive-date = January 20, 2013 | archive-url = https://web.archive.org/web/20130120065516/http://dbt.consultantlive.com/display/article/1145628/1582744 | url-status = dead }}</ref> For example, minorities are not regularly screened for [[colon cancer]] and the death rate for colon cancer has increased among African Americans and Hispanic people. In other cases, inequalities in healthcare reflect a [[systemic bias]] in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of [[Scientific racism|racism in science]] and medicine shows that people and institutions behave according to the ethos of their times.<ref>{{cite journal | vauthors = Bhopal R | title = Spectre of racism in health and health care: lessons from history and the United States | journal = BMJ | volume = 316 | issue = 7149 | pages = 1970–3 | date = June 1998 | pmid = 9641943 | pmc = 1113412 | doi = 10.1136/bmj.316.7149.1970 }}</ref> Nancy Krieger wrote that racism underlies unexplained inequities in healthcare, including treatment for heart disease,<ref>{{cite journal | vauthors = Oberman A, Cutter G | title = Issues in the natural history and treatment of coronary heart disease in black populations: surgical treatment | journal = American Heart Journal | volume = 108 | issue = 3 Pt 2 | pages = 688–94 | date = September 1984 | pmid = 6332513 | doi = 10.1016/0002-8703(84)90656-2 }}</ref> renal failure,<ref name="pmid3288159">{{cite journal | vauthors = Kjellstrand CM | title = Age, sex, and race inequality in renal transplantation | journal = Archives of Internal Medicine | volume = 148 | issue = 6 | pages = 1305–9 | date = June 1988 | pmid = 3288159 | doi = 10.1001/archinte.1988.00380060069016 }}</ref> bladder cancer,<ref>{{cite journal | vauthors = Mayer WJ, McWhorter WP | title = Black/white differences in non-treatment of bladder cancer patients and implications for survival | journal = American Journal of Public Health | volume = 79 | issue = 6 | pages = 772–5 | date = June 1989 | pmid = 2729474 | pmc = 1349641 | doi = 10.2105/ajph.79.6.772 }}</ref> and pneumonia.<ref>{{cite journal | vauthors = Yergan J, Flood AB, LoGerfo JP, [[Paula Diehr|Diehr P]] | title = Relationship between patient race and the intensity of hospital services | journal = Medical Care | volume = 25 | issue = 7 | pages = 592–603 | date = July 1987 | pmid = 3695664 | doi = 10.1097/00005650-198707000-00003 | s2cid = 11637921 }}</ref> Results from a 2023 scoping review of the literature found that in studies conducted in multiracial or multiethnic populations, race or ethnicity variables were rarely included in conceptually thoughtful and analytically informative ways concerning race or ethnicity as markers of exposure to racialized social disadvantage.<ref>{{Cite journal |last=Cené |first=Crystal W. |last2=Viswanathan |first2=Meera |last3=Fichtenberg |first3=Caroline M. |last4=Sathe |first4=Nila A. |last5=Kennedy |first5=Sara M. |last6=Gottlieb |first6=Laura M. |last7=Cartier |first7=Yuri |last8=Peek |first8=Monica E. |date=2023-01-19 |title=Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review |url=https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800612 |journal=JAMA Network Open |language=en |volume=6 |issue=1 |pages=e2250654 |doi=10.1001/jamanetworkopen.2022.50654 |issn=2574-3805 |pmc=9857687 |pmid=36656582}}</ref><ref>{{Cite web |last=Cené |first=Crystal W. |last2=Viswanathan |first2=Meera |last3=Fichtenberg |first3=Caroline M. |last4=Sathe |first4=Nila A. |last5=Kennedy |first5=Sara M. |last6=Gottlieb |first6=Laura M. |last7=Cartier |first7=Yuri |last8=Peek |first8=Monica E. |date=January 2023 |title=Racial Health Equity and Social Needs Interventions: Rapid Review |url=https://www.pcori.org/research-results/2021/rapid-review-racial-health-equity-and-social-needs-interventions}}</ref> [[Raj Bhopal]] writes that these inequalities have been documented in numerous studies. The consistent and repeated findings were that Black Americans received less healthcare than white Americans—particularly when the care involved expensive new technology.<ref>{{cite journal | title = Black-white disparities in health care | journal = JAMA | volume = 263 | issue = 17 | pages = 2344–6 | date = May 1990 | pmid = 2182918 | doi = 10.1001/jama.263.17.2344 | author1 = Council on Ethical Judicial Affairs }}</ref> One recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.<ref>Darrell J. Gaskin, Christine S. Spencer, Patrick Richard, Gerard F. Anderson, [[Neil R. Powe]], and Thomas A. LaVeist, [http://content.healthaffairs.org/cgi/reprint/27/2/518?ijkey=KSQtLI48Rtqmo&keytype=ref&siteid=healthaff "Do Hospitals Provide Lower-Quality Care To Minorities Than To Whites?,"] Health Affairs, March/April 2008</ref><ref>[http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=672918 "In the Literature: Do Hospitals Provide Lower-Quality Care To Minorities Than To Whites?,"] {{Webarchive|url=https://web.archive.org/web/20080316012830/http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=672918 |date=March 16, 2008 }} The [[Commonwealth Fund]], March 11, 2008</ref>

[[Medical device|Medical devices]] are expensive because the process of designing and approving them is long and costly, requiring that they be sold at higher than market price. The costs include: research, design and development, meeting the U.S. Food and Drug Administration's regulatory guidelines, manufacture, marketing, distribution, and business plan.<ref>{{Cite web |title=Thought Leadership Archives |url=https://sterlingmedicaldevices.com/thought-leadership/ |access-date=2023-04-27 |website=Sterling Medical Devices |language=en}}</ref> Cost, alongside the impact of systematic oppression and inequality of communities of color within healthcare, together make medical equipment inaccessible. Most studies focused on access to medical devices and enhancement of affordable local production have concluded that increasing access to medical devices in an attempt to meet healthcare needs is extremely important. <ref>{{Cite web |title=Towards improving access to medical devices through local production |url=https://www.who.int/publications-detail-redirect/9789241510141 |access-date=2023-04-27 |website=www.who.int |language=en}}</ref>

The increase of [[Artificial intelligence in healthcare|artificial intelligence (AI) in health care]] raises issues equity and bias related to how health applications are developed and used. A recent scoping review identified 18 equity issues with 15 strategies to address them to try to ensure AI applications equitably meet the needs of the populations intended to benefit from them.<ref>{{Cite journal |last1=Berdahl |first1=Carl Thomas |last2=Baker |first2=Lawrence |last3=Mann |first3=Sean |last4=Osoba |first4=Osonde |last5=Girosi |first5=Federico |date=2023-02-07 |title=Strategies to Improve the Impact of Artificial Intelligence on Health Equity: Scoping Review |url=https://ai.jmir.org/2023/1/e42936 |journal=JMIR AI |language=en |volume=2 |pages=e42936 |doi=10.2196/42936 |s2cid=256681439 |issn=2817-1705 |doi-access=free }}</ref>

== Prescription drug issues ==
=== Drug efficiency and safety ===
{{See also|Regulation of therapeutic goods in the United States}}
[[File:US timeline. Number of overdose deaths from all drugs.jpg|thumb|250px|[[United States drug overdose death rates and totals over time|US yearly overdose deaths]].]]

The [[Food and Drug Administration|FDA]]<ref>{{cite web|url=https://www.fda.gov/AboutFDA/WhatWeDo/WhatFDARegulates/default.htm|archive-url=https://web.archive.org/web/20090604111232/https://www.fda.gov/AboutFDA/WhatWeDo/WhatFDARegulates/default.htm|url-status=dead|archive-date=June 4, 2009|title=What FDA Regulates|website=[[Food and Drug Administration]]|date=June 4, 2009}}</ref> 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 [[List of pharmaceutical compound number prefixes|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, Inc.]]''<ref>{{cite journal | vauthors = Glantz LH, Annas GJ | title = The FDA, preemption, and the Supreme Court | journal = The New England Journal of Medicine | volume = 358 | issue = 18 | pages = 1883–5 | date = May 2008 | pmid = 18450601 | doi = 10.1056/NEJMp0802108 | doi-access = free }}</ref>

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 US 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".<ref>{{cite web |url=https://www.oyez.org/cases/2000-2009/2008/2008_06_1249/|title=Wyeth v. Levine|work=Oyez |publisher=Chicago-Kent College of Law at Illinois Tech |date=n.d.}}</ref> In June 2009, under the [[Public Readiness and Emergency Preparedness Act]], [[Secretary of Health and Human Services]] [[Kathleen Sebelius]] 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]].<ref>{{USFedReg|74|30294}}, [[Federal Register]]: June 25, 2009 (Volume 74, Number 121), pp. 30294–97.</ref><ref>[http://www.flu.gov/professional/federal/vaccineliability.html Coverage Under the Public Readiness and Emergency Preparedness (PREP) Act for H1N1 Vaccination] Flu.gov, retrieved November 11, 2009</ref>

=== Prescription drug prices ===
{{Main|Prescription drug prices in the United States}}
{{Contradicts other|date=October 2009|1=Prescription drug prices in the United States|4=section}}

During the 1990s, the price of [[prescription drugs]] became a major issue in US 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 US spends more on pharmaceuticals than any other country, although expenditures on pharmaceuticals accounts for a smaller share (13%) of total healthcare costs compared to an [[OECD]] average of 18% (2003 figures).<ref>{{cite web |url= http://www.oecd.org/dataoecd/15/23/34970246.pdf |title=OECD Health Data 2005: How Does the United States Compare |publisher=[[Organisation for Economic Co-operation and Development]] |access-date=April 14, 2007}}</ref> Some 25% of out-of-pocket spending by individuals is for prescription drugs.<ref name="pmid15451969">{{cite journal |vauthors=Heffler S, Smith S, Keehan S, Clemens MK, Zezza M, Truffer C |title=Health spending projections through 2013 |journal=Health Affairs |volume=23 |issue=Suppl 1 Web Exclusives |pages=W4–79–93 |year=2004 |pmid=15451969 |doi=10.1377/hlthaff.w4.79 |url=http://content.healthaffairs.org/cgi/pmidlookup?view=long&pmid=15451969}}</ref> 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% in Canada, and decreased in France and Japan.<ref>{{Cite journal|last1=Stelzner|first1=Mark Joseph|last2=Nam|first2=Daniel Taekmin|date=2020-08-11|title=The big cost of big medicine – calculating the rent in private healthcare|journal=Review of Social Economy|volume=80 |issue=4 |pages=491–513|doi=10.1080/00346764.2020.1804607|s2cid=225500668|issn=0034-6764|url=https://scholarworks.umass.edu/cgi/viewcontent.cgi?article=1269&context=peri_workingpapers|doi-access=free}}</ref> A November 2020 study by the [[West Health]] Policy Center stated that more than 1.1 million [[senior citizens]] in the U.S. [[Medicare (United States)|Medicare]] program are expected to die prematurely over the next decade because they will be unable to afford their prescription medications, requiring an additional $17.7 billion to be spent annually on avoidable medical costs due to health complications.<ref>{{Cite web |title=High Drug Prices and Patient Costs: Millions of Lives and Billions of Dollars Lost |date=November 18, 2020 |publisher=West Health Council for Informed Drug Spending Analysis |url=https://www.cidsa.org/publications/xcenda-summary |access-date=2023-02-20}}</ref>

The US government has taken the position (through the [[Office of the United States Trade Representative|Office of the US Trade Representative]]) that US drug prices are rising because US 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).<ref>See the summary of the official U.S. position in the [http://www.ustr.gov/assets/Trade_Sectors/Intellectual_Property/Special_301_Public_Submissions_2008/asset_upload_file109_14495.pdf "Pharmaceutical Research and Manufacturers of America (PhRMA) Special 301 Submission of 2008"], February 11, 2008, 10–20 ({{webarchive |url=https://web.archive.org/web/20081121034643/http://www.ustr.gov/assets/Trade_Sectors/Intellectual_Property/Special_301_Public_Submissions_2008/asset_upload_file109_14495.pdf |date=November 21, 2008 }}).</ref> The US position (consistent with the primary lobbying position of the Pharmaceutical Research and Manufacturers of America) is that the governments of such countries are [[free rider problem|free riding]] on the backs of US consumers. Such governments should either deregulate their markets, or raise their domestic taxes in order to fairly compensate US 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 US government. In turn, pharmaceutical companies would be able to continue to produce innovative pharmaceuticals while lowering prices for US consumers. Currently, the US, as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the [[Medicare (United States)|Medicare]] program due to the [[Medicare Prescription Drug, Improvement, and Modernization Act]] 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.<ref>{{cite news| url=https://www.nytimes.com/2006/11/06/business/06drug.html | work=The New York Times | title=As Drug Prices Climb, Democrats Find Fault With Medicare Plan | first=Alex | last=Berenson | name-list-style = vanc | date=November 6, 2006 | access-date=May 4, 2010}}</ref>

==== Impact of drug companies ====
The US, along with New Zealand, make up the only countries in the world that allows [[direct-to-consumer advertising]] of prescription drugs. In 2015, the [[American Medical Association]] called for the banning of direct-to-consumer advertising because it is linked with increased drug prices.<ref>{{cite press release | url=https://www.ama-assn.org/press-center/press-releases/ama-calls-ban-dtc-ads-prescription-drugs-and-medical-devices | title=AMA calls for ban on direct to consumer advertising of prescription drugs and medical devices| date=November 17, 2015 | author=AMA }}</ref> 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.<ref>{{cite journal | vauthors = Ventola CL | title = Direct-to-Consumer Pharmaceutical Advertising: Therapeutic or Toxic? | journal = P & T | volume = 36 | issue = 10 | pages = 669–84 | date = October 2011 | pmid = 22346300 | pmc = 3278148 }}</ref>

When healthcare 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.<ref>{{cite news| url=http://articles.latimes.com/2009/dec/16/nation/la-na-health-senate16-2009dec16 | work=Los Angeles Times | title=Senate healthcare bill advances with rejection of imported drugs | first1=Janet | last1=Hook | first2=Noam N. | last2=Levey | name-list-style = vanc | date=December 16, 2009 | access-date=May 4, 2010}}</ref><!---so what? Need to follow this sentence with "critics believe that this fosters increased drug costs since drug companies are not subject to competition" or whatever--->

== Healthcare reform debate ==
{{Further|Healthcare reform in the United States|Service Excellence – Health Care}}

In 2008, prior to the major healthcare reform in 2010, Americans were divided in their views of the US health system; 45% said that the US system was best and 39% said that other countries' systems are better.<ref>[http://www.hsph.harvard.edu/news/press-releases/2008-releases/republicans-democrats-disagree-us-health-care-system.html "Most Republicans Think the U.S. Health Care System is the Best in the World. Democrats Disagree.,"] Press Release, [[Harvard School of Public Health]] and [[Harris Insights & Analytics|Harris Interactive]], March 20, 2008</ref><ref>[http://www.hsph.harvard.edu/news/press-releases/files/Topline__Best_HC_Havard_Harris.doc "Americans' Views on the U.S. Health Care System Compared to Other Countries,"] {{webarchive|url=https://web.archive.org/web/20080408231440/http://www.hsph.harvard.edu/news/press-releases/files/Topline__Best_HC_Havard_Harris.doc |date=April 8, 2008 }} [[Harvard School of Public Health]] and [[Harris Insights & Analytics|Harris Interactive]], March 20, 2008</ref>

Much of the historical debate around healthcare reform centered around [[single-payer health care|single-payer healthcare]], and particularly pointing to the hidden costs of treating the uninsured<ref>{{cite web |url=http://www.iom.edu/Reports/2004/Insuring-Americas-Health-Principles-and-Recommendations.aspx|title=Insuring America's Health: Principles and Recommendations|work=[[Institute of Medicine]] of the National Academies |archive-url=https://web.archive.org/web/20091019103757/http://www.iom.edu/Reports/2004/Insuring-Americas-Health-Principles-and-Recommendations.aspx|archive-date=October 19, 2009|url-status=dead|access-date=October 27, 2007}}</ref> while free-market advocates point to freedom of choice in purchasing health insurance<ref>{{cite web|url=http://www.cato.org/research/articles/reynolds-021003.html|title=No Health Insurance? So What?|last=Reynolds|first=Alan| name-list-style = vanc |date=October 3, 2002|work=The [[Cato Institute]]|archive-url=https://web.archive.org/web/20071014200629/http://cato.org/research/articles/reynolds-021003.html|archive-date=October 14, 2007|url-status=dead|access-date=October 27, 2007}}</ref><ref name="CESR">Center for Economic and Social Rights. [http://cesr.org/ushealthright?PHPSESSID=91...a78f9969da61bd9 "The Right to Health in the United States of America: What Does it Mean?"] October 29, 2004. {{webarchive|url=https://web.archive.org/web/20080214070649/http://cesr.org/ushealthright?PHPSESSID=91...a78f9969da61bd9|date=February 14, 2008}}</ref><ref name="Sade">{{cite journal | vauthors = Sade RM | title = Medical care as a right: a refutation | journal = The New England Journal of Medicine | volume = 285 | issue = 23 | pages = 1288–92 | date = December 1971 | pmid = 5113728 | doi = 10.1056/NEJM197112022852304}}
: Reproduced as {{cite web |last1=Sade |first1=Robert |title=The Political Fallacy that Medical Care is a Right |url=http://www.aapsonline.org/brochures/sademcr.htm |publisher=[[Association of American Physicians and Surgeons]]}}</ref> and unintended consequences of government intervention, citing the [[Health Maintenance Organization Act of 1973|Health Maintenance Organization Act]] of 1973.<ref name="medca">{{cite web|url=http://www.reason.com/0411/fe.rb.mandatory.shtml|title=Mandatory Health Insurance Now! It will save private medicine – and spur medical innovation.|last=Bailey|first=Ronald| name-list-style = vanc |work=Reason Magazine|date=November 2004|archive-url=https://web.archive.org/web/20060618023609/http://www.reason.com/0411/fe.rb.mandatory.shtml <!-- Bot retrieved archive -->|archive-date=June 18, 2006|access-date=June 21, 2006}}</ref>

According to a 2020 study published in ''[[The Lancet]]'', a single-payer [[universal healthcare]] system could save 68,000&nbsp;lives and $450&nbsp;billion in [[Health care finance in the United States|national healthcare expenditure]] annually,<ref>{{cite journal |last1= Galvani |first1=Alison P |last2=Parpia |first2=Alyssa S |last3=Foster |first3=Eric M |last4=Singer |first4=Burton H |last5=Fitzpatrick |first5=Meagan C |date=February 13, 2020|title=Improving the prognosis of health care in the USA|journal=[[The Lancet]] |volume=395 |issue=10223 |pages=524–533 |doi=10.1016/S0140-6736(19)33019-3|pmid=32061298 |pmc=8572548 |s2cid=211105345 }}</ref> while another 2022 study published in the ''[[PNAS]]'', estimated that a universal healthcare system could have saved more than 338,000&nbsp;lives during the [[COVID-19 pandemic in the United States|COVID-19 pandemic in the US]] from its start until March 2022.<ref>{{cite news |last=Nuwer |first=Rachel |author-link=Rachel Nuwer |date=June 13, 2022 |title=Universal Health Care Could Have Saved More Than 330,000 U.S. Lives during COVID|url=https://www.scientificamerican.com/article/universal-health-care-could-have-saved-more-than-330-000-u-s-lives-during-covid/|work=[[Scientific American]]|location= |access-date=June 22, 2022}}</ref>

Ultimately, a single-payer healthcare, sometimes called "[[socialized medicine]]",<ref>{{cite news|url=https://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/|title=What Is 'Socialized Medicine'?: A Taxonomy of Health Care Systems|last=Reinhardt|first=Uwe E.| name-list-style = vanc |date=May 8, 2009|work=The New York Times|access-date=May 4, 2010}}</ref><ref>{{cite news|url=http://voices.washingtonpost.com/ezra-klein/2009/06/health_reform_for_beginners_th_1.html|title=Health Reform for Beginners: The Difference Between Socialized Medicine, Single-Payer Health Care, and What We'll Be Getting|newspaper=The Washington Post|access-date=May 4, 2010}}</ref> was not adopted in the final ACA.

=== Patient Protection and Affordable Care Act (2010) ===
The [[Affordable Care Act|ACA]] (Public Law 111–148) is a healthcare reform bill that was signed into law in the [[United States|US]] by [[President of the United States|President]] [[Barack Obama]] on March 23, 2010. The law includes a large number of [[Provisions of the Patient Protection and Affordable Care Act|health-related provisions]], most of which took effect in 2014, including expanding [[Medicaid]] eligibility for people making up to 133% of [[federal poverty level|FPL]],<ref name="cnn_ref1">{{cite news |url= http://www.cnn.com/2010/HEALTH/03/25/health.care.law.basics/index.html |title=5 key things to remember about health care reform |publisher = CNN |date=March 25, 2010|first = Sabriya|last= Rice| name-list-style = vanc }}</ref> subsidizing insurance premiums for individuals and families making up to 400% of [[federal poverty level|FPL]] and capping expenses from 2% to 9.8% of annual income.<ref name=whitehouse>{{cite web |url=https://obamawhitehouse.archives.gov/health-care-meeting/proposal/whatsnew/affordability |title= Policies to Improve Affordability and Accountability |url-status= live |archive-url= https://web.archive.org/web/20170208081316/https://obamawhitehouse.archives.gov/health-care-meeting/proposal/whatsnew/affordability |archive-date= February 8, 2017 |via=[[NARA|National Archives]] |work=[[whitehouse.gov]]}}</ref><ref>{{cite web |url= http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance |title=Health Care Reform Bill 101: Who gets subsidized insurance?|first = Peter|last = Grier | name-list-style = vanc |date = 20 March 2010 |work=[[The Christian Science Monitor]]}}</ref> For the first time, all health policies sold in the US must cap an individual's (or family's) medical expenses out of pocket annually.<ref>{{cite web|url= http://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/out-of-pocket-maximums.html |title=How do out-of-pocket maximums work? &#124; FAQs |website=Bcbsm.com |access-date=December 1, 2016}}</ref> Other provisions include providing incentives for businesses to provide healthcare benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing [[health insurance exchange]]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 [[tax bracket|brackets]], taxes on [[indoor tanning]], cuts to the [[Medicare Advantage]] program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies;<ref>Peter Grier, [http://www.csmonitor.com/USA/Politics/2010/0321/Health-care-reform-bill-101-Who-will-pay-for-reform Health care reform bill 101: Who will pay for reform?], ''Christian Science Monitor'' (March 21, 2010).</ref> 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).<ref>{{cite news |url= http://www.csmonitor.com/USA/Politics/2010/0319/Health-care-reform-bill-101-Who-must-buy-insurance |title=Health care reform bill 101: Who must buy insurance? |last=Grier|first=Peter | name-list-style = vanc |date=March 19, 2010 |work=[[Christian Science Monitor]] |access-date=April 7, 2010 |location=Washington, D.C.}}</ref> The [[Congressional Budget Office]] estimates that the net effect (including the reconciliation act) will be a reduction in the federal deficit by $143&nbsp;billion over the first decade.<ref>Congressional Budget Office, [http://www.cbo.gov/doc.cfm?index=11379&type=1 Cost Estimates for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation)] (March 20, 2010).</ref> However, two months later, the office subsequently acknowledged that there was an additional $115&nbsp;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 ACA than without, individual plans would be higher by $1,900 with the bill.<ref>{{Cite journal|last=Manchikanti|first=Laxmaiah|name-list-style=vanc|date=January 2011|title=Patient Protection and Affordable Care Act of 2010: Reforming the Health Care Reform for the New Decade|journal=Pain Physician|volume=14|issue=1|pages=E35–E67|doi=10.36076/ppj.2011/14/E35|pmid=21267047|doi-access=free}}</ref>

The first open enrollment period of the ACA 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 US 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.<ref name=":32">{{cite journal | vauthors = Sommers BD, Gunja MZ, Finegold K, Musco T | title = Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act | journal = JAMA | volume = 314 | issue = 4 | pages = 366–74 | date = July 2015 | pmid = 26219054 | doi = 10.1001/jama.2015.8421 | doi-access = free | url = https://dash.harvard.edu/bitstream/1/23586587/1/Sommers%20JAMA%20DASH%20Version%207-2015.pdf }}</ref> 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.<ref name="pmid15055833">{{cite journal | vauthors = Hadley J, Holahan J | title = Is health care spending higher under Medicaid or private insurance? | journal = Inquiry | volume = 40 | issue = 4 | pages = 323–42 | date = 2003 | pmid = 15055833 | doi = 10.5034/inquiryjrnl_40.4.323 | doi-access = free }}</ref>

On December 22, 2017, the [[Tax Cuts and Jobs Act of 2017]] was signed into law by [[Donald Trump|President Donald Trump]]. Inside the final version of the bill was a repeal of the individual mandate in the ACA, 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.<ref>{{Cite news|url=https://www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html|title=Without the Insurance Mandate, Health Care's Future May Be in Doubt|last=Pear|first=Robert| name-list-style = vanc |date=2017-12-18|work=The New York Times|access-date=2018-02-28|language=en-US|issn=0362-4331}}</ref> In 2017, the new Republican healthcare bill known as the [[American Health Care Act of 2017|American Health Care Act]] was passed by the House of Representatives under President Donald Trump. Although the ACA 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 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.<ref>{{Cite news|url=https://www.bbc.com/news/world-us-canada-39233010|title=Trump health bill: Winners and losers|date=2017-05-04|work=BBC News|access-date=2018-02-28|language=en-GB}}</ref>

In May 2023, an international daily, in its article on the US healthcare system, asserted on the need for United States to guarantee healthcare to all its citizens as a basic human right.<ref>{{cite news |title=It's time to guarantee healthcare to all Americans as a human right |newspaper=The Guardian |date=May 18, 2023 |url=https://www.theguardian.com/commentisfree/2023/may/18/healthcare-us-human-right-medicare-for-all-bernie-sanders |access-date=23 May 2023 |last1=Sanders |first1=Bernie }}</ref>

== Health insurance coverage for immigrants ==
{{Main|Immigrant health care in the United States}}

Of the 26.2&nbsp;million foreign immigrants living in the US in 1998, 62.9% were non-US citizens. In 1997, 34.3% of non-US citizens living in the US 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.<ref>{{cite journal | vauthors = Carrasquillo O, Carrasquillo AI, Shea S | title = Health insurance coverage of immigrants living in the United States: differences by citizenship status and country of origin | journal = American Journal of Public Health | volume = 90 | issue = 6 | pages = 917–23 | date = June 2000 | pmid = 10846509 | pmc = 1446276 | doi = 10.2105/AJPH.90.6.917 }}</ref> With the recent healthcare changes, many legal immigrants with various immigration statuses now are able qualify for affordable health insurance.<ref>{{cite web|url=https://www.healthcare.gov/immigration-status-and-the-marketplace/ |title=Find out what immigration statuses qualify for coverage in the Health Insurance Marketplace. |website=HealthCare.gov |access-date=December 1, 2016}}</ref>

Undocumented immigrants within the US do not have access to government funded health insurance. Although the ACA allows immigrants to receive insurance at a discounted rate, the same does not go for those without US citizenship.<ref>{{Cite news|url=http://www.visitorguard.com/obamacare-for-usa-visitors-and-immigrants/#greencard|title=Obamacare: Visitors, International students, immigrants & US citizens|date=December 24, 2013|newspaper=VisitorGuard.com|language=en-US|access-date=November 17, 2016}}</ref> 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 US]], different states have implemented their health insurance programs differently leading to healthcare access disparities between states.<ref name="ooo">{{cite journal |last1=Agrawal |first1=Pooja |last2=Venkatesh |first2=Arjun Krishna |title=Refugee Resettlement Patterns and State-Level Health Care Insurance Access in the United States |journal=American Journal of Public Health |date=2016 |volume=106 |issue=4 |pages=662–663 |doi=10.2105/AJPH.2015.303017 |pmid=26890186 |pmc=4816078 |issn=0090-0036}}</ref> 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.<ref>{{cite web|url=http://www.coveredca.com/individuals-and-families/getting-covered/immigrants/|title=Health Insurance for Immigrants {{!}} Covered California™|website=coveredca.com|access-date=November 17, 2016}}</ref>

== See also ==
{{Portal|Medicine|United States}}
<!-- Please maintain in alphabetical order -->
{{Div col|colwidth=27em}}
* [[Biomedical research in the United States]]
* [[Canadian and American health care systems compared]]
* [[Centers for Disease Control and Prevention timeline]]
* [[Health in the United States]]
* [[Health Care and Education Reconciliation Act of 2010]]
* [[Health care compared]] – tabular comparisons of the US, Canada, and other countries not shown above.
* [[Health care industry]]
* [[Health care politics]]
* [[Health care systems]] (including comparisons)
* [[Health insurance cooperative]]
* [[Healthy People program]]
* [[Health spending as percent of gross domestic product (GDP) by country]]
* [[List of countries by total health expenditure per capita]]
* [[List of healthcare accreditation organizations in the United States]]
* [[Medical centers in the United States]]
* [[Medical debt]]
* [[Medical education in the United States]]
* [[Medicare for All Act]]
* [[Medicare Rights Center]]
* [[Medicare Sustainable Growth Rate]]
* [[Military Health System]]
* [[Osteopathic medicine in the United States]]
* [[School health services]]
* [[Universal Health Care Foundation of Connecticut]]
* [[Visitor health insurance]]
{{div col end}}

== References ==
{{Reflist|32em}}

== Further reading ==
{{Refbegin|32em}}
* {{Cite book |editor-last=Breslow |editor-first=Lester |name-list-style=vanc |title=Encyclopedia of Public Health |series=MacMillan Reference |date=2002}} Four volumes.
* {{Cite book |last=Burnham |first=John C. |name-list-style=vanc |title=What Is Medical History? |date=2005 |pages=163 |publisher=Polity |isbn=0745632254 }}
* {{Cite book |last=Burnham |first=John C. |name-list-style=vanc |title=Health Care in America: A History |date=2015 |publisher=Johns Hopkins University Press |isbn=978-1421416076 }} A standard comprehensive scholarly history.
* {{Cite book |last1=Byrd |first1=W. Michael |first2=Linda A. |last2=Clayton |title=An American health dilemma: A medical history of African Americans and the problem of race: Beginnings to 1900 |publisher=Routledge |name-list-style=vanc |date=2012 }}
* {{Cite book |last1=Christensen |first1=Clayton |last2=Hwang |first2=Jason |last3=Grossman |first3=Jerome |name-list-style=vanc |url=http://innovatorsprescription.com/ |title=The Innovator's Prescription |publisher=McGraw Hill |date=2009 |isbn=978-0-07-159208-6 |access-date=August 22, 2010 |archive-date=November 10, 2013 |archive-url=https://web.archive.org/web/20131110021138/http://innovatorsprescription.com/ |url-status=dead }}
* {{Cite book |last=Deutsch |first=Albert |name-list-style=vanc |title=The Mentally Ill in America: A History of Their Care and Treatment from Colonial Times |url=https://archive.org/details/in.ernet.dli.2015.210004 |date=1937 }}
* {{Cite book |last=Johnston |first=Robert D. |name-list-style=vanc |title=The politics of healing: histories of alternative medicine in twentieth-century North America |publisher=Routledge |date=2004 }}
* {{Cite book |last1=Judd |first1=Deborah |first2=Kathleen |last2=Sitzman |name-list-style=vanc |title=A history of American nursing |edition=2nd |publisher=Jones & Bartlett Publishers |date=2013 }}
* {{Cite book |last1=Leavitt |first1=Judith Walzer |first2=Ronald L. |last2=Numbers |name-list-style=vanc |title=Sickness and health in America: Readings in the history of medicine and public health |edition=3rd |date=1997 }}
* {{Cite book |last=Mahar |first=Maggie |name-list-style=vanc |url=https://books.google.com/books?id=pOfrTRPgv_kC |title=Money-Driven Medicine: The Real Reason Health Care Costs So Much |publisher=Harper/Collins |date=2006 |isbn=978-0-06-076533-0 }}
* {{Cite book |last=McBride |first=David |year=2018 |title=Caring for Equality: A History of African American Health and Healthcare |location=Lanham, MD |publisher=Rowman and Littlefield}}
* {{Cite journal |vauthors=Numbers RL |title=The History of American medicine: A Field in Ferment |journal=Reviews in American History |volume=10 |issue=4 |pages=245–63 |date=1982 |doi=10.2307/2701830 |jstor=2701830 |pmid=11611756}}
* {{Cite book |last1=Risse |first1=Guenter B. |first2=Ronald L. |last2=Numbers |first3=Judith Walzer |last3=Leavitt |name-list-style=vanc |date=1977 |title=Medicine Without Doctors: Home Health Care in American History |location=New York |publisher=Science History Publications/USA|isbn=9780882021652}}
* {{Cite book |last=Starr |first=Paul |name-list-style=vanc |author-link=Paul Starr |title=The Social Transformation of American Medicine |publisher=Basic Books |date=1982 |isbn=0-465-07934-2 |title-link=The Social Transformation of American Medicine }}
* {{Cite book |last=Reid |first=T. R. |author-link=T. R. Reid |year=2009 |title=The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care |title-link=The Healing of America |location=New York |publisher=The Penguin Press |isbn=978-1-59420-234-6}}  [https://archive.org/details/healingofamerica0000reid Online] {{registration required}}.
* {{Cite book |last1=Warner |first1=John Harley |first2=Janet A. |last2=Tighe |name-list-style=vanc |date=2001 |title=Major Problems in the History of American Medicine and Public Health}}
{{Refend}}

== External links ==
{{Wikiquote}}
<!-- Please maintain in alphabetical order -->
* [https://www.cdc.gov/nchs/ National Center for Health Statistics] from the [[Centers for Disease Control and Prevention|CDC]]
* [http://www.cms.hhs.gov/NationalHealthExpendData/01_Overview.asp National Health Expenditure Data (US)] from the [[United States Department of Health and Human Services|HHS]]
* [https://www.who.int/countries/usa/en/ US] profile from the [[World Health Organization|WHO]]
* [https://axelreports.com/industry-analysis/global-blood-purification-equipment-market/206711 And Pharma Market Research Report]
* [https://www.healthcaremailing.com/resources.html Healthcare Market Resources]
* {{curlie|Regional/North_America/United_States/Health|Health Care in the United States}}

{{United States topics}}
{{Health care}}
{{North America topic|Health care in}}
{{World topic|Healthcare in|title=Health care by country}}
{{Authority control}}

[[Category:Healthcare in the United States| ]]
[[Category:Medicare and Medicaid (United States)]]
[[Category:Public services of the United States]]
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[[Категория:Английская Википедия]]
[[Категория:Википедия]]
[[Категория:Статья из Википедии]]
[[Категория:Статья из Английской Википедии]]