healthcare in america essay

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Health Care in the United States, Essay Example

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In the United States, there has long been discussion about the quality and nature of the delivery of healthcare.  The debates have included who may receive such services, whether or not healthcare is a privilege or an entitlement, whether and how to make patient care affordable to all segments of the population, and the ways in which the government should, or should not, be involved in the provision of such services.  Indeed, many people feel that the healthcare in this country is the best in the world; others believe tha (The Free Dictionary)t our health delivery system is broken.  This paper shall examine different aspects of the healthcare system in our country, discussing whether it has been successful in providing essential services to American citizens.

The delivery of healthcare services is considered to be a system; according to the Free Diction- ary (Farlex, 2010), a system is defined as “a group of interacting, interrelated, or interdependent elements forming a complex whole.” This is an apt description of our healthcare structure, as it is compiled of patients, medical and mental health providers, hospitals, clinics, laboratories, insurance companies, and many other parties that are reliant on each other and that, when combined, make up the entity known as our healthcare system.

Those who believe that our healthcare system is the best in the world often point to the fact that leaders as well as private citizens from countries throughout the world frequently come to the United States to have surgeries and other treatments that they require for survival.  A more cynical view of this phenomenon is that if people have the money, they are able to purchase quality care in the U.S., a “survival of the fittest” situation.  Those who lack the resources to travel to the U.S. for medical treatment are simply out of luck, and often will die without the needed care.

In fact, reports by the World Health Organization and other groups consistently indicate that while the United States spends more than any other country on healthcare costs, Americans receive lower quality, less efficient and less fairness from the system.  These conclusions come as a result of studying quality of care, access to care, equity and the ability to lead long, productive lives.  (World Health Organization,2001.) What cannot be disputed is that the cost of healthcare is constantly rising, a fact which was the precipitant to the large movement to reform healthcare in our country in 2010.  More than 10 years ago, the goal of managed care was to drive down the costs of healthcare, but those promises did not materialize (Garsten, 2010.) A large segment of the population is either uninsured or underinsured, and it is speculated that over the next decade, these problems will only increase while other difficulties will arise (Garson, 2010.)

When examining the healthcare system, there are three aspects of care that call for evaluation: the impact of delivering care on the patient, the benefits and harms of that treatment, and the functioning of the healthcare system, as described in an article by Adrian Levy.  Levy argues that each of these outcomes should be assessed and should include both the successes and the limitations of each aspect.  The idea is that there should be operational measurements of patients’ interactions with the healthcare system that would include patients’ experiences in hospitals, using measurements of their functional abilities and their qualities of life following discharge.  The results of patients’ interactions with the healthcare system should be utilized to develop and improve the delivery of healthcare treatment, as well as to develop policy changes that would affect the entire field of healthcare in the United States.

One view of the state of American healthcare is that the system is fragmented; there have been many failed attempts by several presidents to introduce the idea of universal healthcare.  Instead, American citizens are saddled with a system in which government pays either directly or indirectly for over 50% of the healthcare in our country, but the actual delivery of insurance and of care is undertaken by an assortment of private insurers, for-profit hospitals, and other parties who raise costs without increasing quality of service (Wells, Krugman, 2006.) If the United States were to switch to a single-payer system such as that provided in Canada, the government would directly provide insurance which would most likely be less expensive and provide better results than our current system.

It is clear that throwing money at a problem does not necessarily resolve it; the fact that the United States spends more than twice as much on healthcare provision as any other country in the world only makes it more ironic that when it comes to evaluating the service, Americans fall appallingly flat.  In my opinion, if the new healthcare reform bill had included a public option which would have taken the profit margin out of the equation, the nation and its citizens would have been in a much better position to receive quality healthcare.  The fact that people die every day from preventable illnesses and conditions simply because they do not have affordable insurance is a national disgrace.  In addition, many of the people who have been the most adamantly against government “intrusion” into their healthcare are actually on Medicaid or Medicare, federally-funded programs.  Their lack of understanding of what the debate actually involves is striking, and they are rallying against what is in their own best interests.  These are people that equate Federal involvement in healthcare as socialism.  Unless and until our healthcare system is able to provide what is needed to all of its citizens, all claims that we have the best healthcare system in the world are, sadly, utterly hollow.

Adrian R Levy (2005, December). Categorizing outcomes of Health Care delivery. Clinical and investigative medicine, pp. 347-351.

Arthur Garson (2000). The U.S. Healthcare System 2010: Problems Principles and Potential Solutions. Retrieved July 3, 2010, from Circulation: The Journal of the American Heart Association: http://circ.ahajournals.org/cgi/reprint/101/16/2015

The Free Dictionary. (n.d.). Farlex. Retrieved July 3, 2010. http://www.thefreedictionary.com/system

World Health Organization. (2003, July). WHO World Health Report 2000. Retrieved July 3, 2010, from State of World Health: http://faculty.washington.edu/ely/Report2000.htm

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US Health Care vs. Countries with Universal Healthcare

Published by ‍

Dhruv Gupta

June 21, 2021

Inquiry-driven, this article reflects personal views, aiming to enrich problem-related discourse.

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The debate about health care is one of the most important and contentious in the current political climate, being ranked second in the list of important voting issues of the 2020 presidential election, per surveys conducted by the Pew Research Center . America remains one of the only developed nations to not provide its residents with universal health care, much to the chagrin of leading Democrats such as Bernie Sanders and Elizabeth Warren, who advocated for the vast expansion of Medicare to cover all people as part of their primary challenges. In the end, the more moderate Joe Biden secured both the Democtartic presidential bid and the presidency, running on a platform centered around setting up a public option, slightly expanding Medicare coverage, and enforcing regulations on the private sector. Neither of their policies, however, are perfect, nor are they the only possible solutions. The health care policy debate is a multifaceted issue with other countries finding various innovative solutions, all of which America can take some inspiration from.

Of the 92 percent of Americans covered for all or part of 2019, approximately 68 percent were covered through the private sector and 34.1 percent obtained coverage from the public sector. The private sector includes individuals or organizations providing health care or supplying insurance not directly owned or controlled by the government. Everyone is eligible for coverage under the private sector, and 49% of Americans get private health care from their employers. The public sector , on the other hand, encompasses organizations or insurance plans provided and/or controlled by the government. This consists of the government-funded health insurance plans, Medicare, Medicaid, and CHIP, which only certain individuals are eligible for. This system is strewn with issues and requires change immediately.

American healthcare, simply put, is too expensive . Evidence suggests that having insurance lowers mortality; nearly 10% of Americans do not have health insurance due to its unaffordability. The high prices come from an array of places, with one of the largest contributors being the staggering administrative costs. Due to America’s extremely complex multi-payer system with seperate plans from seperate providers with separate coverage, deductibles and premiums, 8% of health care costs go toward administrative costs.

Further burdening the system is the rigid pharmaceutical industry, which offers drugs at continuously rising prices. On average, Americans spend four times as much as their counterparts in other industrialized countries on pharmaceutical drugs due to the low amount of regulation. Fee-for-service transactions also play a large part in the costs of the system. Each procedure or prescription has a seperate cost; health care providers often do more than needed to charge patients extra. Apart from just providing extra unnecessary service, hospitals will also charge you more for them! A procedure that costs $6,390 in the Netherlands and $7,370 in Switzerland costs $32,230 in the United States. Lastly, this system is not ready for the future. America has an unhealthy population and does not have a strong enough healthcare system to compensate; the lifespan of the average American is three years less than that of a Briton.

The two most prominent health care reform plans have both been proposed by Democrats. “Medicare for All,” the plan endorsed by Sanders and Warren, would drastically change the current system. It would create a single-payer national health insurance program to provide all Americans with comprehensive health care coverage, free of charge. There would be no premiums, deductibles, co-pays, or surprise bills. It would also cap the price of prescription drugs by allowing Medicare to negotiate with large companies and completely abolish the private sector of health insurance. This plan would ensure coverage for all Amricans while also providing them with the same quality of service at lower prices. However, analysts believe the government will not be able to negotiate down prices as steeply as Sanders predicted. This plan would also drive up the usage of health care, as people will not be as careful with their health without financial incentives to do so. Other Democrats like Biden have suggested to build upon the current systems in healthcare through the “Public Option” plan. It would set up a public option similar to Medicare that anyone could buy into and expand Medicare coverage to 60- to 65-year-olds. It would also regulate the private sector, capping individual healthcare premiums at 8.5% of income, allowing Medicare to negotiate drug prices with manufacturers, banning surprise medical bills for procedures that require out-of-network hospital care, and ensuring coverage for pre-existing conditions. This plan would also assure that all Americans are insured, while also allowing those who like their current insurance plan to keep it if they can afford to do so. However, private insurers believe that they would not be able to compete with the cheaper public option, and it would be expensive to immediately cover the 8.5% of uninsured Americans on a plan that not everyone is joining.

If either of these policies were to be implemented, America would join the majority of developed countries offering coverage to all their residents. Countries such as France, Germany, Switzerland, and Canada have all adopted some form of universal health care, each with their own unique components and advantages. One constant between all four nations however, is that the average life expectancy of their citizens is over two years longer than that of the United States’. 

French health care is a single-payer system that is both universal and compulsory, with the Statutory Health Insurance (SHI) providing coverage for citizens. The system is paid for by payroll taxes, income taxes, taxes on tobacco and alcohol, and the pharmaceutical sector. The SHI reimburses health care providers for 70 to 80% of their fees, with patients paying the remaining fee out of pocket. French residents pay more income taxes than Americans for SHI, but they pay far less in out-of-pocket costs. France has a longer life expectancy and lower infant mortality rate than America. In addition, 56% of the French population could get a same-day or next-day appointment when sick, as opposed to only 51% in the United States in 2014. That year, only 17% of the French population experienced an affordability barrier, compared to 33% of the United States population.

Switzerland boasts a highly decentralized universal health care system, with cantons, which are similar to American states, in charge of its operation. The system is paid for by enrollee premiums, state taxes, social insurance contributions, and out-of-pocket payments. Swiss residents are required to purchase basic coverage from private nonprofit insurers, which covers physician visits, hospital care, pharmaceuticals, home care, medical services for long-term care, etc. Supplemental insurance can also be purchased, securing a greater choice of physicians and accommodations. Switzerland has lower government spending per capita on healthcare than America, with every resident covered.

Healthcare in Canada is free-of-charge and universal, with the coverage being funded by provincial and federal taxes; estimates find that health care costs approximately $5,789 annually per person. There is no federal plan; each province creates their own health care plan that must abide by the guidelines set by the Canadian Health Act. While Canadian universal health care covers most procedures and costs, some health care services require cost-sharing such as vision care, dental care, and ambulances. Private insurance can also be purchased in Canada to help with these costs, and 2/3 of Canadians have some form of private insurance. 

Germany has a universal multi-payer health care system with statutory health insurance for all of those under a salary level and private insurance for all above that level who choose to purchase their own. The German health care system is financed mostly by employees and employers, with employees donating 7.5% of their salary into a public health insurance pool and employers matching that donation. In this system, those who can afford to pay more will pay more, while those who can’t pay less. Everyone has equal access to healthcare, and the system imposes strict limits on out-of-pocket costs, further protecting their people.

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Health Care in America

Michael Winther June 15, 2009 Essays

An IPS Essay By Michael R. Winther, President of the Institute for Principle Studies

The following article was originally published in early 1994. At the time that he wrote this article, Mike Winther was the Executive Director of the Society for Handicapped, a Modesto, California-based charity. Although this article was written over a decade ago, we feel that it is still timely and relevant to the health care crisis that is once again front-page news in America. We hope this re-publishing will be of educational benefit to our current readership.

Introduction

The debate over health care in America is now front-page news almost every day. Everyone seems to agree that there is something wrong with the system and that something should be done—but what should we do? This issue is obviously important to all Americans, but it is of vastly greater importance to those who, because of disability or age, find themselves more dependent on medical care than the average American. The truth of the matter is that the disabled and elderly stand to benefit most from a good medical care system. Conversely, it is the disabled and elderly who will suffer the most from a bad system.

In this series of articles, we will attempt to go past the political game-playing and look at the real causes and solutions of our health care woes. We will also look at the experiences of other industrialized nations that have tried systems very similar to what is being proposed in America.

PART ONE: Making the Proper Diagnosis

A good physician never prescribes medicine without first giving the patient a complete examination. The doctor knows that selecting the right medication depends on properly diagnosing the patient’s condition. An incorrect diagnosis could result in the wrong drug being administered. The wrong medicine will certainly not promote the patient’s health, and it may even prove fatal.

As we tinker with the health of an entire nation, should we be any less diligent in our diagnosis? After all, a doctor’s incorrect diagnosis harms only one patient, but a misdiagnosis of our nation’s health care system could devastate the health of ten’s of millions.

As I watch the health care debate, one of my greatest concerns is that there is very little emphasis on identifying the causes of the problem. Yes, everyone knows that health care costs are going through the roof, but do we really understand why? I doubt that one person in 100 really understands why costs are out of control, but most of these people think they have a solution anyway. Before we discuss possible solutions, let’s make sure that we understand the problems and their causes. I have identified six factors that contribute substantially to the escalating cost of America’s health care.

Causes of high health care costs:

1. Inadequate supply of health care providers. 2. Over-use of services (excess demand). 3. Lack of consumer price consciousness. 4. Excessive regulation & mandated costs. 5. High risk lifestyles and activities of Americans. 6. Excessive litigation & liability costs.

While this is certainly not a comprehensive list, it covers the causes most frequently identified by “experts” on all sides of the political fence. If this list does reflect the major causes of rising health care costs (which I believe it does), then any real “solution” to the health care crisis must address most, if not all, of these problems. Therefore, any “cure” that does not address these problems, or that makes one of these factors worse, is certainly the wrong medicine.

PART TWO: Supply & Demand

A look at “supply”.

The first two items of the list relate to the supply and demand for medical care. An understanding of supply and demand is absolutely essential to any discussion of prices. Price is simply where supply and demand meet. In this regard, medical care is no different than any other product or service. Everyone has heard of “supply and demand”, but few people have applied this basic concept to medical care.

Imagine for a minute what would happen if we convinced one-half of America’s doctors to retire. This instant shortage of doctors would result in long waits, and those doctors remaining in practice would raise their rates significantly. The reduced supply creates shortages and price increases.

Instead of retiring doctors, what if could magically double the number of well trained and qualified physicians? There would certainly be little or no wait to see a doctor, and prices for an office visit would drop considerably. The increased supply creates better availability and reduced prices.

The idea of increasing the number of doctors, nurses, etc. is a sensitive issue with medical professionals who don’t want to see the standards of their profession compromised—or to see their profession flooded with additional competition. But the truth of the matter is that there is no oversupply of health care providers; in fact, just the opposite is true. Statistics on the average work week of U.S. physicians reinforces what local doctors tell me: they are working very long hours, they are seeing more patients than ever before, and they still cannot keep up with demand. An article appearing in the July 27th issue of the Washington Times stated that, “U.S. physicians fresh out of their residencies are being riddled with job offers.” The article continues, “Two-thirds of young doctors receive at least 50 job offers during their residencies and almost 50 percent receive more than 100.”

The U.S. has approximately 120 medical schools that each average about 100 admissions a year. U.C. Davis Medical School, with 93 positions, has over 5,000 applicants each year. Some medical schools will have over 10,000 applications this year. Unfortunately, many of our best and brightest students will never make it into medical school.

Instead of increasing medical school enrollment, some medical schools have actually reduced the number of annual admissions. In the mid 1980’s, U.C. Davis Medical School admitted 100 students each year; they now admit 93.

As our population has grown larger and older, our supply of trained doctors, nurses, and other professionals has not kept up with the increased demand. It should come as no surprise that health care costs are rising. What is surprising is that none of the current health care proposals make any effort to deal with the supply of health care providers.

A Look At “Demand”

The demand for health care services is indeed increasing significantly in America. There are four major causes of this surge in demand: 1) the aging of America, 2) poor health habits and lifestyles of Americans, 3) the needs of Canadians and others who purchase much of their medical care in the U.S., and 4) the increasing prevalence of third party payers (insurance). The first two factors on this list are widely discussed in the media, but the last two are largely ignored.

Most commentators have discussed the impact of an aging population on the demand for medical care. As medical science enables us to live longer, it also increases the number of years that we consume medical care. It should be obvious that the elderly generally consume more medical care services than the young. As the baby boom generation approaches their golden years, this too will place added stress on our health care providers. The aging “problem” (while it is a contributor to rising demand) is really not a problem as much as it is a tribute to the successes of our health care providers and medical technologies. This “problem” is the result of a health care system that works relatively well.

A second factor affecting the need for health care stems from the risky lifestyle choices of some members of society. Risky behaviors (such as smoking, drug abuse, and gang membership, to name just a few) result in a heavy burden on our medical care system. While these problems will always be with us, we must be careful that our public policy on health care does not encourage these risky activities. In politics there is a well-proven rule of thumb which states, “Subsidize an activity and you will get more of it; tax an activity and you will have less of it.”

Make no mistake—universal health care makes the health-conscious taxpayer pay for the excessive medical needs of those who choose not to protect their health.

In many industrialized countries with government-run health care systems, drug abusers and prostitutes are provided plentiful and free medical care (at taxpayer expense), while many elderly and disabled are denied medical procedures because they are less productive members of society. If you think that this dangerous policy can’t happen here, you should spent some time studying some of the health care reform packages being proposed in Washington… it may very well happen here.

The third factor placing high demand on our health care delivery system may surprise many readers. In addition to serving the needs of Americans, our health care providers are also providing care to many residents of other countries. Of primary significance are Canadians, many of whom travel to the U.S. for medical services.

Due to the geography of Canada, most Canadians live in the southern third of the country and can travel to the U.S. in a short amount of time. Because of Canada’s socialized health care system, many Canadians face long waits for medical procedures that are readily available in the U.S. For example, the wait for a pap smear in most areas of Canada is 5 months, and the wait for hip replacement surgery is about 18 months. The result is predicable: many Canadians, especially middle and upper income families, find it tempting (even necessary) to come to the U.S. for care. These people come to the U.S. and pay full price for the services of our doctors, clinics, and hospitals instead of utilizing the nearly “free” Canadian medical care that they have already paid for with their tax dollars. In some cases, the Canadian government will pay part of the bill for the U.S. hospital visit, but many Canadians come knowing that they will pay much, if not all, of the cost.

How significant is this medical border crossing? While precise figures are not available, some sources estimate that as many as 25% of Canadians come to the U.S. for a significant portion of their medical care. These are important things to remember when someone tells you that the Canadian system is desirable because they have lower per capita health care costs.

The fourth significant factor causing higher demand for health care stems from the increased dependence on third party payers (health insurance). As more and more people obtain comprehensive health insurance, we have fewer cost-conscious consumers when it comes to buying medical care. This is true of both private insurance and government insurance. I have to confess that our family is more likely to go to the doctor when we have met our deductible—knowing that our insurance will be paying all, or most, of the bill. This is human nature, and it is a very good reason why universal comprehensive health insurance will significantly increase demand for medical care.

Some argue that over-utilization can be prevented as long as there is a small co-payment required of the insured with each doctor visit. Co-payments do prevent some over-utilization, but for most people, a $5 co-payment is a very small discouragement when the consumer perceives that they are getting a $40, $50, or $60 visit for their five dollars.

A local college professor who teaches finance has frequently been quoted as saying, “Insurance is best when it covers the unlikely.” This is sound advice that applies equally well to all types of insurance. When insurance begins to cover likely and routine expenses, it is never a smart economic decision. Low deductible, comprehensive coverage encourages people to over-utilize services. This increased demand results in upward pressure on medical prices.

Imagine, for a moment, what would happen if everyone’s auto insurance covered routine maintenance like oil changes and wiper blades. You could just go to your mechanic, have the work done, and the mechanic would be reimbursed by your insurance company. Mechanics would certainly be very busy. In fact, I can imagine that a system such as this would improve the profitability of an auto shop to the extent that many new shops would open up, and existing shops would hire more mechanics.

Now imagine what would happen if we passed a law that limited the supply of mechanics. Certainly the cost of auto repair and the cost of auto insurance premiums would go through the roof. Sound familiar?

When families purchase only catastrophic health coverage and pay for other health care costs from their own pockets, studies show that overall health expenses plummet.

We need to preserve people’s choice to purchase any type of insurance they desire, but unfortunately our tax code encourages the purchase of low deductible health insurance by employers. Many employees covered by these plans would likely choose higher deductible insurance (or simply major medical insurance) were it not for the fact that the employer can provide this benefit tax-free.

Health insurance is an important and necessary part of any good health care system, but health insurance, like all insurance, is only cost effective when it covers unlikely events like major surgeries or illnesses. Our present government policy encourages employers and consumers to make insurance purchase decisions that would normally be unwise. The end result is that millions of consumers have no desire to spend their health care dollars wisely, and many are encouraged to over-utilize the system. Should we be surprised that health care prices are rising?

What will happen to demand—and subsequently to prices—if we pass public-financed comprehensive universal health insurance for everyone?

PART THREE: Is Rationing In Our Future?

The concept of “rationing” is somewhat foreign to most Americans. Sure, some may remember rationing of gasoline and other strategic materials during World War II, but most of us have no concept of how difficult life can be when a vital product or service is rationed by the government. Nevertheless, unless enough Americans object, we will be under a rationing system for our health care within a few short years. If you think that health care rationing won’t happen in American, please read on.

The early Clinton plan is brazen enough to implement rationing and to call it exactly that. However, I suspect that before this legislation—or any similar legislation—is passed, all references to rationing will be given more acceptable names. It might be called “managed allocation of resources” or any number of other euphemisms, but in principle, the result will be the same: rationing.

In a recent article in the Journal of the American Medical Association, David Orentlicher (a medical doctor and attorney) writes:

As the United States moves toward a system of universal access to basic health care benefits, it is clear that not all medically beneficial treatments will be provided. While there is a good deal of wasteful health care spending, most commentators believe that sufficient cost savings cannot be achieved without some restrictions on useful services.

This conclusion should not surprise anyone who has read the first two articles in this series. Since the supply of medical care in America is being artificially limited, and since demand is increasing, price increases are the natural result. If we don’t do anything to increase the supply of medical care (and none of the current proposals do), then the only way to reduce cost is to artificially cut off demand (rationing). **Stacey, this is a potential pull quote.**

The evidence that any form of universal health care (socialized medicine) will result in rationing is overwhelming. First, every country that has adopted any form of national health care or universal health care has made the rationing of services part of their system. Second, those promoting universal health care in America readily grant that rationing will be necessary. Third, even our current publicly-funded health programs for the indigent, elderly, and disabled, limit necessary and beneficial care.

Fortunately, under our current (non-universal) system, only the government payments for medical care are rationed. This means that a government decision not to provide a particular medical procedure does not prevent the patient from finding outside funding for the cost. In our present system, friends, family, charities, and other civic-minded groups can “chip in” to pay for the necessary service. This would not be the case under most universal health care programs, which would actually ration the medical care itself. Under these proposals, certain procedures would be unavailable to certain individuals regardless of their ability to pay.

While this is not a very pleasant picture for anyone, it is especially bleak for the disabled. An inevitable result of rationing is that society (government) will have to decide which procedures will do the most “good” and which patients will “benefit” most from the medical care. The result is that health care dollars will go disproportionately toward the young and able. The experience of the industrialized countries of Europe supports this conclusion. Not only are the disabled and elderly refused treatment that is available to younger or non-disabled patients, but these systems encourage those with disabilities to volunteer for euthanasia (mercy killing).

In Holland, for example, doctors suggest suicide to non-terminally ill debilitated patients. The Washington Times has reported that “voluntary euthanasia” is a common and accepted practice in the Netherlands. According to the London Sunday Observer, euthanasia is administered to people with diabetes, multiple sclerosis, and rheumatism. Articles in British medical journals have reported that cost containment is the overriding goal of most European medical systems. There is no better way to contain costs than to eliminate those requiring significant amounts of medical care.

In America we have gone to considerable effort to prevent discrimination against the disabled. Congress has passed many laws attempting to protect the rights of the disabled, including the recent Americans With Disabilities Act (ADA). Despite all of these laws, however, many legal and medical experts believe that the coming health care rationing will allow methods of rationing that would make it very difficult for some disabled to receive certain types of medical care. One of these experts is David Orentlicher, who is quoted above. In his recent article, he discusses many of the legal issues relating to the Americans with Disabilities Act and health care rationing. He makes a strong case for the view that ADA would probably not prevent the adverse impact of rationing on the disabled and elderly.

As discussed in parts one and two of this series, the real solutions to the high cost of our medical care involve increasing the supply of health care providers and reducing reliance on third party payers. Unfortunately, the major media and our elected officials ignore this important issue.

When we look at the health care systems of Europe and Canada, it is clear that their systems are inferior to our own. Why then do our politicians push us to adopt plans like the systems in Canada and Europe? The problem with the entire health care debate is that everyone is looking to a government-mandated, government-run system as the solution to a “crisis” that may not be as bad as the proposed solutions.

We should remember that everyone suffers when care is rationed, but certainly the aged and disabled have the most to fear.

PART FOUR: The Big Squeeze!

Charities & non-profit organizations are being squeezed out of health care.

Every year in America, non profit organizations and charities raise hundreds of millions of dollars to help provide medical care and medical devices to the indigent. These groups include churches, service clubs, foundations, professional associations, and a variety of other charities. They are able to provide funds (and—as a result—medical care) to countless numbers of low income people without the permission of any government agency. But under the leading health care “solutions” being proposed in Congress, many of these organizations will be put out of the charitable health care business.

Raise the money, buy the care.

In our current health care system, as with almost every area of our economy, money can buy almost any product or service deemed necessary by the consumer. While this is a frightening thought to those with thin pocketbooks, at least this system provides an open door through which charities can provide assistance. As the director of an organization that devotes a portion of its budget to purchasing medical devices for those with limited income, I am concerned about high health care prices, but I am even more concerned about health care availability. Higher prices may require us to raise more money to help someone, and higher prices may even reduce the number of people that we are able to help, but at least we can still help. However, if the health care is unavailable or if it is rationed, no amount of fundraising will buy the necessary services for our clients.

Under these proposed health care plans, there will be two types of health care: affordable care and no care. **Potential pull-quote** If the government makes health care available through its “rationing” plan, it will be affordable. But if it is on the wrong side of the government’s coverage charts, then it will not be available at all, regardless of cost.

Where does this leave our charitable efforts? It means that some organizations will close their doors. Others will simply redirect their efforts away from health care to other activities. This will inevitably leave more people without care, and it will greatly increase the financial burden on government as it tries to fill the gap.

As government does more in a specific area, private charities will generally do less. **Potential pull-quote**

PART FIVE: Cost Vs. Availability

While visiting a retired relative recently, I picked up a magazine off the coffee table. It was a well known and widely circulated publication that is received by millions of retired Americans. One of the articles featured a survey that asked senior citizens in many industrialized countries to state their greatest health care concern. A high percentage of seniors in America stated that the cost of health care was their greatest concern. Seniors in other countries, however, didn’t seem to find cost to be a problem at all.

The article pointed out that the U.S. is the only industrialized country lacking some form of universal socialized health care. This observation is quite correct. The fact that the government pays for much, if not all, of people’s health care in these other countries (Europe and Canada) would certainly explain the survey results. Conspicuously absent from the article, however, was any mention of what the European and Canadian seniors felt was their greatest health care concern. However, based on what we know about these systems, we can confidently conclude that availability and waiting times would probably be at the top of the list for residents in these countries.

If you can’t get medical care, does it really matter whether it is because of cost or because of rationing? The only way to make more medical care available to some without taking it away from others is to have more providers in the system.

PART SIX: Is Health Care More Important Than Freedom?

The trend in modern society is toward the pursuit of more and more security. We want guaranteed employment, guaranteed retirement benefits, and guaranteed health care. The pursuit of these securities is a noble personal and family objective, as long as it remains a private pursuit. But as soon as our attempts to gain security enlist the use of government, our society sacrifices freedom of choice. Our grandparents called that freedom liberty.

In the public sector, any attempt to guarantee security will come at the expense of someone’s liberty. Government cannot give to one person without taking away from another. Both the “giver” and the “getter” lose freedom of choice in the process. The “giver” loses the ability to decide how to spend their money, since it is taxed away in order to fund health care services for the “getter”. And since a government that funds a program has the right to control how the funds are used, the “getter” loses the ability to make decisions about how, when, and where to purchase their medical care. Under a universal health care system, most Americans become both “givers” and “getters”, and are denied personal liberties on both sides of the system.

The irony of the whole political process is that the more we strive for economic security, the less of it we have. There are some widely accepted rules of economics that account for this (which I won’t delve into here), but we can see evidence of this principle throughout America and the world.

The efforts of Europe and Canada to guarantee universal health care, as discussed in our section on rationing, resulted in more health care security for some but far less for others. These nations have traded a health care system that previously limited access based on ability to pay for one that now limits access based on government rationing and scarcity.

Nothing in these programs produced any more health care—they just changed the allocation of existing resources, and charged the taxpayers for the bureaucracy necessary to accomplish the task.

Here are some questions to ponder:

Should we have the freedom… … to choose our own doctor? … to chose the type of treatment we desire? … to choose how we pay for our medical care? … to purchase only high deductible, catastrophic health insurance? … to purchase low deductible, comprehensive health insurance? … to choose not to purchase health insurance at all?

Personally, I want the freedom to make each of these decisions. As an individual, I may not always make the best decision, but my motives will always be pure. I will learn from my mistakes because I will suffer the consequences of them. And no one else will suffer for my mistakes. Can the same be said of any mandatory public-funded system?

PART SEVEN: What Should Be Our Public Policy on Health Care?

1) Modify our government policies that limit the supply of health care providers.

We need more doctors, more nurses, and more trained health technicians—not less. However, our current system allows the supply of these important professionals to be artificially capped.

2) Review government regulation of the health care industry to reduce unnecessary and duplicative regulations and paperwork.

In a recently published book, Edward Annis, M.D., former President of the AMA, claims that prior to Medicare, the average physician spent one-fifth of his or her time caring for the poor. But today, the average physician spends one-fifth of his or her time on regulatory paperwork.

Experts disagree as to how much government paperwork adds to the cost of medical care, but even the most avid proponent of the government regulation will admit that at least 20% of health care costs are for government paperwork. Even President Clinton in his State of the Union Address in 1993 admitted that regulations add over 20% to American’s health care costs, and some sources claim that the figure is closer to 35%.

The only way to reduce these costs is to have less government involvement in health care. More government involvement in medicine will only increase paperwork and regulatory costs.

3) Health insurance needs to cover less not more.

Health insurance, like any other insurance, should cover the “expensive and unlikely” costs, not the “affordable and likely” costs. We need to eliminate tax incentives that encourage employers to buy insurance coverage for “affordable and likely” costs. It is this “over-insurance” that encourages consumers to over-utilize services, thus placing upward pressure on medical care prices.

When government provides full coverage for all, or part, of Americans, it creates the same upward pressure on prices. The result of universal health insurance will be a rapid rise in medical care prices. The only way to curtail these rising costs will be to reduce demand by rationing care.

What Can One Person Do?

1) Write to your representatives in the U.S. Congress and the U.S. Senate. Let them know that you oppose socialized medicine in any form. Encourage them to explore the real solutions outlined above.

2) Inform your friends and associates about the dangers of socialized medicine and rationing. Explain how rationing always discriminates against the disabled and the elderly. Explain that health care providers and individuals should decide who gets medical care—not the government. Provide them with a reprint of this article that we have published on this subject.

3) Write a letter to the editor of your local newspaper explaining just one or two of the issues discussed in these articles.

PART EIGHT: The Danger of Compromise

As discussed in previous sections, the leading health care reform proposals coming out of Washington D.C. contain some very radical and very undesirable features. These proposals are certainly dangerous to the health of Americans. Hopefully Americans will wake up, and these proposals will be soundly defeated. Unfortunately, the media has convinced most Americans that government action of some kind must be taken. So even if the Clinton proposal is defeated, there will probably be some “compromise” legislation that will pass. This “compromise” health care reform may only be half as bad as the Clinton proposals, but it will still ignore the real causes of our problems and will either fail to eradicate escalating costs, or it will ration access to necessary and beneficial care.

There is a well-used political strategy called the dialectic. Most readers may have used one or more variations of this technique in business negations. This strategy works like this: Let’s assume that your 13-year-old wants a $5.00 raise in his allowance. Let’s also assume that your teenager knows that you probably won’t give him as much as he asks for. Instead of asking for five dollars, the astute teen asks for an eight dollar raise, hoping that, after some discussion and debate, you will compromise and provide a raise in the five dollar range. Of course, the teenager would love an eight dollar raise, and if by reason of some temporary insanity you feel generous and consent to the initial request, you will get no complaint from your teenager.

The shrewd teen also knows that it is easier to obtain a lavish allowance in stages rather than all at once. Each compromise raise in allowance places the teenager closer to the ultimate goal.

Politics is no different. Those who want draconian proposals like the Clinton plan will strive for their goal relentlessly, but if it looks like their objective is out of reach, they will gladly negotiate a compromise that gives them part of what they want.

It is perhaps the “compromise” health care plan that is more difficult to defeat, and therefore more dangerous. After months of political battle, the opposition to socialized medicine will become fatigued by the issue. And when the compromise legislation shows up, it will receive much less opposition than would have been the case had it been the first and primary proposal.

Of course, if it passes, the less objectionable compromise legislation will be amended and expanded little by little. Within a decade, it may bear a surprisingly close resemblance to the original proposal, which was rejected as being too expensive, too restrictive, and otherwise undesirable.

Those who are concerned about issues like freedom of choice in health care, government spending and deficits, and the rights of the disabled and elderly to access health care, should oppose socialized medicine in any form. We should accept no compromise that enables government to restrict our freedom to choose providers, facilities, or treatments. We should accept no compromise that ignores the shortages of many types of health care professionals. We should accept no compromise that frees people from responsibility for their poor lifestyle choices. We should accept no compromise that crowds private charities out of providing health care. And last, but not least, we should accept no compromise that moves our country toward systems that have failed in the rest of the world.

In the words of Ben Franklin, “They that can give up a little essential liberty to obtain a little temporary safety deserve neither liberty nor safety.”

More than 20 Years Later

We should not make the mistake of assuming that the socialization of health care is a Republican vs. Democrat issue. Socialist thinking has permeated both political parties—and much of modern Christianity as well. A recent cover of Newsweek magazine boldly proclaimed: “We are all socialists now.” Unfortunately, this isn’t far from the truth.

It is ironic (but not surprising) that the most significant steps toward more socialism in medical care came not under the Clinton administration, but under the administration of George W. Bush. In 2003, Congress passed, and President Bush signed, the Medicare Prescription Drug, improvement, and Modernization Act, which expanded public funding and government control of America’s health care.

In 2007, United Press International quoted David Walker, then U.S. Comptroller General, as saying that this act (Medicare’s prescription drug program) might be the most financially irresponsible U.S. legislation passed in 40 years. This bill was commonly recognized as the single largest federal entitlement program since Lyndon Johnson’s Great Society. This “compromise” health care reform may only be half as bad as the Clinton proposals, but it will still ignore the real causes of our problems and will either fail to eradicate escalating costs, or it will ration access to necessary and beneficial care.

Bill and Hilary Clinton did not immediately achieve all of their health care objectives, but as was predicted in the 1994 article (our lead article for this issue of Principle Perspective), the proposed Clinton plans paved the way for compromise and then gradual steps toward their goal. The boldness of the Clinton health care effort made it possible for a Republican president to do what Hilary and Bill could not do, because the prescription drug plan seemed tame by comparison. This is a classic example of the dialectic strategy at work—thesis, antithesis, and then synthesis. These steps, if repeated, make the radical seem less radical—even reasonable.

Americans should not accept any “victory” in a watered-down, compromise version of a health care bill. Any and all movement toward the expansion of government involvement in health care should be emphatically opposed. Proponents of limited government and free markets need to go beyond defensive strategies. It is not enough to work to stop the further advances of socialism; instead, proponents of free markets need to become aggressive in promoting the repeal of older socialist programs. No matter how good the defense, no sports team ever wins without at least some offense.

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What has the pandemic revealed about the US health care system — and what needs to change?

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With vaccinations for Covid-19 now underway across the nation, MIT SHASS Communications asked seven MIT scholars engaged in health and health care research to share their views on what the pandemic has revealed about the U.S. health care system — and what needs to change. Representing the fields of medicine, anthropology, political science, health economics, science writing, and medical humanities, these researchers articulate a range of opportunities for U.S. health care to become more equitable, more effective and coherent, and more prepared for the next pandemic.

Dwaipayan Banerjee , associate professor of science, technology, and society

On the heels of Ebola, Covid-19 put to rest a persistent, false binary between diseases of the rich and diseases of the poor. For several decades, health care policymakers have labored under the impression of a great epidemiological transition. This theory holds that the developed world has reached a stage in its history that it no longer needs to worry about communicable diseases. These "diseases of the poor" are only supposed to exist in distant places with weak governments and struggling economies. Not here in the United States.

On the surface, Covid-19 made clear that diseases do not respect national boundaries. More subtly, it tested the hypothesis that the global north no longer need concern itself with communicable disease. And in so doing, it undermined our assumptions about global north health-care infrastructures as paradigmatically more evolved. Over the last decades, the United States has been focused on developing increasingly sophisticated drugs. While this effort has ushered in several technological breakthroughs, a preoccupation with magic-bullet cures has distracted from public health fundamentals. The spread of the virus revealed shortages in basic equipment and hospitals beds, the disproportionate effects of disease on the marginalized, the challenge of prevention rather than cure, the limits of insurance-based models to provide equitable care, and our unacknowledged dependence on the labor of underpaid health care workers.

To put it plainly, the pandemic did not create a crisis in U.S. health care. For many in the United States, crisis was already a precondition of care, delivered in emergency rooms and negotiated through denied insurance claims. As we begin to imagine a "new normal," we must ask questions about the old. The pandemic made clear that the "normal" had been a privilege only for a few well-insured citizens. In its wake, can we imagine a health-care system that properly compensates labor and recognizes health care as a right, rather than a privilege only available to the marginalized when an endemic crisis is magnified by a pandemic emergency? 

Andrea Campbell , professor of political science

No doubt, the pandemic reveals the dire need to invest in public-health infrastructure to better monitor and address public-health threats in the future, and to expand insurance coverage and health care access. To my mind, however, the pandemic’s greatest significance is in revealing the racism woven into American social and economic policy.

Public policies helped create geographic and occupational segregation to begin with; inadequate racist and classist public policies do a poor job of mitigating their effects. Structural racism manifests at the individual level, with people of color suffering worse housing and exposure to toxins, less access to education and jobs, greater financial instability, poorer physical and mental health, and higher infant mortality and shorter lifespans than their white counterparts. Residential segregation means many white Americans do not see these harms.

Structural racism also materializes at the societal level, a colossal waste of human capital that undercuts the nation’s economic growth, as social and economic policy expert Heather McGhee shows in her illuminating book, "The Sum of Us." These society-wide costs are hidden as well; it is difficult to comprehend the counterfactual of what growth would look like if all Americans could prosper. My hope is that the pandemic renders this structural inequality visible. There is little point in improving medical or public-health systems if we fail to address the structural drivers of poor health. We must seize the opportunity to improve housing, nutrition, and schools; to enforce regulations on workplace safety, redlining, and environmental hazards; and to implement paid sick leave and paid family leave, among other changes. It has been too easy for healthy, financially stable, often white Americans to think the vulnerable are residual. The pandemic has revealed that they are in fact central. It’s time to invest for a more equitable future.

Jonathan Gruber , Ford Professor of Economics

The Covid-19 pandemic is the single most important health event of the past 100 years, and as such has enormous implications for our health care system. Most significantly, it highlights the importance of universal, non-discriminatory health insurance coverage in the United States. The primary source of health insurance for Americans is their job, and with unemployment reaching its highest level since the Great Depression, tens of millions of workers lost, at least temporarily, their insurance coverage.

Moreover, even once the economy recovers, millions of Americans will have a new preexisting condition, Covid-19. That’s why it is critical to build on the initial successes of the Affordable Care Act to continue to move toward a safety net that provides insurance options for all without discrimination.

The pandemic has also illustrated the power of remote health care. The vast majority of patients in the United States have had their first experience with telehealth during the pandemic and found it surprisingly satisfactory. More use of telehealth can lead to increased efficiency of health care delivery as well as allowing our system to reach underserved areas more effectively.

The pandemic also showed us the value of government sponsorship of innovation in the health sciences. The speed with which the vaccines were developed is breathtaking. But it would not have been possible without decades of National Institute of Health investments such as the Human Genome Project, nor without the large incentives put in place by Operation Warp Speed. Even in peacetime, the government has a critical role to play in promoting health care innovation

The single most important change that we need to make to be prepared for the next pandemic is to recognize that proper preparation is, by definition, overpreparation. Unless we are prepared for the next pandemic that doesn’t happen, we won’t possibly be ready for the next pandemic that does.

This means working now, while the memory is fresh, to set up permanent, mandatorily funded institutions to do global disease surveillance, extensive testing of any at-risk populations when new diseases are detected, and a permanent government effort to finance underdeveloped vaccines and therapeutics.

Jeffrey Harris , professor emeritus of economics and a practicing physician The pandemic has revealed the American health care system to be a non-system. In a genuine system, health care providers would coordinate their services. Yet when Elmhurst Hospital in Queens was overrun with patients, some 3,500 beds remained available in other New York hospitals. In a genuine system, everyone would have a stable source of care at a health maintenance organization (HMO). While our country has struggled to distribute the Covid-19 vaccine efficiently and equitably, Israel, which has just such an HMO-based system, has broken world records for vaccination.

Germany, which has all along had a robust public health care system, was accepting sick patients from Italy, Spain, and France. Meanwhile, U.S. hospitals were in financial shock and fee-for-service-based physician practices were devastated. We need to move toward a genuine health care system that can withstand shocks like the Covid-19 pandemic. There are already models out there to imitate. We need to strengthen our worldwide pandemic and global health crisis alert systems. Despite concerns about China’s early attempts to suppress the bad news about Covid-19, the world was lucky that Chinese investigators posted the full genome of SARS-CoV-2 in January 2020 — the singular event that triggered the search for a vaccine. With the recurrent threat of yet another pandemic — after H1N1, SARS, MERS, Ebola, and now SARS-Cov-2 — along with the anticipated health consequences of global climate change, we can’t simply cross our fingers and hope to get lucky again.

Erica Caple James , associate professor of medical anthropology and urban studies The coronavirus pandemic has revealed some of the limits of the American medical and health care system and demonstrated many of the social determinants of health. Neither the risks of infection nor the probability of suffering severe illness are equal across populations. Each depends on socioeconomic factors such as type of employment, mode of transportation, housing status, environmental vulnerability, and capacity to prevent spatial exposure, as well as “preexisting” health conditions like diabetes, obesity, and chronic respiratory illness.

Such conditions are often determined by race, ethnicity, gender, and “biology,” but also poverty, cultural and linguistic facility, health literacy, and legal status. In terms of mapping the prevalence of infection, it can be difficult to trace contacts among persons who are regular users of medical infrastructure. However, it can be extraordinarily difficult to do so among persons who lack or fear such visibility, especially when a lack of trust can color patient-clinician relationships.

One’s treatment within medical and health care systems may also reflect other health disparities — such as when clinicians discount patient symptom reports because of sociocultural, racial, or gender stereotypes, or when technologies are calibrated to the norm of one segment of the population and fail to account for the severity of disease in others.

The pandemic has also revealed the biopolitics and even the “necropolitics” of care — when policymakers who are aware that disease and death fall disproportionately in marginal populations make public-health decisions that deepen the risks of exposure of these more vulnerable groups. The question becomes, “Whose lives are deemed disposable?” Similarly, which populations — and which regions of the world — are prioritized for treatment and protective technologies like vaccines and to what degree are such decisions politicized or even racialized?

Although no single change will address all of these disparities in health status and access to treatment, municipal, state, and federal policies aimed at improving the American health infrastructure — and especially those that expand the availability and distribution of medical resources to underserved populations — could greatly improve health for all.

Seth Mnookin , professor of science writing

The Covid-19 pandemic adds yet another depressing data point to how the legacy and reality of racism and white supremacy in America is lethal to historically marginalized groups. A number of recent studies have shown that Black, Hispanic, Asian, and Native Americans have a significantly higher risk of infection, hospitalization, and death compared to white Americans.

The reasons are not hard to identify: Minority populations are less likely to have access to healthy food options, clean air and water, high-quality housing, and consistent health care. As a result, they’re more likely to have conditions that have been linked to worse outcomes in Covid patients, including diabetes, hypertension, and obesity.

Marginalized groups are also more likely to be socioeconomically disadvantaged — which means they’re more likely to work in service and manufacturing industries that put them in close contact with others, use public transportation, rely on overcrowded schools and day cares, and live in closer proximity to other households. Even now, more vaccines are going to wealthier people who have the time and technology required to navigate the time-consuming vaccine signup process and fewer to communities with the highest infection rates.

This illustrates why addressing inequalities in Americans’ health requires addressing inequalities that infect every part of society. Moving forward, our health care systems should take a much more active role in advocating for racial and socioeconomic justice — not only because it is the right thing to do, but because it is one of the most effective ways to improve health outcomes for the country as a whole.

On a global level, the pandemic has illustrated that preparedness and economic resources are no match for lies and misinformation. The United States, Brazil, and Mexico have, by almost any metric, handled the pandemic worse than virtually every other country in the world. The main commonality is that all three were led by presidents who actively downplayed the virus and fought against lifesaving public health measures. Without a global commitment to supporting accurate, scientifically based information, there is no amount of planning and preparation that can outflank the spread of lies.

Parag Pathak , Class of 1922 Professor of Economics   The pandemic has revealed the strengths and weaknesses of America’s health care systems in an extreme way. The development and approval of three vaccines in roughly one year after the start of the pandemic is a phenomenal achievement. At the same time, there are many innovations for which there have been clear fumbles, including the deployment of rapid tests and contact tracing.   The other aspect the pandemic has made apparent is the extreme inequality in America’s health systems. Disadvantaged communities have borne the brunt of Covid-19 both in terms of health outcomes and also economically. I’m hopeful that the pandemic will spur renewed focus on protecting the most vulnerable members of society. A pandemic is a textbook situation in economics of externalities, where an individual’s decision has external effects on others. In such situations, there can be major gains to coordination. In the United States, the initial response was poorly coordinated across states. I think the same criticism applies globally. We have not paid enough attention to population health on a global scale. One lesson I take from the relative success of the response of East Asian countries is that centralized and coordinated health systems are more equipped to manage population health, especially during a pandemic. We’re already seeing the need for international cooperation with vaccine supply and monitoring of new variants. It will be imperative that we continue to invest in developing the global infrastructure to facilitate greater cooperation for the next pandemic.

Prepared by MIT SHASS Communications Editor and designer: Emily Hiestand Consulting editor: Kathryn O'Neill

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Home — Essay Samples — Life — Challenges — Health Care in America: Challenges and Prospects

Health Care in America: Challenges and Prospects

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Published: Jun 6, 2024

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Introduction, historical context, current challenges, prospects for reform.

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5 Critical Priorities for the U.S. Health Care System

• Marc Harrison

A guide to making health care more accessible, affordable, and effective.

The pandemic has starkly revealed the many shortcomings of the U.S. health care system — as well as the changes that must be implemented to make care more affordable, improve access, and do a better job of keeping people healthy. In this article, the CEO of Intermountain Healthcare describes five priorities to fix the system. They include: focus on prevention, not just treating sickness; tackle racial disparities; expand telehealth and in-home services; build integrated systems; and adopt value-based care.

Since early 2020, the dominating presence of the Covid-19 pandemic has redefined the future of health care in America. It has revealed five crucial priorities that together can make U.S. health care accessible, more affordable, and focused on keeping people healthy rather than simply treating them when they are sick.

• Marc Harrison , MD, is president and CEO of Salt Lake City-based Intermountain Healthcare.

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Free Healthcare in the United States: A Possible Solution to Public Health Disparities

Nov 23, 2020 | Author Hala Atassi , Public Health Policy

Access to healthcare is one of the remarkable indicators that defines the quality of people’s lives. Despite the thousands of advanced technologies and countless healthcare clinics and hospitals, many people still cannot afford healthcare or health insurance. This has been a global concern for years, which many countries have resolved. However, the United States has yet to significantly progress towards making healthcare more accessible to low-income communities. There are many solutions to this problem that can be implemented today, upon which millions of suffering Americans depend.

Some studies have shown over the years that expensive health care is due to the high cost of defensive medicine, or in other words, physicians ordering expensive tests that may be unnecessary, as a way to deflect legal responsibility from themselves. Deviating from defensive medicine in the healthcare industry might impact physicians economically, but more importantly, it will help achieve affordable healthcare. 

Obamacare (the Affordable Care Act of 2010) is one program that focuses on extending healthcare to Americans and reducing public health disparities. This program lays down a foundation that people under the age of 26 will receive accessible care from their parent or guardian’s health care plans. Afterward, they must pay for their health care plan. Also, the program stipulates that the government provides free healthcare to retired adults from age 55 to 64, to avoid any insurance plan complications. Essentially, Obamacare seeks to expand access to healthcare care, regardless of the scale of one’s medical diagnosis, to ultimately save lives that would have been lost due to the inability to pay expensive medical bills.

Easier access to healthcare will result in a healthier nation. The healthcare system is one of the most important components in life, as the United States’ economy cannot be fully efficient and benefit all people until everyone can access quality, affordable healthcare. Free healthcare (or at least cheaper healthcare) would be the most effective system for America, which other countries like Switzerland and Singapore have demonstrated. The money spent by citizens on their healthcare could be redirected to other social support systems in America, like expanding access to nutritious foods as well. Although free healthcare has many perks, it also has disadvantages. Most notably, overloading health services with a large number of patients would overwhelm already busy healthcare systems. Patients may overuse the perk of free healthcare, leaving not taxpayers to suffer, but rather medical professionals and healthcare systems. Even so, the perceptible advantages of affordable healthcare outweigh the disadvantages. As it is, years of attempts to ameliorate the United States healthcare system have failed the American people, and the situation remains devastating and life-threatening for low-income communities. There should be no debate though as to whether America needs to redesign the public health system, as healthcare is a human right, and nobody should be dying because they cannot afford to live, especially when the government has the economic means to take care of them.

Bibliography:

Gerisch, Mary. “Health Care As a Human Right.” American Bar Association , www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/health-care-as-a-human-right/. 

“Free Health Care Policies.” World Health Organization , World Health Organization, 2020, www.who.int/news-room/fact-sheets/detail/free-health-care-policies. 

Gologorsky, Beverly. “Health Care in the US Should Be Affordable and Accessible.” The Nation , 9 May 2019, www.thenation.com/article/archive/tom-dispatch-health-care-should-be-affordable-and-accessible/. 

Luhby, Tami. “Here’s How Obamacare Has Changed America.” CNN , Cable News Network, 8 July 2019, www.cnn.com/2019/07/08/politics/obamacare-how-it-has-changed-america/index.html.

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• Issue Brief

Health Care Costs: What’s the Problem?

The cost of health care in the United States far exceeds that in other wealthy nations across the globe. In 2020, U.S. health care costs grew 9.7%, to $4.1 trillion, reaching about $12,530 per person. 1 At the same time, the United States lags far behind other high-income countries when it comes to both access to care and some health care outcomes. 2 As a result, policymakers and health care systems are facing increasing demands for more care at lower costs for more people. And, of course, everyone wants to know why their health care costs are so high.

The answer depends, in part, on who’s asking this question: Why does U.S. health care cost so much? Public policy often highlights and targets the total cost of the health care system or spending as a percentage of the gross domestic product (GDP), while most patients (the public) are more concerned with their own out-of-pocket costs and whether they have access to affordable, meaningful insurance. Providers feel public pressure to contain costs while trying to provide the highest-quality care to patients.

This brief is the first in a series of papers intended to better define some of the key questions policymakers should be asking about health care spending: What costs are too high? And can they be controlled through policy while improving access to care and the health of the population?

What (or Who) Is to Blame for the High Costs of Care? 

Total U.S. health care spending has increased steadily for decades, as have costs and spending in other segments of the U.S. economy. In 2020, health care spending was $1.5 trillion more than in 2010 and $2.8 trillion more than in 2000. While total spending on clinical care has increased in the past two decades, health care spending as a percentage of GDP has remained steady and has hovered around 20% of GDP in recent years (with the largest single increase being in 2020 during the COVID-19 pandemic). 1 Health care spending in 2020 (particularly public outlays) increased more than in previous years because of increased federal government support of critical COVID-19-related services and expanded access to care during the pandemic. Yet, no single sector’s health care cost — doctors, hospitals, equipment, or any other sector — has increased disproportionately enough over time to be the single cause of high costs.

One of the areas in health care with the highest levels of spending in the United States is hospital care, which has accounted for about 30% of national health care spending 3 for the past 60 years (and has remained very close to 31% for the past 20 years) (Figure 1). Although hospital spending is the focus of many cost-control policies and public attention, the increases are consistent with the increases seen across other areas of health care, such as for physicians and other professional services. Total spending for some smaller parts of nonhospital care has more than doubled over the past few decades and makes up an increasing proportion of total spending. For instance, home health care as a percentage of total spending tripled between 1980 and 2020, from 0.9% to 3.0%, and drug spending nearly doubled as a proportion of health care spending between 1980 and 2006, from 4.8% to 10.5%, and currently represent 8.4% of health care spending. 1  

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The largest areas of spending that might yield the greatest potential for savings — such as inpatient care and physician-provided care — are unlikely to be reduced by lowering the total number of insured patients or visits per person, given the growing, aging U.S. population and the desire to cover more, not fewer, individuals with adequate health insurance. 

In the past decade, policymaker and insurer interventions intended to change the mix of services by keeping patients out of high-cost settings (such as the hospital) have not always succeeded at reducing costs, although they have had other benefits for patients. 4  

Breaking Down the Costs of Care

Thinking about total health care spending as an equation, one might define it as the number of services delivered per person multiplied by the number of people to whom services are delivered, multiplied again by the average cost of each service: 

Health Care Spending=(number of services delivered per person)×(number of people to whom services are delivered)×(average cost of each service) 

Could health care spending be lowered by making major changes to the numbers or types of services delivered or by lowering the average cost per service? 

Although recent data on the overall utilization of health care are limited, in 2011, the number of doctor consultations per capita in the United States was below that in many comparable countries, but the number of diagnostic procedures (such as imaging) per capita remained higher. 5 Furthermore, no identifiable groups of individuals (by race/ethnicity, geographic location, etc.) appear to be outliers that consume extraordinary numbers of services. 6 The exception is that the sickest people do cost more to take care of, but even the most cost-conscious policymakers appear to be reluctant to abandon these patients. 

In addition to the fact that the average number of health care services delivered per person in the United States was below international benchmarks in 2020,7 the percentage of people in the United States covered by health insurance was also lower than that in many other wealthy nations. Although millions of people gained insurance8 through the Affordable Care Act and provisions enacted during the COVID-19 pandemic, 10% of the nonelderly population remained uninsured in 2020. 9 When policymakers focus on reducing health care spending, considering the equation above, and see that the United States already has a lower proportion of its population insured and fewer services delivered to patients than other wealthy nations, their focus often shifts to the average cost of services.

It's Still the Prices … and the Wages 

A report comparing the international prices of health care in 2017 found that the median list prices (charges) for medical procedures in the United States heavily outweighed the list prices in other countries, such as the United Kingdom, New Zealand, Australia, Switzerland, and South Africa. 10  

For example, the 2017 U.S. median health care list price for a hospital admission with a hip replacement was $32,500, compared with $20,900 in Australia and $12,200 in the United Kingdom. In comparisons of the list prices of other procedures, such as deliveries by cesarean section, appendectomies, and knee replacements, the U.S. median list prices of elective and needed services were thousands of dollars — if not tens of thousands of dollars — more. 10 Yet, the list price for these services in the United States is often much higher than the actual payments made to providers by public or private insurance companies. 11

Public-payer programs (particularly Medicare and Medicaid) tend to pay hospitals rates that are lower than the cost of delivering care12 (though many economists argue these payments are slightly above actual costs, and providers argue they are at least slightly below actual costs), while private payers historically have paid about twice as much as public payers. 13 (See another brief in this series, “ Surprise! Why Medical Bills Are Still a Problem for U.S. Health Care ,” for more information about public and private payers’ role in health care costs.) However, the average cost per service is still high by international standards, even if it’s not as high as list prices may suggest. The high average costs are partially driven by the highly labor-intensive nature of health care, with labor consuming almost 55% of the share of total U.S. hospital costs in 2018. 14 These costs are growing due to the labor shortages exacerbated by the COVID-19 pandemic. 

Reducing U.S. health care spending by reducing labor costs could, theoretically, be achieved by reducing wages or eliminating positions; however, both of those policies would be problematic, with potential unintended consequences, such as driving clinicians away from the workforce at a time of growing need. 

Wage reductions, particularly for clinicians, would require a vastly expanded labor pool that would take years to achieve (and even then, lower per person wages for nonphysicians may not decrease total spending related to health care labor). 15 Reducing or replacing clinical workers over time would require major changes to policy (both public and private) and major shifts in how health care is provided — neither of which has occurred rapidly, even since the implementation of the Affordable Care Act. 

What’s a Policymaker to Do?

Nearly one in five Americans has medical debt, 16 and affordability is still an issue for a large proportion of the population, whether uninsured or insured, which suggests that policymakers should focus on patients’ costs. This may prove more impactful to the individual than reducing total health care spending. 

A majority of the country agrees that the federal government should ensure some basic health insurance for all citizens. 17,18 Although most Americans consider reducing costs to individuals and expanding insurance coverage to be important, no clear consensus about who should bear any associated increased costs exists among patients or policymakers. Half of insured adults currently report difficulty affording medical or dental care, even when they are insured, because of the rising total costs of care and the increasing absolute amount of out-of-pocket spending. 19 Out-of-pocket spending for health care has doubled in the past 20 years, from $193.5 billion in 2000 to $388.6 billion in 2020. 1 These rising health care costs have disproportionately fallen on those with the fewest resources, including people who are uninsured, Black people, Hispanic people, and families with low incomes. 19 Increased cost sharing through copays and coinsurance may force difficult spending choices for even solidly middle-class families. 

The severity and burden of out-of-pocket spending are hidden by the use of data averages; on average, U.S. residents have twice the average household net adjusted disposable income 20 of many other comparable nations and spend more than twice 21 as much per capita on health care. Yet, for those who fall outside these averages — average income, average costs, or both — the financial pain felt at the hospital, clinic, and pharmacy is very real. 

In any given year, a small number of patients account for a disproportionate amount of health care spending because of the complexity and severity of their illnesses. Even careful international comparisons of end-of-life care for cancer patients demonstrate costs in the United States are similar to those in many comparable nations (although U.S. patients are more likely to receive chemotherapy, they spend fewer days in the hospital during the last 6 months of life than patients in other countries). 22 Similarly, although prevention efforts may delay or avoid the onset of illness in targeted populations, such efforts would not significantly reduce the number of services delivered for many years and may lead to an increase in care delivered over the course of an extended life span.

To the average person in the United States, immediate cost-control efforts might best be focused on reducing the cost burden for families and patients. Policymakers should continue to seek ways to promote better health care quality at lower costs rather than try to achieve unrealistic, drastic reductions in national health care spending. Investing in prevention, seeking to avoid preventable admissions or readmissions, and otherwise improving the quality of care are desirable, but these improvements are not quick solutions to lowering the national health care costs in the near term. Long-term policy actions could incrementally address health care spending but should clearly articulate the problem to be solved, the desired outcomes, and the trade-offs the nation is willing to make (as discussed in two companion pieces). 

The U.S. health care system continues to place a disproportionate cost burden on the patients who can least afford it. In the short term, policymakers could focus on targeted subsidies to specific populations — the families and individuals whose household incomes fall outside the average or who have health care expenses that fall outside the average — whose health care costs are unmanageable. Such subsidies could expand existing premium subsidies or triggers that increase support for costs that exceed target amounts. Targeted subsidies are likely to increase total health care spending (especially public spending) but would address the problem of cost from the average consumer, or patient, perspective. Broader policies to ease costs for patients could also be considered by category of service; for instance, consumers have been largely shielded from the increased costs of care related to COVID-19 by the waiving of copays for patients and families. These policies would likely increase national spending as well, but they would make medical care more affordable to some families.

Download Brief

Cite this source: Grover A, Orgera K, Pincus L. Health Care Costs: What's The Problem? Washington, DC: AAMC; 2022. https://doi.org/10.15766/rai_dozyvvh2

• Centers for Medicare & Medicaid Services. National Health Expenditure Data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet . Published Dec. 1, 2021. Accessed Feb. 24, 2022.
• Schneider EC, Shah A, Doty MM, Tikkanen R, Fields K, Williams RD II. Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries. Washington, DC: The Commonwealth Fund. https://doi.org/10.26099/01DV-H208 . Published August 2021. Accessed April 21, 2022.
• Centers for Medicare & Medicaid Services. National Health Expenditure Data: Historical. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical . Published Dec. 15, 2021. Accessed April 22, 2022. 
• Berkowitz S, Ricks KB, Wang J, Parker M, Rimal R, DeWalt D. Evaluating a nonemergency medical transportation benefit for accountable care organization members. Health Affairs. 2022;41(3):406-413. doi:10.1377/hlthaff.2021.00449.
• Organisation for Economic Co-operation and Development. Health Care Utilisation. Paris, France: Organisation for Economic Co-operation and Development. https://stats.oecd.org/index.aspx?queryid=30166# . Published Nov. 9, 2021. Accessed Feb. 24, 2022.
• Abelson R. Harris G. Critics question study cited in health debate. New York Times. June 2, 2010. https://www.nytimes.com/2010/06/03/business/03dartmouth.html?ref=business&pagewanted=all . Accessed Feb. 24, 2022.
• The Commonwealth Fund. Selected Health & System Statistics: Average Annual Number of Physician Visits per Capita. https://www.commonwealthfund.org/international-health-policy-center/system-stats/annual-physician-visits-per-capita . Published June 5, 2020. Accessed April 21, 2022.
• Tolbert J, Orgera K. Key Facts About the Uninsured Population. San Francisco, CA: KFF. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ . Published Nov. 6, 2020. Accessed April 21, 2022.
• Tolbert J, Orgera K, Damico A. What Does the CPS Tell Us About Health Insurance Coverage in 2020? San Francisco, CA: KFF. https://www.kff.org/uninsured/issue-brief/what-does-the-cps-tell-us-about-health-insurance-coverage… . Published Sept. 23, 2021. Accessed April 21, 2022.
• Hargraves J, Bloschichak A. International Comparisons of Health Care Prices From the 2017 iFHP Survey. Washington DC: Health Care Cost Institute. https://healthcostinstitute.org/hcci-research/international-comparisons-of-health-care-prices-2017-ifhp-survey . Published Dec. 2019. Accessed April 21, 2022.
• Bai G. Anderson G. Extreme markup: The fifty US hospitals with the highest charge-to-cost ratios. Health Affairs. 2015;34(6):922-928. doi:10.1377/hlthaff.2014.1414.
• Congressional Budget Office. The Prices That Commercial Health Insurers and Medicare Pay for Hospitals’ and Physicians’ Services. Washington, DC: Congressional Budget Office. https://www.cbo.gov/system/files/2022-01/57422-medical-prices.pdf . Published January 2022. Accessed April 21, 2022.
• Lopez E, Neuman T, Jacobson G, Levitt L. How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature. San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/ . Published April 15, 2020. Accessed March 22, 2022.
• Daly R. Hospitals Innovate to Control Labor Costs. Westchester, IL: Healthcare Financial Management Association. https://www.hfma.org/topics/hfm/2019/october/hospitals-innovate-to-control-labor-costs.html . Published Oct. 1, 2019. Accessed Feb. 24, 2022. 
• Batson BN, Crosby SN, Fitzpatrick, JM. Mississippi frontline: Targeting value-based care with physician-led care teams. J Miss State Med Assoc. 2022;63(1):19-21. https://ejournal.msmaonline.com/publication/?m=63060&i=735364&p=20&ver=html5 .
• Kluender R, Mahoney N, Wong F, et al. Medical debt in the US, 2009-2020. JAMA. 2021;326(3):250-256. doi:10.1001/jama.2021.8694.
• Jones B. Increasing Share of Americans Favor a Single Government Program to Provide Health Care Coverage. Washington, DC: Pew Research Center. https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/ . Published Sept. 29, 2020. Accessed April 21, 2022.
• Bialik K. More Americans Say Government Should Ensure Health Care Coverage. Washington, DC: Pew Research Center. https://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/ . Published Jan. 13, 2017. Accessed March 22, 2022.
• Kearney A, Hamel L, Stokes M, Brodie M. Americans’ Challenges With Health Care Costs. San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/ . Published Dec. 14, 2021. Accessed Feb. 24, 2022.
• Organisation for Economic Co-operation and Development. Income. Better Life Index. Paris, France: Organisation for Economic Co-operation and Development. https://www.oecdbetterlifeindex.org/topics/income/ . Accessed April 21, 2022.
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IvyPanda . (2018) 'Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons'. 11 October.

IvyPanda . 2018. "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

1. IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

Bibliography

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Should the U.S. Government Provide Universal Health Care?

• History of Universal Health Care

27.5 million non-elderly Americans did not have health insurance in 2021, a decline from 28.9 million uninsured Americans in 2019. The largest group of Americans, almost 155 million non-elderly people, were covered by employer-sponsored health insurance. Less than 1% of Americans over 65 were uninsured, thanks to Medicaid, a government provided insurance for people over 65 years old.

The United States is the only nation among the 37 OECD (Organization for Economic Co-operation and Development) nations that does not have universal health care either in practice or by constitutional right. Read more background…

Pro & Con Arguments

Pro 1 The United States already has universal health care for some. The government should expand the system to protect everyone. A national health insurance is a universal health care that “uses public insurance to pay for private-practice care. Every citizen pays into the national insurance plan. Administrative costs are lower because there is one insurance company. The government also has a lot of leverage to force medical costs down,” according to economic expert Kimberly Amadeo. Canada, Taiwan, and South Korea all have national health insurance. In the United States, Medicare, Medicaid, and TRICARE function similarly. [ 178 ] Medicare is the “federal health insurance program for: people who are 65 or older, certain younger people with disabilities, [and] people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).” Patients pay a monthly premium for Medicare Part B (general health coverage). The 2023 standard Part B monthly premium is $164.90. Patients also contribute to drug costs via Medicare Part D. Most people do not pay a premium for Medicare Part A (“inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care”). More than 65.3 million people were enrolled in Medicare according to Feb. 2023 government data. [ 180 ] [ 181 ] Medicaid “provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.” More than 84.8 million people were enrolled in Medicaid as of Nov. 2022. [ 181 ] [ 182 ] [ 183 ] The Children’s Health Insurance Program (CHIP), often lumped in with Medicaid in these discussions, is a “low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program.” CHIP covers more than 6.9 million patients. [ 181 ] [ 182 ] [ 183 ] TRICARE is the “military health system that provides care to almost 10 million active-duty service members, retired personnel, and their families.” Active-duty military members pay $0 for health insurance, while retired members and their families paid a premium up to $1,165 per month (for a member and family) in 2021. [ 184 ] The United States already successfully maintains universal health care for almost 36% of the U.S. population, according to U.S. Census data released in Sep. 2022. As the Baby Boomer generation continues to age and more of the generation becomes eligible for Medicare, estimates suggest about 73.5 million people will use Medcare and about 47% of American health care costs will be paid for by public health services by 2027. [ 185 ] [ 186 ] If the government can successfully provide universal health care for 36% to almost 50% of the population, then the government can provide univeral health care for the rest of the population who are just as in need and deserving of leading healthy lives. Read More

Pro 2 Universal health care would lower costs and prevent medical bankruptcy. A June 2022 study found the United States could have saved $105.6 billion in COVID-19 (coronavirus) hospitalization costs with single-payer universal health care during the pandemic. That potential savings is on top of the estimated $438 billion the researchers estimated could be saved annually with universal health care in a non-pandemic year. [ 198 ] “Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households,” conclude researchers from the Yale School of Public Health and colleagues. [ 201 ] According to the National Bankruptcy Forum, medical debt is the number one reason people file for bankruptcy in the United States. In 2017, about 33% of all Americans with medical bills reported that they “were unable to pay for basic necessities like food, heat, or housing.” If all Americans were provided health care under a single-payer system medical bankruptcy would no longer exist, because the government, not private citizens, would pay all medical bills. [ 131 ] Further, prescription drug costs would drop between 4% and 31%, according to five cost estimates gathered by New York Times reporters. 24% of people taking prescription drugs reported difficulty affording the drugs, according to a Kaiser Family Foundation (KFF) poll. 58% of people whose drugs cost more than $100 a month, 49% of people in fair or poor health, 35% of those with annual incomes of less than $40,000, and 35% of those taking four or more drugs monthly all reported affordability issues. [ 197 ] [ 199 ] [ 200 ] Additionally, 30% of people aged 50 to 64 reported cost issues because they generally take more drugs than younger people but are not old enough to qualify for Medicare drug benefits. With 79% of Americans saying prescription drug costs are “unreasonable,” and 70% reporting lowering prescription drug costs as their highest healthcare priority, lowering the cost of prescription drugs would lead to more drug-compliance and lives not only bettered, but saved as a result. [ 197 ] [ 199 ] [ 200 ] Read More

Pro 3 Universal health care would improve individual and national health outcomes. Since 2020, the COVID-19 pandemic has underscored the public health, economic and moral repercussions of widespread dependence on employer-sponsored insurance, the most common source of coverage for working-age Americans…. Business closures and restrictions led to unemployment for more than 9 million individuals following the emergence of COVID-19. Consequently, many Americans lost their healthcare precisely at a time when COVID-19 sharply heightened the need for medical services,” argue researchers from the Yale School of Public Health and colleagues. The researchers estimated more than 131,000 COVID-19 (coronavirus) deaths and almost 78,000 non-COVID-19 deaths could have been prevented with universal health care in 2020 alone. [ 198 ] Another study finds a change to “single-payer health care would… save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.” [ 201 ] Meanwhile, more people would be able to access much-needed health care. A Jan. 2021 study concludes that universal health care would increase outpatient visits by 7% to 10% and hospital visits by 0% to 3%, which are modest increases when compared to saved and lengthened lives. [ 202 ] Other studies find that universal health coverage is linked to longer life expectancy, lower child mortality rates, higher smoking cessation rates, lower depression rates, and a higher general sense of well-being, with more people reporting being in “excellent health.” Further, universal health care leads to appropriate use of health care facilities, including lower rates of emergency room visits for non-emergencies and a higher use of preventative doctors’ visits to manage chronic conditions. [ 203 ] [ 204 ] [ 205 ] An American Hospital Association report argues, the “high rate of uninsured [patients] puts stress on the broader health care system. People without insurance put off needed care and rely more heavily on hospital emergency departments, resulting in scarce resources being directed to treat conditions that often could have been prevented or managed in a lower-cost setting. Being uninsured also has serious financial implications for individuals, communities and the health care system.” [ 205 ] Read More

Con 1 Universal health care for everyone in the United States promises only government inefficiency and health care that ignores the realities of the country and the free market. In addition to providing universal health care for the elderly, low-income individuals, children in need, and military members (and their families), the United States has the Affordable Care Act (the ACA, formerly known as the Patient Protection and Affordable Care Act), or Obamacare, which ensures that Americans can access affordable health care. the ACA allows Americans to chose the coverage appropriate to their health conditions and incomes. [ 187 ] Veterans’ Affairs, which serves former military members, is an example of a single-payer health care provider, and one that has repeatedly failed its patients. For example, a computer error at the Spokane VA hospital “failed to deliver more than 11,000 orders for specialty care, lab work and other services – without alerting health care providers the orders had been lost.” [ 188 ] [ 189 ] Elizabeth Hovde, Policy Analyst and Director of the Centers for Health Care and Worker Rights, argues, “The VA system is not only costly with inconsistent medical care results, it’s an American example of a single-payer, government-run system. We should run from the attempts in our state to decrease competition in the health care system and increase government dependency, leaving our health care at the mercy of a monopolistic system that does not need to be timely or responsive to patients. Policymakers should give veterans meaningful choices among private providers, clinics and hospitals, so vets can choose their own doctors and directly access quality care that meets their needs. Best of all, when the routine break-downs of a government-run system threaten to harm them again, as happened in Spokane, veterans can take their well-earned health benefit and find help elsewhere.” [ 188 ] [ 189 ] Further, the challenges of universal health care implementation are vastly different in the U.S. than in other countries, making the current patchwork of health care options the best fit for the country. As researchers summarize, “Though the majority of post-industrial Westernized nations employ a universal healthcare model, few—if any—of these nations are as geographically large, populous, or ethnically/racially diverse as the U.S. Different regions in the U.S. are defined by distinct cultural identities, citizens have unique religious and political values, and the populace spans the socio–economic spectrum. Moreover, heterogenous climates and population densities confer different health needs and challenges across the U.S. Thus, critics of universal healthcare in the U.S. argue that implementation would not be as feasible—organizationally or financially—as other developed nations.” [ 190 ] And, such a system in the United States would hinder medical innovation and entrepreneurship. “Government control is a large driver of America’s health care problems. Bureaucrats can’t revolutionize health care – only entrepreneurs can. By empowering health care entrepreneurs, we can create an American health care system that is more affordable, accessible, and productive for all,” explains Wayne Winegarden, Senior Fellow in Business and Economics, and Director of the Center for Medical Economics and Innovation at Pacific Research Institute. [ 190 ] [ 191 ] Read More

Con 2 Universal health care would raise costs for the federal government and, in turn, taxpayers. Medicare-for-all, a recent universal health care proposal championed by Senator Bernie Sanders (I-VT), would cost an estimated $30 to $40 trillion over ten years. The cost would be the largest single increase to the federal budget ever. [ 192 ] The Congressional Budget Office (CBO) estimates that by 2030 federal health care subsidies will increase by $1.5 to $3.0 trillion. The CBO concludes, “Because the single-payer options that CBO examined would greatly increase federal subsidies for health care, the government would need to implement new financing mechanisms—such as raising existing taxes or introducing new ones, reducing certain spending, or issuing federal debt. As an example, if the government required employers to make contributions toward the cost of health insurance under a single-payer system that would be similar to their contributions under current law, it would have to impose new taxes.” [ 193 ] Despite claims by many, the cost of Medicare for All, or any other universal health care option, could not be financed solely by increased taxes on the wealthy. “[T]axes on the middle class would have to rise in order to pay for it. Those taxes could be imposed directly on workers, indirectly through taxes on employers or consumption, or through a combination of direct or indirect taxes. There is simply not enough available revenue from high earners and businesses to cover the full cost of eliminating premiums, ending all cost-sharing, and expanding coverage to all Americans and for (virtually) all health services,” says the Committee for a Responsible Federal Budget. [ 195 ] An analysis of the Sanders plan “estimates that the average annual cost of the plan would be approximately $2.5 trillion per year creating an average of over a $1 trillion per year financing shortfall. To fund the program, payroll and income taxes would have to increase from a combined 8.4 percent in the Sanders plan to 20 percent while also retaining all remaining tax increases on capital gains, increased marginal tax rates, the estate tax and eliminating tax expenditures…. Overall, over 70 percent of working privately insured households would pay more under a fully funded single payer plan than they do for health insurance today.” [ 196 ] Read More

Con 3 Universal health care would increase wait times for basic care and make Americans’ health worse. The Congressional Budget Office explains, “A single-payer system with little cost sharing for medical services would lead to increased demand for care in the United States because more people would have health insurance and because those already covered would use more services. The extent to which the supply of care would be adequate to meet that increased demand would depend on various factors, such as the payment rates for providers and any measures taken to increase supply. If coverage was nearly universal, cost sharing was very limited, and the payment rates were reduced compared with current law, the demand for medical care would probably exceed the supply of care–with increased wait times for appointments or elective surgeries, greater wait times at doctors’ offices and other facilities, or the need to travel greater distances to receive medical care. Some demand for care might be unmet.” [ 207 ] As an example of lengthy wait times associated with universal coverage, in 2017 Canadians were on waiting lists for an estimated 1,040,791 procedures, and the median wait time for arthroplastic surgery was 20–52 weeks. Similarly, average waiting time for elective hospital-based care in the United Kingdom is 46 days, while some patients wait over a year. Increased wait times in the U.S. would likely occur—at least in the short term—as a result of a steep rise in the number of primary and emergency care visits (due to eliminating the financial barrier to seek care), as well as general wastefulness, inefficiency, and disorganization that is often associated with bureaucratic, government-run agencies. [ 17 ] [ 190 ] Joshua W. Axene of Axene Health Partners, LLC “wonder[s] if Americans really could function under a system that is budget based and would likely have increased waiting times. In America we have created a healthcare culture that pays providers predominantly on a Fee for Service basis (FFS) and allows people to get what they want, when they want it and generally from whoever they want. American healthcare culture always wants the best thing available and has a ‘more is better’ mentality. Under a government sponsored socialized healthcare system, choice would become more limited, timing mandated, and supply and demand would be controlled through the constraints of a healthcare budget…. As much as Americans believe that they are crockpots and can be patient, we are more like microwaves and want things fast and on our own terms. Extended waiting lines will not work in the American system and would decrease the quality of our system as a whole.” [ 206 ] Read More

Did You Know?
1. 27.5 million non-elderly Americans did not have health insurance in 2021, a decline from 28.9 million uninsured Americans in 2019. [ ] [ ]
2. Researchers estimated more than 131,000 COVID-19 (coronavirus) deaths and almost 78,000 non-COVID-19 deaths could have been prevented with universal health care in 2020 alone. [ ]
3. 88% of Democrats and 59% of Independents agreed that "it is the responsibility of the federal government to make sure all Americans have healthcare coverage," while only 28% of Republicans agreed. [ ]
4. The United States is the only nation among the 37 OECD (Organization for Economic Co-operation and Development) nations that does not have universal health care either in practice or by constitutional right. [ ]
5. U.S. health care spending rose 2.7% in 2021 to a total of $4.3 trillion nationally and accounted for 18.3% of the U.S. Gross Domestic Product (GDP). [ ] [ ] [ ]

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2021 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec.

2021 National Healthcare Quality and Disparities Report [Internet].

Overview of u.s. healthcare system landscape.

The National Academy of Medicine defines healthcare quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Many factors contribute to the quality of care in the United States, including access to timely care, affordability of care, and use of evidence-based guidelines to drive treatment.

This section of the report highlights utilization of healthcare services, healthcare workforce statistics, healthcare expenditures, and major contributors to morbidity and mortality. These factors help paint an overall picture of the U.S. healthcare system, particularly areas that need improvement. Quality measures show whether the healthcare system is adequately addressing risk factors, diseases, and conditions that place the greatest burden on the healthcare system and if change has occurred over time.

• Overview of the U.S. Healthcare System Infrastructure

The NHQDR tracks care delivered by providers in many types of healthcare settings. The goal is to provide high-quality healthcare that is culturally and linguistically sensitive, patient centered, timely, affordable, well coordinated, and safe. The receipt of appropriate high-quality services and counseling about healthy lifestyles can facilitate the maintenance of well-being and functioning. In addition, social determinants of health, such as education, income, and residence location can affect access to care and quality of care.

Improving care requires facility administrators and providers to work together to expand access, enhance quality, and reduce disparities. It also requires coordination between the healthcare sector and other sectors for social welfare, education, and economic development. For example, Healthy People 2030 includes 5 domains (shown in the diagram below) and 78 social determinants of health objectives for federal programs and interventions.

Healthy People 2030 social determinants of health domains.

The numbers of health service encounters and people working in health occupations illustrate the large scale and inherent complexity of the U.S. healthcare system. The tracking of healthcare quality measures in this report iii attempts to quantify progress made in improving quality and reducing disparities in the delivery of healthcare to the American people.

Number of healthcare service encounters, United States, 2018 and 2019.

• In 2018, there were 860 million physician office visits ( Figure 1 ).
• In 2019, patients spent 149 million days in hospice.
• In 2019, there were 100 million home health visits.
• Overview of Disease Burden in the United States

The National Institutes of Health defines disease burden as the impact of a health problem, as measured by prevalence, incidence, mortality, morbidity, extent of disability, financial cost, or other indicators.

This section of the report highlights two areas of disease burden that have major impact on the health system of the United States: years of potential life lost and leading causes of death. The NHQDR tracks measures of quality for most of these conditions. Variation in access to care and care delivery across communities contributes to disparities related to race, ethnicity, sex, and socioeconomic status.

The concept of years of potential life lost (YPLL) involves estimating the average time a person would have lived had he or she not died prematurely. This measure is used to help quantify social and economic loss from premature death, and it has been promoted to emphasize specific causes of death affecting younger age groups. YPLL inherently incorporates age at death, and its calculation mathematically weights the total deaths by applying values to death at each age. 1

According to the Centers for Disease Control and Prevention (CDC), unintentional injuries include opioid overdoses (unintentional poisoning), motor vehicle crashes, suffocation, drowning, falls, fire/burns, and sports and recreational injuries. Overdose deaths involving opioids, including prescription opioids , heroin , and synthetic opioids (e.g., fentanyl ), have been a major contributor to the increase in unintentional injuries. Opioid overdose has increased to more than six times its 1999 rate. 2

Age-adjusted years of potential life lost before age 65, by cause of death, 2010–2019. Key: YPLL = years of potential life lost. Note: The perinatal period occurs from 22 completed weeks (154 days) of gestation and ends 7 completed days after (more...)

• From 2010 to 2019, there were no changes in the ranking of the top 10 leading diseases and injuries contributing to YPLL. The top 5 were unintentional injury, cancer, heart disease, suicide, and complications during the perinatal period ( Figure 2 ). The remaining 5 were homicide, congenital anomalies, liver disease, diabetes, and cerebrovascular disease.
• Unintentional injury increased from 791.8 per 100,000 population in 2010 to 1,024.3 per 100,000 population in 2019.
• Cancer decreased from 635.2 per 100,000 population in 2010 to 533.3 per 100,000 population in 2019.
• Heart disease decreased from 474.3 per 100,000 population in 2010 to 453.2 per 100,000 population in 2019.

Age-adjusted years of potential life lost before age 65, by cause of death and race, 2019. Key: AI/AN = American Indian or Alaska Native; PI = Pacific Islander.

• In 2019, among American Indian and Alaska Native (AI/AN) people, the top five contributing factors for YPLL were unintentional injuries (1,284.6 per 100,000 population), suicide (457.7 per 100,000 population), liver disease (451.6 per 100,000 population), heart disease (399.8 per 100,000 population), and cancer (339.6 per 100,000 population) ( Figure 3 ).
• In 2019, among Asian and Pacific Islander people, the top five contributing factors for YPLL were cancer (375.7 per 100,000 population), unintentional injuries (299.4 per 100,000 population), complications in the perinatal period (203.4 per 100,000 population), suicide (198.5 per 100,000), and heart disease (197.7 per 100,000 population).
• In 2019 among Black people, the top five contributing factors for YPLL were unintentional injuries (1,085.8 per 100,000 population), heart disease (843.5 per 100,000 population), homicide (801.7 per 100,000 population), cancer (652.7 per 100,000 population), and complications in the perinatal period (560.4 per 100,000 population).
• In 2019, among White people, the top five contributing factors for YPLL were unintentional injuries (1,080.0 per 100,000 population), cancer (530.1 per 100,000 population), heart disease (406.6 per 100,000 population), suicide (387.6 per 100,000 population), and complications in the perinatal period (215.7 per 100,000 population).

Leading causes of death for the total population, United States, 2018 and 2019.

• In 2019, heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, Alzheimer’s disease, and diabetes were among the leading causes of death for the overall U.S. population ( Figure 4 ).
• Overall, kidney disease moved from the 9 th leading cause of death in 2018 to the 8 th leading cause of death in 2019.
• Suicide remained the 10 th leading cause of death in 2018 and 2019.

The years of potential life lost, years with disability, and leading causes of death represent some aspects of the burden of disease experienced by the American people. Findings highlighted in this report attempt to quantify progress made in improving quality of care, reducing disparities in healthcare, and ultimately reducing disease burden.

• Overview of U.S. Community Hospital Intensive Care Beds

The United States has almost 1 million staffed hospital beds; nearly 800,000 are community hospital beds and 107,000 are intensive care beds. Figure 5 shows the numbers of different types of staffed intensive care hospital beds.

Medical-surgical intensive care provides patient care of a more intensive nature than the usual medical and surgical care delivered in hospitals, on the basis of physicians’ orders and approved nursing care plans. These units are staffed with specially trained nursing personnel and contain specialized equipment for monitoring and supporting patients who, because of shock, trauma, or other life-threatening conditions, require intensified comprehensive observation and care. These units include mixed intensive care units.

Pediatric intensive care provides care to pediatric patients that is more intensive in nature than that usually provided to pediatric patients. The unit is staffed with specially trained personnel and contains monitoring and specialized support equipment for treating pediatric patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and care.

Cardiac intensive care provides patient care of a more specialized nature than the usual medical and surgical care, on the basis of physicians’ orders and approved nursing care plans. The unit is staffed with specially trained nursing personnel and contains specialized equipment for monitoring, support, or treatment for patients who, because of severe cardiac disease such as myocardial infarction, open-heart surgery, or other life-threatening conditions, require intensified, comprehensive observation and care.

Neonatal intensive care units (NICUs) are distinct from the newborn nursery and provide intensive care to sick infants, including those with the very lowest birth weights (less than 1,500 grams). NICUs may provide mechanical ventilation, care before or after neonatal surgery, and special care for the sickest infants born in the hospital or transferred from another institution. Neonatologists typically serve as directors of NICUs.

Burn care provides care to severely burned patients. Severely burned patients are those with the following: (1) second-degree burns of more than 25% total body surface area for adults or 20% total body surface area for children; (2) third-degree burns of more than 10% total body surface area; (3) any severe burns of the hands, face, eyes, ears, or feet; or (4) all inhalation injuries, electrical burns, complicated burn injuries involving fractures and other major traumas, and all other poor risk factors.

Other intensive care unit beds are in specially staffed, specialty-equipped, separate sections of a hospital dedicated to the observation, care, and treatment of patients with life-threatening illnesses, injuries, or complications from which recovery is possible. This type of care includes special expertise and facilities for the support of vital functions and uses the skill of medical, nursing, and other staff experienced in the management of conditions that require this higher level of care.

U.S. community hospital intensive care staffed beds, by type of intensive care, 2019. Note: Community hospitals are defined as all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; (more...)

• In 2019, of the more than 900,000 staffed hospital beds in the United States, 86% were in community hospitals (data not shown).
• Most of the more than 107,000 intensive care beds in community hospitals were medical-surgical intensive care (51.9%) and neonatal intensive care beds (21.1%) ( Figure 5 ).

Critical access hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services. As of July 16, 2021, 1,353 CAHs were located throughout the United States. 3 , iv

Distribution of critical access hospitals in the United States, 2021.

• According to CMS, CAHs must be located in a rural area or an area that is treated as rural, v so the number of CAHs varies by state ( Figure 6 ).
• In 2019, California had a population of 39.5 million and 36 CAHs compared with Iowa, which had a population of only 3.2 million but 82 CAHs.
• U.S. Healthcare Workforce

Healthcare access and quality can be affected by workforce shortages, particularly in rural areas. In addition, lack of racial, ethnic, and gender concordance between providers and patients can lead to miscommunication, stereotyping, and stigma, and, ultimately, suboptimal healthcare.

Healthcare Workforce Availability

Improving quality of care, increasing access to care, and controlling healthcare costs depend on the adequate availability of healthcare providers. 4 Physician shortages currently exist in many states across the nation, with relatively fewer primary care and specialty physicians available in nonmetropolitan counties compared with metropolitan counties. 5

The Health Resources and Services Administration (HRSA) further projects that the supply of key professions, including primary care providers, general dentists, adult psychiatrists, and addiction counselors, will fall short of demand by 2030. 6 These concerns have the potential to influence the delivery of healthcare and negatively affect patient outcomes.

Number of people working in health occupations, United States, 2019. Key: EMT = emergency medical technician. Note: Doctors of medicine also include doctors of osteopathic medicine. Active physicians include those working in direct patient care, administration, (more...)

• In 2019, there were 3.7 million registered nurses ( Figure 7 ).
• In 2019, there were 2.4 million healthcare aides, which includes nursing, psychiatric, home health, and occupational therapy aides and physical therapy assistants and aides.
• In 2019, there were 2.1 million health technologists.
• In 2019, 2.0 million other health practitioners provided care, including more than 145,000 physician assistants (PAs).
• In 2019, there were 972,000 active medical doctors in the United States, which include doctors of medicine and doctors of osteopathy.
• In 2019, there were 183,000 dentists.

In recent decades, promising approaches that address the supply-demand imbalance have emerged as alternatives to simply increasing the number of physicians. One strategy relies on telehealth technologies to improve physicians’ efficiency or to increase access to their services. For example, Project ECHO is a telehealth model in which specialists remotely support multiple rural primary care providers so that they can treat patients for conditions that might otherwise require traveling to distant specialty centers. 7

Another strategy relies on peer-led models, in which community-based laypeople receive the training and support needed to deliver care for a (typically) narrow range of conditions. Successful examples of this approach exist, including the deployment of community health workers to manage chronic diseases, 8 promotoras to provide maternal health services, 9 peer counselors for mental health and substance use disorders, 10 and dental health aides to deliver oral health services in remote locations. 11

The National Institutes of Health, HRSA, and the Agency for Healthcare Research and Quality (AHRQ) have sponsored formative research to examine key issues that must be addressed to further develop these models, but all show promise for expanding access to care and increasing overall diversity within the healthcare workforce.

Workforce Diversity

The number of full-time, year-round workers in healthcare occupations has almost doubled since 2000, increasing from 5 million to 9 million workers, according to the U.S. Census Bureau’s American Community Survey .

A racially and ethnically diverse health workforce has been shown to promote better access and healthcare for underserved populations and to better meet the health needs of an increasingly diverse population. People of color, however, remain underrepresented in several health professions, despite longstanding efforts to increase the diversity of the healthcare field. 12

Additional research has found that physicians from groups underrepresented in the health professions are more likely to serve minority and economically disadvantaged patients. It has also been found that Black and Hispanic physicians practice in areas with larger Black and Hispanic populations than other physicians do. 13

Gender diversity is also important. Women currently account for three-quarters of full-time, year-round healthcare workers. Although the number of men who are dentists or veterinarians has decreased over the past two decades, men still make up more than half of dentists, optometrists, and emergency medical technicians/paramedics, as well as physicians and surgeons earning over $100,000. 14

Women working as registered nurses, the most common healthcare occupation, earn on average $66,000. Women working as nursing, psychiatric, and home health aides, the second most common healthcare occupation, earn only $27,000. 14

The impact of unequal gender distribution in the healthcare workforce is observed in the persistence of gender inequality in heart attack mortality. Most physicians are male, and some may not recognize differences in symptoms in female patients. The fact that gender concordance correlates with whether a patient survives a heart attack has implications for theory and practice. Medical practitioners should be aware of the possible challenges male providers face when treating female heart attack patients. 15

Research has shown that some mental health workforce groups, such as psychiatrists, are more diverse than many other medical specialties, and this diversity has improved over time. However, this diversity has not translated as well to academic faculty or leadership positions for underrepresented minorities. It was found that there was more minority representation among psychiatry residents (16.2%) compared with faculty (8.7%) and practicing physicians (10.4%). This difference results in minority students and trainees having fewer minority mentors to guide them in the profession.

Racial and Ethnic Diversity Among Physicians

Diversification of the physician workforce has been a goal for several years and could improve access to primary care for underserved populations and address health disparities. Family physicians’ race/ethnicity has become more diverse over time but still does not reflect the national racial and ethnic composition. 16 , vi

Racial and ethnic distribution of all active physicians (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due (more...)

• In 2019, White people were 60% of the U.S. population and approximately 64% of physicians ( Figure 8 ).
• Asian people were about 6% of the U.S. population and approximately 22% of physicians.
• Black people were 12% of the U.S. population but only 5% of physicians.
• Hispanic people were 18% of the U.S. population but only 7% of physicians.
• People of more than race made up about 3% of the U.S. population but less than 2% of physicians.
• AI/AN people and Native Hawaiian/Pacific Islander (NHPI) people accounted for 1% or less of the U.S. population and 1% or less of physicians (data not shown).

Preventive care, including screenings, is key to reducing death and disability and improving health. Evidence has shown that patients with providers of the same gender have higher rates of breast, cervical, and colorectal cancer screenings. 17

Physicians by race/ethnicity and sex, 2018. Key: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian/Pacific Islander. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working (more...)

• In 2018, among Black physicians, females (53.0%) constituted a larger percentage than males (47.0%) ( Figure 9 ).
• Among White physicians, 65.5% were male.
• Among Asian physicians, 55.7% were male.
• Among AI/AN physicians, 60.1% were male.
• Among Hispanic physicians, 59.5% were male.

White physicians by age and sex, 2018. Note : Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, among White physicians, males were the vast majority of those age 65 years and over (79.3%) and of those ages 55–64 years (71.5%) ( Figure 10 ).
• A little more than half of White physicians age 34 and younger were females (50.6%).
• Among White physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

Black physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, among Black physicians under age 55, females made up a larger percentage of the workforce than males. This percentage decreased with increasing age ( Figure 11 ).
• Females were 44.2% of Black physicians ages 55–64 and 34.9% of Black physicians age 65 and over.

Asian physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, among Asian physicians, males were the vast majority of those age 65 years and over (72.7%) and of those ages 55–64 years (66.3%) ( Figure 12 ).
• Among Asian physicians age 34 and younger, there were more females (52.0%) than males (48.0%).
• Among Asian physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

American Indian or Alaska Native physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, (more...)

• In 2018, among AI/AN physicians, males were the vast majority of those age 65 years and over (73.2%) and of those ages 55–64 years (62.6%) ( Figure 13 ).
• Among AI/AN physicians age 34 and younger, there were more females (57.9%) than males (42.1%).
• Among AI/AN physicians age 45 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

Hispanic physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, most Hispanic physicians age 65 years and over (77.5%) and ages 55–64 years (67.5%) were males ( Figure 14 ).
• Among Hispanic physicians age 34 and younger, there were more females (55.3%) compared with males (44.7%).
• Among Hispanic physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

Racial and Ethnic Diversity Among Dentists

The racial and ethnic diversity of the oral healthcare workforce is insufficient to meet the needs of a diverse population and to address persistent health disparities. 18 However, among first-time, first-year enrollees in dental school, improved diversity has been observed. The number of African American enrollees nearly doubled and the number of Hispanic enrollees has increased threefold between 2000 and 2020. 19 Increased diversity among dentists may improve access and quality of care, particularly in the area of culturally and linguistically sensitive care.

Dentists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and Other are non-Hispanic. If estimates for certain racial and ethnic groups meet data suppression criteria, they are recategorized into (more...)

• In 2019, the vast majority of dentists (70%) were non-Hispanic White ( Figure 15 ).
• Asian people, 18%,
• Hispanic people, 6%
• Black people, 5%, and
• Other (multiracial and AI/AN people), 1.0%.

Racial and Ethnic Diversity Among Registered Nurses

Ensuring workforce diversity and leadership development opportunities for racial and ethnic minority nurses must remain a high priority in order to eliminate health disparities and, ultimately, achieve health equity. 20

Registered nurses by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and (more...)

• In 2019, the vast majority of RNs (69%) were non-Hispanic White ( Figure 16 ).
• Black people, 11%,
• Asian people, 9%,
• Hispanic people, 8%,
• Multiracial people, 2%, and
• Other (AI/AN and NHPI people), 1%.

Racial and Ethnic Diversity Among Pharmacists

Most healthcare diagnostic and treating occupations such as pharmacists, physicians, nurses, and dentists are primarily White while healthcare support roles such as dental assistants, medical assistants, and personal care aides are more diverse. To decrease disparities and enhance patient care, racial and ethnic diversity must be improved on all levels of the healthcare workforce, not just in support roles. 21

Progress has been made toward increased racial and ethnic diversity, but more work is needed. As Bush notes in an article on underrepresented minorities in pharmacy school, “If we are determined to reduce existing healthcare disparities among racial, ethnic, and socioeconomic groups, then we must be determined to diversify the healthcare workforce.” 22

Pharmacists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the exclusion of groups (more...)

• In 2019, the vast majority of pharmacists (65%) were non-Hispanic White ( Figure 17 ).
• Asian people, 20%,
• Black people, 7%,
• Hispanic people, 5%, and
• Multiracial people, 2%.

Racial and Ethnic Diversity Among Therapists

Occupational therapists, physical therapists, radiation therapists, recreational therapists, and respiratory therapists are classified as health diagnosing and treating practitioners. Hispanic people are significantly underrepresented in all of the occupations in the category of Health Diagnosing and Treating Practitioners. Among non-Hispanic people, Black people are underrepresented in most of these occupations.

Asian people are underrepresented among speech-language pathologists, and AI/AN people are underrepresented in nearly all occupations. To the extent they can be reliably reported, data also show that NHPI people are underrepresented in all occupations in the Health Diagnosing and Treating Practitioners group. 21

Therapists include occupational therapists, physical therapists, radiation therapists, recreational therapists, respiratory therapists, speech-language pathologists, exercise physiologists, and other therapists.

Therapists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the exclusion (more...)

• In 2019, the vast majority of therapists (74%) were non-Hispanic White ( Figure 18 ).
• Black people, 8%,
• Asian people, 8%,
• Hispanic people, 8%, and

Racial and Ethnic Diversity Among Advanced Practice Registered Nurses

The adequacy and distribution of the primary care workforce to meet the current and future needs of Americans continue to be cause for concern. Advanced practice registered nurses are increasingly being used to fill this gap but may include clinicians in areas beyond primary care, such as clinical nurse specialists, nurse-midwives, and nurse anesthetists.

Advanced practice registered nurses are registered nurses educated at the master’s or post-master’s level who serve in a specific role with a specific patient population. They include certified nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and certified nurse-midwives.

While physicians continue to account for most of the primary care workforce (74%) in the United States, nurse practitioners represent nearly one-fifth (19%) of the primary care workforce, followed by physician assistants, accounting for 7%. 23

Nurse practitioners provide an extensive range of services that includes taking health histories and providing complete physical exams. They diagnose and treat acute and chronic illnesses, provide immunizations, prescribe and manage medications and other therapies, order and interpret lab tests and x rays, and provide health education and supportive counseling.

Nurse practitioners deliver primary care in practices of various sizes, types (e.g., private, public), and settings, such as clinics, schools, and workplaces. Nurse practitioners work independently and collaboratively. They often take the lead in providing care in innovative primary care arrangements, such as retail clinics. 24

Advanced practice registered nurses by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the vast majority of advanced practice registered nurses (78 %) were non-Hispanic White ( Figure 19 ).
• Asian people, 6%,
• Hispanic people, 6%, and

Racial and Ethnic Diversity Among Emergency Professionals

Workforce diversity can reduce communication barriers and inequalities in healthcare delivery, especially in settings such as emergency departments, where time pressure and incomplete information may worsen the effects of implicit biases. The racial and ethnic makeup of the paramedic and emergency medical technician workforce indicates that concerted efforts are needed to encourage students of diverse backgrounds to pursue emergency service careers. 25

Emergency medical technicians and paramedics by race (left), and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages do not add to 100 due to rounding. In addition, (more...)

• In 2019, the vast majority of emergency medical technicians (EMTs) and paramedics (72%) were non-Hispanic White ( Figure 20 ).
• Hispanic people, 13%
• Asian people, 3%,

Racial and Ethnic Diversity Among Other Health Practitioners

Other health practitioners include physician assistants, medical assistants, dental assistants, chiropractors, dietitians and nutritionists, optometrists, podiatrists, and audiologists, as well as massage therapists, medical equipment preparers, medical transcriptionists, pharmacy aides, veterinary assistants and laboratory animal caretakers, phlebotomists, and healthcare support workers.

Other health practitioners by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the distribution of other health practitioners closely aligned with the racial and ethnic distribution of the U.S. population ( Figure 21 ).
• In 2019, 58% of other health practitioners were non-Hispanic White.
• In 2019, Hispanic people accounted for 20% of other health practitioners.
• Black people, 12%,
• Asian people, 7%,

Racial and Ethnic Diversity Among Physician Assistants

Physician assistants (PAs) are included in the Other Health Practitioners workforce group but are highlighted because they play a critical role in frontline primary care services in many settings, especially medically underserved and rural areas. With the demand for primary care services projected to grow and PAs’ roles in direct care, understanding this occupation’s racial and ethnic diversity is important.

Studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, and patient and staff satisfaction. These providers can also enhance the educational experience of residents and fellows. 26 However, a lack of workforce diversity has detrimental effects on patient outcomes, access to care, and patient trust, as well as on workplace experiences and employee retention. 27

Physician assistants by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the vast majority of physician assistants (73%) were non-Hispanic White ( Figure 22 ).
• Black people, 6%,
• Multiracial people, 3%, and

Racial and Ethnic Diversity Among Other Health Occupations

Other health occupations include veterinarians, acupuncturists, all other healthcare diagnosing or treating practitioners, dental hygienists, and licensed practical and licensed vocational nurses.

Other health occupations by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the vast majority of staff in other health occupations (61%) were non-Hispanic White ( Figure 23 ).
• Black people, 19%,
• Hispanic people, 11%
• Asian people, 6 %,

Racial and Ethnic Diversity Among Health Technologists

Health technologists include clinical laboratory technologists and technicians, cardiovascular technologists and technicians, diagnostic medical sonographers, radiologic technologists and technicians, magnetic resonance imaging technologists, nuclear medicine technologists and medical dosimetrists, pharmacy technicians, surgical technologists, veterinary technologists and technicians, dietetic technicians and ophthalmic medical technicians, medical records specialists, and opticians (dispensing), miscellaneous health technologists and technicians, and technical occupations.

Health technologists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the (more...)

• In 2019, the vast majority of health technologists (63%) were non-Hispanic White ( Figure 24 ).
• Black people, 14%,
• Hispanic people, 13%,
• Asian people, 8%, and

Racial and Ethnic Diversity Among Healthcare Aides

Healthcare aides include nursing, psychiatric, home health, occupational therapy, and physical therapy assistants and aides.

Healthcare aides by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and (more...)

• In 2019, 41% of healthcare aides were non-Hispanic White ( Figure 25 ).
• Black people, 32%,
• Hispanic people, 18%,

Racial and Ethnic Diversity Among Psychologists

The United States has an inadequate workforce to meet the mental health needs of the population, 28 , 29 , 30 and it is estimated that in 2020, nearly 54% of the U.S. population age 18 and over with any mental illness did not receive needed treatment. 31 This unmet need is even greater for racial and ethnic minority populations. Nearly 80% of Asian and Pacific Islander people, vii 63% of African Americans, and 65% of Hispanic people with a mental illness do not receive mental health treatment. 29 , 32 , 33 , 34

These gaps in mental health care may be attributed to a number of reasons, including stigma, cultural attitudes and beliefs, lack of insurance, or lack of familiarity with the mental health system. 35 , 36 , 37 However, a significant contributor to this treatment gap is the composition of the workforce.

The current mental health workforce lacks racial and ethnic diversity. 34 , 38 Research has shown that racial and ethnic patient-provider concordance is correlated with patient engagement and retention in mental health treatment. 39 In addition, racial and ethnic minority providers are more likely to serve patients of color than White providers. 34 , 36

Among psychologists, a key practitioner group in the mental health workforce, 37 , 40 minorities are significantly underrepresented. Psychologists in the United States are predominantly non-Hispanic White, while all racial and ethnic minorities represented only about one-sixth of all psychologists from 2011 to 2015.

Reducing the serious gaps in mental health care for racial and ethnic minority populations will require a significant shift in the workforce. Workforce recruitment, training, and education of more racially, ethnically, and culturally diverse practitioners will be essential to reduce these disparities.

Psychologists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Psychologists include practitioners of general psychology, developmental and child (more...)

• In 2019, the vast majority of psychologists (79%) were non-Hispanic White ( Figure 26 ).
• Hispanic people,10%,
• Asian people, 4%, and
• Multiracial people, 2.0%.

Although the outpatient substance use treatment field has seen an increase in referrals of Black and Hispanic clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients. 41

Substance abuse and behavioral disorder counselors by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Key: AI/AN = American Indian/Alaska Native. Note: White, Black, Asian, AI/AN, and >1 Race are non-Hispanic. (more...)

• In 2019, the majority of substance abuse and behavioral disorder counselors (58%) were non-Hispanic White ( Figure 27 ).
• Black people, 18%,
• Hispanic people, 16 %,
• Asian people, 4%,
• AI/AN people, 1%.
• Overview of Healthcare Expenditures in the United States
• Hospital care expenditures grew by 6.2% to $1.2 trillion in 2019, faster than the 4.2% growth in 2018.
• Physician and clinical services expenditures grew 4.6% to $772.1 billion in 2019, a faster growth than the 4.0% in 2018.
• Prescription drug spending increased by 5.7% to $369.7 billion in 2019, faster than the 3.8% growth in 2018.
• In 2019, the federal government (29%) and households (28%) each accounted for the largest shares of healthcare spending, followed by private businesses (19%), state and local governments (16%), and other private revenues (7%). Federal government spending on health accelerated in 2019, increasing 5.8% after 5.4% growth in 2018.

Personal Healthcare Expenditures

“Personal healthcare expenditures” measures the total amount spent to treat individuals with specific medical conditions. It comprises all of the medical goods and services used to treat or prevent a specific disease or condition in a specific person. These include hospital care; professional services; other health, residential, and personal care; home health care; nursing care facilities and continuing care retirement communities; and retail outlet sales of medical products. 43

Distribution of personal healthcare expenditures by type of expenditure, 2019. Key: CCRCs = continuing care retirement communities. Note: Percentages do not add to 100 due to rounding. Personal healthcare expenditures are outlays for goods and services (more...)

• In 2019, hospital care expenditures were $1.192 trillion, nearly 40% of personal healthcare expenditures ( Figure 28 ).
• Expenditures for physician and clinical services were $772.1 billion, almost one-fourth of personal healthcare expenditures.
• Prescription drug expenditures were $369.7 billion, 10% of personal healthcare expenditures.
• Expenditures for dental services were $143.2 billion, 5% of personal healthcare expenditures.
• Nursing care facility expenditures were $172.7 billion and home health care expenditures were $113.5 billion, 5% and 4% of personal healthcare expenditures, respectively.

Personal healthcare expenditures, by source of funds, 2019. Note: Data are available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Personal healthcare (more...)

• In 2019, private insurance accounted for 33% of personal healthcare expenditures, followed by Medicare (23%), Medicaid (17%), and out of pocket (13%) ( Figure 29 ).
• Private insurance accounted for 37% of hospital, 40% of physician, 15% of home health, 10% of nursing home, 43% of dental, and 45% of prescription drug expenditures.
• Medicare accounted for 27% of hospital, 25% of physician, 39% of home health, 22% of nursing home, 1.0% of dental, and 28% of prescription drug expenditures.
• Medicaid accounted for 17% of hospital, 11% of physician, 32% of home health, 29% of nursing home, 10% of dental, and 9% of prescription drug expenditures.
• Out-of-pocket payments accounted for 3% of hospital, 8% of physician, 11% of home health, 26% of nursing home, 42% of dental, and 15% of prescription drug expenditures.

Prescription drug expenditures, by source of funds, 2019. Note: Data are available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Percentages do (more...)

• Private health insurance companies accounted for 44.5% of retail drug expenses ($164.6 billion in 2019).
• Medicare accounted for 28.3% of retail drug expenses ($104.6 billion).
• Medicaid accounted for 8.5% of retail drug expenses ($31.4 billion).
• Other health insurance programs accounted for 3.0% of retail drug expenses ($11.0 billion).

Other third-party payers had the smallest percentage of costs (1.2%), which represented $4.3 billion in retail drug costs.

• Variation in Healthcare Quality

State-level analysis included 182 measures for which state data were available. Of these measures, 140 are core measures and 42 are supplemental measures from the National CAHPS Benchmarking Database (NCBD), which provides state data for core measures with MEPS national data only.

The state healthcare quality analysis included all 182 measures, and the state disparities analysis included 108 measures for which state-by-race or state-by-ethnicity data were available. State-level data are also available for 136 supplemental measures. These data are available from the Data Query tool on the NHQDR website but are not included in data analysis.

State-level data show that healthcare quality and disparities vary widely depending on state and region. Although a state may perform well in overall quality, the same state may face significant disparities in healthcare access or disparities within specific areas of quality.

Overall quality of care, by state, 2015–2020. Note: All state-level measures with data were used to compute an overall quality score for each state based on the number of quality measures above, at, or below the average across all states. States (more...)

• Some states in the Northeast (Maine, Massachusetts, New Hampshire, and Rhode Island), some in the Midwest (Iowa, Minnesota, North Dakota, and Wisconsin), two states in the West (Colorado and Utah), and North Carolina and Kentucky had the highest overall quality scores.
• Some Southern and Southwestern states (District of Columbia, viii Florida, Georgia, New Mexico, and Texas), two Western states (California and Nevada), some Northwestern states (Montana, Oregon, Washington, and Wyoming), and New York and Alaska had the lowest overall quality scores.
• More information about the measures and data sources included in the creation of this map can be found in Appendix C .
• More information about healthcare quality in each state can be found on the NHQDR website, https://datatools ​.ahrq.gov/nhqdr .
• Variation in Disparities in Healthcare

The disparities map ( Figure 32 ) shows average differences in quality of care for Black, Hispanic, Asian, NHPI, AI/AN, and multiracial people compared with the reference group, non-Hispanic White or White people. States with fewer than 50 data points are excluded.

Average differences in quality of care for Black, Hispanic, Asian, Native Hawaiian/Pacific Islander, American Indian or Alaska Native, and multiracial people compared with White people, by state, 2018–2019. Note: All measures in this report that (more...)

• Some Western and Midwestern states (Idaho, Iowa, Kansas, Montana, Nevada, New Mexico, Oregon, Utah, and Washington), several Southern states (Kentucky, Mississippi, Virginia, and West Virginia), and Maine had the fewest racial and ethnic disparities overall.
• Several Northeastern states (Massachusetts, New York, and Pennsylvania), two Midwestern states (Illinois and Ohio), two Southern States (Louisiana and Tennessee), and Texas had the most racial and ethnic disparities overall.

Major updates made to three data sources since 2018, specifically the Medical Expenditure Panel Survey, Healthcare Cost and Utilization Project, and National Health Interview Survey, have had an outsized impact on what the 2021 NHQDR can include. Trend data were provided in prior versions of the NHQDR but were not directly comparable for almost half of the core measures at the time this report was developed. Therefore, the 2021 NHQDR does not include a summary figure showing all trend measures or all changes in disparities. The report includes summary figures for trends and change in disparities for some populations and the results for individual measures.

More information on providers that may be eligible to become CAHs and the criteria a Medicare-participating hospital must meet to be designated by CMS as a CAH can be found at https://www ​.cms.gov/Medicare ​/Provider-Enrollment-and-Certification ​/CertificationandComplianc/CAHs .

All the criteria for a Medicare-participating hospital to be designated by CMS as a CAH can be found at https://www ​.cms.gov/Medicare ​/Provider-Enrollment-and-Certification ​/CertificationandComplianc/CAHs .

The most recent data year available is 2018 from the Association of American Medical Colleges, the current source for workforce data broken down by both race/ethnicity and sex.

The National Survey on Drug Use and Health at the Substance Abuse and Mental Health Services Administration combines data for Asian and Pacific Islander populations, which include Native Hawaiian populations.

For purposes of this report, the District of Columbia is treated as a state.

This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated.

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The Best Health Care? America & the World

Part 1 of 7

Is U.S. health care the best or ‘least effective’ system in the modern world?

By William Brangham, Jason Kane

What the U.S. can learn from Australia’s hybrid health care system

How Switzerland delivered health care for all — and kept its private insurance

Should U.S. look to UK’s single-payer National Health Service for next health care moves?

What universal health care means during a pandemic

With health care a top issue for voters, what do Biden and Trump propose?

Preview: The Best Health Care? America & the World

By PBS NewsHour

Quiz: What does health care cost around the world?

By Laura Santhanam

COVID-19 has eroded confidence in the U.S. health care system

How Canada got universal health care and what the U.S. could learn

How laid-off Americans may ‘fall through the cracks’ of the health care system during COVID-19

By Courtney Vinopal

Health care in rural America was already fragile. Can it survive COVID-19?

• Copy URL https://www.pbs.org/newshour/series/the-best-health-care-america-the-world

Amid the election-year debate over the future of health care in America, the PBS NewsHour explores the state of the U.S. health care system and how it compares to others worldwide.

United States

Houston, Texas, represents the two poles of health care in America — a hub of medical innovation and cutting-edge clinical care, alongside millions of uninsured Americans suffering from treatable, preventable diseases.

WATCH: Is U.S. health care the best or ‘least effective’ system in the modern world?

QUIZ: What does health care cost around the world? How does the U.S. stack up to the United Kingdom, Switzerland and Australia in terms of health care prices? Take this quiz to see for yourself.

POLL: COVID-19 has eroded confidence in the U.S. health care system Since the pandemic began, more than a third of Americans — 35 percent — feel their health care system is below average worldwide. That’s up from 25 percent in February.

United Kingdom

The United Kingdom is home to the beloved National Health Service, a single-payer system paid for by taxes that covers everyone, but which also leaves some non-critical patients waiting for care.

WATCH: Should U.S. look to UK’s single-payer National Health Service for next health care moves?

Switzerland

Switzerland is often held up as a model for American health care: everyone in the country is covered by a network of competitive private insurance plans. Premiums are expensive, but care is top-tier. And polls show the Swiss love their system.

WATCH: How Switzerland delivered health care for all — and kept its private insurance

Australia has created a successful “hybrid” model: a robust, public system of taxpayer funded health care overlaid with a private insurance market. While younger people are moving away from private insurance, the overall system still achieves universal care and exceptional outcomes.

WATCH: What the U.S. can learn from Australia’s hybrid health care system

When people debate how to fix the broken U.S. system, Canada invariably comes up. Born out of need in a time of economic crisis, Canadian Medicare ensures that if residents receive any form of hospital care, they’re billed nothing.

READ MORE: How Canada got universal health care and what the U.S. could learn

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