Universal Health Coverage: Service coverage index, 2021: ≥80
Population with household expenditures on health > 10% of total household expenditure or income (%), 2015-2021: 4.61%
Population with household expenditures on health > 25% of total household expenditure or income (%), 2015-2021: 0.89%
Source: World health statistics 2025: monitoring health for the SDGs, Sustainable Development Goals. Tables of health statistics by country and area, WHO region and globally. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.
Population coverage for a core set of services, 2021
– Total public coverage: 38.4%
– Primary private health coverage: 52.9%
Source: OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris, doi.org/10.1787/7a7afb35-en.
“Approximately 26 million individuals (7.9% of the U.S. population) were uninsured in 2023. Historically, the uninsured rate was relatively stable from 2008 to 2013 before dropping 6 percentage points by 2016 to 8.6% (Figure 3). This drop in the uninsured rate corresponds with increases in direct-purchase and Medicaid/CHIP coverage, which are associated with the implementation of various provisions of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended), such as the exchanges, premium tax credit, and Medicaid expansion. Since 2016, the uninsured rate slowly increased to 9.2% in 2019 before falling to 7.9% in 2023. This decline corresponds with increases in direct-purchase and Medicaid/CHIP coverage, which were impacted by policies enacted in response to the COVID-19 pandemic.
“The cost of care for the uninsured population is accounted for in multiple spending categories (Figure 1 and Figure 2). Payments made by uninsured individuals for health care services are included in the out-of-pocket total. Any amounts received by providers that help to partially and/or indirectly cover the cost of care for the uninsured are accounted for in corresponding source totals (e.g., Medicare and Medicaid disproportionate share hospital payments are included in program totals).”
Source: Congressional Research Service. In Focus: U.S. Health Care Coverage and Spending. Updated February 19, 2025.
“In 2023, the United States had an estimated population of 330 million individuals. Most of those individuals had private health insurance or were covered under a federal program (such as Medicare or Medicaid). About 7.9% of the U.S. population was uninsured. Individuals (including those who were uninsured), health insurers, and federal and state governments spent approximately $4.6 trillion on various types of health consumption expenditures (HCE) in 2023, which accounted for 16.7% of the nation’s gross domestic product.”
Source: Congressional Research Service. In Focus: U.S. Health Care Coverage and Spending. Updated February 19, 2025.
“• More than half (56%) of U.S. working-age adults were insured all year with coverage adequate to ensure affordable access to care. But there are soft spots requiring policy attention: 9 percent of adults were uninsured, 12 percent had a gap in coverage over the past year, and 23 percent were underinsured, meaning they had coverage for a full year that didn’t provide them with affordable access to heath care.
“• Among adults who were insured all year but underinsured, 66 percent had coverage through an employer, 16 percent were enrolled in Medicaid or Medicare, and 14 percent had a plan purchased in the marketplaces or the individual market.
“• Nearly three of five (57%) underinsured adults said they avoided getting needed health care because of its cost; 44 percent said they had medical or dental debt they were paying off over time.
“• Delaying care has health consequences: two of five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.
“• Nearly half of adults (48%) with medical debt are paying off $2,000 or more; half of those with debt said it stemmed from a hospital stay.”
Source: Sara R. Collins and Avni Gupta, The State of Health Insurance Coverage in the U.S.: Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey (Commonwealth Fund, Nov. 2024). doi.org/10.26099/byce-qc28
“Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. About half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (47%). Among those under age 65, uninsured adults are much more likely to say affording health care costs is difficult (85%) compared to those with health insurance coverage (47%). Additionally, at least six in ten Black adults (60%) and Hispanic adults (65%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more than three times as likely as adults in households with incomes over $90,000 to say it is difficult to afford their health care costs (69% v. 21%). (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)
“When asked specifically about problems paying for health care in the past year, one in four adults say they or a family member in their household had problems paying for care, including three in ten adults under age 50 and those with lower household incomes (under $40,000). Affording health care is particularly a problem for those who may need it the most as one-third of adults who describe their physical health as “fair” or “poor” say they or a family member had problems paying for health care in the past 12 months. Among uninsured adults, half (49%) say they or a family member in their household had problems paying for health care, including 51% of uninsured adults who say they are in fair or poor health.
“The cost of care can also lead some adults to skip or delay seeking services. One-quarter of adults say that in the past 12 months, they have skipped or postponed getting health care they needed because of the cost. The cost of care can also have disproportionate impacts among different groups of people; for instance, women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (28% vs. 21%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.”
Source: Lunna Lopes, Alex Montero, Marley Presiado, and Liz Hamel. Americans’ Challenges With Health Care Costs. KFF. March 1, 2024. Last accessed Nov. 22, 2024.
“Six in ten uninsured adults (61%) say they have skipped or postponed getting health care they needed due to cost. Health insurance, however, does not offer ironclad protection as one in five adults with insurance (21%) still report not getting health care they needed due to cost.
“KFF health polling from March 2022 also looked at the specific types of care adults are most likely to report putting off and found that dental services are the most common type of medical care that people report delaying or skipping, with 35% of adults saying they have put it off in the past year due to cost. This is followed by vision services (25%), visits to a doctor’s offices (24%), mental health care (18%), hospital services (14%), and hearing services, including hearing aids (10%). (Source: KFF Health Tracking Poll: March 2022)”
Source: Lunna Lopes, Alex Montero, Marley Presiado, and Liz Hamel. Americans’ Challenges With Health Care Costs. KFF. March 1, 2024. Last accessed Nov. 22, 2024.
“Adults without insurance were more likely to have unmet need for medical care and prescription drugs due to cost in 2019.
“● In 2019, adults aged 18–64 without insurance (36.3%) were more than three times as likely as those with Medicaid (10.3%) and five times as likely as those with private health insurance (7.3%) to delay or not receive needed medical care due to cost (Table UnmtNd[https://www.cdc.gov/nchs/hus/contents2020-2021.htm#Table-UnmtNd]).
“● Adults aged 18–64 without insurance (18.3%) were twice as likely as those with Medicaid (9.3%) and more than three times as likely as those with private health insurance (4.9%) to not receive needed prescription drugs due to cost in 2019 (Table UnmtNd [https://www.cdc.gov/nchs/hus/contents2020-2021.htm#TableUnmtNd]).”
Source: National Center for Health Statistics. Health, United States, 2020–2021: Annual Perspective. Hyattsville, Maryland. 2023. dx.doi.org/10.15620/cdc:122044
“KFF polling has found that health care costs are a top concern for U.S. adults, and many—even those without debt—make decisions about whether to seek care based on how much it costs and whether they can afford it. This survey finds that those with health care debt are more likely to report delaying or skipping medical care due to costs, though significant shares of those without medical debt also say they or someone in their household has done these things as well. Adults with health care debt are more than twice as likely as those without debt to say they or someone in their family has put off health care they needed due to costs in the past 12 months (64% vs. 28%). Similarly, six in ten (62%) adults with health care debt, compared to about one-third (35%) of those without, say they have relied on home remedies or over-the-counter drugs in the last year instead of going to see a doctor due to costs. Adults with health care debt are also at least twice as likely as those without to say that in the past 12 months, because of the cost, they have skipped a medical test or treatment recommended by a doctor (51% vs. 21%), not filled a prescription, cut pills in half, or skipped doses of a medicine (39% vs. 12%), purchased or tried to purchase medications from outside the U.S. (14% vs. 7%), or obtained leftover medications that were prescribed to another person (12% vs. 5%).
“Overall, about eight in ten (79%) of those with health care debt report taking at least one of these actions in the past 12 months because of the cost, compared to about half (49%) of those without health care debt.”
Source: Lunna Lopes, Audrey Kearney, Alex Montero, Liz Hamel, and Mollyann Brodie. Health Care Debt In The US: The Broad Consequences Of Medical And Dental Bills. KFF. June 16, 2022.
“In the Congressional Budget Office’s projections of health insurance coverage, 92.3 percent of the US population, or 316 million people, have coverage in 2024, and 7.7 percent, or 26 million, are uninsured. The uninsured share of the population will rise over the course of the next decade, before settling at 8.9 percent in 2034, largely as a result of the end of COVID-19 pandemic–related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022. The largest increase in the uninsured population will be among adults ages 19–44. Employment-based coverage will be the predominant source of health insurance, and as the population ages, Medicare enrollment will grow significantly. After greater-than-expected enrollment in 2023, Marketplace enrollment is projected to reach an all-time high of twenty-three million people in 2025.”
Source: Jessica Hale, Nianyi Hong, Ben Hopkins, Sean Lyons, Eamon Molloy, and The Congressional Budget Office Coverage Team. Health Insurance Coverage Projections For The US Population And Sources Of Coverage, By Age, 2024–34. Health Affairs (2024). doi.org/10.1377/hlthaff.2024.00460.
“ In 2023, 25.0 million people of all ages (7.6%) were uninsured at the time of interview. This was lower than, but not significantly different from 2022, when 27.6 million people of all ages (8.4%) were uninsured.
“ In 2023, among adults ages 18–64, 10.9% were uninsured at the time of interview, 23.0% had public coverage, and 68.1% had private health insurance coverage.
“ The percentage of adults ages 18–64 who were uninsured in 2023 (10.9%) was lower than the percentage who were uninsured in 2022 (12.2%).
“ Among children ages 0–17 years, 3.9% were uninsured, 44.2% had public coverage, and 54.0% had private health insurance coverage.
“ The percentage of people younger than age 65 with exchange-based coverage increased from 3.7% in 2019 to 4.8% in 2023.”
Source: Cohen RA, Briones, EM, Martinez ME. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2023. National Center for Health Statistics. 2024. DOI: dx.doi.org/10.15620/cdc/156515.
“• In 2023, most people, 92.0 percent or 305.2 million, had health insurance, either for some or all of the year (Table 1 and Figure 1).
“• In 2023, private health insurance coverage continued to be more prevalent than public coverage, at 65.4 percent and 36.3 percent, respectively.3
“• Of the subtypes of health insurance coverage, employment-based insurance was the most common, covering 53.7 percent of the population for some or all of the calendar year, followed by Medicaid (18.9 percent), Medicare (18.9 percent), direct-purchase coverage (10.2 percent), TRICARE (2.6 percent), and VA and CHAMPVA coverage (1.0 percent).4
“• While the private coverage rate was statistically unchanged between 2022 and 2023, the employment-based coverage rate declined by 0.7 percentage points to 53.7 percent in 2023. At the same time, the rate of direct-purchase coverage increased by 0.3 percentage points to 10.2 percent in 2023.5
“• The 2023 public coverage rate was not statistically different from the rate in 2022. Whereas, Medicare coverage increased by 0.2 percentage points to cover 18.9 percent of people.
“• The uninsured rate for children under the age of 19 increased by 0.5 percentage points to 5.8 percent between 2022 and 2023 (Figure 2).”
Source: Katherine Keisler-Starkey and Lisa N. Bunch, U.S. Census Bureau, Current Population Reports, P60-284, Health Insurance Coverage in the United States: 2023, U.S. Government Publishing Office, Washington, DC, September 2024.
“Age is associated with the likelihood that a person has health insurance coverage, as well as with health coverage type. In general, older adults (aged 65 and older) and children (under the age of 19) are more likely to have health insurance coverage than those aged 19 to 64, in part because their age makes them eligible for certain public health insurance programs. Medicare provides health coverage benefits for most adults aged 65 and older. Children under the age of 19 may qualify for coverage through Medicaid or the Children’s Health Insurance Program (CHIP).13 Since the implementation of the Patient Protection and Affordable Care Act (ACA), children and young adults may receive coverage through a parent or guardian’s plan up to the age of 25.
“For children under the age of 19, the uninsured rate increased 0.5 percentage points to 5.8 percent in 2023. For adults aged 65 and older, the uninsured rate (0.9 percent) was lower in 2023 compared with 2022 (Figure 2).
“There were no statistical changes between 2022 and 2023 for the working-age adult age groups listed in Figure 2; however, uninsured rates differed between the age groups. Among working age adults, those aged 19 to 25 had the highest rate (14.1 percent) uninsured for the entire calendar year of 2023, and those aged 45 to 64 had the lowest (8.6 percent). Overall, the uninsured rate for adults decreased as age increased.”
Source: Katherine Keisler-Starkey and Lisa N. Bunch, U.S. Census Bureau, Current Population Reports, P60-284, Health Insurance Coverage in the United States: 2023, U.S. Government Publishing Office, Washington, DC, September 2024.
“Mark Farrah Associates, which aggregates health insurance data from the National Association of Insurance Commissioners and various other sources, estimated that 189.4 million individuals had private health insurance in the first quarter of 2022.40 Most of these enrollees (124.9 million individuals) were covered under a self-insured group plan; 46.5 million individuals were covered under a fully insured group plan (large and small group).41 A much smaller population (18.0 million individuals) was covered under a nongroup plan, which includes major medical plans offered on and off the health insurance exchanges.42
“Overall, private health insurance enrollment has slightly increased over the past decade (Figure A-1); the total number of enrollees increased by 4.2 million from the first quarter of 2013 to the first quarter of 2022. Over this period, self-insured group plan enrollment increased by 14.2 million individuals, fully insured group plan enrollment decreased by 15.5 million, and nongroup plan enrollment increased by 5.5 million.
“Various factors may have contributed to these changes over time. For example, the rates of employers offering different types of health insurance (i.e., fully insured plans and/or self-insured plans) have fluctuated over time, as have the rates of employees working for employers offering different types of health insurance. In addition, the establishment of the health insurance exchanges and corresponding financial assistance created incentives for eligible individuals to purchase nongroup health insurance.43 Changes in private health insurance enrollment also may relate to broader demographic and economic factors, such as changes in overall population, changes in workforce participation, and consumers’ eligibility for coverage through public programs such as Medicare or Medicaid.”
Source: Fernandez, Bernadette; Forsberg, Vanessa C.; and Rosso, Ryan J. Private Health Insurance: A Primer. CRS R47507. Congressional Research Service: Washington, DC. April 18, 2023, last accessed March 18, 2025.
“While nearly all large firms (firms with 200 or more workers) offer health benefits to at least some workers, small firms (3-199 workers) are significantly less likely to do so. In 2023, 53% of all firms offered some health benefits, similar to the percentage last year (51%).
“Most firms are very small, leading to fluctuations in the overall offer rate, as the offer rates of small firms can vary widely from year to year. Most workers, however, work for larger firms, where the offer rates are high and much more stable. Over ninety percent (94%) of firms with 50 or more workers offer health benefits in 2023. This percentage has remained consistent over the last 10 years. Overall, 91% of workers employed at firms with 3 or more workers are employed at a firm that offers health benefits to at least some of its workers.
“Although the vast majority of workers are employed by firms that offer health benefits, many workers are not covered by their employers. Some are not eligible to enroll (due to factors such as waiting periods or part-time or temporary work status), while others who are eligible choose not to enroll (they may feel the coverage is too expensive, or they may be covered through another source). Overall, at firms that offer coverage, an average of 79% of workers are eligible. Among eligible workers, 75% take up the firm’s offer. Ultimately, 59% of workers at firms that offer health benefits are enrolled in coverage. All of these percentages are similar to those in 2022.
“Among workers at firms offering health benefits, those at firms with a relatively large share of lower-wage workers are less likely to be covered by their own firm than workers at firms with a smaller share of lower-wage workers (42% vs. 61%)3. Similarly, workers at firms with a relatively large share of higher-wage workers are more likely to be covered by their employer’s health benefits than those at firms with a smaller share of higher-wage workers (67% vs. 53%). The share of workers employed at public organizations covered by their own employer (72%) is higher than the shares of workers employed at private for-profit firms (57%) or private non-for-profit firms (57%) covered at their work.
“Across firms that offer health benefits and firms that do not, 53% of all workers are covered by health plans offered by their employer. This is similar to the percentage last year.
Source: Kaiser Family Foundation. Employer health benefits: 2023 annual survey. San Francisco, CA: KFF; Oct. 2023.
“The study sample, which included 897,528 people ages 19–64, was similar to that of the nationally representative American Community Survey and NHIS with respect to the distribution of respondents’ sex, race and ethnicity, and education but was slightly older and had a larger mean household size (appendix exhibit 3).19 We also found that the distribution of insurance coverage as measured in the 2020 NHIS was similar to that of the 2020 Household Pulse Survey, although the Household Pulse Survey produces estimates of non-employer-sponsored insurance coverage that are 3–4 percentage points higher and estimates of uninsurance that are 2–3 percentage points lower than those of the NHIS (appendix exhibit 4).19
“Beginning in early 2021 and continuing through the beginning of 2022, the rate of having any health insurance coverage slowly increased, rising from 87.1 percent during the first week of January 2021 to 89.2 percent in the first week of February of 2022 (exhibit 1). The final data point for insurance coverage represents the survey period from January 26, 2022, to February 7, 2022. Although the unemployment rate steadily declined from 6.8 percent to 4.1 percent from early January 2021 through early February 2022, the rate of employer-sponsored coverage remained relatively flat. The rate of non-employer-sponsored insurance coverage increased from 18.7 percent in early January 2021 to 22.5 percent by early February 2022.”
Source: M. Kate Bundorf, Jessica S. Banthin, Christine Young Kim, and Sumedha Gupta. Employer-Sponsored Coverage Stabilized And Uninsurance Declined In The Second Year Of The COVID-19 Pandemic. Health Affairs 2023 42:1, 130-139
“In 2022, private health insurance enrollment increased at a faster rate compared with 2021, and Medicaid experienced continued strong enrollment growth, all of which contributed to the insured share of the population reaching a historic high of 92.0 percent (exhibit 4).
“During the period 2019–22, Medicaid spending increased 31.0 percent, or 9.4 percent per year, on average, according to our calculations, as enrollment increased by 24.6 percent (about 18 million people) (exhibit 4). Medicaid’s share of national health expenditures increased from 16.4 percent in 2019 to 18.0 percent in 2022. Strong growth in the number of newly insured people, as well as the continuous enrollment requirement from the Families First Coronavirus Response Act of 2020, contributed to strong enrollment and spending growth in the program. However, per enrollee, the growth rate for Medicaid spending averaged 1.7 percent during 2020–22, in part because of large increases in the enrollment of qualifying children and adults, who tend to have lower per enrollee expenditures than disabled and elderly enrollees.9
“Private health insurance spending growth was strong in 2021 and 2022, at 6.3 percent and 5.9 percent, respectively (exhibit 4). During that time, private health insurance enrollment grew by 0.9 percent, on average, with increased Marketplace coverage in both years and increased employer-provided insurance enrollment in 2022 (data not shown). Marketplace enrollment increased partly because of the American Rescue Plan Act of 2021, which expanded subsidies in the Marketplace and lowered premium contributions for certain people.10“
Source: Hartman M, Martin AB, Whittle L, Catlin A; National Health Expenditure Accounts Team. National Health Care Spending In 2022: Growth Similar To Prepandemic Rates. Health Aff (Millwood). Published online December 13, 2023. doi:10.1377/hlthaff.2023.01360
“In 2022, 16.5 million consumers on average were enrolled in insurance plans in the overall individual market, and 13.5 million of these consumers on average were enrolled in plans through the individual exchanges. Our analysis of CMS data shows that enrollment in the overall individual health insurance market—including the individual exchanges—became more concentrated from 2011 through 2022. Specifically, the market became more concentrated from 2011 through 2019, then slightly less concentrated through 2022. Concentration is affected by a number of factors, as noted earlier. For example, health insurance markets can become less concentrated if new issuers enter the market and the market share of existing issuers decreases.
“Three largest issuers. The number of states where at least 80 percent of enrollment in private health insurance was concentrated among the three largest issuers increased from 33 states to 47 states from 2011 through 2019. However, enrollment became less concentrated from 2020 through 2022, when the number decreased to 35 states.
“Single issuer. Further, the number of states where at least 80 percent of enrollment was concentrated in a single issuer increased from 2011 through 2022, from four states to seven states. This number peaked at 12 states in 2019 (see fig. 2 and enclosure for summary statistics by year).25“
Source: US Government Accountability Office. Private Health Insurance: Market Concentration Generally Increased from 2011 through 2022. GAO-25-107194. Washington, DC: GAO, Nov. 14, 2024.
“In 2022, the average annual premiums for employer-sponsored health insurance are $7,911 for single coverage and $22,463 for family coverage. These amounts are each similar to the average premiums in 2021. In contrast to the lack of premium growth in 2022, workers’ wages increased 6.7% and inflation increased 8%.2 This difference may be due to the fact that many of the premiums for 2022 were finalized in the fall of 2021, before the extent of rising prices became clear. As inflation continues to grow at relatively high levels, we could potentially observe a higher increase in average premiums for 2023 than we have seen in recent years.
“The average premium for family coverage has increased 20% over the last five years and 43% over the last ten years [Figure A].
“Covered workers at small and large firms have similar premiums for single coverage ($8,012 vs. $7,873) and family coverage ($22,186 vs. $22,564). The average premiums for covered workers in high-deductible health plans with a savings option (HDHP/SO) are lower than the overall average premiums for single coverage ($7,288) and family coverage ($21,136) [Figure B]. In contrast, the average premiums for covered workers enrolled in PPOs are higher than the overall average premiums for single ($8,272) and family coverage ($23,426). Average premiums for both single coverage and family coverage are relatively high for covered workers in the Northeast and relatively low for covered workers in the South.”
Source: Kaiser Family Foundation. 2022 Employer Health Benefits Survey. San Francisco, CA: KFF; Oct. 27, 2022.
“The Congressional Budget Office estimates that at any given point in 2019, about 12 percent of the population under age 65, or 30 million people, were uninsured—that is, they were not enrolled in a private health insurance plan or a government health program that provides comprehensive major medical coverage. Examining that uninsured population in 2019 reveals groups that were often not reached by current federal programs, subsidies, and other sources of coverage even during a strong economy with historically low unemployment. Those insights will remain important in 2020 and beyond, even though the number of people without health insurance is estimated to increase as a result of the novel coronavirus pandemic, economic changes, and other factors.”
Source: Congressional Budget Office. “Who Went Without Health Insurance In 2019, And Why?” September 2020.
“Public sources constitute just under half of healthcare expenditures in the United States, private third party payer sources about 40%, with the remaining 11% being paid by individuals out of pocket. Even though the proportion of public and private spending on healthcare is roughly comparable, only a minority (36%) of the US population is covered by the public financing system – mainly through Medicare and Medicaid. Currently, the majority of Americans (55%) receive their coverage from private health insurance, with most privately insured individuals obtaining coverage through an employer. Purchasers in the form of health maintenance organizations (HMOs, which provide healthcare services on a prepaid basis through a network of providers) grew rapidly during the 1980s and early 1990s. Their market share has fallen substantially since then, due to a backlash against the tight restrictions put on patients, and preferred provider organizations (PPOs) have come to dominate the private insurance market. These contract with a network of providers, but they tend to pay physicians on a fee-for-service basis, and make it easier to seek care outside the network. In 2019, among insured employees, 44% were in PPOs and only 26% in HMOs or similar plans. Some 30% were in high-deductible plans with a savings option.
Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.
“One in ten Americans is uninsured. Even among those with coverage, high out-of-pocket costs can be a barrier to receiving timely care and medications. Out-of-pocket (OOP) payments (e.g. direct payment by consumers for health services, coinsurance, co-payments, and deductible amounts) per capita have increased substantially in real terms in recent years. However, because of the growth in overall health expenditure, the percentage that OOP spending represents as a proportion of total health expenditure has decreased. Increases in real OOP spending over the last 40 years are not unique to the United States, although it has consistently ranked near the top in OOP spending per capita among high-income countries.
“Payment for health services in the United States depends on the service provided, the type of health provider making the service available, and the funder, as well as the type of facility and geographical location where the service is offered. Given this complexity, payment mechanisms for each type of health service (e.g. inpatient hospital care, prescription drugs) vary widely according to the payer involved. Nevertheless, the United States is considered a leader worldwide in the development and use of innovative payment systems, in an attempt to improve the value of services provided.”
Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.
“As with most aspects of employer-sponsored coverage, it is difficult to generalize about particular service types. Prior to implementation in 2014 of several key coverage requirements under the ACA, states were primarily responsible for determining which services must be covered, and many employers were not subject to these rules if they were self-insured. A key component of the ACA’s policy strategies to increase access to care includes its requirement that all private health plans must cover at minimum a range of preventive services without imposing cost-sharing, a requirement applicable even to firms in the large group market and self-insured firms that employ third-party firms (such as insurers) to perform administrative and payment functions. As of 2014, the ACA also requires all insurers in the individual and small-group markets to provide a minimum set of ‘essential health benefits’, but employers who self-insure are not currently required to offer these benefits, subject only to state requirements in this area, though many choose to do so (Kaiser Family Foundation, 2020a).
“National data are scarce regarding how common it is for particular services to be covered by employer-sponsored plans. In general, though, nearly all employees receive coverage for hospital and doctors’ office visits and prescription drugs, with many firms also offering access to supplemental dental, vision, long-term care and critical illness insurance, though not all firms contribute to the costs of these supplemental plans (Claxton et al., 2019). It should be kept in mind that there are often limits on coverage; deductibles and co-payments are discussed elsewhere in this section. In addition, as healthcare costs have risen, employers have responded by shifting some of the costs of rising premiums to workers in the form of higher deductibles and increased cost-sharing, leading employees in employer-sponsored plans to see the greatest rate of growth for under-insurance (out-of-pocket costs and deductible compared to annual income) in recent years (Commonwealth Fund, 2019).
“One thing that can limit the scope of coverage is utilization management activities (previously called utilization review). These include such things as requiring prior permission to be hospitalized or obtain certain services; second opinions before obtaining reimbursable services; and retrospective reviews after services are already received. Some of these activities, it may be argued, have the potential to reduce unnecessary services, thereby enhancing the quality of care.”
Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.
“Uninsured people have different reasons for not obtaining health insurance. The most common is the cost of health insurance premiums. CBO estimates that roughly one-third of uninsured single adults would have to pay more than 10 percent of their income for health insurance. Uninsured people might not consider insurance to be worth the cost if it requires high deductibles, copayments, or other forms of cost sharing. Alternatively, they might be deterred by the complexity of enrolling in coverage, or they might not be aware that subsidized coverage is available.
“Uninsured people who are eligible for Medicaid or CHIP can generally enroll without paying a premium and would have very low cost sharing in those programs. Again, however, unawareness of their eligibility or the complexity of the enrollment process may prevent them from applying or make it difficult for them to renew their coverage. In addition, recent immigrants may be discouraged from applying for Medicaid coverage for their citizen children because they fear it could prevent them from becoming permanent legal residents.”
Source: Congressional Budget Office. “Who Went Without Health Insurance In 2019, And Why?” September 2020.
“Despite short-term gains owing to the ACA, over the past 20 years the proportion of adults aged 18 to 64 years unable to see a physician owing to cost increased, mostly because of an increase among persons with insurance. In 2017, nearly one-fifth of individuals with any chronic condition (diabetes, obesity, or cardiovascular disease) said they were unable to see a physician owing to cost. In contrast, we found improvements in the proportions receiving 2 clinically indicated preventive services, but worsening for another; little change was observed in the proportions who had received checkups in the prior 2 years.
“Our finding that financial access to physician care worsened is concerning. Persons with conditions such as diabetes, hypertension, cardiovascular disease and poor health status risk substantial harms if they forego physician care. Financial barriers to care have been associated with increased hospitalizations and worse health outcomes in patients with cardiovascular disease and hypertension,14,23 and increased morbidity among patients with diabetes.15,24
“Our results provide important context for understanding the consequences of ACA. The implementation of the ACA’s major coverage provisions in 2014 was associated with a 10 percentage point increase in coverage, and improvements in measures of access to care.25,26 For example, between 2012 and 2014 the proportion of US individuals who reported skipping care because of costs decreased from 43% to 36%, and the number of persons reporting difficulty paying medical bills decreased by 11 million.27 Our findings suggest that these substantial short-term improvements were outweighed by longer-term trends toward reduced affordability. Coverage and access rates were decreasing prior to the ACA28 and improvements from the ACA mostly returned access to levels prevalent in 1998 or left them worse.
“While the absolute proportion of those in the lowest income groups reporting unmet health needs were significantly higher than those in the highest income groups throughout the study period, we note that the lowest income groups experienced the smallest increase in inability to see a physician because of cost. This finding may be explained by substantial yearly increases in Medicaid enrollment that began in 2000.29“
Source: Hawks L, Himmelstein DU, Woolhandler S, Bor DH, Gaffney A, McCormick D. Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017. JAMA Intern Med. 2020 Mar 1;180(3):439-448. doi: 10.1001/jamainternmed.2019.6538. PMID: 31985751; PMCID: PMC6990729.
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Page last updated June 12, 2025 by Doug McVay, Editor.