Health System Overview
Political System
Economic System
Population Demographics
Health System Rankings
Health System Outcomes
Health Expenditures
Health System Financing
Coverage and Access
Costs for Consumers
Health System Resources and Utilization
Population Insurance Coverage For A Core Set Of Healthcare Services* (%) (2019):
Public Coverage: 37%; Primary Private Health Coverage: 53%; Total: 90%
*“Population coverage for health care is defined here as the share of the population eligible for a core set of health care services – whether through public programmes or primary private health insurance. The set of services is country-specific but usually includes consultations with doctors, tests and examinations, and hospital care. Public coverage includes both national health systems and social health insurance. On national health systems, most of the financing comes from general taxation, whereas in social health insurance systems, financing typically comes from a combination of payroll contributions and taxation. Financing is linked to ability-to-pay. Primary private health insurance refers to insurance coverage for a core set of services, and can be voluntary or mandatory by law (for some or all of the population.”
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
Annual household out-of-pocket payment, current USD per capita (2019): $1,235
Source: Global Health Expenditure Database. Health expenditure series. Geneva: World Health Organization. Last accessed April 19, 2022.
Out-of-Pocket Spending as Share of Final Household Consumption (%) (2019): 2.9%
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
Percent of Population Who Experienced Access Barrier to Healthcare Because of Cost in Past Year, 2016: 33%
Source: International Commonwealth Fund. Experienced Access Barrier Because of Cost in Past Year, 2016. Source: 2016 Commonwealth Fund International Health Policy Survey. Last accessed Nov. 17, 2019.
“• More people were insured in 2021 than 2020. In 2021, 8.3 percent of people, or 27.2 million, did not have health insurance at any point during the year, representing a decrease in the uninsured rate and number of uninsured from 2020 (8.6 percent or 28.3 million) (Table 1).
“• In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0 percent and 35.7 percent, respectively.3
“• Of the subtypes of health insurance coverage, employer-based insurance was the most common, covering 54.3 percent of the population for some or all of the calendar year, followed by Medicaid (18.9 percent), Medicare (18.4 percent), direct-purchase coverage (10.2 percent), TRICARE (2.5 percent), and VA and CHAMPVA coverage (1.0 percent) (Table 1 and Figure 1).4
“• Overall, public coverage increased between 2020 and 2021. In 2021, 35.7 percent of people held public coverage for some or all of the year, marking a 1.2 percentage-point increase from 2020.
“• Between 2020 and 2021, the rate of Medicaid coverage increased by 0.9 percentage points to cover 18.9 percent of people (Table 1 and Figure 1).5
“• The uninsured rate among children under the age of 19 decreased 0.6 percentage points to 5.0 percent between 2020 and 2021, driven in part by an increase in public coverage (Figure 2).
“• In 2021, 7.9 percent of fulltime, year-round workers had public health insurance, up 1.8 percentage points from 2020. Among less than fulltime, year-round workers, the percentage with public coverage increased 1.6 percentage points to 22.6 percent during this period (Figure 8).”
Source: Katherine Keisler-Starkey and Lisa N. Bunch, U.S. Census Bureau, Current Population Reports, P60-278, Health Insurance Coverage in the United States: 2021, U.S. Government Publishing Office, Washington, DC, September 2022.
“The share of firms offering health benefits to at least some of their workers varies with firm size. Fewer than half of firms with fewer than 50 employees offer coverage in 2022 compared with 93 percent of firms with 50 or more workers and 99 percent of firms with 200 or more workers (data not shown for 200 or more). The offer rate (the percentage of firms where benefits are offered) for firms with fewer than fifty workers in 2022 is lower than in 2021 (47 percent versus 56 percent, respectively) (exhibit 4).
“The vast majority of firms are small: Firms with three to nine workers account for almost 60 percent of all firms, and those with fewer than fifty employees account for 92 percent of firms (data not shown). As a result, the overall firm offer rate is dominated by firms in this size range. However, most workers work for larger firms—77 percent of workers are employed in firms with fifty or more workers in 2022—in which health coverage offer rates are high (exhibit 4). In 2022, 89 percent of workers are employed at a firm that offers health benefits to at least some workers, which is a statistically significant 2-percentagepoint drop from last year (data not shown).
“However, in 2022, only 60 percent of the workers in firms offering health benefits are enrolled in a plan offered by their own firm (similar to the percentage in 2021); of those not enrolled in a plan offered by their own firm, some might not be eligible for coverage, some might not take up an offer, and some may receive benefits from another employer via their spouse (these categories are not mutually exclusive). At firms offering coverage in 2022, only 78 percent of employees are eligible to enroll in a plan, and of those eligible, just 77 percent have taken up the offer. Eligibility and take-up rates vary with firm characteristics (data not shown).”
Source: Anne B. Martin, Micah Hartman, Joseph Benson, Aaron Catlin, and The National Health Expenditure Accounts Team. National Health Care Spending In 2021: Decline In Federal Spending Outweighs Greater Use Of Health Care. Jan. 2023. Published online ahead of print, accessed Dec. 23, 2022. Health Affairs 0 0:0
“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
“Finally, the insured share of the population increased in 2021 to 91.4 percent, as Medicaid and Marketplace enrollment grew (exhibit 6). The number of uninsured people declined for the second consecutive year, to 28.5 million in 2021 compared with 31.2 million in 2020. In 2021, enrollment in Medicaid increased by 11.2 percent (or 8.5 million) (exhibit 6), and Marketplace enrollment increased by 13.4 percent (or 1.4 million) (data not shown). At the same time, Medicare and total private health insurance enrollment grew 1.7 percent and 0.3 percent, respectively, as a decline in employer-sponsored insurance enrollment partially offset the growth in Marketplace enrollment.”
Source: Anne B. Martin, Micah Hartman, Joseph Benson, Aaron Catlin, and The National Health Expenditure Accounts Team. National Health Care Spending In 2021: Decline In Federal Spending Outweighs Greater Use Of Health Care. Health Affairs 0 0:0
“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.
“In 2020, the United States had an estimated population of 326 million individuals. Most of those individuals had private health insurance or received health care services under a federal program (such as Medicare or Medicaid). About 8.6% of the U.S. population was uninsured. Individuals (including those who were uninsured), health insurers, and federal and state governments spent approximately $3.9 trillion on various types of health consumption expenditures (HCE) in 2020, which accounted for 18.8% of the nation’s gross domestic product.”
Source: Congressional Research Service. In Focus: U.S. Health Care Coverage and Spending. Updated April 1, 2022.
“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.
“Out-of-pocket spending (other than premiums) includes all amounts paid by the privately insured and other insured individuals for coinsurance, deductibles, and services not covered by insurance. It also includes any amounts paid by the uninsured for health care goods and services. Among all individuals, out-of-pocket spending totaled $389 billion (9.9% of total HCE) in 2020.”
Source: Congressional Research Service. In Focus: U.S. Health Care Coverage and Spending. Updated April 1, 2022.
Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.
Page last updated Jan. 31, 2023 by Doug McVay, Editor.
