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Population Insurance Coverage For A Core Set Of Healthcare Services* (%) (2017):
Public Coverage: 35.9%; Primary Private Health Coverage: 54.9%; Total: 90.8%

*”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 (2019), Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/4dd50c09-en.
https://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm

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Out-of-Pocket Spending as Share of Final Household Consumption (%) (2017): 2.8%

Source: OECD (2019), Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/4dd50c09-en.
https://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm

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“In this study, many participants indicated that they delayed care due to cost, even though most were insured, consistent with previous work.^12,13 Approximately 45% of respondents noted that they had delayed or avoided any care due to cost in the last 12 months, despite the fact that 86% of individuals in this sample were insured.”

Smith, Kyle T et al. “Access Is Necessary but Not Sufficient: Factors Influencing Delay and Avoidance of Health Care Services.” MDM policy & practice vol. 3,1 2381468318760298. 26 Mar. 2018, doi:10.1177/2381468318760298
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125037/

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“The United States is the only country of the ten that has substantial OOP costs due to direct payments resulting from uninsurance. However, these costs have almost certainly gone down during the Obama administration because many people obtained coverage under the Affordable Care Act (ACA), which expanded the scope of the Medicaid program for the poor in many states and mandated people not covered elsewhere to insure themselves through insurance exchanges. As a result uninsurance among the adult population age 18 and older dropped from 17.1% in 2013 to 11.0% in 2016 [19]. (The rate is closer to 9% when the entire population is included since children’s uninsurance rates are lower.) Still, many Americans lack insurance coverage and pay for all costs out of pocket.

“Unlike other high-income countries, Americans receive insurance benefits through a number of sources: employers, Medicare (seniors and the disabled), Medicaid (low-income persons and some disabled), and through individual coverage, some of which is purchased from private insurers in the ACA’s insurance exchanges. OOP payments are best considered within each of the main coverage types.

” • Medicaid covers a very wide scope of services and this coverage is deep, with minimal cost sharing requirements. As noted, the breadth of program coverage has risen dramatically in recent years, particularly due to expansion under the ACA, doubling from 35 million people in 2000 to 70 million in 2016. One of the main problems is that physician payment rates are so low in some states that it is difficult for program enrolees to find primary care and specialist physicians to treat them.

” • The breadth of Medicare coverage is nearly universal in the age 65+ population; the program covers many disabled people as well. Since 2006, with the implementation of prescription drug benefits, nearly all types of services are covered. Depth of coverage is relatively low with coinsurance rates as high as 20% for physician services and no out-of-pocket ceiling. As a result, 86% of Medicare beneficiaries have supplemental coverage [20] to pay for many coverage gaps. Sources include subsidized coverage from former employers, unsubsidized “Medigap” private insurance coverage (which is mainly complementary), and Medicaid for those with low incomes. Cost sharing requirements change only modestly year to year.

” • Just over half of insured Americans receive coverage through employers. The scope of services covered tends to be broad. However, cost sharing requirements in such plans have risen steeply in recent years. The most dramatic changes have been for deductibles. On average, annual deductibles for employees who are only covering themselves have gone up almost 2.5-fold, from $602 in 2005 to $1478 in 2016. There have also been substantial increases in the maximum OOP costs beneficiaries can incur each year. In 2005, 33% of employees had a maximum of $3000 or more. But in 2016, this had risen to 66%. Depending on the insurer and type of service, employees are also subject to coinsurance or co-payments, but these requirements have been relatively stable over time except for brand-name drugs that are not on an insurer’s formulary. Most employees do not have coverage for dental care and vision services; for those that do, cost sharing requirements changed little over the past 10 years. There is no major market for complementary coverage. The main supplementary coverage is for dental care.

” • Beginning in 2014, individuals have also obtained coverage on the ACA’s insurance exchanges. Deductibles are quite high in the most commonly purchased “Silver” plans, averaging almost $3600 in 2017 [21].

“U.S. cost-sharing has been rising mostly in the employment-based markets. The reasons for rising deductibles are straightforward: they provide a way of moderating premium increases – which have risen much more slowly than deductibles. In view of these deductible increases, the most likely explanation for relatively stable aggregate OOPs shown in Fig. ​Fig.22 is that OOP growth resulting mainly from deductible increases has been compensated (in the aggregate) by lower utilization. A second reason is that the expansion of Medicaid under the ACA has offset some the aggregate effects of the employer and individual market deductible increases since Medicaid has few cost-sharing requirements. Finally, most people who originally obtained coverage on the ACA exchanges were previously uninsured [22], so the ACA resulted in a net reduction in these people’s OOP spending.”

Rice, Thomas et al. “Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries.” BMC health services research vol. 18,1 371. 18 May. 2018, doi:10.1186/s12913-018-3185-8
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5960112/

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“The United States health-care system can be thought of as multiple systems that operate independently and, at times, in collaboration with each other. Powers in the health sector are divided between the federal and state governments. For example, states fund and manage many public health functions, pay part of the cost of Medicaid and shape its organization within that state, and set the rules for health insurance policies that are not covered by self-insured employer plans.

“On the other hand, products such as pharmaceuticals and medical devices are regulated at federal level. Regulations to achieve objectives of quality, access and cost control in health care may be set by public or private entities, at any or all of federal, state or local levels. However, there is relatively limited planning in terms of regulation, with little coordinated system-level planning in the United States in comparison to other countries, although incentives are sometimes used (for example to promote service provision in underserved areas).

“Private sector stakeholders play a stronger role in the US health-care system than in other high-income countries; the private sector led the development of the health insurance system in the early 1930s, with the major federal government health insurance programmes, Medicare and Medicaid, only arriving in the mid-1960s. Medicare provides coverage for seniors and some of the disabled and Medicaid covers health-care services for some of the poor and near-poor. Both public and private payers purchase health-care services from providers subject to regulations imposed by federal, state and local governments as well as by private regulatory organizations.”

Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2013; 15(3): 1– 431. http://www.euro.who.int/en/about-us/partners/observatory/publications/health-system-reviews-hits/full-list-of-country-hits/united-states-of-america-hit-2013

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“The United States spends more on healthcare than any other OECD country, both as a proportion of GDP (16.9%) and per person (USD 10 586). Spending is expected to increase with healthcare as a proportion of GDP forecast to reach 20% by 2030.

“High levels of spending have not translated into people leading longer lives. Life expectancy at birth is two years below the OECD average, and actually declined by over two months between 2012 and 2017. Nevertheless, 88% of the population rate their health positively.

“Hospitals in the United States provide high-quality care on average, reflected for example by relatively few deaths after heart attacks and stroke, and high cancer survival, in particular for breast cancer (90% five-year net survival). There are, however, inequalities in access to services – for example, the share of adults with a health care need visiting a doctor was the second lowest amongst OECD countries.

“Almost three quarters of adults (71%) and 43% of children are either overweight or obese, both among the highest rates across OECD countries. Diabetes prevalence is 10.8%, the third highest in the OECD. Unhealthy diets and low physical activity contribute to these health problems.”

Source: OECD (2019). Health-At-A-Glance 2019: United States: How Does It Compare?
https://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm
https://www.oecd.org/unitedstates/health-at-a-glance-united-states-EN.pdf

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“Even as reformed by the ACA, the US health care system is one of the least, or perhaps the least, efficient and fair among OECD nations. It is challenging to identify another system less equitable, or more wasteful and cumbersome, than the US health insurance system, even as reformed by the ACA. In this light, the best advice for those curious about the ACA’s insurance reforms may be: “never mind.” Still, those nations with robust roles for private health insurance may find some of the ACA’s new structures, such as the health insurance exchanges, consumer protections, and transparency requirements, to offer valuable ideas and experiences. These innovations will require rigorous evaluation, but they may suggest new approaches to protecting consumers and enabling ease and comparability of purchase.”

Source: John E. McDonough (2015) The United States Health System in Transition, Health Systems & Reform, 1:1, 39-51, DOI: 10.4161/23288604.2014.969121
https://www.tandfonline.com/doi/full/10.4161/23288604.2014.969121

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Links for more specific information on:

• Affordable Care Act
• Medicaid
• Medicare
• Veterans Health Administration

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Health Systems Facts is a project of the Real Reporting Foundation, which also sponsors these sites:

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Page last updated May 22, 2020 by Doug McVay, Senior Policy Analyst.