U.S. Health Care System PDF

The U.S. Health Care System The Commonwealth Fund What is the role of government? The Affordable Care Act (ACA), enacted in 2010, established “shared responsibility” between the government, employers, and individuals for ensuring that all Americans have access to affordable and good-quality health...

The U.S. Health Care System The Commonwealth Fund What is the role of government? The Affordable Care Act (ACA), enacted in 2010, established “shared responsibility” between the government, employers, and individuals for ensuring that all Americans have access to affordable and good-quality health insurance. However, health coverage remains fragmented, with numerous private and public sources, as well as wide gaps in insured rates across the U.S. population. The Centers for Medicare and Medicaid Services (CMS) administers Medicare, a federal program for adults 65 and older and some people with disabilities, and works in partnership with state governments to administer both Medicaid and the Children’s Health Insurance Program (CHIP), a conglomeration of federal–state programs for certain low-income populations. Private insurance is regulated mostly at the state level. In 2014, state and federally administered health insurance marketplaces were established to provide additional access to private insurance coverage, with income-based premium subsidies for low- and middle-income people. In addition, states were given the option of participating in a federally subsidized expansion of Medicaid eligibility. Who is covered and how is insurance financed? In 2015, about 67.2 percent of U.S. residents received health coverage through private voluntary health insurance (VHI): 55.7 percent received employer-provided insurance, and 14.6 percent acquired coverage directly. Public programs covered roughly 37.1 percent of residents: Medicare covered 16.3 percent, Medicaid 19.6 percent, direct-purchase 16.3 percent, and military coverage 4.7 percent.1 In the first quarter of 2016, 27.3 million individuals were uninsured, representing 8.6 percent of the population, down from 9.1 percent in 2015.2 The implementation of the ACA’s major coverage expansions in January 2014 has increased the share of the population with insurance. These reforms include: the requirement that most Americans procure health insurance; the opening of the health insurance marketplaces, or exchanges, which offer premium subsidies to lower- and middle- income individuals; and the expansion of Medicaid in many states, which increased coverage for low-income adults. Between 2014 and the start of 2016, the overall rate of health insurance coverage increased for most racial and ethnic groups. Hispanics had the largest increase (6.6 percentage points), followed by Asian Americans (4.8 points), non-Hispanic blacks (3.1 points), and non-Hispanic whites (2.4 points).3 It is projected that the ACA will reduce the number of uninsured by 24 million by 2018.4 However, with the likely repeal of the health law by the new Congress and administration, it is unknown how progress in reducing the uninsured population will be affected. Public programs provide coverage to various, often overlapping, populations. In 2015, more than 10 million Americans were both entitled to Medicare and eligible for Medicaid services (the so-called dual eligibles).5 CHIP, which in some states is an extension of Medicaid and in others a separate program, covered more than 8.1 million children in low-income families in 2015.6 Undocumented immigrants are generally ineligible for public coverage, and nearly two-thirds are uninsured. Hospitals that accept Medicare funds (which are the vast majority) must provide care to stabilize any patient with an emergency medical condition, and several states allow undocumented immigrants to qualify for emergency Medicaid coverage beyond “stabilization” care. Some state and local governments provide additional coverage, such as coverage for undocumented children or pregnant women. International Profiles of Health Care Systems 173