Healthcare Systems in the United States

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The United States stands alone among industrialized nations as the only healthcare system without a nationwide single-payer or state healthcare system. But the United States is far from a homogenous private sector—financed market. Private, employer-based insurance programs insure only 60–65% of the population. Another 20–25% of the population is insured by a combination of social welfare insurance (Medicaid) and societal healthcare (Medicare). Prior to the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, 13% were uninsured. That legislation created a federal marketplace with state involvement where any individual could seek coverage with a government subsidy, if necessary. The objective of the marketplace in conjunction with the individual mandate provision of the ACA was to insure the remaining 47 million Americans who did not have health insurance prior to 2010. Despite the passage of the ACA, equal access to healthcare in the United States remains problematic. Compared to the universal coverage offered in other industrialized nations, the US system has inherent inequities regarding access. It is only through a view of the historical context of the evolution of the current US healthcare system that one can explain the existence of the current system. The focus of this chapter is to present the US healthcare system from its origins at the turn of the nineteenth century, through the initiation of Medicare in the mid-1960s, up to the passage of the ACA in 2010. As the emphasis in the United States shifts from a fee-for-service system to a value proposition defined by quality over cost, the quality assessment reviewed later in this text becomes especially germane in the realm of spine care in any healthcare system.