The United States: A system built on fragmentation

Abstract

Abstract Background The United States is effectively a laboratory for ways to produce public goods, such as public health, on the cheap. Its c. 90,000 governments compete for residents, businesses, taxes, development, and jobs while also trying to compensate for the lack of universal health care coverage. They all have structural incentives to provide services as cheaply as possible. The effects are diverse and poorly mapped. They can mean innovation in organizational forms, a different and typically less expensive skill mix among the workers, poor quality, or simple under provision. The exact mix can often be hard to identify. It can also mean extreme responsiveness to funding from higher levels of government such as the states or federal government. Methods A comparative historical analysis (CHA) based on government documents, law, and secondary sources. Results The distinctively expansive scope of US public health actions is largely due to the country’s failure to establish a universal health care system, and the diversity of US public health tasks reflects local adaptation of tens of thousands of governments. This means that public health in the United States retains much of the activity it had in, for example, the UK before the establishment of the US. In particular, and even in states that accepted the Medicaid expansion in the Affordable Care Act (ACA), local public health departments provide a substantial amount of direct care and fill in for gaps in health care provision. Conclusions The US public health system is highly fragmented like the governments that run it, and therefore diverse. Reflecting the failures of the US health care system, it carries out many more tasks that in other countries are seen as health, especially primary, care.