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The health care system in the United States (U.S.) has evolved over the past half century to be one of the most complex health care delivery systems in the world. It does not provide universal access to all Americans so its utilization is primarily income dependent. The U.S. government has chosen to let private insurance and private enterprise take the lead in the provision of health care with oversight and regulation by federal and state government. At the same time this country has developed the most sophisticated technology in the world for diagnosis, treatment, and ongoing medical care. There has been, essentially, no rationing of health care in this country, unlike other developed nations.
This has led to a system that is indeed a paradox, where some people have access to the system that exceeds their medical need, and others have no access to health care, up to 52 million Americans according to recent estimates. In this country, unlike other nations, there is not one payer of health care, but several, and individual access and utilization of health care is dependent upon the payer.
According to the latest U.S. census report, 55% of Americans were covered by employer-based private insurance. Employers contract with private health insurance companies to provide health care coverage to their employees. The cost of this coverage approaches 30% of the employee's total wages and, over the past few years, employees have been asked to pay a percentage of this cost, known as co-pays, for medical services. In addition, many employers do not start coverage until the employee has been working for 6 months. Finally, employers vary in the range of services that they provide. Some will offer family coverage and some will limit coverage to specific medical services, hospital care only, for example. Individuals who are terminated from employment after a probationary period must be offered the Consolidated Omnibus Budget Reconciliation Act (COBRA), a continuation of their current health care coverage for 18 months. The employee bears the burden of the premium to sustain his/her health care coverage but cannot be terminated from their health care, in spite of termination of the employment. Other than these instances, employer health care coverage has gone unregulated and employers have seen premiums increase steadily each year.
Twenty-seven percent of the American population is covered by government insurance. This includes federal programs such as Medicare (for individuals over 65 years of age) or Medicaid (for individuals living below the poverty level), or individuals who are covered as federal government employees (military or veterans coverage). By far this health care coverage allows the easiest access and utilization of the health care system. In addition this coverage allows for the most oversight of quality and prevention.
Three percent of Americans pay for their own health insurance. This is very costly, and the coverage ranges from catastrophic care only to full medical coverage. Finally, 15% of Americans are uninsured; these vulnerable citizens tend to use emergency rooms only in a medical crisis. Community health centers are available as a safety net for the uninsured, but the presence of these centers around the country is patchy and they are not supported to the level they need to meet this huge demand. They are especially scarce in rural areas. School-based health centers have evolved over the past two decades to serve some of these uninsured children. In summary, Americans have access and utilize health care based on their economic and employment status.
Suggested Reading
Starfield, B. (2000). Is U.S. health really the best in the world? Journal of the American Medical Association, 284(4), 483–485.
US Census Bureau. (2004). Income, poverty and health insurance coverage in the United States: 2003. Washington, D.C.: U.S. Government Printing Office.
Suggested Resources
The US Department of Labor—www.dol.gov/ebsa/consumer_info_health.html: This website has consumer friendly versions of labor laws that protect people from losing health insurance, define the ability of employees to submit for health coverage and allow employers to understand their responsibility in providing health care coverage. It also has several links to other websites that review health benefits and labor implications.
The National Center for Health Statistics—www.nchs.gov: This national database covers the most recent information on health care utilization and access to care.
The National Association of Community Health Centers—www.nachc.org: Community Health Centers are separately funded by private and public monies to provide health care to individuals who are uninsured or underinsured. This website has a regional list of these centers throughout the country.
National Association of School Based Health Centers—www.nasbhc.org: The National Association of School Based Health Centers (NASBHC) links individuals to states that offer School Based Health Centers (SBHCs). SBHCs are a valuable resource in addressing medical needs of children and youth who may be uninsured or underinsured.
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Bearss, N. (2010). Access and Utilization of Health Care. In: Clauss-Ehlers, C.S. (eds) Encyclopedia of Cross-Cultural School Psychology. Springer, Boston, MA. https://doi.org/10.1007/978-0-387-71799-9_4
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