Intended for healthcare professionals

Feature US Healthcare

The complicated, political, expensive, seemingly eternal US healthcare debate explained

BMJ 2019; 367 doi: (Published 10 October 2019) Cite this as: BMJ 2019;367:l5885
  1. Julie Rovner, chief Washington correspondent
  1. Kaiser Health News
  1. Jrovner{at}

In the US, most people get healthcare through either private or government insurance, says Julie Rovner. When countries around the world are committing to universal health coverage, US politicians are as busy arguing about the balance between public and private approaches as they are debating the question of whether everyone should have access to healthcare

The US is once again deep in a debate over the future of its health insurance system—a debate that has waxed and waned for the better part of a century. This is ironic because the US doesn’t actually have what one could call a health insurance “system.” Rather, it has a hodgepodge of programmes—public and private—that cover most, but far from all, of its residents. And as the cost of medical services continues to grow faster than most Americans’ incomes, even people with private insurance coverage—which comes with ever increasing expenses in the form of deductibles and co-payments—are finding the cost of care becoming more than they can afford. That’s true for the government funded health insurance programme for the elderly and disabled as well.

Fundamentally, this century long debate is focused on whether healthcare in the US should be directed more by the government or more by market forces and private competition. For decades, Democrats have pushed for more government, while Republicans have maintained that a free market would work more efficiently. Currently, just over half of US healthcare is funded by federal, state, and local governments, with the rest coming from the private sector. That means nobody is truly steering the ship. And no one is very happy about that.

The US is unique among developed countries in that it doesn’t guarantee at least a minimum amount of healthcare to its residents. New statistics from the US Census Bureau show that in …

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