The US Healthcare System: Complex and Unequal


Shaped by the institutions, ideas, and interests that drive American policymaking, the US health care delivery system is uniquely complex, costly, and unequal. Initially private, it has become an increasingly complex public/private mix, as incremental reforms adopted over many decades have sought to correct market failures to finance and deliver health care services to vulnerable populations, particularly segments of the low-income demographic. While successive reforms have led to better coverage and access over time, they are unlikely to lead to universal access due to their inability to reduce, or even contain, costs over the long run.

This is a preview of subscription content, access via your institution.


  1. Agency for Healthcare Research and Quality [AHRQ]. (2015). 2014 National healthcare quality and disparities report. Rockville, MD.

  2. American Hospital Association [AHA]. (2016). Fast facts on U.S. Hospitals. Retrieved from American Hospital Association:

  3. Armstrong, D, & Kishan, S. (2015). Biggest health insurers to get even bigger under Obamacare. Bloomberg. Retrieved from:

  4. ASPE (2016). Impacts of the Affordable Care Act’s Medicaid Expansion on Insurance Coverage and Access to Care. Retrieved from ASPE:

  5. Bohm, K., Schmid, A., Gotze, R., Landwehr, C., & Rothgang, H. (2013). Five types of OECD healthcare systems: empirical results of a deductive classification. Health Policy, 113, 258–269.

    Article  Google Scholar 

  6. Bureau of the Census (1964). Statistical abstract of the United States, 1964. Washington, DC: U.S. Government Printing Office.

    Google Scholar 

  7. Campaign Finance Institute. (2014). CFI releases analysis of money in state elections [Press release]. Washington, D.C.

  8. Campaign Finance Institute. (n.d.-a). Aggregated individual contributions by donors to 2012 presidential candidates. Retrieved from: www.CampaignFinanceInstitute.Org:

  9. Campaign Finance Institute. (n.d.-b). Campaign funding sources: house and Senate major party general election candidates, 1984–2014. Retrieved from: www.CampaignFinanceInstitute.Org:

  10. Campaign Finance Institute. (n.d.-c). Number of registered political action committees: 1976–2014. Retrieved from:

  11. Center for Responsive Politics. (2016). Top spenders. Retrieved from

  12. Center for Responsive Politics. (n.d.). American Hospital Assn. Retrieved from

  13. Centers for Medicare & Medicaid Services [CMS]. (2016a). Delivery systems. From

  14. Centers for Medicare & Medicaid Services. (2016b). Medicaid & CHIP: April 2016 monthly applications, eligibility determinations, and enrollment report. Retrieved from

  15. Centers for Medicare & Medicaid Services. (2016c). Medicare enrollment dashboard. Retrieved from

  16. Centers for Medicare & Medicaid Services. (2016d). National health expenditure projections 2014–2024: Forecast summary. Retrieved from

  17. Centers for Medicare & Medicaid Services. (n.d.). 2013 Medicaid managed care: trends and snapshots 2000–2013. Retrieved from:

  18. Claxton, G., Levitt, L., & Long, M. (2016). Payments for cost sharing increasing rapidly over time. Retrieved from Peterson-Kaiser Health System Tracker:

  19. Cohen, R. A., & Kirzinger, W. K. (2014). Financial burden of medical care: a family perspective. Retrieved from National Center for Health Statistics:

  20. Cohen, R. A., Makuc, D. M., Bilheimer, L. T., & Powell-Griner, E. (2009). Health insurance coverage trends, 1959–2007: estimates from the National Health Interview Survey. Retrieved from National Health Statistics Reports:

  21. Collins, S. R., Gunja, M., Doty, M. M., & Beutel, S. (2016). Americans’ experiences with ACA marketplace and Medicaid coverage: access to care and satisfaction. Retrieved from Commonwealth Fund:

  22. Congressional Budget Office. (2016). Private health insurance premiums and federal policy. Retrieved from

  23. Cunningham, P. J., & May, J. H. (2006). A growing hole in the safety net: physician care declines again. Retrieved from

  24. Davis, K. A., Stremikis, K., Doty, M. M., & Zezza, M. A. (2012). Medicare beneficiaries less likely to experience cost- and access-related problems than adults with private coverage. Health Affairs, 31(8), 1–10.

    Article  Google Scholar 

  25. Donald, J. Trump for President, Inc. (2016). Healthcare reform to make American great again. Retrieved from

  26. Employee Benefit Research Institute. (2002). History of health insurance benefits. Retrieved from:

  27. Englehardt, G. V., & Gruber, J. (2004). Social Security and the evolution of elderly poverty. Retrieved from NBER Working Paper Series:

  28. Federal Election Commission. (2016). Quick answers to PAC questions. Retrieved from Federal Election Commission:

  29. Firth, J.; Kirzinger, A., & Brodie, M. (2016). Kaiser health tracking poll: April 2016. Retrieved from

  30. Gabel, J., Green, M., Call, A., Whitmore, H., Stromberg, S., & Oran, R. (2016). Changes in consumer cost-sharing for health plans sold in the ACA’s insurance marketplaces, 2015 to 2016. Retrieved from Commonwealth Fund:

  31. Galewitz, P. (2016). Study projects sharper increases in Obamacare premiums for 2017. Kaiser Health News.

  32. Garfield, R.; Damico, A., Cox, C., Claxton, G., & Levitt, L. (2016). New estimates of eligibility for ACA coverage among the uninsured. Retrieved from

  33. Gold, M., & Casillas, G. (2014). What do we know about health care access and quality in Medicare Advantage versus the traditional Medicare program? Retrieved from Kaiser Family Foundation:

  34. Grogan, C. M. (2015). The role of the private sphere in US healthcare entitlements: increased spending, weakened public mobilization, and reduced equity. The Forum, 13(1), 119–142.

    Article  Google Scholar 

  35. Hilary for America. (2016). Health Care. Retrieved from

  36. Kaiser Family Foundation [KFF] & Health Research & Educational Trust [HRET]. (2013). 2013 Employer health benefits survey. Retrieved from Kaiser Family Foundation:

  37. Kaiser Family Foundation. (2011). Timeline: history of health reform in the U.S. From Kaiser Family Foundation:

  38. Kocher, R., & Sahni, N. R. (2011). Hospitals’ race to employ physicians: the logic behind a money-losing proposition. New England Journal of Medicine, 364(19), 1790–1793.

    Article  Google Scholar 

  39. La Monica, P. R. (2016). UnitedHealthcare to exit most Obamacare exchanges. CNN Money. Retrieved from:

  40. Long, M., Rae, M., Claxton, G., & Damico, A. (2016). Trends in-employer-sponsored insurance offer and coverage rates, 1999–2014. Retrieved from Kaiser Family Foundation:

  41. Maioni, A. (1998). Parting at the crossroads. Princeton, NJ: Princeton University Press.

    Google Scholar 

  42. Martinez, M. E., Cohen, R. A., & Zammitti, E. P. (2016). Health insurance coverage: early release of estimates from the National Health Interview Survey, Jauary-September 2015. National Center for Health Statistics.

  43. Mashaw, J. L. (2013). Legal, imagined, and real worlds: reflections on National Federation of independent business v. Sebelius. Journal of Health Politics, Policy and Law, 38(2), 255–266.

    Article  Google Scholar 

  44. Medicaid and CHIP Payment and Access Commission [MACPAC]. (2015). MACStats: Medicaid and CHIP data book. From MACPAC:

  45. Minnesota Population Center, University of Minnesota. (2016). Integrated Public Use Microdata Series. Retrieved from IPUMS: CPS:

  46. Muise, R. J., & Yerushalmi, R. J. (2013). Wearing the crown of Solomon? Chief Justice Roberts and the Affordable Care Act “tax”. Journal of Health Politics, Policy and Law, 38(2), 291–298.

    Article  Google Scholar 

  47. Nathan, R. (2005). Federalism and health policy. Health Affairs, 24(6), 1458–1466.

    Article  Google Scholar 

  48. National Center for Children in Poverty. (2016). United States demographics of low-income children. Retrieved from National Center for Children in Poverty:

  49. National Center for Health Statistics [NCHS]. (2013). Health, United States, 2012: with special feature on emergency care. Hyattsville, MD.

  50. National Center for Health Statistics. (2015). Health, United States 2014: with special feature on adults aged 55–64. Hyattsville, MD.

  51. National Center for State Courts (2016). Methods of judicial selection. Retrieved from

  52. OECD (2015). Health at a glance 2015: OECD indicators. Paris: OECD Publishing.

    Google Scholar 

  53. Okma, K. G., & Marmor, T. R. (2015). The United States. In K. Fierlbeck & H. A. Palley (Eds.), Comparative health care federalism (pp. 139–148). Surrey: Ashgate.

    Google Scholar 

  54. Pollitz, K. (2016). Surprise medical bills. Retrieved from Kaiser Family Foundation:

  55. Rice, T. R., Rosenau, P., Unruh, L. Y., Barnes, A. J., Saltman, R. B., & van Ginneken, E. (2013). United States of America: health system review. Health Systems in Transition, 15(3), 1–431.

    Google Scholar 

  56. Rodean, J. (2013). Mitigating the loss of private insurance with public coverage for the under-65 population: 2008 to 2012. Retrieved from United States Census Bureau:

  57. Roosevelt, F. D. (1935). Statement on signing the Social Security Act. Retrieved from The American presidency project:

  58. Schoen, C., Radley, D., Riley, P., Lippa, J., Berenson, J., Dermody, C., & Shih, A. (2013). Health care in the two Americas: findings from the scorecard on state health system performance for Low-Income Populations, 2013. From Commonwealth Fund:

  59. Schoen, C., Solis-Roman, C., Huober, N., & Kelcher, Z. (2016). On Medicare but at risk: a state-level analysis of beneficiaries who are underinsured or facing high total cost burdens. Retrieved from Commonwealth Fund:

  60. Short, K. (2015). The supplemental poverty measure: 2014. Retrieved from U.S. Census Bureau:

  61. Smith, J. C., & Medalia, C. (2015). Health insurance coverage in the United States: 2014. Retrieved from U.S. Census Bureau:

  62. Sparer, M. (2012). Medicaid managed care: costs, access, and quality of care. Retrieved from Robert Wood Johnson Foundation:

  63. Tavernise, S., & Gebeloff, R. (2016). Immigrants, the poor and minorities gain sharply under Affordable Care Act. New York Times. Retrieved from

  64. U.S. Census Bureau. (2015). Historical poverty tables: people and families - 1959 to 2014. Retrieved from:

  65. U.S. Census Bureau. (2016a). CPS Table Creator. Retrieved from U.S. Census Bureau:

  66. U.S. Census Bureau. (2016b). How the Census Bureau measures poverty. Retrieved from United States Census Bureau:

  67. Uberoi, N., Finegold, K., & Gee, E. (2016). Health insurance coverage and the Affordable Care Act, 2010–2016. Retrieved from ASPE:

  68. Weissert, C. S., & Weissert, W. G. (2006). Governing health: the politics of health policy (3rd ed.). Baltimore, MD: Johns Hopkins University Press.

    Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Cheryl A. Camillo.

Additional information

Author Note

Cheryl A. Camillo is an Assistant Professor at the Johnson-Shoyama Graduate School of Public Policy (JSGS) at the University of Regina. Prior to her appointment, she was a Fulbright Fellow at JSGS. She is an interdisciplinary scholar-practitioner with over 25 years of health policy experience, including as a mixed methods researcher, senior federal policymaker, and state program executive. Her research focuses on comparative health and social policies at the national and subnational levels of federal governments.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Camillo, C.A. The US Healthcare System: Complex and Unequal. Glob Soc Welf 3, 151–160 (2016).

Download citation


  • Public/private sector mix
  • Health care delivery systems
  • Health insurance coverage
  • Health care access
  • Low-income population