U.S. healthcare coverage can broadly be divided into two main categories: public healthcare (government-funded) andprivate healthcare (privately funded).
The two main publicly funded healthcare programs are Medicare, which provides health services to people over sixty-five years old as well as people who meet other standards for disability, and Medicaid, which provides services to people with very low incomes who meet other eligibility requirements. Other government-funded programs include service agencies focused on Native Americans (the Indian Health Service), Veterans (the Veterans Health Administration), and children (the Children’s Health Insurance Program). A controversial issue in 2011 was a proposed constitutional amendment requiring a balanced federal budget, which would almost certainly require billions of dollars in cuts to these programs. As discussed below, the United States already has a significant problem with lack of healthcare coverage for many individuals; if these budget cuts pass, the already heavily burdened programs are sure to suffer, and so are the people they serve (Kogan 2011).
The U.S. Census (2011) divides private insurance into employment-based insurance and direct-purchase insurance. Employment-based insurance is health plan coverage that is provided in whole or in part by an employer or union; it can cover just the employee, or the employee and his or her family. Direct purchase insurance is coverage that an individual buys directly from a private company.
With all these insurance options, insurance coverage must be almost universal, right? Unfortunately, the U.S. Census Current Population Survey of 2013 shows that 18 percent of people in the United States have no health insurance at all. Equally alarming, a study by the Commonwealth Fund shows that in 2010, 81 million adults were either uninsured or underinsured; that is, people who pay at least 10 percent of their income on healthcare costs not covered by insurance or, for low-income adults, those whose medical expenses or deductibles are at least 5 percent of their income (Schoen, Doty, Robertson, and Collins 2011). The Commonwealth study further reports that while underinsurance has historically been an issue that low-income families faced, today it is affecting middle-income families more and more.
Why are so many people uninsured or underinsured? Skyrocketing healthcare costs are part of the issue. Many people cannot afford private health insurance, but their income level is not low enough to meet eligibility standards for government supported insurance. Further, even for those who are eligible for Medicaid, the program is less than perfect. Many physicians refuse to accept Medicaid patients, citing low payments and extensive paperwork (Washington University Center for Health Policy, n.d.).
Healthcare in the United States is a complex issue, and it will only get more so with the continued enactment of the Patient Protection and Affordable Care Act (PPACA) of 2010. This Act, sometimes called “ObamaCare” for its most noted advocate, President Barack Obama, represents large-scale federal reform of the United States’ healthcare system. The PPACA aims to address some of the biggest flaws of the current healthcare system. It expands eligibility to programs like Medicaid and CHIP, helps guarantee insurance coverage for people with pre-existing conditions, and establishes regulations to make sure that the premium funds collected by insurers and care providers go directly to medical care. It also includes an individual mandate, which requires everyone to have insurance coverage by 2014 or pay a penalty. A series of provisions, including significant subsidies, are intended to address the discrepancies in income that are currently contributing to high rates of uninsurance and underinsurance. In 2012 the U.S. Supreme Court upheld the constitutionality of the PPACA's individual mandate. According to Blumenthal (2014), 20 million people in the United States have gained health insurance under PPACA. This lowers the number of uninsured people to 13 percent.
The PPACA remains contentious. The Supreme Court ruled in the case of National Federation of Independent Businesses v. Sebelius in 2012, that states cannot be forced to participate in the PPACA's Medicaid expansion. This ruling has opened the door to challenges to the PPACA in Congress and the Federal courts, some state governments, conservative groups and independent businesses. A concern to public health officials is fear among some parents that certain vaccines such as the measels, mumps, and rubella (MMR) vaccine are linked to higher risk of autism. According to Uchiyama et al (2007), there is no link between the MMR and autism. However fear of this perceived link pushes some parents to refuse the MMR vaccine for their children.
An additional issue in U.S. healthcare has been the push to legalize marijuana in some states. As of this writing, twenty-three states and the District of Columbia allow the use of medical cannabis (Borgelt 2013). Marijuana reform appears to partly be the repackaging of marijuana from a drug to a "medicine." Medical evidence has demonstrated positive responses in treatment of a variety of illnesses, from some cancers to glaucoma and epilepsy. Concerns regarding cost and long term effects of the PPACA continue to be discussed at various societal levels.