Health care in the United States is complex, costly, and controversial. Individuals want to maximize their health potential, and as a society we want to ensure equitable access to essential services. Currently, most Americans receive their health coverage through mixed public-private financing: Medicare, for adults over age 65 and certain disabled residents; Medicaid, for low-income adults and children (in the 31 states that choose to expand eligibility); employer-sponsored private insurance; individual private insurance sold on exchanges; and Veterans Health Administration and TRICARE for members of the military. Collectively, these financing sources account for about a third of all U.S. spending in 2022, with most of the rest coming from households and businesses.
The United States spends nearly twice as much per capita on health as average peer nations. Many studies point to higher prices as a major driver, but less is known about how the dollars associated with these higher prices are distributed within the system. Moreover, some individuals may face higher costs than others based on their personal preferences, values, and resources.
An important tenet of market economies is that consumers, in this case patients, benefit from competition among providers who offer a variety of choices and options. This premise assumes that there is adequate information about quality, homogenous products, and large numbers of suppliers and customers (here, health care professionals and patients). These conditions do not always hold in practice.
In some cases, information is insufficient and inconvenient, and in others, the products–the processes and outcomes of medical treatment–are not homogeneous as they apply to unique individuals. Some people also have different values for goods and services, and a lack of agreement about those values leads to conflict.
One of the root causes of these conflicts is a profound disagreement about the nature of healthcare and its role in society. Some see it as a commodity, like any other consumer product or service that some can afford and others cannot; others believe it is a right that the government has a moral obligation to provide to everyone. In between are those who see healthcare as a combination of a commodity and a social good, and would therefore distribute it according to need rather than ability to pay.
A unifying factor, which promotes the value of informed decision making, is transparency in which all parties have meaningful information about cost and quality. This enables responsible parties–individuals, public and private payers, and the clinician community itself–to separate quality problems from those arising from resource availability. It also allows them to use information to improve overall quality rather than simply isolate and punish outliers. This approach can also help bridge the sometimes-conflicting elements of professionalism, regulation, competition, malpractice, and value purchasing. It can reduce inequalities and promote affordability. It is a crucial component of the policy agenda to address high and rising costs and achieve better quality of care. A full discussion of the various approaches is beyond the scope of this article.