The health system in the United States often appears a confusing, disorganized, costly mixture of services that do not reach all of the people, are of a mixed quality, and place a large financial burden on the recipients of care. Reinforcing this view are newspaper and Congressional reports of unnecessary surgery, incompetent doctors, low quality nursing homes, the uninsured poor who are unable to secure medical or hospital care because they are unable to pay and, finally, accounts of patients whose life savings are wiped out because of costs not covered by their insurance. Efforts to contain costs have led to a decreasing use of health facilities and increasing competition among hospitals and other agencies. These groups often develop new and costly services that duplicate those already in the community which are not fully utilized, and they advertise on television and in the newspapers to capture 'their share of the market'.
Financing of the health system also appears in disarray, with the federal, state, and local governments accounting for less than half of health expenditures, and private health insurance and patients making up the remainder. Moreover, US expenditures for health services amounted to over 10 per cent of the GNP in 1984, the highest in the world.
When trying to understand the US health system, it should be noted that the delivery of health services has been largely in the domain of the state governments and the private sector. The federal government's role in the delivery of services historically has been confined mainly to personnel in the armed forces and their dependents, veterans, American Indians, Alaskan natives, and to a relatively small cadre of other federal beneficiaries such as those in the Coast Guard and the Public Health Service.
The development and operation of hospitals, medical schools, health departments, and other health agencies are largely independent of the federal government. Licensure of health practitioners and hospitals falls within the power of the state governments, as does the provision of the majority of traditional public health functions. The operation of most hospitals and the provision of most medical, nursing, dental and other health care are carried out by institutions and practitioners independently of government. They are financed by a variety of sources-private health insurance which covers about 76 per cent of the population, Medicare, a federal insurance program for those over 65 years of age, Medicaid, a jointly financed federal/state program for the poor, and a federal program for military dependents.
The growing influence of government on the organization and delivery of health services derives primarily from its increasing share of health expenditures rising from 12.8 per cent in 1950 to 28.9 per cent in 1984.