The structure and stakeholders of the U.S. health system
It’s essential to understand that the United States does not have a single, unified healthcare system. Instead, it’s a complex ecosystem of public and private entities—Medicare, Medicaid, commercial insurers, hospital systems, pharmaceutical companies, and multiple federal and state regulators.
The United States system is fragmented. Unlike systems in other high-income countries, which often have centralized or publicly administered coverage, the United States relies heavily on a market-based approach—with no universal coverage guarantee.
- For high-level overview: Commonwealth Fund U.S. Profile
- To understand who influences healthcare decisions—including insurers, employers, and government agencies: ISPOR's System Overview
think about this
Who has the most power in shaping what care gets delivered and to whom?
The problem of complexity
Now that you see how many players are involved, ask yourself:
What happens when no one is clearly in charge?
Complexity in the U.S. healthcare system undermines access and affordability. Patients struggle to navigate coverage; clinicians face burdensome administrative tasks, and policy fixes get mired in competing interests.
Complexity isn’t just inefficient—it leads to worse outcomes and deep inequities, especially for people who already face barriers due to race, geography, or income.
How well does the United States system perform?
The United States spends more than any other country on healthcare—by far—but lags behind its peers in many key outcomes.
The Commonwealth Fund’s Mirror, Mirror 2024 report ranks the United States last overall compared to nine other high-income nations on:
- Health outcomes
- Equity
- Access
- Administrative efficiency
And even when it comes to high-need patients—those with chronic illness or social vulnerabilities—the United States underperforms. This shows that spending doesn’t equal value.
Disparities and inequities
Let’s zoom in on how these systemic issues affect different populations. The 2024 Commonwealth Fund report on racial equity paints a stark picture:
Black, Hispanic, and Native American populations consistently experience worse access to care, lower quality of care, and worse outcomes.
These aren’t just isolated failures—they’re tied to structural racism, residential segregation, provider bias, and policy-level neglect, as you’ve learned earlier in this course.
At the same time, the 2023 National Healthcare Quality and Disparities Report offers data-rich insights on how these disparities play out by condition, location, and population group.
Portrait of American Healthcare
Focus on distilling high-level patterns:
- Where we’ve made progress (e.g., cancer mortality).
- Where inequities remain entrenched (e.g., maternal health).
Geography matters: State-by-state variation
The U.S. healthcare system does not perform uniformly. Your experience in one state could be vastly different than in another.
Use the Commonwealth Fund’s 2023 State Scorecard to explore how access, equity, and outcomes vary across the country.
Why do some states excel while others fall behind? How do policy decisions—like Medicaid expansion—affect this? Answer this question in the course’s Slack channel .
What can be done?
You now have a fuller picture of the U.S. healthcare system:
- Complex.
- Fragmented.
- Expensive.
- Deeply inequitable.
- Also capable of innovation and reform.
To synthesize your learning:
- Think about what reform would require: Universal coverage? Payment reform? Cultural humility? Public health integration?
- Complete the Policy Brief Written Assignment via E.Flo MD addressing a key gap you identified.
- Engage in discussion via the Slack channel around a single question: Is the U.S. health system failing everyone—or failing some more than others?