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Home > Programs & Publications > Issue Fact Sheets > Fact Sheet 2009: The U.S. Health Care System in International Perspective

Fact Sheet 2009





The United States health care system can best be described as a hybrid.  Fifty-four percent of health care spending in 2007 was by private funds, compared to 46% of spending by public programs like Medicare, Medicaid and the State Children’s Health Insurance Program (SCHIP).[1] Most care, even if publically financed, is delivered privately.

In 2009, of the 83.8% of Americans with some type of health care insurance,[2] employers provided health coverage to just over half, at 56.5%.[3]  Twenty-nine percent of insured American adults received coverage through the U.S. government in 2009, up one percentage point from 2008.[4]  Of the 29% of adult Americans covered by government-paid insurance, 20.4% are on Medicare, 4.7% are on Medicaid, and 3.9% were covered by military or veteran’s insurance.[5]  Slightly more than 13% of insured Americans obtained their health care coverage through some other means, including purchasing it privately for themselves*.[6]

Sixteen percent of Americans have no health coverage whatsoever.[7]

Taxes fund coverage for government employees, totaling 19 million in 2006,[8] and for 45 million persons including the elderly (Medicare),[9] the permanently disabled, the very poor (Medicaid), people with end-stage renal disease, and veterans.

The United States and Mexico are the Organisation for Economic Co-operation and Development (OECD) countries where government plays the smallest role in financing health spending.  Such is the level of health spending in the United States, however, that public (i.e., government) spending on health per capita in the U.S. is greater than in all other OECD countries, except Norway and Luxembourg.[10]

Among OECD countries, there are three main types of health care programs:[11]

        A National Health Service, where medical services are delivered via government-salaried physicians, in hospitals and clinics that are publicly owned and operated.  The U.K. and Spain are examples of such a system.

        A National Health Insurance System, or single-payer system, is a health care system in which a single entity, such as a government-run organization, acts as the administrator to collect all health care fees, and pay out all health care costs.  Medical services are publicly financed but not publicly provided.  Examples include Canada, Denmark, Norway, and Sweden.

        A universal Multi-payer Health Insurance System, or all-payer system, as in Germany and France.  These systems provide universal health insurance via sickness funds, which are used to pay physicians and hospitals at uniform rates.  These rates are negotiated annually.

The High Price of Health Care in the U.S.

·         The U.S. spends considerably more on health care than any other OECD country, averaging $5,440 per person in 2002,[12] and climbing to $7,290 in 2007.[13]  Canada spends 47% less, Sweden spends 54% less, and the U.K. spends 59% less per person than the U.S. on health care.[14]  U.S. health care spending per capita was 2.5 times greater than the OECD median of $2,964 in 2007.[15]

·         The U.S. also spends the highest proportion of Gross Domestic Product (GDP) on health care:  16% in 2007, compared to an 8.9% median for OECD member nations.[16]  This is an increase from 14.6% in 2002.[17]

·         Economic cost:  The Institute of Medicine estimated in 2003 that the lack of health insurance among Americans cost society between $65 and $130 billion per year.[18]  These figures take into account lost earnings from premature death among those without health insurance, lower worker productivity from untreated illnesses, and the cost of paying for the increased use of emergency rooms.  In 1970, total health care spending was about $75 billion, or only $356 per person.  In less than 40 years these costs have grown to $2.2 trillion, or $7,421 per person.  As a result, the share of economic activity devoted to health care has grown from 7.2% in 1970 to 16.2% in 2007.  By the year 2018, the Centers for Medicare and Medicaid Services (CMS) projects that health spending will be one-fifth of the GDP (20.3%).[19]

·         Americans pay higher prices for health care-related services than citizens of other countries.  For instance, the average cost of a one-day hospital stay in the U.S. was $2,434 in 2002, compared with $870 in Canada and even less in other OECD countries.[20]  Prices for pharmaceuticals and physician visits are higher, as well.  Even adjusting for per capita GDP, the supply of health care resources, and the added cost of malpractice litigation, a study in Health Affairs finds that Americans pay more for the same or lower quality care.[21]

Administrative Costs in the U.S.

·         According to the Commonwealth Fund Commission on a High Performance Health System in 2007, U.S. health insurance administrative costs as a share of total health spending are 30% to 70% higher than in countries with mixed private-public insurance systems and three times higher than in countries with the lowest rates.[22]  If the U.S. were to reduce health insurance administrative costs to the average level of countries with mixed private-public insurance systems (such as those in Germany, the Netherlands, and Switzerland) it could save up to $51 billion.  If the U.S. reduced costs further, reaching the average administrative costs of the most efficient countries, it could save an estimated $102 billion per year.[23]

·         Compared to private insurers, Medicare and Medicaid have much lower administrative costs of 25%.[24]

·         Private insurers spent 8% of their premiums on billing, marketing and other financial activities; physician offices spent 14% of revenues; and hospitals spent 711% of revenues on these activities.[25]

·         Despite the large investment in administration, the system is inefficient.  In 2007, U.S. patients were three to four times more likely to report having duplicate tests or that medical records or test results were not available at the time of their appointment than patients in other industrialized countries.[26]

·         In 2005, Health Affairs released a study of health insurance costs in California.  It found that $230 billion of health spending was devoted to insurance administration and only 66% of health spending went to medical care.  Twenty-one percent of private health spending went to billing-related tasks, and an additional 13% of spending went to non-billing administrative functions.[27]

·         Recent studies show that if California were to implement single-payer health care, total spending on health care could be reduced by about $8 billion.[28]

High Costs Drive Americans into Debt

·         A 2005 study found that about half those filing for bankruptcy cited medical causes, indicating between 1.9 and 2.2 million Americans (filer plus dependents) experienced medical bankruptcy.[29]  Among those whose illness led to bankruptcy, the average out-of-pocket expenses were nearly $12,000 since the start of the illness.  Nearly 76% had insurance at the start of the illness.[30]

·         A lapse in health insurance coverage during the two years before filing was a strong predictor of a medical bankruptcy.  In 2001, 38.4% of debtors who had a “major medical bankruptcy” had experienced a lapse in coverage.  Sixty percent of debtors initially had private coverage, but one-third of them lost coverage during their illness.[31]

·         Almost 40% of medical bankruptcies came from people who had experienced a gap in coverage over the past two years.[32]

·         Those covered by government programs were less likely to have experienced coverage interruptions.  Only 5.7% of debtors had Medicare, 8.4% had Medicaid, and 1.6% had veterans or military medical coverage.[33]

·         In 2001, 15% of all homeowners who had taken out a second or third mortgage cited medical expenses for the reason.[34]

·         By 2007, two of five adults (41%) reported they had medical debt or problems with medical bills, up from 34% in 2005.[35]  Uninsured debtors and dependents represent 32.6% of people who filed for medical bankruptcies and 33.1% of those who filed for other bankruptcies. [36]

·         People aged 19 to 64 who lacked coverage (35%) had significantly higher rates of medical bill problems and debt than did those with regular health insurance coverage (60%).  To cope with medical debt, 28% had to significantly change their way of life.[37]

Health Insurance:  Rising Premiums, Falling Coverage

·         In 2008, 46.3 million Americans (15.4%) were uninsured.[38]

·         One in three Americans under the age of 65, nearly 90 million people, lacked health insurance at some point during 2006–2007.  This is 17 million more than 1999–2000.[39]

·         Health insurance premiums in the U.S. are rising fast.  Between 1999 and 2009, average annual health insurance premiums for family coverage increased 131%, with worker contributions to those plans increasing 128% in the same period.[40]

·         In 2008, workers paid an average of $3,354 per year out of their paychecks for their share of premiums. Yearly premiums for family health insurance coverage rose to $12,680 in 2008.[41]

·         A growing number of workers face a deductible of $1,000 or more for single coverage.  In 2009, 22% of workers were enrolled in a plan with a general annual deductible of $1,000 or more.[42]  High deductibles are more common for people working for small employers.  In 2009, 40% of workers at firms employing between three and 99 persons paid $1,000 or more for their deductible.[43]


Who Are the Uninsured in America?

·         Hard-working Americans:  In 2007, more than eight in 10 of the uninsured came from working families.  Seventy percent of these families have one or more family members working full-time and 12% have one or more family members working part-time.[44]

·         Union Difference:  In March 2008, 79% of union workers had jobs with employer health coverage, compared to 52% of nonunion workers.[45]

·         Eighty percent of the uninsured are adults.[46]

·         Two-thirds come from low-income families.[47]

·         Sixty-three percent of the non-elderly uninsured population has an education no greater than a high school diploma.[48]

·         Seventy-nine percent of the uninsured are American citizens.  Minorities are more likely to be uninsured than non-Hispanic whites.[49]

Small Firms, Part-Time Workers, and Younger Workers Have Less Coverage

·         Between 2001 and 2005, rates of self-employment, part-time work, temporary or contract work, and employment in smaller businesses went up.  While 2.2 million more workers joined the workforce, 1.8 million have incomes below the Federal Poverty Level.[50]

·         Smaller firms are significantly less likely to provide health benefits.  In 2009, just under half (46%) of firms with three to nine workers offered health insurance to their employees, compared with 72% of firms with 10-24 employees.  Meanwhile 87% of firms with 25-49 employees and 95% of firms with 50 or more employees offered their employees health benefits.[51]

·         Uninsured workers are found in every industry:  Agriculture, service, wholesale and retail trade, manufacturing, and the public sector each have a sizeable portion of uninsured employees.[52]

·         Firms that employ union workers are much more likely to provide health benefits:  Whereas 63% of employers offered health benefits to their employees in 2008, 99% of firms with union workers offered health benefits.[53]  In addition, union workers paid an average flat monthly contribution for medical insurance of $174.60 for family coverage in 2003 and $196.60 in 2006; non-union workers paid $234.35 in 2003 and $308.88 in 2006.[54]

·         In 2008, the percentage of full-time workers without health insurance was 17.2, while 25.4% of part-time workers were without health insurance.[55]

·         Only 23% of all firms offer benefits to part-time workers.  Moreover, firms with a large number of part-time employees, with high employee turnover rates, and with lower overall wage levels, are less likely to offer benefits to any of their employees.  Only 4% of all workplaces offered health insurance to temporary employees.[56]

·         Sixty percent of employers offered health insurance in 2009, which is not statistically different from the 63% reported in 2008.[57]

·         Eighteen to 24 year-olds are most likely to be uninsured:  Nearly 29% were uninsured in 2008.[58]  A Commonwealth Study found that nearly 60% of employers who offer coverage do not insure dependent children over the age of 18 or 19 if they do not attend college.[59]  Twenty-five to 34 year olds were the second most likely age group to be uninsured:  26.5% were without insurance in 2007.[60]

Minorities and Children Have Less Access to Health Insurance

·         Racial and ethnic minorities are disproportionately more likely to be uninsured:  In 2007, 10.8% of whites, 19.1% of African Americans, 17.6% of Asian Americans and 30.7% of Hispanics were uninsured.[61]

·         Such inequalities can be deadly.  The World Health Organization (WHO) found that in the U.S. 886,202 deaths would have been averted between 1991 and 2000, if mortality rates between white and African Americans were equalized.[62]

·         African American adults (35%) are more likely than other groups to report using the emergency room for conditions that could have been treated by a primary care doctor if one had been available, even after factoring in insurance coverage and poverty status.[63]

·         In the past year, 27% of uninsured Hispanic adults with health problems did not visit a doctor, while 17% of white and African American adults did not.[64]

·         According the U.S. Census, 8 million children (10.9%) were uninsured in 2005.  This number increased to 8.7 million (11.7%) in 2006.[65]  However, this rate declined to 8.1 million (11.0%) in 2007 and again declined to 7.3 million (9.9%) in 2008.[66]


Less Coverage Means Fewer Healthy Americans

·         In 2006, 2,616 people between the ages of 25–34 died due to lack of insurance.  From ages 35–44, there were 3,697 deaths due to lack of insurance, from 45–54, there were 6,903 and from 5564 there were 8,995.  While a greater number of young people are uninsured, it appears that larger numbers of older adults without insurance may die because they lack it.[67]

·         The Institute of Medicine (IOM) study estimates that lack of insurance increases the mortality risk for uninsured working-age adults by 25%.[68]

·         Using the IOM’s methodology and Census Bureau estimates on health insurance coverage, the Urban Institute estimates that 137,000 people age 2564 died between 2000 and 2006 due to lack of insurance.  In 2006 alone, 22,000 people died due to lack of insurance.[69]  This represents one death every 24 minutes.[70]

·         In 2003, 43% of adults without health insurance did not seek medical help for health problems, compared with 10% who were insured.  Uninsured individuals with diabetes, HIV, cardiovascular disease, and mental illness have been consistently shown to have less access to preventative care and worse clinical outcomes.  Uninsured car crash victims have been found to have a mortality rate 37% higher than people with insurance, and uninsured women with breast cancer have a 30–50% higher risk of dying.[71]

·         A study based on 2002 hospital discharge data for adults age 18 and older, reported that, after controlling for socioeconomic status and other factors, lack of insurance increased the risk of death by 24% or 56%, depending on the type of stroke a patient suffered.  Additionally, another study found that after controlling for demographic factors, stage of diagnosis, and initial treatment, lack of insurance increased risk of death from lung and female breast cancer by 19% and 44%, respectively.[72]

·         A study using Health and Retirement Survey Data for adults ages 5564 found that after controlling for socioeconomic status and other factors, uninsurance increased such older adults’ risk of dying over an eight-year period by 3%.  Among this age group, the study estimated that 13,000 people die each year from lack of insurance, making it third on the list of leading causes of death after heart disease and cancer.[73]

·         The uninsured are twice as likely to have an unmet medical need because of cost and four times more likely to have an unmet need for prescription drugs.[74]

Quality of U.S. Health Care in an International Context

·         The U.S. ranked 37th out of 191 member states in terms of “overall health system performance” in the World Health Organization’s 2000 World Health Report.  The rankings were based on measures of the health of the population, the level and distribution of respect and attention shown to patients, and the fairness of financial contribution, all in relation to overall health system expenditures.  A ranking of 37th places the U.S. below such countries as Colombia, Saudi Arabia, and Portugal.[75]

·         The U.S. has the seventh highest infant mortality rate of the 30 OECD member countries.  The countries with higher infant mortality than the U.S. are Turkey, Mexico, Romania, Bulgaria, Latvia, and Lithuania.[76]

·         In 2006, the U.S. also had the eighth lowest life expectancy of the OECD member countries.[77]

·         The U.S. ranks lower than the OECD median in both physicians and hospital beds per capita, despite its high level of spending.[78] 

·         Twenty-eight percent of Americans find it is extremely difficult to get care when needed, as compared to 21% of Canadians, 18% of New Zealanders, and 15% of the British.[79]

·         A 2004 study in Health Affairs compared the quality of care in five countries:  the U.S., the U.K., New Zealand, Canada, and Australia.[80]  No country scored consistently best or worst, and each country had at least one best and one worst rating.  The U.S. had the best five-year survival rate for breast cancer, for instance, but the worst survival rate for kidney transplants, and an increasing rate of mortality among asthmatics.

·         The following chart provides a few key statistics from single-payer nations and the United States:





United States

Total Health Expenditure, Per Capita (2007)[81]





Annual Growth Rate of Total Health Expenditure, per Capita (2006–2007) [82]





Life Expectancy At Birth






Infant Mortality

(per 1,000 births, 2008) [84]





Maternal Mortality

(per 100,000 births, 2003)


(data unavailable)







[1]Health Care Costs:  A Primer”, Kaiser Family Foundation, March 2009.

[2] Mendes, Elizabeth and Frank Newport.  “About One in Six Adults Are Without Health Insurance”, Gallup, July 22, 2009.

[3] Mendes, Elizabeth.  “Nearly 30% of Insured have Government Plans, Up from ’08”, Gallup, June 30, 2009.

[4] Ibid.

[5]  Mendes, Elizabeth.  “Nearly 30% of Insured have Government Plans, Up from ’08”, op. cit.

[6] Ibid.

[7] Mendes, Elizabeth and Frank Newport.  “About One in Six Adults Are Without Health Insurance”, op. cit.

[8] U.S. Department of Commerce, Bureau of the Census, “Federal Government Civilian Employment by Function:  December 2006”, December 2006.; U.S. Department of Commerce, Bureau of the Census, “State Government Employment Data:  March 2006”, March 2006.; U.S. Department of Commerce, Bureau of the Census “2006 Public Employment Data:  Local Governments”, December 2006.

[9]Medicare at a Glance”, Kaiser Family Foundation, November 2008.

[10] Pearson, Mark.  Written Statement, Senate Special Committee on Aging. “Disparities in health expenditure across OECD countries:  Why does the U.S. spend so much more than other countries?”, September 30, 2009.

[11] Physicians for a National Health Program, “Health Care SystemsFour Basic Models”, December 2008.; Reid, T.R.  The Healing of America:  A Global Quest for Better, Cheaper, and Fairer Health Care, 2009, New York, Penguin Press.

[12] Reinhart, U.; P. Hussey and G. Anderson, “U.S. Health Care Spending in an International Context”, Health Affairs, 23 (3):10, 2004; Levit, K., et. al., “Health Spending Rebound Continues in 2002”, Health Affairs, 23 (1):147, 2004.

[14]  Ibid.

[15] Anderson, Frogner, and Ruinhardt, “Health spending in OECD Countries in 2004:  An Update”, Health Affairs, 26(5):1481-1489, September/October 2007.

[16] Ibid.

[17] Anderson, G.; P. Hussey; B. Frogner; and H. Waters.  “Health Spending in the United States and the Rest of the Industrialized World”, Health Affairs 24(4):903-915, July/August 2005.

[18] “Hidden Costs, Value Lost:  Uninsurance in America”, Institute of Medicine, Washington, DC, National Academy Press, June 2003.

[19]Health Care Costs:  A Primer”, Kaiser Family Foundation, March 2009.

[20]  Ibid.

[21] Ibid.

[22]Why Not the Best?  Results from the National Scorecard on U.S. Health System Performance, 2008”, The Commonwealth Fund Commission on a High Performance Health System, July 17, 2008.

[23] Ibid.

[24] U.S. Department of Health and Human Services, Brief Summaries of Medicare & Medicaid, by Dirk Hoffman, Barbara Klees and Catherine Curtis, November 1, 2005.

[25] Kahn, James G., Richard Kronick, Mary Kreger, and David N. Gans.  “The Cost Of Health Insurance Administration In California:  Estimates for Insurers, Physicians, and Hospitals”, Health Affairs, November/December 2005; 24(6):1629-1639.

[26]Why Not the Best?  Results from the National Scorecard on U.S. Health System Performance”, op. cit.

[27] Kahn, James G.; Richard Kronick; Mary Kreger and David N. Gans, op. cit.

[28] Sheils, John F. and Randall A. Haught.  “The Health Care for All Californians Act:  Cost and Economic Impacts Analysis”, The Lewin Group, January 15, 2005.

[29] Himmelstein, David U., Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler.  “Illness and Injury as Contributors to Bankruptcy”, Health Affairs, Web exclusive, February 2, 2005; w5-63 – w5-75. 


[30] Ibid.

[31] Ibid.

[32]  Ibid.

[33] Ibid.

[34] Ibid.

[35]Why Not the Best?  Results from the National Scorecard on U.S. Health System Performance”, op. cit.

[36] Physicians for a National Health Program, slide presentation, 2007.

[37] Ibid.

[38] U.S. Department of Commerce, Bureau of the Census. Income, Poverty, and Health Insurance Coverage in the United States:  2008, by Carmen DeNavas-Walt, Bernadette Proctor, and Jessica Smith, September 2009.

[39]Wrong Direction:  One out of Three Americans are Uninsured”, Families USA, September 2007.

[40]Employer Health Benefits 2009 Summary of Findings”, Kaiser Family Foundation, 2009.

[41] Ibid.

[42] Ibid.

[43] Ibid.

[44]The Uninsured:  A Primer”, The Kaiser Family Foundation, October 2008.

[45]The Union Difference:  Union Workers Have Better Health Care and Pensions”, Rep. AFL-CIO, 2008.

[46] “The Uninsured:  A Primer”, op. cit.

[47] Ibid.

[48] Ibid.

[49] Ibid.

[50]Changes in Employer-Sponsored Health Insurance Coverage:  2001–2005”, Kaiser Commission on Medicaid and the Uninsured, October 2006.

[51]Employer Health Benefits 2009 Annual Survey”, Rep. Kaiser Family Foundation, 2009.

[52]Insuring America’s Health:  Principles and Recommendations:  Uninsurance Facts and Figures:  Fact Sheet 1”, Rep,. Institute of Medicine, January 2004.

[53] Ibid.

[54] The Labor Research Association, “The Growing Gap in Benefits”, September 15, 2006.

[55] U.S. Department of Commerce, Bureau of the Census. Income, Poverty, and Health Insurance Coverage in the United States 2008, op. cit.

[56] Ibid.

[57] Employer Health Benefits 2009 Annual Survey”, op. cit.

[58] U.S. Department of Commerce, Bureau of the Census, Income, Poverty, and Health Insurance Coverage in the United States 2008, op. cit.

[59]Rite of Passage?   Why Young Adults Become Uninsured and How New Policies Can Help”, The Commonwealth Fund, May 2006.

[60] U.S. Department of Commerce, Bureau of the Census. Income, Poverty, and Health Insurance Coverage in the United States 2008, op. cit.

[61]  Ibid.

[62]Closing the Gap in a Generation:  Health Equity through Action on the Social Determinants of Health”, The World Health Organization, August 28, 2008.

[63] Doty, M. M. and A. L. Holmgren.  “Health Care Disconnect:  Gaps in Coverage and Care for Minority Adults”,  The Commonwealth Fund, August 2006.

[64] Ibid.

[65] U.S. Department of Commerce, Bureau of the Census, Income, Poverty, and Health Insurance Coverage in the United States 2008, op. cit.

[66] Ibid.

[67]  Dorn, Stan.  “Uninsured and Dying Because of It”, The Urban Institute, January 8, 2008.

[68] Ibid.

[69] Ibid.

[70] Ibid.

[71]Insuring America’s Health:  Principles and Recommendations:  Uninsurance Facts and Figures:  Fact Sheet 5”, Institute of Medicine, January 2004.

[72] Dorn, Stan, op. cit.

[73] Ibid.

[74] Sanmartin, C., et al.  “Comparing Health and Health Care Use in Canada and the United States”, Health Affairs, 25(4):1139-1140, 2006.

[75]World Health Report 2000 – Health Systems:  Improving Performance”, The World Health Organization. 2000.

[76]  OECD, Social Policy Division, Directorate of Employment, Labour and Social Affairs, “CO1:  Infant Mortality”, 2008.

[77] “Health Status (MORTALITY)”, Health Data, OECD, July 1, 2009.

[78] “Practicing Physicians and Hospital Beds”, Health Data, OECD, July 1, 2009.

[79] Commonwealth Fund Survey, 1998.

[80] Anderson, G., et al.  “How Does the Quality of Care Compare in Five Countries?”, Health Affairs, 23 (3):89, 2004.

[82] Ibid.

[83] CIA World Fact Book, 2008.

[84] Ibid.



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The Department for Professional Employees, AFL-CIO (DPE) comprises 24 AFL-CIO unions representing over four million people working in professional, technical and administrative support occupations.  DPE-affiliated unions represent: teachers, college professors and school administrators; library workers; nurses, doctors and other health care professionals; engineers, scientists and IT workers; journalists and writers, broadcast technicians and communications specialists; performing and visual artists; professional athletes; professional firefighters; psychologists, social workers and many others.  DPE was chartered by the AFL-CIO in 1977 in recognition of the rapidly-growing professional and technical occupations.



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                                                                               October 2009


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