Healthcare in the United States is a dynamic mix of public and marketplace solutions to the challenge of achieving the maximum public good for the greatest number of people. Indeed, in the U.S. the healthcare industry generates over $3 trillion in the economy. This creates a uniquely American paradox that is examined here. The basic structure of the U.S. public-private healthcare delivery system is explored. The dynamics of public sector involvement in healthcare delivery is reviewed, with particular emphasis on the impact of the Patient Protection and Affordable Care Act. Economic impact, employment indicators, and recent cost estimates of public revenue investment will be considered. Finally, a discussion about the future implications of healthcare for public administration in the 21st century is presented. Eight tables and figures present a visual and detailed explanation to accompany the narrative.
TopBackground
Just when did the United States first determine that healthcare warranted public oversight and investment? Nearly from the beginning of our existence. In 1798 the first official effort to deliver healthcare to a segment of the US population was put in place. In this case, it was an economic interest that led President John Adams to the establishment of the Relief of Sick and Disabled Seamen Act. A tax was levied on seamen’s wages to build hospitals and to support for medical care (O'Carroll, Yasnoff, Ward, Ripp, & Martin, 2003). Why did the President intervene? Because at the time sea-travel lay at the heart of economic power. Transporting goods across vast tracts of land internally via rivers and lakes or across the ocean to trade with Europe. While this unique tax was eventually abolished in 1884, the trajectory for public investment in healthcare was firmly set. Subsequent legislation established food safety programs, funding for research, vaccinations, health insurance and more. In 1862 the precursor to our current Food and Drug Administration was established as the Bureau of Chemistry. In 1878 the federal government consolidated quarantine power at the federal government, levering authority away from the states, and transferring it to the Marine Hospital Service (the predecessor of the Public Health Service).
Since the late 18th century, the U.S. healthcare system has been deeply collaborative with the public and private sectors. Over the decades, various legislation has resulted in changes to funding sources, systemic policy initiatives to eradicate disease, research to fund innovation, and building the necessary infrastructure to oversee the establishment of a complex, yet, comprehensive healthcare industry. Table 1 presents a brief overview of health-centered legislative action. Each act has resulted in more deeply cementing the indebtedness of the private healthcare industry to the public sector. Most obviously in terms of funding, but also with regard to oversight and accountability.