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405.2 -Function of the complex payor system in US healthcare

405.2 -Function of the complex payor system in US healthcare


In 2015, The Centers for Disease Control estimated the United States health expenditures were in excess of 3.2 trillion, or nearly double per person than any other country (CDC. 2017). The U.S healthcare expenditures are supported by a complex payer system, comprised of a combination of public governmental payers (Federal, State, and Local), private insurances and personal payments (out of pocket). Unlike many other developed countries, there is no singular payer or universal system of health insurance in the United States. Therefore, healthcare in the U.S. may be advanced, but it is expensive. The prohibitively high costs of healthcare insurance have ultimately limited access for many Americans to healthcare insurance coverage. The United States Census Bureau reported that 28.5 million people (8.8%) did not have health insurance in the year 2017 (U.S. Census Bureau, 2018).

Many of the private healthcare insurance programs in the United States rely heavily on employer/employee insurance coverage, where the employer provides the insurance plan, and both the employee and employer finance. Governmental or public insurance programs (Medicare, Medicaid) are mainly designed to provide coverage for the poor, the elderly and the disabled. Many individuals throughout the United States have both private and public health insurance, although there is very little systemization or organization between the two. Additionally, many U.S. individuals are uninsured or underinsured, having little to no health insurance. Although still able to receive healthcare, the uninsured are often unable to pay their healthcare bills resulting in the care being paid for by others or the uninsured going without care. In the recent past, with the efforts of the Affordable Care Act (ACA), insurance coverage was extended to millions of uninsured U.S. citizens, mandating insurance coverage and making affordable health insurance available to uninsured U.S. citizens. The recent changes to the ACA however, will have considerable effects, as the mandating of insurance for individuals will end.


Define and explain at least three challenges facing the US healthcare complex payer system. Research and address one strategy (at the federal, state, or local level; an example could be the Pre-Existing Conditions aspects of the ACA) that has been, or may be, implemented to resolve one or more of those challenges. What is the goal of that particular strategy, and how is it designed to achieve that goal?

Make sure your reader has the context necessary to understand the challenges and the strategy your examining.



·        FastStats – Health Expenditures




·        About the ACA


·        Is the U.S. Ready for a Single-Payer Health Care System?


·        United States : International Health Care System Profiles


·        Comparisons of Health Care Systems in the United States, Germany and Canada


·        Introduction to the U.S. health care system


·        Health Insurance Coverage in the United States: 2017