Challenges facing the United States of America in implementing universal coverage

In 2012, the United States of America (USA) spent more than 2.8 trillion United States dollars (US$) -i.e. more than 17% of its gross domestic product (GDP) and more than the entire GDP of the United Kingdom of Great Britain and Northern Ireland -on its health-care system. This spending meant that, in 2012, health-care expenditure per capita was substantially higher in the USA than in any other country. It was, for example, 50% higher than that in Norway -i.e. the Organisation for Economic Co-operation and Development (OECD) country with the next highest health-care expenditure per capita. Despite such spending on health care, many United States' residents had no health insurance and several aggregate measures of health quality and outcomes recorded in the USA were poorer than the corresponding data from other high-income countries. Immediately before the implementa-tion of the key elements of the ACA in 2014, 18% of residents younger than 65 years lacked any form of health insurance. 5 As uninsured residents have relatively poor access to the offices of private physicians, they frequently seek care from so-called safety-net providers -such as community centres and the outpatient or emergency departments of hospitals. Compared with their counterparts in other high-income countries, patients in the USA are much more likely to forgo medications and to skip care -especially preventive carebecause of costs. aps in health coverage, problems with access to health care and unhealthy lifestyles are thought to contribute to the many disappointingly poor health outcomes recorded in the USA. The USA performs better than most high-income countries in terms of breast and colorectal cancer survival and 30-day mortality rates for acute myocardial infarction and ischaemic stroke -probably because of high rates of screening for these conditions or their associated risk factors. In contrast, overall rates of cancer, low birth weight and infant mortality, and years of life lost in the USA all exceed the median values for countries in OECD. Life expectancy is lower. Interestingly, most of the differences in mortality between the USA and highperforming countries such as France and Japan are the result of deaths that occur before the age of 50 years. he relatively high costs and poor outcomes that characterize the performance of the United States' health system are the result of many factors. These factors include poverty, a lack of universal health coverage, a general lack of focus on primary care and public health, high rates of accidents, violence and teenage pregnancy, and poor health behaviours -e.g. poor diets and an overreliance on automobiles for travel -that lead to obesity and lack of fitness.