health insurance in the united states health insurance in the united states in the united states, health insurance helps pay for medical expenses through privately purchased insurance, social insurance, or a social welfare program funded by the government. synonyms for this usage include "health coverage", "health care coverage", and "health benefits". in a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. this usage includes both private insurance programs and social insurance programs such as medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like medicaid and the children's health insurance program, which both provide assistance to people who cannot afford health coverage. for details about the number of uninsured persons, see health insurance coverage in the united states. for broader coverage of this topic, see health insurance, insurance in the united states, and health care in the united states. health care in the united states government health programs federal employees health benefits program (fehbp) indian health service (ihs) medicaid / state health insurance assistance program (ship) medicare prescription assistance (spap) military health system (mhs) / tricare children's health insurance program (chip) program of all-inclusive care for the elderly (pace) veterans health administration (vha) private health coverage consumer-driven healthcare flexible spending account (fsa) health reimbursement account (hra) health savings account (hsa) high-deductible health plan (hdhp) medical savings account (msa) private fee-for-service (pffs) health insurance in the united states managed care (ccp) exclusive provider organization (epo) health maintenance organization (hmo) preferred provider organization (ppo) medical underwriting health care reform law emergency medical treatment and active labor act (1986) health insurance portability and accountability act (1996) medicare prescription drug, improvement, and modernization act (2003) patient safety and quality improvement act (2005) health information technology for economic and clinical health act (2009) patient protection and affordable care act (2010) state level reform municipal health coverage healthcare in california healthy san francisco healthy way la my health la fair share health care act (maryland) healthy howard (howard co., maryland) in addition to medical expense insurance, "health insurance" may also refer to insurance covering disability or long-term nursing or custodial care needs. different health insurance provides different levels of financial protection and the scope of coverage can vary widely, with more than 40% of insured individuals reporting that their plans do not adequately meet their needs as of 2007. the share of americans without health insurance has been cut in half since 2013. many of the reforms instituted by the affordable care act of 2010 were designed to extend health care coverage to those without it; however, high cost growth continues unabated. national health expenditures are projected to grow 4.7% per person per year from 2016 to 2025. public healthcare spending was 29% of federal mandated spending in 1990 and 35% of it in 2000. it is also projected to be roughly half in 2025. enrollment and the uninsured main article: health insurance coverage in the united states gallup issued a report in july 2014 stating that the uninsured rate for adults 18 and over declined from 18% in 2013 to 13.4% by in 2014, largely because there were new coverage options and market reforms under the affordable care act. rand corporation had similar findings. trends in private coverage the proportion of non-elderly individuals with employer-sponsored cover fell from 66% in 2000 to 56% in 2010, then stabilized following the passage of the affordable care act. employees who worked part-time (less than 30 hours a week) were less likely to be offered coverage by their employer than were employees who worked full-time (21% vs. 72%). a major trend in employer sponsored coverage has been increasing premiums, deductibles, and co-payments for medical services, and increasing the costs of using out-of-network health providers rather than in-network providers. trends in public coverage public insurance cover increased from 2000–2010 in part because of an aging population and an economic downturn in the latter part of the decade. funding for medicaid and chip expanded significantly under the 2010 health reform bill. the proportion of individuals covered by medicaid increased from 10.5% in 2000 to 14.5% in 2010 and 20% in 2015. the proportion covered by medicare increased from 13.5% in 2000 to 15.9% in 2010, then decreased to 14% in 2015. status of the uninsured the uninsured proportion was stable at 14–15% from 1990 to 2008, then rose to a peak of 18% in q3 2013 and rapidly fell to 11% in 2015. the proportion without insurance has stabilized at 9%. a 2011 study found that there were 2.1 million hospital stays for uninsured patients, accounting for 4.4% ($17.1 billion) of total aggregate inpatient hospital costs in the united states. the costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost-shifting and higher health insurance premiums, or paid by taxpayers through higher taxes. the social safety net the social safety net refers to those providers that organize and deliver a significant level of health care and other needed services to the uninsured, medicaid, and other vulnerable patients. this is important given that the uninsured rate for americans is still high after the advent of the affordable care act, with a rate of 10.9%, or 28.9 million people in 2019. not only is this because the aca does not address gaps for undocumented or homeless populations, but higher insurance premiums, political factors, failure to expand medicaid in some states, and ineligibility for financial assistance for coverage are just some of the reasons that the social safety net is required for the uninsured. most people who are uninsured are non-elderly adults in working families, low income families, and minorities. social safety net hospitals primarily provide services to these populations of uninsured. for example, california's public health care systems are only 6% of the hospitals in the state, yet provide care for 38% of all hospital care of uninsured in california- 123,000 of which are homeless, and 3.6 million of which live below the federal poverty line. one way in which the us has been addressing this need for a social safety net (other than formally/state recognized safety net hospitals) is through the advent of free clinics, an example of a federally qualified health center. a free clinic (for example, the haight-asbury free clinic and the berkeley free clinic) is a clinic that provides services for free and target the uninsured, typically relying on volunteers and lay health workers. the creation of the national council of free clinics reflects not only a need for licensed staff, but serves as filling the gap in healthcare access for primarily uninsured or underinsured populations. death since people who lack health insurance are unable to obtain timely medical care, they have a 40% higher risk of death in any given year than those with health insurance, according to a study published in the american journal of public health. the study estimated that in 2005 in the united states, there were 45,000 deaths associated with lack of health insurance. a 2008 systematic review found consistent evidence that health insurance increased utilization of services and improved health. a study at johns hopkins hospital found that heart transplant complications occurred most often amongst the uninsured, and that patients who had private health plans fared better than those covered by medicaid or medicare. reform the affordable care act of 2010 was designed primarily to extend health coverage to those without it by expanding medicaid, creating financial incentives for employers to offer coverage, and requiring those without employer or public coverage to purchase insurance in newly created health insurance exchanges. this requirement for almost all individuals to maintain health insurance is often referred to as the "individual mandate." the cbo has estimated that roughly 33 million who would have otherwise been uninsured will receive coverage because of the act by 2022. repeal of the individual mandate the tax cuts and jobs act of 2017 effectively repealed the individual mandate, meaning that individuals will no longer be penalized for failing to maintain health coverage starting in 2019. the cbo projects that this change will result in four million more uninsured by 2019, 13 million more by 2027. underinsurance main article: health insurance coverage in the united states § underinsured those who are insured may be underinsured such that they cannot afford full medical care, for example due to the exclusion of pre-existing conditions, or from high deductibles or co-payments. in 2019 gallup found while only 11% reported being uninsured, 25% of u.s. adults said they or a family member had delayed treatment for a serious medical condition during the year because of cost, up from 12% in 2003 and 19% in 2015. for any condition, 33% reported delaying treatment, up from 24% in 2003 and 31% in 2015. history accident insurance was first offered in the united states by the franklin health assurance company of massachusetts. this firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. sixty organizations were offering accident insurance in the us by 1866, but the industry consolidated rapidly soon thereafter. while there were earlier experiments, sickness coverage in the us effectively dates from 1890. the first employer-sponsored group disability policy was issued in 1911, but this plan's primary purpose was replacing wages lost because the worker was unable to work, not medical expenses. before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. during the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and also most prescription drugs, but this was not always the case. the rise of private insurance was accompanied by the gradual expansion of public insurance programs for those who could not acquire coverage through the market. hospital and medical expense policies were introduced during the first half of the 20th century. during the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of blue cross organizations in the 1930s. the first employer-sponsored hospitalization plan was created by teachers in dallas, texas in 1929. because the plan only covered members' expenses at a single hospital (baylor hospital), it is also the forerunner of today's health maintenance organizations (hmos). in 1935 the decision was made by the roosevelt administration not to include a large-scale health insurance program as part of the new social security program. the problem was not an attack by any organized opposition, such as the opposition from the american medical association that derailed truman's proposals in 1949. instead, there was a lack of active popular, congressional, or interest group support. roosevelt's strategy was to wait for a demand and a program to materialize, and then if he thought it popular enough to throw his support behind it. his committee on economic security (ces) deliberately limited the health segment of social security to the expansion of medical care and facilities. it considered unemployment insurance to be the major priority. roosevelt assured the medical community that medicine would be kept out of politics. jaap kooijman says he succeeded in "pacifying the opponents without discouraging the reformers." the right moment never came for him to reintroduce the topic. the rise of employer-sponsored coverage some of the first evidence of compulsory health insurance in the united states was in 1915, through the progressive reform protecting workers against medical costs and sicknesses in industrial america. prior to this, within the socialist and progressive parties, health insurance and coverage was framed as not only an economic right for workers health, but also as an employer’s responsibility and liability- healthcare was in this context centered on working-class americans and labor unions. employer-sponsored health insurance plans dramatically expanded as a direct result of wage controls imposed by the federal government during world war ii. the labor market was tight because of the increased demand for goods and decreased supply of workers during the war. federally imposed wage and price