Despite being documented for decades, racial and ethnic disparities in health and health care persist with some widening in recent years. The COVID-19 pandemic and the nationwide racial justice movement in 2020 increased attention and calls to address racial and ethnic disparities in health and recognition of their root causes, including the ongoing impacts of racism and discrimination. Addressing health disparities is not only important from an equity standpoint but also for improving the nation’s overall health and economic prosperity. This chapter provides an overview of racial and ethnic disparities in health and health care and the factors that drive them, examines the actions to address them, and outlines future considerations.

Health and health care disparities refer to differences in health and health care between groups that stem from broader social and economic inequities. There are multiple definitions of health disparities. Healthy People 2030 defines a health disparity as “a particular type of health difference that is linked with social, economic, and/or environmental disadvantage” and that adversely affects groups of people who have systematically experienced greater obstacles to health. The Centers for Disease Control and Prevention (CDC) defines health disparities as “preventable differences in the burden, disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups and communities.” A health care disparity typically refers to differences between groups in health insurance coverage, affordability, access to and use of care, and quality of care. The terms “health inequality” and “inequity” are also sometimes used to describe unjust differences. Racism, which the CDC defines as the structures, policies, practices, and norms that assign value and determine opportunities based on the way people look or the color of their skin, results in conditions that unfairly advantage some and disadvantage others, resulting in negative mental and physical health outcomes for marginalized groups.

Reflecting the intersectional nature of people’s identities, some individuals experience disparities across multiple dimensions such as race and ethnicity, gender, or sexual orientation.  Beyond race and ethnicity, disparities occur across other factors, including socioeconomic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation. Federal efforts to reduce disparities focus on designated priority populations, including “members of underserved communities: Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.” These groups are not mutually exclusive and often intersect in meaningful ways. Disparities also occur within subgroups of broader racial and ethnic groups, such as ethnic identity, immigration status, and English proficiency.

Health equity generally refers to individuals achieving their highest level of health through the elimination of disparities in health and health care. Healthy People 2030 defines health equity as the attainment of the highest level of health for all people and notes that it requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and health and health care disparities. The CDC describes health equity as when everyone has the opportunity to be as healthy as possible.

The U.S. has a long history of policies and events that have resulted in stark differences in access to resources, opportunities, and power that contribute to racial and ethnic disparities in health today. Dating back to slavery and colonization of the Americas, people of color have been subject to abuse and mistreatment, including medical exploitation and experimentation, family separation, and efforts to eliminate cultural practices and languages. Historic discriminatory policies, such as redlining, have lasting effects today, leading to residential segregation of Black and Hispanic people into urban neighborhoods with more limited resources and increased health risks, including climate-related risks. Anti-immigrant policies have excluded and discriminated against certain groups, contributing to “othering” and “perpetual foreigner” stereotypes, particularly among Asian immigrants, with a resurgence in anti-Asian rhetoric amid the COVID-19 pandemic. Within medicine, disproven beliefs about biological differences by race have led to race permeating clinical decision making and treatment in multiple ways, including through providers’ attitudes and implicit biases, disease stereotyping and clinical nomenclature, and its use in clinical algorithms, tools, and treatment guidelines.

Underlying inequities in social and economic factors that reflect historic and contemporary policies drive racial and ethnic disparities in health (Figure 1). Though health care is essential to health, studies suggest that social and economic factors, often referred to as social determinants of health, are the primary drivers of health outcomes. These include factors such as access to housing and food and economic and educational opportunities. Hispanic, Black, American Indian or Alaska Native (AIAN), and Native Hawaiian or Pacific Islander (NHPI) people fare worse compared to White people across many social and economic factors. Experiences for Asian people are mixed, although some subgroups of Asian people fare worse compared to White people, and Asian immigrants face certain additional challenges.

Experiences with unfair treatment and discrimination negatively impact health and well-being. Despite growing calls to address racism, many adults continue to experience unfair treatment and discrimination in their daily lives and in health care settings. A 2023 KFF survey shows that at least half of AIAN (58%), Black (54%), Hispanic adults (50%), and about 4 in 10 Asian adults (42%) say they experienced at least one type of discrimination in daily life in the past year. These experiences include receiving poorer service than others at restaurants or stores; people acting as if they are afraid of them or as if they aren’t smart; being threatened or harassed; or being criticized for speaking a language other than English. Consistent with other research, which shows that racism has negative effects on mental health and results in certain negative physical health outcomes, the KFF survey finds that adults who report experiences with discrimination in daily life are more likely than others to report adverse effects from worry or stress as well as regular feelings of loneliness, anxiety, and depression. Among those with discrimination experiences, 4 in 10 (40%) say they “always” or “often” felt anxious in the past year, compared to 14% of adults who rarely or never experience such discrimination (Figure 2). Similarly, those with discrimination experiences in their daily life are more than three times as likely as others to say they always or often felt lonely (26% vs. 7%) or depressed (25% vs. 7%) in the past year.

Racism and discrimination also negatively affect people’s health care experiences. Black, Hispanic, AIAN, and Asian adults report higher levels of unfair treatment when seeking health care than their White counterparts and are more likely to report having certain negative experiences with a health care provider because of their race and ethnicity (Figure 3). Reflecting these experiences, half or more of Hispanic, Black, and AIAN adults say they prepare for possible insults from providers or staff and/or feel they must be very careful about their appearance to be treated fairly during health care visits at least some of the time. About a quarter of adults who experienced unfair treatment, a negative experience with a provider, or a language access challenge say it led to worse health, being less likely to seek care, and/or switching providers.

Addressing disparities in health and health care is important not only from an equity standpoint but also for improving the nation’s overall health and economic prosperity. Racial and ethnic health and health care disparities result in higher rates of illness and death across a wide range of health conditions, limiting the overall health of the nation. Research further finds that health disparities are costly, resulting in excess medical care costs and lost productivity, as well as additional economic losses due to premature deaths each year.

It is increasingly important to address health disparities as the population becomes more diverse and stark income inequalities persist. The U.S. Census Bureau projects that people of color will account for over half (52%) of the population in 2050, with the largest growth occurring among people who identify as Asian or Hispanic (Figure 4). Over time, the population has become increasingly racially diverse, reflecting shifting immigration patterns, a growing multiracial population, as well as adjustments to how the Census Bureau measures race and ethnicity. Over time, income inequality within the U.S. has also widened. As of 2022, the top 10% of households in the U.S. had incomes above $216,000 compared with incomes at or below $17,100 among the lowest 10% of households.

Major recognition of health disparities began nearly four decades ago. In 1985, the Report of the Secretary’s Task Force on Black and Minority Health (commonly known as the Heckler Report) documented persistent health disparities that accounted for 60,000 excess deaths each year and synthesized ways to advance health equity. The Heckler Report led to the creation of the U.S. Department of Health and Human Services Office of Minority Health and influenced federal recognition of and investment in many aspects of health equity. Federal recognition of disparities continued in 2003 with the Institute of Medicine’s Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report, which identified systemic racism as a major cause of health disparities in the United States.

Despite the recognition and documentation of disparities for decades and overall improvements in population health over time, many disparities persist, and in some cases, have widened over time. Analysis across a broad range of measures of health finds that Black and AIAN people fare worse than their White counterparts across half or more of these measures. Data for Hispanic people are more mixed relative to White people, with them faring better on some measures but worse on others. In the aggregate, Asian people fare the same or better than White people on many measures of health, although this finding masks disparities among subgroups of the population. Data gaps limit the ability to examine disparities among NHPI people; where data are available, they point to disparities, particularly for certain subgroups of this population. Some examples of disparities in health outcomes include:

• Black infants were more than two times as likely to die as White infants, and AIAN and NHPI infants were roughly twice as likely to die as White infants as of 2022 (Figure 5). Black and AIAN women also had the highest rates of pregnancy-related mortality across groups between 2017 and 2019.
• In 2022, the age-adjusted mortality rates for diabetes for AIAN, NHPI, and Black people were about twice as high as the rate for White people; Hispanic people also had a higher diabetes death rate compared to White people.
• Although Black people did not have higher cancer incidence rates than White people overall and across most types of cancer, they were more likely to die from cancer in 2020.
• In 2021, the HIV diagnosis rate for Black people was roughly eight times higher than the rate for White people, and the rate for Hispanic people was about four times higher than the rate for White people. AIAN and NHPI people also had higher HIV diagnosis rates compared to White people.

There also are ongoing racial and ethnic disparities in health coverage and access to care. Overall, Black, Hispanic, and AIAN people fare worse compared to White people across many measures of health coverage and access to and use of care. Despite large gains in coverage across groups since the Affordable Care Act (ACA), as of 2022, nonelderly AIAN, Hispanic, Black, and NHPI people were more likely to be uninsured compared to their White counterparts (Figure 6), with even higher uninsured rates among noncitizen Hispanic adults. In addition, Hispanic, Black, Asian, AIAN, and NHPI adults are more likely than White adults to report not having a personal health care provider, and Hispanic, Black, AIAN, and NHPI adults are more likely than White adults to report not seeing a doctor in the past 12 months because of cost.

The COVID-19 pandemic widened some racial and ethnic health disparities, including in life expectancy and mortality. During the height of the COVID-19 pandemic, AIAN, Hispanic, and Black people experienced higher rates of death. Beyond these direct health impacts, the pandemic disproportionately negatively impacted the well-being and social and economic factors that drive health for these and other underserved groups. Largely reflecting the impacts of the pandemic, between 2019 and 2021, there was a sharp drop-off in life expectancy, with particularly large declines among some racial and ethnic groups. AIAN people experienced the largest decline in life expectancy of 6.2 years, followed by Hispanic and Black people (4.1 and 3.6 years, respectively) (Figure 7). Following these declines, provisional data for 2022 show a recent uptick in life expectancy, however, disparities persist across racial and ethnic groups. In 2022, life expectancy was lowest for AIAN people at 67.9 years, followed by Black people, whose expectancy was 72.8 years, both lower compared with the life expectancy of 77.5 years for White people.

Early in his presidency, President Biden issued a series of executive orders focused on advancing health equity. These included orders that outlined equity as a priority for the federal government broadly and as part of the pandemic response and recovery efforts. Federal agencies were directed to develop Equity Action Plans. In its Equity Action Plan, the Department of Health and Human Services (HHS) outlined a series of strategies, including addressing increased pregnancy and postpartum morbidity and mortality among Black and AIAN women; addressing barriers that individuals with limited English proficiency face in obtaining information, services, and benefits from HHS programs; leveraging grants to incorporate equity consideration into funding opportunities; implementing equity assessments; investing in resources to advance civil rights; and expanding contracting opportunities for small, disadvantaged businesses. The plan builds on earlier efforts that included increasing stakeholder engagement, establishing the Office of Climate Change and Health Equity, and establishing the National Institutes of Health UNITE Initiative to address structural racism and racial inequities in biomedical research. Since the release of its Equity Action Plan, HHS has taken actions to extend postpartum coverage through Medicaid and the Children’s Health Insurance Program (CHIP); issued rules to strengthen patient protections, including nondiscrimination protections; and issued guidance to ensure that telehealth services are accessible to people with disabilities and those with limited English proficiency.

The Centers for Medicare and Medicaid Services (CMS) released an updated framework to advance health equity for people covered by Medicare, Medicaid, CHIP, and the Health Insurance Marketplaces. The framework outlines five priorities, including expanding the collection, reporting, and analysis of standardized data on demographics and social determinants of health; assessing the causes of disparities within CMS programs and addressing inequities in policies and operations; building capacity of health care organizations and the workforce to reduce disparities; advancing language access, health literacy, and the provision of culturally tailored services; and increasing all forms of accessibility to health services and coverage. State Medicaid programs also are focused on addressing racial disparities in health outcomes. States have increasingly requested and/or received approval for waivers that aim to advance equity. Further, a growing number of states have approved or pending waivers with provisions related to addressing health-related social needs, such as food and housing, often focused on specific populations with high needs or risks.

The Administration and Congress took a range of actions to stabilize and increase access to health coverage amid the pandemic, with some extending beyond the Public Health Emergency but others ending. Early in the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA), which included a temporary requirement that Medicaid programs keep people continuously enrolled during the COVID-19 Public Health Emergency in exchange for enhanced federal funds. Primarily due to this provision, Medicaid enrollment grew substantially and the uninsured rate dropped, with AIAN and Hispanic people experiencing the largest decline. The American Rescue Plan Act (ARPA) of 2021 included an option, made permanent in the Consolidated Appropriations Act 2023, to allow states to extend Medicaid postpartum coverage from 60 days to 12 months, and the majority of states have taken steps to extend postpartum coverage. The Consolidated Appropriations Act also included a requirement for all states to implement 12 months of continuous coverage for children in Medicaid, supporting their coverage stability. However, the broader Medicaid continuous enrollment provision adopted during the Public Health Emergency ended on March 31, 2023, and millions of Medicaid enrollees have been disenrolled since then.

There has been a growing focus on addressing disparities in maternal health. The Biden Administration launched several initiatives focused on addressing inequities in maternal health, including releasing a Blueprint for Addressing the Maternal Health Crisis. Federal agencies also have announced plans and actions to support the Blueprint, including CMS, which released a maternity care action plan; the Health Resources and Services Administration, which committed $90 million to various efforts aimed at improving maternal health, and the Office of the Assistant Secretary for Health, which invested $8.5 million in initiatives designed to reduce pregnancy-related deaths and complications that disproportionately impact people of color and those living in rural areas. Other recent actions have focused on enhancing data on maternal and infant health outcomes and disparities, increasing health care workforce diversity, and expanding access to doulas and other services. States, providers, and health systems; foundations; and communities also are engaged in a broad range of efforts to advance maternal and child health and reduce disparities. Moreover, organizations are advocating for more interventions and support to address maternal mental health and substance use issues, major causes of pregnancy-related mortality and morbidity.

There are efforts underway to increase data available to identify and address disparities. The exclusion of disaggregated data for smaller population groups, including AIAN and NHPI people from many datasets and analyses, limits the visibility and understanding of the health and health care disparities they face and inhibits efforts to address them. There are efforts underway to expand and improve the availability of disaggregated data, including a charge from the Biden Administration to address the systemic lack of disaggregated data. In March 2024, the Office of Management and Budget (OMB) announced revisions to update the minimum standards for collecting and presenting data on race and ethnicity for all federal reporting by adding a new racial category for people who identify as Middle Eastern and North African, moving to collect race and ethnicity through a combined single question instead of asking about Hispanic or Latino ethnicity in a separate question from race, and requiring the collection of detailed racial and ethnic categories. Efforts to disaggregate data may help identify health disparities among smaller racial and ethnic groups and subgroups of larger racial and ethnic groups. They also may inform more culturally attuned and community-informed responses to addressing disparities.

Growing mental health and substance use concerns may contribute to racial and ethnic health disparities. Drug overdose and suicide deaths have increased since the onset of the COVID-19 pandemic, with some groups particularly affected. These trends may lead to new and widening racial and ethnic disparities. For example, AIAN, Black, and Hispanic people experienced larger increases in drug overdose death rates than White people between 2019 and 2021, resulting in the death rate for Black people newly surpassing that of White people by 2020. As of 2022, AIAN people had the highest suicide death rate, about one and a half times higher than the rate for White people (Figure 8). Despite growing mental health concerns, people of color continue to face disproportionate barriers to accessing mental health care, including lack of health insurance coverage and financial and logistical barriers to accessing care, lack of a diverse mental health care workforce, the absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health. As such, it will be important for efforts to expand access to behavioral health to ensure that services address the cultural and linguistic needs of diverse populations.

The Dobbs decision may exacerbate the already large racial disparities in maternal health. The decision to overturn the longstanding Constitutional right to abortion and elimination of federal standards on abortion access has resulted in growing variation across states in laws protecting or restricting abortion. These changes may disproportionately impact women of color, as they are more likely to obtain abortions, have more limited access to health care, and face underlying inequities that would make it more difficult to travel out of state for an abortion compared to their White counterparts. Restricted access to abortions may widen the already stark racial disparities in maternal health. It may also have economic consequences associated with the direct costs of raising children and impacts on educational and employment opportunities. Further, women from underserved communities may be at increased risk for criminalization, as prior to the ruling, there were already cases of women being criminalized for their miscarriages, stillbirths, or infant death, many of whom were low-income or women of color.

Coverage losses following the end of the Medicaid continuous enrollment provision may lead to widening disparities in coverage. The Medicaid continuous enrollment provision, which had halted Medicaid disenrollments since March 2020 as a mechanism to stabilize coverage during the COVID-19 pandemic, ended on March 31, 2023. Following the end of the Medicaid continuous enrollment provision, states resumed Medicaid redeterminations and KFF tracking shows that millions of enrollees have been disenrolled from Medicaid. Although some may transition to other sources of coverage including Marketplace coverage or eventually reenroll in Medicaid, others may become uninsured. While the limited data available on disenrollments by race and ethnicity do not show large differences in disenrollment rates by race or ethnicity, people of color are more likely to be affected since they are disproportionately likely to be covered by Medicaid. Moreover, some groups, such as individuals with limited English proficiency and people with disabilities may face increased challenges in completing the Medicaid renewal process, increasing their risk of coverage loss even if they remain eligible for coverage.

Evolving immigration policies may impact the health and well-being of immigrant families. KFF survey data show that although most immigrants say their finances and employment are better as a result of moving to the U.S., many report facing serious challenges, which extend into health care. Although most immigrants are healthy and employed, they have high uninsured rates, face challenges affording care, and encounter linguistic and cultural barriers to care (Figure 9). Many immigrants lack sufficient information to understand how U.S. immigration laws affect them and their families, and immigration-related fears lead some to avoid certain activities, including participating in assistance programs for food, housing, or health care for which they or their children may be eligible. These fears persist despite the Biden Administration reversing Trump Administration public charge regulations with the aim of reducing fears about participating in programs, including Medicaid and CHIP. Some immigrants also face uncertainty about their immigration status, including people with Temporary Protected Status and Deferred Action for Childhood Arrivals (DACA) recipients. DACA implementation is currently limited subject to court orders, and if the DACA program is found to be unlawful, individuals would lose their DACA status and, subsequently, their work authorizations. Immigration-related fears may increase amid a growing focus on immigration enforcement following the lifting of the Title 42 restrictions that had suspended the entry of individuals at the U.S. border to protect public health during the COVID-19 pandemic and increasing anti-immigrant rhetoric leading into the next presidential election.

Expansions in access to health coverage for immigrants could mitigate some of the challenges they face in accessing health care. States vary in the coverage they provide for their low-income population overall and immigrants specifically. Those that have adopted the ACA Medicaid expansion have broader eligibility for low-income adults, but noncitizen immigrants still face eligibility restrictions for this coverage. Some states have expanded coverage for immigrants by taking up options available in Medicaid and CHIP to cover recent lawfully present immigrant children and pregnant women, and some states have extended coverage to some groups regardless of immigration status through fully state-funded programs. Immigrants in states that have taken up more of these coverage options are less likely to be uninsured. It remains to be seen if additional states will take action to adopt these options or provide state-funded coverage. In May 2024, the Biden Administration published new regulations that will extend eligibility for Marketplace coverage to DACA recipients. Under the regulations, DACA recipients will be newly included in the definition of lawfully present immigrants for the purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums or to enroll in Basic Health Program coverage in states with those programs.

As climate-related events become more common, the impacts on health and health care will increase in both frequency and intensity, with disproportionate impacts on historically marginalized and under-resourced groups. Climate and weather can negatively impact individual and population-level health through multiple pathways, and climate-related health risks are expected to increase going forward. While climate change poses health threats for everyone, people of color, low-income people, and other marginalized or high-need groups face disproportionate risks due to underlying inequities and structural racism and discrimination. For example, historical policies such as redlining have led to residential segregation of Black people into urban neighborhoods that increase their exposure to extreme heat and poor air quality. 

Disparities in access to novel drug therapies and technologies may contribute to and potentially widen racial and ethnic health disparities. People of color have higher rates of chronic diseases, including Alzheimer’s, diabetes, obesity, and other diseases which may benefit from new medical advancements. However, at the same time, they may face increased barriers to accessing new or novel drugs or therapies, which may exacerbate disparities in health going forward.These include affordability challenges due to the high out-of-pocket costs for many new drugs and therapies, which often are not covered by insurance; lack of racial diversity in clinical trials used to test the effectiveness and safety of new drugs and therapies, and underlying biases in clinical decision-making processes, which may increasingly rely on artificial intelligence or algorithms.

Looking to the future, racial and ethnic disparities in health and health care remain a persistent problem despite their longstanding recognition and growing calls to address them. These disparities reflect the ongoing impacts of racism that lead to structural inequities in resources and opportunities as well as bias and discrimination in health care and daily life. Some key challenges ahead for eliminating racial and ethnic health and health care disparities include:

• How to address underlying social and economic inequities that drive disparities in health.
• How to close racial and ethnic gaps in health coverage and prevent further widening of disparities in health coverage.
• How to increase diversity of the health care workforce and expand access to culturally and linguistically competent care.
• How to ensure all communities are visible in data to identify and address disparities.
• How to protect communities from the uneven impacts of climate change and mitigate widening disparities due to climate-related health risks.
• How to mitigate the perpetuation of disparities amid the growing use of AI and clinical algorithms to guide clinical decision-making.

Addressing racial and ethnic health and health care disparities is of increasing significance as the diversity of the country grows. It is important not only from an equity standpoint but also for improving the overall health and economic prosperity of our nation.

• Survey on Racism, Discrimination and Health: Experiences and Impacts Across Racial and Ethnic Groups
• Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants
• Disparities in Health and Health Care: 5 Key Questions and Answers
• Key Data on Health and Health Care by Race and Ethnicity
• Health Coverage by Race and Ethnicity, 2010-2021
• What is Driving Widening Racial Disparities in Life Expectancy?
• Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them
• Key Facts on Health Coverage of Immigrants
• Climate Change and Health Equity: Key Questions and Answers
• Medicaid and Racial Health Equity
• How History Has Shaped Racial and Ethnic Health Disparities: A Timeline of Policies and Events

Ndugga, N., Hill, L., Pillai, D., & Artiga, S., Race, Inequality, and Health. In Altman, Drew (Editor), Health Policy 101, (KFF, July 2024) https://staging-modern.kff.org/health-policy-101-race-inequality-and-health/ (date accessed).

Every health system aims to provide accessible, high-quality care that improves health outcomes at an affordable cost. One way to assess the performance of the United States’ health system is to benchmark it against health systems in similar countries.

Comparing health system performance internationally is complicated, though, as each country has unique political, economic, and social conditions. Because health spending and health outcomes are often correlated with a country’s wealth, this chapter focuses on comparisons of the U.S. to other large and wealthy OECD nations: Australia, Austria, Belgium, Canada, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom.

Despite spending far more money than any peer nation, Americans live shorter lives and often face more barriers to care. Some of this disparity can be attributed to aspects of the U.S. health system, but socioeconomic and other factors also play a role.

From the late nineteenth to mid-twentieth centuries, many nations created health insurance systems that aimed to make health care accessible and affordable to all residents. Some countries, like the United Kingdom, have health systems that are largely publicly funded and operated, while other countries, like Switzerland, have a compulsory private insurance system. Many countries’ health systems include a mix of private and public insurance. Regardless of the financing mechanism, the health systems in all countries that are similarly large and wealthy as the U.S. are largely compulsory, resulting in universal or near-universal health coverage.

During this same period, the United States took a different approach, relying on a largely voluntary private insurance system that resulted in a substantial share of the population being uninsured. Despite decades of calls for a national public health insurance program, it was not until 1965 that two major public insurance programs were created – Medicare for adults age 65 or older and for low-income people – and it was not until the Affordable Care Act passed in 2010 that the U.S. health system was overhauled to create near-universal eligibility for health insurance coverage for lawfully present residents. Even so, the U.S. health system is still largely voluntary and millions of people continue to go without insurance, often citing cost as a barrier.

Wealthy countries, including the U.S., tend to spend more per person on health care and related expenses than lower-income countries. However, even among higher-income countries, the U.S. spends far more per person on health.

Spending Growth

Over the past five decades, the health spending gap between the U.S. and peer nations has widened. In 1970, the U.S. spent about 7% of its GDP on health, similar to spending in several comparable countries (the average of comparably wealthy countries was about 5% of GDP in 1970). The U.S. was relatively on pace with other countries until the 1980s, when health spending in the U.S. grew at a significantly faster rate relative to its GDP. 

The COVID-19 pandemic led to both an increase in health spending and an economic downturn resulting in higher health spending as a share of the GDP in the U.S. and every comparable country between 2019 and 2020. In 2020, the U.S. spent 19.7% of its GDP on health consumption (up from 17.6% in 2019). In 2021, health spending as a share of GDP declined to 18.3% in the U.S.—but remains substantially higher than in peer countries.

Drivers of Health Spending

The largest category of health spending in both the U.S. and comparable countries is spending on inpatient and outpatient care, including payments to hospitals, clinics, and physicians for services and fees such as primary care or specialist visits, surgical care, provider-administered medications, and facility fees. Americans spent $7,500 per person on inpatient and outpatient care, compared to $3,851 in peer countries, on average. The U.S.’s higher spending on providers is driven more by higher prices than higher utilization of care. Patients in the U.S. have shorter average hospital stays and fewer physician visits per capita, while many hospital procedures have been shown to have higher prices in the U.S.­ Higher spending on inpatient and outpatient care drives most of the difference in health spending between the U.S. and its peers. In fact, the U.S. spends more on inpatient and outpatient care than most peer nations spend on their entire health systems (including long-term care, prescription drugs, administration, prevention, and other services).

Prescription drugs are another factor partially explaining the U.S.’s higher health spending. Many prescription drugs cost more in the U.S. than the same drugs do in other comparable nations. In 2021, the U.S. spent $1,635 per capita on prescription drugs and other medical goods (including over-the-counter and clinically delivered pharmaceuticals as­ well as durable and non-durable medical equipment). However, because prescription drugs represent a relatively small share of total health spending, even if per capita prescription drug spending in the U.S. was lowered to be closer to that of comparable countries, that would make only a small dent in the overall difference in health spending.

Spending on health administration is similarly much higher in the U.S. than in comparable countries: $925 per capita. Administrative costs include spending on running governmental health programs and overhead from insurers, but exclude administrative expenditures from health care providers. This includes administrative spending for private health insurance, governmental health programs (such as Medicaid and Medicare) as well as other third-party payers and programs.

The U.S. also spends more on preventive care than peer nations. Activities captured in this spending category vary amongst countries, but in the U.S., it generally consists of public health activities, including preventive health programs and education for immunizations, disease detection, emergency preparedness, and more. The growth in preventive care spending between 2019 and 2021 is notable, considering the 2020 emergence of the COVID-19 pandemic. In the U.S., preventive care spending more than doubled between 2019 and 2020, from $343 to $741 per capita, but subsequently declined to $589 in 2021.

Life Expectancy

Life expectancy is one of the most common measures of health outcomes. In 1980, the average American could expect to live 73.7 years—a similar life expectancy to residents of most wealthy countries. However, in subsequent years, life expectancy continued growing in most other nations at a pace far beyond that of the U.S.

In 1996, Japan became the first nation to report an average life expectancy of 80 years among its population. By 2012, all peer countries had also achieved this milestone. This same year, life expectancy in the U.S. was 78.5 years and began a decade-long plateau. By 2019, the life of the average U.S. resident would be almost four years shorter than the life of the average resident of these comparable wealthy nations (78.8 vs. 82.7 years).

This plateau and four-year gap was already highly concerning, but the health crisis brought on by the COVID-19 pandemic made the situation in the U.S. much worse. Life expectancy dropped, by nearly two years from 78.8 in 2019 to 77.0 in 2020, for the first time ever recorded. The pandemic was not unique to the United States, but this stunning life expectancy drop was – the average comparable nation saw a decline of less than half a year (82.7 to 82.3). In 2021, the situation became even more extreme. Life expectancy in comparable nations saw a small rebound to 82.5 years, but the U.S. saw another drastic decrease to 76.1 years. In 2022, life expectancy rebounded to 77.5 years, still 1.3 years below pre-pandemic levels and almost five years below the average among peer nations.

The life expectancy data presented here are period life expectancy estimates based on excess mortality observed in each year. Period life expectancy at birth represents the mortality experience of a hypothetical cohort if current conditions persist into the future and not the mortality experience of a birth cohort.

Years of Life Lost

The causes of this decrease in life expectancy are multifaceted. When people die before a certain age, the difference between their age at death and the specified age is recorded as life years lost. For example, when looking at years of life lost before age 75, a person who dies at age 60 would be considered to have lost 15 years of life. Examining the causes of these years of life lost can point to the specific factors driving life expectancy down.

The United States has the highest rate of years of life lost by a large margin per 100,000 population aged 75 years old in 2020. However, examining the cause of these years of life lost makes it possible to notice  where the U.S. underperforms compared to these other countries. For example, the U.S. has a significantly higher rate of years of life lost due to heart disease, transport accidents, and accidental poisoning (a category that includes drug overdose) than these other nations.

While cancer is a common cause of premature years of life lost in the United States, most other countries have a similar rate of years of life lost due to cancer in the same population. This indicates that cancer is not a main cause of the discrepancy between the U.S. and peer nations.

Overall, the United States’ higher rates of premature death and disease burden do not necessarily reflect entirely on the quality of care that patients receive in doctor’s offices or hospitals. Life expectancy, mortality rates, and disease burden can also be influenced by factors that are largely outside of the control of the health system, like socioeconomic conditions (e.g. income inequality, structural racism) and differences in health-related behaviors (e.g. diet, exercise, drug use). Children and teens in the U.S. are less likely to make it to adulthood than in peer countries, with the U.S. having higher rates of motor vehicle accidents, firearm deaths, and suicide deaths among children and teens.

Another, more direct way to measure the performance of the health system is to examine the quality of care provided in a hospital or clinical setting. However, inconsistent and imperfect quality metrics make it difficult to compare quality of care in the U.S. and its peers.

In comparison to peer nations, across the limited measures available internationally, the U.S. performs better on some and worse on other indicators of quality of care. For example, the U.S. performs worse on certain measures of treatment outcomes (such as maternal mortality) and some patient safety measures (such as obstetric trauma with instrument and medication or treatment errors). The U.S. performs similarly to or better than peer nations in other measures of treatment outcomes (such as mortality rates within 30 days of acute hospital treatment) and patient safety (such as rates of post–operative sepsis).

Hospital Mortality Rates

Mortality within 30 days of being admitted to a hospital is not entirely preventable, but high quality of care can reduce the mortality rate for certain diagnoses. The 30-day mortality rates after hospital admissions for heart attacks (acute myocardial infarction) and hemorrhagic stroke (caused by bleeding) are similar in the U.S. and comparable countries average. The 30-day mortality rate for ischemic strokes (caused by blood clots) was 4.3 deaths per 100 patients in the U.S. in 2020, compared to an average of 6.2 deaths per 100 patients in similar countries. While the U.S. has lower mortality rates due to these conditions than the average across peer nations, it is important to note that several peer nations have lower rates than the U.S.

Maternal Health

While wealth and economic prosperity are highly correlated with lower maternal mortality rates, the U.S. is an outlier with the highest rate of pregnancy-related deaths (23.8 deaths per 100,000 live births in 2020) when compared to similar countries (3.6 deaths per 100,000 live births).

Within the U.S., there are significant racial disparities in maternal mortality rates. The maternal mortality rate for Black mothers is about three times the rate for White mothers — a disparity that persists across age and socioeconomic groups. Every race and ethnicity, socioeconomic, and age group in the United States sees higher maternal mortality rates than the average in comparable countries. Maternal mortality in the U.S. has risen in recent years, sparking concern from the medical community and policymakers. 

Obstetric trauma is more likely to occur in deliveries where instruments are utilized (i.e., forceps). The rate of obstetric trauma during deliveries with an instrument in the U.S. was 11.7 per 100 vaginal deliveries in 2020, higher than most comparable countries with available data. The rate of obstetric trauma during deliveries without an instrument in the U.S. was 1.7 per 100 vaginal deliveries in 2020, on the lower end among comparable countries with available data.

Hospital Admissions

Hospital admissions for certain chronic diseases, such as cardiac conditions, chronic obstructive pulmonary diseases (COPD), asthma, and diabetes, can arise for a variety of reasons, but preventive services — or lack thereof — play a large role. Hospital admission rates in the U.S. are higher than in comparable countries for congestive heart failure and complications due to diabetes, and some admissions for these chronic conditions could be minimized with adequate primary care. Admission rates in 2020 are likely impacted by the COVID-19 pandemic—patients were less likely to seek hospital treatment, and hospitals were at times overwhelmed and unable to admit patients who would have been admitted in a different year.  

Post-Operative Complications

Rates of post-operative complications are an important measure of hospital safety. Pulmonary embolisms and deep vein thrombosis are common complications after major surgeries, such as hip or knee replacement. The prevalence of post-operative clots for these procedures is higher in the U.S. than in the U.K., Sweden, Belgium, and the Netherlands, but lower than in Australia.

Sepsis is a serious complication for patients with infections, and effects can range from organ failure and shock to death in severe cases. Rates of post-operative infections and sepsis are an important marker of care quality for patients undergoing surgery, because this is a major source of morbidity and mortality that can sometimes be prevented. Prevention is multifactorial and can involve proper operative techniques and training, hygiene and safety protocols, and antibiotic utilization, amongst other things. The rate of post-operative sepsis following abdominal surgery is just under 2% in the U.S., lower than in most peer countries that report data.

Out-of-Pocket Costs

Universal coverage means all residents have health insurance, but it does not mean health care is free. Even in countries with universal coverage, residents often have at least nominal out-of-pocket costs. In fact, people in Switzerland pay more out-of-pocket on health care ($1,688), on average, than Americans do ($1,305) per capita.

Costs are a common barrier to accessing health care in the U.S. More than 1 in 4 Americans report skipping consultations, tests, treatment, or follow-up, and 23% report skipping medication. Only 9.2% of the United States population is uninsured, so these numbers include individuals who have health insurance, but still find medical care unaffordable. While cost-related access barriers are particularly prevalent in the U.S., residents of other countries with universal coverage also report skipping care due to costs.

Appointment Availability

Among people who needed same or next-day medical care, about half (51%) of Americans were able to make a timely appointment, which is somewhat below the average of peer nations (57%).

Physicians

Cost is not the only reason why a person may miss or delay needed medical care. Physician availability can also impact access to care. The U.S. has just 2.7 practicing physicians per 1,000 residents, compared to an average of 3.9 among peer nations.

Also of concern in the U.S. is the ratio of primary to specialty care providers. Most other nations have somewhere between one-quarter and one-half of physicians employed in primary care. Primary care is an integral part of the health system in many nations—a patient sees a primary care physician for most illnesses or injuries and only goes to a specialist or hospital if their primary care doctor decides it is necessary. In the United States, however, only 12% of doctors are primary care physicians (PCPs). Specialist care is more expensive than primary care, driving costs up for patients and health systems.

The U.S. faces this physician shortage and high rates of specialization partly due to how medical education is structured. The U.S. has kept a tight lid on the number of medical schools, as well as the number of training spots available to new doctors. Furthermore, the higher education system in the U.S. places the burden of financing an education on the student, and university tuition is more expensive than in many peer countries. As a result, students borrow money, and most graduate from medical school in significant debt. Because primary care generally comes with a lower salary, some new physicians pursue a higher-paid specialty, even if they would rather work in primary care.

Additionally, the U.S. has only 0.14 psychiatrists per 1,000 residents, the second lowest of all peer nations. Although the U.S. has a high number of specialist providers, only 6% are psychiatrists, compared to an average of 10% of specialists in other countries examined. Despite clear and increasing demand for mental health treatment, psychiatry remains one of the lowest-paid physician specialties in the United States.

The future outlook of health systems will be shaped by various factors, including political and policy changes, technological advancements, economic and demographic shifts, social factors, and unforeseen events – as the COVID-19 pandemic demonstrated. Here are some issues to watch:

Health Outcomes: The United States was already performing worse than its peers across a wide range of health outcomes, but the COVID pandemic widened the gap further and it is not yet clear whether life expectancy and other measures of long-term health outcomes will recover as quickly in the U.S. as in peer nations. The pandemic has underscored the importance of robust health care system capacity, though countries will likely continue to differ in their responses to COVID and preparations for future pandemics. In addition to the pandemic recovery, both the U.S. and peer countries face the challenge of aging populations, leading to increased demand for health care services and long-term care.

Access to Care: Unlike the U.S., similarly large and wealthy nations have long had universal or near-universal health coverage and more robust access to health care. Although the U.S. has recently reached an all-time high rate of insurance coverage, it still lags behind its peers and the ongoing disenrollments from Medicaid may cause the uninsured rate to rise. Additionally, even people who are insured in the U.S. often face such high out-of-pocket costs for medical care that they go without needed care or incur medical debt. Future policymaking in the U.S. may continue to focus on improving insurance coverage rates and addressing cost-related and other barriers to care.

Quality of Care: The adoption of new technologies will shape care delivery in both the United States and its peers. Electronic health records, telemedicine, artificial intelligence, and other digital health tools are becoming more prevalent globally. However, many digital health tools are new, untested, and have unknown implications for quality of care.

Health Spending: Most peer nations place a strong emphasis on cost containment and efficiency and achieve this through regulation of and negotiation with health providers to lower costs. In the U.S., by contrast, the federal and state governments are much more hands-off. However, with the recent passage of the Inflation Reduction Act, the U.S. will start to negotiate certain drug prices. Medicare recently announced the first 10 drugs selected for negotiation under its new drug price negotiation program, which is projected to lower Medicare spending on those drugs. There will likely be ongoing debate over extending drug price negotiation by the federal government outside of Medicare, as well as taking other steps to restrain the price of health care generally.

Health Costs:

• How does health spending in the U.S. compare to other countries? – Peterson-KFF Health System Tracker
• How do healthcare prices and use in the U.S. compare to other countries? – Peterson-KFF Health System Tracker
• What drives health spending in the U.S. compared to other countries – Peterson-KFF Health System Tracker
• How do prices of drugs for weight loss in the U.S. compare to peer nations’ prices? – Peterson-KFF Health System Tracker
• How do prescription drug costs in the United States compare to other countries? – Peterson-KFF Health System Tracker

Health Outcomes:

• How does U.S. life expectancy compare to other countries? – Peterson-KFF Health System Tracker
• Premature mortality during COVID-19 in the U.S. and peer countries – Peterson-KFF Health System Tracker
• What do we know about social determinants of health in the U.S. and comparable countries? – Peterson-KFF Health System Tracker

Access and Quality of Care:

• How does the quality of the U.S. health system compare to other countries? – Peterson-KFF Health System Tracker
• How do U.S. healthcare resources compare to other countries? – Peterson-KFF Health System Tracker
• Percent of adults who made a same-day or next day appointment when needed care

Wager, E. & Cox, C., International Comparison of Health Systems. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2024) https://www.kff.org/health-policy-101-international-comparison-of-health-systems/ (date accessed). 

U.S. government (U.S.) global health efforts aim to help improve the health of people in low- and middle-income countries while also contributing to broader U.S. global development goals, foreign policy priorities, and national security concerns, including helping safeguard the health of Americans. While there is currently no standard, agreed-upon definition of global health, the National Academy of Medicine (formerly Institute of Medicine) defines global health as having “the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities, and deaths.” A key dimension of global health is an emphasis on addressing inequities in health status between rich and poor countries and also for those who are most marginalized within countries, as well as a recognition that the health of people around the world is highly interconnected, with domestic and foreign health inextricably linked.

The U.S. role in global health is multifaceted and includes a broad range of activities. Its primary roles are as a supporter of bilateral (i.e., country-to-country) efforts, directly funding implementation of global health efforts in partner countries, and as a donor to multilateral health institutions (i.e., international organizations that pool support from multiple countries for one or more areas of global health). The U.S. also engages in global health diplomacy through its relationships with other governments, multilateral institutions, non-governmental organizations, and the private sector. Specifically, the U.S. government:

• acts as a donor by providing financial and other health-related development assistance (e.g. commodities, like contraceptives or bed nets for protection from disease-carrying mosquitoes) to low- and middle-income countries;
• operates programs and delivers health services;
• provides technical assistance and other capacity-building support;
• participates in major international health organizations and coordinates health efforts with other stakeholders through global health diplomacy;
• conducts research;
• supports international responses to disasters and other emergencies; and
• partners with governments, non-governmental groups, and the private sector (Figure 1).

U.S. global health activities target a variety of issues and use different intervention approaches such as:

• Health services and systems: improving basic and essential health services, systems, and infrastructure;
• Disease detection and response: supporting surveillance, prevention, and treatment of diseases, including both infectious (e.g. HIV, TB, malaria) and non-communicable diseases (e.g. cardiovascular disease, cancer);
• Population and maternal/child health: promoting maternal health; reproductive health and family planning; child nutrition, immunization, and other child survival interventions;
• Nutrition, water, and environmental health: providing non-emergency food aid and supporting dietary supplementation and food security; clean/safe water and sanitation; mitigation of environmental hazards; and
• Research and development: investigating and developing new technologies, interventions, and strategies, including vaccines, medicines, and diagnostics.

The U.S. government (U.S.) supports global health through a wide array of bilateral and multilateral global health programs in countries around the world. Its major program areas include:

HIV/PEPFAR

While the U.S. first provided funding to address the emerging global HIV epidemic in 1986, U.S. funding and attention for these efforts has grown significantly in the last two decades, particularly following President George W. Bush’s 2003 announcement of the President’s Emergency Plan for AIDS Relief (PEPFAR), the coordinated U.S. government response to global HIV. Now the largest commitment by any nation devoted to a single disease, the launch of PEPFAR led to substantially increased U.S. support for HIV prevention, treatment, and care efforts, as well as U.S. contributions to multilateral entities, including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI). Today, PEPFAR’s efforts aim to ensure that populations with the highest HIV burden – particularly children, young women and adolescents, young men, and key populations— know their HIV status, receive prevention and treatment services, and become virally suppressed.

Tuberculosis (TB)

Since the 1998 launch of USAID’s global TB control program, the U.S. response to global TB has expanded, particularly after 2003 when PEPFAR highlighted the U.S. government’s commitment to addressing TB. Today, these efforts focus on diagnosis, treatment, and control of TB (including multi-drug-resistant and extensively drug-resistant TB, or MDR/XDR TB) as well as on research. The U.S. is also a donor to the Global Drug Facility of the Stop TB Partnership.

Malaria/PMI

Engaged in malaria work since the 1950s, today the U.S. supports expanded malaria efforts in low- and middle-income countries through the President’s Malaria Initiative (PMI), launched in 2005, as well as through research and other activities. PMI programs center on expanding coverage of six key high-impact interventions to control or eliminate malaria, which include: diagnosis of malaria and treatment with artemisinin-based combination therapies (ACTs), entomological monitoring, intermittent preventive treatment in pregnancy (IPTp), indoor residual spraying (IRS) with insecticides, insecticide-treated mosquito nets (ITNs), and seasonal malaria chemoprevention (SMC). The U.S. is also engaged in the RBM Partnership to End Malaria.

Maternal and Child Health (MCH)

Involved in efforts to improve MCH since the 1960s, today U.S. global MCH activities aim to bring to scale a range of high-impact interventions that mitigate maternal, newborn, and under-five deaths; prevent and address the indirect causes of such deaths (such as HIV, TB, and malaria); strengthen integration of maternal health services with family planning; improve equity of access to and use of services by vulnerable populations; and strengthen health systems. The U.S. is also a donor to global organizations and initiatives addressing MCH, such as Gavi, the Vaccine Alliance, the United Nations Children’s Fund (UNICEF), and the Global Polio Eradication Initiative (GPEI).

Nutrition

For more than 40 years, the U.S. has been involved in nutrition efforts in low- and middle-income countries that aim to prevent undernutrition through support for effective interventions, such as nutrition education, nutrition during pregnancy, exclusive breastfeeding, and micronutrient supplementation. U.S. global nutrition efforts are coordinated with the U.S. Feed the Future Initiative (FtF, launched in 2009), which aims to address global hunger and food security.

Family Planning and Reproductive Health (FP/RH)

Engaged since the 1960s in international research on family planning and population issues as well as other FP/RH efforts (including the purchase and distribution of contraceptives in developing countries),  U.S. global FP/RH activities are currently designed to decrease the risk of unintended pregnancies and maternal and child mortality through effective interventions, including contraception, counseling, and post-abortion care. The U.S. also provides funding to global organizations addressing FP/RH, such as the United Nations Population Fund (UNFPA).

Neglected Tropical Diseases (NTDs)

Having historically worked on addressing NTDs through research and surveillance, attention to and funding for U.S. global NTD efforts increased markedly in 2006 with the launch of the USAID NTD Program and the subsequent announcement of expanded efforts across the U.S. government in 2008. Today these efforts focus on seven NTDs (ascariasis or roundworm, hookworm, trichuriasis or whipworm, lymphatic filariasis or elephantiasis, onchocerciasis or river blindness, schistosomiasis or snail fever, and trachoma) that are responsible for the overwhelming majority of the NTD burden but can be controlled and even eliminated with low-cost and effective interventions, such as an integrated control approach targeting multiple NTDs simultaneously through mass drug administration (MDA).

Global Health Security (GHS)

While the U.S. has supported global health security work for more than two decades, its involvement has expanded over time, with attention to these efforts growing significantly due to the COVID-19 pandemic. U.S. global GHS efforts aim to reduce the threat of emerging and re-emerging diseases by supporting preparedness, detection, and response capabilities worldwide. The U.S. has also played a key role in the development and 2014 launch of the “Global Health Security Agenda (GHSA).” Through this international partnership that now involves more than 70 countries and international organizations, the U.S. works to help countries make measurable improvements in their GHS capabilities. The U.S. is also a donor to the new Pandemic Fund, which seeks to provide sustained financing to help countries build their capacity to prevent, prepare for, and respond to epidemics and pandemics.

In FY 2024, U.S. funding for global health totaled $12.3 billion. As Figure 2 shows, the U.S. investment in global health has grown significantly since the early 2000s, in large part due to funding for initiatives such as PEPFAR and PMI but with spikes in some years due to emergency or supplemental funding for disease outbreaks such as Ebola, Zika, and COVID-19. Funding reached its highest level to date in FY 2021, largely due to the U.S. global response to the COVID-19 pandemic.

Although a large majority of the American public overestimates the share of the federal budget that is spent on foreign aid (with nearly half believing that the share is greater than 20%), U.S. foreign aid actually accounts for 1% or less of the federal budget, with U.S. funding for global health—which is part of the foreign affairs budget—accounting for an even smaller share.

U.S. Global Health Funding by Program Area

Looking across funding for the major global health program areas since FY 2006, most U.S. global health funding over time has been directed to HIV programs, accounting for approximately 50% of U.S. global health funding in most years (Figure 3). The Global Fund accounted for the next largest share over the period, followed by MCH and malaria. More recently, the U.S. has emphasized global health security more, with funding for these efforts increasing considerably during the COVID-19 pandemic and afterward. Consistent with this trend, most funding was provided to HIV efforts ($5.4 billion or 44%), followed by the Global Fund ($1.7 billion or 13%) and maternal and child health and global health security (both $1.3 billion or 10%) in FY 2024 (Figure 4).

Bilateral vs. Multilateral Aid

Most U.S. global health funding is provided bilaterally – that is, funding provided by the U.S. directly to or on behalf of a recipient country or region. In FY 2024, about 80% of the U.S. global health budget was provided through bilateral programs. The remainder (about 20%) is provided multilaterally through U.S. contributions to international institutions and organizations (see [“What Multilateral Health Organizations Are Supported by the U.S.?”]).

The U.S. government’s engagement in global health is carried out and overseen by multiple executive branch departments and agencies and the legislative branch, including several congressional committees (Figure 5).

Executive Branch

In general, U.S. global health engagement has developed within two main structures of the Executive Branch of government: the foreign assistance structure, which is predominantly global development-oriented and has close links to foreign policy; and the public health structure, which has its roots in disease prevention, control, and surveillance efforts.

Most funding for and oversight of U.S. global health resides within the foreign assistance structure, including:

• Department of State (State): Established in 1789, the Department of State is the Cabinet-level foreign affairs agency of the United States. It advances U.S. objectives and interests worldwide through its primary role in developing and implementing the President’s foreign policy. It also provides policy direction to USAID, the lead federal agency for development assistance. The Department of State’s new Bureau for Global Health Security and Diplomacy (GHSD) coordinates the Department’s work on global health security, including HIV, and houses PEPFAR.
• U.S. Agency for International Development (USAID): Established in 1961, USAID is an independent U.S. federal government agency that receives overall foreign policy guidance from the Secretary of State. Its role is to support long-term and broad-based economic growth in countries and advance U.S. foreign policy objectives by supporting activities through each of its programmatic functional bureaus (e.g. Bureau for Global Health) and regional bureaus. Most USAID global health programs are coordinated through the Bureau for Global Health, including HIV and other infectious diseases, MCH, nutrition, FP/RH, NTDs, and global health security.
• Millennium Challenge Corporation (MCC): Established in 2004, MCC administers the Millennium Challenge Account (MCA), a U.S. government initiative providing development assistance to eligible countries to promote economic growth and reduce poverty in low- and middle-income countries. Although MCC supports several health-related programs, health is not the main focus or purpose of its work; its design is intended to link MCC contributions for development assistance (to reduce poverty through support for economic growth) to greater responsibility by low- and middle-income countries for successfully attaining certain governance and development benchmarks.

Agencies within the public health structure operate global health programs directly or in conjunction with foreign assistance agencies. They are represented most prominently by several agencies within the Department of Health and Human Services (HHS), including:

• Office of Global Affairs (OGA): OGA’s primary function is global health diplomacy – particularly coordinating and maintaining engagement across HHS and the U.S. government with foreign governments and ministries of health, multilateral organizations, civil society groups, and the private sector – exchanging best practices and sharing technical knowledge to advance U.S. global health priorities and research.
• Centers for Disease Control and Prevention (CDC): With a long history of working on international health issues, CDC focuses on disease control and prevention and health promotion through operations, development assistance, basic and field research, technical assistance, training/exchanges, and capacity building.
• National Institutes of Health (NIH): One of the world’s leading research entities on global health, NIH conducts biomedical and behavioral science research on diseases and disorders to enhance diagnosis, prevention, and treatment and provides technical assistance and training. All 27 of the agency’s institutes and centers engage in global health activities.
• Food & Drug Administration (FDA): The FDA screens pharmaceutical and biological products for safety and efficacy and helps oversee the safety of the U.S. food supply.
• Health Resources and Services Administration (HRSA): HRSA builds human and organizational capacity and promotes health systems strengthening to deliver care in PEPFAR countries.

In addition to the foreign assistance and public health service agencies, other departments and agencies involved in global health include the Department of Defense (DoD), the Department of Agriculture (USDA), the Peace Corps, the Environmental Protection Agency (EPA), the Department of Homeland Security (DHS), the Department of Labor (DoL), the Department of Commerce (Commerce), the Office of the U.S. Trade Representative (USTR), and the National Security Council (NSC). The NSC, which sits within the White House, plays a significant role across the U.S. government, as it is responsible for coordinating and reviewing the U.S. strategy and activities related to global health security, including its international response. In addition, on matters of global health security, it works closely with the White House Office of Pandemic Preparedness and Response (OPPR), which is responsible for domestic policy coordination related to health security.

The daily operations of U.S. global health activities are administered chiefly through the Department of State’s Bureau of Global Health Security and Diplomacy (GHSD), which oversees U.S. global HIV efforts that fall under the PEPFAR program and also provides diplomatic support (through U.S. ambassadors and others) in implementing U.S. global health efforts; USAID; and HHS operating divisions, particularly the CDC. This is also reflected in the way U.S. global health funding is channeled, with most funding provided (appropriated by Congress) to the Department of State (52%), followed by USAID (33%), HHS via NIH (7%) and CDC (5%), and the Department of Defense (DoD) (2%); departments and agencies may then transfer some or all of this funding to other departments and agencies carrying out global health activities.

Legislative Branch

The U.S. Congress introduces, considers, and passes global health-related legislation; oversees global health efforts, specifying how funds for these programs are to be (and not to be) spent; authorizes and appropriates funding; and confirms presidential appointees to key U.S. global health positions. Major committees of the House of Representatives (House) and Senate with jurisdiction over global health efforts include: the House Committee on Foreign Affairs, Senate Committee on Foreign Relations, House Committee on Energy and Commerce, Senate Committee on Health, Education, Labor, and Pensions, and the Senate and House Appropriations Committees.

The U.S. global health response has been defined by numerous governing statutes, authorities, and policy decisions. For instance, the legislation that created PEPFAR in 2003 and its subsequent reauthorizations in 2008, 2013, and 2018 are key statutes of U.S. global health policy, as they govern its bilateral HIV response, bilateral assistance for TB and malaria, and participation in the Global Fund. Other statutory requirements that shape the implementation and scope of U.S. global health activities are those governing U.S. global FP/RH efforts, such as those directing how U.S. funds may not be spent. For instance, the Helms Amendment (1973) prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion. The Kemp-Kasten Amendment (1985) prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it has been invoked at times to restrict funding to UNFPA).

The U.S. provides bilateral support for U.S. global health programs in more than 70 countries, with additional countries reached through U.S. regional global health programs and U.S. contributions to multilateral organizations. Multiple factors determine where the U.S. channels its global health support. While more U.S. support is generally directed to countries facing a higher burden of disease, it is also influenced by factors such as the presence of willing and able partner governments, a history of positive relations and goodwill with host countries, strategic and national security priorities, and funding and personnel availability. The majority of countries receiving U.S. bilateral support for global health (“partner countries”) are located in sub-Saharan Africa (35 countries), followed by the Western Hemisphere (16 countries), East Asia and Oceania (11 countries), South and Central Asia (9 countries), Europe and Eurasia (4 countries), and Middle East and North Africa (4 countries) (Figure 6). Most U.S. bilateral support for global health programs is provided in sub-Saharan Africa (84%) (Figure 7). Furthermore, the top 10 country recipients of U.S. global health funding, representing about 60% of U.S. bilateral support for global health, are all in this region (Figure 8).

The U.S. typically operates more than one health program (HIV, TB, malaria, etc.) in each partner country. While in most countries, the U.S. operates programs in four or fewer global health areas, this number is generally higher in countries in sub-Saharan Africa (five or more).

In addition to its bilateral programs, the U.S. has a long history of engagement with multilateral health organizations and international institutions, beginning with its role in the development of the first such organizations, including the Pan-American Health Organization (PAHO) in the early 1900s and the World Health Organization (WHO) a few decades later. This involvement continues with, for example, the Global Fund (which the U.S. helped to launch in 2001), Gavi (launched in 2000), the GHSA (which the U.S. played a key role in developing and launching in 2014), and the Pandemic Fund (launched in 2022). U.S. support for multilateral global health efforts takes various forms, including:

• Funding. The U.S. is often the largest or one of the largest donors to multilateral health efforts, funding core (generally used to support essential functions and operations) and voluntary (used for specific projects or initiatives the U.S. seeks to support) contributions. About a fifth (19%) of U.S. global health funding supports U.S. contributions to multilateral health organizations (Figure 9).
• Governance. The U.S. is active in the governance structures that oversee multilateral global health organizations and initiatives, including holding permanent or rotating seats on many of their boards.
• Technical assistance. The U.S. offers technical assistance in support of grants to partner countries, providing additional staff capacity to international organizations (by detailing U.S. government employees to these organizations for periods of time).
• Standard setting. The U.S. also engages in standard-setting, weighing in on global plans, treaties, and agreements to respond to a range of health issues as they are developed and considered for approval by the larger body.

Today the U.S. engages with a number of multilateral global health organizations, including health-focused specialty agencies of the United Nations (U.N.) and international financing mechanisms for global health. Key among these are eight to which Congress specifically directs funding (though the U.S. also reaches other multilateral health institutions without direct Congressional appropriations but rather through general support), of which the U.S. is the top contributor to five (the Global Fund, PAHO, UNAIDS, UNICEF, and WHO):

U.N. Agencies

• World Health Organization (WHO): WHO, created in 1948, is the directing and coordinating authority for health within the U.N. system. WHO provides international leadership on global health matters, shaping the health research agenda, setting norms and standards, providing technical support to countries, and monitoring and assessing health trends. The U.S. has been involved in WHO since its creation, providing financial and technical support as well as participating in its governance structure.
• Pan American Health Organization (PAHO): PAHO is the oldest international health agency, founded originally as the International Sanitary Bureau in 1902. The U.S. joined PAHO as a member state in 1925. PAHO, the specialized international health agency for the Americas, “works with countries throughout the region to improve and protect people’s health” and serves as the WHO Regional Office for the Americas and as the health organization of the inter-American System.
• Joint United Nations Programme on HIV/AIDS (UNAIDS): UNAIDS, created in 1996 as the successor organization to the WHO Global Programme on AIDS (GPA), is the leading global organization for addressing HIV/AIDS. Coordinating efforts across the U.N. system, it is made up of 11 U.N. co-sponsors and guided by a Programme Coordinating Board (PCB), which is a subset of its co-sponsors and government representatives. The U.S. currently serves on the PCB.
• United Nations Children’s Fund (UNICEF): UNICEF, created in 1946, aims to improve the lives of children, particularly the most disadvantaged children and adolescents, and is one of the largest purchasers of vaccines worldwide. The U.S. was a founding member that same year.
• United Nations Population Fund (UNFPA): UNFPA, created in 1969, is the largest purchaser and distributor of contraceptives worldwide. While the U.S. helped to found UNFPA and was a leading supporter for many years, its support has fluctuated significantly over the years, due to ongoing U.S. political debates about abortion.

Non-U.N. Financing Mechanisms

• Gavi, the Vaccine Alliance (Gavi): Gavi, created in 2000, is a public-private partnership that aims to increase access to immunization in poor countries. The U.S. has been involved in Gavi since its creation through contributions, participation in Gavi’s governance, and technical assistance. The U.S. is the second largest donor to Gavi’s core programs and the top donor to Gavi’s COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supports low- and middle-income countries through procurement and distribution of COVID-19 vaccines.
• Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund): The Global Fund, created in 2001, is an independent multilateral financing entity that supports HIV, TB, and malaria programs in low- and middle-income countries. The U.S. was involved in creating the Global Fund and maintains a permanent seat on its Board. U.S. contributions and those of other donors are pooled and then provided by the Global Fund to country-driven projects based on technical merit and need.
• TB Global Drug Facility: The Global Drug Facility, created in 2001, is a financing mechanism of the Stop TB Partnership; it provides grants to countries for TB drugs.

U.S. support for multilateral institutions overall has fluctuated over time, reflecting, in part, changing U.S. leadership views on the relative value of bilateralism versus multilateralism. As a result, U.S. engagement in and contributions to specific multilateral health organizations and institutions may change over time. For example, the U.S. under the Trump administration did not participate in the partnership to create  COVAX (an international partnership led by the Coalition for Epidemic Preparedness Innovations [CEPI], Gavi, and WHO) to facilitate greater global access to the COVID-19 vaccine, although Congress did provide $4 billion in emergency funding to Gavi in support of COVID-19 vaccine access. Under the Biden administration, the U.S. joined the COVAX partnership.

Multilateral initiatives complement U.S. bilateral global health efforts, helping make progress toward U.S. goals in various program areas. In some cases, U.S. multilateral global health support allows the U.S. to reach a larger number of countries; it also may help to leverage additional funding and provide opportunities for improved coordination and technical consultations. Additionally, U.S. policies related to funding can greatly influence other financial support for multilaterals. For instance, since U.S. law requires that the U.S. contribution to the Global Fund cannot exceed 33% of total contributions from all donors, the U.S. contribution leverages other donor contributions; in effect, this requirement encourages increased support from other donors and prevents the U.S. from becoming the predominant donor to the Global Fund.

The U.S. is the largest donor to global health, providing almost a third (32%) of all international health assistance among major donors and institutions (Figure 10). The Global Fund – whose top contributor is the U.S. – is the second largest donor to global health.

In addition, the U.S. has historically devoted more of its foreign assistance to health than any other donor government, contributing nearly a quarter of its foreign assistance to global health in 2022 (Figure 11). The U.S. is also the largest government donor to several specific global health areas including HIV and family planning.

The U.S. has been engaged in international health activities for over a century, and today is the largest funder and implementer of global health programs worldwide. In many respects, the U.S. approach to global health will influence and impact how other countries and global entities engage in global health. Among the key issues to watch are:

• The future direction of U.S. leadership in and commitment to global health as well as its ever-evolving strategy toward global health, particularly as U.S. domestic politics increasingly impact decisions about the future of major U.S. global health initiatives (such as the short-term reauthorization of PEPFAR, which was caught up in the larger national debate related to abortion).
• Continued discussion of what U.S. global health funding levels may be going forward, particularly in a challenging U.S. political and budget environment, and whether, given likely funding constraints, U.S. global health efforts will be able to preserve or expand their reach and impact.
• Ongoing efforts to address short- and long-term impacts of COVID-19 on U.S. global health programs in partner countries while better preparing them to meet the next unexpected health challenge through heightened emphasis on building global health security capabilities.
• The appropriate balance between U.S. support for bilateral and multilateral efforts and continuing to coordinate with other donors and multilateral and international organizations, particularly in areas of renewed global concern such as updating the International Health Regulations (IHR), drafting and ratifying a Pandemic Treaty, and contributing to the Pandemic Fund.
• Ways the U.S. aims to accelerate progress across U.S. global health programs sustainably in the context of weak health systems, varied barriers to access, and challenges such as equity and legal and policy hurdles for vulnerable populations and essential health services.
• Attempts to further integrate and better coordinate across disease and program areas of U.S. global health efforts across the U.S. government.

• KFF Global Health Fact Sheets including The U.S. Government and Global Health and Breaking Down the U.S. Global Health Budget by Program Area
• U.S. Global Health Budget Tracker
• The U.S. Congress and Global Health: A Primer
• U.S. Global Health Legislation Tracker
• Key Global Health Positions and Officials in the U.S. Government
• KFF Global Health Budget Summaries
• PEPFAR Policy Resource Hub
• KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries
• KFF Dashboard: Progress Toward Global Malaria Targets in PMI Countries
• What Will Be the Contours of the Biden Administration’s Global Health Agenda?
• Key Issues and Questions for PEPFAR’s Future

Oum, S., Moss, K., & Kates, J., The U.S. Government and Global Health. In Altman, Drew (Editor), Health Policy 101, (KFF, July 2024) https://www.kff.org/health-policy-101-the-u-s-government-and-global-health/ (date accessed).

Health policy and politics are inextricably linked. Policy is about what the government can do to shift the financing, delivery, and quality of health care, so who controls the government has the power to shape those policies. 

Elections, therefore, always have consequences for the direction of health policy – who is the president and in control of the executive branch, which party has the majority in the House and the Senate with the ability to steer legislation, and who has control in state houses. When political power in Washington is divided, legislating on health care often comes to a standstill, though the president still has significant discretion over health policy through administrative actions. And, stalemates at the federal level often spur greater action by states. 

Health care issues often, but not always, play a dominant role in political campaigns. Health care is a personal issue, so it often resonates with voters. The affordability of health care, in particular, is typically a top concern for voters, along with other pocketbook issues, And, at 17% of the economy, health care has many industry stakeholders who seek influence through lobbying and campaign contributions. At the same time, individual policy issues are rarely decisive in elections. 

Health “reform” – a somewhat squishy term generally understood to mean proposals that significantly transform the financing, coverage, and delivery of health care – has a long history of playing a major role in elections. 

Harry Truman campaigned on universal health insurance in 1948, but his plan went nowhere in the face of opposition from the American Medical Association and other groups. While falling short of universal coverage, the creation of Medicare and Medicaid in 1965 under Lyndon Johnson dramatically reduced the number of uninsured people. President Johnson signed the Medicare and Medicaid legislation at the Truman Library in Missouri, with Truman himself looking on. 

Later, Bill Clinton campaigned on health reform in 1992, and proposed the sweeping Health Security Act in the first year of his presidency. That plan went down to defeat in Congress amidst opposition from nearly all segments of the health care industry, and the controversy over it has been cited by many as a factor in Democrats losing control of both the House and the Senate in the 1994 midterm elections. 

For many years after the defeat of the Clinton health plan, Democrats were hesitant to push major health reforms. Then, in the 2008 campaign, Barack Obama campaigned once again on health reform, and proposed a plan that eventually became the Affordable Care Act (ACA). The ACA ultimately passed Congress in 2010 with only Democratic votes, after many twists and turns in the legislative process. The major provisions of the ACA were not slated to take effect until 2014, and opposition quickly galvanized against the requirement to have insurance or pay a tax penalty (the “individual mandate”) and in response to criticism that the legislation contained so-called “death panels” (which it did not). Republicans took control of the House and gained a substantial number of seats in the Senate during the 2010 midterm elections, fueled partly by opposition to the ACA. 

The ACA took full effect in 2014, with millions gaining coverage, but more people viewed the law unfavorably than favorably, and repeal became a rallying cry for Republicans in the 2016 campaign. Following the election of Donald Trump, there was a high profile effort to repeal the law, which was ultimately defeated following a public backlash. The ACA repeal debate was a good example of the trade-offs inherent in all health policies. Republicans sought to reduce federal spending and regulation, but the result would have been fewer people covered and weakened protections for people with pre-existing conditions. KFF polling showed that the ACA repeal effort led to increased public support for the law, which persists today. 

In the 2020 campaign, health reform was a major issue in the Democratic primaries, with a number of prominent candidates supporting a Medicare for All plan. Joe Biden’s platform was centered instead on building upon the ACA. 

The 2024 election presents the unusual occurrence of two candidates – current vice president Kamala Harris and former president Donald Trump – who have already served in the White House and have detailed records for comparison, as explained in this JAMA column.  With President Joe Biden dropping out of the campaign, Harris inherits the record of the current administration, but has also begun to lay out an agenda of her own.

While Trump failed as president to repeal the ACA, his administration did make significant changes to it, including repealing the individual mandate penalty, reducing federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanding short-term insurance plans that can exclude coverage of preexisting conditions. 

In a strange policy twist, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients, with Trump saying it would cause Obamacare to be “dead” and “gone.” But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and federal spending, likely strengthening the ACA. 

In the 2024 campaign, Trump has vowed several times to try again to repeal and replace the ACA, though not necessarily using those words, saying instead he would create a plan with “much better health care.” 

Although the Trump administration never issued a detailed plan to replace the ACA, Trump’s budget proposals as president included plans to convert the ACA into a block grant to states, cap federal funding for Medicaid, and allow states to relax the ACA’s rules protecting people with preexisting conditions. Those plans, if enacted, would have reduced federal funding for health care by about $1 trillion over a decade. 

In contrast, the Biden-Harris administration has reinvigorated the ACA by restoring funding for consumer assistance and outreach and by increasing premium subsidies to make coverage more affordable, resulting in record enrollment in ACA Marketplace plans and historically low uninsured rates. The increased premium subsidies are currently slated to expire at the end of 2025, so the next president will be instrumental in determining whether they get extended. Harris has vowed to extend the subsidies, while Trump has been silent on the issue.

The health care issue most likely to figure prominently in the general election is abortion rights, with sharp contrasts between the presidential candidates and the potential to affect voter turnout. In all the states where voters have been asked to weigh in directly on abortion so far (California, Kansas, Kentucky, Michigan, Montana, Ohio, and Vermont), abortion rights have been upheld. 

Trump paved the way for the US Supreme Court to overturn Roe v Wade by appointing judges and justices opposed to abortion rights. Trump recently said, “for 54 years they were trying to get Roe v Wade terminated, and I did it and I’m proud to have done it.” During the current campaign, Trump has said that abortion policy should now be left to the states. 

As president, Trump had also cut off family planning funding to Planned Parenthood and other clinics that provide or refer for abortion services, but this policy was reversed by the Biden-Harris administration. 

Harris supports codifying into federal the abortion access protections in Roe v Wade.

Trump has often spotlighted the high price of prescription drugs, criticizing both the pharmaceutical industry and pharmacy benefit managers. Although he kept the issue of drug prices on the political agenda as president, in the end, his administration accomplished little to contain them. 

The Trump administration created a demonstration program, capping monthly co-pays for insulin for some Medicare beneficiaries at $35. Late in his presidency, his administration issued a rule to tie Medicare reimbursement of certain physician-administered drugs to the prices paid in other countries, but it was blocked by the courts and never implemented. The Trump administration also issued regulations paving the way for states to import lower-priced drugs from Canada. The Biden-Harris administration has followed through on that idea and recently approved Florida’s plan to buy drugs from Canada, though barriers still remain to making it work in practice. 

With Harris casting the tie-breaking vote in the Senate, President Biden signed the Inflation Reduction Act, far-reaching legislation that requires the federal government to negotiate the prices of certain drugs in Medicare, which was previously banned. The law also guarantees a $35 co-pay cap for insulin for all Medicare beneficiaries, and caps out-of-pocket retail drug costs for the first time in Medicare. Harris supports accelerating drug price negotiation to apply to more drugs, as well as extending the $35 cap on insulin copays and the cap on out-of-pocket drug costs to everyone outside of Medicare.

How Trump would approach drug price negotiations if elected is unclear. Trump supported federal negotiation of drug prices during his 2016 campaign, but he did not pursue the idea as president and opposed a Democratic price negotiation plan. During the current campaign, Trump said he “will tell big pharma that we will only pay the best price they offer to foreign nations,” claiming that he was the “only president in modern times who ever took on big pharma.” 

Beyond drug prices, the Trump administration issued regulations requiring hospitals and health insurers to be transparent about prices, a policy that is still in place and attracts bipartisan support. 

Ultimately, irrespective of the issues that get debated during the campaign, the outcome of the 2024 election – who controls the White House and Congress – will have significant implications for the future direction of health care, as is almost always the case. 

However, even with changes in party control of the federal government, only incremental movement to the left or the right is the norm. Sweeping changes in health policy, such as the creation of Medicare and Medicaid or passage of the ACA, are rare in the U.S. political system. Similarly, Medicare for All, which would even more fundamentally transform the financing and coverage of health care, faces long odds, particularly in the current political environment. This is the case even though most of the public favors Medicare for All, though attitudes shift significantly after hearing messages about its potential impacts. 

Importantly, it’s politically difficult to take benefits away from people once they have them. That, and the fact that seniors are a strong voting bloc, has been why Social Security and Medicare have been considered political “third rails.” The ACA and Medicaid do not have quite the same sacrosanct status, but they may be close. 

•  Election 2024 Resources
• Compare the Candidates on Health Care Policy 
• The Role of Health Care in the New Presidential Election 
• What Would Another Trump Presidency Mean for Health Care? 
• The Implications of the Public’s Preexisting Condition—Amnesia  

Levitt, L., The Politics of Health Care and the 2024 Election. In Altman, Drew (Editor), Health Policy 101, (KFF, September 2024) https://www.kff.org/health-policy-101-the-politics-of-health-care-and-the-2024-election/ (date accessed).

The federal government is not the only place health policy is made in the U.S., but it is by far the most influential. Of the $4.5 trillion the U.S. spent on health in 2022, the federal government was responsible for roughly a third of all health services. The payment and coverage policies set for the Medicare program, in particular, often serve as a model for the private sector. Many health programs at the state and local levels are also impacted by federal health policy, either through direct spending or rules and requirements. Federal health policy is primarily guided by Congress, but carried out by the executive branch, predominantly by the Department of Health and Human Services.  

No one is “in charge” of the fragmented U.S. health system, but the federal government probably has the most influence, a role that has grown over the last 75 years. Today the federal government pays for care, provides it, regulates it, and sponsors biomedical research and medical training.   

The federal government pays for health coverage for well over 100 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the Veterans’ Health Administration, the Indian Health Service, and the Affordable Care Act (ACA).  It also pays to help provide insurance coverage for tens of millions who are active-duty and retired military and for civilian federal workers. 

Federal taxpayers also underwrite billions of dollars in health research, mainly through the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).   

Federal public health policy is spearheaded by the Centers for Disease Control and Prevention. Its portfolio includes tracking not just infectious disease outbreaks in the U.S. and worldwide, but also conducting and sponsoring public health research and tracking national health statistics.  

The Health Resources and Services Administration (HRSA) funds critical health programs for underserved Americans (including Community Health Centers) and runs workforce education programs to bring more health services to places without enough health care providers.  

Meanwhile, in addition to overseeing the nation’s largest health programs, the Centers for Medicare and Medicaid Services (CMS) also operates the federal insurance Marketplaces created by the ACA and enforces rules made by the law for private insurance policies.  

While the federal government exercises significant authority over medical care and its practice and distribution, state and local governments still have key roles to play.   

States oversee the licensing of health care professionals, distribution of health care resources, and regulation of health insurance plans that are not underwritten by employers themselves. State and local governments share responsibility for most public health activities and often operate safety-net facilities in areas with shortages of medical resources.  

All three branches of the federal government – Congress, the executive branch, and the judiciary – play important roles in health policy.  

Congress makes laws that create new programs or modify existing ones. It also conducts “oversight” of how the executive branch implements the laws Congress has passed. Congress also sets the budget for “discretionary” and “mandatory” health programs (see below) and provides those dollar amounts.  

The executive branch carries out the laws made by Congress and operates the federal health programs, often filling in details Congress has left out through rules and regulations. Federal workers in the health arena may provide direct patient care, regulate how others provide care, set payment rates and policies, conduct medical or health systems research, regulate products sold by the private sector, and manage the billions of dollars the federal government spends on the health-industrial complex.   

Historically, the judiciary has had the smallest role in health policy but has played a pivotal role in recent cases. It passes judgment on how or whether certain laws or policies can be carried out and settles disputes between the federal government, individuals, states, and private companies over how health care is regulated and delivered.  Recent significant decisions from the Supreme Court have affected the legality and availability of abortion and other reproductive health services and the constitutionality of major portions of the ACA. 

The Executive Branch – The White House 

Although most of the executive branch’s health policies are implemented by the Department of Health and Human Services (and to a smaller extent, the Departments of Labor and Justice), over the past several decades the White House itself has taken on a more prominent role in policy formation. The White House Office of Management and Budget not only coordinates the annual funding requests for the entire executive branch, but it also reviews and approves proposed regulations, Congressional testimony, and policy recommendations from the various departments. The White House also has its own policy support agencies – including the National Security Council, the National Economic Council, the Domestic Policy Council, and the Council of Economic Advisors, that augment what the President receives from other portions of the executive branch. 

Most federal health policy is made through the Department of Health and Human Services. Exceptions include the Veterans Health Administration, run by the Department of Veterans Affairs; TRICARE, the health insurance program for active-duty military members and dependents, run by the Defense Department; and the Federal Employees Health Benefits Program (FEHB), which provides health insurance for civilian federal workers and families and is run by the independent agency the Office of Personnel Management.   

The health-related agencies within HHS are roughly divided into the resource delivery, research, regulatory, and training agencies that comprise the U.S. Public Health Service and the health insurance programs run by the Centers for Medicare and Medicaid Services (CMS).  

Ten of the 13 operating divisions of HHS are part of the U.S. Public Health Service, which also plays a role in U.S. global health programs. They are:  

• The Administration for Strategic Preparedness and Response (ASPR)
• The Advanced Research Projects Agency for Health  (ARPA-H)
• The Agency for Healthcare Research and Quality (AHRQ)  
• The Agency for Toxic Substances and Disease Registry (ATSDR)  
• The Centers for Disease Control and Prevention (CDC)  
• The Food and Drug Administration (FDA)  
• The Health Resources and Services Administration (HRSA)  
• The Indian Health Service (IHS)  
• The National Institutes of Health (NIH)  
• The Substance Abuse and Mental Health Services Administration (SAMHSA)  

The Centers for Medicare and Medicaid Services (CMS) is by far the largest operating division of HHS. It oversees not just the Medicare and Medicaid programs, but also the federal Children’s Health Insurance Program (CHIP) and the health insurance portions of the Affordable Care Act. Together, the programs under the auspices of CMS account for nearly a quarter of all federal spending in fiscal 2023, cost an estimated $1.5 Trillion in fiscal 2023, and served more than 170 million Americans – more than half the population.  

How Congress oversees the federal health care-industrial complex is almost as byzantine as the U.S. health system itself. Jurisdiction and responsibility for various health agencies and policies is divided among more than two dozen committees in the House and Senate (see Table 1 and Table 2 below).  

In each chamber, however, three major committees deal with most health issues.   

In the House, the Ways and Means Committee, which sets tax policy, oversees Part A of Medicare (because it is funded by the Social Security payroll tax) and shares jurisdiction over other parts of the Medicare program with the Energy and Commerce Committee. Ways and Means also oversees tax subsidies and credits for the Affordable Care Act and tax policy for most employer-provided insurance.   

The Energy and Commerce Committee has sole jurisdiction over the Medicaid program in the House and shares jurisdiction over Medicare Parts B, C, and D with Ways and Means. Energy and Commerce also oversees the U.S. Public Health Service, whose agencies include the Food and Drug Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention.   

While Ways and Means and Energy and Commerce are in charge of the policymaking for most of the federal government’s health programs, the actual amounts allocated for many of those programs are determined by the House Appropriations Committee through the annual Labor-Health and Human Services-Education and Related Agencies spending bill.   

In the Senate, responsibility for health programs is divided somewhat differently. The Senate Finance Committee, which, like House Ways and Means, is in charge of tax policy, oversees all of Medicare and Medicaid and most of the ACA.   

The Senate counterpart to the House Energy and Commerce Committee is the Senate Health, Education, Labor and Pensions Committee, which has jurisdiction over the Public Health Service (but not Medicare or Medicaid).   

The Senate Appropriations Committee, like the one in the House, sets actual spending for discretionary programs as part of its annual Labor-HHS-Education spending bill.  

Under Article 1 of the U.S. Constitution, Congress is granted the exclusive power to “lay and collect Taxes, Duties, Imposts and Excises, and to pay the Debts and provide for the common Defence and General Welfare of the United States.”   

In 1974, lawmakers passed the Congressional Budget and Impoundment Control Act in an effort to standardize the annual process for deciding tax and spending policy for each federal fiscal year and to prevent the executive branch from making spending policy reserved to Congress. Among other things, it created the House and Senate Budget Committees and set timetables for each step of the budget process.   

Perhaps most significantly, the 1974 Budget Act also created the Congressional Budget Office (CBO). This non-partisan agency has come to play a pivotal role in not just the budget process, but in the lawmaking process in general. The CBO issues economic forecasts, policy options, and other analytical reports, but it most significantly produces estimates of how much individual legislation would cost or save the federal government. Those estimates can and do often determine if legislation passes or fails.  

The annual budget process is supposed to begin the first Monday in February, when the President is to present his proposed budget for the fiscal year that begins the following Oct. 1. This is one of the few deadlines in the Budget Act that is usually met.  

After that, the action moves to Congress. The House and Senate Budget Committees each write their own “Budget Resolution,” a spending blueprint for the year that includes annual totals for mandatory and discretionary spending. Because mandatory spending (roughly two-thirds of the budget) is automatic unless changed by Congress, the budget resolution may also include “reconciliation instructions” to the committees that oversee those programs (also known as “authorizing” committees) to make changes to bring the cost of the mandatory programs in line with the terms of the budget resolution. The discretionary total will eventually be divided by the House and Senate Appropriations Committees between the 12 subcommittees, each responsible for a single annual spending (appropriations) bill. Most of those bills cover multiple agencies – the appropriations bill for the Department of Health and Human Services, for example, also includes funding for the Departments of Labor and Education.   

After the budget resolution is approved by each chamber’s Budget Committee, it goes to the House and Senate floor, respectively, for debate. Assuming the resolutions are approved, a “conference committee” comprised of members from each chamber is tasked with working out the differences between the respective versions. A final compromise budget resolution is supposed to be approved by both chambers by April 15 of each year. (This rarely happens.) Because the final product is a resolution rather than a bill, the budget does not go to the President to sign or veto.   

The annual appropriations process kicks off May 15, when the House may start considering the 12 annual spending bills for the fiscal year that begins Oct. 1. By tradition, spending bills originate in the House, although sometimes, if the House is delayed in acting, the Senate will take up its own version of an appropriation first. The House is supposed to complete action on all 12 spending bills by June 30, in order to provide enough time to let the Senate act, and for a conference committee to negotiate a final version that each chamber can approve by October 1.  

That October 1 deadline is the only one with consequences if it is not met. Unless an appropriations bill for each federal agency is passed by Congress and signed by the President by the start of the fiscal year, that agency must shut down all “non-essential” activities funded by discretionary spending until funding is approved. Because Congress rarely passes all 12 of the appropriations bills by the start of the fiscal year (the last time was in 1996, for fiscal year 1997), it can buy extra time by passing a “continuing resolution” (CR) that keeps money flowing, usually at the previous fiscal year’s level. CRs can last as little as a day and as much as the full fiscal year and may cover all of the federal government (if none of the regular appropriations are done) or just the departments for the unfinished bills. Congress may, and frequently does, pass multiple CRs while it works to complete the appropriations process.  

While each appropriations bill is supposed to be considered individually, to save time (and sometimes to win needed votes), a few, several, or all the bills may be packaged into a single “omnibus” measure. Bills that package only a handful of appropriations bills are cheekily known as “minibuses.”   

Meanwhile, if the budget resolution includes reconciliation instructions, that process proceeds on a separate track. The committees in charge of the programs requiring alterations each vote on and report their proposals to the respective budget committees, which assemble all of the changes into a single bill. At this point, the budget committees’ role is purely ministerial; it may not change any of the provisions approved by the authorizing committees.   

Reconciliation legislation is frequently the vehicle for significant health policy changes, partly because Medicare and Medicaid are mandatory programs. Reconciliation bills are subject to special rules, notably on the Senate floor, which include debate time limitations (no filibusters) and restrictions on amendments. Reconciliation bills also may not contain provisions that do not pertain directly to taxing or spending.  

Unlike the appropriations bills, nothing happens if Congress does not meet the Budget Act’s deadline to finish the reconciliation process, June 15. In fact, in more than a few cases, Congress has not completed work on reconciliation bills until the calendar year AFTER they were begun.    

Congress writes the nation’s laws, but it cannot account for every detail in legislation. So, it often leaves key decisions about how to interpret and enforce those laws to the various executive departments. Those departments write (and often rewrite) rules and regulations according to a very stringent process laid out by the 1946 Administrative Procedure Act (APA). The APA is intended to keep the executive branch’s decision-making transparent and to allow public input into how laws are interpreted and enforced. 

Most federal regulations use the APA’s “informal rulemaking” process, also known as “notice and comment rulemaking,” which consists of four main parts:  

• Publication of a “Notice of Proposed Rulemaking (NPRM)” in the Federal Register, a daily publication of executive branch activities.  
• Solicitation to the public to submit written comments for a specific period of time (usually from 30 to 90 days).  
• Agency consideration of public reaction to the proposed rule; and, finally  
• Publication of a final rule, with an explanation including how the agency took the public comments into account and what changes, if any, were made from the proposed rule. Final rules also include an effective date, which can be no less than 30 days but may be more than a year in the future.  

In situations where time is of the essence, federal agencies may truncate that process by issuing “interim final rules,” which can take effect even before the public is given a chance to comment. Such rules may or may not be revised later.   

Not all federal interpretation of laws uses the APA’s specified regulatory process. Federal officials also distribute guidance, agency opinions, or “statements of policy.”  

Given how fragmented health policy is in both Congress and the executive branch, it should not be a surprise that major changes are difficult and rare.  

Add to that an electorate divided over whether the federal government should be more involved or less involved in the health sector, and huge lobbying clout from various interest groups whose members make a lot of money from the current operation of the system, and you have a prescription for inertia. 

One potential wildcard—in June of 2024, the Supreme Court overturned a 40-year-old precedent, known as “Chevron deference,” that gave the benefit of the doubt in interpreting ambiguous laws passed by Congress to federal agencies rather than judges. Overturning Chevron will likely make it easier for outsiders to challenge federal agency actions, but it will be some time before the full ramifications become clear.  

Another problem is that when a new health policy can dodge the minefield of obstacles to become law, it almost by definition represents a compromise that may help it win enough votes for passage, but is more likely to complicate an already byzantine system further. 

Unless the health system completely breaks down, it seems unlikely that federal policymakers will be able to move the needle very far in either a conservative or a liberal direction. 

• FAQs on Health Spending, the Federal Budget, and Budget Enforcement Tools 
• Medicare 101 
• Medicaid 101
• The Affordable Care Act 101
• Employer-Sponsored Health Insurance
• The Regulation of Private Health Insurance
• The U.S. Government and Global Health 
• The U.S. Congress and Global Health: A Primer 

Rovner, J., Congress, the Executive Branch, and Health Policy. In Altman, Drew (Editor), Health Policy 101, (KFF, January 2025) https://www.kff.org/health-policy-101-congress-and-the-executive-branch-and-health-policy/ (date accessed).