proportion of total health care spending that is accounted for by public sources, approximately 40 percent in the United States versus 95 percent in Norway (the highest), 87 percent in the United Kingdom, and over 70 percent in France, Germany, and Japan (Schieber and Poullier, 1991). Distinctiveness is often a matter of pride, as are high expenditures for a socially valued service. No pride can, however, be derived from the fact that this country spends so much more on health care than other countries while leaving a significantly larger fraction of its population uninsured and not appearing to achieve clearly superior health outcomes.

Nonetheless, virtually all economically advanced countries—regardless of how they finance and deliver care—worry that their health care costs are too high or at least increasing too quickly. Furthermore, given the nation's wealth, commitment to medical research and technological development, and other factors, it is quite likely that the United States would lead the world in the proportion of national resources devoted to health care even if 20, 40, or 60 years ago it had adopted some other system of health care coverage. If it had followed the pattern of other developed nations, however, it might not also lead in the proportion of the population uninsured.

Scope and Functions

Within the United States, the offering of health benefits to employees and their families is virtually universal in large and medium-sized organizations (those with 100 or more employees). Only about half of all workers are, however, employed by these organizations, and this fraction is declining. Among the smallest organizations (those with fewer than 25 employees), only about one-third of workers receive coverage directly from their employer, former employer, or union. The reasons are diverse: many small employers feel that even limited coverage is too expensive, others believe their employees do not need or want it, and some do not see its provision as an employer's responsibility. In general, those who manage and work for small organizations operate in environments with problems and options regarding health coverage that differ in significant ways from the environments faced by larger firms.

Large organizations generally cover a large portion of the cost or premium for employee coverage, but their contributions for family coverage vary considerably. In addition, they often help employees understand their health coverage and resolve problems with specific health plans. Moreover, large employers have become increasingly active in health benefit management by offering employees choices among competing health benefit plans, limiting employee choice of health care practitioners, adding managed care features to indemnity health plans, and developing workplace health promo-

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