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In the United States, health insurance has been generally employment‐based, so long as it is affordable for the employer to offer this health care coverage to employees. The higher one's income in this country, the greater the likelihood of having health insurance coverage. The opposite is true for those with low incomes, especially those with poverty‐level incomes. Patients who are at poverty levels often cannot afford insurance premiums nor can they afford, in the majority of instances, out‐of‐pocket health care costs. Since the inception of private health insurance in the late 1920s following the development of hospitals as the center of health care and subsequent rising health care costs (Starr, 1983), private health insurance from third‐party payers such as insurance companies has been generally voluntarily offered as a benefit to employees and sometimes their families. Patients may make payments to providers of health care and third‐party payers. Providers of health care deliver service to patients and bill third‐party payers. Third‐party payers may make payments to providers as direct payment fees for individuals, capitated payment for services for a group of patients, or as prospective payments for future patients. Health insurance distributes health care funds from the healthy to the sick (Figure 2.4).

FIGURE 2.4 Economic relationships in the health care delivery system.

Source: Adapted from “What Can Americans Learn from Europeans?” by U. E. Reinhardt, 1989, Health Care Financing Review [Supplement], pp. 97–103.