The provision of Healthcare in the United States before and after the introduction of the Affordable Care Act. A comparative institutional analysis of OECD countries

Abstract

In this master’s thesis, I present an extended comparative-institutional analysis of healthcare systems across the world, with particular focus on the United States’ healthcare model. To achieve the final goal of evaluating U.S. healthcare and comparing it with other OECD healthcare models, the analysis will start by categorizing and describing welfare states, as they are the big frameworks in which healthcare can be encapsulated. Chapter one will take advantage of the categorization offered by the famous danish sociologist Gøsta Esping-Andersen to provide an overall classifications of welfare models across the world, outlining for each of them the characteristic traits and constructing the rationale for a more peculiar analysis of healthcare systems. After this necessary introduction, chapter two and chapter three will confront the core argument of this thesis, that will be based on an in-depth analysis of the model of healthcare adopted in the United States. The decision of investigating this particular system comes from intense debate that has always characterized U.S. healthcare and from the peculiarity – and controversies – it has generated over the last decade, thanks to the introduction of the Affordable Care Act. The ACA marked a consistent step forward in the provision of healthcare in the United States: promoted by President Barack Obama, its ambitious goal was to increase the access and affordability of the system, being the last stop before a universal healthcare model. After a decade since its implementation, the reform is now mature for an evaluation, that, in this thesis, will be performed using the Iron Triangle of Healthcare, a model for the evaluation of healthcare systems across the world ideated by Professor William Kissick in 1994. The results of this evaluation will outline that, even though access and quality have been improved, costs have dramatically increased, questioning the sustainability of the system in the long run, and the desired universal healthcare model is, in practice, still far from becoming reality. The final chapter will end the work by comparing healthcare systems in OECD countries, taking reference examples that help to concretize the study. The final comparison will outline how difficult it is to produce a perfect model of healthcare, since even the best reference cases have flaws that are now brutally evident with COVID-19 pandemic. Policy makers and institutions have therefore to rethink their current systems, aggregating the positive dimensions already in-place and constructing a more collectively oriented healthcare.