Illness is big business in the United States. In 2000, the world's largest economy spent 13% of its gross domestic product on health care.1 It has a workforce of 650 000 doctors.2 The resources are vast, but how are they administered, and do they really meet the health needs of the United States' 280 million people?

The US system is extremely diverse and decentralised, and traditionally, funding and delivery are separately administered.1

There is a mixture of both private and public funding. Nearly two thirds of people have their health care funded through private insurance schemes through their workplace.1 A much smaller number purchase private health insurance individually.

The federal and state governments commit a large amount of public money to health care through schemes designed to cover those who are not protected by private insurance. The largest of these schemes are Medicare, which finances health care for virtually all people older than 65,1 and Medicaid which provides for approximately 40% of the people who fall below the federal poverty line.3

The delivery of health care is largely by private providers. Two thirds of hospitals are run on a private, not for profit basis; the remainder are private for profit, or public.1

The traditional divide in the United States between funding and delivery underwent dramatic change through the 1990s, with the introduction of a system known as "managed care." Funding and delivery are linked, to address escalating healthcare costs. Individuals pay a set fee to a managed care organisation in return for services. Previously, individual insurance claims were made for services as required.

The United States has the most advanced healthcare technology in the world. Patient satisfaction is generally high. However, high tech multiple intervention treatment does not always equate with high quality effective care. Unnecessary interventions may be a source of illness themselves.

No evidence suggests that the massive expenditure on health translates into greater contact with health services or better health outcomes. Although the United States is the wealthiest nation in the world, and spends the most on health care, it has a lower life expectancy than many nations that spend less. Remember that health indicators are not just the result of health care.

Access to the vast resources in the United States is deeply unequal. Over 40 million people are without health insurance of any kind, either private or public. Lack of insurance varies with ethnic group, education, income, and region. For example, although 14% of the total population are uninsured, this figure is 32% for Hispanics, and 26% for those without a high school diploma.1

The US healthcare system continues to face considerable challenges in meeting the health needs of the US people. Costs are escalating, but spending is apparently not delivering results on a population level. Many countries dream of having the resources for health that the United States has, but it serves as a reminder that resources are not the only barrier to health.