Topic: Health coverage: who's required to have it, and who actually pays
What does United States require?
Everyday topic
The United States has no federal individual mandate — the 2019 Tax Cuts and Jobs Act zeroed out the federal penalty for going uninsured — though Massachusetts, New Jersey, California, Rhode Island, and Washington D.C. still enforce their own state penalties. Coverage is assembled from separate pieces: employer-sponsored insurance is the largest category, Medicare covers those 65 and older, Medicaid is means-tested with eligibility varying by state (roughly 40 states expanded it to 138% of the federal poverty line, about 10 did not), and everyone else can shop healthcare.gov for income-based subsidies. The uninsured rate was 8.0% in 2024 (27.1 million people). Lawfully present immigrants generally wait five years before qualifying for full Medicaid (refugees are exempt); undocumented immigrants can only access Emergency Medicaid. Per-capita spending hit $14,570 in 2023 — 17.6% of GDP — the only one of the seven with no universal coverage guarantee yet by far the highest spending.
What is this topic?
Taiwan's National Health Insurance Act declares enrollment mandatory in its very first article, launched in March 1995, with premiums split employer 60%, insured person 30%, government 10%.
Japan closed the last gap in "universal coverage" only in 1961, after a 1958 law forced every municipality to run its own scheme; patient co-payments still scale by age, from 10% at 75-plus to 30% between 6 and 69.
Indonesia's 2004 SJSN Law states outright that "participation is compulsory," and a foreign worker becomes covered after six months on the job — almost the same threshold Taiwan uses.
Brazil's SUS is the direct product of Article 196 of its 1988 Constitution, "health is a right of all and a duty of the State," free to anyone within its borders.
China, by contrast, reports 95% nominal coverage, but its employee and resident schemes reimburse hospital stays at rates 18 points apart — 84.1% versus 66.0%.
India has no universal mandate at all: PM-JAY reaches only the poorest 40% of households, and out-of-pocket spending still runs 43.4% of the total.
The United States is the only one of the seven with no coverage guarantee whatsoever — its federal mandate has existed in name only since 2019, 8.0% of the population remained uninsured in 2024, and it spends more per person on healthcare than any other.
Sources and dates
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