Who's in charge of American healthcare?
The honest answer: everyone and no one. Understanding who holds which piece is the first step to fixing it.
You don't need a law degree to understand how healthcare is governed. You just need a map.
UNDERSTANDING THE SYSTEM
There is no CEO of American healthcare
Many of us picture "the healthcare system" as one big organization with someone at the top. It isn't. No single department directs every hospital, insurer, doctor, and pharmacy. Instead, authority is spread across Congress, federal agencies, 50 states, private companies, employers, and professional boards. Each controls a different piece.
Imagine trying to fix your city's traffic without knowing who maintains the roads, who runs the buses, or who regulates the airport. Even great ideas would go to the wrong people. Healthcare works the same way.
That complexity can make reform feel impossible. It isn't. Complex systems can be improved, but only when we know which institution is responsible for which part.
Healthcare governance resembles an ecosystem more than a hierarchy.
How Americans Get Coverage
Not one system: six different doors
Most Americans don't have “healthcare.” They have a particular kind of coverage, and each kind is governed by different people under different rules. Change jobs, turn 65, or lose income, and you may walk through a different door, with a different rulebook.
| Coverage type | Share | Who it covers | Who governs it | What that means |
|---|---|---|---|---|
| Employer plan | 53.5% | Workers and their families | Federal law, including ERISA and the tax code | State insurance laws reach employer plans bought from insurers, but generally not self-funded employer plans. |
| Medicare | 20.1% | People 65 and older, plus some people with disabilities | Congress writes the law; CMS administers the program | CMS also oversees private Medicare Advantage plans, which operate under a different set of arrangements from traditional Medicare. |
| Medicaid and CHIP | 17.1% | Lower-income adults, children, pregnant women, people with disabilities, and nursing-home residents | Federal-state partnership | CMS sets federal requirements; each state administers its own program within those requirements. |
| Individual and ACA Marketplace plans | 10.5% | Self-employed people, early retirees, and others without job-based coverage | Federal ACA rules and state insurance regulators | States have different regulatory roles. Pennsylvania operates its own ACA Marketplace, Pennie. |
| Military and veterans' care | 2.8% / 1.2% | Service members, veterans, and eligible family members | Department of Defense and Department of Veterans Affairs | TRICARE serves eligible military communities; the VA operates its own healthcare system, including hospitals. |
| Uninsured | 7.9% | People without health insurance | No single coverage system governs their care | Emergency departments must screen and stabilize qualifying emergency medical conditions; community health centers help fill some gaps. |
Employer plan
53.5% of the population
- Who it covers
- Workers and their families.
- Who governs it
- Federal law, including ERISA and the tax code.
- What that means
- State insurance laws reach employer plans bought from insurers, but generally not self-funded employer plans.
Medicare
20.1% of the population
- Who it covers
- People 65 and older, plus some people with disabilities.
- Who governs it
- Congress writes the law; CMS administers the program.
- What that means
- CMS also oversees private Medicare Advantage plans, which operate under a different set of arrangements from traditional Medicare.
Medicaid and CHIP
17.1% of the population
- Who it covers
- Lower-income adults, children, pregnant women, people with disabilities, and nursing-home residents.
- Who governs it
- Federal-state partnership.
- What that means
- CMS sets federal requirements; each state administers its own program within those requirements.
Individual and ACA Marketplace plans
10.5% of the population
- Who it covers
- Self-employed people, early retirees, and others without job-based coverage.
- Who governs it
- Federal ACA rules and state insurance regulators.
- What that means
- States have different regulatory roles. Pennsylvania operates its own ACA Marketplace, Pennie.
Military and veterans' care
2.8% military / 1.2% VA
- Who it covers
- Service members, veterans, and eligible family members.
- Who governs it
- Department of Defense and Department of Veterans Affairs.
- What that means
- TRICARE serves eligible military communities; the VA operates its own healthcare system, including hospitals.
Uninsured
7.9% · 26.7 million people
- Who it covers
- People without health insurance.
- Who governs it
- No single coverage system governs their care.
- What that means
- Emergency departments must screen and stabilize qualifying emergency medical conditions; community health centers help fill some gaps.
Percentages may overlap because some people have more than one type of coverage during the year. Source: U.S. Census Bureau, Health Insurance Coverage in the United States: 2025, released September 2026.
Six doors, six rulebooks, and no one responsible for how they fit together. That gap is exactly what infrastructure governance is meant to close.
Who holds which piece
The healthcare system is a partnership — and responsibility is shared. Different players govern different parts, from the national level to the state level and within the private sector.
Congress
Writes the laws and sets the budget.
Federal agencies (HHS, CMS, FDA)
Turn laws into rules and run Medicare.
Legislatures and governors
Run Medicaid and regulate facilities and hospitals.
Insurance commissioners
Oversee insurers, rates, and complaints.
Employers
Buy coverage for most working families.
Insurers and PBMs
Manage benefits, claims, and drugs.
Care providers
Hospitals, doctors, nurses, and pharmacies.
Oversight boards
License, accredit, and set standards.
Federal government
Congress writes the laws for Medicare, Medicaid, employer plans, and the ACA.
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States
Many of the biggest opportunities for reform already sit at the state level.
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Insurance commissioners
They review policies, investigate complaints, and enforce consumer protections.
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Private and professional institutions
Government sets the rules, but private organizations deliver most care.
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Patients
Every governance map should end where healthcare begins.
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Following a Healthcare Dollar
Where does the money actually go?
We often say healthcare is expensive. We less often ask where the money goes. Every healthcare dollar starts with someone who pays: your employer, you, or taxpayers. Before it reaches a nurse's paycheck or a hospital bed, it passes through several layers.
Purchasers
Employers, families, and taxpayers
Health plans
Process claims and manage networks
Care providers
Hospitals, practices, labs, pharmacies
Patient care
Clinicians and staff, equipment, buildings
PBMs
Set drug formularies and negotiate pharmacy payments
Each layer adds administration, and each answers to a different authority.
Some of those layers add real value. Others mainly add administration, and each answers to a different authority. Following the dollar helps us ask the right question: is each layer serving the mission of healthcare, or just taking a share of it?
Real numbers that bring this home: In 2025, the average job-based family plan cost $26,993 a year. Workers paid $6,850 of that directly, and employers paid the rest. That employer share is money that could otherwise go toward wages. [Source: KFF 2025 Employer Health Benefits Survey]
Send your concern to the office that can actually act
Citizens often take every healthcare frustration to Congress or the President. But many problems belong somewhere else, and some can be solved without a new law at all. Before asking "Who agrees with me?", ask: "Who has the authority to act?"
| If your concern is about… | Who has authority | Where to start |
|---|---|---|
| Medicare law or federal rules for employer plans (ERISA) | Congress, especially the Senate HELP and Finance Committees | Your U.S. Representative and Senators |
| Tax treatment of job-based insurance | The House Energy and Commerce and Ways and Means Committees | Your congressional representatives |
| Medicare payment rules, Medicare Advantage oversight, or hospital price transparency | CMS, within the Department of Health and Human Services | Public comment on proposed rules at regulations.gov |
| A denied claim, a network with an in-network doctor, or a dispute with a state-regulated insurer | Your state insurance commissioner | File a complaint with your state insurance department |
| A denial from an employer plan that is self-funded | U.S. Department of Labor (Employee Benefits Security Administration) | Your HR department first, then the Department of Labor |
| Medicaid eligibility or benefits | Your state Medicaid agency or state legislature | Your state legislators |
| State insurance laws, PBM rules, licensing, telehealth, or scope of practice | Your state legislature | Your state senator and representative |
| Fraud, price-fixing, hospital mergers, or deceptive practices | Your state attorney general and federal antitrust agencies | Your attorney general's consumer protection office |
| Which plans, PBMs, and networks your job offers | Your employer | Your HR or benefits department |
| Billing practices, patient safety, or quality at a hospital | Hospital leadership and board, plus your state health department | The hospital's patient advocate |
Medicare law or federal rules for employer plans (ERISA)
Who has authority Congress, especially the Senate HELP and Finance Committees.
Where to start Your U.S. Representative and Senators.
Tax treatment of job-based insurance
Who has authority The House Energy and Commerce and Ways and Means Committees.
Where to start Your congressional representatives.
Medicare payment rules, Medicare Advantage, or hospital price transparency
Who has authority CMS, within the Department of Health and Human Services.
Where to start Comment on proposed rules at regulations.gov.
A denied claim or dispute with a state-regulated insurer
Who has authority Your state insurance commissioner.
Where to start File a complaint with your state insurance department.
A denial from a self-funded employer plan
Who has authority U.S. Department of Labor (Employee Benefits Security Administration).
Where to start Contact your HR department first, then the Department of Labor.
Medicaid eligibility or benefits
Who has authority Your state Medicaid agency or state legislature.
Where to start Your state legislators.
State insurance laws, PBM rules, licensing, telehealth, or scope of practice
Who has authority Your state legislature.
Where to start Your state senator and representative.
Fraud, price-fixing, hospital mergers, or deceptive practices
Who has authority Your state attorney general and federal antitrust agencies.
Where to start Your attorney general's consumer protection office.
Which plans, PBMs, and networks your job offers
Who has authority Your employer.
Where to start Your HR or benefits department.
Billing practices, patient safety, or hospital quality
Who has authority Hospital leadership and board, plus your state health department.
Where to start The hospital's patient advocate.
Did you know?
The rules governing American healthcare are often less visible than the bills patients receive. These three facts help explain where authority lies—and why it matters.
The coverage gap
67%
Most job-based plans are beyond your state's reach
About 67% of workers with employer coverage are in self-funded plans, where employers pay claims directly and an insurer may simply administer them. A federal law called ERISA largely exempts these plans from state insurance laws. That means many state insurance protections may not apply to your own plan.
Know your regulator
50 States
The most important office you've never heard of
Every state has an insurance department led by an insurance commissioner or equivalent official. These regulators can investigate complaints and oversee insurers, with authority over matters such as network adequacy and premium rates varying by state. Some commissioners are elected; others, including Pennsylvania's, are appointed. Their offices are an important starting point for insurance concerns.
The hidden middlemen
Nearly 80%
Three middlemen handle most of America's prescriptions
Pharmacy benefit managers (PBMs) help determine which drugs health plans cover and negotiate pharmacy reimbursement. In 2023, the three largest PBMs processed nearly 80% of the roughly 6.6 billion prescriptions filled in the United States. Their influence over drug access and pharmacy payments often goes unnoticed by patients.