<P> Among those whose employer pays for health insurance, the employee may be required to contribute part of the cost of this insurance, while the employer usually chooses the insurance company and, for large groups, negotiates with the insurance company . Government programs directly cover 28% of the population (83 million), including the elderly, disabled, children, veterans, and some of the poor, and federal law mandates public access to emergency services regardless of ability to pay . Public spending accounts for between 45% and 56% of U.S. health care spending . </P> <P> Administration of health care constitutes 30 percent of U.S. health - care costs . </P> <P> Healthcare is subject to extensive regulation at both the federal and the state level, much of which "arose haphazardly". Under this system, the federal government cedes primary responsibility to the states under the McCarran - Ferguson Act . Essential regulation includes the licensure of health care providers at the state level and the testing and approval of pharmaceuticals and medical devices by the U.S. Food and Drug Administration (FDA), and laboratory testing . These regulations are designed to protect consumers from ineffective or fraudulent healthcare . Additionally, states regulate the health insurance market and they often have laws which require that health insurance companies cover certain procedures, although state mandates generally do not apply to the self - funded health care plans offered by large employers, which exempt from state laws under preemption clause of the Employee Retirement Income Security Act . </P> <P> In 2010, the Patient Protection and Affordable Care Act (PPACA) was signed by President Barack Obama and includes various new regulations, with one of the most notable being a health insurance mandate which requires all citizens to purchase health insurance . While not regulation per se, the federal government also has a major influence on the healthcare market through its payments to providers under Medicare and Medicaid, which in some cases are used as a reference point in the negotiations between medical providers and insurance companies . </P>

Who makes health policy in the united states
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