equivalent NHS operations in Wales, Scotland and Northern Ireland do not often fund treatment outside of their own facilities. Whether the NHS funds treatment in a private hospital is a decision for the local commissioning health authority based on formal service contracts. United States The United States has a two-tier health system, but most of the population cannot gain access to the public provision tiers. Healthcare provided directly by the government is limited to military and veteran families and to certain Native American tribes. Certain cities and towns also provide free care directly but only to those who cannot afford to pay. Medicare, Medicaid, and the State Children's Health Insurance Program pay for health care obtained at private facilities but only for the elderly, disabled, and children in poor families. Since enacting the Patient Protection and Affordable Care Act in 2010, Medicaid has been substantially expanded, and federal subsidies are available for low- to middle-income individuals and families to purchase private health insurance. The debate over healthcare reform in the United States has included a proposal for a public option or Medicare for all, a government-run insurance program, available to all US citizens, to compete with or replace private insurance plans. See also Health in Trinidad and Tobago Canadian and American health care systems compared Health care compared – tabular comparisons of the US, Canada, and other countries not shown above Universal health care References Canadian political phrases Health policy