why the us should have universal health care essay

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US Health Care vs. Countries with Universal Healthcare

Published by ‍

Dhruv Gupta

June 21, 2021

Inquiry-driven, this article reflects personal views, aiming to enrich problem-related discourse.

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The debate about health care is one of the most important and contentious in the current political climate, being ranked second in the list of important voting issues of the 2020 presidential election, per surveys conducted by the Pew Research Center . America remains one of the only developed nations to not provide its residents with universal health care, much to the chagrin of leading Democrats such as Bernie Sanders and Elizabeth Warren, who advocated for the vast expansion of Medicare to cover all people as part of their primary challenges. In the end, the more moderate Joe Biden secured both the Democtartic presidential bid and the presidency, running on a platform centered around setting up a public option, slightly expanding Medicare coverage, and enforcing regulations on the private sector. Neither of their policies, however, are perfect, nor are they the only possible solutions. The health care policy debate is a multifaceted issue with other countries finding various innovative solutions, all of which America can take some inspiration from.

Of the 92 percent of Americans covered for all or part of 2019, approximately 68 percent were covered through the private sector and 34.1 percent obtained coverage from the public sector. The private sector includes individuals or organizations providing health care or supplying insurance not directly owned or controlled by the government. Everyone is eligible for coverage under the private sector, and 49% of Americans get private health care from their employers. The public sector , on the other hand, encompasses organizations or insurance plans provided and/or controlled by the government. This consists of the government-funded health insurance plans, Medicare, Medicaid, and CHIP, which only certain individuals are eligible for. This system is strewn with issues and requires change immediately.

American healthcare, simply put, is too expensive . Evidence suggests that having insurance lowers mortality; nearly 10% of Americans do not have health insurance due to its unaffordability. The high prices come from an array of places, with one of the largest contributors being the staggering administrative costs. Due to America’s extremely complex multi-payer system with seperate plans from seperate providers with separate coverage, deductibles and premiums, 8% of health care costs go toward administrative costs.

Further burdening the system is the rigid pharmaceutical industry, which offers drugs at continuously rising prices. On average, Americans spend four times as much as their counterparts in other industrialized countries on pharmaceutical drugs due to the low amount of regulation. Fee-for-service transactions also play a large part in the costs of the system. Each procedure or prescription has a seperate cost; health care providers often do more than needed to charge patients extra. Apart from just providing extra unnecessary service, hospitals will also charge you more for them! A procedure that costs $6,390 in the Netherlands and $7,370 in Switzerland costs $32,230 in the United States. Lastly, this system is not ready for the future. America has an unhealthy population and does not have a strong enough healthcare system to compensate; the lifespan of the average American is three years less than that of a Briton.

The two most prominent health care reform plans have both been proposed by Democrats. “Medicare for All,” the plan endorsed by Sanders and Warren, would drastically change the current system. It would create a single-payer national health insurance program to provide all Americans with comprehensive health care coverage, free of charge. There would be no premiums, deductibles, co-pays, or surprise bills. It would also cap the price of prescription drugs by allowing Medicare to negotiate with large companies and completely abolish the private sector of health insurance. This plan would ensure coverage for all Amricans while also providing them with the same quality of service at lower prices. However, analysts believe the government will not be able to negotiate down prices as steeply as Sanders predicted. This plan would also drive up the usage of health care, as people will not be as careful with their health without financial incentives to do so. Other Democrats like Biden have suggested to build upon the current systems in healthcare through the “Public Option” plan. It would set up a public option similar to Medicare that anyone could buy into and expand Medicare coverage to 60- to 65-year-olds. It would also regulate the private sector, capping individual healthcare premiums at 8.5% of income, allowing Medicare to negotiate drug prices with manufacturers, banning surprise medical bills for procedures that require out-of-network hospital care, and ensuring coverage for pre-existing conditions. This plan would also assure that all Americans are insured, while also allowing those who like their current insurance plan to keep it if they can afford to do so. However, private insurers believe that they would not be able to compete with the cheaper public option, and it would be expensive to immediately cover the 8.5% of uninsured Americans on a plan that not everyone is joining.

If either of these policies were to be implemented, America would join the majority of developed countries offering coverage to all their residents. Countries such as France, Germany, Switzerland, and Canada have all adopted some form of universal health care, each with their own unique components and advantages. One constant between all four nations however, is that the average life expectancy of their citizens is over two years longer than that of the United States’. 

French health care is a single-payer system that is both universal and compulsory, with the Statutory Health Insurance (SHI) providing coverage for citizens. The system is paid for by payroll taxes, income taxes, taxes on tobacco and alcohol, and the pharmaceutical sector. The SHI reimburses health care providers for 70 to 80% of their fees, with patients paying the remaining fee out of pocket. French residents pay more income taxes than Americans for SHI, but they pay far less in out-of-pocket costs. France has a longer life expectancy and lower infant mortality rate than America. In addition, 56% of the French population could get a same-day or next-day appointment when sick, as opposed to only 51% in the United States in 2014. That year, only 17% of the French population experienced an affordability barrier, compared to 33% of the United States population.

Switzerland boasts a highly decentralized universal health care system, with cantons, which are similar to American states, in charge of its operation. The system is paid for by enrollee premiums, state taxes, social insurance contributions, and out-of-pocket payments. Swiss residents are required to purchase basic coverage from private nonprofit insurers, which covers physician visits, hospital care, pharmaceuticals, home care, medical services for long-term care, etc. Supplemental insurance can also be purchased, securing a greater choice of physicians and accommodations. Switzerland has lower government spending per capita on healthcare than America, with every resident covered.

Healthcare in Canada is free-of-charge and universal, with the coverage being funded by provincial and federal taxes; estimates find that health care costs approximately $5,789 annually per person. There is no federal plan; each province creates their own health care plan that must abide by the guidelines set by the Canadian Health Act. While Canadian universal health care covers most procedures and costs, some health care services require cost-sharing such as vision care, dental care, and ambulances. Private insurance can also be purchased in Canada to help with these costs, and 2/3 of Canadians have some form of private insurance. 

Germany has a universal multi-payer health care system with statutory health insurance for all of those under a salary level and private insurance for all above that level who choose to purchase their own. The German health care system is financed mostly by employees and employers, with employees donating 7.5% of their salary into a public health insurance pool and employers matching that donation. In this system, those who can afford to pay more will pay more, while those who can’t pay less. Everyone has equal access to healthcare, and the system imposes strict limits on out-of-pocket costs, further protecting their people.

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Hey, my name is Dhruv Gupta and I’m a 17 year old from California. I enjoy writing satire for YIP, and also serve as the organization's Director of Technology. I also love to stay educated on the new and contentious topics.

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Healthcare is a human right – but not in the United States

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The Supreme Court’s ruling on Dobbs v. Jackson in June is just the latest blow to health rights in the United States. National medical associations in the U.S. agree that abortion is essential to reproductive healthcare. So why would abortion not be protected as such? Because the U.S. does not, and never has, protected a right to health.  

Good health is the foundation of a person’s life and liberty. Injury and disease are always disruptive, and sometimes crippling. We might have to stop working, cancel plans, quarantine, hire help, and in cases of long-term disability, build whole new support systems to accommodate a new normal.

The U.S. remains the only high-income nation in the world without universal access to healthcare. However, the U.S. has signed and ratified one of the most widely adopted international treaties that includes the duty to protect the right to life. Under international law, the right to life simply means that humans have a right to live, and that nobody can try to kill another. Healthcare, the United Nations says, is an essential part of that duty. In 2018, the U.N. Committee on Civil and Political Rights said the right to life cannot exist without equal access to affordable healthcare services (including in prisons), mental health services, and notably, access to abortion. The U.N. committee mentioned health more than a dozen times in its statement on the right to life.

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The bottom line is: the U.S. can’t claim to protect life if it fails to protect health. And it has consistently failed on all three of the U.N.’s measures— the latest being access to abortion.

In the U.S., our debates around healthcare, and especially abortion, are hampered by a lack of right to health. Instead, the Supreme Court in 1973 protected access to abortion through the rights to privacy and due process, not health. Privacy is mentioned only twice by the U.N. committee commentary on the right to life.

Since Dobbs, several state legislatures have declared it fair game to criminalize abortion procedures even in cases where pregnancy threatens maternal health or life. Despite ample evidence that restrictive abortion laws lead to spikes in maternal mortality and morbidity—core public health indicators—the Court prior to the Dobb’s decision has defended abortion as merely a matter of privacy, not health or life. We know this is a myth. Abortion is deeply tied to the ability to stay healthy and in some cases, alive.

Regardless, our political parties remain deeply polarized on access to healthcare, including abortion. But lawmakers should know there is historical backing in the U.S. for elevating a right to health. None other than U.S. president Franklin D. Roosevelt, first proposed healthcare as a human right in his State of the Union address in 1944, as part of his ‘Second Bill of Rights.’ His list featured aspirational economic and social guarantees to the American people, like the right to a decent home and, of course, the right to adequate medical care.

Eleanor Roosevelt later took the Second Bill of Rights to the U.N., where it contributed to the right to health being included in the Universal Declaration of Human Rights in 1948. The right to health is now accepted international law, and is part of numerous treaties, none of which the U.S. Senate has seen fit to ratify. The U.S. conservative movement has historically declared itself averse to adopting rights that might expand government function and responsibility. In contrast, state legislatures in red states are keen to expand government responsibility when it comes to abortion. The conservative movement condemns government interference in the delivery of healthcare—except when it comes to reproductive health. The American Medical Association has called abortion bans a “direct attack” on medicine, and a “brazen violation of patients’ rights to evidence-based reproductive health services.”

Excepting access to abortion, U.S. lawmakers have largely left healthcare to the markets, rather than government. True, the government funds programs like Medicaid and Medicare but these programs vary significantly in quality and access by state, falling far short of providing fair, equitable, universal access to good healthcare.

The only two places where the U.S. government accepts some responsibility for the provision of healthcare are 1) in prisons and mental health facilities; and 2) in the military. While healthcare services in the U.S. prison system are notoriously deficient, they nevertheless exist and are recognized as an entitlement, underpinning the right to life. As an example, in 2005 a federal court seized control of the failing healthcare system in California’s Department of Corrections citing preventable deaths. In the military, free healthcare is an entitlement, and the quality of that care is deemed good enough even for the U.S. president.

So why doesn’t everyone in the U.S. have the same rights?

It is an uphill battle in a country that sees health and healthcare as a private matter for markets and individuals to navigate. But if we want to improve public health in the U.S. we need to start legislating healthcare as a right—and recognize that achieving the highest possible standards of public health is a legitimate government function.

photo: Tony Gutierrez / AP Photo

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• Universal Health Care

The Importance of Universal Health Care in Improving Our Nation’s Response to Pandemics and Health Disparities

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• Proposed Policy Statements
• Date: Oct 24 2020
• Policy Number: LB20-06

Key Words: Health Insurance, Health Care, Health Equity

Abstract The COVID pandemic adds a new sense of urgency to establish a universal health care system in the United States. Our current system is inequitable, does not adequately cover vulnerable groups, is cost prohibitive, and lacks the flexibility to respond to periods of economic and health downturns. During economic declines, our employer-supported insurance system results in millions of Americans losing access to care. While the Affordable Care Act significantly increased Americans’ coverage, it remains expensive and is under constant legal threat, making it an unreliable conduit of care. Relying on Medicaid as a safety net is untenable because, although enrollment has increased, states are making significant Medicaid cuts to balance budgets. During the COVID-19 pandemic, countries with universal health care leveraged their systems to mobilize resources and ensure testing and care for their residents. In addition, research shows that expanding health coverage decreases health disparities and supports vulnerable populations’ access to care. This policy statement advocates for universal health care as adopted by the United Nations General Assembly in October 2019. The statement promotes the overall goal of achieving a system that cares for everyone. It refrains from supporting one particular system, as the substantial topic of payment models deserves singular attention and is beyond the present scope.

Relationship to Existing APHA Policy Statements We propose that this statement replace APHA Policy Statement 20007 (Support for a New Campaign for Universal Health Care), which is set to be archived in 2020. The following policy statements support the purpose of this statement by advocating for health reform:

• APHA Policy Statement Statement 200911: Public Health’s Critical Role in Health Reform in the United States
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

In addition, this statement is consistent with the following APHA policies that reference public health’s role in disaster response:

• APHA Policy Statement 20198: Public Health Support for Long-Term Responses in High-Impact, Postdisaster Settings
• APHA Policy Statement 6211(PP): The Role of State and Local Health Departments in Planning for Community Health Emergencies
• APHA Policy Statement 9116: Health Professionals and Disaster Preparedness
• APHA Policy Statement 20069: Response to Disasters: Protection of Rescue and Recovery Workers, Volunteers, and Residents Responding to Disasters

Problem Statement Discussions around universal health care in the United States started in the 1910s and have resurfaced periodically.[1] President Franklin D. Roosevelt attempted twice in the 1940s to establish universal health care and failed both times.[1] Eventually, the U.S. Congress passed Medicare and Medicaid in the 1960s. Universal health care more recently gained attention during debates on and eventual passage of the Affordable Care Act (ACA).[2]

To date, the U.S. government remains the largest payer of health care in the United States, covering nearly 90 million Americans through Medicare, Medicaid, TRICARE, and the Children’s Health Insurance Program (CHIP).[3] However, this coverage is not universal, and many Americans were uninsured[4] or underinsured[5] before the COVID-19 pandemic.

The COVID-19 pandemic has exacerbated underlying issues in our current health care system and highlighted the urgent need for universal health care for all Americans.

Health care is inaccessible for many individuals in the United States: For many Americans, accessing health care is cost prohibitive.[6] Coverage under employer-based insurance is vulnerable to fluctuations in the economy. Due to the COVID-19 pandemic, an estimated 10 million Americans may lose their employer-sponsored health insurance by December 2020 as a result of job loss.[7] When uninsured or underinsured people refrain from seeking care secondary to cost issues, this leads to delayed diagnosis and treatment, promotes the spread of COVID-19, and may increase overall health care system costs.

The ACA reformed health care by, for instance, eliminating exclusions for preexisting conditions, requiring coverage of 10 standardized essential health care services, capping out-of-pocket expenses, and significantly increasing the number of insured Americans. However, many benefits remain uncovered, and out-of-pocket costs can vary considerably. For example, an ACA average deductible ($3,064) is twice the rate of a private health plan ($1,478).[4] Those living with a disability or chronic illness are likely to use more health services and pay more. A recent survey conducted during the COVID-19 pandemic revealed that 38.2% of working adults and 59.6% of adults receiving unemployment benefits from the Coronavirus Aid, Relief, and Economic Security (CARES) Act could not afford a $400 expense, highlighting that the COVID-19 pandemic has exacerbated lack of access to health care because of high out-of-pocket expenses.[8] In addition, the ACA did not cover optometry or dental services for adults, thereby inhibiting access to care even among the insured population.[9]

Our current health care system cannot adequately respond to the pandemic and supply the care it demands: As in other economic downturns wherein people lost their employer-based insurance, more people enrolled in Medicaid during the pandemic. States’ efforts to cover their population, such as expanding eligibility, allowing self-attestation of eligibility criteria, and simplifying the application process, also increased Medicaid enrollment numbers.[10] The federal “maintenance of eligibility” requirements further increased the number of people on Medicaid by postponing eligibility redeterminations. While resuming eligibility redeterminations will cause some to lose coverage, many will remain eligible because their incomes continue to fall below Medicaid income thresholds.[10]

An urgent need for coverage during the pandemic exists. Virginia’s enrollment has increased by 20% since March 2020. In Arizona, 78,000 people enrolled in Medicaid and CHIP in 2 months.[11] In New Mexico, where 42% of the population was already enrolled in Medicaid, 10,000 more people signed up in the first 2 weeks of April than expected before the pandemic.[11] Nearly 17 million people who lost their jobs during the pandemic could be eligible for Medicaid by January 2021.[12]

While increasing Medicaid enrollment can cover individuals who otherwise cannot afford care, it further strains state budgets.[11] Medicaid spending represents a significant portion of states’ budgets, making it a prime target for cuts. Ohio announced $210 million in cuts to Medicaid, a significant part of Colorado’s $229 million in spending cuts came from Medicaid, Alaska cut $31 million in Medicaid, and Georgia anticipates 14% reductions overall.[11]

While Congress has authorized a 6.2% increase in federal Medicaid matching, this increase is set to expire at the end of the public health emergency declaration (currently set for October 23, 2020)[13] and is unlikely to sufficiently make up the gap caused by increased spending and decreased revenue.[14] Given the severity and projected longevity of the pandemic’s economic consequences, many people will remain enrolled in Medicaid throughout state and federal funding cuts. This piecemeal funding strategy is unsustainable and will strain Medicaid, making accessibility even more difficult for patients.

Our health care system is inequitable: Racial disparities are embedded in our health care system and lead to worse COVID-19 health outcomes in minority groups. The first federal health care program, the medical division of the Freedmen’s Bureau, was established arguably out of Congress’s desire for newly emancipated slaves to return to working plantations in the midst of a smallpox outbreak in their community rather than out of concern for their well-being.[15] An effort in 1945 to expand the nation’s health care system actually reinforced segregation of hospitals.[15] Moreover, similar to today, health insurance was employer based, making it difficult for Black Americans to obtain.

Although the 1964 Civil Rights Act outlawed segregation of health care facilities receiving federal funding and the 2010 ACA significantly benefited people of color, racial and sexual minority disparities persist today in our health care system. For example, under a distribution formula set by the U.S. Department of Health and Human Services (DHHS), hospitals reimbursed mostly by Medicaid and Medicare received far less federal funding from the March 2020 CARES Act and the Paycheck Protection Program and Health Care Enhancement Act than hospitals mostly reimbursed by private insurance.[16] Hospitals in the bottom 10% based on private insurance revenue received less than half of what hospitals in the top 10% received. Medicare reimburses hospitals, on average, at half the rate of private insurers. Therefore, hospitals that primarily serve low-income patients received a disproportionately smaller share of total federal funding.[16]

Additional barriers for these communities include fewer and more distant testing sites, longer wait times,[17] prohibitive costs, and lack of a usual source of care.[18] Black Americans diagnosed with COVID-19 are more likely than their White counterparts to live in lower-income zip codes, to receive tests in the emergency department or as inpatients, and to be hospitalized and require care in an intensive care unit.[19] Nationally, only 20% of U.S. counties are disproportionately Black, but these counties account for 52% of COVID-19 diagnoses and 58% of deaths.[20] The pre-pandemic racial gaps in health care catalyzed pandemic disparities and will continue to widen them in the future.

Our health care system insufficiently covers vulnerable groups: About 14 million U.S. adults needed long-term care in 2018.[21] Medicare, employer-based insurance, and the ACA do not cover home- and community-based long-term care. Only private long-term care insurance and patchwork systems for Medicaid-eligible recipients cover such assistance. For those paying out of pocket, estimated home care services average $51,480 to $52,624 per year, with adult day services at more than $19,500 per year.[22]

Our current health care system also inadequately supports individuals with mental illness. APHA officially recognized this issue in 2014, stating that we have “lacked an adequate and consistent public health response [to behavioral health disorders] for several reasons” and that the “treatment of mental health and substance use disorders in the United States has been provided in segregated, fragmented, and underfunded care settings.”[23]

The COVID-19 pandemic has brought urgency to the universal health care discussion in the United States. This is an unprecedented time, and the pandemic has exacerbated many of the existing problems in our current patchwork health care system. The COVID-19 pandemic is a watershed moment where we can reconstruct a fractured health insurance system into a system of universal health care.

Evidence-Based Strategies to Address the Problem We advocate for the definition of universal health care outlined in the 2019 resolution adopted by the United Nations General Assembly, which member nations signed on to, including the United States. According to this resolution, “universal health coverage implies that all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services, and essential, safe, affordable, effective and quality medicines and vaccines, while ensuring that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor, vulnerable and marginalized segments of the population.”[24]

Our current system is inaccessible, inflexible, and inequitable, and it insufficiently covers vulnerable populations. Here we present supporting evidence that universal health care can help address these issues.

Universal health care can increase accessibility to care: Evidence supporting universal health care is mostly limited to natural experiments and examples from other countries. Although countries with universal health care systems also struggle in containing the COVID-19 pandemic, their response and mortality outcomes are better owing to their robust universal systems.[25]

While individuals in the United States lost health care coverage during the pandemic, individuals in countries with universal health care were able to maintain access to care.[26–28] Some European and East Asian countries continue to offer comprehensive, continuous care to their citizens during the pandemic.

Taiwan’s single-payer national health insurance covers more than 99% of the country’s population, allowing easy access to care with copayments of $14 for physician visits and $7 for prescriptions. On average, people in Taiwan see their physician 15 times per year.[27] Also, coronavirus tests are provided free of charge, and there are sufficient hospital isolation rooms for confirmed and suspected cases of COVID-19.[28]

Thai epidemiologists credit their universal health care system with controlling the COVID-19 pandemic.[29] They have described how their first patient, a taxi driver, sought medical attention unencumbered by doubts about paying for his care. They benefit from one of the lowest caseloads in the world.[29]

Universal health care is a more cohesive system that can better respond to health care demands during the pandemic and in future routine care: Leveraging its universal health care system, Norway began aggressively tracking and testing known contacts of individuals infected with COVID-19 as early as February 2020. Public health officials identified community spread and quickly shut down areas of contagion. By April 30, Norway had administered 172,586 tests and recorded 7,667 positive cases of COVID-19. Experts attribute Norway’s success, in part, to its universal health care system.[26] Norway’s early comprehensive response and relentless testing and tracing benefited the country’s case counts and mortality outcomes.

Once China released the genetic sequence of COVID-19, Taiwan’s Centers for Disease Control laboratory rapidly developed a test kit and expanded capacity via the national laboratory diagnostic network, engaging 37 laboratories that can perform 3,900 tests per day.[28] Taiwan quickly mobilized approaches for case identification, distribution of face masks, containment, and resource allocation by leveraging its national health insurance database and integrating it with the country’s customs and immigration database daily.[28] Taiwan’s system proved to be flexible in meeting disaster response needs.

Although these countries’ success in containing COVID-19 varied, their universal health care systems allowed comprehensive responses.

Universal health care can help decrease disparities and inequities in health: Several factors point to decreased racial and ethnic disparities under a universal health care model. CHIP’s creation in 1997 covered children in low-income families who did not qualify for Medicaid; this coverage is associated with increased access to care and reduced racial disparities.[30] Similarly, differences in diabetes and cardiovascular disease outcomes by race, ethnicity, and socioeconomic status decline among previously uninsured adults once they become eligible for Medicare coverage.[31] While universal access to medical care can reduce health disparities, it does not eliminate them; health inequity is a much larger systemic issue that society needs to address.

Universal health care better supports the needs of vulnerable groups: The United States can adopt strategies from existing models in other countries with long-term care policies already in place. For example, Germany offers mandatory long-term disability and illness coverage as part of its national social insurance system, operated since 2014 by 131 nonprofit sickness funds. German citizens can receive an array of subsidized long-term care services without age restrictions.[32] In France, citizens 60 years and older receive long-term care support through an income-adjusted universal program.[33]

Universal health care can also decrease health disparities among individuals with mental illness. For instance, the ACA Medicaid expansion helped individuals with mental health concerns by improving access to care and effective mental health treatment.[34]

Opposing Arguments/Evidence Universal health care is more expensive: Government spending on Medicare, Medicaid, and CHIP has been increasing and is projected to grow 6.3% on average annually between 2018 and 2028.[35] In 1968, spending on major health care programs represented 0.7% of the gross domestic product (GDP); in 2018 it represented 5.2% of the GDP, and it is projected to represent 6.8% in 2028.[35] These estimates do not account for universal health care, which, by some estimates, may add $32.6 trillion to the federal budget during the first 10 years and equal 10% of the GDP in 2022.[36]

Counterpoint: Some models of single-payer universal health care systems estimate savings of $450 billion annually.[37] Others estimate $1.8 trillion in savings over a 10-year period.[38] In 2019, 17% of the U.S. GDP was spent on health care; comparable countries with universal health care spent, on average, only 8.8%.[39]

Counterpoint: Health care services in the United States are more expensive than in other economically comparable countries. For example, per capita spending on inpatient and outpatient care (the biggest driver of health care costs in the United States) is more than two times greater even with shorter hospital stays and fewer physician visits.[40] Overall, the United States spends over $5,000 more per person in health costs than countries of similar size and wealth.[40]

Counterpoint: Administrative costs are lower in countries with universal health care. The United States spends four times more per capita on administrative costs than similar countries with universal health care.[41] Nine percent of U.S. health care spending goes toward administrative costs, while other countries average only 3.6%. In addition, the United States has the highest growth rate in administrative costs (5.4%), a rate that is currently double that of other countries.[41]

Universal health care will lead to rationing of medical services, increase wait times, and result in care that is inferior to that currently offered by the U.S. health care system. Opponents of universal health care point to the longer wait times of Medicaid beneficiaries and other countries as a sign of worse care. It has been shown that 9.4% of Medicaid beneficiaries have trouble accessing care due to long wait times, as compared with 4.2% of privately insured patients.[42] Patients in some countries with universal health care, such as Canada and the United Kingdom, experience longer wait times to see their physicians than patients in the United States.[43] In addition, some point to lower cancer death rates in the United States than in countries with universal health care as a sign of a superior system.[44]

Another concern is rationing of medical services due to increased demands from newly insured individuals. Countries with universal health care use methods such as price setting, service restriction, controlled distribution, budgeting, and cost-benefit analysis to ration services.[45]

Counterpoint: The Unites States already rations health care services by excluding patients who are unable to pay for care. This entrenched rationing leads to widening health disparities. It also increases the prevalence of chronic conditions in low-income and minority groups and, in turn, predisposes these groups to disproportionately worse outcomes during the pandemic. Allocation of resources should not be determined by what patients can and cannot afford. This policy statement calls for high-value, evidence-based health care, which will reduce waste and decrease rationing.

Counterpoint: Opponents of universal health care note that Medicaid patients endure longer wait times to obtain care than privately insured patients[42] and that countries with universal health care have longer wait times than the United States.[43] Although the United States enjoys shorter wait times, this does not translate into better health outcomes. For instance, the United States has higher respiratory disease, maternal mortality, and premature death rates and carries a higher disease burden than comparable wealthy countries.[46]

Counterpoint: A review of more than 100 countries’ health care systems suggests that broader coverage increases access to care and improves population health.

Counterpoint: While it is reasonable to assume that eliminating financial barriers to care will lead to a rise in health care utilization because use will increase in groups that previously could not afford care, a review of the implementation of universal health care in 13 capitalist countries revealed no or only small (less than 10%) post-implementation increases in overall health care use.[47] This finding was likely related to some diseases being treated earlier, when less intense utilization was required, as well as a shift in use of care from the wealthy to the poorest.[47]

Alternative Strategies States and the federal government can implement several alternative strategies to increase access to health care. However, these strategies are piecemeal responses, face legal challenges, and offer unreliable assurance for coverage. Importantly, these alternative strategies also do not necessarily or explicitly acknowledge health as a right.

State strategies: The remaining 14 states can adopt the Medicaid expansions in the ACA, and states that previously expanded can open new enrollment periods for their ACA marketplaces to encourage enrollment.[48] While this is a strategy to extend coverage to many of those left behind, frequent legal challenges to the ACA and Medicaid cuts make it an unreliable source of coverage in the future. In addition, although many people gained insurance, access to care remained challenging due to prohibitively priced premiums and direct costs.

Before the pandemic, the New York state legislature began exploring universal single-payer coverage, and the New Mexico legislature started considering a Medicaid buy-in option.[49] These systems would cover only residents of a particular state, and they remain susceptible to fluctuations in Medicaid cuts, state revenues, and business decisions of private contractors in the marketplace.

Federal government strategies: Congress can continue to pass legislation in the vein of the Families First Coronavirus Response Act and the CARES Act. These acts required all private insurers, Medicare, and Medicaid to cover COVID-19 testing, eliminate cost sharing, and set funds to cover testing for uninsured individuals. They fell short in requiring assistance with COVID-19 treatment. A strategy of incremental legislation to address the pandemic is highly susceptible to the political climate, is unreliable, and does not address non-COVID-19 health outcomes. Most importantly, this system perpetuates a fragmented response to the COVID-19 pandemic.

An additional option for the federal government is to cover the full costs of Medicaid expansion in the 14 states yet to expand coverage. If states increased expansion and enforced existing ACA regulations, nearly all Americans could gain health insurance.[50] This alternative is risky, however, due to frequent legal challenges to the ACA. Furthermore, high costs to access care would continue to exist.

Action Steps This statement reaffirms APHA’s support of the right to health through universal health care. Therefore, APHA:

• Urges Congress and the president to recognize universal health care as a right.
• Urges Congress to fund and design and the president to enact and implement a comprehensive universal health care system that is accessible and affordable for all residents; that ensures access to rural populations, people experiencing homelessness, sexual minority groups, those with disabilities, and marginalized populations; that is not dependent on employment, medical or mental health status, immigration status, or income; that emphasizes high-value, evidence-based care; that includes automatic and mandatory enrollment; and that minimizes administrative burden.
• Urges Congress and states to use the COVID-19 pandemic as a catalyst to develop an inclusive and comprehensive health care system that is resilient, equitable, and accessible.
• Urges the DHHS, the Agency for Healthcare Research and Quality, the Institute of Medicine, the National Institutes of Health, academic institutions, researchers, and think tanks to examine equitable access to health care, including provision of mental health care, long-term care, dental care, and vision care.
• Urges Congress, national health care leaders, academic institutions, hospitals, and each person living in the United States to recognize the harms caused by institutionalized racism in our health care system and collaborate to build a system that is equitable and just.
• Urges Congress to mandate the Federal Register Standards for Accessible Medical Diagnostic Equipment to meet the everyday health care physical access challenges of children and adults with disabilities.
• Urges national health care leaders to design a transition and implementation strategy that communicates the impact of a proposed universal health care system on individuals, hospitals, health care companies, health care workers, and communities.
• Urges Congress, the Centers for Disease Control and Prevention, the DHHS, and other public health partners, in light of the COVID-19 pandemic, to recognize the need for and supply adequate funding for a robust public health system. This public health system will prepare for, prevent, and respond to both imminent and long-term threats to public health, as previously supported in APHA Policy Statement 200911.

References 1. Palmer K. A brief history: universal health care efforts in the US. Available at: https://pnhp.org/a-brief-history-universal-health-care-efforts-in-the-us/. Accessed September 30, 2020. 2. Serakos M, Wolfe B. The ACA: impacts on health, access, and employment. Forum Health Econ Policy. 2016;19(2):201–259. 3. Centers for Medicare and Medicaid Services. CMS roadmaps for the traditional fee-for-service program: overview. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/roadmapoverview_oea_1-16.pdf. Accessed September 30, 2020. 4. Goldman AL, McCormick D, Haas JS, Sommers BD. Effects of the ACA’s health insurance marketplaces on the previously uninsured: a quasi-experimental analysis. Health Aff (Millwood). 2018;37(4):591–599. 5. Collins SR, Gunja MZ, Doty MM, Bhupal HK. Americans’ views on health insurance at the end of a turbulent year. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2018/mar/americans-views-health-insurance-end-turbulent-year. Accessed August 28, 2020. 6. Tolbert J, Orgera K, Singer N, Damico A. Key facts about the uninsured population. Available at: https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/. Accessed September 12, 2020. 7. Banthin J, Simpson M, Buettgens M, Blumberg LJ, Wang R. Changes in health insurance coverage due to the COVID-19 recession. Available at: https://www.urban.org/research/publication/changes-health-insurance-coverage-due-covid-19-recession. Accessed September 30, 2020. 8. Gaffney AW, Himmelstein DU, McCormick D, Woolhandler S. Health and social precarity among Americans receiving unemployment benefits during the COVID-19 outbreak. J Gen Intern Med. 2020;35(11):3416–3419. 9. Lutfiyya MN, Gross AJ, Soffe B, Lipsky MS. Dental care utilization: examining the associations between health services deficits and not having a dental visit in the past 12 months. BMC Public Health. 2019;19(1):265. 10. Rudowitz R, Hinton, E. Early look at Medicaid spending and enrollment trends amid COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/early-look-at-medicaid-spending-and-enrollment-trends-amid-covid-19/. Accessed August 14, 2020. 11. Roubein R, Goldberg D. States cut Medicaid as millions of jobless workers look to safety net. Available at: https://www.politico.com/news/2020/05/05/states-cut-medicaid-programs-239208. Accessed August 14, 2020. 12. Garfield R, Claxton G, Damico A, Levitt L. Eligibility for ACA health coverage following job loss. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/eligibility-for-aca-health-coverage-following-job-loss/. Accessed August 14, 2020. 13. U.S. Department of Health and Human Services. Renewal of determination that a public health emergency exists. Available at: https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx. Accessed September 30, 2020. 14. Rudowitz RC, Garfield R. How much fiscal relief can states expect from the temporary increase in the Medicaid FMAP? Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscal-relief-can-states-expect-from-the-temporary-increase-in-the-medicaid-fmap/. Accessed August 14, 2020. 15. Downs J. Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. New York, NY: Oxford University Press; 2015. 16. Schwartz K, Damico A. Distribution of CARES Act funding among hospitals. Available at: https://www.kff.org/health-costs/issue-brief/distribution-of-cares-act-funding-among-hospitals/?utm_campaign=KFF-2020-Health-Costs&utm_source=hs_email&utm_medium=email&utm_content=2&_hsenc=p2ANqtz-_NBOAd_787Yk73Ach1gaH-KDgGLsgoe4vPuqKuidkHwExyNBpENTaB_1ofCIpXrzNoNCx8ACiem-YqMKAF8-6Zv7xDXw&_hsmi=2. Accessed August 15, 2020. 17. Rader B, Astley CM, Sy KTL, et al. Geographic access to United States SARS-CoV-2 testing sites highlights healthcare disparities and may bias transmission estimates. J Travel Med. 2020;27(7):taaa076. 18. Artiga S, Garfield R, Orgera K. Communities of color at higher risk for health and economic challenges due to COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Accessed August 14, 2020. 19. Azar K, Shen Z, Romanelli R, et al. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood). 2020;39(7):1253–1262. 20. Millett GA, Jones AT, Benkeser D, et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37–44. 21. Hado E, Komisar H. Long-term services and supports. Available at: https://www.aarp.org/ppi/info-2017/long-term-services-and-supports.html. Accessed September 1, 2020. 22. GenWorth Financial. Cost of care survey. Available at: https://www.genworth.com/aging-and-you/finances/cost-of-care.html. Accessed September 1, 2020. 23. American Public Health Association. Policy statement 201415: support for social determinants of behavioral health and pathways for integrated and better public health. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/28/14/58/support-for-social-determinants-of-behavioral-health. Accessed September 1, 2020. 24. UN General Assembly. Resolution adopted by the General Assembly on 10 October 2019—political declaration of the high-level meeting on universal health coverage. Available at: https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf. Accessed September 30, 2020. 25. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025–1034. 26. Jones A. I left Norway’s lockdown for the US: the difference is shocking. Available at: https://www.thenation.com/article/world/coronavirus-norway-lockdown/. Accessed September 1, 2020. 27. Maizland L. Comparing six health-care systems in a pandemic. Available at: https://www.cfr.org/backgrounder/comparing-six-health-care-systems-pandemicX. Accessed August 20, 2020. 28. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020;323(14):1341–1342. 29. Gharib M. Universal health care supports Thailand’s coronavirus strategy. Available at: https://www.npr.org/2020/06/28/884458999/universal-health-care-supports-thailands-coronavirus-strategy. Accessed August 30, 2020. 30. Shone LP, Dick AW, Klein JD, Zwanziger J, Szilagyi PG. Reduction in racial and ethnic disparities after enrollment in the State Children’s Health Insurance Program. Pediatrics. 2005;115(6):e697–e705. 31. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298(24):2886–2894. 32. Rhee JC, Done N, Anderson GF. Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany. Health Policy. 2015;119(10):1319–1329. 33. Doty P, Nadash P, Racco N. Long-term care financing: lessons from France. Milbank Q. 2015;93(2):359–391. 34. Wen H, Druss BG, Cummings JR. Effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. Health Serv Res. 2015;50(6):1787–1809. 35. Congressional Budget Office. Projections of federal spending on major health care programs. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/presentation/53887-presentation.pdf. Accessed October 12, 2020. 36. Blahous C. The costs of a national single-payer healthcare system. Available at: https://www.mercatus.org/publications/government-spending/costs-national-single-payer-healthcare-system. Accessed October 10, 2020. 37. Galvani AP, Parpia AS, Foster EM, Singer BH, Fitzpatrick MC. Improving the prognosis of health care in the USA. Lancet. 2020;395(10223):524–533. 38. Friedman G. Funding HR 676: the Expanded and Improved Medicare for All Act. How we can afford a national single-payer health plan. Available at: https://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_7.31.13_proofed.pdf. Accessed September 15, 2020. 39. Organisation for Economic Co-operation and Development. Health expenditure and financing. Available at: https://stats.oecd.org/Index.aspx?ThemeTreeId=9. Accessed September 27, 2020. 40. Kurani N, Cox C. What drives health spending in the U.S. compared to other countries? Available at: https://www.healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-s-compared-to-other-countries/. Accessed September 30, 2020. 41. Tollen L, Keating E, Weil A. How administrative spending contributes to excess US health spending. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200218.375060/abs/. Accessed August 30, 2020. 42. U.S. Government Accountability Office. Medicaid: states made multiple program changes, and beneficiaries generally reported access comparable to private insurance. Available at: https://www.gao.gov/assets/650/649788.pdf. Accessed August 30, 2020. 43. How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2017. 44. Organisation for Economic Co-operation and Development. Deaths from cancer: total, per 100,000 persons, 2018 or latest available. Available at: https://data.oecd.org/healthstat/deaths-from-cancer.htm. Accessed October 12, 2020. 45. Hoffman B. Health Care for Some: Rights and Rationing in the United States since 1930. Chicago, IL: University of Chicago Press; 2012. 46. Kurani N, McDermott D, Shanosky N. How does the quality of the U.S. healthcare system compare to other countries? Available at: https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-start. Accessed September 20, 2020. 47. Gaffney A, Woolhandler S, Himmelstein D. The effect of large-scale health coverage expansions in wealthy nations on society-wide healthcare utilization. J Gen Intern Med. 2020;35(8):2406–2417. 48. King JS. COVID-19 and the need for health care reform. N Engl J Med. 2020;382(26):e104. 49. Hughes M. COVID-19 proves that we need universal health care. States are exploring their options. Available at: https://rooseveltinstitute.org/2020/06/25/covid-19-proves-that-we-need-universal-health-care-states-are-exploring-their-options/. Accessed September 1, 2020. 50. Blumenthal D, Fowler EJ, Abrams M, Collins SR. COVID-19—implications for the health care system. N Engl J Med. 2020;383(15):1483–1488.

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Knowledge at Wharton Podcast

Does the u.s. need universal health care, december 8, 2020 • 11 min listen.

Wharton's Robert Hughes explains the moral and social benefits of universal health care and how such a system might look in the U.S.

• Public Policy

Wharton’s Robert Hughes speaks with Wharton Business Daily on SiriusXM about the need for universal health care in the U.S.

Nothing quite exposes the inequalities that exist in American society more than the health care system. It’s a complex combination of private insurance, public programs and politics that drives up costs, creating significant barriers to lifesaving medical treatment for large segments of the population. In America, access to quality health care often depends on income, employment and status.

Why Should Healthcare Be Free?

Robert Hughes, professor of business ethics and legal studies at Wharton, is an advocate for universal health care coverage. Drawing deeply on his research in philosophy, Hughes believes that equal access to medical care is beneficial for both liberty and social stability. Health, he says, should not be tied to wealth.

“I think it’s very disturbing that people have to go to GoFundMe in order to get their medical treatments paid for. It creates a power imbalance,” he said, referring to the crowdsourcing platform used to help raise money for patient bills. “That’s why I say that truly universal health care would be good for people’s liberty. Because you’re not really free if you’re depending on charity, especially discretionary charity like the kind you see on GoFundMe, for a basic need like health care.”

Hughes recently joined the Wharton Business Daily radio show on SiriusXM to discuss universal health care in the context of the presidential election. (Listen to the podcast at the top of this page.) President-elect Joe Biden has said he will protect and rebuild the Affordable Care Act , which has been under attack since it was enacted in 2010 under President Barack Obama.

Does the U.S. Hhave Universal Healthcare Now That Obamacare Exists?

The ACA, commonly referred to as Obamacare, brought the U.S. closer to providing universal health care through subsidized private health insurance, but Hughes said there’s still a wide gap. He believes policymakers should ensure that everyone has coverage and access to the same needed treatments.

“It’s very disturbing that people have to go to GoFundMe in order to get their medical treatments paid for. It creates a power imbalance.”

“I think it’s totally feasible for us to change the health care system, if we all were willing to do the right thing. But we’re not all willing to do the right thing,” Hughes said.

The professor argued the case for universal health care in a paper titled “ Egalitarian Provision of Necessary Medical Treatment ,” which was published last year in the Journal of Ethics. (The author-accepted version is  here .) He examined the health care systems of the U.K., Australia and Canada, concluding that Canada’s single-payer system is the most advantageous for the U.S.

Private insurance would still exist under such a setup, but it could not be used to pay for treatments already covered under universal health care. This provision would eliminate wealth as the controlling factor in health.

Why Doesn’t the U.S. Have Free Healthcare?

“I don’t understand why there’s so much resistance to the idea of truly universal health insurance in the United States, given that this is something that other industrial countries just do,” Hughes said.

He acknowledged that the U.S. doesn’t have the “political will” to change a system that’s been entrenched since the end of World War II, when employers began offering health insurance to their workers instead of higher wages.

“We can’t wave a magic wand and go back to 1946,” he said. “I don’t see the United States completely uprooting all these insurances. And that means we might need to create a model that keeps a lot of what we have, making it more accessible to more people, rather than creating all new institutions from scratch.”

Knowledge at Wharton interviewed Hughes in 2019 about his paper. For an in-depth look into his research and advocacy, read the interview here .

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Study: More Than 335,000 Lives Could Have Been Saved During Pandemic if U.S. Had Universal Health Care

Yale study: universal health care could have prevented thousands of covid deaths..

In the United States, death rates from COVID-19 are higher than in any other high-income country—and our fragmented and inefficient health system may be largely to blame, Yale researchers say in a new study.

If the U.S. had had a single-payer universal health care system in 2020, nearly 212,000 American lives would have been saved that year, according to a new study. In addition, the country would have saved $105 billion in COVID-19 hospitalization expenses alone.

The research team further calculated that in a non-pandemic year, some $438 billion would be saved by single-payer universal health care, like Medicare for All.

The results make a powerful case for health care reform, according to lead author Alison Galvani, Ph.D.

“Americans are needlessly losing lives and money,” said Galvani, director of Yale’s Center for Infectious Disease Modeling and Analysis and an endowed chair in the Department of Epidemiology (Microbial Diseases) at the Yale School of Public Health. “Medicare for All would be both an economic stimulus and life-saving transformation of our health care system.”

The researchers compared people with and without health insurance, examining death rates from COVID-19 and overall. Building on earlier research, they calculated that 131,438 COVID deaths in 2020 could have been avoided with universal single-payer health care.

Overall, including both COVID and non-COVID patients, 211,897 lives would have been saved in 2020 with universal care. From the start of the pandemic in the U.S. to March 2022, those preventable deaths mount to 338,594.

Far from financially burdening the nation, universal single-payer health care would not only have saved lives, it would have also avoided hundreds of billions of dollars in costs. Medicare for All would reduce costs by improving access to preventive care, reducing administrative overhead, and empowering Medicare to negotiate prices, the researchers said. Single-payer health care would also eliminate pricy insurance premiums and reduce fraud.

“A single-payer health care system would be much more economically efficient than our current fragmented structure and would save over $450 billion per year,” Galvani said.

A better alternative

The United States currently spends more on health care than any other nation—both per person and overall. Despite such heavy spending, the piecemeal nature of the U.S. medical insurance system worsened COVID-19’s effects, the researchers argue in the study. Many people without access to adequate health care delayed necessary medical treatment, postponed isolation, and kept working when they felt sick. These factors can fuel infections and deaths.

Most working-age Americans rely on employer-sponsored plans, with each enrollment typically covering more than one person. That system still left 41 million Americans uninsured before the pandemic.

Universal single-payer health care is both economically responsible and morally imperative. Alison Galvani

Then, during the pandemic, over 9 million workers became unemployed. As a result, many people became uninsured including, in some cases, entire families.

Medicare for All would save lives in a number of ways, according to the researchers:

• It would make it easier to access primary care, which helps people prevent or stay on top of chronic conditions like diabetes or high blood pressure. Such conditions can raise the risk of death, including from COVID.
• It would lower financial hurdles to seeking care for illness.
• It would support rural health care facilities and ease pressures on hospitals that are forced to reduce care for other conditions, such as cancer, when COVID infections surge.

“Universal single-payer health care is both economically responsible and morally imperative,” Galvani said.

Meagan C. Fitzpatrick, formerly of the Yale School of Public Health and now with the University of Maryland, is last author on the study. Other co-authors are Alyssa S. Parpia, Abhishek Pandey, Pratha Sah and Kenneth Colón, all of the Yale School of Public Health; Gerald Friedman and Travis Campbell of the University of Massachusetts, Amherst; James G. Kahn of the University of California, San Francisco; and Burton H. Singer of the Emerging Pathogens Institute. Mr. Colón is also affiliated with Syracuse University.

The study appears online in the Proceedings of the National Academy of Sciences . The research was funded by the National Institutes of Health, the Notsew Orm Sands Foundation, and the National Science Foundation.

• Coronavirus

Featured in this article

• Alison Galvani, PhD Burnett and Stender Families Professor of Epidemiology (Microbial Diseases); Affiliated Faculty, Yale Institute for Global Health; Director of the Center for Infectious Disease Modeling and Analysis (CIDMA)
• Alyssa Parpia, MPH Programmer Analyst 1
• Abhishek Pandey, PhD Research Scientist in Epidemiology (Microbial Diseases); Affiliated Faculty, Yale Institute for Global Health

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• 18 May 2021

Universal health care must be a priority — even amid COVID

You have full access to this article via your institution.

The COVID pandemic illustrated how a lack of reliable health care renders communities vulnerable. Credit: John Moore/Getty

Vaccinating the world’s population against COVID-19 remains a global health priority. But it is vital that this effort does not overshadow the need to ensure that everyone, everywhere has access to basic health care.

Despite the urgency of the current crisis, the provision of universal health care remains a priority for Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization (WHO). It is also enshrined in the United Nations Sustainable Development Goals on the basis that health is a prerequisite for economic growth. Governments, scientists and the public should support this goal, because it’s in everyone’s best interests. And they will have an opportunity next week, when the World Health Assembly convenes online.

The pandemic has amply demonstrated how a lack of reliable health care can render communities vulnerable. Although access to health care isn’t the sole factor that determined how well countries fared, its absence clearly fuelled the flames. Many lives have been lost in India because hospitals have been overwhelmed. In the United States, COVID-19 deaths have been higher among people on low incomes, who are less likely to have health insurance and therefore less likely to seek medical care promptly. A similar pattern has been seen elsewhere: one study found that in the poorer neighbourhoods of Santiago, more than 90% of people whose deaths were attributed to COVID-19 died outside health-care facilities ( G. E. Mena et al. Science https://doi.org/f9b4; 2021 ). Moreover, people without reliable health care might be more vulnerable to complications of COVID-19 because of poorly controlled chronic diseases.

Will COVID force public health to confront America’s epic inequality?

A lack of easily accessible health care — and of health systems for sharing information — has impeded the detection and monitoring of COVID-19 infections. Should another deadly virus emerge in a region with inadequate health care, the world could lose valuable time to contain the outbreak. The two largest Ebola outbreaks so far — in West Africa and the Democratic Republic of the Congo — spread for weeks to months before they were identified.

Despite almost a century of calls to provide all people with health care, attempts have been stymied by crises and disease-specific interventions. After the economic depression of the 1930s, international health officials working for the League of Nations touted the need for the provision of basic health services by country-wide networks of clinics. This vision was interrupted by the Second World War, but was revived in 1946, when the newly formed United Nations met to write a constitution for the WHO. The constitution stated that health is a human right, and that governments are responsible for the health of their people.

But the United States nearly rejected the WHO and its constitution outright. At the time, opponents of national health-care provision in the country connected the measure to socialism and communism. The United States eventually signed on, but inserted a clause stating that it could withdraw from the WHO at any time — meaning that the country donating the most money (dues are based on the size of economies) could walk away if it opposed the organization’s ideology.

How to defuse malaria’s ticking time bomb

The next 20 years of single-disease programmes driven by the WHO and global health funders wasn’t ideological, however. Ironically, they were also driven by a wave of scientific advances that offered simple, technological fixes to specific health problems, such as the use of the insecticide DDT to fight malaria and antibiotics to fight infections.

But, in 1978, the push to build up health systems was revived at an international conference on providing everyone with primary health care, held in Alma-Ata in what was then the Soviet Union. The resulting WHO-sponsored Alma-Ata declaration vowed to provide essential care, at the level of neighbourhoods, by the year 2000.

But according to Tedros and health-policy experts, the Alma-Ata declaration was undermined by factors including inadequate political leadership, economic crises, political instability and an over-investment in treating individual diseases ( T. A. Ghebreyesus et al. Lancet 392 , 1371–1372; 2018 ). Others have suggested that the movement lacked defined steps backed by evidence, as well as cost-effectiveness assessments. Compare this with the UN children’s charity, UNICEF, which in the 1980s vowed to save the lives of four million to five million children a year through well-defined and budgeted programmes to deliver vaccines for diseases including measles, tetanus and polio. Government and philanthropic donors grasped the concept immediately, and UNICEF quickly became one of the larger UN agencies. In 2019, its budget was nearly three times that of the WHO.

Childhood immunization programmes save lives, but the lack of investment in strengthening countries’ health systems has led to untold deaths. The answer isn’t to stop vaccinations, of course, but to take cues from the success of UNICEF’s campaign and the failures of Alma-Ata.

Why did the world’s pandemic warning system fail when COVID hit?

In 2019, the WHO once again turned the focus on health care for all, this time at the first UN high-level meeting on universal health care. A corresponding report stated that to provide all people with primary health care, countries, on average, must increase their spending in this area by 1% of their gross domestic product. And world leaders signed a declaration promising to pursue universal health care — in their national context — and provide basic, affordable health services to everyone in the country. To hold them accountable, global-health researchers have created an online portal to track progress towards the attainment of this goal by 2030. For example, the tracker says that about 15% of the populations of the United States and Cuba lack access to essential health services. The rate grows to 20% in China and 45% in India and Kenya.

The WHO has placed ‘health for all’ high on the agenda of next week’s meeting, hoping to drive political and financial commitments from governments. Perhaps mindful of the vagueness that doomed past efforts, Tedros has created a new council of economists, health and development experts to advise on the economics of providing everyone with basic health care, including ways to quantify its value.

Universal health care might seem a lofty goal amid a crisis, but if we do not push for change now, we will regret it. The pandemic has increased the number of people living in extreme poverty, making them more vulnerable to disease. It’s infected, killed and traumatized health-care workers everywhere, most devastatingly in places that had too few already. “Our failure to invest in health systems doesn’t only leave individuals, families and communities at risk, it also leaves the world vulnerable to outbreaks and other health emergencies,” Tedros said in October 2019. “A pandemic could bring economies and nations to their knees.” A few months later, it did. We must not let that happen again.

Nature 593 , 313-314 (2021)

doi: https://doi.org/10.1038/d41586-021-01313-3

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7 Strong Arguments For Why America Should Have Universal Healthcare

With COVID-19 still running its course and no end in sight, the integrity of American healthcare has never been more important. Is the current system truly the best the United States can do for its citizens? Or is socialized medicine a better alternative? Here are seven strong arguments for universal healthcare in America.

1. Lower Overall Costs

The costs of universal healthcare are far lower in other Western countries than private coverage in the United States. For example, administrative expenses alone make up 8% of the nation’s total healthcare costs . On the other hand, other developed countries with universal care don’t reach any higher than 3%.

What’s more, many Americans don’t seek the care they need because the cost of one visit can bankrupt them. Compared to other countries, prices for vital medicine, such as insulin, are sky-high in the United States. Universal healthcare guarantees service to everyone, no matter their financial status. When medical care isn’t such a financial strain, citizens can prioritize their health and seek the treatment they need.

2. Greater Hospital-Patient Trust

One disturbing reason American healthcare is so expensive is the trend of surprise billing. A routine surgery or treatment can cost thousands of dollars more than expected due to additional vague charges. You can even face a hefty fee just for sitting in a waiting room. The U.S. government has made some efforts to fix this problem , but private medical facilities have managed to find loopholes in the legislation.

Universal healthcare takes the billing power away from these facilities, creating more trust between hospital and patient: Payment comes in the form of taxes. While nobody likes to pay more taxes, it’s fairer to pay a fixed amount every year than receive a debilitating hospital bill after one visit.

3. Better Quality Care

The quality of treatment under socialized medicine seems to work better for its citizens than America’s privatized system. Infant mortality rates are lower, average life expectancy is higher and fewer people die from medical malpractice, which happens to be the third-leading cause of death in the United States. 

America also has obesity and cardiovascular disease epidemic, which fills up hospitals and leads to many preventable deaths. Comparable countries with universal healthcare have much lower mortality rates. This is because these nations promote more healthy lifestyles , easing the workload on hospitals and opening up space for people who need urgent care. 

4. More Coverage

Americans rely on their insurance companies to pay for their medical bills, but insurance doesn’t cover every injury or sickness. As you might expect, many citizens go bankrupt from hospital expenses. In contrast, universal healthcare covers any medical issue that might happen to a citizen. So patients don’t need to worry about any loopholes or caveats in their insurance coverage.

5. Shorter Wait Times

Perhaps the biggest criticism of universal healthcare is the extended wait times, but Americans already have long waits. COVID-19 patients are filling up waiting rooms and hospital beds. Because of that, many doctors have begun to hold virtual appointments for patients who can’t see them in person. Still, this solution has only put a dent in the problem. 

Patients under a universal system don’t have to wait for their insurance’s approval before seeking the care they need.

6. Greater Mobility

Since Americans often have to pay their own medical bills, they might feel pressured to keep unfulfilling jobs just for the insurance coverage. So in an ironic twist, they’re forced to put work over their health and well-being just so they can afford healthcare.

Universal healthcare allows you to change jobs without losing coverage. The current privatized system doesn’t embody American values of freedom and liberty. Rather, it restricts their life choices and access to care.

7. Coverage for the Uninsured

Insured citizens at least have access to some healthcare coverage, but the uninsured are entirely on their own. A large percentage of the uninsured have little to no disposable income, and they can’t afford the coverage they need.

Some evidence also suggests that uninsured patients wait longer and receive poorer care than more financially stable patients. As a result, the uninsured have an excess mortality rate of 25% , according to the Institute of Medicine. This negligence is unacceptable and largely avoidable. A universal healthcare system provides its people with care regardless of their insurance status.

America needs universal healthcare. The United States’ private healthcare system has too many glaring flaws to justify its existence. Adopting a universal plan would grant more cost-effective coverage to everyone, including the millions of people who currently can’t afford treatment. A more efficient and trustworthy system would help Americans exercise their fundamental rights to life, liberty, and the pursuit of happiness.

Featured image via CDC on Unsplash

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June 13, 2022

Universal Health Care Could Have Saved More Than 330,000 U.S. Lives during COVID

The numbers of lives lost and dollars spent would have been significantly lower if coverage had been extended to everyone, a new study says

By Rachel Nuwer

A woman walks among a field of some 660,000 white flags representing the number of U.S. lives lost to COVID-19 at the National Mall in Washington, D.C., on September 16, 2021.

Rod Lamkey/CNP/Sipa USA/Alamy Stock Photo

Americans spend more on health care than people in any other nation. Yet in any given year, the piecemeal nature of the American medical insurance system causes many preventable deaths and unnecessary costs. Not surprisingly, COVID only exacerbated this already dire public health issue, as evidenced by the U.S.’s elevated mortality, compared with that of other high-income countries.

A recent study quantified the severity of the impact of the pandemic on Americans who did not have access to health insurance. According to findings published in June 2022 in the Proceedings of the National Academy of Sciences USA , from the pandemic’s beginning until mid-March 2022, universal health care could have saved more than 338,000 lives from COVID alone. The U.S. also could have saved $105.6 billion in health-care costs associated with hospitalizations from the disease—on top of the estimated $438 billion that could be saved in a nonpandemic year.

“Health-care reform is long overdue in the U.S.,” says the study’s lead author Alison Galvani, director of the Center for Infectious Disease Modeling and Analysis at the Yale School of Public Health. “Americans are needlessly losing lives and money.”

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People who do not have insurance usually do not have a primary care doctor, which means they are more likely to suffer from preventable diseases such as type 2 diabetes. They also tend to wait longer to see a doctor when they fall ill. These two factors already contribute to higher mortality rates in nonpandemic years, and they compounded the impacts of COVID. Comorbidities exacerbate the risk of the disease, and waiting to seek care increases the likelihood of transmission to other people.

Prior to the pandemic, 28 million American adults were uninsured, and nine million more lost their insurance as a result of unemployment because of COVID. “Many Americans feel secure in having good health insurance from their employer, but employer-based insurance can be cut off when it is needed most,” Galvani points out.

In the study, Galvani’s team compared the mortality risks of COVID among people with and without insurance, as well as their risks of all other causes of death. The researchers compiled population characteristics of all uninsured Americans during the pandemic, taking into account things such as age-specific life expectancy and the elevation in mortality associated with a lack of insurance. They calculated that 131,438 people could have been saved from dying of COVID in 2020 alone. And more than 200,000 additional deaths from COVID could have been averted between then and the end of the study, bringing the total through March 12, 2022, to more than 338,000.

The researchers also estimated the cost to insure the entire U.S. population—and the savings that measure would produce. They found that a single-payer health-care system would generate savings in three ways: more efficient investment in preventive care; lowered administrative costs; and increased negotiating power for pharmaceuticals, equipment and fees. This would have produced a net savings of $459 billion in 2020 and $438 billion in a nonpandemic year, the authors found. “Medicare for All would be both an economic stimulus and lifesaving transformation of our health-care system,” Galvani says. “It will cost people far less than the status quo.”

Galvani and her colleagues’ findings are “very convincing,” and “the methodology strikes me as exactly right,” says Robert Reich, a professor of public policy at the University of California, Berkeley, who was not involved in the work. “The savings estimates are consistent with every other estimate I’ve seen.”

Ann Keller, an associate professor of health policy and management also at U.C. Berkeley, suspects, however, that the study likely underestimates the deaths that could have been avoided through universal health care because it does not consider the lower rates of chronic disease that often accompany single-payer systems. “Having consistent access to care can prevent chronic disease from occurring and can ensure that patients who develop chronic disease have it better managed,” says Keller, who was also not involved with the research. “I would think that, if one took that into account, the estimates of avoided deaths would be greater than the numbers reported here.”

Whatever the exact figures, Galvani says the message that comes out of the study is clear: “Universal single-payer health care is both economically responsible and morally imperative.”

Pro & Con Quotes: Should the U.S. Government Provide Universal Health Care?

Alison P. Galvani and colleagues from the Yale School of Public Health and other universities, stated:

“The COVID-19 outbreak has underscored the societal vulnerabilities that arise from the fragmented healthcare system in the United States. Universal healthcare coverage decoupled from employment and disconnected from profit motivations would have stood the country in better stead against a pandemic. Emergence of virulent pathogens is becoming more frequent, driven by climate change and other global forces. Universal single-payer healthcare is fundamental to pandemic preparedness. We determined that such a system could have saved 211,897 lives in 2020 alone. Strikingly, it would have done so at lower cost than the current healthcare system, saving the US $459 billion in 2020 at a time of economic tumult. To facilitate recovery from the ongoing crisis and bolster pandemic preparedness, as well as safeguard well-being and prosperity more broadly, now is the time to transition to a healthcare system that can better serve the American people.” - Alison P. Galvani, et al., “Universal Healthcare As Pandemic Preparedness: The Lives and Costs That Could Have Been Saved during the COVID-19 Pandemic,” pnas.org, June 13, 2022

Marc S. Ryan, author of The Healthcare Labyrinth , stated:

“With so much at stake on the healthcare coverage and access front, here is my appeal to Republicans — my own party — to look differently at affordable universal healthcare coverage. There are many great Republican reasons to do so…. If you are wealthy or have good coverage, America is the place to be if you have a health episode. People flock here for the on-demand care, advanced technology, and expertise in our system. But if you are an average American, as the great healthcare economist Uwe Reinhardt titled his seminal healthcare work, you are Priced Out. We spend the most of any developed nation. But, because of high costs, a lack of focus on prevention and wellness, gaps in coverage, and periods of being uninsured, Americans have among the lowest outcomes in the developed world…. The truth is that upfront coverage would help America focus on wellness, prevention, and care management. Care might, in time, move from emergency room and inpatient chaos to relationships with primary care physicians and specialists — where care is relatively cheap and disease and conditions can be caught early.” - Marc S. Ryan, “A Republican Argument for Affordable Universal Healthcare,” medpagetoday.com, Mar. 13, 2023

Josh Bivens, Director of Research at the Economic Policy Institute, stated:

“A fundamental reform like Medicare for All (M4A) would make coverage universal. Further, by providing a counterweight to (or outright eliminating) the substantial market power that keeps prices high and that is currently wielded by many key players in the health care sector (e.g., insurance companies, drug companies, specialty physicians, and device makers), such a reform could also have great success in containing health care cost growth. This could in turn provide relief from many of the ways that rising health costs squeeze family incomes…. Making health insurance universal and delinked from employment widens the range of economic options for workers and leads to better matches between workers’ skills and interests and their jobs. The boost to small business creation and self-employment would be particularly useful, as the United States is a laggard in both relative to advanced economy peers.” - Josh Bivens, “Fundamental Health Reform Like ‘Medicare for All’ Would Help the Labor Market,” epi.org, Mar. 5, 2020

Jeremy C. Kourvelas, Vice President of the Public Health Graduate Student Association and Master’s degree candidate at the University of Tennessee, Knoxville, stated:

“It is no secret that the costs of healthcare in this country have long been spiraling out of control. Two-thirds of all bankruptcies in the United States are due to medical debt whereas medical bankruptcy is virtually non-existent in the rest of the industrialized world. Americans spend over twice as much for healthcare. Premiums continue to rise with no tangible return on investment. Often critics of socialized medicine laud our quality of care as a reason to support our fractured system, but what good is this argument? Universal healthcare would free small business owners from having to provide coverage while simultaneously enhancing the freedom of the worker. Lifespans could be longer, people could be happier and healthier in systems that are simpler and more affordable.” - Jeremy C. Kourvelas, “Universal Healthcare Provides Americans the Security Need in Uncertain Times | Opinion,” tennessean.com, July 16, 2021

Gabriel Zieff, Zachary Y. Kerr, Justin B. Moore, and Lee Stoner, researchers from the University of North Carolina at Chapel Hill and Wake Forest University, stated:

“Non-inclusive, inequitable systems limit quality healthcare access to those who can afford it or have employer-sponsored insurance. These policies exacerbate health disparities by failing to prioritize preventive measures at the environmental, policy, and individual level. Low SES segments of the population are particularly vulnerable within a healthcare system that does not prioritize affordable care for all or address important determinants of health. Failing to prioritize comprehensive, affordable health insurance for all members of society and straying further from prevention will harm the health and economy of the U.S. While there are undoubtedly great economic costs associated with universal healthcare in the U.S., we argue that in the long-run, these costs will be worthwhile, and will eventually be offset by a healthier populace whose health is less economically burdensome. Passing of the Obama-era ACA was a positive step forward as evident by the decline in uninsured U.S. citizens (estimated 7–16.4 million) and Medicare’s lower rate of spending following the legislation [43]. The U.S. must resist the current political efforts to dislodge the inclusive tenets of the Affordable Care Act. Again, this is not to suggest that universal healthcare will be a cure-all, as social determinants of health must also be addressed. However, addressing these determinants will take time and universal healthcare for all U.S. citizens is needed now. Only through universal and inclusive healthcare will we be able to pave an economically sustainable path towards true public health.” - Gabriel Zieff, et al., “Universal Healthcare in the United States of America: A Healthy Debate,” Medicina (Kaunas) , ncbi.nlm.nih.gov, Oct. 30, 2020

Sally C. Pipes, President and Thomas W. Smith fellow in health care policy of the Pacific Research Institute, stated:

“Sen. Bernie Sanders would do well to look at what’s happening across our northern border before he tries to advance legislation that would import Canada’s single-payer health care system, where the government is the only insurer. The new chairman of the influential Senate Health, Education, Labor and Pensions Committee, he’s made clear that he’ll use his position to make the case for universal health care.’ The Canadian health care system, which serves just 38 million people, is in crisis. It is no model for the United States (with our 334 million people)…. Such [lomg] waits for care are endemic to government-run healthcare systems. The reason comes down to the law of supply and demand. In Canada, health care is ‘free’ at the point of service. As a result, demand for care is sky-high. But the government does not have unlimited resources. It effectively limits the supply of care by capping what it will spend — and directing providers to make do within those constraints. The result is rationing and agonizing waits for routine treatment.” - Sally C. Pipes, “Sally C. Pipes: Bernie Sanders Wants Universal Health Care. Canada Shows Why That’s a Bad Idea.,” post-gazette.com, Jan. 24, 2023

Janet Trautwein, CEO of the National Association of Health Underwriters, stated:

“Americans like their private plans. In a recent study of people with employer-sponsored coverage, more than two-thirds said they were satisfied with their insurance. More than three-quarters felt confident it would protect them during a medical emergency. Research by the Kaiser Family Foundation found that what support there is for single-payer declines when people consider its attendant consequences like higher taxes and treatment delays…. Further, single-payer will lead to lower quality care. That’s because government payers rely on lower payments to hospitals and doctors to keep costs in check. Look no further than Medicare. The American Hospital Association says that hospitals receive just 87 cents for every dollar they spend treating Medicare beneficiaries. That’s obviously not sustainable. If a single-payer system — and its low payment rates — were adopted widely, doctors and hospitals would respond by reducing the supply of care they’re willing to provide. Some providers would decide to leave the sector.” - Janet Trautwein, “Trautwein: Single-Payer Health Care Wrong Prescription for America,” bostonherald.com, Apr. 30, 2022

Justin Haskins, research fellow at The Heartland Institute and the director of Heartland’s Stopping Socialism Project, stated:

“Government-run health care systems are designed to control and manipulate markets, limit choices and redistribute wealth, and like most government-run systems, government health care systems fall short because bureaucrats are terrible at making decisions for other people. If government cannot effectively run the Postal Service, VA health system and Amtrak without losing boatloads of money, why would anyone think they could run America’s vast health care system? The key to fixing the health care system is to provide greater access to all people while making key structural reforms that utilize the power of market economics and personal choice. Rather than impose top-down mandates that restrict consumer freedom, the American Health Care Plan would empower everyone with more options and encourage health care savings throughout the system.” - Justin Haskins, “Finally, a Conservative Plan to Fix America’s Broken Health Care System,” thehill.com, July 10, 2021

Robert Moffit, Senior Research Fellow in the Center for Health and Welfare Policy at the Heritage Foundation, stated:

“Self-styled ‘progressives’ in Congress and elsewhere are proposing a government takeover of American health care [Medicare for All]. Such a takeover would destroy Americans’ existing coverage and their right to alternatives outside the government program; and it would erect a system of total political control over virtually every aspect of the financing and delivery of medical care. Nor would it ensure delivery of its central premise and promise: care for every American. Beyond closing off individuals’ alternatives to coverage outside the government program and restricting their medical care through independent physicians, such a government takeover would also introduce an unprecedented politicization of American health care. Congress, beset by frenzied lobbying by powerful special interest groups, would ultimately determine health care budgets and spending, as well as the rules and regulations that would govern care delivery by doctors, hospitals, and other medical professionals. Patients’ personal choices, as well as the professional independence of their doctors and other medical professionals, would be subordinated to the turmoil of congressional politics and the bureaucratic machinations of distant administrators. The machinery of federal control would dwarf the existing federal bureaucratic apparatus that runs today’s Medicare, Medicaid, and Obamacare programs.” - Robert Moffit, “The Truth about Government-Controlled Health Care,” heritage.org, Oct 6, 2020

Tyler Piteo-Tarpy, essayist, stated:

“In a [universal health care] system… the federal government would be in control of the type of care they provide, who they provide it too, the doctors they hire, the amount they pay workers, the taxes they charge to pay for the system, and just about every other aspect of both a government agency and the entire health care industry. My first issue with this scenario is that the government doesn’t have the resources or, quite frankly, aptitude to manage a system this large and complex…, nor should it. The American government was initially designed to be a small, supervising entity for protecting human rights and dealing with matters that individual states couldn’t, such as foreign policy…. [W]hy should the government decide for the people what type of health care they get? A universal health care system would remove people’s right to make choices about their own life by saying that the government knows best, and the result would likely be poorer quality healthcare for individuals because it’s designed for the average [person].” - Tyler Piteo-Tarpy, “Nationalized Health Care Is a Bad Idea, medium.com, Feb. 17, 2020

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Universal Health Care for the United States: A Primer for Health Care Providers

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• 1 Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California.
• 2 Midwifery Institute, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, Pennsylvania.
• PMID: 34165238
• DOI: 10.1111/jmwh.13233

The United States is one of a very few high-income countries that does not guarantee every person the right to health care. Residents of the United States pay more out-of-pocket for increasingly worse outcomes. People of color, those who have lower incomes, and those who live in rural areas have less access to health care and are therefore at even greater risk for poor health. Universal health care, a term for various models of health care systems that provide care for every resident of a given country, will help move the United States toward higher quality, more affordable, and more equitable care. This article defines a reproductive justice and human rights foundation for universal health care, explores how health insurance has worked historically in the United States, identifies the economic reasons for implementing universal health care, and discusses international models that could be used domestically.

Keywords: cost and cost-effectiveness of health care; health equity; health policy; universal health care.

© 2021 by the American College of Nurse-Midwives.

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• Midwives and Universal Health Care: A Call to Action. Kriebs J, Alspaugh A, Van Hoover C. Kriebs J, et al. J Midwifery Womens Health. 2021 Jul;66(4):437-440. doi: 10.1111/jmwh.13232. Epub 2021 Jun 24. J Midwifery Womens Health. 2021. PMID: 34165222 No abstract available.

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Swing States Brace for Battles Over Certification of 2024 Election Results

Plastic is building up in our brains — scientists say it’s a global emergency, federal judge undoes key civil rights protections in louisiana’s cancer alley, it’s no surprise rfk jr. endorsed trump — they’re backed by the same billionaire.

Democrats ran on health care in 2020. In this year’s draft platform, it gets a handful of bullet points.

Universal Health Care Was Big on the 2020 Democratic Platform. Where Is It Now?

Part of the series, fighting for our lives: the movement for medicare for all.

The last time the Democratic Party released a platform, mass death and illness were haunting the political landscape. By mid-August 2020, more than 160,000 United States citizens had died from COVID-19, and the daily mortality rate had just climbed above 1,000. Vaccines were still months away from being available, and nationwide cases exceeded 5.4 million. Inundated with corpses, hospitals around the country deployed “mobile morgues.”

That summer, against a backdrop of global crisis, the Democratic National Committee unveiled bold new language on health care, pledging to “at last build the health care system the American people have always deserved.” A special chapter of the platform, titled, “Achieving Universal, Affordable, Quality Health Care,” was devoted to outlining a slew of reforms, including a plan to introduce a universal public insurance option through the marketplace set up in the Affordable Care Act.

That platform was itself a compromise with progressives, such as Sen. Bernie Sanders (I-Vermont), who had pushed for a single-payer system and the elimination of private insurance through Medicare for All during his popular campaign for the Democratic presidential nomination that year. In 2024, however, it appears that the Democratic Party has abandoned even its watered-down ideals.

The draft Democratic platform for this election cycle, obtained by Politico in July, contains no mention of the phrases “public option” or “universal health care.” In fact, although polls have shown that health care affordability remains a top concern for voters, the issue does not even receive its own chapter. Instead, “Health Care & Prescription Drugs” is just one of several bullet points under a chapter with the milquetoast title, “Lowering Costs.”

The platform obtained by Politico is not set in stone. Notably, it was written when President Joe Biden was still the presumptive nominee, and much of the text focuses on his record as president. While Vice President Kamala Harris signed on to the Sanders-sponsored Medicare for All Act as a senator in 2017, her current position on health care remains vague. Harris campaign aides recently told reporters that she no longer backs Medicare for All, and it seems unlikely that her platform will deviate substantially from the Biden administration’s positions. As a result, the draft offers the best insight into what we can expect to see next week, when delegates convene at the Democratic National Convention to vote on an ​​official party platform.

The 2024 platform is heavy on fluffy language — mostly touting the Biden administration’s past accomplishments — but light on specifics.

“Health care should be a right in America, not a privilege. Every American deserves the peace of mind that quality, affordable coverage brings,” the 2024 platform states. Democrats pledge to continue to fight for the expansion of the Affordable Care Act (ACA), noting that, today, “more Americans have health insurance than ever in history.” A record number of people signed up through the ACA after the passage of the American Rescue Plan Act of 2021, in which the Biden administration made more Americans eligible to receive tax credits to offset the costs of premiums. These temporary enhanced subsidies were renewed once, in the Inflation Reduction Act, but are now set to expire in 2025. In the platform, Democrats pledge to renew the tax credits and fight Republican efforts to let them end.

These perpetually precarious subsidies are a far cry from Medicare for All or a real public option. And while it’s true that the United States has seen a streak of record-low uninsured rates since Biden took office, earlier this month, the Centers for Disease Control and Prevention announced the number of uninsured Americans rose during the first months of 2024, bucking the trend.

“Low-income Americans will be automatically enrolled in the public option at zero cost to them, though they may choose to opt out at any time,” Democrats promised in their 2020 platform. That public option was supposed to include “at least one plan choice without deductibles” and would “cover all primary care without any co-payments and control costs for other treatments by negotiating prices with doctors and hospitals, just like Medicare does on behalf of older people.” There is no mention of such an option in the 2024 plan.

“Whatever Happened to Biden’s Public Option?” KFF Health News asked in article published this April. The piece noted that, despite coming out strong for a “public option” on the campaign trail, Biden didn’t utter the phrase once after December 2020.

There are some promises from the 2020 platform that held true. The Biden administration announced new actions to prevent surprise medical bills, negotiated lower Medicare prices for 10 prescription drugs, and capped insulin co-pays at $35 for Medicare recipients.

Nevertheless, exorbitant health care costs continue to trouble most Americans: Average premiums for an employer-provided family health insurance plan reached $23,968 in 2023, a 7 percent increase that outpaced the rise of both wages (5.2 percent) and inflation (5.8 percent). According to a February 2024 KFF Health Tracking Poll , 74 percent of adults are worried about affording unexpected medical bills.

Medical debt, which is associated with poorer health and increased mortality rates, declined from 2020 to 2022, but 41 percent of adults still report having it. Americans owe an estimated total of $220 billion in medical debt, with about 3 million people owing more than $10,000. And even though Democrats’ sense of urgency has evidently waned, COVID-19 is far from eradicated, with roughly 600 people still dying from the virus every day.

The 2024 draft platform is a depressing reversal from what was already a modest concession for progressives. Still, it was popular pressure that got a nod to universal health care on the 2020 platform in the first place. As Harris fine-tunes her campaign messaging, now is the time for a renewed, sustained push to remind Democrats of their own words: “Health care should be a right in America, not a privilege.”

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Should Healthcare Be Free? Essay on Medical System in America

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
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Introduction

Problem statement, why healthcare should be free, why healthcare should be paid, works cited.

The US government has historically taken a keen interest in the health of its citizens. As far back as the beginning of the 1900s, President Theodore Roosevelt declared that “nothing can be more important to a state than its public health: the state’s paramount concern should be the health of its people” (Gallup and Newport 135). Despite these, the United States is classified as the nation with the most expensive, and yet inefficient, health care system among developed nations.

An expensive health care system translates to an increasing proportion of the population being unable to access the much needed medical care. The New York Times reports that according to census survey carried out in the year 2007, an estimated 45.6 million people in the USA were uninsured and hence unlikely to receive comprehensive medical care from hospitals (1). Due to the perceived inefficiencies, there has been agreement that the current health care system is faulty and therefore in need of radical changes to make it better.

Majority of American’s are greatly dissatisfied with the current health care system which is extremely expensive and highly inefficient. While an effective system can be deemed to be one which is efficient, acceptable and at the same time equitable, the current system is lacking in this attributes.

The aim of this paper will be to analyze the effects that free health care system in America would have. This paper will argue that a health care system which guarantees free health care for all Americans is the most effective system and the government should therefore adopt such a system.

Free health care would result in a healthier nation since people would visit the doctors when necessary and follow prescriptions. Research by Wisk et al. indicated that both middle and lower class families were suffering from the high cost of health care (1). Some families opted to avoid going to the doctor when a member of the family is sick due to the high cost of visiting the doctor and the insurance premiums associated with health care.

In the event that they go to the doctor, they do not follow prescriptions strictly so as to reduce cost. Brown reveals that “60 percent of uninsured people skipped taking dosages of their medication or went without it because it cost too much” (6). Such practices are detrimental to a person’s health and they cost more in the long run.

The last few years have been characterized by financial crises and recessions which have negatively affected the financial well being of many Americans. In these economic realities, the cost of health care has continued to rise to levels that are unaffordable to many Americans. This loss of access to health care has led to people being troubled and generally frustrated. A report by Brown indicates that the price for prescription drugs in the US has escalated therefore becoming a financial burden for the citizens (6).

The productivity of this people is thereby greatly decreased as they live in uncertainty as to the assurance of their health and thereby spend more time worrying instead of being engaged in meaningful activities that can lead the country into even greater heights of prosperity. Free health care would lead to a peace of mind and therefore enable people to be more productive.

Since medical care is not free, many people have to make do with curative care since they cannot afford to visit medical facilities for checkups or any other form of preventive medical care. This assertion is corroborated by Colliver who reveals that many people are opting to go without preventative care or screening tests that might prevent more serious health problems due to the expenses (1).

Research shows that approximately 18,000 adults die annually due to lack of timely medical intervention (The New York Times 1). This is mostly as a result of lack of a comprehensive insurance cover which means that the people cannot receive medical attention until the disease has progressed into advanced stages. This is what has made medical care so expensive since “sick patients need more care than relatively healthy ones” (Sutherland, Fisher, and Skinner 1227).

This is an opinion shared by Sebelius who reveals that 85% of medical costs incurred in the country arise from people ailing from chronic conditions (1). She further notes that if screened early, these diseases such as diabetes and obesity can be prevented thus saving the medical cost to be incurred in their treatment. It therefore makes sense to have a health care system that makes it possible for everyone to access preventive care thus curbing these conditions before they are fully blown.

While most people assume that free health care will result in better services as more people will be able to access health care, this is not the case. The increase in people who are eligible for health care will lead to an increase in the patients’ level meaning that one may have to wait for long before receiving care due to shortage of medical personnel or the rationing of care.

A European doctor, Crespo Alphonse, reveals that when health care is free, people start overusing it with negative implications for the entire system (AP). In addition to this, free health care would invariably lead to cost cutting strategies by hospitals.

This would lead to scenario where finding specialized care is hard and the rate of medical mistakes would increase significantly. As a matter of fact, a survey on Switzerland hospitals found that medical errors had jumped by 40% owing to the introduction of mandatory health insurance (AP). While it is true that free health care will increase the number of people visiting the doctor, this may be a positive thing since it will encourage preventive care as opposed to the current emphasis on curative care.

Free health care is a move towards a socialistic system. As it is, the US is a nation that is built on strong capitalistic grounds. This is against the strong capitalistic grounds on which the United States society is build on. While detractors of the private insurance firms are always quick to point out that the firms make billions of dollars from the public, they fail to consider the tax that these firms give back to the federal government (Singer 1).

Free health care would render players in the health industry such as private insurance companies unprofitable. Free health care will bring about a shift from a profit oriented system to a more people oriented system. Without money as a motivation, research efforts will plummet thereby leading to a decrease in the medical advancement as investment in research will not be as extensive (Singer 1).

The Associate Press reveals that doctors may also lack to be as motivated if they are no incentives and thereby the quality of their work may weaken (1). As such, a free health care system would have far reaching consequences for the economy of the nation since the health care industry is a profitable industry for many.

The Healthcare system is one of the most important components of the U.S. social system since full productivity cannot be achieved without good health. This paper has argued that a free health care system would be the most effective system for America. To reinforce this assertion, the paper has articulated the benefits that the country would accrue from free health care.

With free health care, all Americans would be able to access health services when they need it leading to increased quality of life. In addition, many people would make use of preventive healthcare services, therefore reducing the financial burden that the expensive curative services result in.

The paper has taken care to point out that free health care has some demerits, most notably of which is overloading the health services with a high number of patients. Even so, the observably advantages to be reaped from the system far outweigh the perceived risks. As it is, decades of reform on the US health care system have failed to provide any lasting solution to the problem.

Making health care free for all may be the strategy that will provide a solution for the ideal health care system that has thus far remained elusive. From the arguments presented in this paper, it can irrefutably be stated that free health care will result in a better health care system for the country.

Associate Press. (AP). Europe’s free health care has a hefty price tag . 2009. Web.

Brown, Paul. Paying the Price: The High Cost of Prescription Drugs for Uninsured Americans. U.S. PIRG Education Fund, 2006.

Colliver, Victoria. “Jump in middle-income Americans who go without health insurance,” San Francisco Chronicle (SFGate), 2006.

Gallup, Andrew, and Newport Francis. The Gallup Poll: Public Opinion . Gallup Press, 2005. Print.

Sebelius, Kathleen. Health Insurance Reform Will Benefit All Americans . 2009. Web.

Singer, Peter. Why We Must Ration Health Care . 2009. Web.

Sutherland, Jason., Fisher Elliott, and Skinner Jonathan. “Getting Past Denial – The High Cost of Health Care in the United States” . New England Journal of Medicine 361;13, 2009).

The New York Times. The Uninsured . 2009. Web.

Wisk, Lauren. High Cost a Key Factor in Deciding to Forgo Health Care . 2011. Web.

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IvyPanda. (2018, October 12). Should Healthcare Be Free? Essay on Medical System in America. https://ivypanda.com/essays/free-health-care-in-america/

"Should Healthcare Be Free? Essay on Medical System in America." IvyPanda , 12 Oct. 2018, ivypanda.com/essays/free-health-care-in-america/.

IvyPanda . (2018) 'Should Healthcare Be Free? Essay on Medical System in America'. 12 October.

IvyPanda . 2018. "Should Healthcare Be Free? Essay on Medical System in America." October 12, 2018. https://ivypanda.com/essays/free-health-care-in-america/.

1. IvyPanda . "Should Healthcare Be Free? Essay on Medical System in America." October 12, 2018. https://ivypanda.com/essays/free-health-care-in-america/.

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IvyPanda . "Should Healthcare Be Free? Essay on Medical System in America." October 12, 2018. https://ivypanda.com/essays/free-health-care-in-america/.

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Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review

Chhabi lal ranabhat.

1 Department of Health Promotion and Administration, College of Health Science, Eastern Kentucky University, Richmond, KY, United States

2 Global Center for Research and Development, Kathmandu, Nepal

Shambhu Prasad Acharya

3 Country Strategy and Support, World Health Organization, Geneva, Switzerland

Chiranjivi Adhikari

4 School of Health and Allied Science, Pokhara University, Pokhara, Nepal

5 Indian Public Health-Gandhinagar, Gujarat, India

Chun-Bae Kim

6 Department of Preventive Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea

The goal of universal health coverage (UHC) from the United Nations (UN) has metamorphized from its early phase of primary health care (PHC) to the recent sustainable development goal (SDG). In this context, we aimed to document theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC in a global scenario. Searching with broad keywords circumadjacent to UHC with scope and inter-disciplinary linkages in conceptual analysis, we further narrated the review with the historical development of UHC in different time periods. We proposed, chronologically, these frames as eras of PHC, the millennium development goal (MDG), and the ongoing sustainable development goal (SDG). Literature showed that modern healthcare access and coverage were in extension stages during the PHC era flagshipped with “health for all (HFA)”, prolifically achieving vaccination, communicable disease control, and the use of modern contraceptive methods. Following the PHC era, the MDG era markedly reduced maternal, neonatal, and child mortalities mainly in developing countries. Importantly, UHC has shifted its philosophic stand of HFA to a strategic health insurance and its extension. After 2015, the concept of SDG has evolved. The strategy was further reframed as service and financial assurance. Strategies for further resource allocation, integration of health service with social health protection, human resources for health, strategic community participation, and the challenges of financial securities in some global public health concerns like the public health emergency and travelers' and migrants' health are further discussed. Some policy departures such as global partnership, research collaboration, and experience sharing are broadly discussed for recommendation.

Universal health coverage (UHC) means that the whole universe's population has access to all types of healthcare. It refers to a government system or program that guarantees that all people under that government have access to available health services. The system will provide such services when and as required without causing financial challenges for the individual receiving such services. UHC programs by design offer all essential and quality health services, namely, health promotion, preventive health, medical treatment, rehabilitation, palliative care, and hospice care ( 1 ).

Despite the core definition, UHC is fundamentally a human right and political scheme. The human rights-based approach (HRBA) has established its legacy in inclusive development that follows the United Nations Development Program (UNDP)'s human development approach and integrates standards and principles of human rights, such as participation, non-discrimination, and accountability ( 2 ). It provides a procedural way for implementing UHC at the national level and concludes by highlighting critical areas in which consistent, authoritative, and practical guidance is urgently needed to support countries in getting onto the right road to UHC ( 3 , 4 ). In the same line, addressing UHC requires changing a wide spectrum of laws, policies, and practices that reflect the willingness and capacity of governments to deliver on their commitments and meet their human rights obligations. UHC has been established in a wider, longer, and deeper journey toward the realization of human rights using various legal, historical, institutional, and social arguments.

Globally, there is no consistency in providing healthcare in terms of access, equity, and quality. The UHC concept was developed during the millennium development goal (MDG), 2000–2015. There was a challenge in developing the healthcare package to achieve UHC in Malawi ( 5 ). There is some confusion when setting the priority and designing the policy in Uganda ( 6 ) due to the conceptual unclarity of UHC. Previous assessments have mainly focused on the provision of essential services, the availability of healthcare resources, and health service utilization rates in high-income countries rather than in low-income and middle-income countries ( 7 ). A study in China has revealed that there is some unclarity about the resource pooling in healthcare for ongoing health insurance programs ( 8 ). There is a power imbalance in the global governance sectors, health disparities, few choices in health service access, and institutional barriers according to The Lancet-University of Oslo Commission Report ( 9 ). Due to the different dimensions of the power structure, there has been a shift in obligation from public provision of health services to an individualized responsibility for health outcomes where health is increasingly commodified and citizens are recast as consumers ( 10 ). In low- and middle-income countries, political destination, governance, and resource allocation are lacking to achieve UHC ( 11 ). On the other hand, proper health financing modality is a pathway to achieving UHC. Inappropriate health financing models and disproportional resource allocation are bottlenecks that can hinder achieving UHC ( 11 ). Since UHC is a multisectoral and multidimensional issue with an ambitious health goal, careful and smart resource distribution in healthcare is needed. There is also a need for conceptual and contextual clarity in UHC. There is no uniformity in the conceptual definition or scope of UHC, including whether UHC is achievable, how to move forward, common indicators for measuring its progress, regular monitoring of those indicators, and clear interpretations of those indicators ( 12 ). Therefore, conceptual clarity, proper measurement, and the formation of community-based essential healthcare package are needed ( 13 ). An American education publication company has suggested that a link of historical development of healthcare with UHC should be mandatory to track those indicators ( 14 ). The aim of this study was to describe theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC. A review of past efforts, analysis of current trends, and clear future directions are necessary to achieve UHC.

Methodology

We used a general review approach to dissect UHC from multiple perspectives. To be more focused, conceptual and historical developments toward UHC have been presented from the available literature. We fixed the article's content in light of policy and program confusions in various countries ( 15 ), the multiple foundations of UHC ( 16 ), gaps in healthcare equity and excess during historical paradigm shifts ( 17 ), and the current and future challenges on the path of UHC ( 18 ). The future challenges for UHC presented in this article were articulated on the basis of epidemiological, demographic, existing policy discrepancies, and lifestyle factors associated with healthcare ( 11 , 19 ). We selected the literature in 4 steps as follows: (1) search the literature by keywords through Google, (2) sort the title by those that best match in first 5 webpages, (3) go for full access to the literature from the titles, and (4) pick up it, if the paper is useful or discard it. Major keywords searched for studies were universal health coverage, health disparity, healthcare access, equity, philosophy, historical development, conceptual analysis, social health protection, public health emergency, and so on. The nature of our study does not demand hard inclusion and exclusion criteria. Regarding the quality of literature, almost all were taken from peer-reviewed journals, books, and reports, and all references are available online. A concept analysis is a process to guide the explanation of a concept that might be vague, ambiguous, confusing, or incomplete ( 20 ). It is a well-established methodology in public health practice that is used to examine many contents, which are key for preventive health and health promotion including cultural aspect ( 21 ), empowerment ( 22 ), participation ( 23 ), equity ( 24 ), and health literacy ( 25 ). This study adopted an evolutionary concept analysis process developed by Rodgers ( 26 ) to incorporate ideas by Risjord ( 26 , 27 ). This concept analysis needs to explore contextuality in terms of time, place, and discipline. In contrast, a “theoretical concept analysis” aims to represent the concept as it appears in a particular body of scientific and theoretical literature. A concept analysis is often used to explore new and underdeveloped concepts and theories. Additionally, it can also be used to clarify and define concepts that are open to individual interpretation, multiple truths, and subjectivity ( 28 ).

Historical analysis was performed for health service equity, access, and quality in different stages as a method where the gradual development of UHC was ovulated. We presented healthcare philosophy, theories, and policy practices in three historical periods, namely, health for all (1978–2000), millennium development goal (2000–2015), and ongoing sustainable development goal (SDG, 2015–2030), which includes WHO's 13th General Program of Work (WHO GPW13) period, 2018–2025 (with extension agreed by its member states). We presented health service coverage, financial service coverage, and population coverage using historical trend analysis of modern healthcare. Furthermore, issues of healthcare equity and access have been linked to politics, health financing, human right, and each individual responsibility ( Table 1 ).

Review approach, conceptual, and historical analysis summary.

We performed a conceptual analysis for terminological clarity, theory, philosophy of UHC, and its core linkage with politics, health financing, and social health protection. A historical review was performed to understand how modern healthcare started and chronologically developed globally. Historical phases are divided into before PHC (before 1978), PHC era (1978–2000), millennium development goal (MDG) (2000–2015), and SDG (2015–2030). In these historical periods, there are health priorities, major achievements, and measuring indicators.

Terminological clarity

From an etymological perspective, Universal means “everyone”. It is similar to the Universal Declaration of Human Right and Health as defined by the WHO constitution ( 29 ). Coverage resonates with protection, as does the fundamental human rights principle. Similarly, coverage is linked to social protection under SDG 1.3, which in turn can fasten human right to social security ( 30 ). The Committee on Economic, Social, and Cultural Rights has interpreted coverage as all people covered by the social security system, especially individuals belonging to the most disadvantaged and marginalized groups without discrimination. It has been noted that schemes are necessary to ensure “universal coverage” but not necessarily mandatory contributions ( 31 ).

Theoretical and philosophical ground of universal health coverage (UHC)

UHC implicates a wide array of human rights, including rights to life, health, security, equality and non-discrimination, the standard of living, freedom of movement, association, assembly, information, expression of thought, social security, privacy, participation, a basic standard of living like water, food, housing, education, and access to benefits of scientific progress. These and other rights are protected in international and regional treaties and national constitutions. They also form part of customary international law. Overall, they can be traced back to the Universal Declaration of Human Rights, which has established the groundwork for the international human rights movement ( 29 ).

The Universal Declaration of Human Rights was derived from discrimination and inequality of global polarization during the Second World War shortly after the establishment of the UN, with human rights as one of its foundational purposes ( 32 ). In this spirit, the WHO Constitution (1946) sets the standard for the highest attainable standard of health as a human right ( 33 ). During this period, many industrialized countries emerging from the devastation of the war established their health systems (e.g., France in 1945, the United Kingdom in 1948, and Japan in 1951). To this date, these systems are integral to the wider governance of society, as reflected in the Alma-Ata and Astana declarations on PHC, which reaffirm governments' responsibility to promote the health of their people. Health is referred to as the foundation of human rights ( 34 ). Furthermore, specific legislation and jurisprudence demonstrate how human rights norms and principles should allow national health systems and set parameters for what governments as stewards of these systems can and should do as well as what they are restricted to do ( 35 ). The General Assembly resolutions of WHO to adopt UHC over the years have consistently advocated how human rights—particularly the right to health—provide the overarching framework for UHC ( 36 ). In a similar vein, the UN special rapporteur on the right to health has emphasized that UHC must be understood as a right to health ( 37 ).

Political aspect

UHC is fundamentally a political agenda. In the world of global health governance, UHC is part of an ongoing debate about the relative importance of vertical priorities, individual wellbeing, disease control, eradication, and broader horizontal, health system-strengthening proposals. It is not possible without political priority because there is a need of willpower for health system strengthening and resource allocation for wellbeing, disease control, and prevention ( 38 , 39 ).

The effects of widespread democratization from the 1970's to the late 1990's can help us explain the expansion of UHC in middle-income countries today. Different authoritarian regimes had less accountability to the broad population with a poor commitment toward organized challenges. Those authoritarians were dictatorship in nature, state resources were mobilized to their families, and health services were available to a limited number of people as directed by those authoritarians ( 40 – 42 ). One of the political systems is the cadre-based political system, and it is one of the most promising paths to explore UHC. In particular, left-wing parties are more likely to enact redistributive policies in the spirit of UHC ( 43 , 44 ). Socialist parties enacted universal healthcare across southern Europe when they came to power after democratization despite major recessions that might block health access expansion. Later, it was the left that universalized healthcare in Latin American countries such as Brazil and Chile ( 45 , 46 ). At times, conservative parties have also expanded health coverage for their own political purposes at times ( 47 ). Otto von Bismarck created the first social health insurance in response to socialist challenges. Japan's health insurance expansion was the result of the left labor challenge to the dominant conservative Liberal Democratic Party. The expansion of healthcare access in Mexico was partly a strategy to maintain the popularity of its once-dominant Party of the Institutional Revolution ( 48 , 49 ). It shows that appropriate political vision, conviction, commitment, and related policies engineering are decisive factors to achieve UHC. However, the political nature, ideology, and governance are equally important for healthcare equity, access acceptability, and quality.

UHC and healthcare financing

The concept of healthcare financing schemes is an application and extension of the concept of social protection schemes ( 50 ). Health financing systems mobilize and allocate budget within the health system to meet the current health needs of the population (individual and collective) with an anticipated view of futuristic needs. There should be more choices of healthcare providers and payment modalities (such as direct payment through a third party) and mechanisms developed by the state (such as volunteer insurance, national health service, and social insurance) ( 51 ). Normally, there are four types of healthcare models. Each model is distinct in and of itself. Most countries do not strictly adhere to a single model. Rather, they create a hybrid model that fits their context.

The Beveridge model

Developed in 1948 by Sir William Beveridge in the United Kingdom, the Beveridge model is often centralized through the establishment of a national health service ( 52 ). Fundamentally, there is a single-payer government system with a low cost and a standard benefit. The service is available on their networks. It is fully funded by taxes without needing out-of-pocket payments or cost sharing. Every tax-paying citizen is guaranteed the same access to care. Nobody will ever receive a medical bill. There is a potential risk of overutilization of the Beveridge Model ( 53 ). Due to a high demand of healthcare with free access, there is a chance of rising costs and demands for higher taxes. Thus, many of these systems have regulations in place to manage healthcare demands.

The Bismarck model

The Bismarck model is very popular. It was created near the end of the 19th century by Otto von Bismarck as a more decentralized form of healthcare. In this model, employers and employees are both responsible for paying the health insurance premium through sickness funds created by payroll deductions ( 54 ). Regardless of a preexisting condition, private companies cover all types of services for each employee. Those plans are not meant to be profitable. Normally, healthcare providers are private, whereas insurers are public. In some instances, there is a single insurer (France, Korea). However, in other countries, like Germany and the Czech Republic, there are multiple competing insurers. The government controls the price. However, for UHC, each individual needs to contribute in different modalities. The challenge of the Bismarck model is how to sustain healthcare for a vulnerable and aging population. Now, this model has been adopted by Germany, Belgium, Japan, Switzerland, the Netherlands, France, and partially the USA.

The national health insurance model

The national health insurance model combines different aspects of both the Beveridge model and the Bismarck model. The government acts as the single payer for medical procedures as in the Beveridge model. Similarly, providers are private as in the Bismarck model. This model is driven by private providers, although payments come from a government-run insurance program that every citizen can afford ( 55 ). Fundamentally, the national health insurance model is a universal insurance that could not make or concern for a profit or deny claims either. Usually, there is no need for marketing. Moreover, it is cheaper and much simpler to navigate. This balance between private and public gives hospitals and providers more freedom without needing many complexities of insurance plans and policies ( 56 ). The national health insurance model has been adopted by US Medicare and the health systems in Taiwan, Canada, and South Korea. The demerit of the national health insurance model is the potential for a long waiting list and delay in treatment, which needs special policy departure to overcome those problems, mainly to become flexible on alternate strategies and not stick to one-size-fits-all ( 57 ).

The out-of-pocket (OOP) model

The OOP model is the most common model in less-developed areas and countries where there are not enough financial resources to create a medical system like the three models above. Patients must pay for their procedures from their pockets. It is like a commodity purchase where wealthy people can afford high-quality and professional medical care while poor people might get state or welfare organization that offers basic health services. Thus, healthcare is still driven by income ( 58 ). This model is mainly adopted by India, most Asian and African countries, South America, and uninsured or underinsured populations in the United States.

UHC has a set of objectives that health systems pursue. It is not a simple scheme or a particular set of arrangements in the health system. Making progress toward UHC is not limited to increasing the percentage of the population in an explicit insurance scheme. In countries like Germany and Japan, insurance schemes are used to ensure financial access and financial protection for all populations. In countries such as Sweden, the United Kingdom, and Northern Ireland, financial access and financial protection for all are achieved without anything called an insurance scheme. In most low- and middle-income countries (LMIC), free services are somehow legalized and promised. However, they are far from poor people access victimized by catastrophic health expenditures. In summary, it can be concluded that health financing models are just tools for health equity, access, and financial protection. Countries can assemble health financing models according to their contexts.

Social health protection (SHP) and UHC

Social protection can help individuals and families support their basic needs such as food, housing, and healthcare for vulnerable people (such as the poor, aging, disabled, children, women in difficult conditions, and jobless people) to conduct regular life and promote productivity. It has a series of public or publicly organized and mandated private measures against social distress and economic loss caused by reduction of productivity, stoppage or reduction of earnings, or cost of necessary treatment that can result from ill health ( 59 ). The International Labor Organization (ILO) was promoted by the SHP for international development, whereas the UHC for global health by WHO, both two wings of the United Nations (UN). SHP is a special and adequate package for improving health and ultimately enhancing economic growth. A healthier population can create surplus values in work and profession because they are more creative, hardworking, and low cost of disease burden. Well-managed SHP can deliver universal health coverage (UHC) to appropriate healthcare that is accessible and affordable ( 60 ). The reestablishment of the world economic structure, which led to accelerated real GDP growth across many low- and middle-income countries (LMICs) ( 61 ), might have demanded different and larger benefit packages of social securities all over the world, mainly the LMICs. Basically, those packages are in the form of cash. They can promote human resource productivity. UHC is a consistent healthcare package with the aim of achieving universal coverage in terms of service, population, and complete financial protection. As a result, the programs, resources, and delivery systems have been distributed throughout, increasing the probability of duplication among them. Furthermore, lacking a health technology assessment (HTA) body further jeopardizes the situation in achieving the UHC ( 62 ). To prevent duplication of the program, the efficiency of resource integration of SHP and UHC is useful.

Development and chronology of UHC

Situation and context of healthcare before phc: a period of establishing a scientific foundation in healthcare.

Before the UN establishment, equal access to healthcare for all people was an out-of-the-box agenda because there was no widely acceptable healthcare service with almost feudal type of governments all over the world ( 63 ). The primary features of feudalism were absolutist monarchism, centralization, and hierarchical land ownership. In this system, healthcare was available to all. In addition, there would be bosses rather than leaders. The modern healthcare system was for limited people who had power and resources. The ruling absolute authoritarian persons like popes, including other religious leaders and kings, neither had an agenda to provide accessible health services to all people nor did they have belief in science, research, medicine, or diagnostic tools ( 64 ). Rulers set priority on war and romanticism rather than the welfare of the public and the issue of health as a right associated with the welfare of a country.

Before 1950, there was a slow extension of modern health services. There was no uniformity in health services. Most people used ethnomedicines, complementary services, and alternative services. The occurrence of disease and illness in early explanations was based on myths, stories, religious interpretations, and mischief or vengeance. There was an equal practice of Chinese medicine, Japanese practice, and Ayurvedic practice in Asia ( 65 ). Due to diversity, belief, and efficacy, a continuous research extension of modern health service was not a priority. If there is no uniform health service and system, health access to all people would be low in priority.

During ancient and medieval periods, health and disease were mainly curative focused and mostly resolved with Spells, Chants, Herbals, Ayurveda, and other Traditional Medicines including Yin-Yang that originated in ancient China. To a meager, some thrusts for participation and health financing from the state level were observed during Lichchhavi (ancient) and Malla (medieval) kingships in Nepal, like state-funded Ayurvedic Health House (Arogyashala), regulating the umbilical cord from the state level, and services to provide without discrimination of caste and ethnicity ( 66 ), herbal medicine use in China ( 67 ), use of herbal cosmetics in ancient India ( 68 ), and such. These systems are rooted in communities; they are easy to use and access, and they even have less frequent and less severe side effects, implicating wider acceptability.

Primary health care era (1978–2000): Period focusing on community participation in healthcare

In an international conference convened by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) in Kazakhstan, 134 member countries of WHO ratified the Declaration of Alma-Ata in 1978 ( 34 ). The declaration committed member states to support the PHC as a policy to achieve the WHO definition of health ( 63 ). PHC was set up for social justice and was created for social reform in Europe and the rapid decolonization of Asia and Africa after the end of the Second World War.

PHC was built on principles of equity in access to health services and the right of people to participate in decisions about their own healthcare ( 64 ). Underpinning these principles could deliver preventive and promotive health services, appropriate technology, and intersectoral collaboration ( 69 ). It has been argued that PHC begins a shift in health paradigms—from a definition of health limited to biomedical research, the provision of health services by professionals, and institutional care in hospitals and sub-health units such as health centers to a broader focus that includes social determinants of health ( 70 ). It is well-known that PHC is a visionary concept that pushes conventional understanding of how health improves from the realm of biomedicine into a realm of social, economic, and political investigation and action.

In 2019, the WHO published a book entitled “Review of 40 Years of Primary Health Care Implementation at Country Level.” It concluded that PHC was the main foundation of UHC and SDG. Political will and governance, global movement of health reform, strengthening the health system for healthcare access and equity, partnership, organization, and management are the main enabling factors. Human resources for health, limited financial resources, inadequate policy frameworks, poor quality of health services, and a health information system are key challenges. Context-specific challenges related to health inequities and access barriers are equally sensitive. More importantly, financial protection of health through health insurance was just started. It was not an issue associated with a program or policy.

Community participation (CP) was proposed as one of the fundamental principles of PHC in the declaration. Community participation and engagement (CPE) gained momentum in this era. Various literature have explored five progressive involvement of the community people and ownership in health programs for the UHC–informing, consulting, collaborating, co-creating/empowering, and horizontal engagement ( 71 , 72 ). Nepal's female community health volunteer (FCHV) program, as an example of a community-based approach, was initiated in 1988 for family planning purposes, which proved successful and became popular in many other programs child, maternal, and disease control programs, within a couple of years, and was established as a backbone of the healthcare system ( 73 ).

Assessment of coverage

Primary health care was a beginning step in UHC in terms of equity, access, and quality at this time. Health service was measured by immunization against six killer diseases, case findings, and treatment completion of major diseases (TB, leprosy, malaria, and HIV/AIDS) and birth control. Population coverage was < 50%. There was no concept of financial coverage in this phase. Despite the efforts and similar approaches in other countries like Sri Lanka and some African countries, the CPE reached only to a collaborative (3rd) level ( 74 ) and was even more critical in the countries going through civil conflicts and war-torn societies ( 75 ).

Millennium development goal and health goal (2000–2015): A period of achieving basic healthcare

Millennium development goals (MDGs) were established following the millennium summit of the United Nations in 2000, after the adoption of the United Nations Millennium Declaration. Each goal had specific targets and a fixed timeline to achieve those targets. A total of eight goals were measured by 21 targets.

In the past 13 years, the MDGs managed to focus world attention and global political consensus on the needs of the poorest to achieve a significant change in Official Development Assistance (ODA) commitments (24). They have provided a framework allowing countries to plan their social and economic development and donors to provide effective support at national and international levels ( 72 ). Programs and activities targeted MDGs 4, 5, and 6 in developing countries, focusing on maternal and child health (MCH) and communicable diseases. It has been further criticized that MDGs 4 and 5 were the most important in the African region, while MDGs 7 and 8 were the most important in the Western Pacific region, rather than global perspectives ( 73 ). Low-income countries have attached higher relevance to MDG1 than high-income countries ( 73 ). Arab countries have not considered the MDGs as a top priority for policymakers, academia, or social actors in general, mainly due to ethnic, religious, political, and social limitations ( 74 ).

As reported earlier, a major part of the MDGs has been at least partially accomplished. Many countries are trying to adopt a sustainable path ( 75 ). Despite generally positive outputs, global targets have not been met in some regions, particularly in sub-Saharan Africa and south Asia. Indeed, MDGs have encountered a range of common challenges ( 76 ). There are no measuring indicators regarding financial coverage/protection for health-related goals. As a result, countries have no mandatory or priority to design and implement those programs. Therefore, MDG health-related goals had focused on health service and population coverage other than financial coverage.

At this time, there was a good foundation for UHC. Health service coverage was extended to the basic (or limited) health service package, but not the universal health package. Indicators have been established and measured, such as immunization including more antigens, case findings, free-of-cost treatment completion of major diseases (TB, leprosy, malaria, and HIV/AIDS), four-time antenatal visit, health facility delivery, birth control, vitamin A, and iron distribution to the target population. Approximately 60–80% of the population was covered. For financial coverage, the concept of mandatory health insurance was introduced to overcome out-of-pocket and catastrophic health expenditures. Major programs were focused on mitigating child and maternal mortality in low- and middle-income countries.

Sustainable development goal (SDG) (2015–2030): A period of financial protection in healthcare

Declaration of sustainable development goals (SDG) provides a global political commitment that can influence health financing reform (HFR) for UHC at the national level. For sustainable development, under goal 3 (ensure healthy lives and promote wellbeing for all at all ages), achieving UHC is one of the comprehensive targets for 2030. Universal health coverage is based on the principle that all people should have access to the health services they need without suffering financial hardship while accessing such services ( 77 ). This implies that an effective, efficient, and equitable health financing system is a critical and essential component that contributes to the achievement of the UHC target under the SDG declaration ( 78 – 80 ). It is only possible when resources are carefully managed and spent that all people could feel sustained progress toward UHC. There should be three objectives of health financing viz. equity in the use of health services, quality of care, and financial protection of progress by maintaining transparency, accountability, efficiency, and equity in resource distribution.

In SDG, both aspects of coverage (health service coverage and financial coverage) have been committed. SDG 3.8.1 has concerns about the proportion of population that can access essential quality health services. 3.8.2 is associated with mitigating household catastrophic health expenditures, with increased health insurance. Since 2015, seven years already passed, and we need to achieve the goal until 2030. Although limited financial and significant health service coverage has been achieved, there is still a great challenge to cover the universe from both perspectives by 2030.

In the SDGs, health services, population, and financial coverage are equally focused. The service coverage could be measured by meeting the need for family planning with modern contraception, antenatal, peripartum, and postnatal care for newborn babies, antenatal, peripartum, and postnatal care mothers to reduce maternal mortality ratio, DTP3 vaccine coverage, MCV1 coverage, LRI, and diarrhea treatment to reduce maternal and child mortality, acute lymphoid leukemia treatment, ART coverage, asthma and epilepsy treatment, appendicitis treatment, paralytic ileus and intestinal obstruction treatment, tuberculosis, diabetes and ischemic health disease (IHD) treatment, stroke, chronic kidney disease (CKD) and COPD treatment, and cervical, breast, uterine, and colon/rectum cancer treatment. For financial coverage, health insurance should be mandatory. Advanced health insurance packages would be available by co-payments so that there should be a significant reduction on OOP and catastrophic health expenditure (CHE). Likewise, total health expenditures (individual and government) would increase. Particularly, the government health expenditure (GHE) should be increased because it is not an expenditure but an investment in the people.

The following Figure 1 shows different step-by-step evolution, development, and destination of healthcare over time. These evolution and development have been extended considering financial strength, the needs of people, chronological innovation in medical science, the use of information technologies to adopt healthcare, research in health services, and their replication in different countries.

Universal health coverage (UHC) evolution, development, and destination.

Future challenges and ways forward

Healthcare coverage in public health emergencies.

A public health emergency like a global pandemic is a global challenge for everyone. Public health practitioners, policymakers, researchers, scientists, and public leaders do not have a clear picture of how to handle the situation in terms of the supply chain, breaking disease transmission, economic mobility, and so on. It means that it is an extra challenge to manage financial protection for the at-risk population. In the 13th century, there was a bubonic plague that killed 200 million people in the early period of the 19th century. There was another pandemic of Spanish flu affecting approximately 100 million people. At the end of the 19th century, the global HIV pandemic started. It is still going. Its death volume was more than 35 million. More than 6 million people died recently as a result of the COVID-19 pandemic ( 81 , 82 ). When universal health coverage evolved, the most important goal was financial coverage in complex situations. However, during a pandemic, it is very challenging to achieve financial protection ( 83 ). Developing UHC is the most important issue nowadays.

Healthcare coverage in cross-country traveling and countries with an open border

After globalization and trading, many people travel internationally. Approximately 2 million people travel each day from one country to another ( 84 ). Due to long travel, business work, food habit, and weather factors, there is a high risk of getting sick. To travel across the country, full health insurance plan is needed, and authentic international organization could arrange it. There are very optional and limited plans of health insurance for travel and flight. Similarly, many people keep their regular medicine during travel. However, this regular medicine might be missed sometimes. There is no discussion of a medical plan during international traveling. It is necessary to add those plans as mandatory so that any health emergency individual could use healthcare. People living in boarder areas of two country often problem with health service access and financial assurance'. The recording and reporting of data regarding health service utilization may not be consistent, and there is always a chance of under-reporting, overlap, and verification of patients/clients. So, bilateral or international mechanisms are necessary to solve those challenges.

Addressing the issues of migrant people

According to the UN, the estimated number of international migrants worldwide has increased in the past 20 years, between 2000 and 2020, reaching 281 million in 2020 ( 85 ). In these 20 years, the international migration trend increased by approximately 2% annually. By the end of the year, ~70.8 million individuals were forcibly displaced worldwide due to persecution, human rights violations, political conflict, war, and so on ( 86 ). According to the most recent estimates, 7.7 million people were displaced by the Russia-Ukraine War, which was equivalent to 17.5% of the entire population of Ukraine ( 87 ). Those people left their homes and everything behind in a desperate attempt to escape death and destruction. Even in legal migration, it is very hard to maintain health service access, equity, and quality. In illegal migration/displacement, there is a great challenge to survive and obtain financial coverage for health services far away. Now, it is a high time to think about how to assure basic health service for migrant people and incorporate it within the system of UHC.

Integrating SHP with UHC

There are many resources under social security and protection. Healthcare is a neglected issue in social security programs. However, the focus program under social security is retirement token money. On the contrary, the key challenge during retirement is affordable healthcare. During the retirement period, there is limited coverage under healthcare, especially in the Medicare program due to an insufficient pooled fund. SHP could contribute to health financing for UHC. Seguro, a popular and effective program in Mexico, is a social health protection program that is effective in achieving UHC ( 88 ). There is the possibility of integration and collaboration between social health protection and UHC through information and communication technology (ICT) ( 89 ). For expedited achievement of UHC, better financial health protection with people integration or close collaboration between SHP and UHC is necessary.

Enhancing individual responsibility for health

Health is not only the responsibility of state and individual right but also a personal responsibility. There are many circumstances where health risks can be prevented and minimized. Lifestyle choices like eating, drinking, regular checkup, workplace safety, and safe driving are individual efforts and they significantly contribute to health and establishing wellbeing ( 90 ).

Addressing the global needs-based management of the health workforce

Human resources for health (HRH), especially those fit-for-purpose and fit-to-practice, are key to the UHC, mainly to the expansion of health service coverage and the benefits packages. A review article, which explores the policy lessons on HRH from four countries (Brazil, Ghana, Mexico, and Thailand) that have achieved sustained improvements in UHC, identifies that for effective service coverage, further attention on availability, accessibility, acceptability, and quality (AAAQ) of HRH are imperative. It also suggests partnerships involving health and non-health actors for the success of such HRH production ( 88 ). However, from the deprival aspects, the WHO's policy guiding document on global HRH for the UHC and the SDG underscores that only a 17% reduction of a total of 17.4 million deficit HRH in 2013 is projected to achieve in 2030 and still there will be a lack of around 14.5 million HRH globally, and the largest shortages will be seen in South-East Asia (6.9 million) and Africa (4.2 million). The document also focuses on the imperativeness that the developing countries should provide substantial efforts to the development, recruiting, and retention of HRH, and further recommends that the workforce that we recruit should be skilled to adopt the service delivery models emphasizing the PHC approach ( 91 ). Another HRH review paper mainly focusing on the African region emphasizes producing HRH for strategic leadership, instilling proper ethos and values, and then recruiting with equitable allocation in rural and underserved areas ( 92 ). Fundamentally, healthcare is a highly qualified service-based industry. Therefore, the production, training, mentoring, and mobilization of health human resources significantly impact the access and quality healthcare ( 93 ).

Practically, UHC is an ambitious goal for every single citizen of the world, regardless of income, race, ethnicity, and geography. It is a guarantee of health services in terms of equity, access, quality, and affordability. Since the evolution of PHC, there have been tremendous achievements, mainly in health service accessibility and availability worldwide. It is a triangular balance of healthcare that considers people's needs, affordability, and innovative service models with state responsibility. Average life expectancy has increased by around 25 years. Maternal and child mortality were reduced substantially; hunger and severe malnutrition were negligible; and there were high immunization coverages for major fatal diseases, including HPV, measles, cholera, and typhoid. Still, there is a challenge in providing financial guarantees for public health emergencies, cross-country traveling, healthcare for migrant people, and the collaboration of healthcare with social protection schemes. A major portion of the health budget in the majority of countries is still allocated to tertiary and super-specialized care. Due to operational inefficiency, many countries still fail to recognize health as a right in their constitutions with ineffective implementations of policies, although they have the right policies. Country-specific policy practices such as health transformation plan (HTP) in Iran and Turkey ( 94 ), health system reform in Mexico ( 95 ), and integration of health insurance in the Republic of Korea ( 96 ) could be the best references for low- and middle-income countries. There is clear and big picture regarding UHC in this paper but there is also a clear boundary on it. So, UHC is not free health care, it is not donor funded program, the implementation strategies and practices may not consistent and it is not specific program intervention. To address challenges, a major policy departure might be essential. Moreover, a collaboration between the ILO and WHO by integrating SHP and UHC, research collaborations, and experience sharing could mitigate those challenges. Specific programs are essential in promoting individual responsibility for their health, particularly risk minimization and wellbeing, addressing the needs-based gap of HRH, strategic community participation and engagement, and utilizing ancient health systems with appropriate trade-offs of utilities.

Therefore, our study explored the different aspects of UHC, namely, historical developments, current, and future challenges. This is a hybrid type of study because the literature used in this study is research and policy-related and useful for policymakers, researchers, government agencies, and international organizations. In spite of those implications of our studies, there are some limitations too. First, we did not use specific review protocols, and we did not focus on counting the article as a review study. Similarly, the presentation of writing flow might be subjective and pragmatic rather than purely academic.

Author contributions

CR conceptualized, designed, prepared, reviewed, and led the article. SA, CA, and C-BK thoroughly and periodically reviewed and updated the article. CA primarily addressed reviewers' comments and edited and prepared the revised version. All authors reviewed the final version of the manuscript and agreed to its submission.

Funding Statement

This work is currently receiving a grant (#2022-51-0372) of midterm evaluation of Maternal and Child Health Promotion project in Volta and Oti regions Ghana from the Korea Foundation for International Health (KOFIH).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Dylan Scott answers 9 key questions about universal health care around the world

Vox policy reporter Dylan Scott traveled to Taiwan, Australia, and the Netherlands to see their health systems.

by Lauren Katz

Vox policy reporter Dylan Scott traveled the world last fall to explore what the US can learn from other countries’ health systems , visiting Taiwan, Australia, and the Netherlands. His trips were the foundation for Everybody Covered , a Vox series on health care that also reported on health systems in the United Kingdom and Maryland .

Dylan did a Reddit Ask Me Anything session on Wednesday, January 29, discussing everything from how countries pay for universal health care to what it will take to achieve further health care reform in America. Here’s a roundup of some of the most interesting questions and answers, lightly edited for clarity.

1) How do countries pay for public health insurance?

Icantnotthink: Where does the payment for public health care come from in other countries?

Dylan: Most of these countries use some mix of 1) payroll taxes for individuals, 2) employer contributions, and 3) general government revenue and progressive/sin taxes. To be honest, there isn’t one model to follow. Each country had its own health funding plan that has since been reformed to meet the needs of their current system, just as the US would. But other countries are looking for health care dollars in many of the same places Medicare-for-all supporters think we should here.

2) When it comes to covering everyone, is a country’s population density important?

Verybalnduser: How important would you say a country’s population density is to keeping total cost down?

Dylan Scott: It’s a huge asset. Taiwan has been able to keep its overall spending low — people on the left would say their single-payer program is actually underfunded — and cost sharing low for patients in large part because its urbanized nature makes it easier for a smaller workforce to meet the needs of its patient population. The Netherlands has been very innovative in delivery reforms, meant to keep costs in check, something that’s clearly been aided by its density. Australia , on the other hand, even with a universal public insurance plan, has still struggled with access in its more rural areas.

3) Is there a lot of paperwork in a single-payer system?

ZenBacle: How much paperwork do patients in single-payer systems have to fill out? And how much time do those patients have to spend fighting with health care providers to get them to honor their coverage?

Dylan Scott: One of the benefits of single-payer is there’s a lot less administration. We visited a hospital in Taipei, Taiwan, and while all the clinic lobbies were full, the cashier’s desk was basically empty. One survey finding that stuck out to me showed the doctors in the Netherlands (with private insurance) are more annoyed about paperwork than their peers in more socialized systems. So while I wouldn’t want to try to quantify it off the top of my head, there seems to be less of a paperwork headache.

The Pandemic Playbook Vox explores the successes — and setbacks — in six nations as they fought Covid-19.

• Taiwan’s single-payer success story — and its lessons for America
• Two sisters. Two different journeys through Australia’s health care system.
• The Netherlands has universal health insurance — and it’s all private
• The answer to America’s health care cost problem might be in Maryland
• In the UK’s health system, rationing isn’t a dirty word

4) Between Taiwan, Australia, and the Netherlands, which policy would translate most easily to the US?

Doctor_YOOOOU: Which of these universal health care systems is “closest” in terms of the amount of reform required to the United States?

Dylan: This is a tricky one — no country looks much like the US status quo. The Netherlands does have a lot of the same features as Obamacare (ban on preexisting conditions, individual mandate, government assistance to cover the costs), but it’s available to everybody and it’s stricter. The mandate penalty is harsher, the government rules on cost sharing are more stringent, and the government actually helps set prices and an overall budget for health care. So it’s much more involved than the US government is in administering that private health insurance. And almost all of the insurers are nonprofits.

So we’re talking about huge changes to move the US system to something that looks more like the Dutch — and that’s one I’d name as closest (along with Japan) to what we have right now.

5) Do solutions exist within the US that can be applied to the rest of the country?

Blakestonefeather: You traveled the world to explore what the US can learn, but did you also travel the US to learn if the US can learn? [In other words,] what are the barriers we in America face to learning/being able to learn?

Dylan Scott: We actually did one story in the US, on Maryland’s unique system for paying hospitals . (Every insurer — private, Medicare and Medicaid — pays the same rates for the same services.)

But there is a huge challenge in translating policies from abroad to the US. Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.

Then you’ve got political differences; Princeton economist Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in Congress in the face of industry opposition is certainly a warning sign to any aspiring reformers.

So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.

• 9 things Americans need to learn from the rest of the world’s health care systems

6) What does the American health care system get right?

taksark: What’s something good about the American health care system that could be kept and improved on in a better version?

Dylan Scott: The geographic immensity of the US has forced a lot of experimentation with telemedicine, and that is both a necessity and an area where other countries have tried to draw from what the US has done. I heard a lot from doctors about coming to the US to learn the latest on best practices for delivering care.

I think the US is still seen as a leader in innovative medicine — the question is why can’t we give more people access to it?

7) Besides America, what other countries have private health insurance?

To_Much_Too_Soon: How many other countries besides America have private health insurance?

Dylan: The US relies much more on private health insurance than any other country I’m aware of. About half of US citizens depend on private insurance as their primary coverage, and about 8 percent of our GDP is private health spending; most other developed economies don’t top 4 percent of GDP for private spending.

There are countries like the Netherlands with universal private insurance. But their private insurance is a lot different than ours: Almost all of the insurers are nonprofits, the government sets rules about premiums and cost sharing, there is a global budget for health care costs, etc.

Some countries with single-payer programs, like Australia, allow private insurance as a supplement — so you can get more choice in doctor or can skip the line for surgery. But no developed economy I know of is so dependent on private insurance as the US and with comparatively few regulations about its benefits.

8) What surprised you the most throughout your reporting?

JoseyGunner: What shocked you the most during your travels?

Dylan Scott: I was surprised how often people I talked to were shocked by the worst parts of US health care. The uninsured rates, the deductibles we have to pay, the very idea of a surprise medical bill — all of it was unfathomable to many of the people I met.

9) What are the biggest hurdles to any future health reforms in the US?

Flogopickles: What do you see as America’s biggest hurdle to achieving any sort of movement in affordable care for our citizens?

Dylan Scott: The status quo is powerful for two reasons: One, it’s good enough for enough people that big change feels like a risky proposition to a lot of the population and, two, health industry interests are so influential in Washington, DC. Overcoming those two things — people’s inherent aversion to risk in health care and the power of industry to constrain policymaking, especially price constraints for medical care — are the biggest hurdles to any future health reforms.

Join the conversation

• Read Dylan Scott’s full Reddit AMA

• Sign up for VoxCare, Vox’s health policy newsletter

• Join Vox’s health policy Facebook group

• Listen to the Impact episode about Taiwan’s single-payer system

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Guest Essay

We’re Already Paying for Universal Health Care. Why Don’t We Have It?

By Liran Einav and Amy Finkelstein

Dr. Einav is a professor of economics at Stanford. Dr. Finkelstein is a professor of economics at the Massachusetts Institute of Technology.

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured, and more than twice that number will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance; make sure all insurance plans meet some minimum standards; change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde.

The risk of losing coverage is an inevitable consequence of a lack of universal coverage. Whenever there are varied pathways to eligibility, there will be many people who fail to find their path.

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Laura Santhanam Laura Santhanam

• Copy URL https://www.pbs.org/newshour/health/how-canada-got-universal-health-care-and-what-the-u-s-could-learn

How Canada got universal health care and what the U.S. could learn

Naresh Tinani loves his job as a perfusionist at a hospital in Saskatchewan’s capital. To him, monitoring patient blood levels, heart beat and body temperature during cardiac surgeries and intensive care is a “privilege” — “the ultimate interaction between human physiology and the mechanics of engineering.”

But Tinani has also been on the other side of the system, like when his now-15-year-old twin daughters were born 10 weeks early and battled infection on life support, or as his 78-year-old mother waits months for new knees amid the coronavirus pandemic. While stressful, those moments helped make him “very proud” of his nation’s health care system, a cornerstone of Canadian national identity. He’s proud because during times of true emergency, he said the system took care of his family without adding cost and affordability to his list of worries.

And on that point, few Americans can say the same.

Before the coronavirus pandemic hit the U.S. full speed, fewer than half of Americans — 42 percent — considered their health care system to be above average, according to a PBS NewsHour/Marist poll conducted in late July. Roughly as many people — 49 percent — said the Canadian system was better than their own. Compared to people in most developed nations, including Canada, Americans have for years paid far more for health care while staying sicker and dying sooner . 

In the United States, unlike most countries in the developed world, health insurance is often tied to whether or not you have a job. More than 160 million Americans relied on their employers for health insurance before COVID-19, while another 30 million Americans were without health insurance before the pandemic. 

Tens of millions more Americans lost their health care coverage when coronavirus fears triggered a recession this year. Numbers are still shaking out, but one projection from the Urban Institute and the Robert Wood Johnson Foundation suggested as many as 25 million more Americans became uninsured in recent months. That study suggested that millions of Americans will fall through the cracks and may fail to enroll for Medicaid, the nation’s safety net health care program, which covered 75 million people before the pandemic. 

How do health care prices in the United States compare to those in other countries? The price tag for common procedures can be staggeringly different, depending on where the patient receives care. Test how much you know with this quiz.

When people debate how to fix the broken U.S. system (an especially common conversation during presidential election years), Canada invariably comes up — both as an example the U.S. should admire and as one it should avoid. During the 2020 Democratic primary season, Sen. Bernie Sanders touted Canada’s single-payer model as the antidote needed to heal the U.S. health care system, pitching his own version called “Medicare for All.” Sanders dropping out of the race in April fueled speculation that Biden might adopt a more progressive platform, including on health care, to woo Sanders’ diehard supporters. 

Every health care system has its strengths and weaknesses, including Canada’s. Here’s how that nation’s system works, why it’s admired (and sometimes disparaged) by some in the U.S., and why outcomes in the two countries have been so different during the COVID-19 pandemic. 

How Canada developed its system

The Canadian health system hasn’t always been this way; it was born out of need in a time of economic crisis. In 1944, voters in the rural province of Saskatchewan, hard-hit during the Great Depression, elected a democratic socialist government after politicians had campaigned for a basic right to health care. At the time, people felt “that the system just wasn’t working” and they were willing to try something different, said Greg Marchildon, a health care historian who teaches health policy and systems at the University of Toronto.

Three years later, the same politicians, led by Saskatchewan Premier Tommy Douglas, replaced the privately insured and funded health care system and instead used taxes to cover all hospital care province-wide. The change was met with pushback. On July 1, 1962, doctors staged a 23-day strike in the provincial capital of Regina to protest universal health coverage. But ultimately, the program “had become popular enough that it would become too politically damaging to take it away,” Marchildon said. 

Other provinces took notice. Those efforts spread nationwide and eventually established what would become the Canadian health care system, known as Medicare, through the Canada Health Act of 1984 . 

Under this law, Canada’s 13 provinces and territories control their health care, meaning those governments get to decide how to design and deliver their health care system — not unlike Medicaid in the U.S, which is managed by the states. To receive federal dollars, provinces and territories must meet five basic criteria : public administration, comprehensiveness, universality, portability and accessibility. If you move between provinces — from Toronto to Vancouver, for instance — your insurance travels with you. Everyone (except undocumented immigrants) carries a health insurance card that covers them. These plans cover medically necessary hospital care and essential physician services, but do not include dental, out-of-hospital medications, long-term care, ambulance services or vision care — a big sticking point in the current Canadian debate over health care. To pay for uncovered care, two-thirds of Canadians rely on supplemental insurance plans typically paid by employers (as is the case in much of the U.S.). 

Who has coverage?

Today, severe job losses do not leave people completely uninsured in Canada, said Colleen Flood, who directs the University of Ottawa’s Centre for Health Law, Policy and Ethics. Amid the pandemic, Canadians can get tested for the virus when they need it and they don’t fear that the cost of a test or treatment could financially break them if COVID-19 doesn’t kill them first, Flood said: “Coast to coast, every Canadian has the security of health care for them if they do get sick.”

“To Canadians, the notion that access to health care should be based on need, not ability to pay, is a defining national value,” Dr. Danielle Martin, chief medical officer at Women’s College Hospital and professor at the University of Toronto, wrote in a 2018 Lancet article that unpacked the Canadian health care system.

Americans simply don’t live with that confidence, Flood said. Losing a job is “bad enough, but to imagine that you’re going to have to lose everything you’ve got to qualify for Medicaid. Sell your house. Sell your car and basically be on the bones of your ass before you get any medical coverage.”

“It’s a human right to have access to health care,” Flood said.

Cheryl Camillo, a former technical director for the Centers for Medicare and Medicaid Services, came from Maryland to the University of Regina in Saskatchewan to learn about the roots of the Canadian health care system and how the U.S. and Canadian systems can benefit from each other. Camillo said Americans could benefit from the Canadian system with “less paperwork, less red tape, less cost for sure, even after factoring in taxes, more convenience, more choice, more opportunity in work lives, more time and more happiness and more social cohesion and more value.”

Most Canadians understand their system requires tradeoffs, including wait times of months for certain procedures or treatment, Martin told the NewsHour. For instance, to protect its universal access, Canadian law forbids people from buying additional insurance to cover hospital care. 

It is a law that Vancouver-based orthopedic surgeon Dr. Brian Day has fought in court since 2009. He has set up private hospitals in Canada and in the U.S. to offer elective surgeries and to reduce waitlists filled with the hundreds of people wanting procedures. Day, who argues for more private dollars in his nation’s health care system, said that the Canadian system doesn’t offer enough coverage, noting that people still have to seek private insurance for services not covered by the Canada Health Act, such as dentistry, mental health care or medications not prescribed in a hospital (though they do cost less than in the U.S.). He says people are dying while waiting for treatment, pointing to data from the Canadian Institute for Health and Information that suggested Canadian patients wait for some procedures four times longer than those in France, and thinks that those who are willing to pay should be able to get services sooner. Even in Canada, “The biggest determinants of health is wealth,” he added. And yet, Day doesn’t see what is happening south of his border as a better approach.

“Neither the Canadian or the U.S. are the models that should be looked at,” he said. Where we should be looking: Switzerland, he said. The country allows private health insurance, but if a person is unable to pay, the government pays their premiums for them, Day said, out of tax money and other funds. “The thing that is wrong with the U.S. is it needs universal health care.”

In 2019, health expenses drove more Americans into bankruptcy than any other reason, according to the American Journal of Public Health . That same year, health care consumed 17 percent of the U.S. gross domestic product, a greater share than in any other developed country, including Canada, which was at 10.8 percent, according to the latest OECD data . 

Canadians don’t typically worry about medical bankruptcy. If you get hit by a bus and receive any form of hospital care, you’re billed nothing. Taxes cover the cost of hospital care, such as emergency room visits or operations to remove tumors.

Patient advocate Carolyn Canfield, who lives in British Columbia, has had to confront a life-threatening cancer diagnosis, but not the endless medical costs that many in the U.S. face. Born and raised in the U.S., after Canfield emigrated to Canada after college. More than a decade ago, she noticed suspicious symptoms. She saw her doctor who referred her for testing. The biopsy revealed a malignant growth, and her doctor referred her to a specialist. 

“That cost me $0. I had no out-of-pocket expenses,” she said. “I never saw a bill.” 

In early March, Naresh Tinani’s 78-year-old mother had been waiting four months to replace her knee cap. Age and osteoporosis had taken their toll, and she was ready for the relief an elective surgery would bring, he said. She underwent diagnostic tests and consulted with doctors. Within three days of her operation, Tinani said, Canada entered lockdown due to COVID-19 and hospitals stopped conducting elective surgeries. Several more months passed. After the country began easing lockdown restrictions, the hospital contacted Tinani’s mother to see if she wanted to go forward with her surgery. However, because of her age, concerns about the virus and coordinating family members to care for her during her recovery, Tinani said his mother chose to postpone her knee replacement. It’s now been nearly a year since she first sought out the procedure, and she’s not sure when the surgery will be possible again.

Left to right: Robin Tinani stands over her newborn daughter, Mira, in the NICU. Mira and her twin sister, Jaya, were born 10 weeks premature and fought infections after birth. They received weeks of care in the Canadian hospital system, and their family was charged nothing. Naresh Tinani, a perfusionist at Regina Qu’Appelle Health Region in Saskatchewan, attends a sporting event with his mother, Nirmala Tinani. His mother, 78, has waited for roughly a year to undergo knee replacement surgery, an elective procedure. Photos courtesy of Naresh Tinani

The amount of time Canadians wait for medical care depends on the type of procedure, and wait times have shifted over time. The Canadian Institute for Health Information tracks provincial-level data on wait times for elective procedures for non urgent outpatient specialty services, such as cataracts and hip replacements. Some provinces are better at meeting benchmarks than others. However, “Canadians are not dropping dead” as a result, Martin said.

At the same time, a senior with bad or painful arthritis may have to wait a year for hip replacement surgery, Martin said. 

“It’s a real problem in Canada and not one we should sugar-coat,” she said. 

For roughly 20 years, Wendell Potter worked to sow fear of the Canadian health care system — including long wait times like these — in the minds of Americans. As the head of corporate communications for health insurance giant Cigna, Potter said industry executives felt the public Canadian system exposed shortcomings in the private U.S. health system and potentially threatened their profits. 

That led Potter and his peers to perpetuate the idea that wait times forced Canadians to forgo needed medical care and live in peril. Potter said he and his colleagues cherry-picked data and obscured the bigger picture, but to get that mischaracterization to take root in people’s imagination, “there needs to be a kernel of truth there,” he said. 

In this case, Canadians at the time experienced longer wait times for non-emergency elective procedures, such as knee and hip replacements. Massive health insurance companies poured money into promoting this idea until it bloomed into a mischaracterization of the entire Canadian health care system. 

The trick to getting misinformation to stick is to “repeat it over and over and over again, over years, and get friends to repeat it,” Potter said.

Eventually, Potter’s conscience got the better of him, he said. In 2008, he abandoned corporate communications after he was told to defend a company decision not to pay for the liver transplant of 17-year-old Nataline Sarkisyan , despite doctors saying the procedure would save her life. She died. He is now president of Medicare for All Now, an advocacy group that promotes universal health coverage.

“We wanted people to think they needed to wait for care that was life-saving,” Potter said. “That was absolutely not true. In [the U.S.], many people wait and never get the care they need because they’re either uninsured or underinsured.”

Like Tinani’s mother, many Americans have also delayed care amid the pandemic out of concern that they might spread or get exposed to the virus while sitting in a waiting room or standing in line for medications. Even routine childhood vaccinations nosedived during the pandemic, pushing the U.S. Department of Health and Human Services on Aug. 19 to allow pharmacists to train and qualify to administer vaccines to children ages 3 to 18, all in an effort to increase those rates and prevent mini-epidemics from spiraling amid COVID-19.

Quality and outcomes

When the U.S. health insurance industry smeared the Canadian system, they chose carefully selected points of attack, Potter said. They tossed into the echo chamber the fact that Americans stood a better chance of surviving breast cancer than Canadians. They neglected to say Canadians were more likely to live after a cervical cancer diagnosis than Americans. In fact, Canadians enjoy better health outcomes overall than Americans, from infant mortality to life expectancy. The COVID-19 pandemic belongs on that list, too.

Canada has about one-tenth of America’s population. During the COVID-19 pandemic, Canada has seen many fewer cases and illnesses, but the difference is not proportionate. More than 128,000 Canadians have gotten sick, more than 9,100 more have died, and cases have started to plateau, according to the latest data from Johns Hopkins University . But cases are accelerating in the U.S., which has become the global epicenter for the virus, with roughly 6 million confirmed cases and 183,000 deaths — or the equivalent of one in five COVID-19 fatalities worldwide.

One strength of the Canadian system to shine through during the pandemic is that everyone is insured, Martin said. There, patients admitted into hospitals don’t have to bicker over bills with insurance companies or double-check coverage before they rush to the hospital or ask for medical care. Hospitals work with a single insurer, she said, and that means care is better coordinated across institutions.

“Anybody that needs COVID care is going to get it,” she said.

Dr. Ashish Jha, who has directed the Harvard Global Health Institute and now serves as the dean of the Brown University School of Public Health, has a slightly different take. He said outcome disparities for coronavirus patients in the U.S. and Canada present “a reflection that has nothing to do with the underlying health system” but rather reflects leaders and their political will and priorities. While America’s health care system is among the world’s best in terms of innovation and technology, Jha said that U.S. political leaders have shown themselves to be unwilling to trade off short-term pain of lockdowns and job losses for a long-term public health crisis and economic instability. Those officials prematurely reopened the country before COVID-19 transmission subsided, he said. They also didn’t ramp up testing quickly enough to effectively monitor when and where outbreaks would occur and repeatedly undermined the public health community in its efforts to effectively respond to the virus. He said leaders in the U.S. have not offered a clear consistent message or decisive leadership to unite the country and get everyone moving in the same direction. During pandemics and times of national crisis, the public should not also worry about how to be smart consumers of health care, he said. 

“It’s really frustrating to have to divert so much political energy towards what should be a no-brainer,” Jha said. “This is the time when everybody who needs to be tested, is tested — everybody who needs to be taken care of is taken care of.” And that starts with uniform access to effective health care, he said.

Why reform is hard in both countries

As the U.S. entered lockdown under coronavirus, Sen. Bernie Sanders announced on April 8 that he had pulled the plug on his presidential run. A week later he endorsed former Vice President Joe Biden. After contests in 28 states and two territories, his path to winning the Democratic nomination had narrowed significantly despite an early edge. The next month, in a gesture designed to appeal to Sanders’ heartbroken supporters, Biden announced plans to expand Medicare. His campaign has proposed offering “every American a new choice, a public health option like Medicare” to make insurance more affordable. 

As Potter watches COVID-19 rage in the U.S., the former health care communications executive said Americans live in “fear of having big out-of-pocket bills without assurance that we’ll have our expenses covered.” With the number of uninsured Americans nearly double what they were before novel coronavirus, according to some estimates, Potter said that is not sustainable. In the latest PBS NewsHour-Marist poll, 56 percent of Americans think the U.S. response to the coronavirus pandemic was below average, if not the worst, in the world.

READ MORE: Is U.S. health care the best or ‘least effective’ system in the modern world?

This pandemic could bring the country to a breaking point, Potter said, pushing more Americans to call for a health care system that goes beyond the reforms of the Affordable Care Act, which the Trump administration has repeatedly attacked and attempted to dismantle. 

But if that happens, he said, the same private health insurance system that paid him to lie will reignite misinformation campaigns and fight hard to keep what it has. 

“You will see this campaign resurface to try to scare people away from change,” he said. “It happens every time there is a significant push to change the health care system. The industry wants to protect the status quo.” 

There’s no perfect health care system, and the Canadian system is not without flaws, Flood said. For years, debates have raged about expanding that nation’s health care system to include broader benefits covering few gaps where patients are still exposed to costs. In June 2019, New Democrat Party Leader Jagmeet Singh proposed expanding Canada’s pharmaceutical drug coverage. The eventual goal of these changes that have been debated in varying degrees for years is to encompass dental, vision, hearing, mental health and long-term care to create “a head to toe health care system.”

And yet it is natural for Canadians to compare systems with their neighbors and simply “feel grateful for what they have.” She says that kind of complacency has insulated Canada’s system from further improvements that produce generally better outcomes for lower costs, as in the United Kingdom, the Netherlands or Switzerland. 

“As Canadians, we don’t push hard enough for the system to get better because we’re always relieved that at least it’s not the American system,” Flood said.

Laura Santhanam is the Health Reporter and Coordinating Producer for Polling for the PBS NewsHour, where she has also worked as the Data Producer. Follow @LauraSanthanam

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