Universal health care refers to a national health care system in which every person has access to medical services. Though universal health care can refer to a system administered entirely by the government, most countries achieve universal health care through a combination of state and private participants that comprises hospitals and clinics, health care practitioners, insurance providers, and employer-supported programs. Each country institutes universal health care according to its own needs and capabilities. Systems funded entirely by the government are considered single-payer health insurance.
As of 2022, several countries, including Australia, Canada, Germany, and South Korea, have implemented single-payer health care systems. In some single-payer systems, such as the National Health Services in the United Kingdom, the government provides health care services. Under most single-payer systems, however, the government administers insurance coverage, while nongovernmental organizations, including private companies, provide treatment and care. Other universal health care systems require that all citizens ineligible for public insurance benefits purchase private insurance as a means of ensuring total coverage.
Americans express ongoing concern for the high cost of health care. In a 2022 poll conducted by the Pew Research Center, 61 percent of Americans responded that the executive and legislative branches of government should make lowering health care costs a major economic priority. However, Americans continue to debate whether the federal government should implement universal health care coverage. A 2020 report issued by Pew found that 63 percent of Americans believe the federal government holds the responsibility for ensuring all Americans have health care coverage, either through a national single-payer program or a mix of public and private programs.
Starting in 2020, the COVID-19 pandemic illuminated inadequacies in the US health care system, such as the disparities in social protections and structural inequalities for people in low-income and marginalized communities. Supporters of universal health care note the long-term advantages for public health and reducing the overall cost burden to society. Critics of universal health care characterize such proposals as economically unfeasible and detrimental to private enterprise and innovation in medical care.
In 1993 President Bill Clinton established a Task Force on National Health Care Reform and congressional members introduced the Health Security Act. The proposal would have required all individuals to acquire health insurance and all employers of more than five thousand people to provide health coverage to their employees. The bill met with opposition from policymakers, insurance companies, and physician groups, and did not pass. Representative Jim McDermott (D-WA) introduced the similarly named American Health Security Act in 1993, which would have created universal health care through state administered plans. McDermott reintroduced a version of the bill at each session of Congress until choosing not to seek reelection in 2016.
In the early twenty-first century, state and federal officials showed renewed interest in expanding health care coverage. In 2003 Representative John Conyers Jr. (D-MI) introduced the United States National Health Insurance Act, which called for a single-payer health care system. Conyers continued to introduce the bill at every subsequent session of Congress until he resigned from office in 2017.
State legislators succeeded in expanding health coverage in Massachusetts in 2006. The Massachusetts system mandated that every citizen obtain health insurance or pay fines. The reform led Massachusetts to achieve 98 percent health coverage within four years, higher than any other state. Experts attributed the success of the Massachusetts system to government subsidies, which enabled more people to purchase insurance, and to the program's insurance mandate, which appealed to insurance companies because they acquired more customers.
Barack Obama made expanding health coverage a central focus of his presidency. The efforts of his administration led to the passage of the Patient Protection and Affordable Care Act (ACA) of 2010, often referred to as "Obamacare." The ACA implemented new regulations on health insurance plans to ensure universal eligibility, implemented a health insurance mandate, and provided eligible participants tax credits on insurance premiums. The federal government collaborated with states to set up health insurance marketplaces selling approved plans to individuals and families unable to obtain coverage through an employer or a publicly funded program. According to the Kaiser Family Foundation, the percentage of Americans under age sixty-five who did not have health insurance for more than one year dropped from 17.8 percent in 2010 before the law went into effect to 10 percent in 2016, the final year of Obama's presidency.
The ACA demonstrated effectiveness in expanding access to health care coverage and reducing the number of people without health insurance. Tax credits for health insurance enrollment were allocated based on income and the system's benefits aided individuals in low-income households, older enrollees not yet eligible for Medicare, and enrollees with preexisting conditions. Critics of the system note that some individual premiums increased despite promises to the contrary, while many plans relied on high deductibles, making consumers pay for hefty out-of-pocket expenses before insurance benefits provided coverage. Opponents argued that the insurance mandates undermined individual freedoms. The penalties for failure to obtain an approved insurance plan remained unpopular. Alternatively, some critics considered the overhaul of the health care system insufficient, contending that a single-payer system would better serve the population.
Donald Trump campaigned on overturning the ACA during the 2016 presidential election. He supported the 2017 congressional vote to repeal the financial penalties tied to the health insurance mandate, which became effective in 2019. Researchers from the Harvard Medical School and City University of New York's Hunter College determined that the number of uninsured people in the United States increased by an estimated 2.3 million from 2016 to 2019. The analysis linked the lack of health care coverage to thousands of premature deaths during that period.
Senator Bernie Sanders (VT-I) introduced the Medicare for All Act of 2017, a proposal to expand government health insurance coverage to all citizens and residents. In 2018 more than sixty Democratic members of the House of Representatives formed the Medicare for All Caucus to sponsor briefings on health care reform. The COVID-19 pandemic renewed calls for single-payer legislation. Representatives Pramila Jayapal (D-WA) and Debbie Dingell (D-MI) introduced the Medicare for All Act of 2021. The following year Sanders and fourteen fellow senators introduced the Medicare for All Act of 2022.
Joe Biden's campaign platform during the 2020 presidential election included a Medicare-like health insurance program, or a "public option" administered by the federal government. Biden supported the congressional passage of the American Rescue Plan Act of 2021, which expanded eligibility for health insurance premium tax credits through 2022 as part of an effort to serve a heightened need during the COVID-19 pandemic. The Centers for Medicare and Medicaid Services reported that 14.5 million people enrolled in or renewed health insurance programs through federal and state marketplaces during the open enrollment period for 2022, an increase of over 20 percent from the previous year. Biden signed a series of executive orders based on the administration's policy to expand access to health insurance coverage under the ACA, to reduce out-of-pocket costs for consumers, and to ensure quality health insurance benefits.
Proponents of universal health care contend that thousands of premature deaths due to lack of health insurance could be avoided. By ensuring that citizens and residents have access to affordable medical services, universal health care can improve overall public health by treating the sick, promoting preventative care, and providing basic care to all patients. Critics warn, however, that universal health care could lead to decreased quality of care and long wait times. A commonly cited fear associated with single-payer systems relates to the rationing of medical services, which refers to the limiting of health care services based on the availability of resources. Some critics argue that a health care system without a role for private insurance could lead to a decrease in quality of service.
In response to concerns over rationing, some medical experts and economists assert that rationing exists in all health care systems because resources are always limited. In the United States, however, how these resources are rationed is determined by patients' abilities to pay rather than their medical needs. Discrepancies in medical treatment throughout the United States also suggest that access to medical services can be dependent on where patients live and where they are employed as well as demographic factors such as race, gender, and ethnicity.
Starting in 2020 the COVID-19 crisis exacerbated vulnerabilities and highlighted disparities within the US health care system. The country lagged in pandemic readiness, especially compared to nations with universal health care systems. The United Nations (UN) warned that the pandemic revealed shortcomings in health care systems worldwide. In October 2020 UN secretary-general António Guterres called for global investment in universal health care, identifying the gap in health coverage as one of the causes for the devastating effects of the COVID-19 pandemic. The UN warned that disparities in treatment and fragmented health care systems cause individual suffering and larger social and economic challenges.
A survey of US health care coverage conducted by the Commonwealth Fund between March and June 2021 found that one in ten adults from ages nineteen to sixty-four went uninsured during the first six months of the year, with higher rates of uninsured among Latinx (20 percent) and Black (11 percent) adults compared to white (7 percent) and Asian/Pacific Islander (3 percent) adults. Fifty percent of uninsured adults and more than 40 percent of insured adults indicated they experienced issues with paying medical bills or debt during 2020. Those affected by COVID-19 due to illness, loss of income, or loss of employer-based health insurance coverage experienced elevated rates of problems with medical bills and debts.
Many critics of universal health care cite the potential costs of implementation as the primary reason for their opposition. Some critics of universal health care have voiced concern that a single-payer system would lead to people seeking unnecessary treatments and that the overuse of services would drive overall costs up. Proponents, however, counter this argument by suggesting that the increased use of preventative services would reduce the need for expensive treatments because health issues could be identified earlier. Supporters of single-payer plans expect savings would be derived from regulating and capping costs associated with medical care and pharmaceuticals, along with reductions in administrative costs by eliminating private insurance and billing organizations from the process and decreasing the amount of unnecessary paperwork. An economic analysis of Medicare for All conducted by the Congressional Budget Office and released in January 2021 projected that the legislation would achieve universal health care and reduce out-of-pocket costs for consumers, while having a downward effect on overall health care spending.
"This is a struggle against the 'economic royalists', as Franklin D Roosevelt once termed them, of our day—and for the interests of ordinary working people."
Adam Gaffney is an instructor at Harvard Medical School, a pulmonary and critical care doctor at Cambridge Health Alliance, and president of Physicians for a National Health Program. He blogs at the Progressive Physician.
In the following viewpoint, Gaffney disputes US conservatives' common argument against universal health care that the costs to implement and sustain such a system make it unaffordable. Citing research from both ends of the political spectrum, the author indicates that single-payer policies like Medicare for All would save the country trillions of dollars over a decade. Further, Gaffney suggests, the unaffordability argument against single-payer health care persists despite evidence of its inaccuracy because corporations and the wealthy have disproportionate control and influence over US politics. The author concludes that Democratic and progressive proponents should focus more of their messaging on the positive impact that universal health care has on broader socioeconomic inequities.
"'Affordable health care for all' from government is an economic oxymoron."
Eric Rozenman is a communications consultant for the Jewish Policy Center in Washington, DC.
In the following viewpoint, Rozenman argues that single-payer universal health care is unrealistic because it would cost too much for the country to implement and maintain. Because of high costs, the author suggests, the resulting system would require the government to delay people's access to care and could lead to rationing. The author claims that Democratic politicians' support for universal health care is disingenuous, implying that it represents a tactic to obtain power under the guise of acting in the interest of citizens' welfare. Rozenman concludes that universal health care would effectively turn all citizens into wards of the state, which conflicts with American individualism and could restrict economic prosperity.
"Access to government health insurance does not automatically translate into access to medical care."
Robert Moffit is a senior fellow in domestic policy studies at the Heritage Foundation, a conservative public policy organization based in Washington, DC.
In the following viewpoint, he opposes the single-payer health care proposals advocated and introduced by Democratic lawmakers that are commonly referred to as "Medicare for All." Citing problems in the British and Canadian single-payer national health care systems, Moffit argues that access to care in the United States would worsen under a Medicare for All plan. The author acknowledges that there are serious problems in the US health care market but maintains that a single-payer Medicare for All reform would fail to solve those problems and could negatively impact the aspects of US health care that citizens indicate are working well for them.
"Other high-income countries spend less on health care than the United States because they have lower prices, not because they receive less care."
Jamie Daw is assistant professor of health policy and management at the Mailman School of Public Health at Columbia University in New York.
In the following viewpoint, Daw argues that US politicians should look to Germany's model of social health insurance for inspiration rather than Canada's single-payer model. She notes that the German system for universal health care has been developed and tested over time, with many other European and Asian countries adopting similar models. Because the German system is multipayer, Daw contends, it provides a better example for US policymakers to use when advocating an American universal health care system. The author concludes that a hybrid system of publicly and privately funded plans can meet the goals of universal affordable coverage without eradicting the private health care industry, which many Americans cite as a reason for their opposition to single-payer proposals.