Universal Health Care: Overview

Introduction

Universal health care is a term that describes any system in which all residents of a country (or, sometimes, of a smaller jurisdiction) have guaranteed access to health care. Such systems most commonly include some form of medical insurance provided by the government. In the United States, numerous proposals for universal health care have been suggested over the years, but the country remains an outlier among developed nations in lacking universal health care. The issue has been part of presidential campaign platforms as early as 1912, when Theodore Roosevelt, a progressive Republican, ran on a pro-universal health care platform. Although President Barack Obama signed a major health care reform law in 2010, which greatly increased the number of Americans with health insurance coverage, the debate over true universal health care continues.

Those in favor of universal health care often claim that basic health care is a human right, much like public education, and should be provided equitably to all citizens. However, there are two distinct main positions within the pro-universal coverage stance regarding the proper role of the government in health care. The single-payer universal insurance model would require that the government pay for citizens' medical care costs, similar to the manner in which private insurance companies or existing government-funded programs such as Medicare operate. In contrast, the universal care model (also known as socialized medicine) would require that the government itself provide the necessary medical facilities and procedures for its citizens. There are also various hybrid or multi-payer models in which some combination of government-funded insurance, private insurance, and government-provided care together achieve universal health care coverage. Most proponents of universal health care in the US, though, favor government-subsidized care rather than government-provided care. They suggest that a universal single-payer system funded by tax revenue would maintain flexibility and individual control over health choices, as the main functional difference from the traditional US health care system would simply be who actually pays the bills.

Critics of universal health care mainly take issue with the level of government involvement required, arguing that it would politicize medical decisions and decrease personal choice. In order for such a system to be workable, they claim, the government would have to either restrict access to many treatments and procedures or allow unfettered access to all. Critics argue that these impractical choices would in turn severely decrease the flexibility or severely increase the cost of health care, with neither outcome being desirable. Essentially, this argument concludes that a permissive universal health care system would result in an abundance of abuse and a sharp increase in taxes, while a restrictive universal health care system would result in a lack of choices for individuals in need of services.

Understanding the Discussion

Managed care: Health insurance systems that aim to control health care costs, utilization, and quality by contracting with a limited network of health care providers, among other methods. Includes health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans.

Medicaid: A taxpayer-funded US government program that provides health insurance to low-income individuals and families. Medicaid is administered by the individual states, so regulations and eligibility requirements may vary from state to state.

Medicare: A taxpayer-funded government program that provides health insurance to elderly and disabled persons. Signed into law in 1965 by President Lyndon B. Johnson, Medicare is an amendment to the Social Security Act.

Multi-payer: A health care system in which health care costs are paid for by multiple entities, often including public and private contributions, as well as tax revenue.

Single-payer: A health care system in which a single entity pays the costs of health care. In countries with single-payer universal health care, the single payer is usually the government or a government-run organization.

Socialism: An economic and cultural model in which society, rather than the individual, is considered the dominant entity. Under a socialist model, all decisions should be made for the benefit of society as a whole, rather than for the benefit of individual interests. Socialism tends to be deeply controversial in the US, as some see it as a means to a more equitable society while others consider it to be in direct opposition to the nation's capitalist democratic values. The term is also often misunderstood, as opponents frequently conflate it with communism.

Socialized medicine: A form of single-payer health care in which the government directly runs the health care facilities and employs the health care workers, in addition to paying for care.

History

Before the twentieth century, the state of American health care was highly irregular and often informal. The medical field was well populated but often poorly trained, and most treatment occurred in patients' homes under a simple fee-for-service model. The accessibility and quality of care varied greatly across locations and individual providers. This began to change with scientific advances, industrialization, professional standardization, and social reform in the late nineteenth century. The development of modern hospitals in urban centers was particularly influential. Initially, hospitals were mostly considered community service providers rather than for-profit businesses. Some institutions, particularly in large cities like New York, offered free treatment and medicine to all. Others charged patients directly for the cost of care, but often made concessions for poorer patients. Many hospitals were subsidized by wealthy benefactors or other charitable donors.

As medical science continued to advance, treatment became both more popular and more expensive. As a result, many health care providers steadily increased their fees or scrambled to compete for limited public and philanthropic funding. By the 1920s, hospitals were increasingly focused on demand from middle- and upper-class patients who could afford to pay for whatever services they needed or wanted. Rising costs also led to the emergence of health insurance. Meanwhile, there was also growing recognition of the link between poverty and illness and the corresponding problem of inadequate health care for low-income Americans. Many European countries and some other industrialized nations had begun to establish national health insurance programs covering all or most citizens to help cover costs for those unable to afford care on their own. However, the concept faced strong resistance in the US.

The Great Depression heightened calls to improve health care access. When President Franklin Delano Roosevelt drafted the Social Security Act of 1935, he planned to include universal health coverage in its provisions. Due to pressure from the medical industry and other politicians over cost concerns, however, he ultimately dropped that aspect to ensure that the act would pass in Congress. The few subsequent efforts for universal health care, including further proposals by President Roosevelt and President Harry Truman in the 1940s, were similarly shot down by staunch opposition from medical and insurance industry lobbyists. Instead, the US health care system became dominated by private health insurance. Employers discovered they could bypass wage controls and high income tax rates by paying medical insurance costs for their workers, and government policies further strengthened the connection between employment and health insurance coverage. From 1940 to 1950, the number of Americans enrolled in some form of health insurance plan spiked from about 20.6 million to over 142.3 million.

Major insurers, whether nonprofits like Blue Cross and Blue Shield or commercial companies, reimbursed physicians based on whatever price they charged, and reimbursed hospitals based on a percentage of actual costs incurred as well as a percentage of capital costs. This “cost plus” model incentivized physicians to set high prices and hospitals to spend as much as possible on care. Accordingly, health care costs continued to rise sharply, further boosted by the emergence of new treatments and technologies. While many citizens were insulated from the true increase in costs thanks to insurance plans, the price of health insurance also steadily increased. Those without employer-sponsored coverage often went completely uninsured and struggled to afford even routine medical care.

The federal government aimed to address the growing number of Americans who could not afford health insurance with the establishment of Medicare and Medicaid in 1965. These programs greatly expanded insurance coverage for those over age sixty-five (Medicare) or with low incomes (Medicaid). However, they did not achieve universal health care coverage, and they continued the cost-plus reimbursement model, so health care prices and spending continued to rise. Some supporters of universal health care nevertheless saw Medicare and Medicaid as a first step toward government-funded health care for all citizens; over the following decades, proponents also often cited Medicare as proof that the administrative costs for government-funded health insurance can be significantly lower than those of private companies. Yet others came to see the programs as in fact a significant obstacle to a true universal health care system. In this view, Medicare and Medicaid further segmented the population, giving specific groups desirable, but disparate, solutions to the health care problem. Creating a universal health care system would therefore face more opposition from those who were generally happy with their own health care and feared the upheaval of radical change.

Health care became an increasingly contentious political issue through the late twentieth century as costs continued to rise rapidly. Many employers stopped offering health insurance or shifted more costs to employees as premium prices increased. Some efforts were made to improve access to at least basic live-saving health care. Notably, the Emergency Medical Treatment and Labor Act, passed in 1986, guaranteed emergency medical care to everyone—even non-citizens—regardless of their ability to pay for it. There was also a new wave of calls for universal health care. President Bill Clinton vowed in 1993 to create a universal health care system and said he would veto any health care bill that failed to provide universal coverage. Clinton’s plan garnered early support, but it was eventually defeated amid conservative backlash.

Deepening political partisanship continued to dominate the debate over universal health care into the twenty-first century. Many liberals favored reform toward some form of universal coverage, although proposals varied widely. Progressives often called for a universal single-payer system, with "Medicare for All" becoming a popular term for universal government-sponsored insurance. Others took the idea a step further, proposing universal socialized medicine similar to an expanded Veterans Health Administration or the United Kingdom's National Health Service. On the other hand, some moderates felt a single-payer system would be too expensive or just not politically feasible, and instead suggested expanding the existing insurance system to achieve universal coverage or creating some other form of multi-payer universal system. Conservatives, meanwhile, tended to strongly oppose any expansion of government into the health care sector as too expensive and potentially infringing on civil liberties.

The US health care system underwent major reform in 2010, when President Barack Obama signed the Patient Protection and Affordable Care Act (ACA, also widely known as Obamacare) into law. While the bill did not establish a true universal health care system, supporters characterized it as a historic compromise that would greatly improve health care access, primarily by providing health insurance to millions of Americans who were previously without coverage. The ACA originally required all Americans to have health insurance by 2014 or pay a penalty, a provision known as the individual mandate. Opposition proved fierce, however, even after the bill became law. Many Republicans argued that the ACA was an egregious example of overreach by the federal government and would greatly add to the national debt; some also falsely villainized it as socialized medicine. Several legal challenges ultimately reached the Supreme Court but failed to overturn the law; notably, National Federation of Independent Business v. Sebelius (2012) held that states could not be forced to expand Medicaid under the ACA but upheld the rest of the legislation. King v. Burwell (2015) affirmed the constitutionality of the ACA's insurance marketplaces, or exchanges.

Through the 2010s, data showed that the ACA did succeed in significantly reducing the percentage of uninsured Americans. Public opinion also shifted steadily in favor of the law, despite ongoing vocal Republican criticism. There were fresh efforts to repeal the ACA after Republican Donald Trump was elected president in 2016, and the Tax Cut and Jobs Act of 2017 effectively removed the individual mandate, but the act remained in place. Aside from Republican opposition, however, there was also continued pressure from many progressives to go beyond the ACA and establish a true universal health care system. For example, Bernie Sanders made Medicare for All a staple of his high-profile presidential campaigns in 2016 and 2020. Proponents of universal health care pointed out that millions of Americans still lacked health insurance despite gains under the ACA, health care costs continued to rise, and the US continued to lag behind many other developed nations in several key health indicators.

Universal Health Care Today

Debate over universal health care continues from both sides. Some proponents argue that flaws in the ACA were due mainly to Republican obstructionism and could be corrected to provide essentially universal care while maintaining most of the established insurance system. Other proponents go further, advocating for a true single-payer system and framing health care as a human right. Many such advocates claim that the American health care system in its current state is a failure, even with the improvements made by the ACA. Notably, while the United States spends more on health care than any other developed nation, the country’s life expectancy has trended significantly lower than some comparable countries. Most observers consider the US to be the only industrialized nation without some form of universal health care. Proponents often stress that universal single-payer systems have proven feasible in countries such as Canada and Japan.

Opponents of universal health care, meanwhile, continue to claim that such a system would be too expensive, represent too much government overreach, or both. They tend to believe that the modern medical industry is successful and suggest that this success is based largely on competition and consumer choice. Making health care universal, they argue, would threaten this democratic, capitalist sensibility. Furthermore, critics of universal health insurance often cite the slippery-slope argument: if medicine and medical care were to be suddenly universally accessible, people might then request the same kind of universal access to food, shelter, or higher education—which might destroy both the American work ethic and the capitalist system that has been the country’s foundation since its establishment.

These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

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