Universal Health Coverage in the U.S.: The Surrounding Debate

By Hunter Bershtein

Edited By Michelle Lu

Universal Health Coverage (UHC) is a health coverage policy where people have access to the full range of quality health services they need, regardless of when and where they need them, and without financial burden. Nearly all the wealthiest countries have adopted a UHC system, with the exception of the United States.

Instead, the U.S. currently has a mixed healthcare system. Private or market-based insurance coverage accounts for most of the coverage in the U.S. Private insurance is sometimes paid fully out-of-pocket but usually subsidized by employers. On the other hand, public, government-funded programs, such as Medicare and Medicaid, provide a small amount of public coverage for those who would otherwise not be able to afford quality medical services. Medicare coverage is structured to help those over 65, while Medicaid coverage is designed for those with low income. Although Medicaid usually covers anyone whose household income falls below 138% of the federal poverty line, some states have additional age, family, and disability requirements. In addition to the low-income requirement, for 10 of the 50 states, you must be 65 or older, under 19, pregnant, living with a disability, or an adult caring for a child to qualify for Medicaid. These ten states are known as states without Medicaid expansion.

Private, market-based health insurance is expensive, with an average out-of-pocket cost of $5,724 per year for an individual plan, as reported in a 2023 USA Today article. As such, most people who rely on private health insurance have employer-sponsored plans, which have an average outof-pocket cost of $1,401 per year, as reported in the same article. According to The Professional Society for Health Economics and Outcomes Research, in 2019, 6% of U.S. citizens received coverage through private health insurance not provided by an employer, while 50% of U.S. citizens received coverage through private health insurance provided by an employer. Regarding public coverage, 20% of U.S. citizens relied on Medicare, 14% on Medicaid, and 1% on other public forms of insurance, such as those for veterans. These numbers leave 9% of Americans uninsured.

The Kaiser Family Foundation, a non-profit healthcare research organization, conducted a national survey and found that most uninsured people do not have health coverage because they cannot afford it or are not eligible. This gap exists because many people are too rich to qualify for Medicaid but too poor to afford market-based coverage. Further, in states without Medicaid expansions, many adults whose household incomes fall below 138% of the poverty line are ineligible for Medicaid because of the additional age, family, and disability requirements. This ineligibility gap in coverage is known as the Medicaid gap and accounts for over 2 million uninsured adults alone.

Along these lines, differing versions of UHC exist to fill such a coverage gap. The U.K. employs a fairly traditional model, with few options for and minimal use of privatized care.

On the other hand, European countries like Switzerland, the Netherlands, and Germany have blended systems with substantial government-funded and market-based components. It does not matter where the coverage comes from. As long as a nation provides quality care to all its citizens, it achieves the goal of

UHC. Since private health insurance is already so prominent, a blended UHC system would likely fit the current U.S. healthcare coverage structure better than an entirely government-funded one.

There is significant pushback against UHC from private health insurance companies, even if it includes market-based coverage. Switching to UHC would mean that the government decides the baseline for what must be covered by health insurance. Health insurance compa- the U.S. life expectancy at birth is nearly three years lower than the OECD average. The U.S. also has an average of 336 avoidable deaths per 100,000 people, whereas the OECD average is 225, the highest of the OECD members. Further, the obesity rate in the U.S. is nearly double that of the OECD average, and adults in the U.S. are the most likely to have multiple chronic conditions out of any of the 38 OECD countries. Yet, perhaps surprisingly, the U.S. spends nearly twice as much of its GDP on healthcare compared to other OECD countries, a whopping 17.8% compared to the 9.6% OECD average. These additional costs are primarily due to the administrative costs of running private insurance companies, increased expenditure on prescription drugs since prices are market-driven, and wages for physicians and nurses, which are higher in the U.S. than in other OECD countries. nies like to have the option to deny services that they do not deem medically necessary to maximize profits. Higher government regulation of health insurance coverage in a UHC system would limit this decisive power.

The Organization for Economic Co-operation and Development (OECD) is an intergovernmental organization that includes 38 high-income, highly developed countries. According to the OECD, UHC provides better health outcomes at a lower cost than the mixed coverage system in the U.S. Based on data from the 38 OECD countries,

With many other wealthy countries providing cheaper and better health care through UHC, one might wonder why the U.S. still uses a mixed coverage system. Though the statistics above suggest that UHC offers better health outcomes for citizens, there are still avid critics and proponents of implementing the UHC plan in the U.S.

Most wealthy, westernized nations have adopted a UHC model. However, none are as geographically large, populous, and ethnically or racially diverse as the U.S. Due to cultural values, varying climates, and population densities, different regions of the U.S. come with distinct health needs and logistical challenges in implementing UHC.

Reproductive care and women’s health are good examples of medical fields with apparent state-to-state differences. All-cause mortality for women of reproductive age (15 to 44) is a standard metric for women’s health. In a report by The Commonwealth Fund, a research organization that aims to improve the performance of the U.S. healthcare system, in 2021, the state with the highest allcause mortality for women ages 15 to 44, West Virginia, was nearly triple that of Hawaii, the lowest-ranking state. Twelve of the 15 states that ranked lowest for reproductive care and women’s health have restrictive abortion laws and fewer maternal care providers on average. To implement UHC in the U.S. states lacking in reproductive care and women’s rights would need additional funds to increase the number of providers. Further, reproductive care and women’s rights would need to become a federal rather than a state issue, a legal transition that would take time and accrue administrative costs. Women’s health is one of many healthcare issues that differ from state to state. As such, critics of UHC in the U.S. argue that the implementation would not be feasible, organizationally or financially, as it is in smaller, more homogenous nations.

Indeed, implementing UHC in the U.S. would come with high upfront costs. The government would need funds to cover the infrastructure changes required to provide health services to a larger sector of the population, insuring and treating a previously uninsured and largely unhealthy segment of the population, and expanding the range of services provided to include services like dental, vision, and hearing. In a paper published in Medicina by Zieff et al. 2020 that analyzes the debate surrounding the implementation of

UHC in the U.S., a recent proposal suggested that a 7.5% payroll tax plus a 4% income tax on all Americans, with higher-income citizens subject to higher taxes, would be required to implement UHC in the U.S. However, other studies suggest that more than these proposed taxes would be necessary, with cost estimates ranging from 32 to 42 trillion across the first ten years, with 1.1 to 2.1 trillion needed to maintain UHC annually after the first decade. Although the upfront cost would be very high considering the current coverage gap in the U.S., the annual expenditure would eventually fall to rates similar to other OECD countries, around 3000 to 6000 USD per capita.

For the average American, switching to UHC would cost less than paying out-of-pocket for private coverage; however, for the highest earners in America, UHC would incur higher costs than private coverage. As such, a tax increase would put the majority of healthcare costs on the wealthy, an unwelcome change that some would describe as government overreach.

Another argument against implementing a UHC plan in the U.S. is general system inefficiency, resulting in longer patient wait times. The Zieff et al. 2020 paper also indicated that Canadians were on the waiting list for over 1 million procedures, and the median wait time for arthroplasty (joint-restoring) surgery was 20-52 weeks. In the U.K., the average waiting time for elective hospital-based care was 46 days, with some patients waiting over a year. At least in the short term, implementation of UHC in the U.S. would lead to an increase in wait times. Wait times are a function of the number of patients seeking care and the number of available appointments. As such, eliminating the financial barrier to seeking care would result in an immediate influx of primary and emergency care visits. Without increasing the number of doctors and hospitals, wait times are bound to shoot up. Luckily, most experts agree that provider supply will increase in the long run to meet provider demand, but it is hard to estimate how long this adjustment will take.

Some policymakers suggest that the government should intervene to help provider supply adjust more quickly. Two such suggestions are to expand the scope of practice for nonphysician providers and increase pay to incentivize primary care providers. Expanding the scope of practice allows nonphysician providers such as advanced practice registered nurses (APRNs) to conduct laboratory tests, prescribe drugs, and teach and counsel patients. APRNs are authorized to perform such services based on their training, but state regulations currently deny the ability to practice such independence and prescriptive authority. Increasing pay means raising the salary for care providers so more people enter the field, thus increasing the supply of care. Policies such as these would increase the supply of healthcare and medical services to compensate for the influx of patients seeking care due to UHC implementation and help reduce wait times to baseline levels faster.

On the other hand, proponents of implementing UHC in the U.S. argue that UHC would help fight against the growing chronic disease crisis, mitigate costs associated with this crisis, reduce health disparities related to socioeconomic status (SES) and other identifies such as race and ethnicity, and increase opportunities for preventative health initiatives.

Chronic diseases, such as cardiovascular diseases and type II diabetes, take a heavy toll on the nation’s economy. Low SES is associated with many unfavorable health determinants, such as decreased access to and quality of health insurance, which ultimately leads to worse health outcomes on average for low SES individuals. For example, low SES diabetics are at a higher mortality risk, and uninsured diabetics account for 55% more emergency room visits than their insured diabetic counterparts. Individuals with uncontrolled high blood pressure, which disproportionately affects the low SES population, have more than 2000 USD greater annual healthcare costs than their counterparts with normal blood pressure. Lastly, the cost of obesity, another disease that disproportion- ately affects low SES individuals in the U.S., costs the nation an estimated 66 billion annually, as per conservative estimates. As such, UHC in the U.S., including preventative care measures, could improve the overall public health of the U.S. and decrease the economic strain associated with unhealthy low-SES individuals in the long run.

Although they incur upfront costs, preventative care measures lessen the cost associated with uninsured, unhealthy populations. According to a literature review by Trust for America’s Health, a non-profit organization dedicated to community health, investing 10 USD per person annually in community-based programs to combat physical inactivity, poor nutrition, and smoking could save more than 16 billion USD annually within five years, equating to a return of 5.60 USD per dollar invested. While UHC does not guarantee the enactment of preventative care measures, it would encourage investment in low SES communities because reducing chronic conditions and poor health outcomes in this population would reduce the tax burden required to fund UHC in the U.S. By promoting healthy lifestyle behaviors such as increased exercise and better nutrition, improving en- vironmental factors such as preserving more green spaces in low-income communities, and developing policy-based interventions such as banning sweetened beverages in public schools, we as a society could reduce the national financial burden UHC implementation would incur on the richer, generally healthier population.

Although many high-income, developed nations have implemented UHC, the U.S. still provides health care in a mixed system. Implementing UHC in the U.S. would incur high upfront costs funded at least partly by the richer sector of the population and increase wait times in the short run due to an influx of patients requesting care. However, UHC would also ultimately improve public health outcomes and mitigate health inequities in the long run. Further, it would be possible to reduce the cost burden with time by enacting preventative care measures, especially in low SES communities. While an ideal UHC system would be better for the nation’s public health, implementation comes with many logistical, financial, and cultural barriers to overcome.

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