universal healthcare debate essay

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Universal Healthcare in the United States of America: A Healthy Debate

Gabriel zieff.

1 Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; ude.cnu.liame@rrekz (Z.Y.K.); [email protected] (L.S.)

Zachary Y. Kerr

Justin b. moore.

2 Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@eroomsuj

This commentary offers discussion on the pros and cons of universal healthcare in the United States. Disadvantages of universal healthcare include significant upfront costs and logistical challenges. On the other hand, universal healthcare may lead to a healthier populace, and thus, in the long-term, help to mitigate the economic costs of an unhealthy nation. In particular, substantial health disparities exist in the United States, with low socio–economic status segments of the population subject to decreased access to quality healthcare and increased risk of non-communicable chronic conditions such as obesity and type II diabetes, among other determinants of poor health. While the implementation of universal healthcare would be complicated and challenging, we argue that shifting from a market-based system to a universal healthcare system is necessary. Universal healthcare will better facilitate and encourage sustainable, preventive health practices and be more advantageous for the long-term public health and economy of the United States.

1. Introduction

Healthcare is one of the most significant socio–political topics in the United States (U.S.), and citizens currently rank “healthcare” as the most important issue when it comes to voting [ 1 ]. The U.S. has historically utilized a mixed public/private approach to healthcare. In this approach, citizens or businesses can obtain health insurance from private (e.g., Blue Cross Blue Shield, Kaiser Permanente) insurance companies, while individuals may also qualify for public (e.g., Medicaid, Medicare, Veteran’s Affairs), government-subsidized health insurance. In contrast, the vast majority of post-industrial, Westernized nations have used various approaches to provide entirely or largely governmentally subsidized, universal healthcare to all citizens regardless of socio–economic status (SES), employment status, or ability to pay. The World Health Organization defines universal healthcare as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship” [ 2 ]. Importantly, the Obama-era passage of the Affordable Care Act (ACA) sought to move the U.S. closer to universal healthcare by expanding health coverage for millions of Americans (e.g., via Medicaid expansion, launch of health insurance marketplaces for private coverage) including for citizens across income levels, age, race, and ethnicity.

Differing versions of universal healthcare are possible. The United Kingdom’s National Health Services can be considered a fairly traditional version of universal healthcare with few options for, and minimal use of, privatized care [ 3 ]. On the other hand, European countries like Switzerland, the Netherlands, and Germany have utilized a blended system with substantial government and market-based components [ 4 , 5 ]. For example, Germany uses a multi-payer healthcare system in which subsidized health care is widely available for low-income citizens, yet private options—which provide the same quality and level of care as the subsidized option—are also available to higher income individuals. Thus, universal healthcare does not necessarily preclude the role of private providers within the healthcare system, but rather ensures that equity and effectiveness of care at population and individual levels are a reference and expectation for the system as a whole. In line with this, versions of universal healthcare have been implemented by countries with diverse political backgrounds (e.g., not limited to traditionally “socialist/liberal” countries), including some with very high degrees of economic freedom [ 6 , 7 ].

Determining the degree to which a nation’s healthcare is “universal” is complex and is not a “black and white” issue. For example, government backing, public will, and basic financing structure, among many other factors must be extensively considered. While an in-depth analysis of each of these factors is beyond the scope of this commentary, there are clear advantages and disadvantages to purely private, market-based, and governmental, universal approaches to healthcare, as well as for policies that lie somewhere in-between. This opinion piece will highlight arguments for and against universal healthcare in the U.S., followed by the authors’ stance on this issue and concluding remarks.

2. Argument against Universal Healthcare

Though the majority of post-industrial Westernized nations employ a universal healthcare model, few—if any—of these nations are as geographically large, populous, or ethnically/racially diverse as the U.S. Different regions in the U.S. are defined by distinct cultural identities, citizens have unique religious and political values, and the populace spans the socio–economic spectrum. Moreover, heterogenous climates and population densities confer different health needs and challenges across the U.S. [ 8 ]. Thus, critics of universal healthcare in the U.S. argue that implementation would not be as feasible—organizationally or financially—as other developed nations [ 9 ]. There is indeed agreement that realization of universal healthcare in the U.S. would necessitate significant upfront costs [ 10 ]. These costs would include those related to: (i) physical and technological infrastructural changes to the healthcare system, including at the government level (i.e., federal, state, local) as well as the level of the provider (e.g., hospital, out-patient clinic, pharmacy, etc.); (ii) insuring/treating a significant, previously uninsured, and largely unhealthy segment of the population; and (iii) expansion of the range of services provided (e.g., dental, vision, hearing) [ 10 ].

The cost of a universal healthcare system would depend on its structure, benefit levels, and extent of coverage. However, most proposals would entail increased federal taxes, at least for higher earners [ 4 , 11 , 12 ]. One proposal for universal healthcare recently pushed included options such as a 7.5% payroll tax plus a 4% income tax on all Americans, with higher-income citizens subjected to higher taxes [ 13 ]. However, outside projections suggest that these tax proposals would not be sufficient to fund this plan. In terms of the national economic toll, cost estimations of this proposal range from USD 32 to 44 trillion across 10 years, while deficit estimations range from USD 1.1 to 2.1 trillion per year [ 14 ].

Beyond individual and federal costs, other common arguments against universal healthcare include the potential for general system inefficiency, including lengthy wait-times for patients and a hampering of medical entrepreneurship and innovation [ 3 , 12 , 15 , 16 ]. Such critiques are not new, as exemplified by rhetoric surrounding the Clinton Administration’s Health Security Act which was labeled as “government meddling” in medical care that would result in “big government inefficiency” [ 12 , 15 ]. The ACA has been met with similar resistance and bombast (e.g., the “repeal and replace” right-leaning rallying cry) as a result of perceived inefficiency and unwanted government involvement. As an example of lengthy wait times associated with universal coverage, in 2017 Canadians were on waiting lists for an estimated 1,040,791 procedures, and the median wait time for arthroplastic surgery was 20–52 weeks [ 17 ]. Similarly, average waiting time for elective hospital-based care in the United Kingdom is 46 days, while some patients wait over a year (3). Increased wait times in the U.S. would likely occur—at least in the short term—as a result of a steep rise in the number of primary and emergency care visits (due to eliminating the financial barrier to seek care), as well as general wastefulness, inefficiency, and disorganization that is often associated with bureaucratic, government-run agencies.

3. Argument for Universal Healthcare

Universal healthcare in the U.S., which may or may not include private market-based options, offer several noteworthy advantages compared to exclusive systems with inequitable access to quality care including: (i) addressing the growing chronic disease crisis; (ii) mitigating the economic costs associated with said crisis; (iii) reducing the vast health disparities that exist between differing SES segments of the population; and (iv) increasing opportunities for preventive health initiatives [ 18 , 19 , 20 , 21 ]. Perhaps the most striking advantage of a universal healthcare system in the U.S. is the potential to address the epidemic level of non-communicable chronic diseases such as cardiovascular diseases, type II diabetes, and obesity, all of which strain the national economy [ 22 , 23 ]. The economic strain associated with an unhealthy population is particularly evident among low SES individuals. Having a low SES is associated with many unfavorable health determinants, including decreased access to, and quality of health insurance which impact health outcomes and life expectancies [ 24 ]. Thus, the low SES segments of the population are in most need of accessible, quality health insurance, and economic strain results from an unhealthy and uninsured low SES [ 25 , 26 ]. For example, diabetics with low SES have a greater mortality risk than diabetics with higher SES, and the uninsured diabetic population is responsible for 55% more emergency room visits each year than their insured diabetic counterparts [ 27 , 28 ]. Like diabetes, hypertension—the leading risk factor for death worldwide [ 29 ], has a much higher prevalence among low SES populations [ 30 ]. It is estimated that individuals with uncontrolled hypertension have more than USD 2000 greater annual healthcare costs than their normotensive counterparts [ 31 ]. Lastly, the incidence of obesity is also much greater among low SES populations [ 32 ]. The costs of obesity in the U.S., when limited to lost productivity alone, have been projected to equate to USD 66 billion annually [ 33 ]. Accessible, affordable healthcare may enable earlier intervention to prevent—or limit risk associated with—non-communicable chronic diseases, improve the overall public health of the U.S., and decrease the economic strain associated with an unhealthy low-SES.

Preventive Initiatives within A Universal Healthcare Model

Beyond providing insurance coverage for a substantial, uninsured, and largely unhealthy segment of society—and thereby reducing disparities and unequal access to care among all segments of the population—there is great potential for universal healthcare models to embrace value-based care [ 4 , 20 , 34 ]. Value-based care can be thought of as appropriate and affordable care (tackling wastes), and integration of services and systems of care (i.e., hospital, primary, public health), including preventive care that considers the long-term health and economy of a nation [ 34 , 35 ]. In line with this, the ACA has worked in parallel with population-level health programs such as the Healthy People Initiative by targeting modifiable determinants of health including physical activity, obesity, and environmental quality, among others [ 36 ]. Given that a universal healthcare plan would force the government to pay for costly care and treatments related to complications resulting from preventable, non-communicable chronic diseases, the government may be more incentivized to (i) offer primary prevention of chronic disease risk prior to the onset of irreversible complications, and (ii) promote wide-spread preventive efforts across multiple societal domains. It is also worth acknowledging here that the national public health response to the novel Coronavirus-19 virus is a salient and striking contemporary example of a situation in which there continues to be a need to expeditiously coordinate multiple levels of policy, care, and prevention.

Preventive measures lessen costs associated with an uninsured and/or unhealthy population [ 37 ]. For example, investing USD 10 per person annually in community-based programs aimed at combatting physical inactivity, poor nutrition, and smoking in the U.S. could save more than USD 16 billion annually within five years, equating to a return of USD 5.60 for every dollar spent [ 38 ]. Another recent analysis suggests that if 18% more U.S. elementary-school children participated in 25 min of physical activity three times per week, savings attributed to medical costs and productivity would amount to USD 21.9 billion over their lifetime [ 39 ]. Additionally, simple behavioral changes can have major clinical implications. For example, simply brisk walking for 30 min per day (≥15 MET-hours/week) has been associated with a 50% reduction in type II diabetes [ 40 ]. While universal healthcare does not necessarily mean that health policies supporting prevention will be enacted, it may be more likely to promote healthy (i) lifestyle behaviors (e.g., physical activity), (ii) environmental factors (e.g., safe, green spaces in low and middle-income communities), and (iii.) policies (e.g., banning sweetened beverages in public schools) compared to a non-inclusive system [ 34 , 35 , 36 ].

Nordic nations provide an example of inclusive healthcare coupled with multi-layered preventive efforts [ 41 ]. In this model, all citizens are given the same comprehensive healthcare while social determinants of health are targeted. This includes “mobilizing and coordinating a large number of players in society,” which encourages cooperation among “players” including municipal political bodies, voluntary organizations, and educational institutions [ 41 ]. Developmental and infrastructural contributions from multiple segments of society to a healthcare system may also better encourage government accountability compared to a system in which a select group of private insurers and citizens are the only “stakeholders.” Coordinated efforts on various non-insurance-related fronts have focused on obesity, mental health, and physical activity [ 41 ]. Such coordinated efforts within the Nordic model have translated to positive health outcomes. For example, the Healthcare Access and Quality (HAQ) Index provides an overall score of 0–100 (0 being the worst) for healthcare access and quality across 195 countries and reflects rates of 32 preventable causes of death. Nordic nations had an average HAQ score of 95.4, with four of the five nations achieving scores within the top 10 worldwide [ 42 ]. Though far more heterogenous compared to Nordic nations, (e.g., culturally, geographically, racially, etc.), the U.S. had a score of 89 (29th overall) [ 42 ]. To provide further context, other industrialized nations, which are more comparable to the U.S. than Nordic nations, also ranked higher than the U.S. including Germany (92, 19th overall), Canada (94, 14th overall), Switzerland (96, 7th overall), and the Netherlands (96, 3rd overall) [ 42 ].

4. Conclusions

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.

Author Contributions

Conceptualization, G.Z., Z.Y.K., J.B.M., and L.S.; writing-original draft preparation, G.Z.; writing-review and editing, Z.Y.K., J.B.M., and L.S.; supervision, L.S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Should the U.S. Government Provide Universal Health Care?

• History of Universal Health Care

27.5 million non-elderly Americans did not have health insurance in 2021, a decline from 28.9 million uninsured Americans in 2019. The largest group of Americans, almost 155 million non-elderly people, were covered by employer-sponsored health insurance. Less than 1% of Americans over 65 were uninsured, thanks to Medicaid, a government provided insurance for people over 65 years old.

The United States is the only nation among the 37 OECD (Organization for Economic Co-operation and Development) nations that does not have universal health care either in practice or by constitutional right. Read more background…

Pro & Con Arguments

Pro 1 The United States already has universal health care for some. The government should expand the system to protect everyone. A national health insurance is a universal health care that “uses public insurance to pay for private-practice care. Every citizen pays into the national insurance plan. Administrative costs are lower because there is one insurance company. The government also has a lot of leverage to force medical costs down,” according to economic expert Kimberly Amadeo. Canada, Taiwan, and South Korea all have national health insurance. In the United States, Medicare, Medicaid, and TRICARE function similarly. [ 178 ] Medicare is the “federal health insurance program for: people who are 65 or older, certain younger people with disabilities, [and] people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).” Patients pay a monthly premium for Medicare Part B (general health coverage). The 2023 standard Part B monthly premium is $164.90. Patients also contribute to drug costs via Medicare Part D. Most people do not pay a premium for Medicare Part A (“inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care”). More than 65.3 million people were enrolled in Medicare according to Feb. 2023 government data. [ 180 ] [ 181 ] Medicaid “provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.” More than 84.8 million people were enrolled in Medicaid as of Nov. 2022. [ 181 ] [ 182 ] [ 183 ] The Children’s Health Insurance Program (CHIP), often lumped in with Medicaid in these discussions, is a “low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program.” CHIP covers more than 6.9 million patients. [ 181 ] [ 182 ] [ 183 ] TRICARE is the “military health system that provides care to almost 10 million active-duty service members, retired personnel, and their families.” Active-duty military members pay $0 for health insurance, while retired members and their families paid a premium up to $1,165 per month (for a member and family) in 2021. [ 184 ] The United States already successfully maintains universal health care for almost 36% of the U.S. population, according to U.S. Census data released in Sep. 2022. As the Baby Boomer generation continues to age and more of the generation becomes eligible for Medicare, estimates suggest about 73.5 million people will use Medcare and about 47% of American health care costs will be paid for by public health services by 2027. [ 185 ] [ 186 ] If the government can successfully provide universal health care for 36% to almost 50% of the population, then the government can provide univeral health care for the rest of the population who are just as in need and deserving of leading healthy lives. Read More

Pro 2 Universal health care would lower costs and prevent medical bankruptcy. A June 2022 study found the United States could have saved $105.6 billion in COVID-19 (coronavirus) hospitalization costs with single-payer universal health care during the pandemic. That potential savings is on top of the estimated $438 billion the researchers estimated could be saved annually with universal health care in a non-pandemic year. [ 198 ] “Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households,” conclude researchers from the Yale School of Public Health and colleagues. [ 201 ] According to the National Bankruptcy Forum, medical debt is the number one reason people file for bankruptcy in the United States. In 2017, about 33% of all Americans with medical bills reported that they “were unable to pay for basic necessities like food, heat, or housing.” If all Americans were provided health care under a single-payer system medical bankruptcy would no longer exist, because the government, not private citizens, would pay all medical bills. [ 131 ] Further, prescription drug costs would drop between 4% and 31%, according to five cost estimates gathered by New York Times reporters. 24% of people taking prescription drugs reported difficulty affording the drugs, according to a Kaiser Family Foundation (KFF) poll. 58% of people whose drugs cost more than $100 a month, 49% of people in fair or poor health, 35% of those with annual incomes of less than $40,000, and 35% of those taking four or more drugs monthly all reported affordability issues. [ 197 ] [ 199 ] [ 200 ] Additionally, 30% of people aged 50 to 64 reported cost issues because they generally take more drugs than younger people but are not old enough to qualify for Medicare drug benefits. With 79% of Americans saying prescription drug costs are “unreasonable,” and 70% reporting lowering prescription drug costs as their highest healthcare priority, lowering the cost of prescription drugs would lead to more drug-compliance and lives not only bettered, but saved as a result. [ 197 ] [ 199 ] [ 200 ] Read More

Pro 3 Universal health care would improve individual and national health outcomes. Since 2020, the COVID-19 pandemic has underscored the public health, economic and moral repercussions of widespread dependence on employer-sponsored insurance, the most common source of coverage for working-age Americans…. Business closures and restrictions led to unemployment for more than 9 million individuals following the emergence of COVID-19. Consequently, many Americans lost their healthcare precisely at a time when COVID-19 sharply heightened the need for medical services,” argue researchers from the Yale School of Public Health and colleagues. The researchers estimated more than 131,000 COVID-19 (coronavirus) deaths and almost 78,000 non-COVID-19 deaths could have been prevented with universal health care in 2020 alone. [ 198 ] Another study finds a change to “single-payer health care would… save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.” [ 201 ] Meanwhile, more people would be able to access much-needed health care. A Jan. 2021 study concludes that universal health care would increase outpatient visits by 7% to 10% and hospital visits by 0% to 3%, which are modest increases when compared to saved and lengthened lives. [ 202 ] Other studies find that universal health coverage is linked to longer life expectancy, lower child mortality rates, higher smoking cessation rates, lower depression rates, and a higher general sense of well-being, with more people reporting being in “excellent health.” Further, universal health care leads to appropriate use of health care facilities, including lower rates of emergency room visits for non-emergencies and a higher use of preventative doctors’ visits to manage chronic conditions. [ 203 ] [ 204 ] [ 205 ] An American Hospital Association report argues, the “high rate of uninsured [patients] puts stress on the broader health care system. People without insurance put off needed care and rely more heavily on hospital emergency departments, resulting in scarce resources being directed to treat conditions that often could have been prevented or managed in a lower-cost setting. Being uninsured also has serious financial implications for individuals, communities and the health care system.” [ 205 ] Read More

Con 1 Universal health care for everyone in the United States promises only government inefficiency and health care that ignores the realities of the country and the free market. In addition to providing universal health care for the elderly, low-income individuals, children in need, and military members (and their families), the United States has the Affordable Care Act (the ACA, formerly known as the Patient Protection and Affordable Care Act), or Obamacare, which ensures that Americans can access affordable health care. the ACA allows Americans to chose the coverage appropriate to their health conditions and incomes. [ 187 ] Veterans’ Affairs, which serves former military members, is an example of a single-payer health care provider, and one that has repeatedly failed its patients. For example, a computer error at the Spokane VA hospital “failed to deliver more than 11,000 orders for specialty care, lab work and other services – without alerting health care providers the orders had been lost.” [ 188 ] [ 189 ] Elizabeth Hovde, Policy Analyst and Director of the Centers for Health Care and Worker Rights, argues, “The VA system is not only costly with inconsistent medical care results, it’s an American example of a single-payer, government-run system. We should run from the attempts in our state to decrease competition in the health care system and increase government dependency, leaving our health care at the mercy of a monopolistic system that does not need to be timely or responsive to patients. Policymakers should give veterans meaningful choices among private providers, clinics and hospitals, so vets can choose their own doctors and directly access quality care that meets their needs. Best of all, when the routine break-downs of a government-run system threaten to harm them again, as happened in Spokane, veterans can take their well-earned health benefit and find help elsewhere.” [ 188 ] [ 189 ] Further, the challenges of universal health care implementation are vastly different in the U.S. than in other countries, making the current patchwork of health care options the best fit for the country. As researchers summarize, “Though the majority of post-industrial Westernized nations employ a universal healthcare model, few—if any—of these nations are as geographically large, populous, or ethnically/racially diverse as the U.S. Different regions in the U.S. are defined by distinct cultural identities, citizens have unique religious and political values, and the populace spans the socio–economic spectrum. Moreover, heterogenous climates and population densities confer different health needs and challenges across the U.S. Thus, critics of universal healthcare in the U.S. argue that implementation would not be as feasible—organizationally or financially—as other developed nations.” [ 190 ] And, such a system in the United States would hinder medical innovation and entrepreneurship. “Government control is a large driver of America’s health care problems. Bureaucrats can’t revolutionize health care – only entrepreneurs can. By empowering health care entrepreneurs, we can create an American health care system that is more affordable, accessible, and productive for all,” explains Wayne Winegarden, Senior Fellow in Business and Economics, and Director of the Center for Medical Economics and Innovation at Pacific Research Institute. [ 190 ] [ 191 ] Read More

Con 2 Universal health care would raise costs for the federal government and, in turn, taxpayers. Medicare-for-all, a recent universal health care proposal championed by Senator Bernie Sanders (I-VT), would cost an estimated $30 to $40 trillion over ten years. The cost would be the largest single increase to the federal budget ever. [ 192 ] The Congressional Budget Office (CBO) estimates that by 2030 federal health care subsidies will increase by $1.5 to $3.0 trillion. The CBO concludes, “Because the single-payer options that CBO examined would greatly increase federal subsidies for health care, the government would need to implement new financing mechanisms—such as raising existing taxes or introducing new ones, reducing certain spending, or issuing federal debt. As an example, if the government required employers to make contributions toward the cost of health insurance under a single-payer system that would be similar to their contributions under current law, it would have to impose new taxes.” [ 193 ] Despite claims by many, the cost of Medicare for All, or any other universal health care option, could not be financed solely by increased taxes on the wealthy. “[T]axes on the middle class would have to rise in order to pay for it. Those taxes could be imposed directly on workers, indirectly through taxes on employers or consumption, or through a combination of direct or indirect taxes. There is simply not enough available revenue from high earners and businesses to cover the full cost of eliminating premiums, ending all cost-sharing, and expanding coverage to all Americans and for (virtually) all health services,” says the Committee for a Responsible Federal Budget. [ 195 ] An analysis of the Sanders plan “estimates that the average annual cost of the plan would be approximately $2.5 trillion per year creating an average of over a $1 trillion per year financing shortfall. To fund the program, payroll and income taxes would have to increase from a combined 8.4 percent in the Sanders plan to 20 percent while also retaining all remaining tax increases on capital gains, increased marginal tax rates, the estate tax and eliminating tax expenditures…. Overall, over 70 percent of working privately insured households would pay more under a fully funded single payer plan than they do for health insurance today.” [ 196 ] Read More

Con 3 Universal health care would increase wait times for basic care and make Americans’ health worse. The Congressional Budget Office explains, “A single-payer system with little cost sharing for medical services would lead to increased demand for care in the United States because more people would have health insurance and because those already covered would use more services. The extent to which the supply of care would be adequate to meet that increased demand would depend on various factors, such as the payment rates for providers and any measures taken to increase supply. If coverage was nearly universal, cost sharing was very limited, and the payment rates were reduced compared with current law, the demand for medical care would probably exceed the supply of care–with increased wait times for appointments or elective surgeries, greater wait times at doctors’ offices and other facilities, or the need to travel greater distances to receive medical care. Some demand for care might be unmet.” [ 207 ] As an example of lengthy wait times associated with universal coverage, in 2017 Canadians were on waiting lists for an estimated 1,040,791 procedures, and the median wait time for arthroplastic surgery was 20–52 weeks. Similarly, average waiting time for elective hospital-based care in the United Kingdom is 46 days, while some patients wait over a year. Increased wait times in the U.S. would likely occur—at least in the short term—as a result of a steep rise in the number of primary and emergency care visits (due to eliminating the financial barrier to seek care), as well as general wastefulness, inefficiency, and disorganization that is often associated with bureaucratic, government-run agencies. [ 17 ] [ 190 ] Joshua W. Axene of Axene Health Partners, LLC “wonder[s] if Americans really could function under a system that is budget based and would likely have increased waiting times. In America we have created a healthcare culture that pays providers predominantly on a Fee for Service basis (FFS) and allows people to get what they want, when they want it and generally from whoever they want. American healthcare culture always wants the best thing available and has a ‘more is better’ mentality. Under a government sponsored socialized healthcare system, choice would become more limited, timing mandated, and supply and demand would be controlled through the constraints of a healthcare budget…. As much as Americans believe that they are crockpots and can be patient, we are more like microwaves and want things fast and on our own terms. Extended waiting lines will not work in the American system and would decrease the quality of our system as a whole.” [ 206 ] Read More

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Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons

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Every citizen of every country in the world should be provided with free and high-quality medical services. Health care is a fundamental need for every human, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal health care is the provision of healthcare services by a government to all its citizens (insurancespecialists.com). This means each citizen can access medical services of standard quality. In the United States, about 25% of its citizens are provided with healthcare funded by the government. These citizens mainly comprise the elderly, the armed forces personnel, and the poor (insurancespecialists.com).

Introduction

Thesis statement.

• Universal Healthcare Pros
• Universal Healthcare Cons

Works Cited

In Russia, Canada, and some South American and European countries, the governments provide universal healthcare programs to all citizens. In the United States, the segments of society which do not receive health care services provided by the government usually pay for their health care coverage. This has emerged as a challenge, especially for middle-class citizens. Therefore, the universal health care provision in the United States is debatable: some support it, and some oppose it. This assignment is a discussion of the topic. It starts with a thesis statement, then discusses the advantages of universal health care provision, its disadvantages, and a conclusion, which restates the thesis and the argument behind it.

The government of the United States of America should provide universal health care services to its citizens because health care is a basic necessity to every citizen, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal Healthcare Provision Pros

The provision of universal health care services would ensure that doctors and all medical practitioners focus their attention only on treating the patients, unlike in the current system, where doctors and medical practitioners sped a lot of time pursuing issues of health care insurance for their patients, which is sometimes associated with malpractice and violation of medical ethics especially in cases where the patient is unable to adequately pay for his or her health care bills (balancedpolitics.org).

The provision of universal health care services would also make health care service provision in the United States more efficient and effective. In the current system in which each citizen pays for his or her health care, there is a lot of inefficiency, brought about by the bureaucratic nature of the public health care sector (balancedpolitics.org).

Universal health care would also promote preventive health care, which is crucial in reducing deaths as well as illness deterioration. The current health care system in the United States is prohibitive of preventive health care, which makes many citizens to wait until their illness reach critical conditions due to the high costs of going for general medical check-ups. The cost of treating patients with advanced illnesses is not only expensive to the patients and the government but also leads to deaths which are preventable (balancedpolitics.org).

The provision of universal health care services would be a worthy undertaking, especially due to the increased number of uninsured citizens, which currently stands at about 45 million (balancedpolitics.org).

The provision of universal health care services would therefore promote access to health care services to as many citizens as possible, which would reduce suffering and deaths of citizens who cannot cater for their health insurance. As I mentioned in the thesis, health care is a basic necessity to all citizens and therefore providing health care services to all would reduce inequality in the service access.

Universal health care would also come at a time when health care has become seemingly unaffordable for many middle income level citizens and business men in the United States. This has created a nation of inequality, which is unfair because every citizen pays tax, which should be used by the government to provide affordable basic services like health care. It should be mentioned here that the primary role of any government is to protect its citizens, among other things, from illness and disease (Shi and Singh 188).

Lastly not the least, the provision of universal health care in the United States would work for the benefit of the country and especially the doctors because it would create a centralized information centre, with database of all cases of illnesses, diseases and their occurrence and frequency. This would make it easier to diagnose patients, especially to identify any new strain of a disease, which would further help in coming up with adequate medication for such new illness or disease (balancedpolitics.org).

Universal Healthcare Provision Cons

One argument against the provision of universal health care in the United States is that such a policy would require enormous spending in terms of taxes to cater for the services in a universal manner. Since health care does not generate extra revenue, it would mean that the government would either be forced to cut budgetary allocations for other crucial sectors of general public concern like defense and education, or increase the taxes levied on the citizens, thus becoming an extra burden to the same citizens (balancedpolitics.org).

Another argument against the provision of universal health care services is that health care provision is a complex undertaking, involving varying interests, likes and preferences.

The argument that providing universal health care would do away with the bureaucratic inefficiency does not seem to be realistic because centralizing the health care sector would actually increase the bureaucracy, leading to further inefficiencies, especially due to the enormous number of clientele to be served. Furthermore, it would lead to lose of business for the insurance providers as well as the private health care practitioners, majority of whom serve the middle income citizens (balancedpolitics.org).

Arguably, the debate for the provision of universal health care can be seen as addressing a problem which is either not present, or negligible. This is because there are adequate options for each citizen to access health care services. Apart from the government hospitals, the private hospitals funded by non-governmental organizations provide health care to those citizens who are not under any medical cover (balancedpolitics.org).

Universal health care provision would lead to corruption and rent seeking behavior among policy makers. Since the services would be for all, and may sometimes be limited, corruption may set in making the medical practitioners even more corrupt than they are because of increased demand of the services. This may further lead to deterioration of the very health care sector the policy would be aiming at boosting through such a policy.

The provision of universal health care would limit the freedom of the US citizens to choose which health care program is best for them. It is important to underscore that the United States, being a capitalist economy is composed of people of varying financial abilities.

The provision of universal health care would therefore lower the patients’ flexibility in terms of how, when and where to access health care services and why. This is because such a policy would throw many private practitioners out of business, thus forcing virtually all citizens to fit in the governments’ health care program, which may not be good for everyone (Niles 293).

Lastly not the least, the provision of universal health care would be unfair to those citizens who live healthy lifestyles so as to avoid lifestyle diseases like obesity and lung cancer, which are very common in America. Many of the people suffering from obesity suffer due to their negligence or ignorance of health care advice provided by the government and other health care providers. Such a policy would therefore seem to unfairly punish those citizens who practice good health lifestyles, at the expense of the ignorant (Niles 293).

After discussing the pros and cons of universal health care provision in the United States, I restate my thesis that “The government of United States of America should provide universal health care to its citizens because health care is a basic necessity to every citizen, regardless of age, sex, race, religion, and socio economic status”, and argue that even though there are arguments against the provision of universal health care, such arguments, though valid, are not based on the guiding principle of that health care is a basic necessity to all citizens of the United States.

The arguments are also based on capitalistic way of thinking, which is not sensitive to the plight of many citizens who are not able to pay for their insurance health care cover.

The idea of providing universal health care to Americans would therefore save many deaths and unnecessary suffering by many citizens. Equally important to mention is the fact that such a policy may be described as a win win policy both for the rich and the poor or middle class citizens because it would not in any way negatively affect the rich, because as long as they have money, they would still be able to customize their health care through the employment family or personal doctors as the poor and the middle class go for the universal health care services.

Balanced politics. “Should the Government Provide Free Universal Health Care for All Americans?” Balanced politics: universal health . Web. Balanced politics.org. 8 august https://www.balancedpolitics.org/universal_health_care.htm

Insurance specialists. “Growing Support for Universal Health Care”. Insurance information portal. Web. Insurance specialists.com 8 august 2011. https://insurancespecialists.com/

Niles, Nancy. Basics of the U.S. Health Care System . Sudbury, MA: Jones & Bartlett Learning, 2010:293. Print.

Shi, Leiyu and Singh, Douglas. Delivering Health Care in America: A Systems Approach . Sudbury, MA: Jones & Bartlett Learning, 2004:188. Print.

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IvyPanda. (2018, October 11). Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/

"Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." IvyPanda , 11 Oct. 2018, ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

IvyPanda . (2018) 'Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons'. 11 October.

IvyPanda . 2018. "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

1. IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

Bibliography

IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." October 11, 2018. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

Should the U.S. Government Provide Universal Health Care?

The United States is the only nation among the 37 OECD (Organization for Economic Co-operation and Development) nations that does not have universal health care either in practice or by constitutional right. For more on universal health care, explore the ProCon debate .

Not Clear or Not Found

Former Candidates

Kamala Harris:

“First, when we pass my plan, all Americans will immediately have the ability to buy into Medicare. This is similar to the immediate, introductory buy-in provided in Senator Sanders’ Medicare for All bill. Right away, it will lower costs and give us a baseline plan as we transition to Medicare for All. Second, we will set up an expanded Medicare system, with a 10-year phase-in period. During this transition, we will automatically enroll newborns and the uninsured into this new and improved Medicare system, give all doctors time to get into the system, and provide a commonsense path for employers, employees, the underinsured, and others on federally-designated programs, such as Medicaid or the Affordable Care Act exchanges, to transition. This will expand the number of insured Americans and create a new viable public system that guarantees universal coverage at a lower cost. Expanding the transition window will also lower the overall cost of the program.” - Kamala Harris, “My Plan for Medicare for All,” kamalaharris.medium.com , July 29, 2019

Jill Stein:

“Our healthcare system is in crisis. The United States spends more on healthcare than any other high-income country but has worse health outcomes, including the lowest life expectancy at birth and the highest rate of people with multiple chronic diseases. 25 million people were uninsured in the US in 2023. Many of those who are insured still can’t afford healthcare due to huge out-of-pocket costs. Researchers estimate this lack of adequate healthcare led to over 330,000 excess deaths from Covid-19. The Wall Street parties are funded by the insurance industry, the pharmaceutical industry, and other big healthcare profiteers to perpetuate this failed system that puts profits over people. Healthcare is a human right. We need a universal healthcare system that is equitable, comprehensive, free at point of service, and accessible to every single person in the US.” - Jill Stein, “Platform,” jillstein2024.com (accessed Aug. 19, 2024)

Chase Oliver:

“Healthcare is too expensive because of government overregulation. We should advocate for market alternatives to heavily regulated employer-provided insurance such as the Direct Primary Care model.” Editors’ Note: The Direct Primary Care model is described by the program itself as “an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. Patients have extraordinary access to a physician of their choice, often for as little as $70 per month, and physicians are accountable first and foremost their patients. DPC is embraced by health policymakers on the left and right and creates happy patients and happy doctors all over the country!” - Chase Oliver, “Platform,” votechaseoliver.com (accessed May 28, 2024) Source for Editors’ Note: Direct Primary Care Coalition, “What Is Direct Primary Care?,” dpcare.org (accessed May 28, 2024)

Donald Trump:

“I don’t want to terminate Obamacare, I want to REPLACE IT with MUCH BETTER HEALTHCARE. Obamacare Sucks!!!” “The Democrats are pushing for Universal HealthCare while thousands of people are marching in the UK because their U system is going broke and not working. Dems want to greatly raise taxes for really bad and non-personal medical care. No thanks!” “I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. We must not allow citizens with medical problems to go untreated because of financial problems or red tape…. Working out detailed plans will take time. But the goal should be clear: Our people are our greatest asset. We must take care of our own. We must have universal healthcare.” - Donald Trump, truthsocial.com , Nov. 29, 2023 Donald Trump, twitter.com , Feb. 5, 2018 Donald Trump, The America We Deserve , 2000

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Home — Essay Samples — Nursing & Health — Universal Health Care — Universal Healthcare: Benefits, Challenges, and International Examples

Universal Healthcare: Benefits, Challenges, and International Examples

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Published: Sep 7, 2023

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Benefits of universal healthcare, challenges of universal healthcare, international examples of universal healthcare.

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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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Article content

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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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.

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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
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• 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.

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Healthcare Debates: Is Healthcare a Right or Privilege?

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The debate in the United States over whether or not healthcare is a right or a privilege has been raging for over a century . Do all U.S. citizens have a right to access healthcare, regardless of their position in a free market system? Or, as healthcare services are a limited resource requiring money to operate, is access to healthcare just like every other commodity—a privilege reserved for those who are competitive in the free market?

As there is real-life evidence to support both outlooks, the debate over whether healthcare is a right or a privilege ultimately is a values-based debate. Where someone stands on this debate comes down to how they view rights, the role they believe the government has in enforcing these rights, whether or not they believe healthcare is something every individual deserves, and whether they believe we are connected or separate.

Keep reading to learn more about the fundamental questions we must ask ourselves as individuals and what our nation must answer as a collective to come to a consensus around whether or not healthcare is a right or a privilege.

Positive Rights vs. Negative Rights

When the healthcare debate rages, one of the dialectics that fuels the debate is the semantic meaning of the word “rights.” While we all have a generalized sense of what this means—something we are entitled to simply because we exist—the debates over healthcare arise from differing ideas regarding how rights are idealized and from these idealizations: how they should be enforced.

Parties who believe that healthcare is a right often operate from the rhetoric of positive rights, whereas those who believe health care is a privilege often operate from the rhetoric of negative rights.

Those who see healthcare as a privilege will often use the rhetoric of negative rights . In a negative-rights framework , rights are restraints on actions rather than an obligation to act. In the case of the constitutional decree that we have the right to life, liberty, and the pursuit of happiness, a negative rights outlook would mean that you have no obligation to help another person to attain life, liberty, or happiness—but you do have a duty not to get in their way.

In the case of healthcare, those who believe in a negative rights framework believe that you cannot have healthcare as a right because it places a positive obligation on others to provide access through the nonconsensual surrender of income to the state. From a negative rights perspective, the only duty or obligation we have to one another in regard to healthcare is not to threaten choice or bar access, but we should not be forced to contribute to the care of others.

Parties who see rights from this perspective believe that helping with healthcare needs to be voluntary (i.e., free-market decisions or healthcare charities run on voluntary donations). The government’s role in healthcare is to protect this individual’s right to choose. Simply put, in a negative rights framework, healthcare can be available through the mechanisms of a free market system, but it is not a right.

Those who advocate greater governmental responsibility in healthcare are often working from a positive rights perspective —a framework where a positive duty is imposed on us to sustain the welfare of those in need.

There is a major global consensus that health—and all the circumstances that mediate health—is a fundamental human right (see the UN Universal Declaration of Human Rights and the World Health Organization’s Constitution ). Healthcare is often a necessary tool for the attainment of access to health and, from a positive rights perspective, it is something that should be provided to everyone, whether or not they can participate meaningfully in a free market system.

From this point of view, marginalized populations who struggle to find adequate work or cannot work (e.g., the young, the poor, the elderly, those with debilitating chronic diseases, the disabled) should have a right to healthcare. In this framework, it is the government’s duty to ensure that the conditions that mediate fundamental human rights are attainable, regardless of the lottery of the birth. Therefore, the government has a right to impose taxes that will help those for whom the free market system imposes an undue burden.

In a positive rights framework, healthcare is a tool to attain the basic human right of health, and it is the duty of the people to ensure access to it.

Does Everyone Deserve Healthcare?

As a result of an unequal system of healthcare that began during World War II, the idea of healthcare as a basic entitlement that we all contribute to—much like clean water, garbage collection, roads, etc.—has experienced a complete breakdown in American cultural consciousness.

In linking health insurance to employment and thereby intrinsically linking access to care to employment, the U.S. became the land of an inequitable system whereby different people with varying circumstances became subject to different rules for healthcare. This history is integral to the way we speak about whether or not people deserve healthcare.

For parties who believe that healthcare is a privilege , one of the key beliefs is that rights do not distinguish between the deserving and the undeserving . Within this framework, narratives of self-reliance and hard work are key rhetorical cornerstones. Those who do not believe healthcare is a right often assert that work is the key that opens the door to healthcare all throughout the lifecycle. Earning money, saving for health, and choosing employment with health coverage is what hardworking, self-reliant individuals should do in their productive working years to ensure access to the privilege of healthcare for themselves and for their children.

As these individuals work, they pay into Medicare, and this is the system that ensures that hardworking, self-reliant individuals will retain access to health care when they are no longer capable of work.

For those who are working hard and earning wages that do not cover the cost of healthcare, access to government assistance or charity is an earned privilege. However, from this point of view, those who are not productive members of society do not deserve access to care—nor to collective pools of money paid into by those who are productive. Supporting those who cannot contribute is seen as detrimental to the system, opening the door for abuse of the system.

Parties that believe healthcare is a right tend to use rhetorical frameworks that demonstrate all lives have equal value and that access to healthcare for all is necessary for a prosperous society .

Because of these centralized beliefs, those who believe that everyone deserves healthcare argue that it should not be linked to one’s capacities to work. There are many people who—through no fault of their own—are born with physical or mental disorders that bar them from work and many who, despite having some productive years, develop chronic conditions that prohibit them from working.

There are also those who do work—like the estimated 35 percent of the adult workforce in the United States who are in the gig economy—who do not have access to healthcare because of lack of access to employer coverage. Those who believe healthcare is a right state that investing in the health of all these people is essential because, with healthcare, these humans have the capacity to live up to their greatest potentials and may contribute to our communities in a way that cannot always be measured within a framework of contribution to a GDP.

Overall, supporting those who cannot work can lead to abuses in the system, but this is a small price to pay for opening the door to all citizens to live up to their greatest human potential.

Are We Separate or Connected?

Ultimately, all the questions that come before connect to one penultimate question around whether our fates are connected or if they are separate.

Those who believe healthcare is a right utilize the rhetoric of the connected . What impacts one of us impacts all of us —both in the realm of the negative and the in the realm of the positive. Healthcare, therefore, needs to be a right because if the most vulnerable member of our society is not cared for, it means that we—as a collective—are not cared for.

The real-world implications of this are seen in a healthcare system that is the most expensive, least effective, and least accessible in the western world. Those who see healthcare as a right argue that improving access to healthcare saves us money, heals people, and creates a more engaged citizenry.

Those who believe healthcare is a privilege utilize the rhetoric of the separate . It is the belief that we have a duty only to our own freedoms and to reap the benefits of the work we have done. Being forced to use what we have earned against our will to help another is akin to theft .

By putting the responsibility for healthcare on the shoulders of the individuals in need, we will ultimately save money because prices will become more competitive, and the citizenry will become more engaged if they wish for healing. They believe that our healthcare system is the most expensive and least effective in the western world because there is too much assistance on which people are becoming dependent.

In Conclusion: Is Healthcare a Right or a Privilege?

The debate over whether healthcare is a right or a privilege has more questions than answers—and the answers to these questions are not straightforward. If they were, this debate wouldn’t have a century-old history. What individuals believe about healthcare comes down to a complex mixture of:

• Life experience – Did they have a work-ending condition?
• Values – Do all human lives have equal value?
• Ideologies – Are rights negative or positive?

When debating in the realm of ideals, it is challenging to come to a conclusion as the values underlying the belief are often antithetical and irreconcilable. This begs one more question: can we come up with a system of healthcare that blends both ideologies so that we can move into a healthcare system that costs less, is more effective, and is a win-win for our ideals and the health of our citizenry?

Becca Brewer, MEd

Becca Brewer is building a better future on a thriving earth by healing herself into wholeness, divesting from separation, and walking the path of the loving heart. Previously to her journey as an adventurer for a just, meaningful, and regenerative world, Becca was a formally trained sexuality educator with a master of education.

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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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"Healthcare for All"?: The Gap Between Rhetoric and Reality in the Affordable Care Act

Introduction.

According to its proponents, the passage of the Affordable Care Act (ACA) 1 “enshrined . . . the core principle that everybody should have some basic security when it comes to their health care.” 2   However, the ACA does not ensure healthcare coverage for many groups.  Indeed, projections indicate that 27 million uninsured Americans will remain even after enactment of all of the ACA ’s provisions. 3   Most sizeable among these groups are certain classes of noncitizens, including but not limited to undocumented immigrants.

Why does the statutory reality differ from the lofty, expansive language used by the ACA ’s proponents in Congress and the White House, especially with respect to noncitizens?  A parsing of the ACA ’s legislative history, particularly the congressional floor debates over the bill, reveals two possible answers.  Both answers are instructive to advocates hoping to extend access to health insurance coverage to all noncitizen groups.  First, at least some legislators implicitly qualify the notion of healthcare for all with the requirement that beneficiaries of the law must pay taxes  Second, at least some legislators seem to exclude certain noncitizen groups from their definition of “Americans,” which is used interchangeably with the terms “everybody” or “all” throughout the legislative history of the ACA .

Part I of this Essay examines the ACA ’s statutory and accompanying regulatory language, identifying three noncitizen groups that receive reduced or no protections under the law: (1) recently arrived legal immigrants; (2) noncitizens present under temporary nonimmigrant visas, known as nonim­migrants; and (3) undocumented immigrants.  Part II explores the legislative history of the ACA and the idealistic statements repeatedly made by legislators about the idea of healthcare for all.  It identifies similar statements made by proponents of previous versions of healthcare reform during prior presidential administrations, suggesting a historical pattern of disconnect.

Part III concludes that implicit normative and economic arguments legislators made against the expansion of healthcare coverage to these excluded groups, particularly the undocumented, offer a partial explanation for the gap between the rhetoric and reality of the ACA .  It also critiques these arguments and offers suggestions to advocates for expanded healthcare coverage in overcoming these implicit arguments against true healthcare for all.

I. The Affordable Care Act and Exclusion of Certain Noncitizen Groups

This Part distills a general outline of the ACA ’s contours before analyzing how recent legal immigrants, legal nonimmigrants, and undocumented immi­grants are not protected under the new legislation.  The ACA is both voluminous and complex, clocking in at nearly 1000 pages and containing various provisions that will not go into effect until later this decade. 4   Multiple constitutional and political challenges to the ACA , the most significant of which the U.S. Supreme Court resolved only in June of 2012, 5 slowed down the states’ implementation of the bill. 6   Further, the U.S. Department of Health and Human Services is still promulgating regulations in accordance with the statute’s decrees more than two years after the bill’s passage. 7   All of this uncertainty over the ACA makes it difficult to analyze the ACA with a high degree of specificity.  However, even a general summary of the law demonstrates the notable absence of the three groups identified above from all of the ACA benefits.

A. General Outline of the ACA

B. reduced protections for recently arrived legal immigrants, c. reduced protections for legal nonimmigrants.

The ACA also fails to offer full protections to the nearly two million nonimmigrant residents in the United States. 32   Nonimmigrants, who are present in the country on temporary visas and include university students, skilled and unskilled laborers recruited by U.S. employers, and family members of U.S. citizens or lawful permanent residents, 33 are often a forgotten group. 34   Yet many of these individuals lawfully reside in this country for up to several years.  Many of them undoubtedly require access to healthcare at some point during their time here.

D. Reduced Protections for Undocumented Immigrants

Finally, the estimated eleven million undocumented immigrants in this country 40 are specifically excluded from virtually all of the ACA ’s protections  As one commentator summarizes:

II. Legislative History of and Rhetoric Surrounding the Affordable Care Act

The ACA deliberately refrained from extending full access to healthcare for recently arrived LPRs and nonimmigrants.  The ACA also excluded undocu­mented immigrants from all, or virtually all, of its protections.  Yet, as this Part demonstrates, the ACA ’s statutory realities appear to belie the expansive language used by the ACA ’s advocates, who repeatedly defended the idea of healthcare access to “everyone” or “all Americans” in the sponsor statements, floor debates, and signing statements associated with the bill. 47   This trend is a continuation of history, as policymakers who pushed previous iterations of healthcare reform during previous presidential administrations also employed universal language in publicizing their efforts.  Yet policymakers did not include groups like the undocumented in their policy proposals.  The result is an apparent, longstanding tension between the ideas of healthcare for all and healthcare for noncitizens.

A. The Legislative History of the ACA

Representative Louise Slaughter’s seemingly contradictory statements are indicative of this paradox.  Representative Slaughter called up the bill for a vote and in her remarks stated:

The legislative history of the bill is less clear, however, about the reasons for offering diminished protection to newly arrived LPRs and nonimmigrants.  Only one congressman made a floor statement about the plight of newly arrived legal immigrants under the bill.  Representative Honda lamented that the bill did not “lift the 5 year bar on legal immigrant participation in Medicaid.  Legal immigrants are tax paying [sic] citizens in waiting who work hard and contribute.  It is only fair that we afford them equal access to the benefits of Medicaid.” 58   Meanwhile, no floor statements, committee reports, or other statements made by lawmakers suggested that legislators were preoccupied by the fate of nonimmigrants under the bill.

Finally, after the bill passed both Congressional houses and landed on President Obama’s desk on March 23, 2010, the president also used expansive, even universal, language when referring to the beneficiaries of the ACA :

B. History of Healthcare Reform Advocacy in America

The ACA was an unprecedented overhaul of our nation’s healthcare system.  It was the product of decades of advocacy for expanded access to healthcare for Americans that germinated in Theodore Roosevelt’s presidential administration nearly a century ago. 60   As healthcare costs and the number of uninsured in the United States continued to balloon, the political will to reform the system strengthened.  And just like with the ACA , the idea that “all Americans” deserved access to healthcare animated the political discourse through Republican and Democratic presidencies alike in the last hundred years, though the concrete proposals failed to extend protection to all noncitizen groups.  The ACA ’s repetition of history may be instructive in understanding why legislators persist in leaving out certain noncitizens from their conception of universal healthcare.

The rhetoric past legislators and policy advocates used to push for such legislation also centered around the notion that “all Americans deserve healthcare.”  For example, Mrs. Clinton and other advocates of her plan 1993 Health Care Reform Plan made such statements as “If we do not have universal coverage . . . we do not have health care reform.” 65   And yet, past iterations of healthcare expansion legislation, such as the 1993 plan, did not cover undocumented immigrants beyond already existing emergency Medicaid protections in the event of immediate and severe health crises. 66   In the past, as in the present, a gap existed between the ideals that animated the push for healthcare reform and the substance of the proposals ultimately put forth with respect to noncitizen groups like the undocumented.

III. Implicit Rationale for the Gap Between Reality and Rhetoric: The Definition of “American”

It is, of course, impossible to definitively explain how the entire 111th U.S. Congress rationalized the exclusion of the three noncitizen groups identified above.  Parsing the legislative history—particularly the floor debates—reveals implicit economic and normative social assumptions legislators made about the role of undocumented immigrants in particular.  Perhaps these assumptions explain, at least in part, the inconsistencies in the statutory language of and legislative history about the ACA explored in this Article.  This Part explores these potential economic and social rationales, critiques them, and offers ways for healthcare reform advocates to overcome them.

A. Concerns About Economic Freeridership

Most of the comments made by legislators concerned the potential for undocumented immigrants to benefit from the ACA are economic in nature.  Time and time again, legislators opposed to the bill mentioned the fear that undocumented immigrants would benefit from free healthcare at the (presumably legally present) taxpayers’ expense 67 and “open[] the floodgates” to millions more of the undocumented who would further burden our welfare system. 68   News reports suggest the floodgates argument also partially explains why legislators declined to lift the Medicaid residency and immigrant status requirements in the ACA for legal immigrants and nonimmigrants. 69   A plausible way this fear qualifies the seemingly unconditional healthcare for all is the idea that legislators actually mean healthcare for all who pay into the system.

Second, the floodgates argument is also specious.  The number of legal immigrants and nonimmigrants would not increase with expanded access to Medicaid because the United States has caps on the number of immigrants and nonimmigrants who may enter the country each year. 74   Further, many immi­gration analysts argue that undocumented are primarily motivated to enter this country due to the presence of brighter economic opportunities, especially in the unskilled and low-skilled sectors, where the supply of U.S. citizen workers is low. 75   Whether healthcare benefits are available is ancillary when compared to whether upward social and economic mobility is possible through available jobs. 76   The decrease in the number of undocumented immigrants during the past four years 77 as the American economy underwent a recession and a slow recovery 78 supports this view of immigration.

Finally, some studies have shown that giving all individuals access to preventative and nonemergency healthcare is ultimately more cost-effective for the nation as a whole. 79   In support of this point, it is worthwhile to note that the undocumented population is generally younger and healthier than the American population as a whole, 80 and adding them into insurance risk pools may lower premiums and costs of emergency healthcare for all. 81   It is true that other studies claim that the federal government may not gain money from subsidizing so many Americans’ health insurance. 82   It is impossible, however to deny the longterm gains in economic productivity and reduction in emergency room and emergency Medicaid costs that would result if all people—including recently arrived LPRs, nonimmigrants and the undocumented—had health insurance. 83   The possibility of realizing such gains would seem to merit seriously considering expanding undocumented immigrants’ rights to access healthcare.

Perhaps most who opposed the ACA covering undocumented immigrants generally oppose the concept of the ACA .  It is true that those who mentioned the potential economic burdens that undocumented immigrants would create by receiving benefits under the ACA were opposed to the ACA as a whole on other grounds.  This includes the idea that the ACA was too redistributivist. 84   This counterargument, however, fails to explain why those who supported the ACA and the idea that wealthy taxpayers pay more taxes for all less wealthy Americans’ health insurance also supported excluding the noncitizen groups identified above from the bill.

If indeed some legislators were motivated to deny undocumented immi­grants, recently arrived LPRs, and nonimmigrants access to full healthcare benefits under the ACA because of economic concerns, those who advocate for expanded healthcare coverage for these three noncitizen groups may do well to make two primary economic arguments supporting coverage.  First, these groups, particularly the undocumented, contribute to federal tax revenue.  Second, the national economy and federal government would benefit from an expansion of coverage for all three groups.

B. Healthcare as a Privilege of Citizenship

Another solution to overcoming legislators’ exclusive definition of “American” is to expand the definition of “American” in the political discourse to include the noncitizen groups in question.  This task would be no less Herculean, as it requires changing long-held views on the role of immigrants in the United States. 106   This effort, however, would have the added benefits of staving off the desire of some legislators to oppose CIR efforts if and when that mantle is again taken up by public officials and of preventing legislators from potentially limiting the benefits to which newly legalized immigrants are entitled.

A close examination of the ACA ’s legislative history suggests two possibly interrelated ways that legislators reconciled the competing concepts of universal healthcare and fewer healthcare protections for noncitizens in crafting the ACA .  Perhaps understanding these rationales will allow healthcare advocates on behalf of noncitizens to redouble their efforts to obtain equal access to healthcare for recently arrived legal immigrants, nonimmigrants, and the undocumented.

Despite the rhetoric of universal healthcare and healthcare for all that pervaded the healthcare debate, the ACA does not fully protect certain legal immigrants or nonimmigrants and fails to protect the undocumented at all, leaving millions of Americans still without access to health insurance.  The legislative history of the ACA suggests that legislators’ biases towards these noncitizen groups, particularly with respect to the economic impact of insuring them and the idea that they are not “American,” may explain this gap.  Advocates for universal healthcare must combat these biases, push for comprehensive immigration reform, or, preferably, employ both strategies in order for rhetoric to meet reality in the concept of healthcare for all.

• For the purposes of this Essay, the ACA also refers to the Health Care and Education Reconciliation Act of 2010, which was passed a week later to amend portions of the Patient Protection and Affordable Care Act.  See Pub. L. No. 111-152, 124 Stat. 1029 (2010). ↩
• Joe Biden & Barack Obama, Remarks by the President and Vice President at Signing of the Health Insurance Reform Bill (Mar. 23, 2010), available at http://www.whitehouse.gov/the-press-office/remarks-president-and-vice-president-signing-health-insurance-reform-bill . ↩
• How the Number of Uninsured May Change With and Without the Health Care Law , N.Y. Times , June 27, 2012, http://www.nytimes.com/interactive/2012/06/27/us/how-the-number-of-uninsured- may-change-with-and-without-the-health-care-law.html . ↩
• U.S. Dep’t of Health & Human Serv., Key Features of the Affordable Care Act by Year , Healthcare.gov , http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html (last visited June 30, 2013). ↩
• Adam Liptak, Justices, by 5–4, Uphold Health Care Law; Roberts in Majority; Victory for Obama , N.Y. Times , June 29, 2012, at A1. ↩
• Abby Goodnough & Robert Pear, With Obama Re-elected, States Scramble Over Health Law , N.Y. Times, Nov. 8, 2012, http://www.nytimes.com/2012/11/09/health/states-face-tight-health-care-deadlines.html . ↩
• See, e.g. , Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program, 78 Fed. Reg. 33,233 (June 4, 2013) (to be codified at 45 C.F.R. pts. 155–156). ↩
• Health Care Reform Tops Obama’s Priority List , PBS NewsHour (June 8, 2009, 12:30 PM), http://www.pbs.org/newshour/updates/health/jan-june09/healthpreview_06-08.html . ↩
• Shailagh Murray & Lori Montgomery, House Democrats Pull Together on Health Care , Wash. Post , Oct. 30, 2009, http://www.washingtonpost.com/wp-dyn/content/article/2009/10/29/AR2009102901841_pf.html . ↩
• Sheryl Gay Stolberg & Robert Pear, Obama Signs Health Care Overhaul Bill, With a Flourish , N.Y. Times , Mar. 23, 2010, http://www.nytimes.com/2010/03/24/health/policy/24health.html . ↩
• See id. ↩
• Allison K. Hoffman, Three Models of Health Insurance: The Conceptual Pluralism of the Patient Protection and Affordable Care Act , 159 U. Pa. L. Rev. 1873, 1915–16 (2011). ↩
• See Liptak, supra note 5. ↩
• Robert Pear & Abby Goodnough, States Decline to Set Up Exchanges for Insurance , N.Y. Times , Nov. 17, 2012, at A14 . ↩
• Originally, state-run exchanges were slated to begin running on January 1, 2014; however, delays have ensued due to constitutional uncertainty surrounding the Act and recalcitrance on the part of some states.  The federal government will run exchanges in any states that are unwilling or unable to run their own exchanges.  Id. ↩
• Hoffman, supra note 12, at 1916–17. ↩
• Id . at 1916 . ↩
• Id. at 1920. ↩
• See Robert Pear, Uncertainty Over States and Medicaid Expansion , N.Y. Times , June 29, 2012, at A16 . ↩
• Liptak, supra note 5. ↩
• John Elwood, What Did the Court “Hold” About the Commerce Clause and Medicaid? , Volokh Conspiracy (July 2, 2012, 11:28 AM), http://www.volokh.com/2012/07/02/what-did-the-court-hold-about-the-commerce-clause-and-medicaid .  States may now choose whether to expand Medicaid coverage without incurring a loss of federal Medicaid funding if they choose not to expand.  Pear, supra note 19.  If they do choose to expand, they may seek the ACA ’s additional funding for the expansion.  Id. ↩
• Id. ↩
• Karla Guerrero, Waiting Five Years for Healthcare: How Restricting Immigrants’ Access to Medicaid Harms All , 21 Annals Health L. Advance Directive 109, 113 (2011). ↩
• Id. at 112–13. ↩
• Ruth Ellen Wasem, Cong. Research Serv., Noncitizen Eligibility for Federal Public Assistance: Policy Overview and Trends 4 (2012). ↩
• Guerrero, supra note 23, at 115 (“Emergency Medicaid covers the costs of emergency medical treatment through the Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, which requires hospitals to treat individuals facing medical emergencies regardless of their ability to pay, their immigration status, or whether the hospital could receive reimbursement for services that went beyond simply stabilizing the patient’s medical emergency.”). ↩
• See Mee Moua et al., Immigrant Health: Legal Tools/Legal Barriers , 30 J.L. Med. & Ethics 189, 192 (2002). ↩
• Alison Siskin, Cong. Research Serv., Treatment of Noncitizens Under the Patient Protection and Affordable Care Act 4 (2011). ↩
• Guerrero, supra note 23, at 115–16 (footnote omitted). ↩
• Michelle Nicole Diamond, Legal Triage for Healthcare Reform: The Conflict Between the ACA and EMTALA , 43 Colum. Hum. Rts. L. Rev. 255, 298–99 (2011); see also Tim Rutten, Op-Ed., Immigration Reform and the Healthcare Debate , L.A. Times , Jan. 9, 2010, http://articles.latimes.com/2010/jan/09/opinion/la-oe-rutten9-2010jan09 (explaining how Los Angeles–area hospitals would be disproportionately impacted by cuts to the emergency medical treatment program). ↩
• Emily Deruy, Healthcare Overhaul Would Cause Longer Emergency Room Lines for Some Immigrants , ABC News (Sept. 25, 2012), http://abcnews.go.com/ABC_Univision/Politics/longer-emergency-room-lines-undocumented-immigrants-affordible-care/story?id=17321383 . ↩
• Michael Hoefer et al., Office of Immigration Statistics, Estimates of the Unauthorized Immigrant Population Residing in the United States: January 2011 , at 4 (2012). ↩
• See Justin Hess, Comment, Nonimmigrants, Equal Protection, and the Supremacy Clause , 2010 B.Y.U. L. Rev. 2277, 2278. ↩
• Id. at 2287. ↩
• See, e.g. , Ill. Health Matters, Immigrants and the ACA : A Primer 1, http://illinoishealthmatters.org/wp-content/uploads/2012/09/Immigrants-and-the-ACA-1.pdf (last visited June 30, 2013); see also Nathan Cortez, Embracing the New Geography of Health Care: A Novel Way to Cover Those Left out of Health Reform , 84 S. Cal. L. Rev. 859, 889 (2011). ↩
• Nat’l Immigration Law Ctr., “Lawfully Present” Individuals Eligible Under the Affordable Care Act 1, 6 (2012), www.nilc.org/document.html?id=809. ↩
• Siskin , supra note 28, at 7–8. ↩
• Howard F. Chang, Immigration Policy, Liberal Principles, and the Republican Tradition , 85 Geo. L.J. 2105, 2109 (1997). ↩
• See Diamond, supra note 30, at 275–78. ↩
• Id. at 277. ↩
• Cortez, supra note 35, at 870 (footnotes omitted). ↩
• See Sarah Kliff & Ezra Klein, Individual Mandate 101: What It Is, and Why It Matters , Wash. Post , Mar. 27, 2012, http://www.washingtonpost.com/blogs/wonkblog/post/individual-mandate-101-what-it-is-why-it-matters/2011/08/25/gIQAhPzCeS_blog.html . ↩
• The U.S. Department of Health and Human Services recently issued a rule clarifying that individuals granted deferred action were not considered “lawfully present” under the law.  Robert Pear, Limits Placed on Immigrants in Health Care Law , N.Y. Times , Sept. 17, 2012, http://www.nytimes.com/2012/09/18/health/policy/limits-placed-on-immigrants-in-health-care-law.html . ↩
• Maggie Mertens, Health Care for All Leaves 23 Million Uninsured , NPR (Mar. 24, 2010, 10:37 AM), http://www.npr.org/blogs/health/2010/03/health_care_for_all_minus_23_m.html . ↩
• See supra notes 30, 38, and accompanying text. ↩
• Jennifer Ludden, Health Care Overhaul Ignores Illegal Immigrants , NPR (July 8, 2009, 12:00 AM), http://www.npr.org/templates/story/story.php?storyId=106376595 . ↩
• This Paper utilizes a narrow approach to legislative history, following the example of Lee Epstein & Gary King, The Rules of Inference , 69 U. Chi. L. Rev. 1, 75 (2002).  See Janet L. Dolgin & Katherine R. Dieterich, When Others Get Too Close: Immigrants, Class, and the Health Care Debate , 19 Cornell J.L. & Pub. Pol’y 283, 312–14 (2010) for a broader view of the ACA ’s legislative history with respect to the undocumented. ↩
• House Democrats Announce Health-Care Bill , Wash. Post , Oct. 29, 2009, ST2009102902154 " target="_blank" rel="noopener noreferrer">http://www.washingtonpost.com/wp-dyn/content/article/2009/10/29/AR2009102902240.html?sid= ST2009102902154 . ↩
• See, e.g. , id . (“It is with great pride and with great humility that we come before you to follow in the footsteps of those who gave our country Social Security and then Medicare and now universal, quality, affordable health care for all Americans.”) (statement of Rep. Nancy Pelosi); id. (“[W]e’re here at a historic time, when for over half a century a family elected by their citizens to come to this Congress have raised the banner of health care for all that they could afford.”) (statement of Rep. Steny Hoyer); id . (“47 million Americans who do not have health care will be grateful for this day . . . . This bill offer [sic] everyone, regardless of income, age, sex, health status, the peace of mind in knowing that they will have real access to quality, affordable health insurance when they need it.”) (statement of Rep. John Dingell). ↩
• Id. ; Who Are the Uninsured? , N.Y. Times , Aug. 23, 2009, http://prescriptions.blogs.nytimes.com/ 2009/08/23/who-are-the-uninsured . ↩
• E.g. , 155 Cong. Rec. H12 ,623, H12 ,848 (daily ed. Nov. 7, 2009) (“[T]his bill will do for America what we should have done 100 years ago: provide health care for all Americans as a matter of right, not as a matter of privilege.”) (statement of Rep. Braley); 155 Cong. Rec. H12 ,598, H12 ,619 (daily ed. Nov. 7, 2009) (“Every American deserves the promise of quality affordable health care, and this is our moment to fulfill that promise.”) (statement of Rep. Langevin); id. at H12 ,621 (“Let me be absolutely clear: every single American should have access to affordable and quality health-care coverage.”) (statement of Rep. Ackerman). ↩
• E.g. , 155 Cong. Rec. H12 ,623, H12 ,844 (daily ed. Nov. 7, 2009) (“We are creating a new health insurance marketplace and requiring everyone to have coverage, which I support.”) (statement of Rep. Frank); 155 Cong. Rec. H12 ,598, H12 ,611 (daily ed. Nov. 7, 2009) (“[I]t is clear that Congress needs to make reforms to expand health care coverage so that everyone in this great Nation has health insurance.”) (statement of Rep. Diaz-Balart); id. at H12 ,614 (“Six principles have guided my work and determined my vote on this legislation: health insurance reform must create stability, contain costs, guarantee choice, improve quality, cover everyone, and include a strong public option.  The Affordable Health Care for America Act delivers on each of these principles.”) (statement of Rep. Heinrich). ↩
• 155 Cong. Rec. H12 ,623, H12 ,851 (daily ed. Nov. 7, 2009) (“This bill cuts healthcare for our seniors by hundreds of billions of dollars while providing subsidized health care of illegal immigrants, which will draw more illegals into our country.”) (statement of Rep. Rohrabacher); id. at H12 ,870 (“As if that wasn’t enough, the bill opens the floodgates of taxpayer money for illegal immigrants to abuse the system and obtain free government health insurance—all on the backs of law-abiding Americans.”) (statement of Rep. Rogers). ↩
• Representative Holt stated, Another myth is that health reform would provide federal benefits for undocumented aliens. Undocumented immigrants currently may not receive any federal benefits except in specific emergency medical situations. There are no provisions in the House health reform bill that would change this policy. In fact, the legislation explicitly states that federal funds for insurance would not be available to any individual who is not lawfully present in the United States. ↩
• 155 Cong. Rec. H12 ,598, H12 ,620 (daily ed. Nov. 7, 2009) (emphasis added). ↩
• Id. at H12 ,615. ↩
• 155 Cong. Rec. H12 ,623, H12 ,899 (daily ed. Nov. 7, 2009). ↩
• Biden & Obama, supra note 2. ↩
• See Bryan J. Leitch, Comment, Where Law Meets Politics: Freedom of Contract, Federalism, and the Fight Over Health Care , 27 J.L. & Pol. 177, 178 (2011). ↩
• See Lance Gable, The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights , 39 J.L. Med. & Ethics 340, 342 (2011). ↩
• See id. ; David U. Himmelstein & Steffie Woolhandler, Op-Ed, I Am Not a Health Reform , N.Y. Times , Dec. 15, 2007, http://www.nytimes.com/2007/12/15/opinion/15woolhandler.html (dis­cuss­ing President Nixon’s healthcare reform bill). ↩
• For example, see W. John Thomas, Play It Again, Hillary: A Dramaturgical Examination of a Repeat Health Care Plan Performance , 19 Stan. L. & Pol’y Rev. 283, 290 (2008), for a brief overview of the 1993 Health Care Reform Plan. ↩
• Adam Clymer, Hillary Clinton Courts Four Senators Backing Rival Health Care Proposal , N.Y. Times , Oct. 30, 1993, http://www.nytimes.com/1993/10/30/us/hillary-clinton-courts-four-senators-backing-rival-health-care-proposal.html . ↩
• See Health Care Reform May Leave Out Undocumented Aliens , 70 No. 35 Interpreter Releases 1195, 1195 (1993). ↩
• E.g. , 155 Cong. Reg. H12,598, H12 ,607 (daily ed. Nov. 7, 2009) (“Millions of illegal immigrants will receive taxpayer subsidies for enrollment in subsidized health care plans [under the initial House version of the ACA ].”) (statement of Rep. Posey); id. at H12 ,615 (“This massive government takeover of our health care still allows the 20 million people in this country that are illegally here to get one of those fake Social Security cards without benefit of even a photo ID and get some of that free government health care that everybody else has to pay for.”) (statement of Rep. Poe); 155 Cong. Rec. H12 ,623, H12 ,870 (daily ed. Nov. 7, 2009) (statement of Rep. Rogers); see also Dolgin & Dieterich, supra note 47, at 284. ↩
• 155 Cong. Rec. H12 ,623, H12 ,870 (daily ed. Nov. 7, 2009) (statement of Rep. Rogers). ↩
• See Julia Preston, Health Care Debate Focuses on Legal Immigrants , N.Y. Times , Nov. 3, 2009, http://www.nytimes.com/2009/11/04/health/policy/04immig.html . ↩
• Eduardo Porter, Illegal Immigrants Are Bolstering Social Security With Billions , N.Y. Times , Apr. 5, 2005, http://www.nytimes.com/2005/04/05/business/05immigration.html . ↩
• Nina Bernstein, Tax Returns Rise for Immigrants in U.S. Illegally , N.Y. Times , Apr. 16, 2007, http://www.nytimes.com/2007/04/16/nyregion/16immig.html . ↩
• Juliet Lapidos, Editorial, The 47 Percent , N.Y. Times (Sept. 18, 2012, 11:47 AM), http://takingnote.blogs.nytimes.com/2012/09/18/the-47-percent . ↩
• Brian Palmer, Exactly How Many Americans Are Dependent on the Government? , Slate (Sept. 18, 2012, 1:07 AM), http://www.slate.com/articles/news_and_politics/explainer/2012/09/romney_says_47_percent_of_americans_receive_direct_government_assistance_is_that_true_.html . ↩
• Cong. Budget Office, Immigration Policy in the United States 8 (2006) . ↩
• See Damien Cave, Better Lives for Mexicans Cut Allure of Going North , N.Y. Times , July 6, 2011, http://www.nytimes.com/interactive/2011/07/06/world/americas/immigration.html . ↩
• See , e.g. , Dayna Bowen Matthew, The Social Psychology of Limiting Healthcare Benefits for Undocumented Immigrants—Moving Beyond Race, Class, and Nativism , 10 Hous. J. Health L. & Pol’y 201, 204 (2010) (“[W]e know empirically that the sole or primary motivation to immigrate to the United States is not to participate in the healthcare system.”).  Matthew also posits a public health reason for extending health insurance coverage to all noncitizens: preventing the spread of treatable, communicable diseases.  See id. at 203. ↩
• See Michael Muskal, Illegal Immigration to U.S. Stays Down, Pew’s Latest Numbers Show , L.A. Times , Dec. 6, 2012, http://www.latimes.com/news/nation/nationnow/la-na-nn-pew-illegal-immigration-down-20121206,0,4267690.story (“The number of illegal immigrants in the U.S., which stood at about 8.4 million in 2000, peaked at about 12 million in 2007 and has been tapering since . . . .”). ↩
• Further, the Mexican economy has improved in the last few years, dissuading many Mexicans from leaving home to enter the United States.  See Cave, supra note 75.  Some, however, also credit increased enforcement efforts with the decrease in the U.S. undocumented population.  Matthew, supra note 76, at 202. ↩
• See Christopher M. Hughes, Op-Ed, Health Care for All: Expanding Medicaid Would Save Lives, Suffering and Money , Pittsburgh Post-Gazette (Oct. 4, 2012, 12:17 AM), http://www.post-gazette.com/stories/opinion/perspectives/health-care-for-all-expanding-medicaid-would-save-lives-suffering-and-money-656060 . ↩
• Ludden, supra note 46. ↩
• Patrick J. Glen, Health Care and the Illegal Immigrant 58 (Georgetown Pub. Law & Legal Theory Research Paper No. 12-024, 2012). ↩
• E.g. , James C. Capretta, Obamacare: Impact on Future Generations , Heritage Found. (June 1, 2010), http://www.heritage.org/research/reports/2010/06/obamacare-impact-on-future-generations . ↩
• See Ezekiel J. Emanuel, Op-Ed, Saving by the Bundle , N.Y. Times (Nov. 16, 2011, 7:55 PM), http://opinionator.blogs.nytimes.com/2011/11/16/saving-by-the-bundle ; see also Ann Weilbaecher, Immigrant Health Care: Social and Economic Costs of Denying Access , 17 Annals Health L. 337, 337–38 (2008); Ludden, supra note 46. ↩
• See, e.g. , 155 Cong. Rec. H12 ,598, H12 ,616 (daily ed. Nov. 7, 2009) (“[T]oo many people in America are uninsured, 47 million.  Well, subtract from that 47 million illegal aliens which will be funded under this bill, immigrants, those that qualify for Medicaid and other government programs, employer programs that make over ,000 a year, now you’re down to really only 12.1 million Americans who are without affordable options.  That is less than 4 percent of America.  And for that you would throw out the liberty of America, throw out the baby with the bathwater of the best health insurance industry in the world, the best health care delivery system in the world, destroyed by a desire to create a dependency society to steal our freedom.”) (statement of Rep. King). ↩
• For support of this theory, see Dolgin & Dieterich, supra note 47, at 312–13. ↩
• See supra note 52 and accompanying text. ↩
• See Biden & Obama, supra note 2. ↩
• See supra notes 63–65 and accompanying text. ↩
• See supra note 53 and accompanying text. ↩
• See John F. Manning, The New Purposivism , 2011 Sup. Ct. Rev. 113, 172 (cautioning against over-analyzing the breadth of a term used in the legislative history such as “substantially all”). ↩
• See supra note 84. ↩
• Dolgin & Dieterich, supra note 47, at 311–25. ↩
• Black-White Conflict Isn’t Society’s Largest , Pew Res. Ctr. (Sept. 24, 2009), http://www.pewsocialtrends.org/2009/09/24/black-white-conflict-isnt-societys-largest . ↩
• See Matthew, supra note 76, at 222 (discussing the “Us-Them dichotomy” espoused by many “in-group” Americans). ↩
• See id. at 201 (quoting Otis L Graham, The Unfinished Reform: Regulating Immigration in the National Interest , in Debating American Immigration, 1882–Present 89, 91 (2001)). ↩
• Dolgin & Dieterich, supra note 47, at 285 (“[I]mmigrants—especially undocumented, Hispanic immigrants—have become scapegoats on which social discontent and economic anxiety are displaced.”).  See generally Mark Hugo Lopez et al., Pew Hispanic Ctr., Illegal Immigration Backlash Worries, Divides Latinos (2010) (explaining how animosity towards the undocumented has led to Latinos fearing prejudice and discrimination based on their ethnic characteristics, regardless of their immigration status). ↩
• See, e.g. , Olga Popov, Note, Towards A Theory of Underclass Review , 43 Stan. L. Rev. 1095, 1099 (1991). ↩
• Matthew, supra note 76, at 202. ↩
• See Dolgin & Dietrich, supra note 47, at 312–14, for a discussion suggesting that the ACA ’s proponents neglected to include the undocumented in the bill because it would be “politically explosive.” ↩
• See supra note 58 and accompanying text identifying the dearth of legislative history regarding reasons for giving reduced protections for these two groups under the ACA . ↩
• Most conceptions of comprehensive immigration reform include a path to citizenship for at least some portion of the undocumented community.  See Understanding Immigration Reform , N.Y. Times , Dec. 9, 2012, http://www.nytimes.com/roomfordebate/2012/12/09/understanding-immigration-reform ; see also Preston, supra note 69 (“‘We are not trying to expand health care coverage to illegal immigrants through this legislation,’ said Senator Jeff Bingaman, Democrat of New Mexico.  ‘That will have to be dealt with through comprehensive immigration reform.’”). ↩
• See supra note 36. ↩
• See Editorial, Inching Toward Immigration Reform , Wash. Post , Nov. 30, 2012, http://www.washingtonpost.com/opinions/inching-toward-immigration-reform/2012/11/30/3a016b70-38e0-11e2-8a97-363b0f9a0ab3_story.html . ↩
• See, e.g. , supra note 43 and accompanying text. ↩
• See Matthew, supra note 76, at 225. ↩

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Argumentative Essay On Universal Healthcare

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• Gawande, Atul. “The United States Can Achieve Universal Health Care Without Dismantling the Existing Health Care System.” Universal Health Care . Detroit: Greenhaven Press, 2010. 190.
• Jackson Jr., Jesse L. “The United States Should Guarantee the Right to Health Care Through a Constitutional Amendment.” Grover, Jan. Healthcare . Detroit: Greenhaven Press, 2007. 28.
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What the Health-Care Debate Is Really All About

Published January 19, 2010

The Public Discourse

By James C. Capretta

It’s not unusual for political and legislative battles in the nation’s capital to be sharply partisan. But even by Washington standards, the health-care debate has been exceptionally contentious and polarizing. The bills that have passed in the House and the Senate are supported almost exclusively by Democrats, and Congressional Republicans are nearly unanimous in the view that these bills merit their total and unyielding opposition (so far, only one House Republican has voted for the Democratic proposals). Both sides are waging the fight with such an extreme take-no-prisoners attitude that even long-time Washington observers have been taken aback by the intensity of the struggle.

All of this political fighting can be disconcerting to average citizens. Why, on an issue that is plainly so important, can’t our nation’s elected leaders check their politics at the door and work out an agreement that elicits broad-based support instead of war-room like campaigns to prevail over their opponents?

The answer is that the disagreement over what must be done to improve American health-care is profound and largely irreconcilable. This isn’t your usual, run-of-the-mill political fight. The two sides hold diametrically opposed views that simply do not easily allow for compromise. Moreover, the outcome of the battle will be highly consequential, not just for our system of financing and delivering health-care, but also for our economy and democratic processes. In short, the stakes are very, very high, and both sides know it.

Many people suppose that the heart of the disagreement is over whether or not to expand coverage to more people. It is, of course, a primary objective of the Democratic sponsors of the current initiative to ensure that every American, or nearly so, is enrolled in some kind of health insurance plan on a continuous basis.

But Republicans are not opposed to expanding coverage to the uninsured. In 2008, presidential candidate John McCain proposed a plan which would have provided to every American household a tax credit which could only be used to purchase a health insurance policy. It was, in a very real sense, a “universal coverage” plan in that it sought to ensure that every American would have the financial wherewithal, provided by the federal government, to acquire some level of health insurance protection. The issue, then, is not over expanding coverage to all.

No, the real sticking point between the two sides is over how to allocate resources in the health-care sector. Both sides agree that the status quo is unsustainable, largely because costs are rising much more rapidly than wages or governmental revenues. The crucial question is what to do about the problem. Put differently, the question health-care reform advocates must answer is this: what process will be put in place to bring about continual improvement in the productivity and quality of patient care? That might strike some as more of a technical question than one of fundamental importance.  But, in reality, it’s just another way of saying that resources are scarce and must be allocated in some fashion. The only way to slow rising costs without lowering the quality of care provided is to improve the efficiency of the interactions between doctors and hospitals and those they care for. The question before policymakers is what reforms are most likely to lead to better care at less cost.

The Obama administration believes a governmental process is the answer. There are a series of provisions in the House and Senate bills which try to use the leverage of Medicare payment policy to force doctors and hospitals to change how they practice medicine. For instance, there are penalties for hospitals that have too many of their patients readmitted for care, and for physicians who are outliers in terms of how many services they render for certain diagnoses.

Other reforms are introduced as pilot programs that might be expanded later. In addition, the Senate bill picks up on the idea pushed by the administration to set up an independent Medicare commission which would make ongoing recommendations for cost-cutting in the program through provider-payment reforms. Congress could not reject the commission’s proposals without substituting ideas that achieve similar levels of savings, but the commission couldn’t make any recommendations that alter any aspect of the program other than payment policies for providers of services.

Some of these reforms might actually work and marginally improve matters from the status quo. But would they fundamentally change Medicare, much less the rest of American health care? No, they wouldn’t.

The Congressional Budget Office (CBO) projects that relatively small savings will result from the Medicare commission idea, and even smaller amounts will be saved by the other reforms touted by the administration. In ten years’ time, even if all of the ideas were fully implemented, Medicare and the rest of American health-care would look and operate largely as it does today, which is to say as a fee-for-service insurance model that rewards volume and fragmentation, not integration and efficiency. Adding tens of millions of people to an unreformed system will only exacerbate rising costs, putting even more pressure on the federal budget as well as household incomes.

Proponents of a governmental process have an unbounded confidence in the ability of the federal government to centrally plan and control an extremely complex sector of the American economy. But there is nearly a half century of experience with the Medicare program indicating that this confidence is entirely misplaced.

There have been countless efforts over the years to measure quality and  set payments in the Medicare program accordingly to encourage patients to see the doctors and go to the hospitals that are the most efficient and provide the best care. Most of the ideas have been tested in demonstration programs, or floated as legislative initiatives. But virtually none of them have gone anywhere.

Why? The answer is simple: Politicians are incapable of building what amounts to a government-administered “preferred provider network.” They simply can’t pick one hospital over another, or one physician practice over another, because that implies that some physicians or hospitals in their districts are inferior. And that’s just not something an elected official ever wants to do.

So, instead, they prefer to hit spending targets with across-the-board payment-rate reductions which treat all licensed providers equally.Every hospital, doctor, and other service provider gets cut the same, without regard to any measure of how well or badly they treat patients. That’s been the history of the Medicare program, and, in fact, that’s how the current Congress plans to achieve most of the $500 billion in Medicare savings in the health-care bills.

But these kinds of arbitrary price controls are also very dangerous for the quality of American medicine. They drive out willing suppliers of services, after which the only way to balance supply and demand is with waiting lists and rationing of care. That’s why so many other countries have months-long waits for expensive care. They control costs by artificially holding down prices with government regulation. And they pay the price “off-budget” by making their citizens wait for care they would rather access much more quickly.

That’s the big danger of the health-care bills being drafted in Congress. They would put the federal government in the cost-control driver’s seat, and all experience indicates that will lead, in time, to arbi trary price setting and rationing.

There is an alternative to this kind of governmental process. It involves building a real marketplace, one where cost-conscious consumers choose between competing insurers and delivery systems based on price and quality. The government can and should play an important oversight role in such a reformed system. But the difficult organizational changes and innovations necessary to provide better care at lower cost would come from those delivering the services, not Congress, or the Department of Health and Human Services, or even an independent commission.

The new Medicare prescription drug benefit was constructed just this way when it was enacted in 2003. Beneficiaries get a fixed dollar entitlement that they can use to buy coverage from a number of different competing plans. The insurers understand that they have to keep costs down to attract price-sensitive enrollees. And the government has no role in setting premiums or drug prices.

And how is it working? Costs have come in forty percent below original expectations.

Opponents of a market-based reform argue that it is impossible to reconcile price-based allocation of health services with equity. But that is not true. In the Medicare drug program, low-income seniors get additional help to pay for their prescriptions through a special funding stream. And all indications are that poor seniors are getting what they need from the program.

The country faces a choice here. We can choose to rely entirely on the federal government to allocate resources in the health-care sector, or we can choose to let consumers and suppliers make decisions in a decentralized marketplace with the government providing oversight and enforcing consumer protections. There is an irreversible aspect to this decision, whenever it is made, which perhaps explains why it has been delayed so long in our political processes. Once we finally decide, definitively, to head down one of these paths, it will be very difficult to change course later and go the other way. Which is why all concerned are bringing to the current fight in Congress every resource they can muster to prevail.

James C. Capretta is a fellow at the Ethics and Public Policy Center.

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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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Astrakhan State Medical Academy

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Founded in 1918, the Astrakhan State Medical Academy is a non-profit public higher education institution located in the large city of Astrakhan (population range of 500,000-1,000,000 inhabitants), Astrakhan Oblast. Officially recognized by the Ministry of Health of the Russian Federation, Astrakhan State Medical Academy (ASMU) is a small-sized (uniRank enrollment range: 3,000-3,999 students) coeducational Russian higher education institution. Astrakhan State Medical Academy (ASMU) offers courses and programs leading to officially recognized higher education degrees such as bachelor's degrees, master's degrees and doctorate degrees in several areas of study. See the uniRank degree levels and areas of study table below for further details. This 105-year-old Russian higher-education institution has a selective admission policy based on entrance examinations and students' past academic records and grades. ASMU also provides several academic and non-academic facilities and services to students including a library, as well as administrative services.

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Fields of Study and Degree Levels Matrix

The following Astrakhan State Medical Academy's Fields of Study/Degree Levels Matrix is divided into 6 main fields of study and 4 levels of degrees, from the lowest undergraduate degree to the highest postgraduate degree. This matrix aims to help quickly identify Astrakhan State Medical Academy's academic range and degree level offering.

This University offers courses in at least one of the following subjects:

• Applied Arts
• Museum Studies
• Performing Arts
• Religion and Theology
• Visual Arts
• Other Arts & Humanities Studies
• Accounting / Finance
• Anthropology / Archaeology
• Business / Commerce / Management
• Communication and Media Studies
• Development Studies
• Library and Information Science
• Physical Education / Sport Science
• Political and International Studies
• Social Policy / Public Administration
• Social Work
• Sociology / Psychology
• Tourism / Hospitality
• Other Business & Social Science Studies
• Aboriginal / Indigenous People Studies
• African Studies
• American & Caribbean Studies
• Ancient and Modern Languages
• Asian Studies
• English Studies
• European Studies
• French Studies
• Germanic Studies
• Indian / South Asian Studies
• Italian Studies
• Middle Eastern Studies
• Portuguese Studies
• Russian / Eastern European Studies
• Spanish Studies
• Other Language & Cultural Studies
• Anaesthesia
• Biomedical Science
• Dermatology
• Medicine / Surgery
• Natural / Alternative Medicine
• Obstetrics / Gynaecology
• Optometry / Ophthalmology
• Orthopaedics
• Otorhinolaryngology
• Radiography
• Speech / Rehabilitation / Physiotherapy
• Other Medical & Health Studies
• Aeronautical Engineering
• Agricultural Engineering
• Architectural Engineering
• Biomedical Engineering
• Chemical Engineering
• Civil and Environmental Engineering
• Computer and IT Engineering
• Electronic and Electrical Engineering
• General Engineering
• Geological Engineering
• Industrial Engineering
• Mechanical / Manufacturing Engineering
• Mining and Metallurgical Engineering
• Other Engineering Studies
• Agriculture / Forestry / Botany
• Aquaculture / Marine Science
• Architecture
• Biology / Biochemistry / Microbiology
• Computer / Information Technology
• Energy / Environmental Studies
• Food Science
• Mathematics / Statistics
• Neuroscience
• Pharmacy / Pharmacology
• Textiles and Fibre Science
• Zoology / Veterinary Science
• Other Science & Technology Studies

Notice : please contact or visit the university website for detailed information on Astrakhan State Medical Academy's areas of study and degree levels currently offered; the above matrix may not be complete or up-to-date.

Programs and Courses

Courses and programs.

Click here to explore a list of Astrakhan State Medical Academy courses and programs or, if not available yet, search for them with our Search Engine powered by Google. We are constantly adding university courses and programs worldwide with the cooperation of university representatives.

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Tuition Fees

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Yearly Tuition Fees Range Matrix

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Notice : please contact the university's Admission Office for detailed information on Astrakhan State Medical Academy's yearly tuition fees which apply to your specific situation and study interest; tuition fees may vary by program, citizenship/residency, study mode (i.e. face to face or online, part time or full time), as well as other factors. The above matrix is indicative only and may not be up-to-date.

Applying for admission is the first step towards achieving students' academic and career goals and accessing the many opportunities and resources that a university has to offer. Read our " Introduction to University Admissions " article to learn more.

Admission Information

uniRank publishes below some basic Astrakhan State Medical Academy's admission information.

Gender Admission

This institution admits Men and Women (coed).

Admission Selection

Has Astrakhan State Medical Academy a selective admission policy? Yes, based on entrance examinations and students' past academic records and grades.

Admission Rate

Astrakhan State Medical Academy's acceptance rate range is not reported.

International Students Admission

International students are welcome to apply for admission at this institution.

Admission Office

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Notice : admission policy and acceptance rate may vary by areas of study, degree level, student nationality or residence and other criteria. Please contact Astrakhan State Medical Academy's Admission Office for detailed information on their admission selection policy and acceptance rate; the above information may not be complete or up-to-date.

Size and Profile

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uniRank publishes below some major size and profile indicators for Astrakhan State Medical Academy.

Student Enrollment

Astrakhan State Medical Academy has an enrollment range of 3,000-3,999 students making it a small-sized institution.

Academic Staff

This institution has a range of 400-499 academic employees (Faculty).

Control Type

Astrakhan State Medical Academy is a public higher education institution.

Entity Type

Astrakhan State Medical Academy is a non-profit higher education institution.

Campus Setting

Not reported

Academic Calendar

Religious affiliation.

Astrakhan State Medical Academy does not have any religious affiliation.

Facilities and Services

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University Facilities

uniRank provides below an overview of Astrakhan State Medical Academy's main facilities:

University Library

University housing, sport facilities/activities, university services.

uniRank provides below an overview of Astrakhan State Medical Academy's main services:

Financial Aid

Study abroad, distance learning, academic counseling, career services.

Notice : please contact or visit the university website for detailed information on Astrakhan State Medical Academy's facilities and services; the information above is indicative only and may not be complete or up-to-date.

Recognition and Accreditation

There are different types of legal recognition and quality assessment of higher education institutions around the world, depending on the country and its legal and higher education system... read our article about university accreditation and recognition to learn more.

Institutional Recognition or Accreditation

Astrakhan State Medical Academy is legally recognized and/or institutionally accredited by: Ministry of Health of the Russian Federation

Specialized or Programmatic Accreditations

Not available; please use the Feedback/Error report form at the end of this page to submit a list of Astrakhan State Medical Academy's official programmatic or specialized accreditations. If you are an official representative of this university you can also claim and update this entire university profile free of charge (UPDATE ALL).

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Important : the above section is intended to include only those reputable organizations (e.g. Ministries or Departments of Higher Education) that have the legal authority to officially charter, license, register or, more generally, recognize Astrakhan State Medical Academy as a whole (institutional legal recognition), accredit the institution as a whole (institutional accreditation) or accredit its specific programs/courses (programmatic accreditation).

Memberships and Affiliations

University memberships and affiliations to external organizations can be important for several reasons... read our article about university affiliations and memberships to learn more.

Affiliations and Memberships

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Academic Structure

Academic divisions can provide valuable insights into the range of fields of study and disciplines a University focuses on and the institution's level of specialization. Comprehensive or Generalist Universities typically offer a wide range of academic programs and have many academic divisions and subdivisions across different disciplines, while Specialized Universities tend to focus on a narrower range of programs within a specific field or industry and have fewer academic divisions and a simplified organizational structure. Read our guide article " Understanding Academic Divisions in Universities - Colleges, Faculties, Schools " to learn more about academic divisions and typical university organizational structures.

Not available; please use the Feedback/Error report form to submit a list of Astrakhan State Medical Academy's official first-level academic divisions. If you are an official representative you can also claim and update this entire university profile free of charge (UPDATE ALL).

Social Media

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uniRank publishes brief reviews, rankings and metrics of some Astrakhan State Medical Academy's social media channels as a starting point for comparison and an additional selection tool for potential applicants.

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Free online courses, open education global.

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Astrakhan Oblast

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This chapter presents all basic political, economic, and demographic data on a territorial unit of the Russian Federation, Astrakhan Oblast. Astrakhan Kingdom was conquered by Ivan the Terrible and integrated into the Russian state in 1556. The region’s economy peaked during the first decade of the 20th century following the construction of the Trans-Caspian Railroad and the development of the Baku oil fields. Astrakhan Governor Anatolii Guzhvin is one of the few governors in power who were originally appointed to the post by President Boris Yeltsin in 1991 when the institution was created. Despite Guzhvin’s ties to Moscow, his loyalty to Astrakhan is greater than any sense of obligation he feels toward the federal government. Guzhvin is critical of the federal government’s fiscal policies toward the regions. Elections to the Astrakhan Oblast legislature were held in October 1997, yielding assembly dominated by independents with a small representation of Communists.

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Astrakhan Oblast, Russia

The capital city of Astrakhan oblast: Astrakhan .

Astrakhan Oblast - Overview

Astrakhan Oblast is a federal subject of Russia, part of the Southern Federal District, situated in the Caspian Lowlands where the Volga River flows into the Caspian Sea. Astrakhan is the capital city of the region.

The population of Astrakhan Oblast is about 989,400 (2022), the area - 49,024 sq. km.

Astrakhan oblast flag

Astrakhan oblast coat of arms.

Astrakhan oblast map, Russia

Astrakhan oblast latest news and posts from our blog:.

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History of Astrakhan Oblast

In ancient times, the territory of the Astrakhan region was crossed by trade routes of the Persians and the Arabs. In the 8th-10th centuries, the territory belonged to the Khazar Khanate. There is a hypothesis that Itil, the capital of the Khazar Khanate, was located on this territory. It was destroyed by Prince Svyatoslav in 965.

Later, Polovtsy settled on this land. In the first half of the 13th century, the Mongol-Tatars came to the area. After them, Tatars of the Astrakhan Khanate and Kazakhs became the main population of the region.

In 1556, during the reign of Ivan the Terrible, the Astrakhan Khanate was annexed to the Russian state and ceased to exist. Astrakhan krai became the southeastern military outpost of Russia. In particular, in 1569, the Turks unsuccessfully besieged the fortress of Astrakhan.

In the 17th century, trade, fishing and salt industries developed in the region. In the middle of the 17th century, the uprising of Stepan Razin took place on the territory of Astrakhan region. In 1722, near the mouth of the Kutum River, a shipyard called the Astrakhan Admiralty was built. In the 1730s-1740s, the processing of silk and cotton began here.

Astrakhan Oblast was created in 1943. The region gained its current borders in 1957.

Steppe landscapes of Astrakhan Oblast

Astrakhan Oblast scenery

Author: Dvornikov Mikhail

Steppe road in the Astrakhan region

Astrakhan Oblast - Features

Astrakhan Oblast is located in the south-east of the East European Plain within the Caspian Lowlands. It is an area of deserts and semi-deserts. Astrakhan oblast borders on the Volgograd region in the north, the Republic of Kalmykia in the west and Kazakhstan in the east.

It is located on the border between Europe and Asia, the Volga River gives access to five seas. The main cities of the region are Astrakhan (518,700), Akhtubinsk (35,500), Znamensk (25,700), Harabali (17,100).

The climate of Astrakhan Oblast is continental, dry. Winters are with little snow, frequent thaws and unstable snow cover; summers are hot. January is the coldest month, the average temperature is minus 10-20 degrees Celsius. July is the hottest month - the average temperature is plus 35-45 degrees Celsius.

According to the 2010 census, the ethnic composition of the local population is the following: Russians (67.6%), Kazakhs (16.3%) and Tatars (6.6%). Orthodox Christianity is the main religion. However, Muslims also make up a significant group of the population (more than 20%). Historically, this province was a place where Kazakhs and Tatars settled. The largest Kazakh community in Russia lives in the Astrakhan region.

Astrakhan Oblast views

Paved road in Astrakhan Oblast

Author: V.Kildushov

Camels in Astrakhan Oblast

Author: Viktor Grigoriev

The Volga-Don Shipping Canal in Astrakhan Oblast

Author: Kudanov Pavel

Astrakhan Oblast - Economy

Natural resources of the region include natural gas, oil, salt, gypsum.

The industrial complex of Astrakhan, the economic center of the region, includes shipbuilding, pulp and paper industry, fish processing industry. The leading industries are fuel industry, mechanical engineering, power engineering, food industry. Astrakhan gas condensate field, the largest in the European part of Russia, is located in the area. Astrakhan Gas Processing Plant produces gas for cars, diesel and boiler fuel.

Agricultural lands make up more than 3.4 million hectares - the cultivation of tomatoes, peppers, aubergines, courgettes, cucumbers, carrots, beets, onions, cabbage, watermelons. Rice is traditionally grown along the Volga. The leading branch of livestock is sheep breeding.

The region stretches for over 400 km in the form of a narrow stripe on both sides of the Volga-Akhtubinsk flood-lands. Flooded for a long time, the territory of the delta serves as spawning-ground for such fish as sturgeon, stellate sturgeon, white sturgeon and others.

Astrakhan oblast of Russia photos

Pictures of astrakhan oblast.

Lenin Monument in Astrakhan Oblast

Bridge in Astrakhan Oblast

Author: Anatoliy Martyshkin

Church in Astrakhan Oblast

Limanskiy Khurul - the only active Buddhist temple in Astrakhan Oblast

Limanskiy Khurul in Astrakhan Oblast

Author: Moskaluk Vitaly

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