Issue Date: September 23, 2005

Universal Health Care

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The U.S. is the only developed nation in the world that does not provide universal, taxpayer-supported health care to its residents. Instead, most Americans either pay for their own private coverage or use the insurance provided to them by their employers. Americans aged 65 and older are eligible for the government-run, publicly funded Medicare program; low-income Americans can receive health care from Medicaid, which is run by individual states and receives funding from states and the federal government. The remainder, however--a total of 44.7 million Americans, according to the Kaiser Commission on Medicaid and the Uninsured--are without any form of health insurance. An additional 16 million are insured, but lack the money to pay for medical bills.

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Dr. Robert Hernandez speaks with a patient at the Christus Coushatta Rural Health Center in Louisiana.

For the Americans who can afford it, health insurance is not a luxury but a necessity. Without it, costs of doctor's visits and prescription medicine can be dauntingly high, and extended hospital stays can prove to be financially ruinous to the uninsured. The high total of uninsured Americans is one of many oft-repeated statistics that have led some commentators to declare a health care crisis in the U.S.

Although Americans spent $5,267 per capita on health care expenditures in 2003--by far the highest such figure in the world--the performance of the U.S. health care industry is comparatively mediocre, according to the World Health Organization (WHO). The U.S. ranks 29th in the world in life expectancy and 37th in child mortality rates for children under five years old. "Basically, you die earlier and spend more time disabled if you're an American rather than a member of most other advanced countries," says the WHO's Christopher Murray, summing up his organization's findings.

Universal health care is a fact of life in many foreign countries, with varying degrees of success. Germany has had a universal health plan in place since Chancellor Otto van Bismarck introduced the concept in the late 19th century, an event that is often referred to as the birth of the welfare state. Canada's socialized health care is a source of civic pride for many of its residents, although a June 2005 ruling by the Canadian Supreme Court will allow privately owned insurance companies to compete with the government-sponsored system. (Currently, Cuba and North Korea are the only countries where it is illegal to purchase private health insurance.) Britain's National Health Service has been supplying free health care since 1948, although it is often criticized for being underfunded. Some have proposed that the U.S. too should have a universal health care system. [See 2005 Canada's Health Care System (sidebar)]

Jeremy Eagle

Supporters of a universal health insurance plan say that the U.S.'s health care shortcomings could be cured if coverage were extended to everyone in the country. A universal health care plan--also known as a single-payer plan, where the government is the "single payer" using tax dollars to pay the country's medical bills--would drastically reduce health care costs such as co-payments and deductibles, supporters assert.

The result of a universal health care plan in the U.S. would be more equitable treatment for the nation's poor, who cannot afford to buy private health care, supporters say. Many argue that the U.S., the richest country in the world, should not have a health care system that leaves 45 million people uninsured. Supporters also maintain that a universal health care system would simplify the complicated commercial system, eliminating the bureaucratic hoops that many Americans must jump through in order to see a doctor.

Those who oppose the idea of bringing universal health care to the U.S. often cite the aforementioned foreign countries as evidence that such a plan would not work. They note that patients in those countries often have to wait several weeks to see a doctor, because of lengthy waiting lists. Many residents of those countries complain of subpar medical care as well; because hospitals are not privately owned, they have no need to compete against each other to provide the best care at the cheapest prices, critics point out.

Critics of universal health care also express concern that allowing the federal government to control the nation's health insurance is another step toward socialism. Opponents caution that government should not be so big and powerful that it controls every aspect of people's lives.

Attempts to Bring Universal Health Care to the U.S.

There have been several serious, large-scale campaigns to introduce some form of universal health care into the U.S. since the start of the 20th century. Each time, however, the idea was ultimately defeated.

In 1915, when most laborers were not paid for days they could not work due to sickness, the American Associations for Labor Legislation (AALL) proposed the idea of compulsory health insurance for all workers in the U.S. The AALL's plan drew upon elements from various European health care programs, including Germany's. The idea garnered support from some politicians on the state level, but was eventually rejected by American Federation of Labor president Samuel Gompers, who argued that government-sponsored health care amounted to little more than a so-called nanny state.

A modified version of a universal health care plan was introduced in the 1930s, during the Great Depression. President Franklin Roosevelt (D, 1933-45) selected members of the Committee on the Costs of Medical Care (CCMC), a prominent medical reform group, to serve on two of his New Deal committees. Among the goals of those committees was to reform health care to meet the needs of a depressed economy. The CCMC advocated a universal health care system as a solution to the country's woes, but due to pressure from groups such as the American Medical Association (AMA), that plan had to be watered down in the New Deal committees. Eventually, Roosevelt, fearing retribution from the AMA and private insurance companies, completely excised health care reform from the Social Security Act of 1935.

Just a few years later, President Harry Truman (D, 1945-53) announced his strong support for a national medical insurance program. The Wagner-Murray-Dingell bill, which proposed to create a universal health care system by drawing money from Social Security payroll taxes, was drafted in 1943. But despite Truman's support, the bill did not pass; it also faltered in the next three Congresses. Some observers say the Wagner-Murray-Dingell bill failed to gain support because of an unprecedented public relations effort by the AMA, which warned of the "socialized" nature of the bill. Coupled with the U.S.'s growing fear over the Soviet Union and communism in general, the AMA's advertising campaign proved to be devastating.

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In September 1993, President Bill Clinton (D) displays a proposed national health plan card. His health care reform plan was widely opposed both by conservatives and liberals.

A similar public relations battle ensued during the debate on Medicare, a federally funded health care plan for the elderly that was first proposed during the presidency of John Kennedy (D, 1961-63). The AMA again bought radio and television advertising and organized letter-writing campaigns to turn public opinion against Medicare. Organized labor, however, countered the AMA with petition drives and letter-writing campaigns of their own, supporting the proposed system. Eventually, President Lyndon Johnson (D, 1963-69) signed the Social Security Amendments of 1965 into law, creating both Medicare and its companion program, Medicaid. [See 2003 Medicare and Medicaid Update]

During the struggle to get Medicare signed into law, the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO), a leading coalition of labor unions in the U.S., created a group called the National Council of Senior Citizens to lobby for Medicare's passage. That group, along with Sen. Edward Kennedy (D, Mass.) and the Committee for National Health Insurance (CNHI), worked throughout the 1970s to try to create a universal health care system. Eventually, however, the CNHI's plans lost steam as the U.S. slid into a recession and health care costs swelled.

By the 1990s, health care was again a hot topic in the U.S. following the election of President Bill Clinton (D, 1993-2001). His rise to the White House was due in part, observers say, to the emphasis he placed on sweeping health care reform during his campaign. Yet Clinton's health care bill, delivered to Congress in November 1993, was widely criticized by both liberals and conservatives.

Conservatives derided the plan as government-run health care, liberals argued that the plan made too many concessions to the private insurance industry, and both sides complained that the 1,400-page proposal was far too complex and confusing. Political experts now say that the failure of the Clinton health plan was one of the main reasons the Republicans dominated the midterm elections in 1994 and were able to seize control of Congress for the first time in 40 years.

Health Care Developments Under President Bush

Health care reform was a major theme of the 2000 presidential campaign of Texas Gov. George W. Bush (R) and his reelection campaign in 2004. He has made no secret, however, of his opposition to the idea of universal health care. "The fundamental question facing the country is, Can we have a health care system that is available and affordable without the federal government running it?" Bush told reporters in January 2005.

Since taking office in 2001, Bush has been active in his attempts to reform Medicare. In 2003, he signed into law the Medicare Prescription Drug Modernization Act. According to supporters, the $400 billion reform bill will allow senior citizens more choices. It will allow them to purchase important prescription medicine from a wider range of U.S. drug companies, as well as open the Canadian drug market to U.S. consumers, provided that the drugs they buy have been approved by the U.S. Food and Drug Administration. The act also includes subsidies to private insurance companies to make them more competitive with Medicare, a move that critics have described as being a roundabout way for Bush to dismantle the government-funded Medicare program. [See 2003 Prescription-Drug Pricing]

The Medicare Modernization Act also included a provision allowing for the creation of Health Savings Accounts (HSAs). Americans can now set aside pre-taxed income into their own private HSA, which can later be used to cover health costs. Employees can take their HSAs along as they move from job to job. Supporters tout HSAs as a way for small business owners to save money on providing health care to their employees. However, HSAs have been criticized for being accessible only to high-income workers who can afford to divert money into them.

Although Bush has said he does not support the idea of universal health care, he also maintains that he is not actively hostile toward government-funded health care programs, as some of his critics have alleged. During his 2004 presidential campaign, Bush pointed out that during his first term, enrollment in Medicaid and the Children's Health Insurance Program--a program designed for children of parents who are not poor enough to qualify for Medicaid yet cannot afford private health insurance--increased by 7.5 million.

Some observers, however, argue that this is not necessarily an encouraging development. "There were more low-income people under Bush than previously, so they became eligible for public programs," says Diane Rowland of the Kaiser Commission on Medicaid and the Uninsured. Some critics of the Bush administration have cited increasing poverty rates as proof of the necessity for universal health care. The number of Americans under the federal poverty level has increased by 9% since Bush took office.

Indeed, the large number of uninsured Americans has led some to declare a health care crisis in the U.S. "Large numbers of Americans have no health insurance at all, and those who do have insurance are faced with soaring premiums that threaten to make coverage unaffordable for individuals, families and employers," the editorial board of the New York Times writes. Reports have suggested that people across the U.S. are paying more money for less coverage. A Kaiser Family Foundation study on health care benefits for 2004 found that a smaller percentage of Americans are covered by job-based health care. The study further showed that, from 2003 to 2004, U.S. employers incurred a 12% increase in the cost of providing health benefits to their workers.

Many states have worked to provide health insurance to a wider range of residents. Montana, for instance, increased its tax on cigarettes to subsidize health care for underprivileged residents. Yet on a national level, universal health care seems unlikely in the near future, experts say. Still, universal health care has many vocal supporters--including groups such as Physicians for a National Health Program and the National Academy of Sciences--who remain active in promoting a plan that they say would increase the quality of life for millions of Americans. On the other side of the debate, critics remain adamantly opposed to the plan, which they say would give too much power to the federal government.

Supporters Tout Benefits of Universal Health Care

Supporters of a universal health care plan argue that insurance should not be a privilege enjoyed by some of the population--it should be a right extended to the entire population. Advocates point out that every other nation in the developed world extends some form of health care coverage to all of its citizens. Under the U.S.'s current system, nearly 45 million Americans are uninsured, amounting to 17.7% of the nonelderly population in the U.S. Furthermore, supporters point out that polls suggest that Americans want a universal health care system like Canada's.

Jeremy Eagle

According to universal health care proponents, the U.S.'s current commercial health care system, which consists mainly of private insurance companies selling job-based coverage, results in health care becoming just another commodity, no different than a sports car or a six-pack of cola. As Arnold Relman, the former editor of the influential New England Journal of Medicine, argues, to treat health care as if it were a simple commodity is to lose sight of what it is supposed to do. Relman writes:

Since patients usually know little about the technical aspects of medicine and are often sick and frightened, they cannot independently choose their own medical services in the way that consumers choose most services in the usual market.... [M]edical care is not really a 'market' at all in the classical economic sense, and therefore...the basic theories of economics are not relevant to the discussion of the first principles of health care.

In other words, proponents say, subjecting health insurance to the laws of the free market subverts the goal of providing affordable health care to as many people as possible. Therefore, they argue, it is necessary to remove health care from the market, and the best way to do that is for the government to simply provide insurance to every single American.

Backers of universal health coverage also say that the current U.S. health care system is far too expensive, which is why so many millions remain uninsured. (About one-third of the 45 million uninsured Americans live below the federal poverty level.) Those without health insurance "remain the powerless in a scary world where even a relatively minor illness or injury can mean economic disaster and where preventable medicine, like a physical checkup or blood test, is an unaffordable luxury," consumer advocate Ralph Nader writes. Universal coverage, by reducing bureaucratic red tape and streamlining administration, could save billions of dollars a year, supporters contend. The National Coalition on Health Care has declared that a publicly funded universal health care system could, in fact, save up to $1.1 trillion each year for the first 10 years of its existence.

Responding to critics' charges that a universal health care system would be unwieldy and inefficient, supporters of such a plan counter that the U.S. already has one of the least effective health care systems in the developed world. "Americans tend to believe that we have the best health care system in the world," writes New York Times columnist Paul Krugman. "But it isn't true. We spend far more per person on health care than any other country--75% more than Canada or France--yet rank near the bottom among industrial countries in indicators from life expectancy to infant mortality." The U.S. spends more than $1,000 per capita per year on paperwork and administrative tasks related to health care, while Canada spends about $300, supporters point out.

More proof that the current commercial health care system needs to be overhauled is found in the needless deaths and prolonged illnesses of the uninsured, advocates maintain. Each year, there are more than 18,000 deaths directly attributable to a lack of proper health insurance, according to a 2002 study by the Institute of Medicine. "Lack of health insurance is killing many more Americans than terrorism," journalist and activist Holly Sklar concluded.

The Institute of Medicine's study also found that uninsured Americans with colon or breast cancer are up to 50% likelier to die from their disease than insured persons; trauma victims are 37% likelier to die. Such statistics show that "in spite of its many impressive features, [the U.S.'s commercial health care system] has ultimately failed to make even basic care consistently available to all of our citizens," says William McGuire, the chief executive of the UnitedHealth Group, the largest private health insurance company in the U.S.

Finally, supporters maintain that universal health care systems can be successfully run--just look at Canada or France or Germany, they say. Indeed, many supporters point out that the U.S. itself has a popular single-payer health care system in the form of Medicare, which has been overwhelmingly embraced by senior citizens since its inception in 1965. Those who champion a universal health care system in the U.S. often cite Medicare as proof that such a plan could work.

Keep Health Care Privatized, Critics Urge

Opponents of universal health care--including economic conservatives, Bush administration officials and many representatives from private insurance companies--have warned that a move toward government-sponsored health care is a move toward socialism. While it may sound like a good idea, universal health coverage would actually eliminate consumer choice when it comes to health care, critics say. The federal government, by providing health care to all U.S. residents, would essentially control that aspect of people's lives, which opponents maintain is an unconscionable move toward bigger government. "Socialism by any other name is still socialism," writes Thomas Sowell, a senior fellow on public policy at the conservative Hoover Institution. Universal health care would just give the government another reason to raise taxes, opponents maintain.

Critics also allege that, far from being an antidote to the complex commercial U.S. health care system, a government-sponsored system would increase red tape and make receiving standard medical care markedly more difficult. "[I]t is a waste to have us drawn into a bureaucratic maze, in order to cover routine things like annual checkups or occasional antibiotics," Sowell writes. Opponents warn that a federal health care program, no matter how large, would be hard-pressed to provide speedy, high-quality care to all 295 million people living in the U.S.

As evidence, critics cite statistics from other countries that have national health care systems in place. Writing for the conservative National Review Online, Iain Murray, a native of Britain, says that his home country's National Health Service "provides below-par service. Sometimes the treatment can be excellent, but more often, you have to wait months or years for operations; equipment is outdated, and doctors are overworked." Patients seeking medical attention in countries such as Canada and Germany often must put their names on waiting lists before they can see a doctor. Critics also allege that the length of visits to doctors' offices tend to be shorter in countries with government-funded health care.

A June 2005 court ruling in Canada is further evidence that universal health care cannot work, opponents say. In that case, the Canadian Supreme Court reversed a long-standing policy when it decided that residents of the province of Quebec should be allowed to purchase private health insurance, even if that private insurance overlaps the coverage provided by Canada's national health care system. The written decision was a stern denunciation of the national system: "Access to a waiting list is not access to health care...[I]n some serious cases, patients die as a result of waiting lists," the court wrote.

Observers say they expect residents in other provinces to follow suit in demanding the option to buy private health care. The court's decision "ought to be an eye-opener for the U.S., where 'single-payer,' government-run health care is still a holy grail of the political left," the editorial board of the Wall Street Journal writes.

Responding to arguments that health care should not be treated as if it were a simple commodity, critics of universal health care maintain that the health care industry is indeed a business like any other. And, like any business where goods are sold, some people will simply be unable to afford those goods. "Health care isn't immune from the laws of economics," the Journal writes. "Politicians can't wave a wand and provide equal coverage for all merely by declaring medical care to be a 'right,' in the word that is currently popular on the American left." Indeed, because they exist within the framework of a free-market economy, private health insurance companies can compete with one another to provide the best product, and consumers reap the benefits, critics say.

Many of those opposed to the idea of universal health coverage dispute the notion that there is a health care crisis in the U.S., which universal health care advocates cite as proof that the current system needs to be reformed. Many pundits say that the oft-invoked figure of 45 million uninsured Americans is inflated due to the preponderance of "young, well-educated, healthy people, who are unlikely to get sick" and therefore choose not to buy insurance, according to libertarian Larry Elder. And, as he further argues, people who truly cannot afford health insurance can go on Medicaid, which was specifically designed for low-income Americans.

Even the controversy surrounding the supposed inefficiency of the U.S. health care system is overblown, opponents of universal health care say. Although it is true that the U.S. ranks relatively low in categories like infant mortality and life expectancy, critics say that those are not always reliable indicators of how successful health care is in a given country--nor are they compelling arguments for universal health care. David Gratzer of the conservative Manhattan Institute, writing in the Weekly Standard, says that although Mexicans in the U.S. have less access to health care than both Native Americans and African Americans, they have a lower infant mortality rate than either group. Gratzer also writes that 95% of women in the U.S. who are diagnosed with breast cancer have their tumor detected in the first two stages of the disease, compared with just 80% in Europe.

Universal Health Care in the U.S.: A Realistic Goal?

The debate over universal health care has remained a largely theoretical one since the Clinton health care plan failed in 1993. Few candidates for public office explicitly state that they favor government-sponsored health care. Notable exceptions include Rep. Dennis Kucinich (D, Ohio), who ran for the Democratic nomination for president in 2004, and Nader, who has been on the presidential ballot in each election year since 1996.

Still, health care reformers continue to press for universal coverage, which they say is the only way to ensure that everyone receives equitable health treatment, regardless of income bracket. Some state governments have attempted to pass universal health care bills. In Oregon, for example, petitioners are attempting to make universal health care a ballot initiative in 2008. State governments in California and Vermont are seriously debating the merits of universal health care.

Meanwhile, Bush's health care reforms have been met with a mixed reception from the public. HSAs have been slow to gain popularity with workers since going into effect in January 2005. The AARP, a lobbying group for older Americans, endorsed the Medicare Modernization Act, although AARP is pushing for improvements to it. Many other groups have expressed concern over the bill, which does not take full effect until 2006.

One reform measure Bush is unlikely to adopt, however, is universal health care. Experts say that the U.S. will likely remain the only developed nation without universal health care for years to come.

Discussion Questions & Activities

1) Why do you think the U.S. is the only developed country in the world without a universal health care plan?

2) Would you be willing to have to be put on a waiting list in order to see a doctor, even if the visit were paid for by the government? Why or why not?

3) Do you agree or disagree with the idea that universal health care would give the federal government too much influence over Americans' lives?

4) Would you ever vote for a presidential candidate who supported universal health care? Why or why not?

5) Compare the Canadian health care system with that of the U.S.: Which system do you think is better?

Bibliography

Freudenheim, Milt. "Some Tentative First Steps Toward Universal Health Care." New York Times, December 7, 2002, C1.

Fund, John. "Canada's 'Free' Health Care Has a High Price Tag." Wall Street Journal, August 12, 2005, A9.

Gratzer, David. "The Return of HillaryCare." Weekly Standard, May 23, 2005, 20.

Hoffman, Beatrix. "Health Care Reform and Social Movements in the United States." American Journal of Public Health, January 2003, 75.

"Japan 'The Most Healthy Country.'" BBC News Online, June 5, 2000, news.bbc.co.uk.

"Kerry vs. Bush on Health Care." New York Times, October 3, 2004, WK10.

Krugman, Paul. "Ailing Health Care." New York Times, April 11, 2005, A19.

Murray, Iain. "No, Not the NHS!" National Review Online, February 19, 2004, www.nationalreview.com.

Nader, Ralph. "Adding Insult to Injury." Sfbg.com, August 1, 2001, www.sfbg.com.

Relman, Arnold. "The Health of Nations." New Republic, March 7, 2005, 23.

Sklar, Holly. "Time for Health Care for All on Medicare's 40th Anniversary." Common Dreams, August 1, 2005, www.commondreams.org.

Sowell, Thomas. "Universal Health Care." Townhall.com, May 6, 2003, www.townhall.com.

Sowell, Thomas. "Universal Health Care: Part II." Townhall.com, May 7, 2003, www.townhall.com.

"Unsocialized Medicine." Wall Street Journal, June 13, 2005, A12.

Additional Sources

Additional information about universal health care can be found in the following sources:

Pipes, Sally. Miracle Cure: How to Solve America's Health Care Crisis and Why Canada Isn't the Answer. San Francisco: Pacific Research Institute, 2004.

Quadagno, Jill. One Nation, Uninsured: Why the U.S. Has No National Health Insurance. New York: Oxford University Press, 2005.

Key Words and Points

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Contact Information

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