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There have been a lot of debates and discussions recently, both on this forum and in other venues, about the state of healthcare. Looking at the rising costs of health insurance, and at the growing numbers of the uninsured, many are calling for government intervention, and the institution of a system where care is guaranteed to all - usually described as "universal" healthcare. It's a fascinating topic - the issues involved include humanitarian, financial and ideological ones. Unfortunately, debate on the subject is characterised by a startling phenomenon: one side is right, and the other is completely wrong.
Given the importance of medicine, I feel that it would be useful to clarify this issue. I will explain clearly, and with evidence, why it is that universal healthcare of any sort would be better than the current system in every significant way. If you find yourself disagreeing with this assertion, I ask that you read on before replying, as all conceivable objections will be addressed and resolved.
Why The Current Situation Is Bad
At the moment, healthcare in America is provided mostly by private entities, who charge high fees. These fees can be attributed largely due to the difficulty and expense of the medical profession, and although they are significantly higher(1) than those of similar nations this difference is only a small portion of healthcare costs. There then exists the health insurance industry, a loose network of corporations that charge individuals or organisations premiums and will pay for their health costs if any are incurred.
Unfortunately, this system has enormous problems. As of 2006(2), 44.8 million people in America do not have health insurance. Many are unable to afford it, many are denied coverage by insurers who believe that as customers they will not be economical, and others choose not to purchase it. Without health insurance, the up-front costs of health care are impossible for most people to afford. In fact, 50.35%(3) of all bankruptcies were caused, at least in part, by medical fees. In 2001, this was 2,038,549 bankruptcies.
Furthermore, health insurance does not fully cover medical expenses. Different insurers and different plans have many exemptions, co-pays, threshholds and other expense-minimising devices. As a result, 62%(4) of those two million bankruptcies occurred despite the debtors having health insurance coverage for the duration of their illness.
As well as failing to provide care, and driving individuals into bankruptcy, the existing system is also exorbitantly expensive. Health care spending is now 15%(5) of U.S. GDP - the highest in the world. The costs to businesses, who commonly pay premiums for their employees in lieu of salary, rose by 13.9%(6) in 2003. The annual cost increase has been above inflation since at least 1981. Paying more doesn't result in more value, either - obesity, diabetes, and similar disorders are more common in the United States than anywhere else in the developed world, the U.S. is ranked 72nd(7) in overall health, and life expectancy is below that of 41 other countries.(8)
What Is Universal Health Care?
Universal Health Care, or UHC, refers to a wide range of different systems, the common characteristic of which is that a nation's government guarantees all its citizens access to healthcare. Every developed nation (OECD member) in the world, apart from the United States, has a UHC system. There are three main types:
In a fully public system, there is no or little private healthcare, and the health insurance industry is not a significant one. Medical service providers are government employees, and the education of doctors is also subsidized. The most well known example of a fully public system is the original English NHS, although a private sector is now developing in the U.K. as well.
In an optional public, the government provides the same services, but a private health services industry also exists (generally regulated), and . Sometimes health insurers exist, used by people who prefer private services. This is the most common, and examples include Australia and Sweden.
In a subsidized private system, the government pays for health care, but it is provided by private entities. Either the government acts as a health insurer for the populace, or it pays the fees for private health insurers to do so. This is done in Canada.
For the purposes of discussion, I will be assuming the characteristics of an optional public system, like those used in most of Europe. However, the benefits of UHC apply to all of the above types of organization.
How UHC Will Improve Things
The single largest problem with healthcare in America is that many people don't have it. It's obvious how UHC solves this: by providing it to all citizens directly (or paying for it to be done). By definition, this is no longer a problem under UHC. All developed nations other than the United States make this guarantee to their citizens, and have so far been able to uphold it. The two reasons which make a person uninsurable - insurer decisions and lack of money - will no longer exist.
The second major problem with the current system is its high cost. This can be divided into two parts: individual cost, and government cost - which to the individual shows up as taxation. UHC is inherently cheaper - far cheaper - due to economies of scale, the bargaining position of monopolies with regard to drugs and salaries, reduced administrative costs, and the lack of a profit motive. When it comes to individual health care costs:
According to the World Health Organisation(9), average American individual spending on healthcare is $3371 per year. Since this includes the uninsured and those covered by their employers, actual costs are higher. For comparison:
Australia: $1017
Canada: $916
Sweden: $532
United Kingdom: $397
The first of those is the second-highest in the world - meaning that Americans pay, not including taxes, more than three times as much as citizens of any other nation. This would be somewhat justifiable if they received better healthcare, but again - 28% have no care at all, life expectancy is below all other developed nations, and general health rating is below all other developed nations.
It is commonly assumed that this difference in cost is because under UHC systems, higher taxes are required to fund the system. Not so. As mentioned, UHC is a great deal cheaper than private healthcare, and as a result America's health-related taxation is also the highest in the world. According to the OECD(10), in 2006, American government spending on healthcare was $2887 per person. For comparison:
Australia: $2106
Canada: $2338
Sweden: $2468
United Kingdom: $2372
American healthcare taxes are in fact the highest in the OECD, with France second at $2714. In conclusion, every single UHC system in the world costs less money for individuals, requires lower taxes, and provides better care to more people than the American health care system. By implementing UHC in the U.S., things can only get better.
Frequently Raised Objections
There are many incorrect arguments against the implementation of UHC in the United States. In order to better facilitate discussion, I will explain the errors found in the most common.
"America isn't Europe!", or It Won't Work Here
The argument from American exceptionalism states that what works in Europe will not work in the U.S. It's said that this is because European nations have more people in less space, resulting in less logistical difficulties, and because European government is more competent.
Firstly, not all developed nations are European. The most obvious example that counteracts the logistical argument is Australia, where there are 20 million people in only slightly less space than America's 300 million. This does indeed affect prices, as can be seen by comparing Australia to Sweden or the U.K. - but it doesn't bring them anywhere near the levels currently experienced in America.
The argument that American government is uniquely incompetent, and cannot do things that every other nation in the world can do, is simply nonsense. Not only has America, and American government, achieved many things that other countries have not, America has so many resources and the improvement in care and cost from moving to UHC is so large that even with incredible inefficiencies it would still be a good idea.
"It is immoral to force me to pay for others' healthcare."
You are already paying for others' healthcare. Furthermore, you are paying far more than you would be under UHC. The U.S. government incurs massive costs from paying hospital fees when ER visitors have no money, and from the limited coverage that it provides, which cannot take advantage of economies of scale and which has to subsidise corporate profit.
As demonstrated above, U.S. taxes devoted to healthcare are the highest in the world. Even if you choose not to have health insurance, under the current system, you are still paying more for others' healthcare than you would be paying for theirs plus your own under UHC.
"This is socialism."
It is not socialist to recognise that there is a service the free market is inefficient at providing, and to decide it should better be provided by the government. Even the most staunch libertarian admits that there are some services in this category, such as national defence.
Secondly, it is irrelevant whether this is a "socialist" policy; it's effective. It costs less and provides better care to more people, and as a result is used literally everywhere else in the entire world. Those who want to ensure that society remains ideologically committed to market capitalism need to look for other issues, as if they cling to this one they will only end up providing evidence against their position.
"I don't want more government bureaucracy."
UHC will involve much less bureaucracy than is commonly assumed, as it can replace the existing partial systems like Medicare and also the plethora of state-specific programs. Regardless, the lives and money saved are more important than any potential expansion of the state.
"Why don't we try making the system even more private instead? That might help."
It might. However, there's no evidence to suggest it, and many reasons to presume it wouldn't. By its nature, the less publicly-supported a system, the more people will be unable to purchase health services.
The only potential gain would be reduced costs due to some sort of market mechanism, and in practice this has never occurred; every private healthcare system that has ever existed in world history has proved inefficient and been replaced by public systems, and given the demonstrable gains that have resulted the U.S. must follow.
"Doctors will be paid less."
They probably will. In nations with UHC, doctors often earn less - for example, U.S. doctors earn 30% more than Canadian doctors - but this isn't an inherent problem. It is still one of the highest-paying professions in the world, and there are many other ways of attracting skilled people to medicine - such as subsidising their education.
It is sometimes claimed that doctors paid less in a country with UHC will instead go elsewhere where they can be paid more, but once the U.S. has UHC there will not be an elsewhere to go.
"Medical research is funded by the payments of the rich in the current system, and will be reduced."
It is not true that most medical research is done in the United States. In 2000, U.S. research spending was $46 billion, but European spending was also $43 billion(11). And although U.S. research spending doubled in the last decade, the funding's efficacy has actually decreased(12).
Secondarily, if the option for private healthcare still exists - and there is no reason why it should not - there will still be people choosing to pay more for a higher quality of care, faster service, et cetera. Their profits will still be reinvested in the development of new drugs, equipment and understanding of the human body, as they still are in nations with UHC today. Even in the United States, private spending accounts for only 57%(13) of research spending.
"With the option of private healthcare, the rich will 'opt out' and costs will go up."
This isn't necessarily true at all; although private healthcare is usually allowed in UHC nations (for good reasons), it doesn't have to decrease the taxes paid by all to support the public system!
"Other countries fix drug prices, so the US has to pay more for drugs."
This is another common misconception. U.S. healthcare does not include higher pharmaceutical spending than other countries; it's around the average or even slightly lower. From the OECD(14):
Canada: 17.7%
Germany: 15.2%
Iceland: 13.3%
Australia: 13.3%
US: 12.4%
Sweden: 12%
Ireland: 11.6%
In Conclusion
Thank you for reading. To those who were not previously supporters of UHC, I apologise if anything seemed condescending, but there's no shame in being wrong due to not having all the facts or having been misled. If anyone has questions feel free to ask, and hopefully we can now discuss what sort of UHC system ought to be implemented or how the political will for it can be gathered, rather than being bogged down by misconceptions about its desirability.
1. http://query.nytimes.com/gst/fullpage.html?res=9C0CE7DE113FF93AA1575AC0A966958260
2. http://www.census.gov/Press-Release/www/releases/archives/health_care_insurance/009789.html
3. http://www.pnhp.org/bankruptcy/Bankruptcy Fact Sheet - Updated.pdf
4. http://www.pnhp.org/bankruptcy/Bankruptcy Fact Sheet - Updated.pdf
5. http://www.who.int/whr/2006/whr06_en.pdf
6. http://www.businessweek.com/magazin...mallbiz+index+page_top+small+business+stories
7. http://www.businessweek.com/magazin...mallbiz+index+page_top+small+business+stories
8. http://edition.cnn.com/2007/HEALTH/08/13/life.expectancy.ap/index.html
9. http://www.who.int/whosis/database/core/core_select_process.cfm?countries=all&indicators=nha
10. http://stats.oecd.org/wbos/default.aspx?DatasetCode=HEALTH
11. http://www.bmj.com/cgi/content/short/335/7632/1232-a
12. http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/tb/1767
13. http://hsc.utoledo.edu/research/nih_research_benefits.pdf
14. http://stats.oecd.org/wbos/default.aspx?DatasetCode=HEALTH
Given the importance of medicine, I feel that it would be useful to clarify this issue. I will explain clearly, and with evidence, why it is that universal healthcare of any sort would be better than the current system in every significant way. If you find yourself disagreeing with this assertion, I ask that you read on before replying, as all conceivable objections will be addressed and resolved.
Why The Current Situation Is Bad
At the moment, healthcare in America is provided mostly by private entities, who charge high fees. These fees can be attributed largely due to the difficulty and expense of the medical profession, and although they are significantly higher(1) than those of similar nations this difference is only a small portion of healthcare costs. There then exists the health insurance industry, a loose network of corporations that charge individuals or organisations premiums and will pay for their health costs if any are incurred.
Unfortunately, this system has enormous problems. As of 2006(2), 44.8 million people in America do not have health insurance. Many are unable to afford it, many are denied coverage by insurers who believe that as customers they will not be economical, and others choose not to purchase it. Without health insurance, the up-front costs of health care are impossible for most people to afford. In fact, 50.35%(3) of all bankruptcies were caused, at least in part, by medical fees. In 2001, this was 2,038,549 bankruptcies.
Furthermore, health insurance does not fully cover medical expenses. Different insurers and different plans have many exemptions, co-pays, threshholds and other expense-minimising devices. As a result, 62%(4) of those two million bankruptcies occurred despite the debtors having health insurance coverage for the duration of their illness.
As well as failing to provide care, and driving individuals into bankruptcy, the existing system is also exorbitantly expensive. Health care spending is now 15%(5) of U.S. GDP - the highest in the world. The costs to businesses, who commonly pay premiums for their employees in lieu of salary, rose by 13.9%(6) in 2003. The annual cost increase has been above inflation since at least 1981. Paying more doesn't result in more value, either - obesity, diabetes, and similar disorders are more common in the United States than anywhere else in the developed world, the U.S. is ranked 72nd(7) in overall health, and life expectancy is below that of 41 other countries.(8)
What Is Universal Health Care?
Universal Health Care, or UHC, refers to a wide range of different systems, the common characteristic of which is that a nation's government guarantees all its citizens access to healthcare. Every developed nation (OECD member) in the world, apart from the United States, has a UHC system. There are three main types:
In a fully public system, there is no or little private healthcare, and the health insurance industry is not a significant one. Medical service providers are government employees, and the education of doctors is also subsidized. The most well known example of a fully public system is the original English NHS, although a private sector is now developing in the U.K. as well.
In an optional public, the government provides the same services, but a private health services industry also exists (generally regulated), and . Sometimes health insurers exist, used by people who prefer private services. This is the most common, and examples include Australia and Sweden.
In a subsidized private system, the government pays for health care, but it is provided by private entities. Either the government acts as a health insurer for the populace, or it pays the fees for private health insurers to do so. This is done in Canada.
For the purposes of discussion, I will be assuming the characteristics of an optional public system, like those used in most of Europe. However, the benefits of UHC apply to all of the above types of organization.
How UHC Will Improve Things
The single largest problem with healthcare in America is that many people don't have it. It's obvious how UHC solves this: by providing it to all citizens directly (or paying for it to be done). By definition, this is no longer a problem under UHC. All developed nations other than the United States make this guarantee to their citizens, and have so far been able to uphold it. The two reasons which make a person uninsurable - insurer decisions and lack of money - will no longer exist.
The second major problem with the current system is its high cost. This can be divided into two parts: individual cost, and government cost - which to the individual shows up as taxation. UHC is inherently cheaper - far cheaper - due to economies of scale, the bargaining position of monopolies with regard to drugs and salaries, reduced administrative costs, and the lack of a profit motive. When it comes to individual health care costs:
According to the World Health Organisation(9), average American individual spending on healthcare is $3371 per year. Since this includes the uninsured and those covered by their employers, actual costs are higher. For comparison:
Australia: $1017
Canada: $916
Sweden: $532
United Kingdom: $397
The first of those is the second-highest in the world - meaning that Americans pay, not including taxes, more than three times as much as citizens of any other nation. This would be somewhat justifiable if they received better healthcare, but again - 28% have no care at all, life expectancy is below all other developed nations, and general health rating is below all other developed nations.
It is commonly assumed that this difference in cost is because under UHC systems, higher taxes are required to fund the system. Not so. As mentioned, UHC is a great deal cheaper than private healthcare, and as a result America's health-related taxation is also the highest in the world. According to the OECD(10), in 2006, American government spending on healthcare was $2887 per person. For comparison:
Australia: $2106
Canada: $2338
Sweden: $2468
United Kingdom: $2372
American healthcare taxes are in fact the highest in the OECD, with France second at $2714. In conclusion, every single UHC system in the world costs less money for individuals, requires lower taxes, and provides better care to more people than the American health care system. By implementing UHC in the U.S., things can only get better.
Frequently Raised Objections
There are many incorrect arguments against the implementation of UHC in the United States. In order to better facilitate discussion, I will explain the errors found in the most common.
"America isn't Europe!", or It Won't Work Here
The argument from American exceptionalism states that what works in Europe will not work in the U.S. It's said that this is because European nations have more people in less space, resulting in less logistical difficulties, and because European government is more competent.
Firstly, not all developed nations are European. The most obvious example that counteracts the logistical argument is Australia, where there are 20 million people in only slightly less space than America's 300 million. This does indeed affect prices, as can be seen by comparing Australia to Sweden or the U.K. - but it doesn't bring them anywhere near the levels currently experienced in America.
The argument that American government is uniquely incompetent, and cannot do things that every other nation in the world can do, is simply nonsense. Not only has America, and American government, achieved many things that other countries have not, America has so many resources and the improvement in care and cost from moving to UHC is so large that even with incredible inefficiencies it would still be a good idea.
"It is immoral to force me to pay for others' healthcare."
You are already paying for others' healthcare. Furthermore, you are paying far more than you would be under UHC. The U.S. government incurs massive costs from paying hospital fees when ER visitors have no money, and from the limited coverage that it provides, which cannot take advantage of economies of scale and which has to subsidise corporate profit.
As demonstrated above, U.S. taxes devoted to healthcare are the highest in the world. Even if you choose not to have health insurance, under the current system, you are still paying more for others' healthcare than you would be paying for theirs plus your own under UHC.
"This is socialism."
It is not socialist to recognise that there is a service the free market is inefficient at providing, and to decide it should better be provided by the government. Even the most staunch libertarian admits that there are some services in this category, such as national defence.
Secondly, it is irrelevant whether this is a "socialist" policy; it's effective. It costs less and provides better care to more people, and as a result is used literally everywhere else in the entire world. Those who want to ensure that society remains ideologically committed to market capitalism need to look for other issues, as if they cling to this one they will only end up providing evidence against their position.
"I don't want more government bureaucracy."
UHC will involve much less bureaucracy than is commonly assumed, as it can replace the existing partial systems like Medicare and also the plethora of state-specific programs. Regardless, the lives and money saved are more important than any potential expansion of the state.
"Why don't we try making the system even more private instead? That might help."
It might. However, there's no evidence to suggest it, and many reasons to presume it wouldn't. By its nature, the less publicly-supported a system, the more people will be unable to purchase health services.
The only potential gain would be reduced costs due to some sort of market mechanism, and in practice this has never occurred; every private healthcare system that has ever existed in world history has proved inefficient and been replaced by public systems, and given the demonstrable gains that have resulted the U.S. must follow.
"Doctors will be paid less."
They probably will. In nations with UHC, doctors often earn less - for example, U.S. doctors earn 30% more than Canadian doctors - but this isn't an inherent problem. It is still one of the highest-paying professions in the world, and there are many other ways of attracting skilled people to medicine - such as subsidising their education.
It is sometimes claimed that doctors paid less in a country with UHC will instead go elsewhere where they can be paid more, but once the U.S. has UHC there will not be an elsewhere to go.
"Medical research is funded by the payments of the rich in the current system, and will be reduced."
It is not true that most medical research is done in the United States. In 2000, U.S. research spending was $46 billion, but European spending was also $43 billion(11). And although U.S. research spending doubled in the last decade, the funding's efficacy has actually decreased(12).
Secondarily, if the option for private healthcare still exists - and there is no reason why it should not - there will still be people choosing to pay more for a higher quality of care, faster service, et cetera. Their profits will still be reinvested in the development of new drugs, equipment and understanding of the human body, as they still are in nations with UHC today. Even in the United States, private spending accounts for only 57%(13) of research spending.
"With the option of private healthcare, the rich will 'opt out' and costs will go up."
This isn't necessarily true at all; although private healthcare is usually allowed in UHC nations (for good reasons), it doesn't have to decrease the taxes paid by all to support the public system!
"Other countries fix drug prices, so the US has to pay more for drugs."
This is another common misconception. U.S. healthcare does not include higher pharmaceutical spending than other countries; it's around the average or even slightly lower. From the OECD(14):
Canada: 17.7%
Germany: 15.2%
Iceland: 13.3%
Australia: 13.3%
US: 12.4%
Sweden: 12%
Ireland: 11.6%
In Conclusion
Thank you for reading. To those who were not previously supporters of UHC, I apologise if anything seemed condescending, but there's no shame in being wrong due to not having all the facts or having been misled. If anyone has questions feel free to ask, and hopefully we can now discuss what sort of UHC system ought to be implemented or how the political will for it can be gathered, rather than being bogged down by misconceptions about its desirability.
1. http://query.nytimes.com/gst/fullpage.html?res=9C0CE7DE113FF93AA1575AC0A966958260
2. http://www.census.gov/Press-Release/www/releases/archives/health_care_insurance/009789.html
3. http://www.pnhp.org/bankruptcy/Bankruptcy Fact Sheet - Updated.pdf
4. http://www.pnhp.org/bankruptcy/Bankruptcy Fact Sheet - Updated.pdf
5. http://www.who.int/whr/2006/whr06_en.pdf
6. http://www.businessweek.com/magazin...mallbiz+index+page_top+small+business+stories
7. http://www.businessweek.com/magazin...mallbiz+index+page_top+small+business+stories
8. http://edition.cnn.com/2007/HEALTH/08/13/life.expectancy.ap/index.html
9. http://www.who.int/whosis/database/core/core_select_process.cfm?countries=all&indicators=nha
10. http://stats.oecd.org/wbos/default.aspx?DatasetCode=HEALTH
11. http://www.bmj.com/cgi/content/short/335/7632/1232-a
12. http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/tb/1767
13. http://hsc.utoledo.edu/research/nih_research_benefits.pdf
14. http://stats.oecd.org/wbos/default.aspx?DatasetCode=HEALTH
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