A framework to understand universal health care


One of the most popular topics in health care is the idea of universal health care coverage. You know the soundbites: “Medicare for all.” “Single-payer system.”

While universal coverage sounds desirable to many, some factors must be considered. In this post, I’m going to provide an aerial view of this complicated topic. My goal is to translate this issue into patient-friendly language that all of us can understand. This topic isn’t going away anytime soon and is likely to play a significant role in the 2020 presidential election.

Terminology basics

First, it’s important to understand what exactly universal health care entails. Quite simply, it does not mean coverage for all people, in all circumstances, for all services. This is the first point many don’t realize or neglect to acknowledge when creating political soundbites.

Instead, universal health care answers the question of who is covered, what services are covered and the cost associated with each service. It’s fully transparent, which is not a feature of our current health care system. At its core, universal health care arises from the ideology that health care is a right for Americans (not a privilege), and Americans should be able to access the health care system without incurring financial hardship or ruin.

Now, in a vacuum, I’d venture to guess the vast majority of us don’t object to this ideology. Unfortunately, it’s not that simple. It’s the way in which universal health care would be implemented and how it would be funded that makes this a highly controversial and complex topic.

Structure of universal health care

Countries such as Canada, France, Germany, and Switzerland already offer universal health care. In these cases, the federal government pays for health care, but it is provided by private companies. This is a very important distinction to make. In the U.S., Medicare, Medicare Advantage and Medicaid are examples of such a system.

On the other hand, in the United Kingdom, the government both pays for and provides health care services. This is “socialized” medicine. In the U.S., this type of system already exists with the Department of Veteran Affairs.

Advantages of universal health care

The obvious main advantage is universal coverage, thus helping those that would otherwise not have health insurance. A second important advantage is cost control. The government would control the cost of medication and medical services through negotiation and regulation. It would also drastically decrease the administrative cost of dealing with different private health insurers. Presently, doctors must deal with many private insurance companies, all of whom want something different and require unrealistic administrative tasks for physicians. This could be greatly streamlined.

Disadvantages of universal health care

At its core, universal health care forces healthy people to pay for others’ medical care. Is this fair? Why should an active, healthy-eating, non-smoker pay for health care for an obese, sedentary diabetic who chain smokes all day? Chronic diseases, like diabetes and heart disease, make up 85 percent of health care costs. These are loaded questions, and I don’t plan to provide answers, but hopefully, you can see the point of contention.

Second, with universal health care, people might not be as careful with their health spending. For example, if I know it won’t cost me anything, I might elect to go to the ER instead of waiting four weeks for an appointment. Not convinced about this point? Most universal health care systems report long wait times for elective procedures. For example, let’s say you have chronic back pain and your doctor has recommended an MRI. Under this type of system, it is entirely plausible that your MRI would be scheduled 4-6 months down the road? Is that good care?

Third, health care costs could overwhelm governmental budgets. This might negatively impact funding for other things such as education, defense, and infrastructure.

Finally, to rein in costs as much as possible, the government might limit some services that have a low probability of success. Instead of an expensive medication or major operation, the government might instead pay only for end-of-life services. In other words, the government could seize control of some medical decisions from the doctors.

In case you think I’m exaggerating, allow me to remind you the Affordable Care Act included the Independent Payment Advisory Board (IPAB) provision. This board is independent of any medical entity, Congress or democratic process. IPAB is composed of 15 unelected bureaucrats appointed by the President and confirmed by the Senate. Their task would be to control Medicare spending (i.e., refuse coverage in certain situations). I don’t know about you, but this is a frightening amount of power for 15 non-medical people devoid of any real accountability. Thankfully, President Obama never appointed anyone to IPAB, but there has been plenty of mainstream media coverage of these so-called “death panels.”

Paying for universal health care

OK, let’s pretend universal health care is on its way. How will it be financed? Likely in one of three ways:

1. Single-payer system. The government taxes all citizens for health care. It doesn’t matter if you use it or not. There would likely be a marginal tax rate, much like income taxes. This is the approach of “Medicare for all” by Bernie Sanders.

2. Insurance mandate. This would mandate all citizens to purchase health care. Germany uses such a system, and obviously, this sounds somewhat familiar to the Obamacare individual mandate.

3. Two-tier approach. The government taxes citizens to provide basic government health care services. Citizens can also choose to supplement with private health insurance. France utilizes this system.


This is an incredibly complex topic and one that certainly cannot be given justice in a single post. However, I hope I’ve provided you with a basic framework to approach the discussion. My goal is to educate you enough so that you can cut through the political soundbites to accurately understand emerging health care policy proposals.

Kevin Tolliver is an internal medicine physician who blogs at My Medical Musings.

Image credit: Shutterstock.com


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