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.
What Is Universal Healthcare?
Universal health care is an umbrella term for “a system that provides medical services to all people. The government offers it to everyone regardless of their ability to pay, and largely funds it through taxes,” according to economic expert Kimberly Amadeo.
Single-payer health care is one type of universal health care in which the “government provides free health care paid for with revenue from income taxes. Services are government-owned and service providers are government employees. Every citizen has the same access to care.” The United Kingdom, Spain, New Zealand, and Cuba have single-payer systems. In the U.S., military personnel and veterans have access to a single-payer system via the armed services and the Department of Veterans Affairs.
Social health insurance is a program in which “everyone [is required] to buy insurance, usually through their employers. Employers deduct taxes from employee payrolls to cover the costs, and the taxes go into a government-run health insurance fund that covers everyone. Private doctors and hospitals provide services. The government controls health insurance prices.” Germany, France, Belgium, the Netherlands, Japan, and Switzerland use the social health insurance model. Obamacare was originally modeled on social health insurance, however the program has changed.
A national health insurance “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.” Canada, Taiwan, and South Korea all have national health insurance. In the U.S., Medicare, Medicaid, and TRICARE function similarly.
Countries with universal healthcare include but are not limited to Australia, Brazil, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, the Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and Taiwan.
Health Care Spending
U.S. health care spending rose 2.7% in 2021 to a total of $4.3 trillion nationally and accounted for 18.3% of the U.S. Gross Domestic Product (GDP). Of the $4.3 million, health insurance paid 71% (with private insurance paying 28%, and government programs covering the rest via Medicare, Medicaid, and other programs), patients paid 10% as did other third party payers (such as the Indian Health Service), investment covered 5%, and government public health activities accounted for 4%. Per person, health care costs averaged $12,914.
56% of Americans were worried about “paying medical costs for serious illness or accident” in 2022. As a financial worry, it was only topped by the worry of “not having enough money for retirement.” Additionally, 43% were worried about “paying medical costs for normal healthcare,” which was the fourth most prevalent financial worry in 2022. Meanwhile, 20% of American adults reported “major, unexpected medical expenses” with an average cost of $1,000 to $1,999 between May 2021 and May 2022.
41% of American adults, about100 million people, are in medical debt. Over 50% of American adults reported going into debt because of medical (or dental) bills. 25% of those with medical debt owe more than $5,000 and about 20% don’t believe they will ever be able to pay off the debt.
People in medical debt cut spending on basics like food and clothing (63%), exhausted their savings (48%), had to take on extra work (40%), delayed a home purchase or their education (28%), asked for help from a charity (24%), and/or changed their living situation (19%). And, 17% of those in medical debt filed bankruptcy or lost their home as a result. A 2019 study found that of people who file for bankruptcy, about 67% file due to medical debt, with about 530,000 families in the United States filing for bankruptcy annually because of medical debt.
Health Care in a Global Context
The World Health Organization ranked the U.S. health care system at 37 out of its 191 member countries, between Costa Rica and Slovenia, in a landmark 2000 report.
In 2005 the United States and the other member states of the World Health Organization signed the World Health Assembly resolution 58.33, which stated that nations should “transition to universal coverage of their citizens… with a view to sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care.”
The Commonwealth Fund ranked the United States last in overall health care among 11 high-income countries based on access to care, care process, administrative efficiency, equity, and health care outcomes. Norway, the Netherlands, and Australia were the top three countries.
The United States spends $11,912 per person on health care, the most of any OECD country. Germany follows the U.S. with $7,382 per person, while South Korea spent the least at $3,914 per person.
A Jan. 31, 2023 Commonwealth Fund report found that the United States “spends nearly 18 percent of GDP on health care, yet Americans die younger and are less healthy than residents of other high-income countries” and “[n]ot only does the U.S. have the lowest life expectancy among high-income countries, but it also has the highest rates of avoidable deaths.” According to the report, the U.S. spends much more than the other 37 OECD (Organisation for Economic Co-operation and Development; members are countries generally considered “high-income” or “developed”) countries, per person and as a percentage of GDP, and is the only OECD country that does not have universal health care.
Further, the U.S. has the highest maternal and infant mortality rates, among the highest suicide rate, the highest rate of patients with multiple chronic illnesses, and the highest obesity rate. And yet the U.S. also has one of the lowest levels of doctors and hospital beds, and Americans are least likely to visit a doctor. The Commonwealth Fund concluded, “Not only is the U.S. the only country we studied that does not have universal health coverage, but its health system can seem designed to discourage people from using services.”
Historic Debate on Universal Health Care
Throughout the 18th and 19th century the US federal government did not finance or otherwise provide health care to the public. In the early 20th century, a debate over universal health care began to emerge. In 1915 the American Association for Labor Legislation drafted a series of bills to provide state medical benefits to low income workers. In 1920 the New York State Commissioner of Health, Hermann Biggs, began promoting public health services at the county level, and Charles-Edward Amory Winslow, the Chair of the Department of Public Health at Yale University, wrote: “I look to see our health departments in the coming years… enable every citizen to realize his birthright of health and longevity.” That same year the American Medical Association‘s House of Delegates passed a resolution officially opposing compulsory health insurance in the United States, with one group of delegates from Illinois calling it a “dangerous bolshevik” scheme.
Government-funded health insurance was considered by President Franklin D. Roosevelt’s Committee on Economic Security, but it was not included as part of the 1935 Social Security Act, in part due to opposition from the American Medical Association. In 1938, health care reform to provide universal coverage was proposed by Roosevelt as an extension of social security, and U.S. Surgeon General Thomas Parran argued that “equal opportunity for health is a basic American right.” In Feb. 1939, Senator Robert Wagner (D-NY) introduced the National Health Care Act, which would have implemented a national health care system, however, the bill did not gain the necessary support in Congress and died in committee.
In 1945, in another attempt at universal health care, President Harry S. Truman sent a message to Congress asking for a new national health insurance program to be run by the federal government. The voluntary program would have allowed individuals to pay monthly fees in return for coverage of all medical expenses. The program was introduced in Congress as the Social Security Expansion Bill. The bill never passed, in part, due the American Medical Association characterizing it at “socialized medicine.” Although a national health program for all US citizens was not achieved, proponents of the plan continued to advocate for government-funded health insurance by shifting focus to providing coverage to Americans over the age of 65 and the economically disadvantaged.
By the early 1960s, debate grew over the King-Anderson bill, a precursor to Medicare, that would have extend Social Security to cover the medical bills of Americans over the age of 65. Ronald Reagan, who opposed the bill, warned in a 1961 spoken word record that “one of the traditional methods of imposing statism or socialism on a people has been by way of medicine.” Despite some public opposition, Medicare (the Social Security Act Amendments of 1965) was eventually passed by the House (307-116) and the Senate (77-6), and was signed into law by President Lyndon B. Johnson on July 30, 1965. President Harry Truman (then 81 years old) was enrolled as the first beneficiary, because, in 1945, he was the first president to propose national health insurance.
In 1971, President Richard Nixon laid out a National Health Strategy to reform the health insurance system and move towards universal health care. In a 1972 message to Congress, President Nixon continued to advocate for universal health care, arguing that “reform of our health care system – so that every citizen will be able to get quality health care at reasonable cost regardless of income and regardless of area of residence – remains an item of highest priority on my unfinished agenda for America in the 1970s.” A competing plan by Senator Ted Kennedy, the Health Security Act, sought to implement a universal single-payer federal health insurance plan to be financed through taxes. Despite their efforts, by the end of the Nixon presidency, no health care legislation had reached the President’s desk.
President Clinton brought the issue of national health care back to the forefront. On Sep. 22, 1993, he delivered a speech to Congress stating that the “most urgent priority” of the nation was to provide “every American health security, health care that can never be taken away, health care that is always there.” Three months later the Health Security Act was introduced to move the United States towards the goal of universal coverage by requiring all individuals to obtain health insurance and instituting an employer mandate to provide insurance. The Association of American Physicians and Surgeons (AAPS) called the act “socialist,” and a “forfeiture of our freedom” that would “destroy private insurance.” Simultaneously, other legislators introduced a competing act to create a federally run “single-payer” national health insurance plan. As in the 1970s, none of the plans had enough support to the President’s desk.
In 2003, Representative John Conyers, Jr. (D-MI) introduced the United States National Health Insurance Act (or the Expanded and Improved Medicare for All Act) that would not pass Congress, but would provide the foundation for later bills and presidential campaign promises.
Obamacare and Medicare for All
During an Oct. 7, 2008 election debate, then-Senator Barack Obama stated that health care should be a “right for every American.” In a June 15, 2009 speech as U.S. President delivered to the American Medical Association (AMA), Obama urged Congress to craft legislation that would ensure coverage for all Americans. After intense debate, lawmakers passed the Patient Protection and Affordable Care Act (PPACA), which was signed into law on Mar. 23, 2010. According to a 2013 White House estimate, 27 million previously uninsured people would gain coverage under Obamacare. A separate 2013 study found that despite the expansion in health insurance coverage under Obamacare, 29.8 to 31 million people would still remain without health care coverage by 2016.
About 8% of Americans remain uninsured in 2022, about 26 million people, the lowest percentage in decades due largely to changes in policy during the COVID-19 (coronavirus) pandemic. By 2023, more than 16 million Americans had health insurance via Obamacare, the highest number since the PPACA was signed in 2010. The 2023 enrollees included about 3.6 million people who were not previously enrolled in Obamacare.
The PPACA did not institute universal health care, and some members of Congress, including Senator Bernie Sanders (I-VT) and Representative Jim McDermott (D-WA), and organizations, including Physicians for a National Health Program (PNHP) and the American Nurses Association, continued to advocate for the implementation of a “single-payer” health care system in the United States that would guarantee universal health care for all Americans under a federally run health insurance plan.
On Sep. 13, 2017, Senator Sanders introduced a Medicare for All bill that would have created a single-payer health care system in the United States. His bill, which had been introduced previously without any co-sponsors, drew at least 15 Senate co-sponsors. However, the plan did not pass Congress.
Medicare for All became a hot button topic in the 2020 presidential election. Only the Green Party candidate, Howie Hawkins, supported the plan, while Joe Biden (D), Donald Trump (R), and Libertarian candidate Jo Jorgensen did not.
Gallup has asked Americans whether the government should ensure health care since 2000. The first year (2000), 59% agreed that the government should ensure health care. Support hit a low in 2013, when 43% agreed, but support rebounded and, by 2022, 57% supported government ensured heath care. 53% were partial to a private insurance based system, while 43% were partial to a government-run system.
The partisan divide is stark, however: 88% of Democrats and 59% of Independents agreed that “it is the responsibility of the federal government to make sure all Americans have healthcare coverage,” while only 28% of Republicans agreed. Further, 72% of Democrats, 46% of Independents, and 13% of Republicans support a government-run health care system.