Universal Healthcare: Weighing the Pros and Cons
Universal health care (UHC) is a system under which "all people have access to the full range of quality health services they need, when and where they need them, without financial hardship," according to the World Health Organization. Universal healthcare is sometimes a contentious issue, with physicians presenting solid arguments on both sides. Proponents point to improved healthcare equity, improved public health, fewer ethical issues caused by insurance companies, and lower costs to society. Opponents, on the other hand, cite increased bureaucracy, longer wait times for some procedures, and, potentially, reduced physician pay. Overall, 71% of physicians surveyed on Sermo support universal healthcare and a further 15% are not sure which way to jump. These are all valid arguments. It’s also worth addressing a misconception up front. Universal healthcare does not necessarily mean “free” healthcare. Universal healthcare simply means that everyone is guaranteed coverage, which can also be handled using a private health insurance system or a combination system. The Affordable Care Act (ACA), for example, was designed to improve coverage within a private insurance system. Medicaid, for example, is a dual-payer system because funding comes from both the federal government and the state.
Currently, 72 countries have some form of UHC, according to the World Population Review. Universal coverage means that more people seek care, resulting in an overall healthier population and government spending on increased preventative measures. A key part of this is improved healthcare equity. Lower income people get access to primary care, without having to resort to using the emergency room for non-emergency situations, shortening wait times for everyone.
Understanding Universal Healthcare Models
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. On the other hand, European countries like Switzerland, the Netherlands, and Germany have utilized a blended system with substantial government and market-based components. 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.
To provide a clearer picture, here's a breakdown of different UHC models:
- Single-Payer Systems: In this model, the government provides free health care paid for with revenue from income taxes. Every citizen has the same access to care, and service providers may be public or private health care facilities, but the care is free at the point of service. The United Kingdom, Spain, New Zealand, and Cuba have single-payer systems.
- Social Health Insurance: In this system, 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.
- National Health Insurance: This approach 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.
Countries with Universal Healthcare
At least 20 countries have single payer healthcare and more have some form of universal coverage.
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- The United Kingdom: The UK has a single payer system through the National Health Service. Private insurance is used by higher income individuals to supplement coverage.
- Germany: Germany was the first country to introduce a social health care system, in 1883. At the start, it covered blue-collar workers, who were at high risk of occupational illness.
- Taiwan: Taiwan is considered to have the best healthcare system in the world.
- Australia: Australia uses a public-private model.
- India: In theory, India has universal healthcare on a multi-payer system similar to Germany’s. Tax-funded public hospitals charge only small co-payments for most services.
- Argentina: Argentina also has a public-private system. Care can be received free of charge at public medical facilities.
- Brazil: Healthcare in Brazil is a constitutional right and is free for everyone including foreigners.
- Egypt: Egypt has a similar system to India.
Pros of Universal Healthcare
Universal healthcare can additionally help society-wide health issues by "addressing the growing chronic disease crisis, mitigating the economic costs associated with said crisis" and "reducing the vast health disparities that exist" between levels of society, said an article published in the journal Medicina. UHC may also lead to better outcomes during pandemics like Covid-19. "When any of us is exposed, all of us are," said Milwaukee Independent. "Universal, effective and affordable health care makes us all stronger and safer."
- For Physicians:
- More Consistent Patient Access to Care: Because patients have more consistent access, they will come in more regularly, improving healthcare equity.
- Potential for More Predictable Income: This can make clinic income more predictable and reduce cash flow issues.
- Reduced Administrative Burden: Single payer systems tend to have standard reimbursements that are sent automatically. Single payer also typically means one set of rules for every patient, with no need to look up specific details, and that physicians can refer a patient to any specialist without needing to check with the patient’s health insurance. In a universal healthcare system, practices will spend less time on billing issues such as following up with patients who do not make payment.
- For Patients and the Public:
- Guaranteed Access to Essential Healthcare Services: One of the biggest benefits of universal healthcare coverage is that it ensures access to necessary medical services for all citizens.
- Reduced Financial Barriers to Treatment: There is reduced risk of a patient stopping care because they or a family member are facing financial difficulties.
- Less Stress About Medical Bills and Insurance Coverage: High levels of stress slow healing and reduce outcomes. 51% of physicians on Sermo say they have patients who are concerned about costs, and this is not limited to patients with lower incomes.
- Improved Public Health: Universal coverage means that more people seek care, resulting in an overall healthier population and government spending on increased preventative measures. 59% of physicians believe improved access to healthcare is a primary benefit of universal healthcare coverage.
- Positive Societal Changes: UHC may be "more likely to promote healthy lifestyle behaviors, environmental factors and policies compared to a non-inclusive system," said Medicina. The government may also focus on decreasing pollution and regulating food to prevent health problems in the first place. UHC gives the government an incentive to make society healthier and safer.
- Reduced Financial Burden: While UHC could lead to increased taxes, it would also bring down insurance premium prices and reduce the chance of medical bankruptcy.
Cons of Universal Healthcare
Not all physicians are enthused about universal healthcare. An increase in people seeking healthcare without a matching increase in availability of clinicians can result in increased loads, longer hours, and longer waits for patients.
- For Physicians:
- Potential for Lower Reimbursement Rates: Physicians commonly point to low reimbursement rates from Medicare/Medicaid as a concern.
- Increased Patient Loads and Longer Working Hours:
- Risk of Lower Quality Care in Overstressed Systems: If systems become overstressed, the quality of care can suffer, impacting a doctor’s ability to do their job as well as their mental health.
- Less Autonomy in Treatment Decisions: A key concern for many physicians is reduced autonomy in treatment decisions. Government regulations may impact care through prior authorizations and national guidelines.
- More Bureaucracy and Administrative Oversight: Many physicians are concerned about this expanding under a universal system and having to spend more time complying with regulations, although this is obviously offset by less time dealing with health insurance.
- For Patients and the Public:
- Longer Wait Times for Appointments and Procedures: We often think of this as a concern for patients, but it also affects physicians. Doctors face clinical, emotional, and professional challenges if delays in treatment affect outcomes, and it can strain the doctor-patient relationship. Universal health coverage systems must also prioritize essential care, and this can result in delays in accessing more advanced treatments and elective or “cosmetic” treatments.
- Economic Strain Could Lead to Higher Taxes: Taxes are likely to go up under a universal system, although this is offset by reduced or absent insurance premiums and reduced costs for businesses who no longer have to provide employer sponsored care. However, in times of downturn, benefits could have to be reduced and/or taxes raised further.
- General Inefficiency: Health care run by the government is doomed to face the same inefficiencies as the government itself. There may also be an increase in "general wastefulness, inefficiency and disorganization that is often associated with bureaucratic, government-run agencies."
- Reduced Quality of Care: The transition to UHC could disrupt hospitals and, in turn, their quality of care. A "single-payer system that paid hospitals using Medicare rates would result in a substantial decline in hospitals' average payment rates," said the Congressional Budget Office.
- Increased Taxes: UHC can be pricey. While much of this cost could be covered by taxing the wealthy, "taxes on the middle class would have to rise in order to pay for it" as well, said the Committee for a Responsible Federal Budget.
Physician's Compensation Under Universal Healthcare
Physicians and other countries without universal healthcare worry about reduced compensation. Overall, compensation is likely to rise from increased utilization even if individual fees for service decline, and physician compensation may also be increased as practices spend less money on billing, which would be greatly simplified, and more on patient care. While some practices may see net gains, others-especially smaller or rural practices-may face tighter margins. However, while compensation may go up, hours worked may also increase due to falling reimbursement and increased use of care.
Impact on Medical Practices
The impact of universal healthcare depends in part on your practice type. However, the likely changes would be an increase in the overall number of patients, improved consistency in compliance with care, and greatly streamlined billing. Doctors will gain broader access to patients and specialists, as well as less time spent dealing with billing and insurance, and will no longer have to deal with issues such as payment plans for uninsured patients.
The Debate in the United States
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.
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The debate over universal health care in the United States has a long history.
- Early 20th Century: In 1915 the American Association for Labor Legislation drafted a series of bills to provide state medical benefits to low income workers.
- 1930s: 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.
- 1940s: In 1945, President Harry S. Truman sent a message to Congress asking for a new national health insurance program to be run by the federal government.
- 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. Medicare (the Social Security Act Amendments of 1965) was eventually passed and signed into law by President Lyndon B. Johnson on July 30, 1965.
- 1970s: In 1971, President Richard Nixon laid out a National Health Strategy to reform the health insurance system and move towards universal health care. 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.
- 1990s: President Clinton brought the issue of national health care back to the forefront. 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.
- 2000s: In 2003, Representative John Conyers, Jr.
- 2010s: Lawmakers passed the Patient Protection and Affordable Care Act (PPACA), also called the Affordable Care Act (ACA) or Obamacare, which was signed into law on March 23, 2010. On September 13, 2017, Senator Sanders introduced a Medicare for All bill that would have created a single-payer health care system in the United States.
Public Opinion
Gallup has asked Americans whether the government should ensure health care since 2000. The first year (2000), 59 percent agreed that the government should ensure health care. Support hit a low in 2013, when 43 percent agreed, but support rebounded and, by 2022, 57 percent supported government ensured heath care. The partisan divide is stark, however: 88 percent of Democrats and 59 percent of Independents agreed that “it is the responsibility of the federal government to make sure all Americans have healthcare coverage,” while only 28 percent of Republicans agreed.
Americans are split-46 percent to 49 percent respectively-on whether that healthcare should be a national, government-run system or a private insurance system.
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