Can America Afford Universal Healthcare?

United States

It has the best doctors, the highest per-person healthcare costs, and nearly 46 million uninsured citizens - the US healthcare system. Hardly any other country in the First World has such an imbalanced system that clearly shows the gap between rich and poor.

A third of the American population has no health insurance. (& copy AP)

Many Americans believe that, as current President George W. Bush claims, the US has "the best healthcare system in the world". In fact, it is a system with enormous strengths. Those with good health insurance in the US have instant access to the latest medical technology and highly trained and specialized health professionals. The United States is a global leader in basic medical research and innovation. In the past decade, 14 of the 24 Nobel Prizes in Medicine were awarded to scientists from the United States. In 2007 alone, the National Institute for Health spent $ 29 billion on medical research, surpassed by private pharmaceutical and biotechnology companies that invested $ 59 billion. In recent years, the US has been a world leader in introducing new pharmaceutical and biotechnological products.

Yet the downside of this track record is a health system that is seriously ill in many ways. It is the most expensive healthcare system in the world, with an average cost of $ 7,000 per person in 2006. It consumes 16 percent of the US gross domestic product. Seen worldwide, the USA thus has a share of almost half of all global health costs. Despite the massive cash benefits, nearly 46 million citizens of the country, 15.3 percent of the population, have no health insurance at any one time, and nearly a third of the population, over 80 million Americans, have been temporarily uninsured for the past two years. Finally, comparative studies have found that the quality of health care in the United States is by no means exceptional. The US health care system is very good in some areas, not in others, and is average in an international comparison of the industrialized nations.

Private and public insurance

Unlike other wealthy nations, the United States does not have general insurance coverage. Most Americans, 54 percent, are insured through their employer. While employers are not legally obliged to offer health insurance, because it is tax-exempt, it is an attractive perk. Most large corporations offer them, but smaller companies often don't. Part-time and short-term employees as well as contract workers often have no health insurance. Most employees have to pay part of the insurance premium (usually a quarter of the amount) themselves and many cannot afford it, so they decline the offer of health insurance through their employer.

Over a quarter of the US population is covered by public insurance. The so-called "Medicare" program insures all persons over 65 years of age as well as disabled citizens, regardless of their personal possessions or income. Medicare is a social security program funded through payroll taxes, general taxes, and eligible contributions. It mainly covers hospital costs as well as care and medication. Medicare is a US-wide program and is available to everyone in all states and territories. A second public health insurance program called "Medicaid", however, is managed by the federal government AND by the individual states, so that access criteria and benefits vary from state to state. Medicaid caters to specific groups of low-income citizens such as the elderly, disabled, pregnant women, and children and their families. A special sub-program called State Children's Health Insurance caters for children whose families are not low enough income to qualify for Medicaid. Various smaller government programs take care of the health care of special groups such as veterans, Indians or active soldiers.

Only a very small percentage of the population, around 5 percent, have private health insurance with no affiliation to an employer. Insurers sell these individual policies on condition that the health of the insured person is carefully examined. The insurance benefit and the premium are also measured according to this. These insurances often offer fewer benefits and require a higher contribution to medical care than group insurances. But for the self-employed and employees without access to the public or employer insurance system, they are the only option.

Finally, as noted, many Americans are uninsured. Over 70 percent of the uninsured come from families in which at least one member works, but almost two-thirds live with incomes above the state-set poverty line. Young adults and ethnic minorities, especially Hispanics, are at greatest risk of being uninsured.


Those who are not insured in the USA are not automatically excluded from all health care. Most hospitals are required by law to accept an emergency room. You can, however, bill the sick person for this. In many parts of the USA, "Safety-Net" hospitals and clinics offer free or reduced-cost care for the uninsured. But those who do not have insurance go to the doctor less often, even with serious illnesses, have no family doctor or take care of preventive care. This group is less likely to cash prescriptions, end up in the hospital for preventable ailments more often, and are often diagnosed (too) late with cancer. It is estimated that 22,000 Americans die prematurely each year because they are uninsured.

Approximately 25 million people in the US are underinsured, which means they have health insurance, but they still have to spend a large part of their income on medical and hospital bills because their insurance has little coverage or a very high co-payment. Many of the uninsured or underinsured have great financial difficulties, run up their savings accounts, run up huge debts, or have to borrow money with their house as collateral. Medical expenses are one of the leading drivers of bankruptcy in the United States.

Despite the enormous cost of the US health care system, it does not offer benefits that are superior to those in other countries. In general, American patients have shorter waiting times for a specialist or special treatment, but they have to wait longer to see a general practitioner and often do not have access to medical care at night or on weekends - except through the emergency room in hospitals. Health care is fragmented and patients often lack long-term relationships with doctors because they have to change them when their employer changes or the insurance company imposes new conditions. A recent study examining preventable deaths in 19 nations found that the United States has the highest percentage of preventable deaths.

Attempts at reform

Attempts to reform the US health system are manifold, they began in 1917 and continue to this day. Although there was substantial progress in the 1960s in extending health care to the elderly, the disabled and some of the socially disadvantaged, the US is still a long way from providing health care to all citizens.

There are a number of reasons for this. First of all, US political institutions are not designed to allow radical change. Laws must travel through both houses of Congress and then be approved by the President. Larger bills require a majority of 60 of the 100 senators. The balance of forces between the federal and state levels must also be considered. Unless an enormously broad political arc can be drawn for consensus on general health insurance coverage, this project is unlikely. Second, Americans lack the commitment to social solidarity that other nations have. Americans tend to believe more in individual responsibility and are suspicious of any government program. That is also the reason why only certain categories of poor citizens - the "honorable poor" - are cared for through Medicaid. Third, the US lacks a strong labor movement and socially oriented parties that exist in other nations. Fourth, interest groups play a bigger role, not least because of the type of campaign funding in the US, which relies on contributions from interest groups. For decades, the doctors' lobby resisted reforms, while the lobby for health insurers and pharmaceutical companies has played an important role in recent years. Finally, political fatigue has made reform difficult. However, if health system costs continue to rise and access to health care continues to be problematic, a political coalition for reform could emerge. Perhaps then the sick US health system will get the powerful medicine it needs.