6 minute read

National Health Care

The development of a national system of HEALTH CARE in the United States has remained a major topic of debate throughout the United States, especially since the 1980s. Healthcare costs in the United States have risen dramatically during the past 40 years, due in part to longer average life spans, which give rise to greater costs because older citizens require greater care, and the employment of technologies that extend the life of patients, which generally results in greater spending. Insurance costs have likewise increased dramatically, and a relatively large percentage of U.S. citizens and other residents are uninsured or underinsured. According to information from the CENSUS BUREAU in 2001, 41.2 million Americans, constituting 14.2 percent of the population, did not have HEALTH INSURANCE.

The healthcare system is largely controlled by the free market, which is believed to provide limitations on how much physicians and other specialists can charge to their patients. However, many critics of the current system, including organizations composed of physicians, note that the system has become largely bureaucratic and that cost-cutting measures and pressures caused by competition and the need for profit have reduced the effectiveness of medical practice. Despite these problems, many commentators have not been able to agree as to the proper level of control that state or federal governments should have over health care.

Following WORLD WAR II, the number of Americans that had private insurance policies grew dramatically. In 1965, Congress approved the development of MEDICARE and MEDICAID to assist the elderly and the poor in being able to afford medical care. The vast majority of U.S. citizens were covered by either private or public insurance at that time. However, healthcare costs experienced a dramatic growth during the 1970s, and employers were forced to pay for the bulk of this increase as they paid their employees' premiums. Many companies in the early 1980s began to require employees to pay deductibles on their insurance policies, and some small companies began to refuse to provide insurance at all.

Beginning in the 1980s, scholars and other commentators began to propose a variety of major reforms to the healthcare system to create a truly national system. In 1989, an article in the New England Journal of Medicine by David Himmelstein and Steffe Woolhander maintained that the system of health care in the United States was failing. A considerable amount of concern by those authors and others was directed towards the overhead costs and other administrative expenses incurred by insurance companies and healthcare providers. According to one study in 1987, the total cost of healthcare administration was an estimated $96.8 billion to $120.4 billion, accounting for 19.3 to 24.1 percent of the total spending on health care in the United States. In 1989, the more than 1,500 private health insurers in the United States consumed an estimated eight percent of their total revenues through overhead costs.

A number of commentators compared the healthcare system in the United States with the national system in Canada. Administrative healthcare costs in the United States were estimated in 1983 to be 60 percent higher than those in Canada, and Canada's system provides healthcare coverage for all of its citizens. Canada employs a so-called single-payer form of national health insurance in which the federal government administers and finances the plan. All Canadians are covered under the plan, which provides for a basic benefit package. Citizens are not required to pay a deductible or co-payment, and the government forbids private insurance companies from duplicating the services provided under the government plan. The single-payer approach reduces overhead expenses dramatically because the government pays the medical costs directly to the provider.

Although many in the medical community supported proposals to adopt a form of the single-payer model, critics noted the population of the United States is roughly ten times the population of Canada. These critics also noted that the costs of such a system would be paid for with taxes, so citizens are required to pay for this system indirectly. Moreover, adoption of such a system would involve a high level of governmental involvement, which conservative commentators dislike.

Other proposals for national health care have been introduced and have likewise been advocated unsuccessfully. Some proposals include mandates that all employers provide insurance coverage to all employees. Other proposals focus on market-based solutions, including the development opment of medical savings accounts holding funds, which individuals could use to spend for healthcare costs. The competing sides to the debate are generally unable or unwilling to compromise their positions, and the reform effort remains largely a matter of rhetoric.

The issue of healthcare reform was a major debate during the 1992 presidential campaign. Most of the Democratic candidates, including eventual nominee BILL CLINTON, advocated their own strategies for this reform, as did the incumbent president GEORGE H.W. BUSH. Clinton's proposal, which was a compromise between several reform alternatives, purported to guarantee practically universal coverage by requiring employers to provide health insurance to all full-time employees. The plan would have also established a national health board and an ADMINISTRATIVE AGENCY that would have been responsible for determining the maximum allowable growth rate of insurance premiums of private insurers.

After Clinton was elected, the healthcare reform initiative was a top priority in the first two years of his first term. However, Clinton encountered many roadblocks. He was criticized for having his wife, HILLARY RODHAM CLINTON, take the lead in promoting the proposal. The plan was also very complex, and the administration was criticized for failing to articulate it properly to the public. Several bills that would have given rise to major healthcare reform were introduced before Congress in 1993 and 1994, but Congress refused to take action with respect to most of them. The most significant of these bills was the National Health Security Act, S. 1757, 103d Cong., in 1994, but its consideration was stalled at the committee level.

Republicans won a sweeping victory in the 1994 congressional elections, and the enthusiasm for providing a national healthcare system declined. Evidence also suggested that increases in healthcare costs had begun to stabilize. From 1993 to 1997, U.S. spending on health care remained at 13.5 percent of the country's gross national product (GNP). In 1997, the United States experienced only a 4.8 percent increase in healthcare spending, which was an all-time low. Moreover, by 1997, private companies and individuals paid about 53.6 percent of the overall health expenditures, which was considerably less than the percentage paid 20 years prior.

Although major healthcare reform in the United States appears less likely than it did during the early 1990s, commentators note that the poor still suffer from the market-based system. Many lower-class workers suffer more than nonworkers, primarily due to the current public insurance systems, especially Medicaid. These workers are often paid too much to qualify for Medicaid, yet their employers do not provide insurance and the workers cannot afford to pay insurance premiums from private companies. Even more disconcerting to many observers is the number of children who are uninsured and whose families do not qualify for Medicaid. As many as 8.5 million children under the age of 18 are uninsured, according to the 2001 census.

Beyond the political and economic considerations in the debate regarding national health care are questions of whether citizens in the United States possess the right to such care. Few people question that Congress has the power, both under the COMMERCE CLAUSE and Spending Clause of the Constitution, to enact national healthcare legislation, but some maintain that health is one of the basic HUMAN RIGHTS that the Constitution impliedly protects. Other commentators disagree strongly, noting that no citizen has the inherent right to health care and that health care providers deserve to be paid the market value for their services. Other critics add that the intervention required of the government in a national health-care system would make citizens too dependent upon the state, which could lead the government to take excessive control over its citizens' lives.


Hacker, Jacob S. 1996. "National Health Care Reform: An Idea Whose Time Came and Went." Journal of Health Politics, Policy, and Law 21 (winter).

"National Power and Health Care" (panel discussion). 1995. Cornell Journal of Law and Public Policy 7 (spring).


Medicaid; Medicare.

Additional topics

Law Library - American Law and Legal InformationFree Legal Encyclopedia: National Environmental Policy Act of (1969) to Notice