Our search yielded 2070 results, from which 1899 were excluded based on review of publication date, title and abstract and 104 excluded after full manuscript review. Sixty-seven documents were included in the final scoping review for an overall inclusion rate of 3.2%. Table 3 includes the results of each arm of the search. Four sources came up across multiple databases, specifically three sources that came up in the PubMed and the Google Scholar – Economic searches, and one source that came up in the Google Scholar – Social and the Google Scholar – Economic searches. These were attributed to the first database from which they were reviewed. The final result being four sources were logged as ineligible in the Google Scholar – Economic search however they could have been attributed to the PubMed or Google Scholar – Social search given a different, random reading order.
Table 3
Scoping Search Inclusion and Exclusions
Search | Total number of results | Round 1 excluded based on citation, title or abstract | Round 2 excluded based on full manuscript review | Total number articles included in scoping review | % of publications eligible: |
PubMed: ("Economics"[Mesh] OR Economic*[title] OR "Cost benef*"[title/abstract] OR "Soci*") AND ("Universal Health Care"[Mesh] OR "universal healthcare"[tiab] OR "universal health care"[tiab] OR "universal health coverage"[tiab]) AND ("United States"[Mesh] OR "United States*"[tiab] OR "USA"[tiab] OR "U.S."[tiab] OR "America"[title]) | 478 | 402 | 41 | 35 | 7% |
Google Scholar: "congressional budget office" AND ("universal health care" OR "universal healthcare" OR "universal health coverage") AND ("national health expenditure" OR "national health expenditures") | 528 | 1003 | 48 | 28 | 2.59% |
Google Scholar: "congressional budget office" OR "Center for Medicare and Medicaid" AND ("universal health care" OR "universal healthcare" OR "universal health coverage" OR "comprehensive health insurance" OR "single-payer") AND ("national health expenditure" OR "national health expenditures") | 551 |
Google Scholar: "department of health and human services" AND ("universal health care" OR "universal healthcare" OR "universal health coverage" OR "comprehensive health insurance" OR "single-payer") AND ("soci*") | 513 | 494 | 15 | 4 | 0.77% |
The most common reason for exclusion was publication outside the date range (n = 1703) followed by books (n = 77) and content not focused on the impacts of universal healthcare (n = 77). Figure 1 presents the inclusion and exclusion diagram.
Economic Impacts
Thirty-eight documents discussed the economic impacts of universal healthcare in the US. Themes presented included the impact on 1) government spending, 2) individual spending and income, 3) national health expenditures, and the impact on the US’s 4) GDP and economy, and 5) impacts on specific costs and cost-controls.
Government spending
Reviewed literature almost unanimously agreed that providing universal coverage will require increased federal government budget or deficit spending (3, 4, 13, 17–21). Estimates for federal deficit increases range from $1.1 trillion to $2.1 trillion per year while federal budget spending estimates range from $14 trillion to $44 trillion over 10 years (3, 4, 21, 22). One estimate however found a model with supplemental insurance would realize a reduction in annual federal expenditure of $40 billion (23). While federal spending is likely to increase state and local government spending is likely to decrease as they would no longer be responsible for Medicaid or covering retired public employees until they were eligible for Medicare (13, 17, 20).
Individual spending and income
The impact of universal healthcare on individual spending and finances is of great importance. As with almost every potential impact of universal healthcare, impact on individual finances will depend on the exact formulation and package (13, 24). There is overwhelming evidence that individuals in the US are foregoing care because of financial limitations, both for those uninsured and for those underinsured or with prohibitively high deductibles or copays (3, 4, 9, 12, 19, 25–32). Universal healthcare would eliminate the majority of this issue, though individuals still suffer financial risk under universal healthcare systems (33). However, universal healthcare will undoubtably require individual contributions in the form of taxes. Collecting payments through income tax could allow for a progressive structure saving low-wage earners money (22, 34). In addition, this cost would be shared among a broader base using federal tax dollars (35). So, while taxes would increase, other out of pocket costs such as premiums would be eliminated leading to individuals paying less (35–37). In fact, in one proposal from Oregon, a proposed plan that would double or triple taxes while providing universal care with no premiums or copays still forecasted the average household would pay less (37). Estimates for the US and examples from other countries show that a system with little or no out of pocket costs (e.g., copays, premiums, deductibles) would lower costs for most, but not necessarily all, individuals (1, 4, 17, 22, 23, 33, 38, 39). One estimate for a nationalized healthcare system estimated an average annual savings of $2400 (40). An additional source of cost savings to individuals is the elimination of covering the costs for uninsured individuals who often have more costly healthcare expenses because of foregoing care (9).
Universal healthcare may also indirectly impact individuals’ finances through labor and employment changes. The most common individual economic impact discussed is potential changes to physician and healthcare provider income. There is concern that physician revenue will decrease, either because of reduced reimbursement or because of wage reduction (4, 22, 41, 42). Due to reduction in overhead costs however(17), many estimate that physician net income will actually increase or remain the same (4, 17, 36, 42, 43). The Congressional Budget Office estimated provider payments increasing $39,816-$157,412 under Medicare-for-All (17). As with other economic impacts, the specific plan will ultimately influence physician payments and income (44). Eliminating employer-based insurance may have positive impacts for workers without a college degree, increasing annual earning and raising employment rates among this group through the elimination of the “flat tax” of insurance premiums (45).
National health expenditures
The discussion of universal healthcare model costs to the US government and individuals is undoubtably important to both those groups. However, it is important to remember the reality that healthcare spending is paid by someone, whether the government or individuals and so increases in one area can mean decreases in another. For this reason, looking at the impact of national healthcare expenditure overall can give a holistic view of the impact a universal healthcare system has on costs. The literature varied on assessment of universal healthcare’s impact on national health expenditures. The exact impact is dependent on the plan (4) with some reducing costs (1, 17, 23, 46, 47), some increasing costs (22), and some increasing spending in the short term but realizing net reductions in spending after a few years (13, 23, 48, 49). Overall, most plans realized significant reductions in healthcare spending – one estimate projected a 13% reduction from current spending, the equivalent of more than $450 billion per year (1).
Gross domestic product
Medical spending continues to grow in the US, and the percent of GDP continues to increase (18, 35). As with other measures of spending, the US spends approximately double that of other OECD countries: around 18% of GDP to other countries’ average of 9% (13, 27). Estimates for money saved by the institution of Medicare for All ranged from 1.58–3.67% of GDP (18, 46). One source discussed the positive impact universal healthcare might have on the US economy by keeping money in low-wage workers’ pockets thus adding trillions to the national economy annually (40).
Impacts on specific costs and cost-controls
As has been a recurring theme, the extent and magnitude of universal healthcare on costs depends on the type of system and the assumptions and policies contained therein. The literature discussed the impact of various types of healthcare systems on healthcare costs and the cost control measures needed to balance cost increases and cost savings. Cost controls include supply side controls (e.g., not increasing physicians or hospital beds) (13, 47), negotiated prices for prescriptions and medical equipment (23, 46, 48), setting of provider reimbursement rates (4, 22, 48, 49), and policies to reduce fraud and waste (50).
There was unanimous agreement that utilization costs would increase (4, 13, 36, 43, 47, 49, 51), however there is evidence that these increases would be either entirely or mostly offset by savings in other areas or by redistribution of utilization wherein previously uninsured increase utilization but that is offset by previously insured reducing use (47, 49, 51). Specific estimates of the cost of increased utilization costs, before considering offsets, ranged from 2%-21% (36, 47, 49).
The primary offset to increase utilization discussed was that a single payer system would significantly reduce administrative costs through simplification (4, 9, 13, 17, 19, 23, 27, 28, 36, 38, 43, 46, 49, 50). Estimated administrative savings ranged widely, from 1.2–20% of healthcare spending (19, 36, 49). Other estimates included a reduction of administrative costs of 7% for hospitals, 4% − 11% for physicians, and 3% for other medical providers (17, 52). Another area where savings may be realized is through reduced prescription costs through negotiated prices; with estimates of around $180 billion savings (3, 4, 13, 19, 23, 47, 49).
The impact on other costs was mixed. Physician and clinical costs were estimated to reduce by $23 billion (19). One estimate predicts that using Medicare payment rates would reduce costs by 1.4% − 10% (49). A modest .5%-5% savings off the current $87.5 billion burden from fraud, abuse, duplication and overtreatment may be realized through a single payer system (19, 49). Sources reviewed did not reach consensus on the impact on hospital costs with the impact covering the whole spectrum from an increase in costs of up to 3% (47), to no change in costs (43), to a decrease in costs of $39.5 to $59 million (19, 36). The current system has suffered high costs from consolidation and a non-single payer system, like a public option, could introduce competition that might reduce costs (34, 44). Other costs discussed include the high upfront costs associated with building and or expanding the healthcare infrastructure (21) and dislocation, the idea that Medicare reimbursement rates will not be sustainable without a diverse payor mix supplementing payments (50).
Finally, healthier people have lower healthcare costs so a healthcare system with incentive to maintain a health population has the ability to address non-communicable chronic disease, a very expensive problem in the US (21). Putting off care is associated with higher costs I the future so ensuring individuals can access care sooner reduces these excess costs (9, 23). Delay of care due to cost controls, such as long wait times, is also associated with higher expenses so cost controls must take this into account (53).
Social Impacts
Sixty-three documents discussed social impacts of universal healthcare in the US. From these documents, six themes emerged: 1) healthcare access, utilization, and health outcomes, 2) quality of care, 3) patient and provider experience, 4) individual and societal externalities, 5) potential opposition and support, and 6) equity.
Healthcare access, utilization, and health outcomes
Unsurprisingly, there was almost unanimous agreement that universal healthcare would increase access to care (2–4, 9, 12, 13, 19, 25–31, 33, 38–40, 54–59). However, it was noted that actual effect on access would depend on the model (13), and that insurance coverage is only one component of access and there are other barriers to care (29, 56). Likewise, healthcare utilization is likely to increase, especially for primary and preventive services (1, 17, 42, 59). Inclusion of substance use and mental health services would address a major contributor to the reduced life expectancy in the Us over recent years (9). This utilization is likely to be higher among newly covered individuals with decreases among those previously insured (17, 51).
Many papers discussed the benefit to individuals of expanded coverage and the improved health outcomes that would follow (2, 13, 27, 60, 61). It is estimated that quality healthcare for the entire country would save over 68,000 lives and 1.73 million life years annually (19, 55, 62). Individuals without insurance have a higher odds of death (3), increased mortality (31, 54, 63), delays in starting treatment, reduced treatment adherence and worse outcomes (12, 21, 54), and increased maternal morbidity compared to those with insurance (64, 65). While the exact impact on expansion or contraction of services covered will vary by proposal and its relation to an individual’s current coverage, many universal healthcare proposals would expand coverage to provide comprehensive benefits (3, 23, 33, 38–40, 48). It was noted however that long wait times are associated with poorer health outcomes (53) so while increased wait times are not inevitable they may counteract some of the positive outcomes likely to be seen. In addition to comprehensive healthcare benefits there was discussion of the impact universal healthcare could have on social investments addressing upstream social determinants of health (35, 66).
Quality of care
Papers in our review warned of the very real concerns around the impact of a universal healthcare system on quality of care. Healthcare coverage does not automatically equate to access to quality care (67). While there was optimism that quality may increase under a single payer system because providers can focus on appropriate services to match needs rather than being limited by the structures set by payors with incentives to limit costs (3, 19), ultimately it will depend on the provision of high value care versus low value care (47). There is also the very real concern that reduced budgets may lead hospitals to decrease investments in quality, something that has been seen before after Medicare payment decreases resulted in increases in hospital mortality rates (41).
Opponents of universal healthcare are concerned about innovation and competition being stifled with a move away from a capitalist healthcare system (21). Specifically, the impact on the pharmaceutical industry and their innovation and development investments were discussed and there is some hope that the market will spread these costs over more economies in order to continue (3).
Patient and provider experience
In addition to economic costs or benefits, universal healthcare systems can have positive or negative provider and patient experience that will impact satisfaction. Concerns about wait times and rationing of care have been put forward as potential negative consequences of increased demand and cost control measures (3, 4, 13, 21, 33, 35, 40). Reviewed literature put forward that international comparisons and economic modeling showed these fears may be unfounded (3, 26, 27). Additional evidence shows that providers prioritize more high value care when facing high demand for care (17).
Provider experience navigating the payment process of a single payer system is likely to be better than the administratively complex system currently in place (4, 13, 46, 47, 68). Patient experience is likely to improve as well with increased portability and patient choice(4, 13, 27). However, many are satisfied with their current insurance and moving 100 million people off their current insurance, as would be required under a single payer/Medicare for All-type program, would be incredibly disruptive (22, 48, 50).
Individual and societal externalities
Switching from the current system to universal healthcare in the US would lead to large changes in the labor market, most significantly, the elimination of many jobs in the US economy. Positions in the private health insurance and healthcare administration fields would become redundant, while positions in hospitals and pharmaceutical companies may be lost to balance reduced budgets (3, 4, 19, 34, 36, 41, 48). Universal coverage would eliminate job-lock, where individuals are forced to stay in low-paying jobs or not able to start their own businesses because they need to keep their health insurance, allowing individuals more freedom to pursue higher paying or more fulfilling careers and positions without concern for their health insurance (13, 40, 69). Universal healthcare may indirectly improve physician job satisfaction by lessening the administrative burden present in the current system as well as eliminating the concern over unpaid treatment (19). It must be noted however, that potentially negative consequences such as reduced autonomy and increased demand for care may outweigh these benefits (19). Finally, universal healthcare would also have a positive impact on the US economy through increases in worker productivity (19, 21). Estimates for lost productivity from obesity alone is estimated at around $66 billion (21).
As previously discussed, inability to pay for care leads many to forego treatment, however even if care can be accessed, there can be negative financial implications. Health expenses force over 100 million people worldwide into extreme poverty every year (57). Financial toxicity and concerns over medical expenses can happen under universal healthcare schemes, however they are more common in countries with private health insurance (32, 33, 48). Medical debt and medical bankruptcy are common in the US for uninsured and underinsured adults with medical expenses accounting for 19.3% of people living in poverty (1, 4, 25, 26). Medical debt is also associated with housing instability and homelessness (23). A universal healthcare system with little to no out-of-pocket costs could have a significant impact on poverty in the US (4).
Equity
One of the most important impacts universal healthcare can have is addressing the huge health disparities present in the US under the current system (27, 48). As with many measures of healthcare, the US ranked near-last in equity when ranked against peer countries (13). Universal healthcare that is accessible to all is central to the idea that health is a human right and should not be determined by one’s ability to pay or by employment (1, 9, 19, 35). This was put into stark focus when 9.2 million workers lost employer-sponsored health insurance in the beginning of the COVID-19 pandemic (26). Universal coverage would help address racial, ethnic, and income related disparities (1, 3, 4, 9, 12, 13, 21, 23, 25, 31, 34, 39, 56–58, 60, 62, 64–66). However, while universal healthcare is necessary, it is not sufficient to eliminate these disparities (1, 4, 9, 13, 29, 33, 56, 58, 59, 64, 65, 67, 70–72). Reparative investment in hospital infrastructure in disinvested communities will be needed to rectify decades of neglect (36, 43). Another way universal healthcare may promote equity is through addressing racial and gender pay gaps in medicine, specifically in primary care which would be emphasized under this system and where a large number of physicians are women and members of minorities (42). There is also evidence that employer-based insurance feeds into labor market inequality (45). Any program will need to be implemented with care so as to avoid structural or systematic barriers(22), or entrenching or exacerbating current inequities (28).
Potential opposition/support
The purpose of this review was to identify the economic and social impacts of implementing a universal healthcare scheme in the US and as such, it was beyond the scope to investigate the political feasibility of such a change. Many of the sources reviewed discussed facilitators and barriers to implementation of universal healthcare and so we include them here as they can inform potential sources of happiness or frustration after such implementation. Barriers to implementing universal healthcare in the US include the fact that many people are happy with their current insurance and benefits or oppose universal healthcare that would eliminate private insurance (20, 22, 34, 39, 48). The culture of the US is such that many are not supportive of government involvement with healthcare or that it is the government’s responsibility (9, 13, 22, 39). However, the majority of American believe it is the government’s responsibility to ensure health insurance for all Americans (1), and most physicians and Americans (polls range from 50–68%) are in favor of a national Medicare for All plan (22, 34, 48, 73), though some estimates put this support lower at 33% of Americans in favor of a single payor system (1). While Americans usually balk at tax increases, a proposed state-administered plan in Oregon that would provide care with no out of pocket costs but increase taxes 2–3 times – something usually put forth as a non-starter - received strong support with 62% supporting the plan (37). While there is support for this type of change there is less agreement on the specifics of the formulation (39). There is also a lot of misinformation so it is hard for voters to get accurate information which can lead to misunderstandings such as the ability to keep private insurance under Medicare for All (22, 26).
Others have logistical concerns and feel an overhaul of the system is not feasible, things that work in the current system may not scale, so smaller policy changes are the better way to go (3, 21, 50, 69). Other countries have succeeded with this large overhaul (3). There are also concerns about partisanship at the state and federal levels as well as state and federal cooperation presenting challenges for smooth implementation (33, 34, 73). Finally, opposition from industry as well as political resistance will pose problems for implementation of a single payer system (13, 26, 50, 69).