The phrase universal health care has about it the shimmer of moral inevitability. It sounds so simple, so incontestable, so just. Who, after all, would oppose the idea that everyone should be cared for? But as with many political incantations, its music conceals its meaning. “Universal” does not mean “unlimited.” It means “everyone is covered,” not “everything is covered.” And once government assumes the burden of paying for care, that distinction becomes decisive.
In New York, for example, private insurers are now required to cover a new technology for chemotherapy patients: scalp cooling, which helps prevent hair loss. It is an admirable policy, and a humane one. But notice how it works. The state does not fund the treatment; it simply orders private insurers to pay for it. That sort of benevolence is easy because it costs the government nothing. It is the moral vanity of redistribution without the fiscal inconvenience of actually redistributing.
When government itself must pay, the calculus changes. What begins as a promise of compassion ends as an exercise in triage. Every expense competes with every other, and the word “universal” becomes synonymous not with abundance, but with limits.
I was once struck by a story from a man who had lost a leg years ago and spoke of the new generation of prosthetic limbs — lighter, stronger, some even responsive to neural impulses. They are marvels of human ingenuity, and marvels of cost. His lament was that such devices should be universally available, which he took as an argument for universal health care. This was echoed by those reading his social media post, many of whom demanded “Universal healthcare now!” But of course, that system would not supply the latest prosthetic to every amputee. It would standardize to the cheapest model deemed “adequate.” Governments, unlike individuals, do not spend money. They allocate scarcity.
Advocates of nationalized care often point to Europe as proof that universal systems work. They are correct, in the same way that one might say the traffic in London “works.” It functions, yes, provided one accepts congestion, delay, and an occasional sense of futility as part of the bargain.
In Britain, the National Health Service has achieved universality largely through uniformity. The NHS has a waiting list of more than seven million people — the equivalent of every resident of Arizona waiting for care. It is common for cancer treatments to be postponed or denied altogether, not because the therapy is ineffective, but because it is deemed not “cost-effective.” In France, patients pay privately for much of their dental and optical care because the “universal” system does not cover it. Germany’s vaunted model relies on strict reimbursement ceilings that make certain advanced treatments uneconomical to provide. Even Japan, often hailed as a triumph of efficiency, achieves that reputation by capping reimbursements so low that hospitals must operate at the margins of insolvency.
Every one of these systems is universal. None is comprehensive. They provide care for all, but not all the care that patients may need. They are equal in the way a ration book is equal — everyone gets the same portion, regardless of appetite.
We need not cross the Atlantic to see the dynamic at work. Our own Medicare system has perfected the art of appearing generous while paying providers less than the cost of service. Doctors and hospitals offset the losses by charging private patients more, a quiet subsidy that keeps the system solvent. But eliminate private insurance, and the cross-subsidy vanishes. Then government must either raise taxes dramatically or drive down reimbursement further, forcing providers out of practice. Medicare-for-all would quickly become Medicare-for-fewer.
And still, some would add to this structure the ideology of equity — that is, the distribution of medical care according to political categories rather than medical need. Under such reasoning, certain groups might receive priority not because they are sicker, but because they are symbolically favored. Bureaucracy would merge with ideology, and universality would yield to politicization — a system that rations not only by cost, but by creed.
That is not to say that America’s fragmented healthcare system does not need to be fixed. What truly distinguishes American health care, for all its inefficiencies, is its lack of transparency. We enter hospitals as supplicants, with no idea what anything costs. Only after discharge does the ledger appear, as if descending from Sinai. In no other industry would we tolerate this. We demand to know the price of a car, a meal, or a mortgage before purchase. Only in medicine do we regard ignorance as virtue. Perhaps we think it gauche to assign a dollar value to care, but prices are how a free people keep institutions honest. When patients know what they are paying for, competition thrives, and costs fall. When government hides those prices behind paperwork and policy, both vanish into bureaucracy.
This, in the end, is the paradox of “universal” health care. The more we centralize compassion, the less compassionate it becomes. Bureaucracies can distribute fairness, but they cannot dispense mercy. A government large enough to provide care for all will soon be large enough to decide which care all will receive. And like every monopoly, it will do so with the indifference that always attends unaccountable power.
The goal of reform should not be to make government the physician of the nation, but to make sure every citizen has access to a physician — and to the freedom that comes with choice, transparency, and competition. For when government becomes everyone’s doctor, it treats citizens not as patients, but as liabilities.
Universal coverage, properly understood, is not a triumph of compassion. It is the triumph of semantics over arithmetic — a comforting phrase that hides a costly truth. What we call “universal” health care is universal only in its limitations: everyone is covered, and everyone lacks.
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