Explainer: Why the US can’t – or won’t – provide universal healthcare to its citizens

By Ali Ziraatpishe

The United States, the richest country in the world with an annual GDP exceeding $28 trillion, is reeling under one of its biggest government shutdowns currently. Now in its 30th day, it is the second-longest in American history, caused mainly by partisan conflict over healthcare spending. At its core lies the question of who receives medical care and who must pay for it.

Disputes concerning federal funding for Medicaid expansion, Affordable Care Act subsidies, and pandemic-era health programs have stopped government operations.

Yet this situation is not only a fiscal crisis but also a moral collapse within a political system that regards health as a purchasable good rather than a basic right.

In most countries around the world, universal healthcare is accepted as a collective duty. However, in the US, nearly half of Americans delay treatment due to cost, and about 100 million live with medical debt. Each year, an estimated 68,000 people die from preventable diseases because they cannot afford proper care.

The federal government’s shutdown over healthcare funding exposes not only legislative paralysis but also a national indifference that accepts suffering in the service of ideology and profit.

Why does the US not have universal healthcare?

The US lacks universal healthcare, not because it lacks resources, but because it refuses to provide it to citizens. With yearly health spending above $4.5 trillion, nearly 17.3 percent of GDP, the country spends more per person on healthcare than any other country, yet performs worse in equity and access.

This failure began with President Harry Truman’s 1945 plan for national health insurance, defeated by powerful groups that saw social welfare as excessive government control.

In the 1950s, the American Medical Association’s “Operation Coffee Cup” urged doctors’ wives to resist public healthcare as a socialist threat, while private insurers and pharmaceutical firms built lobbying systems to block change.

Employer-based health insurance, strengthened by wartime tax breaks in the 1940s, deepened inequality by tying medical access to full-time jobs, excluding the poor, the jobless, and the chronically ill.

The federal structure worsened the problem, requiring cooperation among Congress, the states, and corporations for any major reform. As a result, nearly 27 million Americans remain without insurance, and over 40 percent of working-age adults avoid medical care due to cost.

How did the issue of healthcare cause current shutdown?

The latest US government shutdown is not only a procedural failure but the expected result of a healthcare system built on economic weakness and ideological division.

In 2024, federal healthcare spending reached about $1.98 trillion, nearly 29.4 percent of the federal budget and around 6.9 percent of the country’s GDP.

When combined with health-related tax breaks, especially the exclusion of employer-sponsored insurance premiums that cost the Treasury another $399 billion in lost revenue, the total fiscal weight of healthcare rose above $2.4 trillion, nearly half of all national health spending.

The direct cause of the shutdown is the end of enhanced premium tax credits under the Affordable Care Act, which grew from $52 billion in 2020 to about $110 billion in 2024.

Republican lawmakers have demanded sharp reductions to these subsidies and a rollback of federal support for Medicaid expansion, arguing that the programs cannot be sustained.

Democrats have refused to pass a continuing resolution that excludes healthcare funding, warning that millions would lose coverage immediately. This deadlock has stopped the budget process, suspended essential services, and left more than 800,000 federal employees without work.

Beneath the political conflict lies a darker truth: healthcare has become the clearest mirror of America’s class divide and moral decline. The government is holding citizens’ access to medicine as leverage in fiscal disputes. Hospitals dependent on Medicaid funds face collapse, while states warn of closures that could leave millions without care.

What are Medicare, Medicaid, and Obamacare?

The US is the only wealthy country in the world without a unified healthcare system, depending instead on separate public programs—Medicare, Medicaid, and the Affordable Care Act (ACA), each created to address limited gaps rather than provide universal coverage.

Medicare, established in 1965, was meant to protect older citizens from medical debt. Funded by payroll taxes and federal revenues, it now covers about 66 million people and costs over $1.1 trillion yearly, nearly 21 percent of total health spending.

Its coverage remains incomplete. It excludes vision, dental, and long-term care, forcing retirees to buy costly private “Medigap” or Medicare Advantage plans. Privatization and administrative waste have deepened these flaws; Medicare Advantage alone has overbilled taxpayers by an estimated $140 billion in the past three years.

Medicaid, also created in 1965, was designed as a safety net for the poor but now reflects America’s economic and political divides. Covering around 82 million people, it spends over $830 billion annually, yet eligibility and benefits vary sharply across states.

In wealthier or more liberal states such as California and New York, Medicaid covers many residents, while in conservative states like Texas and Mississippi, strict limits leave millions in a coverage gap, earning too much for Medicaid but too little for private insurance.

The Affordable Care Act (ACA), or Obamacare, enacted in 2010, sought to close these gaps by expanding Medicaid, creating insurance exchanges, and subsidizing private coverage for low- and middle-income citizens.

The ACA reduced the uninsured rate from 16 percent in 2010 to about 8 percent in 2023, yet nearly 27 million Americans still lack insurance. Rising premiums and political hostility, through lawsuits and budget cuts, have weakened its impact.

What are the effects on ordinary Americans?

In a country where medical care is treated as a privilege rather than a right, daily life for millions is a constant choice between survival and debt.

About 27 million people, or 8 percent of the population, remain uninsured, while nearly half of all adults are underinsured, burdened by deductibles and co-pays so high they deter treatment. Even insured citizens often avoid care, fearing annual out-of-pocket costs reaching $5,000 to $10,000.

The impact is severe. Medical debt is the main cause of personal bankruptcy, affecting over 2 million families each year and totaling more than $195 billion nationwide.

For those with chronic conditions such as diabetes, heart disease, or asthma, the system functions as a slow punishment. Insulin, costing under $10 to produce, sells for about $300 per vial, forcing rationing that leads to preventable deaths. Dialysis patients, depending on Medicare, face rural clinic closures, while the unhoused lose routine access to care entirely.

Among the country’s one million homeless people, many suffer from untreated illness, mental disorders, and addiction, as hospitals are only required to treat emergencies.

The poor and working class bear the heaviest burden. Families in American states that rejected Medicaid expansion fall into the “coverage gap,” earning too much for Medicaid but too little for private insurance.

Black and Indigenous communities suffer most: infant mortality in predominantly Black counties is over twice the national average, and life expectancy in the poorest counties is up to 15 years shorter than in the richest. Even the insured face instability, as coverage tied to employment can vanish with job loss, illness, recession, or shutdown.

The human toll is visible everywhere: overcrowded emergency rooms, neglected mental illness, and preventable deaths. For the poor, the sick, and the unseen, the healthcare system offers no safety—only a reflection of the country’s neglect.