And The Bills Just Keep Piling Up
When Taiwan introduced national health coverage in 1995, forty-three percent of its people were uninsured. During the first year, uninsured individuals were two-times more likely to visit a physician or be admitted to a hospital than those who previously had coverage. As a result, increased utilization of patient care services boosted health spending 13.4 percent.
From a U.S. perspective, that same 13.4 percent increase in health care expenditures would have increased the country’s medical costs by $707 billion in 2024.1 As a thought exercise, if America wanted to begin its own universal health care plan, would increased utilization lead to a similar boost in spending?
It is a reasonable concern. Studies show that when people have access to more affordable health care, they use it. However, Taiwan’s circumstances in the 1990s are different from ours today. For one, only 8 percent of our population is uninsured, compared to 43 percent in Taiwan at the time (although another 23 percent of our working age adults are underinsured). Second, Taiwan had more elderly people who needed insurance in 1995 than the United States currently does as Medicare covers people over age 65.
Historical Utilization
More to the point, history does not bear out that utilization rates will naturally rise and bring about a significant cost burden. Research by Professors David Himmelstein and Stephanie Woolhandler (my professors at Hunter College) looked at 13 large-scale health coverage expansions for wealthier countries from 1938 to 2014, including the rollouts of Medicare, Medicaid, and the Affordable Care Act. They found that overall, increases in utilization were mostly modest, and in some cases, there was no increase at all.
Professors Himmelstein and Woolhandler attribute modest utilization increases to a finite supply of physicians and beds, which act as a constraining factor to people getting treated. Recent analysis gives credibility to this assertion that supply-side constraints can limit both hospital capacity and physician services.
Still, if we want to establish a universal health care plan, we should have some estimate of how much increased utilization might cost the country. One way to estimate the potential increase is to multiply the number of uninsured children and adults by the average spend for individuals in each age group. In that case, estimated spending would grow approximately 5.63 percent, or $293 billion, for the first year due to increased utilization. You can follow the math in the Notes section.2
More Debt
In my last blog, I noted that if the United States did roll out a universal health care plan, it would immediately face a $542 billion funding gap. If we are going to follow the Dutch financing rules, households and businesses would pay less into the program than they currently are—but our expenses would still remain the same.
Add on $293 billion, the estimated amount for increased utilization, to the $542 billion we needed previously and the sum adds up to $835 billion. If we want an All-American universal health care plan, we can come up with that money by either increasing taxes, borrowing more, or taking money from existing programs to pay for our insurance coverage.
That is hard to do when our deficit is at record levels, we don’t like levying new taxes in our country, and almost every other spending program we have is on life support.
Or we could keep our fragmented care system we have now, where the average deductible for a Bronze plan in 2026 is $7,476.
In my next blog, I explore one way we might be able to come up with the money.
Note: This is an ongoing series of blogs to develop an affordable, universal health care plan before the 2028 presidential election.
Calculations:
1$5.279T x 13.4% ~ $707B
2In 2024, 28,000,000 people had no health insurance (CMS, NHE Table 22)
Of that amount, about 4.7 million were children ages 0-18 (Based on 16.8 percent uninsured children)
23.3 million were adults ages 19-64.
In 2020, the average spend for an uninsured adult was $9,151. For a child it was $4,212.
If we want average spending to reflect 2024 prices, we need to multiply each amount by the growth in health care costs for years, 2021, 2022, 2023, and 2024 (CMS Table 1). The math would be as follow:
$9,151 would be 9151 x (1+0.041) x (1+0.048) x (1+0.074) x (1+0.072) = $11,500
$4,212 would be 4212 x 1.048 x 1.048 x 1.074 x 1.072 = $5,290
Total healthcare spend for adults = $11,500 x 23.3 million = $268 billion
Total health care spend for children = $5,290 x 4.8 million = $25 billion
Total spent on uninsured for the first year of universal health care =$293 billion
$293 billion/5.3 trillion = 5.63%
Selected References
Anderer, S. (2025). US hospital bed shortage looms as occupancy rates climb. JAMA, 333(16), 1386. https://doi.org/10.1001/jama.2025.2574
Association of American Medical Colleges. (n.d.). Addressing the physician workforce shortage. Association of American Medical Colleges. https://www.aamc.org/advocacy-policy/addressing-physician-workforce-shortage
Buchmueller, T. C., Grumbach, K., Kronick, R., & Kahn, J. G. (2005). The effect of health insurance on medical care utilization and implications for insurance expansion: A review of the literature. Medical Care Research and Review, 62(1), 3–30. https://doi.org/10.1177/1077558704271718
Bunch, L. N., & Ketema, H. (2025). Health insurance coverage in the United States: 2024 (Report No. P60-288). U.S. Census Bureau. https://www.census.gov/library/publications/2025/demo/p60-288.htm
Cheng, S.-H., & Chiang, T.-L. (1997). The effect of universal health insurance on health care utilization in Taiwan: Results from a natural experiment. Journal of the American Medical Association, 278(2), 89 – 93. https://doi.org/10.1001/jama.1997.03550020047038
Collins, S. R., & Gupta, A. (2024). The state of health insurance coverage in the U.S.: Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey. Commonwealth Fund. https://doi.org/10.26099/byce-qc28
Gaffney, A., McCormick, D., Bor, D., Woolhandler, S., & Himmelstein, D. U. (2019). Coverage expansions and utilization of physician care: Evidence from the 2014 Affordable Care Act and 1966 Medicare/Medicaid expansions. American Journal of Public Health, 109(12), 1694–1701. https://doi.org/10.2105/AJPH.2019.305330
Gaffney, A., Himmelstein, D. U., Woolhandler, S., & Kahn, J. G. (2021). Pricing universal health care: How much would the use of medical care rise? Health Affairs, 40(1), 105–112. https://doi.org/10.1377/hlthaff.2020.01715
Galvani, A. P., Parpia, A. S., Foster, E. M., Singer, B. H., & Fitzpatrick, M. C. (2020). Improving the prognosis of health care in the USA. Annals of Internal Medicine, 172(7), 504–505. https://doi.org/10.7326/M18-2806
Long, M., Lo, J., Wallace, R., & Pestaina, K. (2026, January 5). Policy changes bring renewed focus on high-deductible health plans. KFF. https://www.kff.org/patient-consumer-protections/policy-changes-bring-renewed-focus-on-high-deductible-health-plans/
Murray-Watson, R. (2024, June 19). Personal healthcare spending in the United States. HIPAA Journal. https://www.hipaajournal.com/personal-healthcare-spending-in-the-united-states/
Sommers, B. D., Baicker, K., & Epstein, A. M. (2012). Mortality and access to care among adults after state Medicaid expansions. New England Journal of Medicine, 367(11), 1025–1034. https://www.nber.org/programs-projects/projects-and-centers/oregon-health-insurance-experiment/oregon-health-insurance-experiment-results
Tolbert, J., Cervantes, S., Bell, C., & Damico, A. (2026, April 9). Key facts about the uninsured population. KFF. https://www.kff.org/uninsured/key-facts-about-the-uninsured-population/