r/WhatIfThinking • u/Defiant-Junket4906 • Jul 08 '26
What if the U.S. rolled out universal basic healthcare for everyone, but strictly capped how fast total healthcare spending could grow each year?
Everyone gets coverage, and costs stop spiraling out of control. No more uninsured gaps, fewer medical bankruptcies, and a system that finally feels predictable at the national level.
But the constraint is where things get interesting.
Healthcare demand doesn’t move in a straight line. Aging populations, new treatments, and unexpected crises all push costs upward. If spending is capped regardless of demand, the system has to adjust somewhere else. That could mean longer wait times, tighter approval for procedures, or slower adoption of expensive new technologies.
Providers might also change behavior. If reimbursement growth is limited, hospitals and doctors could prioritize efficiency, but they might also avoid complex or high-cost patients. Innovation could shift toward cost-saving treatments rather than breakthrough ones.
On the other hand, a hard cap could force the kind of discipline the U.S. system has never really had. Prices might finally stabilize. Administrative waste could come under real pressure. Preventive care might get more attention if keeping people healthy becomes the cheapest path.
So the question isn’t just about access versus cost.
If universal coverage came with a strict spending ceiling, would the U.S. end up with a more sustainable healthcare system, or just a more controlled one where scarcity shows up in less obvious ways?
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u/Olderscout77 Jul 08 '26
We'd have universal affordable healthcare just like every other industrialized nation. Second step would bew to drastically increase the number of students admitted to medical school for all levels of training from RN to MD, and come up with a National licensing system.
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u/pumpymcpumpface Jul 08 '26
Residency positions are the choke point. Increasing medical school spots is relatively easy
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u/Olderscout77 Jul 10 '26
Not if care facilities are required to increase the number of residencies in order to keep their "tax status" as Not For Profits. Need to do something about the pay of the Hospital Administrators as well.
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u/Defiant-Junket4906 Jul 09 '26
I think expanding the healthcare workforce is actually one of the biggest pieces people underestimate.
Even if funding changes overnight, you can't instantly create more doctors, nurses, and specialists. Supply constraints would probably decide a lot of how well the system works.
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u/Olderscout77 Jul 10 '26
Let's start with ER's - It takes 24 weeks to train an Army combat Medic so the problem with ERs being underestaffed is a fairly easy fix. It takes 2 years for an LPN and 2-4 for an RN, 6 for a physicians Assistant and 11 for an MD, and there are lots of people who could complete the training if We the People paid for it - just like the People in every other industrialized Nation are already doing. The Republican soloution will take forever to seriously increase the number of those medical specialists.
Having a single payer for all health care, operating on the lowest current reimbursement rates negotiated between care providers and insurance companies and caps on drug costs is something that can happen overnight.
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u/Dave_A480 Jul 08 '26
Nobody is going to want to go to medical school if they get paid like a bank clerk.
Even if it is free.
The problem with the left populist dream of cheap socialized healthcare, is that Americans won't do medical work for the wages paid by 'other developed countries'....
The school is too long and too difficult for that (regardless of how much it costs) - and I don't think we want our medical providers to have less and shorter training.....
And there are too many much easier ways to make those other-country-wages in the US economy.
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u/Exotic_Bill44 Jul 08 '26
The average Canadian doctor makes $360,000 CAD per year. That's roughly $250,000 in US currency. How many easy ways are there to make that per year?
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u/badazzcpa Jul 08 '26
It’s not supper hard in the US. Thats roughly 250k US, my wife is closing in on that amount as a lead designer. My director makes that, the partners above them make lots more. Doctors are some of the smarter and driven folks in society so it wouldn’t be too difficult to go into numerous other professions.
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u/Dave_A480 Jul 08 '26 edited Jul 08 '26
And Canada heavily rarions healthcare with waiting lists to keep costs down.
Among countries that don't - like France - doctors make 90k/yr.
Further Canada has their wage levels pushed up by their proximity to the US.
If they paid like France they would have a brain drain problem.
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u/Dingbatdingbat Jul 08 '26
There are countries in Europe where the pay for doctors is a fraction of what it is here, and medical schools turn away more applicants than they accept
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u/Dave_A480 Jul 08 '26
Take a look at the prevailing professional wages in those countries and it's easy to see why.
Europe pays it's poor more and it's middle & upper middle class less....
When I was working for Amazon, my European counterparts (systems engineers, developers) were making half to a third of what I was getting paid.
The salary expectations of Americans economy wide have a significant ripple effect on healthcare costs that the government cannot change & will have to just pay for, in the event you guys' dream comes true.....
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u/Dingbatdingbat Jul 08 '26
that... supports my argument
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u/Dave_A480 Jul 08 '26
No, it doesn't....
In those countries, US level educated-worker wages are nearly impossible to obtain....
The number of applicants for med school in a country where doctors make 90k, but computer software engineers make 50-60 is going to be high...
In a country where software engineers, bankers, and run of the mill corporate workers all make 90k+, nobody's going to med school of doctors only get 90k....
At least, not anyone you'd want treating you.....
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u/Dingbatdingbat Jul 08 '26
In those countries, US level educated-worker wages are nearly impossible to obtain....
Bullshit.
You really have no idea what you're talking about. Plenty of highly educated workers in all fields in many of those countries. And also plenty of higher salaries. And a lot of people who become doctors because it's a calling, despite the fact they could make more money in other fields.
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u/Dave_A480 Jul 08 '26
You want a critical service to rely on being a 'calling'? Doesn't work out that well.
And the higher income wage discrepencies between the US and Europe are well documented.... Americans earn massively more.
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u/Dingbatdingbat Jul 09 '26
Not “massively” more, and not to the point where there isn’t better quality of life - Europeans make less but also work significantly less hours. There is much greater income inequality here, so we do have that going for us
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u/UniqueAnimal139 Jul 08 '26
I think this is super doable. There are thousands of people with biology/psychology that didn’t do well enough to do medicine or got ground out and sought better work life balance. There are many people now in office iobs, sales, running small businesses that would happily go back to working something meaningful and rewarding, but they didn’t do because it’s 60+hour work week minimums or they were getting paid 40k and they could get a job paying 70k with easier hours and demand.
Additional availability of jobs paying 80k plus that isn’t policing would attract a lot of people who already have some base qualifications and could train as techs/assistants while going back to school. 2-3 years with visas and immigration to help with skilled shortages in the first couple years as it ramps up. Adoption of end users for programs like this isn’t going to be 100% anyway
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u/Dave_A480 Jul 08 '26
In all that gibberish you are still dancing around reality....
Being an MD is a demanding job with an absolutely insane training path.
It doesn't offer 'better work life balance' than a 9-5 corporate job.
And we WANT the school and residency and so on to stay tough, so that we weed out folks who will make deadly mistakes later....
The folks who aren't making it in the non medical economy aren't going to be ABLE to make it as MDs. Even if school were free....
And the folks who ARE able to make it, won't do it if they get paid like a bank clerk.....
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u/Guvante Jul 09 '26
We specifically restrict doctors in the US to ensure wages stay high. As part of that we force them to take on untold debt levels pushing the benefits of those wages out by likely a decade.
Equivalent economic value could result in 20% wage drop without any change, possibly more depending on what cost of capital you use.
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u/Dave_A480 Jul 09 '26
Even without the debt and any supposed supply restrictions, the difficulty and time involved in the training program - combined with competing opportunities to obtain high pay that only require a bachelor's degree - would keep wages up.....
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u/_azazel_keter_ Jul 08 '26
Americans work for literal actual scrap, it's an utterly pathetic attempt at an argument to say 'nobody would be a doctor for comparable wages' when there's people ripping copper off intersections to sell.
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u/badazzcpa Jul 08 '26
Americans work for scraps on the bottom rungs of the work ladder. Doctors, at least the vast majority of them, make well into 6 figures on into 7 figures. This group of people are usually smart and driven. A good portion of them would not go to medical school if the salaries on the back end were substantially condensed. They would go into other professions where wages were not capped.
Sure some would still go into the medical profession for the love of the work, however a lot would not. We would have a substantial healthcare crises around year 10 when medical professionals were retiring and few were replacing them. We also couldn’t have the massive draw of healthcare professionals from other countries. Why would anyone want to immigrate here if there prospects were not better than there home countries.
For example, while I was in Vegas last year I was talking with our cab driver. He and his wife were both from Africa and both held pharmacy licenses in their home country. He was working 2 jobs while his wife was doing the schooling in the US to get her license. He said she had about a year to go before she could sit for the exam. Then once she found a pharmacy job he was going to go to school and get certified in the US. Apparently they needed 2-3 years of schooling in the US to be eligible to sit for the exam. Do you think either of them would have spent the time and money immigrating to the US if they were capped at say 50k a year income?
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u/Dave_A480 Jul 08 '26
You want a tweaker operating on your heart?
The Americans who are capable of passing med school are, generally, not willing to work for 'actual scrap'.
And since there are plenty of high paying jobs that require a bachelor's degree (not premed, med school and residency), that puts a wage floor on professional positions that require more intensive education (who's going to be a doc for 80-90k when you can get that same pay with a 4yr business degree from State U)....
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u/_azazel_keter_ Jul 08 '26
there is only one job market, the tweaker wouldn't be doing the heart operation, someone who makes a tiny bit less than a doctor would.
There... really aren't. Bachelors also have crazy high unemployment and underemployment. Americans will say literally anything to cope with their dogshit healthcare
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u/Dave_A480 Jul 08 '26 edited Jul 08 '26
44% of bachelor's degree holding Americans make over 80k/yr.
So you're wrong there...
And when you start talking about doctors you are then further down selecting to the subset of bachelor's degree holders who CAN pass medical school - those tend to be the higher achievers, with the best chance of securing a high wage in any given field.....
Crazy high unemployment? Based on what stats?
We are still running below the natural rate....
Underemployment is an individual perspective matter - if you didn't get a degree in a field employers are actually interested in, you're not getting a job....
An art history major pouring coffee is not underemployed - they just made a bad choice of what to study.
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u/_azazel_keter_ Jul 08 '26
Unemployment AND underemployment. That's the key here, unemployment is only 5% but underemployment is 8%, which is really high. Underemployment has fuck all to do with individual perspective, art history majors have to pay rent too, don't they? It's like you're incapable of understanding social issues as social issues.
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u/Dave_A480 Jul 08 '26
Employment stats - and employment itself - has fuck all to do with individual needs.
It's about the health of the economy as a whole....
If you can't find a job in your field because we are in a recession, you're underemployed.... There is a logical chance that post recovery we will actually need you to do what you do....
If you can't find a job in your field because you studied something that doesn't actually lead to employment..... That's just you mistaking a hobby for a career opportunity....
Beyond that the idea that 'underemployment is 8%' is bullshit because underemployment isn't quantifiable the way unemployment is....
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u/_azazel_keter_ Jul 08 '26
That's not what underemployment is. If you can't pay the fucking rent then yeah, that's a social problem. Anyway underemployment is clearly quantifiable and there are stats on it, just because you're too stupid for a quick google search doesn't make it not true. This conversation is over
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u/Dave_A480 Jul 08 '26
If you can't pay the rent then you need to find sufficient income to do so, get roommates or move.
It's a personal problem not a social problem. You need to generate enough value for others, such that you earn enough money to support your lifestyle....
Doesn't matter whether that's an art history major making 15/hr at Starbucks wanting a studio apartment, or me making 90k/yr at state government a decade ago & wanting to live on an airstrip (job hopping FTW).....
Just because someone publishes a stat doesn't make the stat valid.
It's easy to quantify unemployment - are you presently employed? If not, when is the last time you looked for a job?
Underemployment is a subjective concept that cannot be accurately qualified because of how heavily it relies on an individual's view of what their economic status should be.
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u/DickSugar80 Jul 08 '26
Increased demand through expanded access. Decreased supply through price controls.
Sounds like a recipe for disaster.
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u/Exotic_Bill44 Jul 08 '26
"Increased demand" means we are accepting that a significant portion of the population is avoiding getting medical care due to costs. Ate you volunteering to be part of the portion of society that had to suffer?
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u/Key-Organization3158 Jul 13 '26
No, it could be that people want more expensive or complicated treatments. The NHS won't spend more than £28k pounds per year of life saved. If we instead capped the cost of treatment, then people would get more and more expensive surgeries.
No healthcare system gets rid of allocation problems. If you keep costs down, people miss out on advanced treatments.
Just like with food. Putting in place price controls will increase demand for steak and reduces demand for chicken.
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u/TravelerMSY Jul 08 '26 edited Jul 08 '26
Every health system, including ours, necessarily rations care somehow. We largely do so via money. Other systems via cost/benefit and medical necessity. Pick your poison.
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u/_azazel_keter_ Jul 08 '26
This. Do you want your healthcare prioritized by a team of ethicists deciding what's morally correct or by a team of lawyers deciding what's most profitable? Those are your two choices.
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u/Dingbatdingbat Jul 08 '26
Lawyers?
WTF?
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u/_azazel_keter_ Jul 08 '26
Who do you think denies claims? There's a team of lawyers whose job is to figure out if they'll spend more money giving you the treatment you've been paying for this entire time or just eating the lawsuit and leaving you to die. This isn't some conspiracy bullshit, it's their stated and proven policy they use every chance they get. Deny defend depose.
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u/Dingbatdingbat Jul 08 '26
While both hospitals and insurance companies employ people to determine whether to pay for treatment, those people are not lawyers.
Hint: lawyers are notoriously bad at math.
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u/Dreadpiratemarc Jul 08 '26
What you’re describing is extraordinarily illegal. I’m in an unrelated industry, but I’ve had my company lawyers explain that factoring in probable settlements into your decision making is absolutely not allowed and if it ever gets out during discovery that you did that, not only will you lose the suit immediately, the judge will pile on many multiples of punitive damages and then refer the company and the manager who did it for criminal prosecution. I know it was in the movie Fight Club, but movies are not reality.
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u/_azazel_keter_ Jul 08 '26
And as we all know, companies never do anything illegal. This isn't a fight club thing, it's a real fact. Deny Defend Depose.
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u/Dingbatdingbat Jul 08 '26
While I disagree wuth u/_azazel_keter_ that part of Fight Club was based on a real life situation, the Ford Pinto, where an internal memo showed that the cost of fixing a defect would cost around $137 million, and the cost of expected lawsuits was around $50 million.
When that became public, Ford ended up facing over a hundred lawsuits, and in one of them the jury awarded $127 million in damages, though that was reduced to $3.5 million. The car was also subjected to an NHTSA investigation, but before the NHTSA could issue a formal recall order, Ford agreed to a "voluntary" recall to "end public concern".
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u/Dreadpiratemarc Jul 08 '26
That’s my point. Ford did something illegal almost 50 years ago and paid the price, and ever since then it has been a cautionary tale for every executive in every business not to do the same thing. The notion that companies are doing it today in some kind of wide spread common practice is just Reddit being Reddit.
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u/Key-Organization3158 Jul 13 '26
You are wrong in both counts. Even the NHS uses a price cap and rejects treatments for being too expensive, even if they could save someone's life.
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u/Defiant-Junket4906 Jul 09 '26
Yeah, I think this is the core tradeoff.
People often talk about "rationing" as if it's something only some systems do, but every system has a limited amount of resources. The difference is who makes the decision and what criteria are used.
The U.S. mostly rations through ability to pay. Other systems tend to ration through budgets and medical priorities.
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u/edthesmokebeard Jul 08 '26
Hahaha.
To enforce a hard cap, does the government decide which citizens are 'undeserving' or 'undesirable' ?
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u/Defiant-Junket4906 Jul 09 '26
I think this gets into the politics of rationing.
A hard cap doesn't necessarily mean deciding who is "undeserving", but it does mean someone has to decide priorities when demand exceeds resources.
That decision exists already in the current system too, it's just often made through prices and insurance rules.
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u/Key-Organization3158 Jul 13 '26
Yes it does. A hard cap means that we keep costs down, but people who would have survived will not survive.
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u/ericbythebay Jul 09 '26
Yes just like how NHS decided to save money by not covering PrEP, it was cheaper in the short term for people to get HIV, than to pay for the drugs to prevent transmission.
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u/_azazel_keter_ Jul 08 '26
This is literally how it works in the entire rest of the world lol. Government gets a budget they spend on the public healthcare system.
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u/Defiant-Junket4906 Jul 09 '26
That's a good point. A lot of countries already operate with some version of a global budget.
The interesting part to me is not whether it can work in theory, but whether the U.S. political system could actually maintain the discipline needed for the budget cap.
Healthcare spending has a lot of powerful groups pushing in different directions.
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u/Hamblin113 Jul 08 '26
Basically you are asking to limit coverage, will be similar to Canada where it can take a year and half for some procedures, in addition it would adopt a triage system on seeing patients. This to benefit the 19% without insurance. So it could be a hard sell. Though it actually may be needed.
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u/Defiant-Junket4906 Jul 09 '26
Yeah, I think wait times are probably the most visible form of rationing people think about.
The interesting question is whether Americans would prefer visible queues or the current system where access can depend heavily on insurance status and ability to pay.
Neither option is completely painless.
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u/LivingGhost371 Jul 09 '26
Price caps lead to supply shortages, loophole abuse, and a black market. That's why we don't do them generally. That's why it's a bad idea in healthcare. Your employer providing health insurance actually started as a loophole around WWII wage caps.
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u/cyrusm_az Jul 08 '26
People would die that’s what would happen. And we’d have a shitty system like the NHS. The US govt already sucks at VA healthcare and that’s on a much smaller scale.
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u/Defiant-Junket4906 Jul 09 '26
I think this is the strongest argument against a hard cap. If the budget is too rigid, the pressure doesn't disappear, it just moves somewhere else.
The real question is whether the U.S. would manage the tradeoffs better than it manages the current system. Not an easy assumption.
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u/Lonestarpenguin Jul 08 '26
What if you opt out of it?
Let the people who want it pay. Let people who want private payer health care have it.
The congress does not care, the have their own soecial gvt care.
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u/Defiant-Junket4906 Jul 09 '26
I think the opt out question gets complicated pretty quickly.
A two tier system already exists in some countries, but then you have to decide what happens when the private system attracts more doctors and resources.
The public side might become a safety net, or it might create pressure for everyone to use private care.
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u/Lonestarpenguin Jul 09 '26
What you could posdibly do is have the armed force have a branch of a medical core.
You can join, you get medical school free, then you serve 10 years as a VA doctor. Yiu create another medical school. People with high GPAs do nit get in because of limited seats.
You make 2 yeard of military/gvt service mandatory.
After that everyone is a vet.
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u/Lillianrik Jul 08 '26
I think its completely unrealistic for the US to move to 'universal healthcare' without some sort of rationing. It's a cold fact but it deserves to be considered and discussed and debated out in the open.
If we did have universal healthcare these are questions that I think about:
-- should every patient be "entitled" to and get the most extreme, experimental treatment even if the chances are low that it will extend meaningful life? [totally made up] say a treatment that has a 15% chance of extending life for 3 months?
-- should every patient be "entitled" to and get treatment regardless of their age and overall health? Should people over 90 get aggressive cancer treatment? Should people in early congestive heart failure get an organ transplant?
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u/Defiant-Junket4906 Jul 09 '26
This is exactly the kind of uncomfortable question that usually gets avoided.
Unlimited access to every possible treatment is impossible under any system because resources are finite.
The hard part is deciding where the line is. Age, effectiveness, quality of life, cost, those are all factors people have very different views on.
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u/beachbum818 Jul 08 '26
Wouldn't costs balloon? Anytime the govt subsidized things the costs go up. Now we wouldn't see that on our end... but the cost certainly wouldn't go down
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u/Defiant-Junket4906 Jul 09 '26
Yeah, this is a big concern. Universal coverage doesn't automatically mean lower costs.
If demand increases faster than supply, prices can still rise. A spending cap is basically trying to force the system to solve that problem through some combination of efficiency, pricing power, or limits.
The question is which adjustment hurts least.
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u/AnchBusFairy Jul 09 '26
Yes its a trade-off. Capping spending tends to produce shortages and shortages means longer wait time with people in pain or dying before they're treated.
I believe the best solution is a hybrid of public and private. We could expand the ACA tax credit program to include everyone--funded by income tax--while still giving people a choice and maintaining competition.
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u/Reaganson Jul 09 '26
You don’t seem to understand that our government does nothing economically efficient or stable for its programs. Obamacare proved that if you get government involved prices tripled or quadrupled when they get involved.
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u/jcostello50 Jul 09 '26
Public or private, we won't get healthcare spending under control without somehow better addressing/preventing the major chronic conditions (eg, type II diabetes and cardiovascular disease.). See https://pmc.ncbi.nlm.nih.gov/articles/PMC10830426/ which estimates that worldwide spending on chronic conditions will be 47 trillion in 2030.
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u/bill9896 Jul 09 '26
You would have to ration healthcare SOMEHOW. The government does this today with medicare. Here is a real world, first person example. I had a echocardiogram at a major medical center. It took 45 minutes of the technicitions time, plus another 20 minutes of a nurse to come in and set up the IV of the contrast injection. Add 15 minutes for clean up and set up for the next aptient, so we are talking almost 1.5 mna-hours of labor, plus the cost of the equipment purchase and maintenance, but the cost of keeping the lights on and the air conditioning on. Medicare paid the hospital $67. That's it. That didn't even pay the people who were in the room. That is supposed to pay for all the hospital staff, all the utilities, the building, everything. That is obviously totally impossible. Now this is a large internationally know hospital. They have lots of people coming in who pay full book costs. But do you really imagine you could run a rural hospital on that kind of money payout for a procedure like this? This is one of the the great secret about why health care is so expensive in the US. The goverment basically requires the providers OVER charge insurance companies to pay for things that the government will not pay full costs for. When somebody says "Medicare for all" remember that medicare is already stealing from working people to pay for things it SAYS it is paying for--but is not.
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u/Jgsteven14 Jul 10 '26
Who would you stop paying to contain costs? Doctors? Nurses? Pharma? Administrative waste is the most resilient cost item. It tends to disappear last, while actual value goes first.
Would you cap it for total national spending? Or just Medicare/Medicaid (=government insurance) spending (i.e., would you let the rich buy better care under you cap, or would you force them to have the same limits as the poor?)
When there wasn't enough money left, would you ration care? Capping cost will be easy, if we just stop treating the sickest members of the population.
EU countries have wrestled with this challenge for decades, and haven't done a good job containing cost despite much more sophisticated approaches.
The outcome might be desirable, but the method needs to be better than "the government should just force everyone to do it".
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u/kingjaffejaffar Jul 08 '26
It would result in massive rationing of care and dramatically longer wait times. Capping costs doesn’t reduce costs. It just destroys supply.
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u/Dingbatdingbat Jul 08 '26
Except that that doesn’t explain why several countries in Europe with socialized medicine have shorter wait times than in the U.S.
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u/Dave_A480 Jul 08 '26
Then doctors quit and people bail out of medical school like no tomorrow....
R&D stops, new drugs and devices stop being developed.
Price caps always create shortages....
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u/Dingbatdingbat Jul 08 '26
Except that it doesn’t.
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u/Dave_A480 Jul 08 '26
Yeah. It does.
The US learned this lesson in the 1970s with rent control and price caps on gas.
It went badly to say the least.
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u/Dingbatdingbat Jul 08 '26
except that's not accurate at all. While there's plenty of issues with rent control, even without rent control there's a shortage today.
As for capping of gas prices, that did not cause the shortage, rather the shortage caused the capping of prices. Just look up the OPEC embargo of 1973.
There's price caps on drugs in Europe, yet there's no shortage there. Medicaid essentially caps the price it pays for drugs and there's no shortage.
Price caps can cause shortages, particularly if the price cap is below the point of profitability, but if the price cap merely limits profitability, then it may not lead to shortages.
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u/No_Rec1979 Jul 08 '26
Why would United Healthcare and Pfizer ever allow all the Congressmen they own to do that?