United States National Health Care Act

United States National Health Care Act
United States National Health Care Act
Great Seal of the United States.
Full title To provide for comprehensive health insurance coverage for all United States residents, and for other purposes.
Acronym USNHCA / Single-Payer Health Care
Legislative history
  • Introduced in the House of Representatives as H.R.676 by Rep. John Conyers (D-MI) on January 26, 2009
  • Committee consideration by: Committee on Energy and Commerce, Committee on Ways and Means, Committee on Natural Resources
Major amendments
Relevant Supreme Court cases
Health care reform in the United States
Enacted legislation
of late

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The United States National Health Care Act, or the Expanded and Improved Medicare for All Act (H.R. 676), is a bill introduced in the United States House of Representatives by Representative John Conyers (D-MI). The bill had 88 cosponsors as of October 7, 2009.

The act calls for the creation of a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. Under the policies this Act would enact, all medically-necessary medical care decided between doctor and patient would be paid for automatically and directly by the Government of the United States, ending the need for private insurance for such care, and probably recasting private insurance companies as purely supplemental coverage, to be used when non-essential care is sought, as often happens in the United Kingdom for things like dentistry services.

The national system would be paid for through taxes, and these monies, which replace insurance premiums and, with them, the main core justification for private insurances to begin with. Advocates of this "single-payer health care", such as economist Paul Krugman, have argued that by eliminating insurance companies as they exist now, and thus also their administrative overhead, overall health care costs would be reduced sufficiently to cover the presently uninsured—and everyone else—with ease and possibly even ultimately a monetary surplus.[1]

The bill was first introduced in 2003,[2] when it had 25 cosponsors, and has been reintroduced in each Congress since. However, it has always failed, including in its latest (unofficial) push by activists during the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act. H.R. 676 was expected to be debated and voted upon by the House in September 2009,[3] but was never debated.[4] Advocates who remained staunchly for single-payer health care as the ultimate vote and passage of the America's Affordable Health Choices Act of 2009 loomed, tried in vain to present HR 676 as a viable alternative to the Affordable Health Care for America Act, H.R. 3962, but were ignored, and even in some cases arrested by police during various nationwide debate events, with the implicit approval of Max Baucus, who acted as head of these debates.

Currently, advocacy of HR 676 has once again faded to the sidelines, and even many of its most intense advocates seem to have accepted that single-payer health care is now once again a long-term project that is years, perhaps decades, away from realisation. Some in the movement have presently proposed a shift in emphasis away from an effort at a national law and more efforts towards enactments of single-payer systems within individual U.S. states, the idea being that state-level single-payer would serve as living models for the arguments for federal coverage.


Elements of the bill

The summary of the National Health Care Act includes the following elements, among others:[5]

  1. Expands the Medicare program to provide all individuals residing in the United States and U.S. territories with free (i.e. tax-funded) health care that includes all medically necessary care. This would include primary care and prevention, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.
  2. Prohibits an institution from participating unless it is a public or nonprofit institution. Allows nonprofit health maintenance organizations (HMOs) that deliver care in their own facilities to participate. On the whole, private insurances would be replaced with the new nationalized system for all basic, major care.
  3. Gives patients the freedom to choose from participating physicians and institutions—which, given the coverage of the new national system, would be any institution or clinic in the United States receiving any degree of public funding (i.e. the vast majority).
  4. Prohibits a private health insurer from selling health insurance coverage that duplicates the benefits provided under this Act. Allows the private insurers to sell benefits that are not medically necessary, such as cosmetic surgery benefits.
  5. Sets forth methods to pay institutional providers of care and health professionals for services. Prohibits financial incentives between HMOs and physicians based on utilization.
  6. Establishes the USNHC Trust Fund to finance the Program with amounts deposited: (1) from existing sources of government revenues for health care; (2) by increasing personal income taxes on the top 5% of income earners; (3) by instituting a progressive excise tax on payroll and self-employment income; and (4) by instituting a small tax on stock and bond transactions. Transfers and appropriates amounts that would have been appropriated for federal public health care programs, including Medicare, Medicaid, and the State Children's Health Insurance Program. These taxes would be paid instead of insurance premiums, as the government (instead of private insurance companies) would be paying for the care under this single-payer system.
  7. Establishes a program to assist individuals whose jobs are eliminated (e.g., within insurance companies) due to the simplified single-payer administrative process.
  8. Requires creation of a confidential electronic patient record system.
  9. Establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability.
  10. Provides for: (1) the eventual integration of the Indian Health Service into the Program; and (2) evaluation of the continued independence of Department of Veterans Affairs (VA) health programs.
  11. The bill covers treatments on or after the first day of the year that begins one full year after passage (January 1, 2013 if the bill is passed in 2011). Compensation continues for 15 years to owners of converting for-profit providers for reasonable financial losses.

Cost analysis of the bill

An analysis of the bill by Physicians for a National Health Program who estimated the savings at $350 billion per year in 2008.[6] Others have estimated a 40% savings[7] due to elimination of insurance company overhead costs.[8]

The Congressional Budget Office has yet to "score" or evaluate the bill as of August 2009.[citation needed] Paying for the 55% of medical costs not already covered by government programs would shift significant costs from insurance companies to the government, but this cost would be offset by tax revenues to the extent determined by Congress, as insurance premiums now paid to insurance companies would be replaced by taxes paid to the government. The immediate savings realized would be from the removal of insurance company overhead and hospital billing costs having to do with those private insurances. Paul Krugman described this savings as follows in 2005:[9]

The great advantage of universal, government-provided health insurance is lower costs. Canada's government-run insurance system has much less bureaucracy and much lower administrative costs than our largely private system. Medicare has much lower administrative costs than private insurance. The reason is that single-payer systems do not devote large resources to screening out high-risk clients or charging them higher fees. The savings from a single-payer system would probably exceed $200 billion a year, far more than the cost of covering all of those now uninsured.

Applying Krugman's $200 billion savings estimate to the U.S. population of approximately 300 million people representing 100 million households,[10] this amounts to approximately $650 per person or $2,000 per household. A study by Harvard University and the Canadian Institute for Health Information estimated the 1999 costs of U.S. health care administration at nearly $300 billion, accounting for 30.1% of health care expenses, versus 16.7% in Canada. This study estimated the U.S. per-person administrative cost at $1,059.[11] One organization that advocates nationalized health care estimated this savings could be as high as $350 billion per year in "...overhead, underwriting, billing, sales and marketing departments as well as huge profits and exorbitant executive pay."[12]

The incremental cost of covering the 46 million uninsured was not scored for this bill. However, a similar cost was estimated by the CBO at approximately $100 billion per year for the America's Affordable Health Choices Act of 2009.[13] This would partially offset the savings indicated above.


H.R. 676, though introduced in 2003, initially received little attention; with the June 2007 release of the Michael Moore documentary Sicko, which focuses on the status of health care in the only developed country without universal health care, interest in the Act was renewed.[14][15] The DVD edition of the film includes a segment (Sicko Goes To Washington) promoting the bill.[16][17][18]

In 2009 the bill was reintroduced and renamed from the United States National Health Insurance Act to the United States National Care Act, a reflection of the fact that the bill provides health care instead of providing health insurance. Health care was a major part of Barack Obama's campaign promises, and while he admitted that only a single payer system would provide universal coverage, the plan favored by Obama would be to increase insurance coverage instead. However, town hall remarks by Obama have indeed included support for a single payer system, particularly during his 2003-era pronouncements.[19]

In 2007, about 46 million Americans were without health insurance, but increasing insurance would still not provide coverage for the approximately one third of those who actually qualify for Medicare and Medicaid but are unable or unwilling to apply.[20]


The bill proposes an expansion of the Medicare program to the non-elderly to provide universal coverage and allows individuals to select their own doctors. The bill would create a single-payer system, with Medicare replacing the 1,300 private insurance companies currently involved, which would reduce net costs between $100 and $250 billion annually, based on estimates. The savings relates to the approximately one-third of health care expenses that are spent on administrative overhead rather than medical service delivery. Also, rather than covering 80% of medical costs with the remaining 20% to be paid either out-of-pocket by the patient or via a privately-underwritten "supplemental" insurance plan, as Medicare is structured now, HR 676 would cover 100% of all expenses. One of the alternative names for HR 676 among activists is "Medicare for All", but this is not quite fully accurate, given that if "Medicare for All" were all that really comprised HR 676, then the universal coverage would still need to pay the remaining 20%. Under HR 676 no one will need to do this. Activists claim they use "Medicare for All" as a slogan to increase ease of understanding of what single-payer is among the general U.S. populace, who, they contend, might not understand the scheme as well if a "full" explanation were given from the outset.

H.R. 676 does represent a significant expansion of government in health care, and is in fact the one example among health care plan options in the United States that would objectively qualify as a "government takeover" of health care. This is one of the primary arguments that opponents of the bill use when they come out against it. However, advocates do not see the prospect of a "government takeover of health care" as pejorative the way some others in the country do; they claim it is no different than "government-run" parks and recreation facilities, "government-run" police departments or "government-run" fire departments. Under HR 676 the government would be essentially replacing the foremost part of the private health insurance industry.[21] Conservatives historically have argued against the expansion of government programs, offering significant resistance to the current and prior health care reform efforts,[22] and the bill would raise taxes for higher-income individuals.[21] On July 30, 2009, Rep. Anthony Weiner offered Republicans an opportunity to oppose government-run health care programs by putting forth an amendment[23] that would eliminate Medicare.[24] Every single Republican representative (and every Democrat) on the House Energy and Commerce committee voted to continue Medicare.[25]

Opinion polling

According to the liberal media criticism organization Fairness and Accuracy in Reporting, a 1987 New York Times/CBS poll showed 78% of people saying that the "government should guarantee medical care to everyone."[26] Between 2003 to 2009, 17 opinion polls showed a majority of the public supports various levels of government involvement in health care in the United States.[27] Many polls, such as ones administered through CNN,[28] AP-Yahoo,[29][30] New York Times/CBS News Poll,[31][32] and Washington Post/ABC News Poll,[33] Kaiser Family Foundation[34] showed a majority in favor of a form of national health insurance, often compared to Medicare. The Civil Society Institute[35] and Physicians for a National Health Program[36] have both found majorities in favor of the government offering guaranteed insurance, and a Quinnipiac poll in three states in 2008 found majority support for the government ensuring "that everyone in the United States has adequate health-care" among likely Democratic primary voters.[37]

In contrast, a January 2010 Rasmussen Reports poll of registered voters showed only 34% of respondents in favor of single-payer health care, with a majority (52%) opposed.[38] Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care."[39] Responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare," less favorably when stated as "socialized."[40]

Medical tourism

Since the act covers all "residents," a section was added requiring the Secretary of HHS to create a rule addressing the possibility of medical tourism (Section 101(e))[citation needed].

See also


  1. ^ Krugman-NYT-One Nation, Uninsured-June 2005
  2. ^ H.R. 676
  3. ^ "Single Payer Gets A Vote (Updated)". Daily News (New York). July 31, 2009. http://www.nydailynews.com/blogs/dc/2009/07/single-payer-gets-a-vote.html. 
  4. ^ "H.R. 676: United States National Health Care Act or the Expanded and Improved Medicare for All Act (Govtrack.us)". http://www.govtrack.us/congress/bill.xpd?bill=h111-676. Retrieved 12/1/2009. 
  5. ^ United States National Health Care Act - Summary
  6. ^ Physicians for a National Health Program (2008) "Single Payer System Cost?" PNHP.org
  7. ^ Hogg, W.; Baskerville, N; Lemelin, J (2005). "Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis". BMC Health Services Research 5 (1): 20. doi:10.1186/1472-6963-5-20. PMC 1079830. PMID 15755330. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1079830. 
  8. ^ Levy A.R. et al. (2010). "International comparison of comparative effectiveness research in five jurisdictions: insights for the US". Pharmacoeconomics 28 (10): 813–30. doi:10.2165/11536150-000000000-00000. PMID 20831289. http://www.ingentaconnect.com/content/adis/pec/2010/00000028/00000010/art00004. 
  9. ^ NYT-Krugman-One Nation, Uninsured
  10. ^ U.S. Census Report-Projection of Households and Families in the U.S.
  11. ^ Research Report-Harvard & Canadian Institute for Health Information-Costs of Healthcare Administration in the U.S. and Canada 2003
  12. ^ PNHP-Single Payer National Health Insurance
  13. ^ CBO Report-July 14
  14. ^ Insuring America's Health: Principles and Recommendations, Institute of Medicine of the National Academies of Science.
  15. ^ The Case For Single Payer, Universal Health Care For The United States, John R. Battista, M.D. and Justine McCabe, Ph.D.
  16. ^ American Health Care Reform.org
  17. ^ Towards Universal Health Care
  18. ^ Universal Health Plan is Endorsed The Boston Globe August 13, 2003
  19. ^ Town Hall Meeting on Health Care
  20. ^ More Americans Have No Health Insurance retrieved 21 September 2009
  21. ^ a b Summary of the Bill
  22. ^ The New Republic-Conservatism is Dead-Tanenhaus-February 2009
  23. ^ http://energycommerce.house.gov/Press_111/20090730/hr3200_weiner_1.pdf
  24. ^ Anthony Weiner (2009-07-30). "Weiner Challenges the Republicans to Put-Up or Shut-Up on Healthcare". http://www.youtube.com/watch?v=sTh-Yu9RfF0. 
  25. ^ "Committee on Energy and Commerce - 11th Congress: Roll call vote: Rep Weiner 06A". Committee on Energy and Commerce. http://energycommerce.house.gov/Press_111/20090730/hr3200_weiner_1_rc.pdf. 
  26. ^ Fear & Loathing at the Democratic Convention
  27. ^ http://www.wpasinglepayer.org/PollResults.html
  28. ^ New polls on universal, tax-supported health care | Physicians for a National Health Program
  29. ^ http://l.yimg.com/a/i/us/nws/elections/2008/yahoo2topline.pdf
  30. ^ Where are we on reform? | Physicians for a National Health Program
  31. ^ In Poll, Wide Support for Government-Run Health
  32. ^ CBS News. http://www.cbsnews.com/htdocs/pdf/SunMo_poll_0209.pdf. 
  33. ^ Question 49
  34. ^ Kaiser Health Tracking Poll: July 2009 - Topline
  35. ^ "Health care survey: 2 out of 3 Americans now favor government-guaranteed coverage". Dermatology Nursing. 2004. http://findarticles.com/p/articles/mi_hb6366/is_6_16/ai_n29141381/. 
  36. ^ Public opinion on health care reform | Physicians for a National Health Program
  37. ^ Question 9: "Do you think it's the government's responsibility to make sure that everyone in the United States has adequate health-care, or don't you think so?"
  38. ^ Rasmussen Reports
  39. ^ http://www.politifact.com/truth-o-meter/statements/2009/oct/01/michael-moore/michael-moore-claims-majority-favor-single-payer-h/
  40. ^ http://www.politifact.com/truth-o-meter/statements/2009/oct/01/michael-moore/michael-moore-claims-majority-favor-single-payer-h/

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