Well, that’s it for healthcare reform. I really think the U.S. can have its cake and eat it too. In other words, we can have universal healthcare and eventually reduce healthcare spending in the process. Check out Parts I-VIII of this series for details.

Yes, insurers do contribute to the high cost of healthcare in the U.S., mostly by increasing the administrative burden of providers, e.g., time and staff needed for care authorization and payment. However, this administrative burden serves a purpose: to reduce unnecessary spending associated with healthcare fraud and low-value care, an estimated $300 billion per year for fraud and $340 billion a year for low-value care.  I’m sure there are ways to lessen the burden, perhaps by standardizing forms, requirements and procedures across insurers. But administrative reform isn’t going to put a big dent in U.S. healthcare spending, because it already plays a relatively small role in overall spending.  

Here’s an idea, inspired by Amazon’s example.  Why not offer “reward points” to patients for using healthcare providers offering clinically necessary care at a price below a region’s mean? …Similar to Amazon’s system, reward points would be converted to a cash value and applied to a patient’s co-pays, deductibles or insurance premiums. Since Medicare and private insurers already use regional price means to determine payment rates, a reward point system wouldn’t be that hard to implement. However, it wouldn’t work well without other conditions, such as mandatory insurance, transparent pricing and a sufficient number of local providers for meaningful price comparisons

Despite decades of cost-saving reforms, U.S. healthcare is still the most expensive in the world (per capita and GDP). Yet U.S. physicians keep making more money every year. And the entire healthcare system benefits financially from income generated by our doctors.

Roemer's law states that "a hospital bed built is a bed filled." In essence, Roemer's Law argues that hospitals and physicians do what they can to take advantage of their available resources and if demand for services are less than capacity, hospitals and physicians will figure ways to induce more demand. The motivation here is to make as much money as capacity allows.

For the purposes of this post, I’m defining mandatory insurance coverage as 99% of the U.S.population with some form of public or private health insurance. As for the remaining 1%, there will always be a few conscientious objectors, especially in America.

So how do we do it? Mostly by following the example of Massachusetts, which has already achieved 98% coverage. So how does Massachusetts do it?

A universal healthcare system could be established in the U.S. by leveraging existing structures like Medicare, Medicaid, and the insurance industry, using a range of provider and consumer incentives to control costs. Our current system already covers around 92% of the U.S. population under age 65 - only 8% to go!. That seems eminently doable, especially considering that over half the currently uninsured are actually eligible for healthcare coverage but simply have not enrolled in a government program. The rest are ineligible for government assistance, mostly due to immigration status or affordable alternatives given their income. Here’s the breakdown…

California, Massachusetts, New Jersey, Rhode Island, Vermont, and Washington, D.C., already have insurance mandates. Residents in these areas must have qualifying health coverage or face tax penalties. Except for New Jersey, their uninsured populations are lower than the U.S. rate of 7.9%. For instance, the uninsured rate is just 2.8% in Massachusetts and 3% in Washington D.C. That’s not too far from universal coverage.

A universal healthcare system can be established in the U.S. by leveraging existing structures like Medicare, Medicaid, and the insurance industry, using a range of provider and consumer incentives to control costs. The old and disabled would continue to receive Medicare and government support would be available for low-income households.

Here are components of the existing system that would be retained, expanded or tweaked in my proposed universal healthcare system…

Should the U.S. have a universal healthcare system? By all means! No American should be denied necessary care. Besides, according to the latest Pew survey, 66% of Americans want a universal system, the younger the stronger the support. Even Republicans are getting on the universal healthcare bandwagon - 41% in the latest poll, up from 32% in 2021 (Pew Research, 2025). The time has come to get serious about what such a system should look like in the U.S.