Barriers to Universal Health Coverage in the US

Under the 2015 Sustainable Development Goals, all United Nations Member States set out to pursue the implementation of universal health coverage (UHC) to reach this objective by 2030. This commitment reaffirms the urgency for greater access to essential health services for all people without exposing them to financial hardship. With the U.S. struggling to ensure universal health care, especially for socioeconomically vulnerable populations, concerns arise about navigating the health care system towards the improved cost, coverage, and access. While these barriers to UHC remain a considerable challenge, the U.S. could potentially overcome them through further Medicaid expansion, improved preventative and promotive initiatives, and setting the course toward a single-payer system.

These barriers are particularly challenging because the cost and insurance coverage are intertwined with access to health care. As Shi & Singh (2022) note, without enhanced cost-containment measures, improvements in the effectiveness of the healthcare delivery system “will remain elusive, because cost, access, and quality are interrelated” (p. 249). Moreover, a cross-sectional study by Coombs et al. (2021) showed that 71.1% of 50,103 respondents cite affordability, ability to pay for health care services, and insurance as the most prevalent barrier to accessing health care. As the authors note, the reduced access to health care is evident in the heightened risk of having no usual source of care, restraining from medical care due to cost, and attending work when sick. Furthermore, the lack of healthcare coverage was attributed to low- and middle-income American households “avoiding care due to cost,” who also “did not have a primary care provider” (Griffith et al., 2017, p. 6). These challenges largely stem from the low availability of government-sponsored health insurance, high administrative costs of private insurance, and the complexities of the multi-payer system, which provide an insight into possible solutions.

An extensive Medicaid implementation under the Affordable Care Act (ACA) has been characterized by a significant increase in insurance coverage and health care use, especially among lower-income families across the U.S. In Medicaid expansion states between 2013-2015, households in lower socioeconomic strata with annual income below $25,000 saw a 15% increase in insurance coverage and 7.7% in having a primary care provider (Griffith et al., 2017). As the authors further note, this expansion under the ACA has also resulted in a 7.5% decrease in avoiding medical care due to cost for lower-income households. Moreover, a 2015 survey of 60,766 respondents with family income below 138% of the federal poverty level showed an 8.2% greater increase in insurance rates in expansion states against non-expansion states (Miller & Wherry, 2017). Consequently, expanding enrollment in Medicaid would considerably improve cost, coverage, and overall access to medical care in the U.S., particularly for economically vulnerable populations.

While Medicaid aims to increase access to medical intervention for an illness or health problem, improved disease prevention and health promotion initiatives could also prove to be a catalyst for growth. While preventive and promotive health programs cannot solve “every health problem, these principles have yet to be accorded their rightful place in the U.S. health care delivery system” (Shi & Singh, 2022, p. 253). As the authors note, overwhelmingly focusing the medical model of health care delivery on intervention rather than prevention/promotion entails significantly higher national health expenditure against health issues that otherwise could have been averted or mitigated. In other words, by enhancing disease prevention and health promotion measures, the national healthcare system could markedly reduce health care costs and, in turn, devote investment into improving access and insurance coverage.

Furthermore, part of the reason for the high cost of health care in the U.S. is the multi-payer health care system financed by government-private sector cooperation. Indeed, due to the intrinsic complexities of the U.S. multi-payer system, Medicaid programs are often prone to health fraud, including cost-duplication, higher billing rates, and provision of more services than needed (Shi & Singh, 2022). So much so that, as the authors note, cost-duplication alone accounts for nearly 25% of overall national health care expenditure. In contrast, a single-payer system enables a streamlined health care reimbursement processing, which would considerably reduce administrative health care expenses and save patients from excess financial burden, further promoting greater access and coverage.

In summary, the barriers to UHC in the U.S. are the limited availability of public insurance, high administrative expenses in private insurance, and the room for extensive health fraud within the complicated multi-payer system. These challenges impede the progress towards a more efficient health care delivery system, characterized by greater access, insurance coverage, and reasonable costs of health care services. This progress can be catalyzed by further Medicaid expansion, improved disease prevention and health promotion programs, and an initiative towards a generally single-payer system.


Coombs, N. C., Meriwether, W. E., Caringi, J., & Newcomer, S. R. (2021). Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM – Population Health, 15. Web.

Griffith, K., Evans, L., & Bor, J. (2017). The Affordable Care Act reduced socioeconomic disparities in health care access. Health Affairs, 36(8), 1503-1510. Web.

Miller, S., & Wherry, L. R. (2017). Health and access to care during the first 2 years of the ACA Medicaid expansions. New England Journal of Medicine, 376(10), 947-956. Web.

Shi, L., & Singh, D. A. (2022). Essentials of the U.S. health care system. Jones & Bartlett Learning. Web.

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