15th November 2026
The debate over Medicare for All in the United States raises an interesting question. If America finds it so difficult to provide affordable healthcare for its population, how do Britain, Germany, France, the Netherlands and other developed countries manage to provide universal or near-universal coverage?
The United States spends more money on healthcare than any other developed country, yet millions of Americans remain uninsured or struggle with the cost of medical treatment.
According to the OECD's Health at a Glance 2025 report, American healthcare spending reached approximately $14,885 per person in 2024, measured in purchasing power adjusted dollars. That compares with $6,747 in the United Kingdom, $7,367 in France and $9,365 in Germany.
America spends approximately two and a half times the OECD average per person.
These figures do not mean that every country provides the same services or achieves the same results. However, they raise an important question about whether the American system is delivering value for the money being spent.
Britain: Healthcare funded through taxation
The British National Health Service is probably the model most familiar to American supporters of universal healthcare.
The NHS was established in 1948, based on the principle that healthcare should be available according to medical need rather than the ability to pay.
It is principally funded through general taxation and National Insurance contributions, although the latter are not a dedicated NHS insurance premium.
Most NHS treatment is free at the point of use. Patients do not receive bills for ordinary GP consultations, hospital treatment or emergency care.
There are exceptions, including prescription charges in England, although prescriptions are free in Scotland, Wales and Northern Ireland. Dental and optical services also have different charging arrangements.
One important advantage is that people do not normally need to worry about losing their health insurance when changing jobs or becoming unemployed.
However, the NHS has its own serious problems.
Waiting lists for hospital treatment, pressure on emergency departments, staff shortages and difficulties accessing some GP services have become major concerns.
The NHS demonstrates that universal coverage can be organised without patients paying directly for most treatment, but it also demonstrates that providing a service free at the point of use does not remove the need for sufficient funding, staff and hospital capacity.
Germany: A different approach to universal coverage
Germany provides an interesting alternative because it does not rely on a single national health service.
Instead, it operates a system of statutory health insurance, funded mainly through contributions from employees and employers.
Most residents are covered by non-profit statutory health insurance funds, known as sickness funds. Contributions are linked to earnings, with employers and employees sharing the cost.
There is also a private insurance system, available to certain higher earners, self-employed people and other eligible groups.
Unlike Britain, patients generally have more direct choice over their health insurance arrangements and healthcare providers.
The German system provides universal coverage while retaining a significant role for insurance organisations and independent medical practices.
It is not necessarily cheap. Germany spends considerably more per person on healthcare than Britain, but still substantially less than America.
It demonstrates that universal healthcare does not require the government to own or operate every hospital or medical practice.
France: Combining public funding with private provision
France operates another model, based on compulsory health insurance financed through social contributions and taxation.
The system provides broad coverage for residents, with the government playing a substantial role in determining what treatments are covered and how healthcare providers are reimbursed.
Patients can often choose their doctors and hospitals, including private providers.
Many French people also have supplementary insurance, known as a mutuelle, which helps cover costs not fully reimbursed by the statutory system.
The result is a system combining public financing, private medical provision and additional insurance.
France spends more per person than Britain, but considerably less than the United States.
It also illustrates that universal coverage does not mean every medical service must be provided by a government-owned organisation.
The Netherlands: Private insurance with compulsory coverage
The Netherlands offers perhaps the most interesting comparison for Americans who favour retaining a role for private insurance.
Residents are required to purchase basic health insurance from competing private insurers.
However, this is not the same as the largely employment-based and fragmented American insurance market.
The Dutch government determines the basic package of benefits, insurers must accept applicants for that package regardless of their medical history, and premiums and risk equalisation arrangements are regulated.
People can choose between insurers, while the government provides income-related assistance to help lower-income households meet insurance costs.
There are deductibles and some patient contributions, but the system ensures that everyone has access to basic coverage.
The Netherlands demonstrates that private insurance companies can operate within a universal healthcare framework, provided there are strong rules governing coverage and affordability.
What do the international comparisons tell us?
The Commonwealth Fund's 2024 Mirror, Mirror report compared healthcare systems in ten developed countries, examining access to care, quality, administrative efficiency, equity and health outcomes.
The United States came last overall, while Australia, the Netherlands and the United Kingdom occupied the first three positions.
The report identified several important weaknesses in the American system.
Patients face considerable difficulties dealing with insurance companies, medical bills and coverage restrictions. Doctors and hospitals spend substantial time dealing with insurance administration.
In contrast, countries with universal coverage generally have fewer financial barriers preventing people from seeking treatment.
However, the comparison also revealed that no country has a perfect healthcare system.
The United States performed relatively well in some measures of the care process, including preventive services and patient safety. Other countries also face waiting lists, staffing shortages and difficulties accessing particular treatments.
The lesson is not that every aspect of European healthcare is superior. It is that universal coverage can be achieved through several different financing and delivery arrangements.
Could America adopt a European model?
This is where the political debate becomes more complicated.
America has a population of more than 340 million people, a large and influential private healthcare industry, and a complicated mixture of federal and state responsibilities.
Replacing the existing system overnight would create enormous disruption.
However, there is no requirement for America to copy the British NHS.
It could instead introduce compulsory basic health insurance, as in the Netherlands, with government regulation ensuring that everyone is covered.
Alternatively, it could expand Medicare gradually, introduce a public insurance option and retain private insurance for supplementary services.
Germany and France also demonstrate that employers can contribute towards healthcare financing without necessarily becoming responsible for arranging every employee's insurance policy.
The American government could negotiate more effectively over prescription drug prices, simplify medical billing and introduce stronger controls over insurance practices.
These changes would not automatically deliver the same savings as a complete single-payer system, but they could address some of the problems without requiring an immediate transformation of the entire healthcare industry.
The cost of doing nothing
There is another economic consideration.
Healthcare costs affect more than patients and government budgets. They also influence business competitiveness, household finances and employment decisions.
American employers spend substantial sums providing health insurance for their workers. Smaller businesses can find this particularly difficult, while employees may be reluctant to change jobs because they fear losing their existing medical cover.
Medical debt is also a significant problem for American households.
A healthcare system that provides universal coverage could reduce some of these pressures, although the costs would have to be financed through taxation, insurance contributions or a combination of both.
The important point is that the existing American system is not free. Households and businesses already pay enormous amounts, but those payments are distributed across insurance premiums, employer contributions, taxes and direct medical bills.
Changing the financing arrangements would not make the underlying healthcare requirements disappear.
A for the American political debate
The experience of Britain and European countries challenges the suggestion that universal healthcare is beyond the financial capabilities of a wealthy country.
There are several workable models, ranging from Britain's tax-funded NHS to Germany's insurance-based arrangements and the Netherlands' regulated private insurance system.
Each has advantages and disadvantages.
The British system offers protection against large medical bills but struggles with waiting times and capacity. Germany provides greater choice and a different relationship between insurers and providers, but costs more. The Netherlands retains private insurers while ensuring universal basic coverage through regulation.
For Democrats, these examples provide alternatives to the choice between maintaining the existing American system and immediately replacing it with a single government-run insurance programme.
They also demonstrate why the debate should not be reduced to whether healthcare should be publicly or privately provided.
The more important questions are how it is financed, how efficiently money is spent, whether everyone is covered and whether patients can obtain treatment when they need it.
America already spends more on healthcare than any other developed country. The international evidence suggests that the challenge is not simply finding more money.
It is deciding whether the country can organise the money it already spends in a way that delivers better access, greater financial security and improved health outcomes.
Perhaps the most uncomfortable question for American politicians is not whether the country can afford universal healthcare, but why it currently spends so much more than other wealthy nations while leaving so many people struggling to obtain it.
Commonwealth Fund Mirror Mirror 2024 comparative performance of ten healthcare systems
Health at a Glance 2025