When you pay top dollar for a good or a service, it’s reasonable to expect the best.

The United States spends more per capita on healthcare than any other country in the world, amounting to more than $3 trillion, or about one-sixth of the country’s economy.

But despite the high price tag, the United States is still the only wealthy, developed nation without universal health coverage.

Now, as congressional Republicans remain divided over healthcare reform, the issue of universal health coverage is getting renewed attention on both sides of the political spectrum.

Sen. Bernie Sanders, I-Vt., has repeated calls for a Medicare for All program that would provide health coverage for people of all ages, while gradually replacing the for-profit insurance industry.

“If every major country on Earth guarantees healthcare to all people, and costs a fraction per capita of what we spend, don’t tell me that in the United States of America, we cannot do that,” Sanders said at a Boston rally in March.

Sanders has put forward similar proposals before, in the Senate and as a nominee for Democratic Party leadership.

More surprising are the prominent conservative voices advocating for some form of universal coverage.

In an op-ed last month, Christopher Ruddy, chief executive officer of the conservative site Newsmax, and an ally of President Donald Trump, called for “an upgraded Medicaid system to become the country’s blanket insurer for the uninsured.”

A few days later, conservative writer Ross Douthat devoted his New York Timescolumn to pondering how to make U.S. healthcare more like Singapore’s low-cost universal system, though he thinks it’s implausible.

While Republicans continue to disagree over plans for health reform, discussion about the possibility of a universal system for the United States may grow.

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The political divide

Since the Affordable Care Act (ACA) — commonly known as Obamacare — was enacted, Republicans have vowed to repeal it, but last month the party was too divided to move forward with a House vote on their replacement bill.

That bill, the American Health Care Act (AHCA) — sometimes called Ryancare or Trumpcare —would have repealed major parts of the ACA, including the individual mandate that requires people who don’t buy insurance to pay a fine.

It also would have phased out the ACA’s expansion of Medicaid and allowed insurers to charge older adults higher premiums than younger people.

According to a report from the nonpartisan Congressional Budget Office, the bill would have left 24 million Americans uninsured within the next decade.

The main disagreement that stalled the bill was between the GOP’s far-right conservatives, who want to get rid of as much of the ACA as possible, and moderate Republicans, who want to ensure their constituents don’t lose health insurance.

“I believe this bill, in its current form, will lead to the loss of coverage and make insurance unaffordable for too many Americans, particularly for low-to-moderate income and older individuals,” said Rep. Charlie Dent, R-Pa., co-chair of a moderate Republican caucus called the Tuesday Group, in a statement.

Political blog FiveThirtyEight’s analysis showed that it would be impossible for the Trump administration to get enough votes for the bill to pass the House without support from moderate Republicans.

Four Republican senators also sent a letter to Senate Majority Leader Mitch McConnell, R-Ky., indicating they would not support the plan to phase out the ACA’s Medicaid expansion because “reform should not come at the cost of disruption in access to healthcare for our country’s most vulnerable and sickest individuals.”

It’s those types of statements that fuel speculation — in The New York Times, for example —that the Trump administration might have more success in reforming healthcare by embracing a universal system that covers everyone.

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What is universal healthcare?

The terms “universal” and “single-payer” are sometimes confused when it comes to healthcare — but they are not the same thing.

Universal health coverage is a broad term meaning that everyone has “access to good quality health services without suffering financial hardship,” according to the Organization for Economic Cooperation and Development.

There are at least two major types of universal health coverage, explained William Hsiao, PhD, a health economist at the Harvard T.H. Chan School of Public Health who has designed universal healthcare systems in Taiwan, Sweden, and Malaysia, among others.

One is the “National Health Service” model, used in the United Kingdom.

It is a single-payer system because it is tax-funded and most healthcare is provided by the government through public hospitals and clinics.

In the United States, the U.S. Department of Veterans Affairs operates in a similar way.

The other type is the “National Health Insurance” model, in which the government mandates that everyone have health insurance, but services are delivered by a mix of public, nonprofit, and for-profit providers.

Within this second model, a range of different systems exists worldwide — some are single-payer, but others are multi-payer.

Canada’s healthcare system and the U.S. Medicare system are single-payer. Everyone is required to pay into a government insurance plan, which in turn pays doctors and hospitals.

Multi-payer systems operate differently.

In Switzerland, for example, residents must buy insurance from competing nonprofit insurers, and the government subsidizes premiums, while also subsidizing doctors and hospitals.

France, often considered to have the best healthcare system in the world, requires residents to enroll in government-funded insurance, but allows for private complementary insurance, too.

Though different, the United Kingdom, Canadian, Swiss, and French systems are all considered universal.

And in each country, the government spends less per capita on healthcare than the U.S. government spends.

In fact, the U.S. government spends more per capita on healthcare than any other government except Norway and the Netherlands.

But high spending doesn’t translate into better health outcomes in the United States.

Compared with other wealthy countries, the United States has lower life expectancy, a higher infant mortality rate, and significant rates of chronic disease, according to a 2015 report from the Commonwealth Fund.

“Around the world, I tell other countries, you can learn from America’s health system by understanding what not to do,” Hsiao told Healthline.

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Why U.S. healthcare stands out

In order for a universal system to work, Hsiao said the government must require that everyone participate.

The ACA’s individual mandate is meant to keep the health insurance market financially sound by pushing healthy people to buy insurance — but it is one of Republicans’ most disliked aspects of the law.

Hsiao thinks the reason the United States doesn’t have a universal system is that Americans place such a high value on individual liberty.

“If you believe individual liberty is most important, it means that everyone can make their own choice, to choose what insurance they have or not,” Hsiao said.

It’s also a matter of history.

The United States developed an extensive private health system at a time when other countries lagged behind, according to Gerald Friedman, PhD, a health economist at University of Massachusetts at Amherst, who supports the single-payer movement.

After World War II, it was straightforward for other countries to move from minimal coverage to universal programs because they had few private interests to contend with.

Americans, on the other hand, had a vested interest in their private system. Employers and employees wanted to keep insurance as a tax-free job perk, while healthcare providers wanted to protect their income.

Those private interests are part of the reason U.S. healthcare is so expensive.

For years, Friedman tried to convince people that a single-payer system would save the country money.

“Then I realized every dollar I talked about saving is a dollar of somebody’s income,” he told Healthline. “It may be a health insurer, it may be a drug company, it may be a hospital.”

In countries where health insurance is government-run or nonprofit-run, there is no profit factor to drive up prices.

A Commonwealth Fund report found that high healthcare spending in the United States was mostly driven by greater use of technology and higher healthcare prices.

For example, a typical bypass surgery in the Netherlands costs about $15,000 while in the United States it costs about $75,000.

Prescription drugs are also pricier in the United States — sometimes more than double what other countries pay.

That’s at least in part because other governments evaluate drugs for cost-effectiveness and set prices, but the U.S. government doesn’t.

The government agency that runs Medicare is actually prohibited from negotiating drug prices.

Another factor driving up U.S. healthcare costs are administrative expenses, since a system with many different insurance companies creates complex billing arrangements.

A study in the journal Health Affairsfound that those types of expenses made up more than 25 percent of total U.S. hospital expenditures.

That’s about double the rate of administrative expenses in Canada and Scotland, which both have universal, single-payer systems.

If the United States reduced those expenses, the study authors estimate it would save more than $150 billion per year.

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Conservative approaches

The conservatives who have spoken in favor of universal healthcare — still a minority among right-wing thinkers — tend to prefer multi-payer systems.

Ruddy’s plan, for example, would include private insurance markets, in addition to bolstering Medicaid and Medicare.

Another multi-payer model discussed by conservatives is Singapore’s healthcare system.

The country has a unique program that requires citizens to pay into personal accounts — with matching employer contributions — that are used to cover care as part of a subsidized national health insurance scheme.

Avik Roy, Forbes opinion editor and founder of conservative think tank FREOPP, based his ACA replacement plan on the Singapore and Swiss models.

In a Washington Examiner op-ed, Roy wrote, “Singapore and Switzerland spend far less on healthcare than we do and yet achieve all of the things that Americans value about their own system: choice, technology, and physician access.”

Critics point out that both systems are heavily regulated and government subsidized — aspects that traditional conservatives would resist.

Roy said he’s been arguing for at least five years that conservatives should embrace the cause of universal coverage.

“The perception on the right is that universal coverage costs too much and it would require more government intervention in the healthcare system,” Roy told Healthline.

He disagrees.

“Because the cost of our system is so high, if you have a lower cost system, you could actually cover everyone and spend less money,” Roy said.

Roy generally opposes single-payer models, but that’s not true of all conservatives.

F.H. Buckley, a professor at Antonin Scalia Law School at George Mason University, and a Trump supporter, recently called on the president to support a single-payer system, noting that he promised his plan would leave no one uninsured.

“The simplest way to do this is universal healthcare, on the Canadian model, with a right of individuals to purchase a Cadillac plan on top of this out-of-pocket,” Buckley wrote in the New York Post.

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Medicare for all

Though it’s highly unlikely, if Trump did want to support a single-payer plan, there is one in the works.

Sanders said he would introduce a bill to create a single-payer system within weeks.

Several progressive groups, including the Working Families Party, Social Security Works, and National Nurses United have endorsed the move.

“Our job is not just to prevent the repeal of the Affordable Care Act,” Sanders told crowds at the Boston rally. “Our job is to join the rest of the industrialized world, [and] guarantee healthcare to all people as a right.”

An estimated 28 million people in America still don’t have health insurance, despite the ACA.

Supporters say the Medicare for All plan would cut U.S. healthcare costs dramatically and provide universal coverage.

“A single-payer system would provide enormous efficiencies in administrative costs and in drug savings. Those savings could be used to provide healthcare for everyone without breaking the bank,” said Dr. Adam Gaffney, a board member of the advocacy group Physicians for a National Health Program (PNHP).

Friedman estimates the Medicare for All plan would save the U.S. economy about $200 billion per year, while expanding access to healthcare services.

“If we paid prices for drugs like Europeans and Canadians do, then we would save $100 billion right away,” he added.

Critics of the plan argue that it would lead to higher taxes and increase federal spending, with no guarantee it would rein in costs.

But single-payer advocates insist there would be overall savings.

“For many people, you will see good benefit in paying for healthcare through a tax instead of a premium,” Gaffney said.

Hsiao and Friedman told Healthline that people generally don’t understand the true costs they already pay for health coverage.

“Your employer gives you a total compensation package,” Hsiao explained. “The health insurance premium paid by the employer squeezes down our cash compensation.”

Friedman said that a single-payer system would benefit business because the current burden of health insurance raises U.S. labor costs.

“It’s one factor leading companies to leave the country or to import stuff from other countries, rather than hiring Americans to do it,” he added.

Another Medicare for All bill was already put forward by Rep. John Conyers, D-Mich., in the House, in January.

The bill has virtually no chance of passing and hasn’t even received support from a majority of House Democrats, though Conyers tweeted that it has “record-breaking” support compared to previous versions.

Rep. Steve Cohen, D-Tenn., one of the bill’s co-sponsors, told Healthline he supports the legislation because he represents a low-income constituency in Memphis that would benefit from it.

He said that under the AHCA, Memphis would have been among the hardest hit cities for loss of benefits.

“If an idea has merit, it’s worth supporting,” Cohen said. “Most new ideas and good ideas take a while to percolate. And if you believe it’s a good idea, you should support it regardless of the political climate.”

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The high stakes of health reform

Vicki Tosher, a 64-year-old editor from Colorado, told Healthline she’s “been counting down the days” until her 65th birthday, when she will qualify for Medicare.

A three-time breast cancer survivor, she knows too well the financial stress that can accompany a serious illness.

In 2003, after her second breast cancer diagnosis, Tosher said her medical expenses hit an all-time high, at more than $20,000 for the year.

Then in 2009, she lost her job, followed by her employer-backed health insurance, and learned that none of the private health insurers in Colorado would cover her because of her previous breast cancer diagnoses.

“The risk of recurrence was just too high,” she told Healthline. “I was uninsurable.”

Tosher eventually found high-risk coverage through a state program and switched to a cheaper ACA plan when Colorado’s insurance marketplace opened.

Last year, Tosher faced another breast cancer diagnosis, and even with an ACA subsidy, she said the financial hardship is significant.

“I plan my budget around making sure I have enough money to pay my medical bills,” she said.

But she knows others who face greater difficulties.

Tosher helped found the Colorado nonprofit Sense of Security, which provides grants to people with breast cancer who are struggling financially.

“We try to allow them to focus on treatment and healing rather than worrying about whether or not they’re going to be able to feed their families or lose their homes,” she said.

It’s people like Tosher and those she’s helped who are at the heart of why health reform causes contentious and emotional debate.

No politician wants to be responsible for someone with cancer losing their health insurance or home.

Tosher was relieved when Republicans withdrew their ACA replacement bill because she felt the fringes on both sides of the issue would not cooperate to create a workable plan.

“The biggest sense of relief I have is that people are going to have to start talking to one another,” she added.