The United States provides universal health care. Sound laughable? It’s true: all individuals in America, whether citizens, immigrants, or tourists, are entitled to government subsidized care in the event of medical emergency. While the uninsured may not be able to get a routine doctor’s appointment, they are guaranteed life saving surgery and medical intervention, regardless of cost. Indeed, care for indigents can occasionally run into the hundreds of thousands per year, as they repeatedly return to the emergency room for treatments of illness caused by chronic diseases like diabetes. The US spends roughly 75 billion annually on treating the nation’s 40+ million uninsured; the situation among alcoholics in Seattle has become so absurd that they are being given housing and routine medical care, since this decreases the cost of treating them in emergency situations.

Perhaps it is no surprise then that America spends a larger percentage of its GDP on health care than almost any other nation, and yet it lags on a wide range of health indicators, including overall life expectancy. How did such a situation emerge? Largely by accident, it turns out. In 1986, the EMTALA was passed by Congress, denying hospitals the right to refuse critically ill patients. Federal and state governments partially reimburse providers for costs incurred for this treatment through Medicaid and Medicare. Unfortunately, critical care is provided without any cost-benefit analysis whatsoever; it is considered a criminal act to withhold treatment from elderly, terminally ill patients, even if it would extend their life by a matter of weeks.

As US healthcare costs continue to spiral upward at rates often double and triple that of overall inflation, the situation becomes increasingly untenable. But what are the alternatives to America’s current system?

1. Remove required treatment burdens from hospitals, leaving the burden of care to individuals, charities, and local and state government.

2. Provide routine medical care to the uninsured, eliminating the treatment gap for the uninsured.

3. Require all Americans to buy insurance, or to pay a healthcare tax to pay for the implied insurance provided by emergency rooms.

4. Begin to consider rationing publicly funded health care based on cost-benefit analysis, taking into account a procedure’s likelihood of success, its cost, the patient’s age, and other factors.

Option 1 is politically infeasible for an industrialized nation, and is included only for completeness. Providing routine medical care to the uninsured, as in option 2, would expand America’s current system to be more similar to European systems of comprehensive universal public health care. Nations like the UK and Canada ration non-critical care within their systems in order to control costs; the very notion of health care rationing is anathema in the US currently, making public dialogue on public universal care close to impossible. Australia, meanwhile, has a hybrid healthcare system which includes public insurance for all while enabling private care to co-exist, potentially providing a model for US healthcare reform.

Massachusetts has begun a program similar to that outlined in option 3, in which all residents without insurance are required to purchase insurance or pay a tax to subsidize the emergency coverage that all residents receive. Poor residents are provided with assistance to pay for an insurance policy, enabling all residents to acquire coverage. This system provides the benefit of extending coverage across the population, while forcing everyone to contribute, thus averaging out costs across healthy and less healthy individuals. Since the system provides a net increase in medical coverage, however, it will result in increased costs over time.

This brings us to option 4, the unspeakable in the American health care dialogue: rationing. In practical terms, medical decision-makers find it difficult to discuss the notion of saving $100,000 by not performing a procedure, even if it has a 1 in 1,000 chance of success. Cost-benefit based rationing of care is not a solution to the problems of health care access. Rather, it is an eventuality that will have to be confronted, as public expenditure on health care cannot forever grow faster than the economy. Until then, America’s broken universal healthcare system will continue to plod along, destined to hit the wall when we just can’t find another dollar to keep 95 year-old vegetables alive another minute.