The Effect of Large-scale Health Coverage Expansions in Wealthy Nations on Society-Wide Healthcare Utilization

  • Adam GaffneyEmail author
  • Steffie Woolhandler
  • David Himmelstein


Most analysts project that a reform like Medicare-for-All that lowers financial barriers to care would cause a surge in the utilization of services, raising costs despite stable or even reduced prices. However, the finite supply of physicians and hospital beds could constrain such utilization increases. We reviewed the effects of 13 universal coverage expansions in capitalist nations on physician and hospital utilization, beginning with New Zealand’s 1938 Social Security Act up through the 2010 Affordable Care Act in the USA. Almost all coverage expansions had either a small (i.e., < 10%) or no effect on society-wide utilization. However, coverage expansions often redistributed care—increasing use among newly covered groups while producing small, offsetting reductions among those already covered. We conclude that in wealthy nations, large-scale coverage expansions need not cause overall utilization to surge if provider supply is controlled. However, such reforms could redirect care towards patients who most need it.


healthcare reform healthcare utilization 



We thank the following individuals for their assistance and guidance:

New Zealand: Ian Powell and Lyndon Keene.

UK: Martin Gorsky; John Mohan; Martin Powell.

Sweden: Finn Diderichsen.

Canada: Greg Marchildon

Finland: Lauri Vuorenkoski

Belgium: Jean-Pierre Unger; Pol De Vos.

Australia: Stephen Duckett. Of note, Dr. Duckett provided the table and citation for reference 128.

Portugal: Pedro Pita Barros.

Greece: Alexis Benos; Elias Kondilis; Charalampos Economou. Of note, Elias Kondilis provided the data displayed in E-Figure 2.

Spain: Vicente Navarro

Norway: Andy Oxman; Ingrid Sperre Saunes.

Taiwan: Tsung-Mei Cheng

Compliance with Ethical Standards

Conflict of Interest

The authors serve as leaders of physicians for a National Health Program (PNHP), a non-profit organization that favors coverage expansion through a single-payer program. None of them receives any compensation from that group; some of Dr. Gaffney’s travel on behalf of the organization is reimbursed by it. The authors report no conflicts of interest with any commercial entities.

Supplementary material

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ESM 1 (DOCX 96 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  1. 1.Harvard Medical School Cambridge Health AllianceCambridgeUSA
  2. 2.City University of New York at Hunter CollegeNew YorkUSA

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