What is single-payer health reform?

Universal coverage for all medically necessary care – health care that’s publicly financed but largely privately delivered.

In the U.S. context, “single payer” usually refers to “single-payer national health insurance,” a nonprofit system in which everyone is covered under a single public or quasi-public plan that pays for care, but the delivery of care remains largely in private hands.

Under a single-payer system, every resident of the U.S. would be covered from birth to death for all medically necessary care, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs. Patients would no longer face financial barriers to care such as premiums, copays and deductibles, all of which would be abolished. Coverage would be portable – e.g. no longer tied to employment or to an insurer’s network of providers – and truly universal.

Patients would have free choice of doctor and hospital. The restrictive networks associated with today’s private insurance companies would be eliminated.

Doctors would regain autonomy over patient care, no longer micromanaged by private insurers or burdened by costly paperwork.

The single-payer system’s overarching aim is to provide comprehensive health coverage to everyone in the country, and to do so equitably, efficiently and at lower cost to individuals and the nation.

Key features of a single-payer program are concisely enumerated here. For a recent, detailed description of such a plan, see the Physicians’ Proposal for Single-Payer Health Reform published in the American Journal of Public Health.

How can we afford it?

By slashing administrative waste, retaining current public funding of care, and introducing modest new progressive taxes.

The system would be funded in part by the savings obtained from replacing today’s welter of inefficient, profit-oriented, private insurance companies – and the system-wide administrative waste they generate – with a single streamlined, nonprofit public payer. Such savings, estimated in 2017 to be about $500 billion annually, would be redirected to patient care.

Existing tax revenue would fund much of the system. According to a 2016 study in the American Journal of Public Health, tax-funded expenditures already account for about two-thirds of U.S. health spending. That revenue would be retained and supplemented by modest new taxes based on ability to pay, taxes that would typically be fully offset by the elimination of today’s premiums and out-of-pocket expenses for care. The vast majority of U.S. households – one study says 95 percent – would come out financially ahead.

The system would also reap savings from its powerful bargaining clout, e.g. its ability to negotiate with drug and medical supply companies for lower prices.

It would also save money by giving hospitals annual lump-sum (“global”) budgets to run their operations, rather than have them bill for every Band-Aid, and by regulating hospitals’ capital expenditures (new buildings, major equipment) on the basis of community need. All hospitals would be required to transition to nonprofit status, another source of the system’s savings.

Over the past several decades, more than two dozen independent analyses of federal and state single-payer legislation by agencies such as the Congressional Budget Office, the General Accountability Office, the Lewin Group, and Mathematica Policy Research Group have found that the administrative savings and other efficiencies of a single-payer program would provide more than enough resources to provide first-dollar coverage to everyone in the country with no increase in overall U.S. health spending.

Will a single-payer system work?

Other countries show it works well. Our own Medicare program is instructive.

Yes. Single-payer programs in other nations such as Canada, Taiwan, and Australia show that it’s possible to provide high-quality care for everyone at about half the cost, per capita, that the U.S. is spending now. Medical outcomes in such systems are generally as good if not better than those with private insurance in the U.S., and everyone is covered.

Our traditional Medicare program, which provides coverage for our nation’s seniors and the severely disabled, operates with low overhead, about 2 percent, in comparison with private insurers’ average overhead of about 12-14 percent. And Medicare enjoys very strong public approval ratings. That said, today’s Medicare suffers from serious deficiencies such as high cost sharing and gaps in coverage. And because it operates alongside many other insurance plans, hospitals and other providers have to maintain their complex and expensive cost tracking and billing systems. A single-payer national health insurance program would correct those deficiencies, creating, in effect, an improved version of Medicare for all.

Is this program ‘socialized medicine’?

No. It’s closer to Canada’s system than the U.K.’s.

In socialized medicine systems, hospitals are owned by the government and doctors are salaried public employees. Although socialized medicine has worked well for our Veterans Administration, and for countries that have single-payer “national health services” like England, Sweden and Spain, that way of organizing care is not the same as what we are talking about here.

Canada is often cited as an example of a country with single-payer health insurance. Canada’s federal and provincial governments handle the system’s financing, but care is delivered mainly through doctors in private practice and privately owned hospitals.

In many ways our traditional Medicare program, which is a form of social insurance, bears a resemblance to single-payer national health insurance.

Is there support for this approach in Congress?

Support in the House and Senate is at an all-time high.

The Medicare for All Act of 2019, H.R. 1384, is currently in Congress. The bill would establish an American single-payer health insurance system, publicly financed and privately delivered, that builds on the existing Medicare program. H.R. 1384 was introduced by Rep. Pramila Jayapal and more than 100 co-sponsors in February of 2019. Its predecessor, H.R. 676, was co-sponsored by a majority of the House Democratic caucus in the previous (115th) Congress.

Polls over the past two decades show that 72 percent of the U.S. population supports this approach.

On the Senate side, Sen. Bernie Sanders has introduced the Medicare for All Act of 2019, S. 1129, which had 14 original co-sponsors. PNHP has welcomed Sanders’ bill, but notes it could be strengthened in several important ways.

What about Obamacare?

The Affordable Care Act (“Obamacare”) aims to expand coverage to about 30 million Americans by requiring people to buy private insurance policies (partially subsidizing those policies by government payments to private insurers) and by expanding Medicaid. However:

• About 30 million people will still be uninsured in 2023, and tens of millions will remain underinsured.
• Insurers will continue to strip down policies, maintain restrictive networks, limit and deny care, and increase patients’ co-pays, deductibles and other out-of-pocket costs.
• The law preserves our fragmented financing system, making it impossible to control costs.
• The law continues the unfair financing of health care, whereby costs are disproportionately borne by middle- and lower-income Americans and those families facing acute or chronic illness.
• Currently, 12 states have refused to expand Medicaid.

This handy chart compares single payer and the ACA.