Is a Single-Payer System the Answer? It Depends, What’s the Question?

by JHI Staff on January 17, 2014

There’s been a growing amount of attention paid recently in the U.S. media to the question of whether our country should offer universal health coverage, and move to a “single-payer” health care system. The two concepts are sometimes used almost interchangeably, as in this article about former Secretary of State Colin Powell’s advocating that the U.S. adopt those approaches to paying for health care:

“I have benefited from that kind of universal health care in my 55 years of public life,” Powell said....“And I don’t see why we can’t do what Europe is doing, what Canada is doing, what Korea is doing, what all these other places are doing.” Europe, Canada and Korea all have a “single-payer” system, in which the government pays for the costs of health care.

I’m sure Mr. Powell is aware of the differences between the concepts of universal health coverage (sometimes called universal health care) and single-payer systems, but it’s easy to misinterpret him as meaning that with either one, everyone in the country gets full health care and the government foots the bill. But as this article from Forbes points out, that’s really not the case. As the article puts it, universal health coverage “is less about how healthcare is funded and focuses more on who has access to healthcare.” What’s more, a single-payer system doesn’t necessarily guarantee everyone full access to good health care.

A single-payer system is one in which payer (almost always the government) pays all health care costs. It’s generally considered one form of universal health coverage, and it’s by far the most common form of universal health coverage in the world. But saying that the government pays all costs isn’t the same as saying everyone gets all the care they need. Critical questions remain: For example, does the government only pay for health care for citizens? That can be a big issue in many countries that have large permanent-resident non-citizen populations who may be living under work or student visas, or who may not be granted citizenship for reasons relating to their origins even though they were born in the country. It might be a sticky issue in the U.S. if the government were to take over all health care costs, for example, given our large population of non-citizen residents.

In addition, just because the government pays all costs doesn’t mean that it actually covers all the health care that people may feel they need or deserve. It may only provide what might be considered to be a low level of care, or the needed services may not be available to some or all of the population. As the World Health Organization notes, true universal health coverage entails

a strong, efficient, well-run health system....access to essential medicines and technologies, [and] a sufficient capacity of well-trained, motivated health workers.

Any or all of these may be lacking in countries that have single-payer systems. (You even hear complaints to that effect in countries like Canada and the U.K. that are considered models of single-payer systems—though on the whole these systems are pretty good, and of course any system has its boosters and detractors.)

By the same token, countries without single-payer systems can do a good job of making sure the great majority of the population has access to good care. Singapore comes to mind. There, as I’ve noted in a previous post, the government requires people to save up so they can afford to pay for decent health care out of pocket.

What’s more, the U.S., for all its health care shortcomings, actually doesn’t do a bad job in making good care available to virtually everyone who lives in the country. People who don’t have insurance can end up in heavy debt if they need costly treatments, but they won’t be denied treatment. And the fact is, between employer-paid insurance, state or federally subsidized insurance, and government-paid health care, including Medicare, Medicaid, and military and veteran benefits, the vast majority of people in the U.S. are either covered or can afford to be. It’s a flawed system, but not nearly the catastrophe it’s often made out to be, especially given the high general quality of care here. Under Obamacare, the breadth of coverage and affordability will further improve for most people who currently find it hard to get coverage.

Would a single-payer system work well here? The argument relayed to us by the media is often between people who take the opposite extreme points of view: that government ruins everything and should leave as much as possible to the super-efficient private sector, or that the private sector is unethical and should be shouldered aside by the fair and effective government. As you might guess, I’m not especially comfortable with either extreme view. But I’m fairly agnostic about where we ought to be between those extremes.

The question of how much of our health care should be paid for by the government is important, but I don’t think there’s a right answer. From my point of view it’s really the wrong question to focus on. The real question should be: What are the best ways to deliver the highest quality care to the most people? The answer to that question has less to do with who foots the bill and more to do with what it takes for a population to have access to a lot of good, local hospitals; to a pool of dedicated, highly trained clinicians; to the latest standard of care in evidence-based diagnosis and treatment, and to the education and support they need to take good care of themselves.

We have all that in the U.S., but many countries throughout the world are still working on it. Let’s remember that the next time an article makes it sound like we’re a backwards nation in terms of health care because we don’t have a single-payer system or universal health care. Sure, we have problems here, but in many ways they’re the easier problems to solve.


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Health Care Communitarianism in Colombia
June 23, 2014 at 9:15 am

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Natalia Ojeda January 26, 2014 at 2:31 pm

Mr Thompson,
As a Spanier who was trained at JH in the 90s and live and practice in Bilbao, Spain, since 1997, I totatlly agree with your view of the decline of the health care system in my country. Sadly, the Basque region (northern Spain) enjoyed for many years an excellent public health system used for the all population. The quality of the service is no longer the same and now far to be desirable and the causes were well pointed out in your description. As part of our local academic system in this part of the world, I am conscius that our local public institutions would support a change for going back to the system that once made us feel as proud citizens. I wonder if we could collaborate with JHI and make the Basque health system to recover the radiance; specifically to aim "a strong, efficient, well-run health system....access to essential medicines and technologies, [and] a sufficient capacity of well-trained, motivated health workers".
Natalia Ojeda


CALynn January 19, 2014 at 2:16 pm

Seriously? This article is not a joke? The author actually writes that the US doesn't do a bad job of making health care available to everyone in the US.
The US health care system is the worst on the planet. It is a convoluted mess of redundancy, inefficiency and waste. Further it is immoral. It wastes billions on advertising, back-patting promotion in colorful ads sprayed in newspapers, billboards, and magazines across the US. Every time I watch the 30-times-a-day advertisement for Cancer Centers of America, I feel like puking. It is available only if you can afford it. Everything in the US health care system has the same caveat: ONLY IF YOU CAN AFFORD IT. Before my father died a year ago, he had FIVE health care policies: Medicare, Supplemental Medicare, PAAD, The VA, and Medicaid. I am still getting bills from health "care" servicers even though they were paid handsomely. This article is a joke, for sure. Universal single-payer health care is synonymous with Improved and Expanded Medicare for all. And that is what the US needs, not its current profit-first, take 30 to 35% off the top for CEO compensation and overhead/profit immoral insurance companies. I am going to barf now.


Joe Lendvai January 17, 2014 at 11:31 pm

Far from being clear, I find the author's views, sad, callous and simply inaccurate. Single payer is universal health care. That's the whole point, to cover everyone, period. And for less than what we as nation are paying today, and in my case, we as Mainers are paying today. No one is questioning the talent and caring of the American medical community. It's the uncontrolled costs, needless complexity, waste, unneeded treatments, inefficiency and fraud; the daily fear of getting sick and not not being able to pay for treatment is why 37% of us don't see a doctor, even when we should. (See Nov. 2013 health systems survey, "Access, Affordability…" by The Commonwealth Fund).
And I am not even addressing the 45 million plus uninsured and even more underinsured, the real human costs that is dismissed by the author. Sad. Wrong. I can only shake my head in disappointment.


wenda royster January 17, 2014 at 10:15 am

Mr. Thompson,
Thank you so very much for this clarity, with all due respect to the General Powell you are correct.
I grew up on Military bases abroad and state side having free medical and dental care. Yes, the treatment was free but if a particular expertise was needed one had to seek attention outside the system and pay. I suppose for many it served their needs well, however for specialized services and expert medical care many times one has to explore other options. I feel it is critical to remember everyone is different, what works for one may not work for another.
Wenda Royster


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