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Single-payer health care

Single-payer health care is a system in which governments, rather than private insurers, pay for all Canada, or they may own and employ health care resources and personnel, as in the United Kingdom.

The term "single-payer" thus describes only the funding mechanism, health care financed by a single public body from a single fund. It does not specify the type of delivery or for whom doctors work.

The actual funding of a "single payer" system comes from all or a portion of the covered population. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.


  • Description 1
  • Single-payer systems in various countries and regions 2
    • Australia 2.1
    • Canada 2.2
    • Spain 2.3
    • Taiwan 2.4
    • United Kingdom 2.5
    • United States 2.6
      • National policies and proposals 2.6.1
      • State proposals 2.6.2
        • California
        • Hawaii
        • Illinois
        • Massachusetts
        • Minnesota
        • Montana
        • New York
        • Oregon
        • Pennsylvania
        • Vermont
      • Public opinion 2.6.3
      • Advocacy groups 2.6.4
  • See also 3
  • References 4


Single-payer health insurance collects all medical fees and then pays for all services through a single government (or government-related) source.[2] In wealthy nations, this kind of publicly managed insurance is typically extended to all citizens and legal residents. Examples include the United Kingdom's National Health Service, Australia's Medicare, Canada's Medicare, and Taiwan's National Health Insurance.

The standard usage of the term "single-payer health care" refers to health insurance, as opposed to health care delivery, operating as a public service and offered to citizens and legal residents towards providing nearly universal or universal health care. The fund can be managed by the government directly or as a publicly owned and regulated agency.[2] Some writers describe publicly administered health care systems as "single-payer plans." Uncommonly, some writers have described any system of health care that intends to cover the entire population, such as voucher plans, as "single-payer plans."[3]

Single-payer systems in various countries and regions

Many nations worldwide have single-payer health insurance programs. These programs generally provide some form of universal health care, which are implemented in a variety of ways. In some cases, doctors may be contracted and hospitals run by the government, such as in the Canada.


Health care in Australia is provided by both private and government institutions. Medicare is the publicly funded universal health care venture in Australia. It was instituted in 1984 and coexists with a private health system. Medicare is funded partly by a 2% income tax levy[6] (with exceptions for low-income earners) but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme that considerably subsidises a range of prescription medications. The Minister for Health, currently Sussan Ley, administers national health policy, elements of which (such as the operation of hospitals) are overseen by individual states.


Health care in Canada is delivered through a publicly funded health care system, which is mostly free at the point of use and has most services provided by private entities.[7] It is guided by the provisions of the Canada Health Act of 1984.[8] The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between patient and physician. Canada's provincially-based Medicare systems are cost effective partly because of their administrative simplicity. In each province, each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses health care to be involved in billing and reclaim. Private insurance represents a minimal part of the overall health care system.

Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, except in British Columbia, the only province to impose a fixed monthly premium, waived or reduced for those on low incomes.[9]There are no deductibles on basic health care and copayments are extremely low or nonexistent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). A health card is issued by the provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care.[10] There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but they are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered but can be paid out of pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for preexisting conditions.

Pharmaceutical medications are covered by public funds for the elderly or the indigent[11] or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Canadians wait for some treatments and diagnostic services. Survey data shows that the median wait time to see a special physician is a little over four weeks, with 89.5% waiting less than three months. The median wait time for diagnostic services such as MRI and CAT scans[12] is two weeks, with 86.4% waiting less than three months.[13] The median wait time for surgery is four weeks, with 82.2% waiting less than three months. In addition, there is concern of a "brain drain" as high-quality medical graduates leave Canada for better-paying careers in the U.S.[14]


Building upon less structured foundations, in 1963 ,the existence of a single-payer health care system in Spain was established by the Spanish government.[15] The system was sustained by contributions from workers and covered them and their dependents.[16] The universality of the system was established only in 1986. At the same time, management of public health care was delegated to the different autonomous communities in the country.[17]

Since 1997, public authorities can delegate management of publicly funded health care to private companies.[18] Additionally, in parallel to the single-payer healthcare system, there are private insurers, which provide coverage for some private doctors and hospitals. Employers will sometimes offer private health insurance as a benefit,[19] with 14.8% of the Spanish population being covered under private health insurance in 2013.[20]

In 2000, the Spanish healthcare system was rated by the World Health Organization as the 7th best in the world.


Healthcare in Taiwan is administrated by the Department of Health of the Executive Yuan. As with other developed economies, Taiwanese people are well-nourished but face such health problems as chronic obesity and heart disease.[21] In 2002, Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population.[21] In 2002, there were a total of 36 hospitals and 2,601 clinics in the country. Per capita health expenditures totaled US$752 in 2000.[21] Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 (or $951 US in 2009[22]); 64.9 percent of the expenditures were from public funds.[21] Overall life expectancy in 2009 was 78 years.[23]

The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan that centralizes the disbursement of health care funds. The system promises equal access to health care for all citizens, and coverage had reached 99% by the end of 2004.[24] NHI is mainly financed through premiums, which are based on the payroll tax and supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many health care providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.

United Kingdom

Healthcare in the United Kingdom is a devolved matter so England, Northern Ireland, Scotland and Wales each have their own systems of private and publicly funded healthcare, generally referred to as the National Health Service (NHS). Each country has different policies and priorities, which has resulted in a variety of differences existing between the systems;[25][26] however, each country provides public healthcare to all UK permanent residents that is free at the point of need paid for from general taxation. In addition, the private health care sector, considerably smaller than its public equivalent, is funded as part of an employer scheme or occasionally paid directly by the customer but provision can be restricted for those with conditions such as AIDS/HIV.[27]

The individual systems are:

United States

A number of proposals have been made for a universal single-payer health care system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All"), but none have achieved more political support than 20% congressional cosponsorship.

Advocates argue that preventive health care expenditures can save several hundreds of billions of dollars per year because publicly funded universal health care would benefit employers and consumers, as employers would benefit from a bigger pool of potential customers. Also, health care costs could be reduced, producing a more competitive labor market and reducing inequities between employers, producing a more fluid economy and increasing economic growth, aggregate demand, corporate profit, and quality of life.[28][29][30] Also, for example, cancer patients are more likely to be diagnosed at Stage I, when curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room when, treatment can involve years of hospitalization and is often terminal.[31][32] Others have estimated a longterm savings amounting to 40% of all national health expenditures from preventive health care,[33] although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventive care is more expensive.[34]

Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe that savings would be realized through preventive care and the elimination of insurance company overhead and hospital billing costs.[35] An analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year.[36] The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.[37]

Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, are seen as possible routes to enacting single payer on the federal level.[38][39] In December 2014, Vermont canceled its plan for single payer health care.[40]

National policies and proposals

Medicare in the United States is a single-payer healthcare system, but is restricted to senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease.[41] Government is increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on individuals' medical care in 2004.[42] However, studies have shown that the publicly administered share of health spending in the U.S. may be closer to 60% as of 2002.[43] According to Princeton University health economist Uwe Reinhardt, U.S. Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) represent "forms of 'social insurance' coupled with a largely private health-care delivery system" rather than forms of "socialized medicine." In contrast, he describes the Veterans Administration healthcare system as a pure form of socialized medicine because it is "owned, operated and financed by government."[44] In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the RAND Corporation reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients currently using United States Medicare.[45]

The United States National Health Care Act is a perennial piece of legislation introduced in the United States House of Representatives by Representative John Conyers (D-MI) every year since 2002.[46] The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. Under a single payer system, all medical care would be paid for by the government of the United States, ending the need for private health insurance and premium, and probably recasting private insurance companies as providing purely supplemental coverage to be used when nonessential care is sought. The bill was first introduced in 2002[46] and has been reintroduced in each Congress since. During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act. H.R. 676 was expected to be debated and voted upon by the House in September 2009,[47] but was never debated.[48]

The Congressional Budget Office and related government agencies scored the cost of a single payer health care system several times since 1991. The General Accounting Office published a report in 1991 noting that "if the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs [10 percent of health spending] would be more than enough to offset the expense of universal coverage.”[49] The CBO scored the cost in 1991, noting that "the population that is currently uninsured could be covered without dramatically increasing national spending on health" and that "all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured.[50] A CBO report in 1993 stated, "The net cost of achieving universal insurance coverage under this single payer system would be negative," in part because "consumer payments for health would fall by $1,118 per capita, but taxes would have to increase by $1,261 per capita" in order to pay for the plan.[51] A July 1993 scoring also resulted in positive outcomes, with the CBO stating that, "[a]s the program was phased in, the administrative savings from switching to a single-payer system would offset much of the increased demand for health care services. Later, the cap on the growth of the national health budget would hold the rate of growth of spending below the baseline."[52] The CBO also scored Sen. Paul Wellstone's American Health and Security Act of 1993 in December 1993, finding that "by year five (and in subsequent years) the new system would cost less than baseline."[53]

State proposals

Several single-payer state referendums and bills from state legislatures have been proposed, but, with the exception of Vermont,[54] all have failed. In December 2014, Vermont canceled its plan for single payer health care.[40]


California attempted passage of a single-payer bill as early as 1994,[55] and the first successful passages of legislation through the California State Legislature, SB 840 or "The California Universal Healthcare Act" (authored by Sheila Kuehl), occurred in 2006 and again in 2008.[56] Both times, Republican Governor Arnold Schwarzenegger vetoed the bill.[57] State Senator Mark Leno has reintroduced the bill in each legislative session since.[58]


In 2009, the Hawaii state legislature passed a single-payer health care bill that was vetoed by Republican Governor Linda Lingle. While the veto was overridden by the legislature, the bill was not implemented.[59]


In 2007, the Health Care for All Illinois Act was introduced and the Illinois House of Representatives' Health Availability Access Committee passed the single-payer bill favorably out of committee by an 8–4 vote. The legislation was eventually referred back to the House rules committee and not taken up again during that session.[60]


Massachusetts had passed a universal health care program in 1986, but budget constraints and partisan control of the legislature resulted in its repeal before the legislation could be enacted.[61] Question 4, a nonbinding referendum, was on the ballot in 14 state districts in November 2010, asking voters, "[S]hall the representative from this district be instructed to support legislation that would establish health care as a human right regardless of age, state of health or employment status, by creating a single payer health insurance system like Medicare that is comprehensive, cost effective, and publicly provided to all residents of Massachusetts?" The ballot question passed in all 14 districts that offered the question.[62][63]


The Minnesota Health Act, which would establish a state-wide single payer health plan, has been presented to the Minnesota legislature regularly since 2009. The bill was passed out of both the Senate Health Housing and Family Security Committee[64] and the Senate Commerce and Consumer Protection Committee[65] in 2009, but the House version was ultimately tabled.[66] In 2010, the bill passed the Senate Judiciary Committee on a voice vote[67] as well as the House Health Care & Human Services Policy and Oversight Committee.[68] In 2011, the bill was introduced as a two-year bill in both the Senate[69] and House,[70] but did not progress. It has been introduced again in the 2013 session in both chambers.[71][72]


In September 2011, Governor Brian Schweitzer announced his intention to seek a waiver from the federal government allowing Montana to set up a single payer health care system.[73] Governor Schweitzer was unable to implement single-payer health care in Montana, but did make moves to open government-run clinics[74] and, in his final budget as governor, increased coverage for lower-income Montana residents.[75]

New York

New York State has been attempting passage of the New York Health Act, which would establish a state-wide single-payer health plan, since 1992. The New York Health Act has passed the Assembly twice, once in 1992 and again in 2015, but has failed to advance through the Senate after referrals to the Health Committee. On both occasions, the legislation passed the Assembly by an almost two-to-one ratio of support.[76]


The state of Oregon attempted to pass single payer health care via Oregon Ballot Measure 23 in 2002, and the measure was rejected by a significant majority.[77] Previous bills, including the Affordable Health Care for All Oregon Act, have been introduced in the legislature but have never left committee. The Affordable Health Care Act may be reintroduced in the 2013 session.[78]


The Family Business and Healthcare Security Act has been introduced in the Pennsylvania legislature numerous times, but has never been able to pass.[79][80][81]


In December 2014, Vermont canceled its plan for single payer health care.[40] Vermont passed legislation in 2011 creating Green Mountain Care.[82] When Governor Peter Shumlin signed the bill into law, Vermont became the first state to functionally have a single payer health care system.[83] While the bill is considered a single-payer bill, private insurers can continue to operate in the state indefinitely, meaning it does not fit the strict definition of single-payer. Representative Mark Larson, the initial sponsor of the bill, has described Green Mountain Care's provisions "as close as we can get [to single-payer] at the state level."[84][85]

Vermont abandoned the plan in 2014, citing costs and tax increases as too high to implement.[86]

Public opinion

Advocates for single payer point to support in polls, although the polling is mixed depending on how the question is asked.[87] Polls from Harvard University in 1988,[88] the Los Angeles Times in 1990,[89] and the Wall Street Journal in 1991[90] all showed strong support for a health care system comparable to the system in Canada. More recently, however, polling support has declined.[87][91] A 2007 Yahoo/AP poll showed a majority of respondents considered themselves supporters of "single-payer health care,"[92] and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all."[93] Polls by Rasmussen Reports in 2011[94] and 2012[95] showed pluralities opposed to single payer health care.

A 2001 article in the [91] Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare."[87]

Advocacy groups

Physicians for a National Health Program[96] the American Medical Student Association[97] and the California Nurses Association[98] are among advocacy groups that have called for the introduction of a single payer health care program in the United States. A study published in the Annals of Internal Medicine found that 59% of physicians "supported legislation to establish national health insurance" while 9% were neutral on the topic, and 32% opposed it.[99]

See also


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