Single-payer healthcare

Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs. Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the United Kingdom). The term "single-payer" thus only describes the funding mechanism—referring to health care financed by a single public body from a single fund—and does not specify the type of delivery, or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.

Background

Single-payer health insurance collects all medical fees, then pays for all services, through a "single" government (or government-related) source. 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 healthcare delivery, operating as a public service and offered to citizens and legal residents towards providing near-universal or universal health care. The fund can be managed by the government directly or as a publicly owned and regulated agency. Some writers describe publicly administered health care systems as "single-payer plans". Some writers have described any system of health care which intends to cover the entire population, such as voucher plans, as "single-payer plans", although this is uncommon usage.

Worldwide health care systems

Main article: Health care system § International comparisons

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 employed, and hospitals run by, the government such as in the United Kingdom. Alternatively the government may purchase healthcare services from outside organizations. This is the approach taken in Canada.

Australia

Main article: Health care in Australia

Health care in Australia is provided by both private and government institutions. The Minister for Health, currently Peter Dutton, administers national health policy, elements of which (such as the operation of hospitals) are overseen by individual states. The current system, known as Medicare, was instituted in 1984 and coexists with a private health system. Medicare is funded partly by a 1.5% income tax levy (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.

Canada

Main article: Health care in Canada

See also: Canadian and American health care systems compared and Medicare (Canada)

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. It is guided by the provisions of the Canada Health Act of 1984. 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 a person and his or her 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 is only 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 which is waived or reduced for those on low incomes. There are no deductibles on basic health care and co-pays are extremely low or non-existent (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. 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 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. These 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 pre-existing conditions.

Pharmaceutical medications are covered by public funds for the elderly or indigent, 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 do 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 is two weeks, with 86.4% waiting less than three months. 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.

Taiwan

Main article: Healthcare in Taiwan

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. In 2002 Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population. 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. Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 (or US$951 in 2009); 64.9 percent of the expenditures were from public funds. Overall life expectancy in 2009 was 78 years.

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 which centralizes the disbursement of health-care funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004. NHI is mainly financed through premiums, which are based on the payroll tax, and is 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

Main article: Healthcare in the United Kingdom

Healthcare in the United Kingdom is a devolved matter, meaning 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 or NHS. Each country having different policies and priorities has resulted in a variety of differences existing between the systems. That said, each country provides public healthcare to all UK permanent residents that is free at the point of need, being paid for from general taxation. In addition, each also has a private healthcare sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.

The individual systems are:

• England: National Health Service
• Northern Ireland: Health and Social Care in Northern Ireland (HSCNI)
• Scotland: NHS Scotland
• Wales: NHS Wales

United States

A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (H.R. 676, also known as "Medicare for All") but none have achieved more political support than 20% congressional co-sponsorship. Critics argue that a single-payer system is not viable at the federal level for the United States. Any national system would be paid for in part through taxes replacing insurance premiums, but also by savings realized through the provision of preventative universal healthcare and the elimination of insurance company overhead and hospital billing costs. An analysis of the bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year. Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventative health care. Preventative care can save several hundreds of billions of dollars per year in the U.S., because for example cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal. Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, may serve as living models supporting federal single-payer coverage.

National policies and proposals

Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease. 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. However, studies have shown that the publicly administered share of health spending in the U.S. may be closer to 60% as of 2002. According to Princeton University health economist Uwe E. 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." 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.

The United States National Health Care Act (or the "Expanded and Improved Medicare for All Act," H.R. 676), is a bill introduced in the United States House of Representatives by Representative John Conyers (D-MI). The bill had 88 cosponsors in 2009. 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 premiums, and probably recasting private insurance companies as providing purely supplemental coverage, to be used when non-essential care is sought. The bill was first introduced in 2003, when it had 25 cosponsors, 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, but was never debated.

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 "[I]f 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.” 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. A CBO report in 1993 stated that "[t]he 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. 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." 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.

State proposals

Several single-payer state referendums and bills from state legislatures have been proposed, but, with the exception of Vermont, all have failed.

California

California attempted passage of a single-payer bill as early as 1994, 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. Both times, Governor Arnold Schwarzenegger vetoed the bill. State Senator Mark Leno has reintroduced the bill in each legislative session since.

Illinois

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.

Massachusetts

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. 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.

Minnesota

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 and the Senate Commerce and Consumer Protection Committee in 2009, but the House version was ultimately tabled. In 2010, the bill passed the Senate Judiciary Committee on a voice vote as well as the House Health Care & Human Services Policy and Oversight Committee. In 2011, the bill was introduced as a two-year bill in both the Senate and House, but did not progress. It has been introduced again in the 2013 session in both chambers.

Montana

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. Governor Schweitzer was unable to implement single-payer health care in Montana, but did make moves to open government-run clinics and, in his final budget as governor, increase coverage for lower-income Montana residents.

Oregon

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. 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.

Pennsylvania

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

Vermont

Main article: Vermont health care reform

Vermont passed legislation in 2011 creating Green Mountain Care. When Governor Peter Shumlin signed the bill into law, Vermont became the first state to functionally have a single payer health care system. 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."

Public opinion

Advocates for single payer point to support in polls although the polling is mixed depending on how the question is asked. Polls from Harvard University in 1988, the Los Angeles Times in 1990, and the Wall Street Journal in 1991 all showed strong support for a health care system comparable to the system in Canada. More recently, however, polling support has declined. A 2007 Yahoo/AP poll showed a majority of respondents considered themselves supporters of "single-payer health care," 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." Polls by Rasmussen Reports in 2011 and 2012 showed pluralities opposed to single payer health care.

A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan." 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."

Advocacy groups

Physicians for a National Health Program the American Medical Student Association and the California Nurses Association 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.

See also

• Health care reform debate in the United States
• International comparisons of health care systems – tabular comparisons of the US, Canada, and other countries not shown above.
• The Kucinich Amendment, an amendment to the America's Affordable Health Choices Act of 2009 which would have empowered the Secretary of Health and Human Services to waive the federal law that pre-empts state law on employee-related health care.
• Monopsony
• National health insurance
• Publicly funded health care
• Public health insurance option ("the public option")