- Single-payer health care
Single-payer health care is an American term describing the payment for doctors, hospitals and other providers of health care from a single fund. The Canadian health care system, the British
National Health Service, Australia's Medicare, and Medicare in the U.S. for the elderly and disabled are single-payer systems.
According to the National Library of Medicine's Medical Subject Headings (
MeSH) thesaurus, a "Single-Payer System" is
An approach to health care financing with only one source of money for paying health care providers. The scope may be national (the Canadian System), state-wide, or community-based. The payer may be a governmental unit or other entity such as an insurance company. The proposed advantages include administrative simplicity for patients and providers, and resulting significant savings in overhead costs. [Medical Subject Headings thesaurus, National Library of Medicine. [http://www.nlm.nih.gov/cgi/mesh/2008/MB_cgi?mode=&index=17627&field=all&HM=&II=&PA=&form=&input= "Single-Payer System"] Year introduced: 1996, (From Slee and Slee, Health Care Reform Terms, 1993, p106) ]
Some writers argue that the single payer is the government,Chua, Kao-Ping. [http://www.amsa.org/uhc/SinglePayer101.pdf "Single Payer 101".] February 10, 2006] but the preceding definition as well as some single-payer proponents in the U.S. leave the government's role open to interpretation. [ [http://www.pnhp.org/news/2004/august/lessons_from_three_c.php Lessons from Three Countries with Single Payer | Physicians for a National Health Program ] ] However, the term "single payer" is never used to indicate that the patient bears sole responsibility for all payment.
The term single-payer is sometimes used in the U.S. to distinguish systems paid from a single (governmental) source with other systems of
universal health carein which the government has a higher degree of control, up to and including administering hospitals and employing doctors and staff, though logically these too are single-payer systems. When the term single payer is used in this way, doctors' practices and hospitals may remain private and negotiate with the government for fees.fact|date = June 2008
Single payer is one alternative proposed for reforming the U.S. health care system. Proponents argue that it would provide universal coverage with at least the same quality and lower costs. Critics argue that single payer would harm quality of care and medical innovation, and instead advocate tax
incentives [cite web |url=http://www.whitehouse.gov/infocus/healthcare |title=Making Private Health Insurance More Affordable for Low-Income Americans |accessdate=2007-05-22 |format=Fact Sheet |work=White House ] and free marketapproaches. [cite news |first=Karla |last=Dial |title=New Study Favors More Government Health Care, Sparks Broad Skepticism |url=http://www.heartland.org/Article.cfm?artId=21159 | work=Health Care News |publisher=The Heartland Institute |date=2007-05-07 |accessdate=2007-05-22 ] Opponents of publicly funded health carein the U.S. often lump single payer systems along with others under the pejorativeterm socialized medicine. [ [http://www.cato.org/pub_display.php?pub_id=8686 Socialized Medicine is already here] , The Cato Institute, 2007-09-6]
Types and variations
The United States, Canada and Australia have single-payer health insurance programs named "Medicare"; however, Australia's program provides universal health insurance, while U.S. Medicare is only for senior citizens and the disabled. [ [http://www.dfat.gov.au/facts/health_care.html] Dead link|date=March 2008] Government is increasingly involved in U.S. health care spending, paying about 45 percent of the $2.2 trillion the nation spent on medical care in 2004. [cite news |first=Julie |last=Appleby |title=Universal care appeals to USA |url=http://www.usatoday.com/money/industries/health/2006-10-15-universal-usat_x.htm |work= |publisher=USA Today |date=2006-10-16 |accessdate=2007-05-22 ]
Princeton Universityhealth economist Uwe E. Reinhardt, Medicare, Medicaidand 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 VA healthcare system as a pure form of socialized medicine because it is "owned, operated and financed by government." [ [http://online.wsj.com/article/SB118411829790962883.html "Letters: For Children's Sake, This 'Schip' Needs to Be Relaunched"] , Wall Street Journal, July 11, 2007, Uwe E. Reinhardt and others.]
The Veterans Administration is a single-payer system and provides excellent quality, said Reinhardt. In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the
RANDCorp. reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients in the rest of the U.S. health system. [ [http://www.annals.org/cgi/reprint/141/12/938 Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.] Asch SM, et al. Ann Intern Med. 2004 Dec 21;141(12):938-45. [PMID15611491] ]
Some writers describe socialized 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," [A Health Care Plan So Simple, Even Stephen Colbert Couldn’t Simplify It, By ROBERT H. FRANK, New York Times, February 15, 2007 [http://www.nytimes.com/2007/02/15/business/15scene.html] Fuchs [http://www.robert-h-frank.com/PDFs/Emanuel-Fuchs.NEJM.3-24-05.pdf] ] although this is an uncommon usage.
Canada's system is an example of single-payer health care. The national government provides part of the funding, provincial governments manage the hospitals (and provide the brunt of the funding), and doctors in private practice contract with the government for fee-for-service payments. Many Canadian citizens have supplemental health insurance, which covers expenses not covered by Canadian Medicare. Fees for doctors, hospitals and other providers are set by negotiations among doctors' associations, provincial or regional governments, and the national government. Global budgets eliminate the cost of billing individually for huge numbers of products and services.Physicians for a National Health Program. [http://www.pnhp.org/facts/what_is_single_payer.php "What is Single Payer?"] ]
The provision of health care in Canada is done mostly via private practitioners, although most hospitals are public. [cite book |title=Recent Social Trends in Canada, 1960-2000 |last=Lance |first=Roberts |authorlink= |coauthors= |year=2005 |publisher=McGill Queen's University Press |location= |isbn=0773529551 |pages=317 | url=http://books.google.com/books?id=qnPOqwsR5UsC&pg=PA317&vq=private+hospitals&dq=private+hospitals+in+canada&sig=bm0gw6tOQ9osAyHPrh1JFGd-4cQ ] Patients may go to any doctor or hospital in the country. [ [http://bcn.boulder.co.us/health/healthwatch/canada.html Single Payer Health Care System ] ]
Detractors of the Canadian health care system sometimes refer to it as
socialized medicinebecause it is regulated by the government. [http://www.ibdeditorials.com/IBDArticles.aspx?id=270338135202343 A Canadian doctor reflects on socialized medicine.] Supporters describe it as single-payer health care, because health care is provided privately but is paid from a single source, a publicly funded insurance program where costs are controlled.
Proponents and intent
One of the leading organizations in support of single payer in the U.S. is
Physicians for a National Health Program(PNHP), which seeks to establish a system similar to that in Canada.
In Congress, Rep.
John Conyers, Jr. (D-MI) has introduced The United States National Health Insurance Act(HR 676). As of August 2008, HR 676 had 91 co-sponsors. [cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d110:HR00676:@@@P |title=H.R. 676 |accessdate=2008-08-26 |work=Library of Congress THOMAS ]
Converting to a single-payer system is seen by proponents as a solution to the flaws in the current U.S. system. The U.S. health care system is the most expensive in the world on both a per-capita basis and as a percentage of GDP. [cite news |url=http://www.oecd.org/dataoecd/20/51/37622205.xls |title=Expenditure on Health |publisher=OECD Health Division |accessdate=2007-03-13] Despite this expenditure, the current U.S. system fails to provide universal coverage. More than 45 million Americans, about 15 percent of the population, lacked health insurance in 2007. [cite web | url=http://www.census.gov/prod/2008pubs/p60-235.pdf |title=Income, Poverty, and Health Insurance Coverage in the United States: 2007 | month=August | year=2008 | accessdate=2008-08-26 |format=PDF |work=U.S. Census Bureau] The lack of universal coverage contributes to another flaw in the current U.S. health care system: on most dimensions of performance, it under performs relative to other industrialized countries.cite web |url=http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 |title=Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care | date=2007-05-15 |accessdate=2007-05-22 |work=Report by the Commonwealth Fund ] In a 2007 comparison by the
Commonwealth Fundof health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the U.S. ranked last on measures of quality, access, efficiency, equity, and outcomes.
For example, U.S. ranks 22nd in infant mortality, between Taiwan and Croatia, [cite news |url=https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html |title=Rank Order - Infant Mortality Rate |publisher=CIA World Factbook |accessdate=2007-03-13] 46th in life expectancy, between Saint Helena and Cyprus, [cite news |url=https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html |title=Rank Order - Life Expectancy at Birth |publisher=CIA World Factbook |accessdate=2007-03-13] and 37th in health system performance, between Costa Rica and Slovenia. [cite news |url=http://www.who.int/whr/2000/en/annex01_en.pdf |title=The World Health Report 2000 |publisher=
World Health Organization|accessdate=2007-03-13|format=PDF]
The U.S. system is often compared with that of its northern neighbor, Canada (see
Canadian and American health care systems compared). Canada's system is largely publicly funded. In 2005, Americans spent an estimated US$6,401 per capita on health care, while Canadians spent US$3,326. [http://www.oecd.org/dataoecd/46/33/38979719.pdf OECD Health Data 2007: How Does Canada Compare] ] This amounted to 15.3% of U.S GDP in that year, while Canada spent 9.8% of GDP on health care.
A 2007 review of all studies comparing health outcomes in Canada and the U.S. found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." [http://www.openmedicine.ca/article/view/8/1] Open Medicine, Vol 1, No 1 (2007), Research: A systematic review of studies comparing health outcomes in Canada and the United States, Gordon H. Guyatt, et al.] Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds [The trade association [http://www.ahip.org AHIP] , America's Health Insurance Plans, has some 1,300 members.] of insurance companies in the U.S. to provide universal care. [ [http://www.nybooks.com/articles/18802 "The Health Care Crisis and What to Do About It"] By Paul Krugman, Robin Wells, New York Review of Books, March 23, 2006] An often-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 30 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs. [ [http://www.pnhp.org/publications/nejmadmin.pdf Costs of Health Administration in the U.S. and Canada] Woolhandler, et al, NEJM 349(8) Sept. 21, 2003]
Theoretically, advocates suggest, shifting the U.S. to a single-payer health care system could provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system could also theoretically eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.
Opponents and criticisms
Several criticisms have been leveled against the idea of changing the U.S. health care system to a single-payer system. Some proponents argue that perhaps the largest obstacle is a lack of political will. [ [http://www.pnhp.org/news/2007/february/timid_ideas_wont_fi.php Timid ideas won't fix health mess] . By Marie Cocco, Sacramento Bee, February 10, 2007] While polling data indicate that U.S. citizens are concerned about health care costs and think the system needs reform (see Polls, below) most are generally satisfied with the quality of their own health care. According to a Joint Canada/United States Survey of Health in 2003, 86.9% of Americans reported being "satisfied" or "very satisfied" with their health care services, compared to 83.2% of Canadians. [ [http://www.statcan.ca/english/freepub/82M0022XIE/2003001/tables/table7.htm Satisfaction with health care and physician services, Canada and United States, 2002 to 2003] ] In the same study, 93.6% of Americans reported being "satisfed" or "very satisfied" with their physician services, compared to 91.5% of Canadians (according to the study authors, that difference was not statistically significant).
Some medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the
RAND Corporationand the Department of Veterans Affairs asked 236 elderly patients at 2 managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author. [ [http://online.wsj.com/article/SB115758434624755703.html Capital: In health care, consumer theory falls flat] David Wessel, Wall Street Journal, September 7, 2006.] [cite press release |title=Rand study finds patients' ratings of their medical care do not reflect the technical quality of their care |publisher=RAND Corporation |date=2006-05-01 |url=http://www.rand.org/news/press.06/05.01.html |accessdate=2007-08-27] [ [http://www.annals.org/cgi/content/abstract/144/9/665 Patients' Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care] , John T. Chang, et al., Ann Intern Med. 2006 May 2;144(9):665-72. [PMID16670136] ]
For this reason, some U.S. reformers argue for other, more incremental changes to achieve universal health care, such as tax credits or vouchers. [Emanuel EJ, Fuchs VR. [http://content.nejm.org/cgi/content/full/352/12/1252 Health care vouchers -- a proposal for universal coverage] . N Engl J Med 2005;352:1255-1260.] However, proponents of a single-payer system, such as Marcia Angell, M.D., former editor of the "
New England Journal of Medicine", assert that incremental changes in a free-market system are "doomed to fail." [cite web |url=http://www.pbs.org/healthcarecrisis/Exprts_intrvw/m_angell.htm |title=Are we in a health care crisis? |accessdate=2007-05-22 |work=PBS companion website: The Health Care Crisis: Who's At Risk? ]
Other criticisms of single-payer health care as a solution for universal coverage in the U.S. include:
* A single-payer system could put the government, rather than private insurance companies, in the role of deciding which procedures and medications would be covered.
* In a single-payer system where hospitals and practitioners remain private, public money goes into private hands and therefore must be guarded to protect public trust.
:: Note, however, that this issue does not arise in total public health care systems (which may also be single-payer) where the hospitals and / or general practitioners work for the government. In this case the prioritization of access to government funded services is done according to the patients' needs as judged by medical professionals. There are no bureaucrats cross-checking doctors' records against either patients medical insurance coverage (as in the present system) or against medical contracts (as in a single-payer system with private practitioners).
* Converting to a single-payer system could be a radical change, creating administrative chaos. [cite news |first=Leif Wellington |last=Haase | title=Universal Coverage: Many Roads to Rome? | url=http://www.motherjones.com/commentary/columns/2006/03/universal_coverage.html | |publisher=Mother Jones |date=2006-03-09 |accessdate=2007-05-21]
In recent public opinion polls, majorities of Americans say that the current health care system needs fundamental changes, and that they are dissatisfied with the quality and costs of health care, although they are satisfied with the quality of their own health care. Those polled believe the federal government should guarantee insurance for all Americans, even if they had to pay higher taxes. In some polls, respondents prefer a universal health insurance program, "like Medicare," even if it limited their choice of doctors, and even if there were waiting lists for non-emergency treatments. But respondents were split when they were asked whether the federal government should require all Americans to participate in a national health plan.
According to a
New York Times/ CBS Newspoll in February 2007, [New York Times/CBS News Poll, Feb. 23-27, 2007, N=1,281 adults nationwide. cite news |url=http://graphics8.nytimes.com/packages/pdf/national/03022007_poll.pdf |title=The New York Times/CBS News Poll, Feb. 23-27, 2007 |publisher: The New York Times |accessdate=2007-08-19|format=PDF] 54% of respondents said that "fundamental changes are needed" in the health care system, and 36% said that "Our health care system has so much wrong with it that we need to completely rebuild it." 57% were dissatisfied with the quality of health care in this country, although 77% were satisfied with the health care they themselves received. 81% were dissatisfied with the cost of health care, and 52% were dissatisfied with the costs of their own health care. 65% said that providing for the uninsured was more important than keeping costs down. 95% said that it is a serious problem that many Americans do not have health insurance. 64% said that the federal government should guarantee health insurance for all Americans, and 60% would pay higher taxes to do so. But only 43% said that it would be fair for the government in Washington to require all Americans to participate in a national health care plan funded by taxpayers, compared to 48% who said it would be unfair.
According to a
Washington Post- ABC Newspoll in October 2003, [ [http://www.washingtonpost.com/wp-srv/politics/polls/vault/stories/data102003.html] "Washington Post-ABC News Poll: Health Care," October 20, 2003] [ [http://www.healthtogether.org/healthtogether/resources/news_universal_health.html] America's HealthTogether] 62% of respondents preferred "a universal health insurance program, in which everybody is covered under a program like Medicare that's run by the government and financed by taxpayers," compared to 32% who preferred the current system, in which most people get their health insurance through employers. 56% would support a universal health insurance program even if it limited their own choice of doctors, and 63% would support it even if it meant there were waiting lists for some non-emergency treatments.
Several single payer referendums have been proposed at the state level, but so far all have failed to pass:
Californiain 1994, [ [http://www.kff.org/statepolicy/1075-index.cfm The California Single-Payer Debate, The Defeat of Proposition 186 - Kaiser Family Foundation ] ] Massachusettsin 2000, and Oregonin 2002. [ [http://www.heartland.org/Article.cfm?artId=10803 Free-Market Reformers Are Winners in Election 2002 - by Joe Moser - The Heartland Institute ] ]
The California state legislature has twice passed SB 840, The Health Care for All Californians Act, a single-payer health care plan. Both times, Governor
Arnold Schwarzenegger(R) vetoed the bill, once in 2006 and again in 2008. [ [http://www.onecarenow.org/sb840.htm OneCareNow.org: Senate Bill 840] ] [ [http://www.leginfo.ca.gov/pub/07-08/bill/sen/sb_0801-0850/sb_840_bill_20080930_status.html Official California Legislative Information: Current Bill Status: SB 840] ]
In April 2008, the Illinois House of Representatives' Health Availability Access Committee passed the single-payer bill HB 311, "The Health Care for All Illinois Act," [ [http://www.healthcareil.org/ Health Care for All Illinois] ] favorably out of committee by an 8-4 vote. [ [http://www.ilga.gov/legislation/BillStatus.asp?DocNum=311&GAID=9&DocTypeID=HB&LegId=27071&SessionID=51 Illinois General Assembly Bill Status: HB 311] ]
Canadian and American health care systems compared
Consumer driven health care
Health care reform
Kaiser Family Foundation
National health insurance
National Physicians Alliance
Publicly-funded health care
United States National Health Insurance Act
Universal health care
* Institute of Medicine Committee on the Consequences of Uninsurance. Hidden costs, value lost: uninsurance in America. Washington, DC: National Academies Press, 2003. [http://www.nap.edu/catalog/10719.html] Frequently-cited source.
* [http://pnhp.org/ Physicians for a National Health Program] Advocates for single-payer system. Extensive source material from peer-reviewed journals.
National Center for Policy AnalysisCorporate-funded free-market think tank opposed to single payer health insurance
*Boffey, Phillip [http://www.nytimes.com/2007/09/28/opinion/28fri4.html?_r=2&oref=slogin&oref=slogin "The Socialists Are Coming! The Socialists Are Coming!"] Editorial on U.S. "socialized medicine" in the military, the Veterans Health Administration, and Medicare, The New York Times, September 28, 2007
* [http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm Single Payer, Universal Health Care For The United States - Myths and Facts]
* [http://www.kff.org/uninsured/kcmu_statehealthreform.cfm States Moving Towards Comprehensive Health Care Reform in the U.S.] , The Henry J. Kaiser Family Foundation
* [http://npalliance.org/content/pages/2008_presidential_candidate_health_plan_report_card 2008 Presidential Candidate Health Plan Report Card] issued by the
National Physicians Alliance
* [http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/ Sick Around the World: Can the U.S. learn anything from the rest of the world about how to run a health care system?] from Frontline, PBS.
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