Universal health care, (also referred to as universal health coverage, universal coverage, universal care or socialized health care) usually refers to a system that provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes. Universal health care is not one-size-fits-all and does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered. It is described by the as a situation where citizens can access health services without incurring financial hardship. The Director General of WHO describes universal health coverage as the “single most powerful concept that public health has to offer” since it unifies “services and delivers them in a comprehensive and integrated way”. United Nations member states have agreed to work toward worldwide universal health coverage by 2030. One of the goals with universal healthcare is to create a system of protection which provides equality of opportunity for people to enjoy an attainable level of health.
The first move towards a national health insurance system was launched in in 1883, with the Sickness Insurance Law. Industrial employers were mandated to provide injury and illness insurance for their low-wage workers, and the system was funded and administered by employees and employers through "sick funds", which were drawn from deductions in workers' wages and from employers' contributions. Other countries soon began to follow suit. In the, the provided coverage for primary care (but not specialist or hospital care) for wage earners, covering about flirten im internet tipps one third of the population. The established a similar system in 1912, and other industrialized countries began following suit. By the 1930s, similar systems existed in virtually all of Western and Central Europe. introduced an employee health insurance law in 1927, expanding further upon it in 1935 and 1940. Following the of 1917, the established a fully public and centralized health care system in 1920. However, it was not a truly universal system at that point, as rural residents were not covered.
In, a universal health care system was created in a series of steps, from 1939 to 1941. In, the state of introduced a free public hospital system in the 1940s.
Following, universal health care systems began to be set up around the world. On July 5, 1948, the United Kingdom launched its universal. Universal health care was next introduced in the of (1955), (1956), (1956), (1961), and (1964). Universal health insurance was then introduced in (1961), and in through stages, starting with the province of in 1962, followed by the rest of Canada from 1968 to 1972. The Soviet Union extended universal health care to its rural residents in 1969. introduced its Servizio Sanitario Nazionale (National Health Service) in 1978. Universal health insurance was implemented in beginning with the Medibank system in 1975, which led to universal coverage under the system, established in 1984.
From the 1970s to the 2000s, Southern and Western European countries began introducing universal coverage, most of them building upon previous health insurance programs to cover the whole population. For example, built upon its 1928 national health insurance system, with subsequent legislation covering a larger and larger percentage of the population, until the remaining 1% of the population that was uninsured received coverage in 2000. In addition, universal health coverage was introduced in some countries, including (1989), (1995), (1995), and (2001).
Following the collapse of the Soviet Union, retained and reformed its universal health care system, as did other former Soviet nations and countries.
Beyond the 1990s, many countries in, the,, and the region, including developing countries, took steps to bring their populations under universal health coverage, including which has the largest universal health care system in the world. A 2012 study examined progress being made by these countries, focusing on nine in particular:,,,,,,, the, and.
Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (by direct or optional insurance) for services beyond those covered by the public system. Almost all European systems are financed through a mix of public and private contributions. Most universal health care systems are funded primarily by (like in Spain, Denmark, and Sweden). Some nations, such as Germany and France and Japan employ a multipayer system in which health care is funded by private and public contributions. However, much of the non-government funding is by contributions by employers and employees to regulated sickness funds. Contributions are compulsory and defined according to law. A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency.Universal health care systems are modestly redistributive. The progressivity of health care financing has limited implications for overall.
This is usually enforced via legislation requiring residents to purchase insurance, but sometimes the government provides the insurance. Sometimes, there may be a choice of multiple public and private funds providing a standard service (as in Germany) or sometimes just a single public fund (as in Canada). and the US are based on compulsory insurance.
In some European countries, in which private insurance and universal health care coexist, such as Germany, Belgium, and the Netherlands, the problem of is overcome by using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus, a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price, and there is no advantage to eliminate people with higher flirten im internet tipps risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but they compete mainly on price and service. In some countries, the basic coverage level is set by the government and cannot be modified.
The at one time had a "community rating" system by, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. That resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market, which then made higher profits at VHI's expense. The government later reintroduced community rating by a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.
Among the potential solutions posited by economists are single-payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance or limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.
Single-payer health care is a system in which the government, rather than private insurers, pays for all costs. Single-payer systems may contract for healthcare services from private organizations (as is the case in ) or own and employ healthcare resources and personnel (as was the case in before of the ). "Single-payer" thus describes only the funding mechanism and refers 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.
In tax-based financing, individuals contribute to the provision of health services through various taxes. These are typically pooled across the whole population, unless local governments raise and retain tax revenues. Some countries (notably the United Kingdom, Canada, Ireland, Australia, New Zealand,, Spain, Portugal and the ) choose to fund health care directly from taxation alone. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.
Social health insurance
In social health insurance, contributions from workers, the self-employed, enterprises, and governments are pooled into a single or multiple funds on a compulsory basis. It is based on risk pooling. The social health insurance model is also referred to as the 'Bismarck Model,' after Prussian Chancellor Otto von Bismarck, who introduced the first universal health care system in Germany in the 19th century. The funds typically contract with a mix of public and private providers for the provision of a specified benefit package. Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health. Within social health insurance, a number of functions may be executed by parastatal or non-governmental sickness funds or in a few cases, by private health insurance companies. Social health insurance is used in a number of Western European countries and increasingly in Eastern Europe as well as in Israel and Japan.
In private health insurance, premiums are paid directly from employers, associations, individuals and families to insurance companies, which pool risks across their membership base. Private insurance includes policies sold by commercial for profit firms, non-profit companies, and community health insurers. Generally, private insurance is voluntary in contrast to social insurance programs, which tend to be compulsory.
In some countries with universal coverage, private insurance often excludes many health conditions that are expensive and the state health care system can provide. For example, in the United Kingdom, one of the largest private health care providers is, which has a long list of general exclusions even in its highest coverage policy, most of which are routinely provided by the. In the United States, dialysis treatment for end stage renal failure is generally paid for by government, not by the insurance industry. Those with privatized () are the exception and must get their dialysis paid through their insurance company, but those with end stage generally cannot buy Medicare Advantage plans.
The has also suggested that the country should embrace insurance to achieve universal health coverage. General tax revenue is currently used to meet the essential health requirements of all people.
Community-based health insurance
A particular form of private health insurance that has often emerged if financial risk protection mechanisms have only a limited impact is community-based health insurance. Individual members of a specific community pay to a collective health fund, which they can draw from when they need of medical care. Contributions are not risk-related, and there is generally a high level of community involvement in the running of these plans.
Implementation and comparisons
See also: and
Universal health care systems vary according to the degree of government involvement in providing care and/or health insurance. In some countries, such as the UK, Spain, Italy, Australia and the Nordic countries, the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights, not on the purchase of insurance. Others have a much more pluralistic delivery system, based on obligatory health with contributory insurance rates related to salaries or income and usually funded by employers and beneficiaries jointly.
Sometimes, the health funds are derived from a mixture of insurance premiums, salary related mandatory contributions by employees and/or employers to regulated sickness funds, and by government taxes. These insurance based systems tend to reimburse private or public medical providers, often at heavily regulated rates, through mutual or publicly owned medical insurers. A few countries, such as the Netherlands and Switzerland, operate via privately owned but heavily regulated private insurers, which are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance.
Universal health care is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually, some costs are borne by the patient at the time of consumption, but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others, tax revenues are used either to fund insurance for the very poor or for those needing long-term chronic care.
The United Kingdom in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the United States), and their relative costs and key health outcomes. A wider international comparison of 16 countries, each with universal health care, was published by the in 2004. In some cases, government involvement also includes directly managing the, but many countries use mixed public-private systems to deliver universal health care.
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Figure 2. Global Prevalence of Universal Health Care in 2009; 58 countries: Andorra, Antigua, Argentina, Armenia, Australia, Austria, Azerbaijan, Bahrain, Belarus, Belgium, Bosnia and Herzegovina, Botswana, Brunei Darussalam, Bulgaria, Canada, Chile, Costa Rica, Croatia, Cuba, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Moldova, Mongolia, Netherlands, New Zealand, Norway, Oman, Panama, Portugal, Romania, Singapore, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, Taiwan, Thailand, Tunisia, UAE, Ukraine, United Kingdom, Venezuela.
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CNN will host a town hall with Republican Sens. Lindsey Graham and Bill Cassidy, who will be debating health care with Sens. The views expressed in this commentary are his own. Without regard for consequences, the law expanded government insurance programs and imposed considerable federal authority over US health care via new mandates, regulations and taxes. Insurance premiums skyrocketed even as deductibles rose; consumer choices of insurance on state marketplaces have rapidly vanished; and for those with ACA coverage, doctor and hospital choices have narrowed dramatically.
Meanwhile, consolidation across the health care sector has accelerated at a record pace, portending further harm to consumers, including higher prices of medical care. Join us on Twitter and Facebook. Business Markets Tech Luxury. Stars Screen Binge Culture Media. Single payer health care defined Culture Gadgets Future Chat with us in Facebook Messenger.
Tapper presses Sanders on single-payer troubles Story highlights Scott W. Democrats are now championing a precarious form of health care -- single payer For decades, single payer health care has failed to deliver on and care in numerous other countries, writes Atlas. Almost inexplicably, even more top-down control -- single-payer health a system in which the government provides nationalized health insurance, sets all fees for medical care and pays those fees to doctors and hospitals -- has found new support from the left.
And this despite its decades of documented failures in other countries to provide timely, quality medical care, and in the face of similar problems in our own single-payer Veterans Affairs system. Clearly, this moment cries out for the truth about single-payer health care -- conclusions from historical evidence and data.
Single-payer health care is proven to be consistently plagued by these characteristics:. Massive waiting lists dangerous delays for medical appointments.
In those countries with the single payer health care defined experience of single-payer government insurance, published data demonstrates massive waiting lists and unconscionable delays that are unheard of in the United States. In England aloneapproximately 3. On health care, GOP has a promise and a deadline to keep.
Ironically, US media outrage was widespread when pre-ACA data showed that time-to-appointment for Americans averaged That selective reporting failed to note that those waits were for healthy check-ups in almost all cases, by definition the lowest medical priority.
Even for simple physical exams and purely elective, routine appointments, US wait times before ACA were shorter than for seriously ill patients in countries with nationalized, single-payer insurance. Life-threatening delays for treatment, even for patients requiring urgent cancer treatment or critical brain surgery. And in if you needed life-changing orthopedic surgerylike hip or knee replacement, you would wait a startling 38 weeks -- about the same time it takes from fertilization to a full-term human mann sucht frau in freiburg life.
Before single payer health care defined ACA, the United States was by far the most frequent country where new cancer drugs were first launched -- single payer health care defined a factor of at least four -- compared to any country studied in the previous decade, including Germany, Japan, Switzerland, France, Canada, Italy and the UK, according to the Annals of Oncology in Six things you better know about Graham-Cassidy health care bill.
Median time to approval in the United States was about half of that in Europe. All 23 drugs approved by both were available to US patients first. And yet, only months ago, NHS in England introduced a new " Budget Impact Test " to cap drug prices, a measure that is specifically designed to further restrict drug access even though the delays will break their own NHS Constitution pledges to its citizens.
Despite what might suppose about a likely strength of a government-centralized system, the facts show that single-payer systems cannot even outperform our system in something as scheduled and routine as cancer screening tests.
Confirming numerous prior OECD studies, a Health Affairs study reported single payer health care definedbefore any Affordable Care Act screening requirements, that the United States had superior screening rates to all 10 European countries with nationalized systems for all cancers. Likewise, the single payer single payer health care defined of Canada fails to deliver screening tests for the most common cancers as broadly as the US system, including PAP smears and colonoscopies.
And Americans are more likely to be screened younger for cancer than in Europe, when the expected benefit is greatest. Not US patients have had less advanced disease at diagnosis than in Europe for almost all cancers.
It might be said that the bottom about a health care system is the data on outcomes from treatable illnesses.
And while some studies have noted that Canadians and Germans, for example, have longer life expectancies lower infant mortality rates than Americans do, they are misleading. Those statistics are extremely coarse and depend on a wide array of complex inputs having little to do with single payer health care defined care, including differences in lifestyle smoking, obesity, hygiene, safe sexpopulation heterogeneity, environmental conditions, incidence of suicide and homicide and even differences in what counts as a live birth.
Rand Paul is wrong on health care bill. The truth is that the UK, Canada and other European countries for decades have used wait lists for surgery, diagnostic procedures and doctor appointments specifically as a means of rationing care. And long waits for needed are not simply inconvenient. Research for example, here has consistently shown that waiting for medical has serious consequences, including pain and suffering, worse medical outcomes and significant costs to individuals in foregone wages and to the overall economy.
In contrast to countries with single-payer health systems, it is broadly acknowledged that "waiting lists are not a feature in the States" for medical care, as stated by Dr.
Sharon Wilcox in her study comparing strategies to measure and reduce this important failure of centralized health systems. What has been the response to the public outcry about unacceptable waits for care in single-payer systems? First, a growing list of European governments have issued dozens of "guarantees" with intentionally lax targets, and even those targets continue to be missed. Instead of judging health system reforms by the number of people classified as "insured," reforms should focus on making excellent medical care single payer health care defined broadly available and affordable without restricting its use or creating obstacles to future innovation.
Reducing the cost of medical care requires creating conditions long proven to bring down prices while improving quality: Single-payer systems in countries with decades of experience have been proven in numerous peer-reviewed scientific journals to be to the US system in terms of both access and quality.
Americans single payer health care defined superior access to health care -- whether defined by access to screening; wait-times for single payer health care defined, treatment, or specialists; timeliness of surgery; or availability of technology drugs.
A single-payer system finances health care for an entire population by using one public agency to collect all contributions and pay all bills. In the United States.
A of health care characterized by universal and comprehensive coverage. Single-payer health care is similar to the health services provided single payer health care defined Medicare in the Single payer health care defined. The government pays for care that is delivered in the private mostly not-for-profit sector.
Doctors are in private practice and are paid on a fee-for-service basis from government funds. The government does not own manage their medical practices or hospitals. Single-payer health care is distinct and different from socialized medicine in which health care facilities and workers receive payment as government employees.
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Single-Payer Health Care: America Already Has ItRelated queries:
Single-payer system is a health care system in which one entity – a single payer – collects all health care fees and pays for all health care costs. Proponents of.
Jun 27, · Home» Harvard Health Blog» Single payer healthcare: Pluses, minuses, and what it means for you As someone who researches inequities flirten im internet tipps in health care.
A single-payer system finances health care for an entire population by using one public agency to collect all contributions and pay all bills. In the United States.
Jun 27, · Home» Harvard Health Blog» Single payer healthcare: Pluses, minuses, and what it means for you As someone who researches inequities in health care.
Jun 27, · Home» Harvard Health Blog» Single payer healthcare: Pluses, minuses, and what it means for you As someone who researches inequities in health care.
As a result of the November 2016 elections, the future of health care reform in the U.S. is unclear. President Donald Trump and Congressional Republicans have vowed to repeal and replace the Affordable Care Act (ACA). Although details of the replacement plan are uncertain, Republican plans frequently aim to give states more flexibility to manage health care programs. As national health care policies evolve, states will be faced with decisions on what they can do to provide health insurance and access to care for their residents, particularly if Medicaid expansion and insurance marketplace subsidies are eliminated.
One alternative financing plan in which states have shown periodic interest is a single-payer health care system. National health insurance administered by a single payer has been considered in the U.S. since the early 1900s, but has been a polarizing issue, with staunch advocates and strong opposition. , In 2010, Vermont passed legislation for a state-based single-payer system under a Section 1332 waiver of the ACA. However, the plan stalled flirten im internet tipps at the end of 2014, with the governor’s office citing higher than expected tax estimates needed to finance the system. , Other bills have been periodically proposed at the federal and state levels, although few have garnered substantial support. Nonetheless, Senator Bernie Sanders’s 2016 presidential campaign drew renewed attention to single-payer health care. In November 2016, Colorado residents voted to reject a ballot measure for a state single-payer system. In February 2017, the California legislature introduced a bill stating an intent to establish a state single-payer system.
Although single-payer plans have been continually proposed in the U.S., the term is used with different meanings. Single-payer is often used in political rhetoric, with some using it to refer to the Canadian health care system, and others using it synonymously with “socialized medicine” and other variations. Canada has a single-tiered, tax-financed system that is administered by provinces, and care is delivered by private non-profit providers. In contrast, socialized medicine typically refers to systems such as the National Health Service in the United Kingdom, which is a tax-financed system with mostly government-run health facilities.
In this work, we compare single-payer definitions and health care reform proposals involving a single payer in the U.S. We assess the breadth of proposal provisions across health care system functions. To assess how the provisions aim to improve the health care system, we describe provisions related to access, quality, and costs. Clearly defined policy proposals would inform the debate on whether a single-payer system could be a viable reform alternative in the U.S.
We conducted searches on legislative and academic databases to identify single-payer proposals; searches were conducted between May and December 2014. We used the following search terms: single payer, Medicare for all, national health insurance, Beveridge model, universal coverage, publicly funded, United States, America, definition, proposal, plan, and bill. We excluded search results from earlier than 1990, because single-payer in its current usage appeared in the early 1990s.
The search for single-payer bills on, Scout, and WestlawNext yielded 262 results. We reviewed titles and bill summaries to determine inclusion. Resolutions were excluded. If a legislature produced multiple versions of a bill, we included the most recent version. We identified additional state legislation via Google searches and reference mining. This resulted in three federal and 20 state bills.
Literature searches on PubMed, Scopus, and Academic Search Complete yielded 2498 articles. We excluded articles discussing only legislative proposals, politics, stakeholder perspectives, implementation, or reform in other countries. Title and abstract screening resulted in 29 articles. A full-text review resulted in two proposals that were not legislative bills.
In this paper, we refer to journal articles, bills, and Vermont’s Act 48 collectively as single-payer proposals.
Assessment of proposals
Framework of health care system functions. Source: Adapted from Kutzin (2001).
To evaluate how the provisions would improve the health care system, we considered linkages to access, quality, and cost containment. As the impacts of the provisions have not been scored, we coded the intent and plausible impact based on the proposal text. The first reviewer (JL) coded sections relating to access, quality, and cost. Text was marked as “access” if related to insurance coverage, benefit design, and provider access or availability. Text was marked as “quality” if related to systems or procedures that could impact quality of care through changes in provider behavior or standardization. Text was marked as “cost” if related to cost-control strategies and systems or procedures affecting prices or payment. We allowed text to be coded as more than one category. An additional tag was used to mark the text with unclear assignment. For text marked as unclear, a second reviewer (RB) independently coded the text. The reviewers discussed and reconciled the assignment. JL documented the provisions into a matrix and tallied the results to identify common themes. RB reviewed the full set of final assignments.
The search methodology was intended to capture a range of recent proposals but was not exhaustive. Proposals involving a single payer but not explicitly including the term may have been missed during screening.
The manual coding was subject to human error. In addition, the initial extraction of relevant text was conducted by one reviewer. While a second reviewer checked the full set of final assignments, it is possible some relevant text was omitted from the initial extraction.
The coding of access, quality, and cost was based on intent and plausible impact of the provisions rather than a formal scoring of impact. The assessment relied on the detail contained in the proposals. An omission of a provision may indicate a lack of detail rather than a deliberate design choice. Furthermore, an omission does not preclude adoption of a measure at a later time; many proposals indicate that some details would be determined at a later date after additional studies.
The term single-payer originated in the early 1990s to differentiate the Canadian health care system, which has government financing and private delivery, from that of the United Kingdom, where the government is responsible for both financing and delivery. It has since evolved to often describe financing by a single public entity irrespective of the type of delivery.
Although the single payer is typically conceived of as a public entity, some definitions do not restrict the payer to government only. Slee and Slee include the possibility of an insurance company as the payer. Their definition is also inclusive of subnational systems, which is descriptive of the Canadian system decentralized to local payers for each province/territory. Similarly, Kutzin describes flexible geography and public/private sector affiliation, while specifying coverage of the main service package.
In a 2009 special issue on single-payer concepts, several authors note the lack of consensus on what is meant by single-payer. This review builds upon the prior work by identifying key characteristics across the numerous definitions, and puts them in context with proposals. Several definitions restrict the scope of a single payer within a broader system. Oliver describes a single collector that can have multiple local payers. Tuohy suggests using the population covered, service category, and jurisdiction to describe a single-payer system within a broader hybrid. White describes citizens in a geographic area, who make mandatory contributions and receive coverage for medical and hospital care. Going beyond population, services, and financing, Blewett includes the possibility of simplified administration and explicit cost controls. Glied refers to single-payer advocates who call for little or no cost sharing and private, non-for-profit providers. Glied also describes single-payerness based on the number of revenue sources, use of private insurance, and subnational financing. Stone calls single-payer a rhetorical term to avoid the term “social insurance.”.
Single-Payer Proposals, by Single-Payer Category and with Enumeration of Components of Definitions Included in Each Proposal
The three federal bills were the Medicare For All Act, American Health Security Act, and National Health Insurance Act. – Versions of these bills have been repeatedly introduced in Congress. All three propose coverage of comprehensive benefits. The Medicare for All Act and the American Health Security Act are similar and include combinations of taxes, payment reform, no cost sharing, and banning of private insurance duplicating the single-payer plan.
We identified 20 state proposals from across the country (6 Northeast, 3 South, 4 Midwest, 7 West). , – All offer universal coverage of comprehensive benefits, except the Connecticut bill, which is solely a statement of purpose. The proposals vary in the level of detail and the extent that provisions would be determined at a later date, as well as how cost sharing, provider choice, supplemental insurance, quality of care, and cost controls are addressed.
We compared the proposal contents to components of single-payer definitions (Table ). All the proposals indicate the payer and relevant geography. All except the Connecticut bill specify the eligible population, benefits, and financing. Most discuss the types of providers that could participate in the system and how they would be paid. Administrative costs, cost controls, and the role of private insurance are discussed in many proposals, but as with the definitions, these components are not consistent across proposals.
In the following sections, we describe the breadth of the proposals and access, quality, and cost provisions. Based on key distinguishing features, we categorize the proposals as traditional, cost sharing, high-level, and catastrophic (Table and online Appendix Tables ). The traditional mann sucht frau in freiburg proposals provide coverage of comprehensive benefits with no cost sharing (free care for all). The cost-sharing proposals also offer comprehensive benefits but may allow cost sharing; in addition, these proposals tend to be cost-conscious and would study or later implement cost-containment strategies. The high-level proposals are less detailed and contain fewer access, quality, and cost provisions. The sole catastrophic proposal diverges from the others by offering income-related benefits.
Breadth Across Health Care System Functions
Breadth of single-payer proposals across health care system functions. Source: Author’s analysis of single-payer proposals.
The two exceptions that do not address all four functions are the Connecticut bill (statement of purpose only) and the Health-Insurance Solution. The Health-Insurance Solution details fund collection and pooling for a specified population, but does not include specific changes to provider payment, covered services, or provider eligibility.
Access, Quality, and Cost Provisions
Key access, quality, and cost provisions in single-payer proposals. Source: Author’s analysis of single-payer proposals. Note: The quality/cost category includes provisions that have implications for both quality and cost.
With the Health-Insurance Solution and the Connecticut bill constituting the two exceptions, 23 proposals (92%) would provide eligible residents with comprehensive benefits. “All medically necessary health care” is mentioned in 11 proposals (44%). Twelve proposals (48%) specify no cost sharing (deductibles, copayments, and coinsurance); six proposals leave cost sharing to be determined following analyses. In 17 proposals (68%), patients have free choice of providers; this extends only to primary care providers in five proposals that require referrals for specialty care.
The role of private voluntary health insurance is discussed in 16 proposals (64%), ranging from prohibiting substitutive and/or supplementary insurance to no mention of restrictions. Of these, nine proposals allow some type of private insurance. None prohibit complementary private insurance.
Other access-related provisions include the establishment of an enrollment system (e.g., with minimal language and literacy barriers), ensuring adequate resources in underserved areas, addressing state issues (e.g., reimbursement for out-of-state services, reciprocity agreements with other states), and monitoring access (e.g., annual reviews of unmet needs).
Health care provider guidelines, standards, and monitoring are included in 16 proposals (64%). Ten proposals (40%) include review and modification of the benefits package based on value and safety; four proposals (16%) mention reducing the use of ineffective or inappropriate care.
The establishment of electronic systems for records and payments has implications for both quality and cost, and is included in 14 proposals (56%). Also spanning quality and cost, 13 proposals (52%) include formularies for prescription drugs and medical supplies to allow for standardized use of efficacious and cost-effective medications and to support bulk purchasing and price negotiations.
Other quality-related provisions include studies on new models of care, ensuring a workforce able to deliver quality care (including adequate payments to support the workforce), care coordination, promotion of preventive care, and public reporting of quality ratings and prices.
The most common cost provision is global budgets for total expenditures (17 proposals; 68%). The global budget is typically set based on prior-year expenditures and projected growth in gross domestic (or state) product. A threshold for administrative costs is set as a proportion of total expenditures in 13 proposals (52%).
Provider payment is addressed in 12 proposals (48%): nine would have hospitals and health maintenance organizations operating under institutional global budgets, and three mention additional studies of payment models. Nine proposals (36%) specify the authority to implement cost-containment strategies if necessary; five proposals (20%) plan to study cost-containment approaches. Other cost-related provisions include medical fraud investigations, migration effect studies, and eliminating the tax exclusion for employer-sponsored insurance premiums.
Although single-payer is typically defined primarily as a financing mechanism for universal coverage, legislators and researchers have proposed single-payer systems as comprehensive reform with changes across the health care system functions and aims to improve access, quality, and cost containment. Many common provisions are not unique to single-payer—for example, establishing provider standards, formularies, and electronic records—but could potentially be achieved to a greater extent or at a broader scale with a single-payer system.
Meaningful policy discussions involving single-payer may be aided by a common understanding. We suggest following Tuohy’s approach in defining single-payer within a hybrid of subnational systems (characterized by a specified population, service categories, and jurisdiction), because it captures widely what people mean by single-payer, while including common characteristics by which systems may differ. Subnational systems for specific populations such as Medicare or state-based systems could be considered single-payer within the broader U.S. system.
Single-payer is not a one-size-fits-all approach. Proposals are heterogeneous and provisions can be modular. To achieve national universal coverage, policymakers may consider the catastrophic type of proposal as a more conservative approach than the traditional single-payer. Means-tested and high-deductible plans both provide a form of catastrophic coverage; however, means-testing differs by providing lower cost sharing to lower-income households.
States considering single-payer would face numerous decisions about benefit design, financing, payment mechanisms, and other features. The traditional proposal with no cost sharing was the most common type we reviewed. However, we found several state proposals that allow cost sharing to encourage the use of effective services or if cost controls were needed. The cost sharing proposals also frequently featured cost-conscious provisions such as the authority to implement cost-containment strategies if needed and further study of cost controls and payment mechanisms. These cost provisions may be even more likely after Vermont’s single-payer experience, which had wide variation in cost saving assumptions that contributed to high estimated taxes needed to finance the system. To advance, a proposal would likely need to address issues beyond those specified in the high-level proposals.
Although cost-containment provisions are frequently in proposals, strategies are often unspecified. Single-payer systems are thought to reduce costs through lower administrative costs and prices, , but the extent and time frame of these reductions is unknown. Bulk drug purchasing by a single payer able to negotiate prices may help reduce costs, although the magnitude possible at a large scale is uncertain. In addition, price reductions may be at the expense of medical research and innovation and may require initial investments. , Similar to the ACA, a single-payer system could employ a host of different approaches to cost containment and payment reform. These uncertainties contribute to substantial variation in cost analyses of proposals.
Single-payer proposals face many of the same political and implementation challenges as the ACA, which are typical of any system-wide reform. For example, the benefits package and provider reimbursement must be determined. The proposals frequently have an expert board/committee to determine covered services, benefit design, budgets, and payment rates. These boards are intended to ensure that effective, appropriate care is provided and reimbursed through the system. However, they are also often perceived as taking away patient and provider choice through a form of rationing.
States face additional implementation challenges. Under Section 1332 of the ACA, states can apply for a federal waiver to pursue alternative reform, but are required to provide coverage as comprehensive and affordable as the health insurance marketplaces. States could have increased opportunities to pursue alternative reform pathways if the ACA is repealed and Medicaid block grants allow federal funds to be more easily redirected. States must also address how to reimburse services obtained by residents temporarily out of state, and determine eligibility and contributions of non-residents who work in the state.
Although universal coverage is an important step, it does not guarantee access to care. There have been concerns about narrow provider networks restricting access and lowering the perceived quality of plans. , Although provider networks would not be an issue if patients had free choice of providers, access could be restricted if provider supply is inadequate. Opponents of single-payer systems often point to waiting times in single-payer systems in other countries. – The system capacity required to meet the needs of all residents depends in part on provider participation in the program.
A key factor in provider supply is payment policy in the single-payer system. Many proposals describe payment arrangements such as fee-for-service with rates negotiated between a board and provider groups, and salaried in institutions with global budgets. Several proposals would develop new payment models through demonstration projects. However, it is unclear how providers will respond to payment changes due to rate negotiations, global budgets, or other payment models. Furthermore, health care providers may have the option of participating in the single-payer system and/or a parallel private market.
The proposals frequently mention private insurance options but vary in the types allowed. Substitutive insurance duplicating the single-payer plan is frequently banned; restrictions on other types are less common. Complementary insurance (for services not covered by the single-payer plan) or supplementary insurance (for faster or improved access to the same services as those covered by the single-payer plan) are common in other countries. , For example, Canadians often purchase complementary coverage for prescription drugs and dental services. Among U.S. Medicare beneficiaries, “wraparound” (or supplemental) plans are widespread; however, estimated spending by Medigap enrollees is 27–45% higher than those without Medigap. , While complementary insurance covers a service gap excluded from statutory benefits, supplementary insurance creates a parallel risk pool for the same services. Allowing coverage for faster access (i.e., “jumping the queue”) or private care by those who can pay may create inequities in access with a two-tiered system. Differences in payment arrangements could result in providers favoring one system over the other, leading to inadequate provider supply in the latter system.
Many states have proposed legislation to establish a single-payer health care system. The majority of the proposals call for sweeping changes across the health care system and aim to improve access, quality, and cost containment. Within the structure of a single-payer system, there are many critical characteristics that are variable. Section 1332 of the ACA provides states with an opportunity to design and implement alternative reform within the boundaries of equivalent coverage and affordability, and states may have increased flexibility under alternative plans if the ACA is repealed.
As the political conversation on how to improve the health care system continues, it is helpful to have an understanding of what is meant by single-payer and the content of proposals. Further research on cost-containment strategies and provider responses to payment reforms would inform cost analyses and support policymakers on future health care reform decisions.