Single-payer national health insurance is a nonprofit system in which a single public or quasi-public agency organizes health financing, but delivery of care remains largely in private hands.
Currently, the U.S. health care system is outrageously expensive, yet inadequate. Despite health expenditures of $10,348 per person in 2016, more than twice that of other industrialized nations, the United States performs poorly in comparison on major health indicators such as life expectancy, infant mortality, and chronic disease.
Moreover, those same industrialized nations provide comprehensive coverage to their entire populations, while the U.S. leaves 28 million people completely uninsured and another 41 million underinsured, i.e. inadequately protected in the event of illness of medical need.
The reason we spend more and get less than the rest of the world is because of our heavy reliance on a highly inefficient, dysfunctional patchwork of private and largely for-profit payers.
Private insurers waste our health care dollars on things that have nothing to do with care: bloated overhead costs, including underwriting, tracking, billing, and sales and marketing campaigns, as well as exorbitant executive pay and an overweening imperative to deliver maximum returns to private shareholders.
In addition to this above, doctors and hospitals have to maintain costly administrative staffs to deal with the complex bureaucracy stemming from this patchwork of multiple payers.
As a result, administrative costs consume about one-third (31 percent) of Americans’ health dollars, most of which is waste.
Single-payer financing, i.e. the elimination of the private-insurer middlemen and their replacement by a single, streamlined, nonprofit agency that pays all medical bills, is the only way to recapture this wasted money. The potential savings on paperwork, more than $500 billion per year, is enough to provide comprehensive coverage to everyone in the country without increasing overall U.S. health spending.
Under a single-payer system, all residents of the United States would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drugs, and medical supply costs. Patients would no longer face financial barriers to care such as copays and deductibles, and would regain free choice of doctor and hospital. Doctors would regain autonomy over patient care.
Physicians would either be paid on a fee-for-service basis according to a negotiated formulary or receive a salary from a hospital or nonprofit HMO/group practice. Hospitals would receive a lump-sum annual budget for operating expenses. Health facilities and expensive equipment purchases would be managed by regional health planning boards. The new system would also have the bargaining clout to negotiate lower costs for pharmaceutical drugs, medical equipment, and other supplies.
The system would be affordable. It would retain current levels of public funding, which now account for about two-thirds of U.S. health spending. Modest new taxes, based on ability to pay, would replace premiums and out-of-pocket payments currently paid by individuals and businesses. The vast majority of households would pay less for care than they do now. Costs would be controlled through negotiated fees, global budgeting and bulk purchasing.
Other nations have demonstrated that single-payer health systems work, and work well.
As William Hsiao, Ph.D., professor of economics at the Harvard School of Public Health and the designer of Taiwan’s successful single-payer system, observed in a 2009 New York Times interview: “You can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.”
Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform
First published in the American Journal of Public Health, June 2016, Vol 106, No. 6
Key Features of Single-Payer
A useful summary detailing the main features of single-payer.
Statement of Dr. Marcia Angell Introducing the U.S. National Health Insurance Act
A great overview of the need for and logic of a single-payer system.
Liberal Benefits, Conservative Spending
Another great overview and introduction to single payer.
The case for eliminating the private health insurance industry
By Don McCanne, M.D. and Leonard Rodberg, Ph.D.
Single Payer: Facts and Myths
Myths as Barriers to Health Care Reform
A paper refuting many of the myths associated with single payer.
“Mythbusters” by the Canadian Health Services Research Foundation
A series of brief papers debunking common misconceptions about the Canadian health system.
“Moral Hazard:” The Myth of the Need for Rationing
Would single payer lead to “overuse” of medical services? No, according to papers in the New England Journal of Medicine and the Canadian Medical Association Journal, as well as in a Malcolm Gladwell piece from the New Yorker.
Two-thirds of Americans support Medicare for all
By Kip Sullivan, J.D.
Health Economics and Financing
Financing single-payer national health insurance: Myths and facts
One-page handout on single-payer financing.
Introduction: How Much Would a Single-Payer System Cost?
A review of government and independent studies of the cost of a single-payer system.
Administrative Waste Consumes 31 Percent of Health Spending
Woolhandler, et al. “Costs of Health Administration in the U.S. and Canada,” NEJM 349(8); Sept. 21, 2003
Administrative Costs Account for 25.3 Percent of Total U.S. Hospital Expenditures
Himmelstein, et al. “A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far,” Health Affairs 33(9); September 2014
60 Percent of Health Spending is Already Publicly Financed, Enough to Cover Everyone
Woolhandler, et al. “Paying for National Health Insurance – And Not Getting It,” Health Affairs 21(4); July/Aug. 2002
The Case Against For-Profit Care
Overview: The High Costs of For-Profit Care
Editorial by David Himmelstein, M.D. and Steffie Woolhandler, M.D. in the Canadian Medical Association Journal.
For-Profit Hospitals Cost More and Have Higher Death Rates
A pair of studies published by a team of researchers led by Dr. P.J. Devereaux, published in the Canadian Medical Association Journal.
For-Profit Hospitals Cost More and Have Higher Administration Expenses
Himmelstein, et al, “Costs of Care and Admin. At For-Profit and Other Hospitals in the U.S.” NEJM 336, 1997
For-Profit HMOs Provide Worse Quality Care
Himmelstein, et al. “Quality of Care at Investor-Owned vs. Not-for-Profit HMOs” JAMA 282(2); July 14, 1999
Healthcare Spending and Utilization in Public and Private Medicare
NBER Working Paper No. 23090, January 2017
Quality and Malpractice
Introduction: Medical Malpractice, Health Care Quality and Health Care Reform
A forum report by Gordon Schiff, M.D.
How Single-Payer Improves Health Care Quality
A brief by PNHP (makes a great handout!)
A Better Quality Alternative: Single-Payer National Health Insurance
Schiff, et al. “A Better Quality Alternative” JAMA, 272(10); Sept. 12 1994
Comprehensive Quality Improvement Requires Comprehensive Reform
Schiff, et al. “You Can’t Leap a Chasm in Two Jumps,” Public Health Reports 116, Sept/Oct 2001
Quality of Care Under Single Payer National Health Insurance
Two-page table developed by Gordon Schiff, M.D., April 2007
The Failures of Other Reform Options
International Health Systems
Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care
By Eric C. Schneider, M.D., Dana O. Sarnak, David Squires, Arnav Shah, and Michelle M. Doty, Commonwealth Fund, July 14, 2017
International Health Systems for Single Payer Advocates
By Dr. Ida Hellander
International Resources on National Health Insurance
Compiled by Joel A. Harrison, Ph.D., M.P.H.
Health Care Systems – Four Basic Models
An excerpt from T.R. Reid’s book on international health care, “We’re Number 37!”
State Single-Payer Bills
Key Features of Single-Payer
A useful handout to help recognize state single-payer legislation
Analysis of ColoradoCare Ballot Initiative (2016)
By Ida Hellander, M.D., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.