Single-payer health care is medical care funded from a single insurance pool, run by the state.[4] Single-payer is form of monopsony: a market in which one buyer faces many sellers. Single-payer is not the same as universal health care (it is possible to have either without the other). A single-payer-universal-health-care plan for an entire population can be financed from a pool to which many parties – employees, employers, and the state – have contributed.
Single-payer health insurance collects all medical fees, and then pays for all services, through a "single" government (or government-related) source.[5] 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.
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 UK). 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.
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Canada, Australia, Taiwan, and the United Kingdom have single-payer health insurance programs. These programs provide universal health care. Single-payer healthcare may be operated in a number of ways. In some cases doctors may be employed, and hospitals run by, the government as in the United Kingdom. Alternatively the government may purchase healthcare services from outside organizations. This is the approach taken in Canada.
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,"[6] although this is an uncommon usage. The standard usage refers to health insurance, as opposed to healthcare delivery, operating as a public service, like fire departments, community libraries, and other publicly-funded services, 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.[5]
Health care in Canada is an example of single-payer health care.[7] The national government provides part of the funding, provincial governments manage the hospitals and provide the bulk of the funding, and doctors in private practice contract with the government for fee-for-service payments. Although many Canadian citizens have supplemental private insurance from their employers, this covers non-medically necessary expenses not covered by Canadian Medicare, and accounts for 12% of national health care spending.[8]
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 high potential costs (as is the case in the U.S.) of billing individually for huge numbers of products and services.
Health care provision in Canada is a mix of private and public services, although most hospitals are public.[9] Patients may go to any doctor or hospital in the country.[10]
Canadians do wait for some treatments and diagnostic services. Survey data show 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[11] is two weeks, with 86.4% waiting less than three months.[12] 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.[13]
Taiwan instituted a single-payer system, called the National Health Insurance (NHI), in 1995. In a 2009 interview, Dr. Michael Chen, Vice President and CFO of Taiwan's National Health Insurance Bureau, explained that before NHI was instituted, Taiwan "sent our people around the world to learn their programs, including the United States" to compare models. Dr. Chen indicated that Taiwan's single-payer NHI program "is modeled after (U.S.) Medicare. And there are so many similarities — other than that our program covers all of the population, and Medicare covers only the elderly. "[14][15]
A number of proposals have been made for a universal single-payer healthcare system in the United States, none of which has achieved significant political support, with polling showing support for various levels of government involvement depending on wording.[16] Proposers include Physicians for a National Health Program,[17] The American College of Physicians[18] and the American Medical Student Association.[19]
In Congress, Rep. John Conyers, Jr. (D-MI), and Rep. Dennis Kucinich (D-OH) have introduced the United States National Health Care Act (HR 676). The bill has been introduced in every term of Congress under the same name since it was first introduced in 2003 in the 108th Congress with 38 cosponsors.[20]
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Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens and certain other classes of people.[7] 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.[21] However, studies have shown that the publicly-administered share of health spending in the U.S. is closer to 60%.[22]
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."[23]
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 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 U.S. Medicare.[24]
Several single-payer state referendums and bills from state legislatures have been proposed, but so far all have either failed to pass both legislatures or were vetoed by the governor, including (states where the debate is also current) California as early as 1994,[25] Massachusetts in 2000, and Oregon in 2002.[26]
In 2009 the House of Representatives Education and Labor Committee approved an amendment to the House health care bill, which would allow individual states to adopt a single-payer Medicare-for-all-style health plan. The amendment was proposed by Democratic Congress member Dennis Kucinich of Ohio. The Kucinich Amendment received support from some conservatives supporting states rights as it would allow states more freedom to explore various models including, but not limited to, single payer.[27]
In Minnesota, the Minnesota Health Act, which would establish a state-wide single payer health plan, has been presented to the Senate as SF118 and to the House as HF135, in identical language. This bill was passed by several critical committees in both houses, has been designated as a two-year bill, and awaits a second reading in the House Health Care and Human Services Policy & Oversight Committee.[28] Two out of three of the 2010 Democratic-Farmer-Labor Party candidates for governor have indicated they would sign the bill, if passed; the Republican Party candidate does not support such a measure (two of the candidates interviewed that indicated they would not have since left the race).[29]
The California State Legislature has twice passed a state-level single payer bill, SB 840, "The California Universal Healthcare Act" (authored by Sheila Kuehl), in 2006 and again in 2008.[30] Both times, Governor Arnold Schwarzenegger vetoed the bill.[31] State Senator Mark Leno later re-introduced "The California Universal Healthcare Act" in March 2009, newly renumbered as SB 810,[32] and in January 2010, the California Senate passed SB 810. On the last day of the 2010 legislative session, the Democrats pulled SB 810 from the Assembly floor as Governor Arnold Schwarzenegger said he would veto it a third time, with Senator Mark Leno announcing he would reintroduce the bill again in January the 2011 legislative session as Jerry Brown is sworn in as the new Governor of California.[33][34] The bill has received support from the California Nurses Association/National Nurses United.[35]
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,"[36] favorably out of committee by an 8–4 vote.[37]
In February 2010, the 301-member Pennsylvania Democratic State Committee unanimously endorsed a resolution calling for passage of single payer healthcare, Senate Bill 400 and House Bill 1660, also known as the "Family and Business Healthcare Security Act."[38]
In September 2011, Governor Brian Schweitzer did a news interview discussing his desire to obtain a waiver from the federal government similar to the waiver Vermont used, and set up their own universal health care system similar to what was established in the Canadian provence of Saskatchewan.[39]
In Massachusetts, Question 4, a nonbinding referendum was on the ballot in 14 districts in November 2010, asking voters, "Shall 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?"[40] With 222 of 228 precincts reporting, in all 14 districts, including five in which majorities had voted for Republican Senator Scott Brown, Question 4 passed, with 63.5% of the overall votes being cast in favor of the ballot referendum for establishing a Massachusetts single payer system.[41][42]
The legislature of Vermont, including both the Democratic and Progressive Party, endorses single payer health care and has hired William Hsiao, the designer of Taiwan's single payer health care system, to design three possible systems of universal health care, one being a single payer model. Governor Peter Shumlin supports this move.[43][44]
The Vermont health bill, H.202, has led to the creation of Green Mountain Care, a private/public single payer exchange system that will give universal coverage to Vermonters and create an electronic system of medical records in an effort to make the system efficient and accessible.[45] In April 2011, it passed the Vermont Senate.[46] In May 2011, the governor signed it into law, making Vermont the first state to have a single payer health care system.[47]
Physicians for a National Health Program[48] the American Medical Student Association[7] and the California Nurses Association[49] are among those that have called for the introduction of a single payer health care program. In Congress, Rep. John Conyers, Jr. (D-MI) has repeatedly introduced The United States National Health Care Act (HR 676). As of August 2008, HR 676 had 91 co-sponsors.[50]
The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings,[51] probably because of the 40% cost savings associated with universal preventative care.[52]
The issue has often been debated, most recently in the 2008 presidential elections. A CBS News/New York Times poll published in February 2009 reported that 59% say the government should provide national health insurance (up from 40% thirty years earlier)[53] A study published in the Annals of Internal Medicine concluded that 59% of physicians "supported legislation to establish national health insurance" while 9% were neutral on the topic, and 32% opposed it.[54]
According to the media criticism organization Fairness and Accuracy in Reporting, a 1987 New York Times/CBS poll showed 78% of people saying that the "government should guarantee medical care to everyone."[55] Between 2003 and 2009, 17 opinion polls showed a majority of the public supports various levels of government involvement in health care in the United States.[16] Many polls, such as ones administered through CNN,[56] AP-Yahoo,[57][58] New York Times/CBS News Poll,[59][60] and Washington Post/ABC News Poll,[61] Kaiser Family Foundation[62] showed a majority in favor of a form of national health insurance, often compared to Medicare. The Civil Society Institute[63] and Physicians for a National Health Program[64] have both found majorities in favor of the government offering guaranteed insurance, and a Quinnipiac poll in three states in 2008 found majority support for the government ensuring "that everyone in the United States has adequate health-care" among likely Democratic primary voters.[65]
In contrast, a October 2011 Rasmussen Reports poll of registered voters showed only 35% of respondents in favor of single-payer health care, with a plurality (49%) opposed.[66] Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care."[67] 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," less favorably when stated as "socialized."[67]