Most Universal Health Care is NOT Single Payer…

The ultimate goal of health care reform should be universal health insurance. It’s about creating a system in which every American has access to the health care they need when they need it, without losing everything they have worked for in the process. It’s about making the system affordable and reducing costs significantly.

Single-payer is definitely one way to do that, but it’s not the only way. I support the concept as an ideal way to cut costs, but cutting costs is only one aspect of universal health care. And frankly, there are two things everyone must keep in mind when supporting a single-payer health care system. The first is obvious. It’s would require the United States to do something it has never done before; to take over an entire industry and essentially nationalize it. To say that won’t be easy is a massive understatement, and it will not be done with one bill. It will ake many bills over decades, and a long transition, if it is to happen at all. Even expanding Medicare, which would be the best way to implement such a system, will be a hard sell. The elderly will be nervous, and they vote in huge numbers. In other words, it will take a long, very difficult concerted effort to transform the views of millions of people; something we progressives have not been very good at for decades.

In other words, it will take a long, very difficult concerted effort to transform the views of millions of people; something we progressives have not been very good at for decades.

But the second thing to keep in mind is just as important as the first. Because this will be incredibly difficult and may even be impossible, we have to keep Republicans out of office in the meantime, so we can tweak what we have. We have to accept that single-payer may never happen, and put in place a system that meets all of the necessary goals in the meantime, just in case. We have to prepare for the eventuality that we may never get a single-payer system, and prepart accordingly.

And that’s okay. The fact is, every other developed country in the world has a universal health care system, but very few are single-payer systems. In fact, before Obamacare, WHO had the United States ranked as #37 in the world when it came to health care outcomes, and of the 36 countries ahead of us, only two have a single-payer system. (Source

There are many ways to accomplish universal health care, and single-payer is nothing more than a method for paying for it. As long as the system provides access to everyone (eventually) and costs keep going down, then the system could be great as-is. And if single-payer adherents would take off their blinders long enough to look, they would find that Obamacare incorporates some of the best aspects of the world’s best universal health care systems. With tweaking, it could become the best. Of course, with the GOP running government, there will be no tweaks.

Here are some examples of how other universal health care systems work.


Set up in 1945 and constantly adjusted by the French government, by many measures the French health care system is the best in the world. (Source) The health insurance system is largely funded through taxes, with French workers paying 20% of their gross pay into the Social Security System, which includes health care and retirement assistance. If that sounds like a lot, consider that workers here pay 7.65% of their gross pay into the Medicare and Social Security trust funds, with employers matching that. That’s 15.3%, and no one gets health insurance for that, at least until they’re 65.

While French law mandates universal coverage, and every legal resident of France has access to a wide choice of general practitioners and specialists, everyone needs private insurance or self-insurance also, because Social Security only covers 75%, and the patient’s private insurer has to foot the bill and wait 10 days for reimbursement.

French health officials control most aspects of health care as the sizes and numbers of hospitals, and how to allocate technical equipment, so that everyone in the country has adequate access to care without creating an expensive glut of unnecessary expensive machines. However, the system is a public/private partnership, with for-profit private sector companies accounting for 35% of hospital beds and most surgical procedures.

About 56% of all health professionals work in private practice, while 36% work in public hospitals or clinics. Prices are set by experts in the field, and negotiated by physicians’ unions and the public health insurance funds. The French system is expensive to maintain, and often runs a deficit, but the French still only only spend 10% of their GDP on health care, compared to 16% in the United States, and they cover everyone. Just as importantly, their health care inflation rate has always been less than 4%, whereas ours averaged more than three times that before Obamacare.


The German health insurance system has been around since Otto von Bismarck oversaw passage of the Health Insurance Act of 1883.  Like France, the German system is a hybrid public/private partnership. That said, almost all health insurance is private, albeit non-profit.

German residents are required to carry health insurance if they are working. Those who make less than €4,050 per month are mandatory enrollees of the public German health insurance system and pay 14.9% of their gross salary, with the worker paying 51% and the employer paying 49% of the premium. Non-working spouses are automatically covered by a worker’s policy. Unemployment insurance includes full health coverage. German children are officially considered “national treasures” and an investment in the country’s future, so they receive coverage by the government out of general revenues.

The German system is a single-collector system, not single-payer. Premiums are collected in a government-run central fund that pools risk for the entire health care financing system, and the funds are redistributed to the nearly 200 independent, non-profit, competitive, non-governmental “sickness funds,” (insurance companies” that each German can choose for coverage. When a person chooses a particular sick fund, the central fund will pay that particular sick fund a capitation payment based on that person’s actuarial risk. It works much like an HMO here in the U.S. Usually, the employer automatically signs up a new worker with an insurance company, but sometimes the employee is asked if they have a preferred insurance company. Insurance companies must provide a minimum level of coverage, and there are no “pre-existing conditions” or exclusions. While most insurance services are provided by private companies, there is no profit element in the system. When WHO ranked natonal health outcomes, the German system ranked


The Australian Medicare system was created in 1975 as a public system with a strong private component. Every legal resident of Australia has basic coverage by virtue of living there, which means they have access to the extensive public hospital system, and receive a 75% reimbursement for outpatient medical treatment to any doctor with a Medicare number. To pay for this, every working person pays a 1.5% tax on all income, although those with higher incomes pay an extra 1% if they don’t have “adequate” private coverage.

Private, non-profit insurance plays a significant role in the Australian system, because it takes pressure off the public system and keeps the Medicare income tax low. A portion of private insurance premiums goes to Commonwealth-State Health Care Agreements, to defray the cost of the “free” hospital care.

Nearly half of Australians carry private insurance, in part because the government encourages it.  Though many have cited the program as unfair to those who can’t afford private insurance, those with private policies receive a government rebate of up to 30% of their premiums (up to 40% if they’re over 65). There are also shorter waiting lists for many procedures and a wider selection of doctors in private hospitals, and they also offer more personalized service than in the public system. Those with private insurance usually have more treatment choices, such as dental, optical, chiropractic or holistic care, for which coverage is either limited or nonexistent under Medicare.


Canada’s Medicare system is a universal single-payer system that covers about 70% of the country’s health care expenses.  The Canada Health Act requires that all Canadian residents are fully insured for hospitalization and basic health care. About 91% of hospital costs and 99% of physician services are financed by the public sector.

Though the insurance system is mostly public, the Canadian health care delivery system is not “socialized medicine,” and is private, not public. While the federal government provides provinces with money to finance health care, it doesn’t pay the salaries of medical professionals, and it doesn’t make treatment decisions. It simply makes sure they get paid. Most physicians receive a set fee at rates negotiated annually by the provincial governments and the medical associations within the province. Approximately 65% of Canadians also carry supplemental private insurance, most of which they receive through employers. Private insurance covers elective medical services and those services not fully covered by Medicare, such as pharmaceuticals, dental and ophthalmological services.

The Canadian system has many flaws. They could stand to spend more money recruiting and training doctors, as there has been a shortage of physicians in the country for some time, which causes some folks to have to drive a long way to see a doctor, and waiting times are a significant problem in some areas.  That said, most Canadians love their system.  Also, health care represents 10.7% of their GDP as of 2008, even though they cover everyone.

United Kingdom

The United Kingdom is the exception when it comes to universal health care, in that it’s the only truly socialized system of medicine among the 36 countries ahead of the United States on the WHO list. There is a lot to like about the UK health care systems (England, Northern Ireland, Scotland and Wales actually have different systems with similar approaches), but they also carry a cautionary tale when it comes to developing a completely socialized single-payer system.

The NHS systems are publicly funded and provide almost all health services for UK residents. Services such as primary care, in-patient and long term care are free to all patients, although some health care sectors, such as ophthalmology, dentistry and prescription drugs incur relatively small charges.

The English NHS, created in 1948, is run according to the NHS Constitution for England, which guarantees the rights and obligations of everyone involved in the system, including patients and medical professionals. Medical professionals who are signed up with England NHS are considered government employees. The most common complaint about NHS usually has to do with the fact that the system is completely government run, and therefore is subject to the whims and fancies of those running the government. NHS suffered greatly under “conservative” governments, to the point that is almost collapsed under its own weight back in the 1970s and 1980s, as the “conservatives” cut funding and ordered unrealistic changes under the guise of “efficiency.” During the Thatcher era, the UK only spent about 6% of GDP on health care, which resulted in an extremely high level of dissatisfaction. Since then, subsequent governments have increased funding greatly, bringing  spending levels up to  8.4% of GDP, which is just slightly below the 8.9% average of OECDs, and about 1% below the EU average.

The two “single payer” systems above are #18 and #30 in health outcomes, according to WHO. While that’s better than our system, the other systems mentioned above rank much higher. Instead of being wedded to the “single-payer” option, wouldn’t it be a better idea to be open to whatever works? Again, there is no panacea when it comes to creating a universal health care system in the US. Single-payer is potentially part of a fix, but it is not, in itself, the basis of a successful health care system.

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One comment

  1. Thank you for this great summation, Milt! As a long-time single payer advocate, I knew a lot of this but not in detail. While it was easier to say that ACA was originally Heritage Foundation’s brain child and is Romneycare, it is NOT. The only thing that really is from those sources is the mandate – which would be required under any other plan as well. ACA took the consumer cost scale embedded in the one funding bill in the CA effort to pass single payer – a sliding scale linked to INCOME – rather than the flat $200 subsidy everyone got in MA no matter what the premium cost was. ACA has vastly lower contributions – MA required a deductible of $15,000 per person per year. Think about that. Moreover, only a couple of things such as childhood immunizations, lay outside the deductible while ACA has dozens of screening and preventive care treatments that are at NO extra cost. Because of the scale and the no-cost care, lower income people are served vastly more reasonably than in MA or even in France, Canada, etc. where they pay huge portions of their income. I did not expect to like ACA as a long-time single payer supporter, but it has worked to the benefit of most people’s well being. It serves as an essential and just foundation for a future system that is less political (no access for undocumented immigrants) and more comprehensive system. Why we are still demanding a system even Vermont cannot make economically fair is beyond me. This has been an eye-opening experience in economic reality and political folly.

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