Deconstructing Single Payer, One Dinner Party at Time

Murray-Ross
Murray-Ross
By Murray Ross, PhD, Vice President and Institute for Health Policy Director

Earlier this summer in California we had our gubernatorial primary where health care, and specifically the issue of single payer, was front and center.

In the weeks leading up to the primary I found myself fielding questions from friends and acquaintances about what people mean by a “single-payer” health care system. At dinner with friends, I was asked questions such as: “can you explain to me what exactly a single-payer model is?” and “a single-payer model means that everyone gets coverage, right?” and “I’ve heard we’re the only developed country without a single-payer model.”

These conversations reminded me that many voters — and even policymakers — often do not know exactly what single payer means, something that should be concerning to health policy professionals. What’s more, single payer sounds like a simple concept to understand (after all, it’s a single payer), but the reality is surprisingly complex.

At Kaiser Permanente’s Institute for Health Policy (IHP), we endeavor to close the gap in understanding between health care experts and the broader public. I had not anticipated dinner parties becoming a platform for realizing IHP’s mission, but perhaps I shouldn’t have been surprised. My neighbors, like many Californians and Americans generally, have heard (and sometimes experienced) that the health care system is failing to meet expectations, especially in the realm of being simply unaffordable, and they are looking for trustworthy information on which to ground their opinions.

As the director for IHP I wanted to share a few of the most common questions I’ve fielded in the past month and how I respond.

What does the term ‘single payer’ mean? Who is the single payer? What’s the alternative?

All developed countries have a health system grounded in either a single- or multi-payer model. In these models, the ‘payer’ refers literally to the entities in the system who pay for doctors, hospitals, and other health care services. In a single-payer model, this means a single entity (generally the government, though it need not be) provides payments for all health care services.

In contrast, ‘multi payer’ refers to any system in which multiple entities pay for health care services. Like single-payer systems, multi-payer systems can vary greatly, ranging from the relatively decentralized system we have in the U.S. where coverage is provided through both private and public entities to more centralized systems — such as those in Germany, Japan, or the Netherlands.

True, but basically every developed country besides the U.S. has a single-payer system, right?

The idea that all other countries use a single-payer model is a common misconception. However, most other countries do provide universal coverage; in other words, they craft systems where all people have access to affordable health services. Universal coverage is an outcome, single payer is one way, but by no means the only way, to achieve this outcome.

In fact, the models by which other countries achieve universal coverage — a goal strongly shared by Kaiser Permanente — vary greatly.

To give just a few examples:

  • Universal coverage via single-payer models: Broadly the nations that use a single-payer system fall into two camps. Some countries (such as Canada and Australia) use a ‘national’ or ‘public’ insurance model that pays independent hospitals and doctors. Others (for example, England, Spain, and New Zealand) pay for health services out of tax revenue with some doctors and hospitals either employed or operated by the government.
  • Universal coverage via multi-payer models: Despite their name, multi-payer systems in other countries typically involve a single public entity — whether at the national, state, or local level — that collects taxes that are paid to multiple, competing public and/or private insurance companies who pay providers (most of whom are private). This model, used by countries such as Germany, Japan, the Netherlands, Switzerland, France, and Belgium, relies on centralized regulation, but allows insurers to maintain autonomy.

Well, I just want everyone to have coverage — single payer is the best way to do that, right?

Right now, in the U.S. — and perhaps particularly in California — the public narrative has begun to equate single payer with universal coverage, but again this isn’t accurate. Looking at our peer nations, we see that it’s the design and structure of the health care system — not the number of payers — that determines whether a country achieves true universal coverage. Grounding ourselves in concrete examples and evidence will be important as we move forward in this conversation.

Obviously, details start to matter pretty quickly when you’re talking about something as complex as financing the U.S. health care system. Ultimately, as policy professionals, we must ask ourselves if our goal is to ensure that everyone in our communities has access to affordable, high quality care, what is the most effective, achievable and sustainable tool to achieve this? In our analysis, the changes outlined in the single-payer proposals put forward so far are neither necessary nor sufficient to achieve this objective.

As a nation we stand at a crossroads in our path towards health reform. At Kaiser Permanente we believe we must unite around the goal of universal coverage and that the best way to achieve this goal is to continue building on the progress made over the last decade, with tens of millions of people gaining coverage.

Perhaps even more importantly, however, we need to have a strong public dialogue around this issue, making sure that voters and policymakers have access to credible and complete information. The future of our nation’s health depends on it. One dinner at a time is a good start, but it’s not nearly enough.

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