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 United Kingdom). "Single-payer" describes the mechanism by which healthcare is paid for by a single public authority, not a private authority, nor a mix of both.[4][5]
payer single
Within single-payer healthcare systems, a single government or government-related source pays for all covered healthcare services.[6] Governments use this strategy to achieve several goals, including universal healthcare, decreased economic burden of health care, and improved health outcomes for the population. In 2010, the World Health Organization's member countries adopted universal healthcare as a goal;[7] this goal was also adopted by the United Nations General Assembly in 2015 as part of the 2030 Agenda for Sustainable Development.[8]
A single-payer health system establishes a single risk pool, consisting of the entire population of a geographic or political region. It also establishes a single set of rules for services offered, reimbursement rates, drug prices, and minimum standards for required services.[9]
In wealthy nations, single-payer health insurance is typically available 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.
Typically, "single-payer healthcare" refers to health insurance provided as a public service and offered to citizens and legal residents; it does not usually refer to delivery of healthcare services. The fund can be managed by the government directly or as a publicly owned and regulated agency.[6] Single-payer contrasts with other funding mechanisms like 'multi-payer' (multiple public and/or private sources), 'two-tiered' (defined either as a public source with the option to use qualifying private coverage as a substitute, or as a public source for catastrophic care backed by private insurance for common medical care), and 'insurance mandate' (citizens are required to buy private insurance which meets a national standard and which is generally subsidized). Some systems combine elements of these four funding mechanisms.[11]
In contrast to the standard usage of the term, some writers describe all publicly administered systems as "single-payer plans", and others have described any system of healthcare which intends to cover the entire population, such as voucher plans, as "single-payer plans", although these usages generally do not meet strict definitions of the term.[12]
Several nations worldwide have single-payer health insurance programs. These programs generally provide some form of universal health care, which is implemented in a variety of ways. In some cases doctors are employed and hospitals are run by the government, such as in the UK or Spain.[13][14] Alternatively, the government may purchase healthcare services from outside organizations, such as the approach taken in Canada.
While physician income initially boomed after the implementation of a single-payer program, a reduction in physician salaries followed, which many feared would be a long-term result of government-run healthcare. However, by the beginning of the 21st century, medical professionals were again among Canada's top earners.[21]
Despite the initial shock on Taiwan's economy from increased costs of expanded healthcare coverage, the single-payer system has provided protection from greater financial risks and has made healthcare more financially accessible for the population, resulting in a steady 70% public satisfaction rating.[23]
The current healthcare system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health care funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[24]
In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002. Taiwan's success with a single-payer health insurance program is owed, in part, to the country's human resources and the government's organizational skills, allowing for the effective and efficient management of the government-run health insurance program.[23]
South Korea used to have a multipayer social health insurance universal healthcare system, similar to systems used in countries like Japan and Germany, with healthcare societies providing coverage for the whole populace. Prior to 1977, the country had voluntary private health insurance, but reforms initiated in 1977 resulted in universal coverage by 1989.[25] A major healthcare financing reform in 2000 merged all medical societies into the National Health Insurance Service. This new service became a single-payer healthcare system in 2004.[26]
The Nordic countries are sometimes considered to have single-payer health care services, as opposed to single-payer national health care insurance like Taiwan or Canada. This is a form of the 'Beveridge Model' of health care systems that features public health providers in addition to public health insurance.[27]
The term "Scandinavian model" or "Nordic model" of health care systems has a few common features: largely public providers, limited private health coverage, and regionally-run, devolved systems with limited involvement from the central government.[28] Due to this third characteristic, they can also be argued to be single-payer only on a regional level, or to be multi-payer systems, as opposed to the nationally run health coverage found in Taiwan and South Korea.
Healthcare in the United Kingdom is a devolved matter, meaning that England, Scotland, Wales, and Northern Ireland all have their own system of private and publicly funded healthcare, generally referred to as the National Health Service (NHS). With largely public or government-owned providers, this also fits into the 'Beveridge Model' of health care systems, sometimes considered to be single-payer, with relatively little private involvement compared to other universal systems. Each country's having different policies and priorities has resulted in a variety of differences existing between the systems.[29][30] That said, each country provides public healthcare to all UK permanent residents that is free at the point of use, being paid for from general taxation.
India has a universal multi-payer health care model that is paid for by a combination of public and private health insurances along with the element of almost entirely tax-funded public hospitals.[36] The public hospital system is essentially free for all Indian residents except for small, often symbolic co-payments in some services.[37] At the federal level, a national health insurance program was launched in 2018 by the Government of India, called Ayushman Bharat. This aimed to cover the bottom 50% (500 million people) of the country's population working in the unorganized sector (enterprises having less than 10 employees) and offers them free treatment even at private hospitals.[36] For people working in the organized sector (enterprises with more than 10 employees) and earning a monthly salary of up to Rs 21000 are covered by the social insurance scheme of Employees' State Insurance which entirely funds their healthcare (along with pension and unemployment benefits), both in public and private hospitals.[38][39] People earning more than that amount are provided health insurance coverage by their employers through the many public or private insurance companies. As of 2020, 300 million Indians are covered by insurance bought from one of the public or private insurance companies by their employers as group or individual plans.[40] Unemployed people without coverage are covered by the various state insurance schemes if they do not have the means to pay for it.[41]In 2019, the total net government spending on healthcare was $36 billion or 1.23% of its GDP.[42] Since the country's independence, the public hospital system has been entirely funded through general taxation.
Building upon less structured foundations, in 1963 the existence of a single-payer healthcare system in Spain was established by the Spanish government.[47] The system was sustained by contributions from workers, and covered them and their dependants.[48]
Additionally, in parallel to the single-payer healthcare system there are private insurers, which provide coverage for some private doctors and hospitals. Employers will sometimes offer private health insurance as a benefit, with 14.8% of the Spanish population being covered under private health insurance in 2013.[51][52]
A number of proposals have been made for a universal single-payer healthcare system in the United States, among them the Medicare for All Act originally introduced in the House in February 2003 and repeatedly since.[55]
Backers of single-payer or Medicare for All note that minorities and the poor, as well as rural residents in general, are less able to afford private health insurance, and that those who can must pay high deductibles and co-payments that threaten families with financial ruin.[65][66]
A 2008 analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year.[70] The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.[71]
The Medicare for All Act is a perennial piece of legislation introduced many times in the United States House of Representatives by then Representative John Conyers (D-MI).[75] The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. The bill was first introduced in 2003 and has been reintroduced in each Congress since.[75] During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act, H.R. 676 was expected to be debated and voted upon by the House in September 2009, but was never debated.[76][77] In the wake of Bernie Sanders' 2016 presidential campaign, in which a push for universal healthcare featured prominently, single-payer proposals gained traction. Conyers reintroduced his bill in the House of Representatives in January 2017. Four months later, the bill was supported by 112 co-sponsors, surpassing for the first time the 25% mark of co-sponsorship.[78] In September of the same year, Sanders himself, together with 16 co-sponsors, introduced a Medicare-for-all bill in the Senate (S. 1804).[79] An analysis of a Mercatus Center study of the 2017 proposal by economist Jeffrey Sachs found that "it rightfully and straightforwardly concludes that M4A would provide more health care coverage at lower cost than the status quo, projecting a net reduction in national health expenditures of roughly $2 trillion over a 10-year period (2022-2031), while also enabling increased health care coverage."[80] 2ff7e9595c
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