Single-payer health care

Overview
Single-payer health care is an American term describing the payment for doctors, hospitals and other providers for health care from a single fund. The Canadian health care system and Medicare in the U.S. for the elderly are single-payer systems.

According to the National Library of Medicine, a "Single-Payer System" is

"An approach to health care financing with only one source of money for paying health care providers. The scope may be national (the Canadian System), state-wide, or community-based. The payer may be a governmental unit or other entity such as an insurance company. The proposed advantages include administrative simplicity for patients and providers, and resulting significant savings in overhead costs. (From Slee and Slee, Health Care Reform Terms, 1993, p106) Year introduced: 1996"

Some writers assume that the single payer is the government, but the preceding definition as well as some single-payer proponents in the U.S. leave the government's role open to interpretation.

Single payer is one alternative proposed for reforming the  U.S. health care system. Proponents argue that it would provide universal coverage with at least the same quality and lower costs. Critics argue that single payer would harm quality and innovation and advocate tax code incentives and free market approaches instead.

The term single-payer is often used in the U.S. to distinguish systems paid from a single source with other systems of universal health care in which the government has a higher degree of control, up to and including administering hospitals and employing doctors and staff. (See socialized medicine.) Under single payer, doctors' practices and hospitals may remain private and negotiate for payments with the government.

Types and variations
Canada is an example of single-payer health care. The national government provides part of the funding, provincial governments manage the hospitals (and provide the brunt of the funding), and doctors in private practice contract with the government for fee-for-service payments. Many Canadian citizens have supplemental health insurance, which covers expenses not covered by Canadian Medicare. 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 cost of billing individually for huge numbers of products and services.

The United States and Australia also have single-payer health insurance programs named Medicare; however, Australia's program provides universal health insurance, while  U.S. Medicare is only for senior citizens and the disabled. Government is increasingly involved in U.S. health care spending, paying about 45 percent of the $2.2 trillion the nation spent on medical care in 2004.

Scotland, Norway, and Finland have implemented single payer health insurance. Each country's citizens share risk in a common pool.

According to Princeton University health economist Uwe E. Reinhardt, single-payer systems such as Medicare, Medicaid and the Canadian system are properly called "social insurance" systems, because they're coupled with a largely private delivery system.

The Veterans Administration is a single payer system and provides excellent quality, said Reinhard. In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the RAND Corp. reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients in the rest of the U.S. health system, he said.

Some writers describe socialized 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," although this is an uncommon usage.

Proponents and intent
One of the leading organizations in support of single payer in the U.S. is Physicians for a National Health Program (PNHP), which seeks to establish a system similar to that in Canada.

In Congress, Rep. John Conyers, Jr. (D-MI) has introduced The United States National Health Insurance Act (HR 676). HR 676 has 76 co-sponsors, including Dennis Kucinich (D-OH), who is a candidate for president.

Converting to a single-payer system is seen by proponents as a solution to the flaws in the current U.S. system. The U.S. health care system is the most expensive in the world on both a per-capita basis and as a percentage of GDP. Despite this expenditure, the current U.S. system fails to provide universal coverage. Nearly 47 million Americans, about 16 percent of the population, lacked health insurance in 2006. The lack of universal coverage contributes to another flaw in the current U.S. health care system: on most dimensions of performance, it underperforms relative to other industrialized countries. In a 2007 comparison by the Commonwealth Fund of health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the U.S. ranked last on measures of quality, access, efficiency, equity, and outcomes.

For example, U.S. ranks 22nd in infant mortality, between Taiwan and Croatia, 46th in life expectancy, between Saint Helena and Cyprus, and 37th in health system performance, between Costa Rica and Slovenia.

The U.S. system is often compared with that of its northern neighbor, Canada (see Canadian and American health care systems compared). Canada's system is largely publicly funded. In 2004, Americans spent an estimated US$6,102 per capita on health care, while Canadians spent US$3,165. A 2007 review of all studies comparing health outcomes in Canada and the U.S. found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds of insurance companies in the U.S. to provide universal care. An often-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 30 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs.

Theoretically, advocates suggest, shifting the U.S. to a single-payer health care system could provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system could also theoretically eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.

Opponents and criticisms
"Political barriers to single payer are very strong," said Jonathan Oberlander, political scientist, University of North Carolina, Chapel Hill, and it is "very unlikely" in the U.S. "All that money we spend on health care is income to insurance companies and providers, the pharmaceutical industry and so on...They're deeply invested in keeping the status quo." Oberlander comments that one of the "poignant scenes" in the movie Sicko, is a scene in which Michael Moore puts price tags over Congressmens' heads. The health care insurance and pharmaceutical industries give a lot of money to fund election campaigns and in return expect political obligation not to upset the status quo.

Several criticisms have been leveled against the idea of changing the U.S. health care system to a single-payer system.

Perhaps the largest obstacle is a lack of political will.

While polling data indicate that U.S. citizens are concerned about health care costs and think the system needs reform (see Polls, below) most are generally satisfied with the quality of their own health care. According to a Joint Canada/United States Survey of Health in 2003, 86.9% of Americans reported being "satisfied" or "very satisfied" with their health care services, compared to 83.2% of Canadians. In the same study, 93.6% of Americans reported being "satisfed" or "very satisfied" with their physician services, compared to 91.5% of Canadians (according to the study authors, that difference was not statistically significant).

A few medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the RAND Corporation and the Department of Veterans Affairs asked 236 elderly patients at 2 managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author.

For this reason, some U.S. reformers argue for other, more incremental changes to achieve universal health care, such as tax credits or vouchers. However, proponents of a single-payer system, such as Marcia Angell, M.D., former editor of the New England Journal of Medicine, assert that incremental changes in a free-market system are "doomed to fail."

Other criticisms of single-payer health care as a solution for universal coverage in the U.S. include:
 * A single-payer system could put the government, rather than health care providers and insurers, in the role of deciding which procedures and medications would be covered.
 * In a single-payer system where hospitals and practitioners remain private, public money goes into private hands and therefore must be guarded to protect public trust. This could require a level of bureacracy similar to the bureacracy associated with private insurance.
 * Note however, that this issue does not arise in total public health care systems (which may also be single-payer) where the hospitals and / or general practitioners work for the government. In this case the prioritization of access to government funded services is done according to the patients' needs as judged by medical professionals. There are no bureaucrats cross-checking doctors records against either patients medical insurance cover (as in the present system) or against medical contracts (as in a single-payer system with private practitioners).


 * Converting to a single-payer system could be a radical change, creating administrative chaos.

Polls
In recent public opinion polls, majorities of Americans say that the current health care system needs fundamental changes, and that they are dissatisfied with the quality and costs of health care, although they are satisfied with the quality of their own health care. Those polled believe the federal government should guarantee insurance for all Americans, even if they had to pay higher taxes. In some polls, respondents prefer a universal health insurance program, "like Medicare," even if it limited their choice of doctors, and even if there were waiting lists for non-emergency treatments. But respondents were split when they were asked whether the federal government should require all Americans to participate in a national health plan.

According to a New York Times/CBS News poll in February 2007, 54% of respondents said that "fundamental changes are needed" in the health care system, and 36% said that "Our health care system has so much wrong with it that we need to completely rebuild it." 57% were dissatisfied with the quality of health care in this country, although 77% were satisfied with the health care they themselves received. 81% were dissatisfied with the cost of health care, and 52% were dissatisfied with the costs of their own health care. 65% said that providing for the uninsured was more important than keeping costs down. 95% said that it is a serious problem that many Americans do not have health insurance. 64% said that the federal government should guarantee health insurance for all Americans, and 60% would pay higher taxes to do so. But only 43% said that it would be fair for the government in Washington to require all Americans to participate in a national health care plan funded by taxpayers, compared to 48% who said it would be unfair.

According to a Washington Post-ABC News poll in October 2003, 62% of respondents preferred "a universal health insurance program, in which everybody is covered under a program like Medicare that's run by the government and financed by taxpayers," compared to 32% who preferred the current system, in which most people get their health insurance from employers. 56% would support a universal health insurance program even if it limited their own choice of doctors, and 63% would support it even if it meant there were waiting lists for some non-emergency treatments.

State proposals
Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994, Massachusetts in 2000, and Oregon in 2002.

In 2006, the state legislature of California passed SB 840, The Health Care for All Californians Act, a single payer health care system, but Governor Arnold Schwarzenegger (R) vetoed the bill. California State Senator Sheila Kuehl has reintroduced the bill.