Single-Payer Wonkiness

Single-payer health insurance has a lot to recommend it. Some—but not all—single-payer systems provide convenient and comprehensive access to care. Some—but not all—singer-payer systems can constrain excessive costs. When it comes to single-payer, it’s the wonky aspects that matter, not the big vision thing.  Overall, there is no particular connection between single-payer systems and quality.


Country Health System rankings
The UK has a single-payer system, as do Norway, Canada, Australia and New Zealand. Switzerland, Sweden, Germany, the Netherlands and France do not.

The US of course already has a single-payer system, in fact several. But these are highly uneven. The VA has fairly comprehensive access to services and relatively strong cost control. Medicare and Medicaid (separately) are not particularly great, with holes in coverage and not very effective cost control. The point is, there is nothing magical about single-payer.



Besides the US, all other advanced countries—whether single-payer or not—have some kind of cost control and also better access to care than in the US. Some are single-payer systems and some are not. Germany has a global budget cap—and not single payer. The UK has a healthcare budget—and a single-payer that is willing to say no to certain services and drugs that are not sufficiently cost-effective.



The US has neither a global cap nor a government willing to say no (outside the VA). Without some binding cost-control, all of the things that seem attractive about a single-payer plan—easily accessible healthcare, access to any provider, no insurance-company review—will lead straight to higher costs. Sanders’ proposal includes rigorous cost-control measures included, such as tough negotiation with drug manufacturers and lower hospital and provider costs. But if so, why not start with these first, to show that the cost-control is real, and then move to single-payer, when it can be demonstrated that it won’t bankrupt the system?



The Center for Health Advancement is committed to fostering evidence-based policy. That means being wonky sometimes. Many people seem to be inspired by Bernie Sanders’ commitment to single-payer healthcare. The political heavy-lifting to make it work will require enthusiasm for cost-control. Let’s hope the excitement for a single-payer plan now translates into the hard and wonky work of coverage expansion and cost-control in the future.

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