Getting to Single Payer, Part III

August 15, 2017

What Do We Mean When We Say “Single Payer”?

By Jill Zorn

chess-pawn-social-mobilityI probably should have started the Single Payer series with this post.  That’s because “single payer” means different things to different people.


Policy Prescription or Goal?


To some supporters, single payer is a goal.  I have seen that goal or principle described many different ways:

These phrases are about what we aspire to, what we value.  They don’t describe a policy for getting there.

Many articles that use the term single payer to mean a goal often point out that other countries that guarantee coverage and care to their residents have gone about it in different ways.

Jonathan Oberlander summarizes these differences in this New England Journal of Medicine article:

U.S. observers often mistakenly lump all foreign health systems together under the single-payer label — a classification that grossly oversimplifies the range of models in place elsewhere. In some rich democracies (Germany, the Netherlands, and Switzerland among them) people enroll in multiple insurance plans, which are typically highly regulated and are operated by private companies or nonprofit associations…Most U.S. single-payer advocates instead have in mind emulating Canada, where all legal residents in each province or territory receive coverage from one government insurance plan for medically necessary hospital and physician services.

A Specific Policy

To others, single payer is a term that means more than the goal of access to good, affordable coverage and care. Instead, it is a literal description of how that coverage should be structured:

Physicians for a National Health Program (PNHP)Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes health care financing…The program would…(replace) today’s inefficient, profit-oriented, multiple insurance payers with a single streamlined, nonprofit, public payer…

As noted in this quote, there is also a movement toward using the terms “single payer” and “Medicare for all” interchangeably.

The Bernie Sanders campaign popularized the term “Medicare for all“, while defining that term to mean: “a federally administered single-payer health care program.” Healthcare-Now! also uses “single payer” and “Medicare for all” somewhat interchangeably, as does the Campaign for Guaranteed Healthcare.

To these groups, the focus on a “single government payer” is crucial.  They are very specific in saying that employers would no longer be responsible for health care costs and coverage decisions.  And they believe this structure is necessary both to reduce administrative costs and enhance negotiating power.  They don’t believe that other hybrid approaches, such as those Oberlander mentions, above, should be considered.


To make it even more confusing, messaging strategy also plays into what terminology is used.

Because “single payer” may not be very meaningful to people outside of the rarified world of progressive health policy, “Medicare for all” seems to be gaining more traction.  By using the name of a familiar and popular program, Medicare, single payer supporters believe they can make the concept more approachable to more people.

Are they right?  This poll shows that Medicare for all is the preferred terminology.  In contrast, the June Kaiser Health Tracking poll finds little difference between the “Medicare for all” or “single payer” labels.

Whether one or more of the five terms listed under Goal in the first part of this blog would be any more popular is hard to say.  Herndon Alliance, a group formed in 2005 to work on messaging prior to the run up to the fight to pass what became known as the Affordable Care Act (ACA), conducted extensive market research on how to talk about health reform.  At the time, “quality, affordable health care” polled better than universal coverage.  Without current messaging research, it’s hard to know what is the “right” terminology to use now.

So, What DO We Mean by Single Payer?

For the purpose of this blog series, I am choosing to refer to single payer as a goal, rather than a specific policy prescription.

While we may not agree on terminology, or on policy solutions, at least most of us can agree on the goal: quality, affordable coverage and care for all, universal health care, guaranteed lifetime coverage for all or whatever you choose to call it.  And that is a good place to start the next phase of the discussion:  how to get there.

To read the rest of the blogs in this series, click here.

To Learn More

Here are a few resources about how other countries structure their health care systems:

Health Care Systems – The Four Basic Models: An excerpt from T.R. Reid’s book The Healing of America:  A global Quest for Better, Cheaper and Fairer Health Care, as featured in public television’s Frontline program, Sick Around the World.

Road to Single-Payer:  Understanding Different Universal Health Care Systems: Blog post by Jon Walker

Single Payer Is Not a Principle: Article in Democracy by Harold Pollack
(See especially the discussion under this heading: 2. Single payer provides one path to universal coverage.  There are many others.)

The fix for American health care can be found in Europe: Article in The Economist

International Profiles of Health Care Systems: Commonwealth Fund

In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to Affordability of Health Care: Commonwealth Fund

*Stay tuned in August 2019 for new blogs on the subject of getting to universal health care, updated to include new Medicare-For-All proposals, as the health care debate heats up ahead of the 2020 elections.


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