Single payer healthcare: Pluses, minuses, and what it means for you

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As someone who researches inequities in health care, I’ve diligently followed the debate about healthcare reform. However, most of my friends (and I suspect most Americans) wonder exactly what single payer healthcare is and how will it affect them. In a New England Journal of Medicine perspective piece, Jonathan Oberlander, PhD, a professor of social medicine at the University of North Carolina in Chapel Hill, expounds on the history and obstacles facing calls for single payer healthcare reform.

Problems with the current U.S. healthcare system

Oberlander points out that the impetus for reorganizing the entire healthcare system has to do with the regrettable state of healthcare in the United States. Currently, the healthcare finance structure is made of an impressively complicated network of multiple payers, involving both private and government health insurance options. Despite spending more on healthcare than comparable countries, the U.S. has the lowest life expectancy and performs poorly on a variety of health outcomes. Thus, our complex network of insurance plans is wasteful — in large part due to high administrative costs and lack of price control.

Inequity is another major problem. The United States remains the only developed country without universal healthcare. The Affordable Care Act has made important gains toward improving and expanding health insurance coverage. However, it was never designed to provide universal healthcare and 30 million Americans remain uninsured.

What is a single payer healthcare system?

In a single payer healthcare system, rather than multiple competing health insurance companies, a single public or quasi-public agency takes responsibility for financing healthcare for all residents. That is, everyone has health insurance under a one health insurance plan, and has access to necessary services — including doctors, hospitals, long-term care, prescription drugs, dentists and vision care. However, individuals may still choose where they receive care. It’s a lot like Medicare, hence the U.S. single payer nickname “Medicare-for-all.”

Proponents advocate that a single payer system would address several problems in the U.S. system. Universal health coverage would be a major step towards equality, especially for uninsured and underinsured Americans. Overall expenses and wasteful spending could be better controlled through cost control and lower administrative costs, as evidenced in other countries. Furthermore, a single payer system has more incentive to direct healthcare spending toward public health measures. For example, targeting funding towards childhood obesity prevention programs in elementary schools and daycares reduces the rates and complications of obesity more effectively and at lower costs than paying for doctor visits to recommend healthier diets and increased physical activity.

At the same time, we must also recognize the potential tradeoffs of transitioning to a single payer system. Lengthy wait times and restricted availability of certain healthcare services (such as elective surgery or cosmetic procedures) are important criticisms. Thus, despite its advantages, single payer will not ease the constant tension of balancing access, quality and cost in healthcare. However, Oberlander suggests these issues are much smaller in countries with single payer healthcare when compared to the current U.S. system.

How could single payer be successful in the U.S.?

Oberlander implies the major obstacles to adopting Medicare-for-all are political, rather than actual practical problems within the single payer structure. Stakeholders who stand to lose — such as health insurers, organized medicine, and pharmaceutical companies — represent a powerful opposition lobby. Public opinion needs to be redirected to focus on how the net benefits of a single payer system outweigh the tradeoffs discussed above. Furthermore, despite the individual level savings, behavioral economics predicts the general public will wince at the notion of transferring healthcare spending from employers to higher taxes managed by the federal government. Additionally, despite long term savings projected from moving to a single payer system, the upfront costs of the transition are also politically unpopular.

A way forward

If the major barrier to implementing single payer healthcare in the U.S. is a matter of politics, the pathway forward will require mobilizing public support. A recent poll suggests 58% of Americans support Medicare-for-all. Interestingly, whereas a majority of physicians support transitioning to single payer, they are less likely to believe their colleagues share this opinion. This raises an interesting question of whether the “conventional wisdom” that it is too difficult to reorganize the healthcare insurance system overshadows actual public opinion.

Multiple strategies to continue to push for Medicare-for-all have been proposed. This includes individual states implementing a single payer system as a demonstration of feasibility, which failed before implementation in Vermont but will be on Colorado’s 2016 ballot. An alternative proposes implementing a single payer system on a federal level by lowering the Medicare qualifying age every few years. Through education of the general population about the merits of single payer, perhaps eventually the public will vote politicians into office willing to overcome Medicare-for-all’s political barriers.

Related Information: Harvard Health Letter


  1. Steve

    Insurers add only one advantage, cost containment. That is, they say no. They look for the cheap way out. But do they improve outcomes? And is their cost containment exceeded by the amount of money they take out of the system. We pay much more for healthcare and have less favorable outcomes than our other developed nation cohorts.
    We should do the smartest thing, without any need to make profitable insurance companies.
    Who could still sell the same products they offer to Medicare members.

  2. tom

    We have the best health care in the world for a reason. Have you seen our crusted out mail trucks and Amtrak trains? They look third world. Congress has raided SS and the highway improvement fund. The government, money and management are just a bad combo all the way around.

  3. Diane J. Peterson

    I recommend purging “system” from any speech pertaining to health care in the U.S. Accurately naming what we have in health care is vital to understanding and ameliorating our problem. Thus, correctly labeling the American health care chaos as chaos–for that is surely what we have, not a health care system–will assist Americans in coping with our problem. For many years, our culture did not have a label for a widespread problem happening in the privacy of homes, but now that we have labeled the problem accurately as “domestic abuse” or as “wife battering,” we have improved coping mechanisms for addressing that problem. Similarly, if we begin talking about our American health care chaos, and refrain from incorrectly speaking or writing about it as something as logical as a system, we will be doing ourselves a favor by using a term which more precisely reminds us of the problem plaguing us. Our health care chaos does not deserve the dignity of being thought of or talked about as a respectable system. Characterizing the chaos by naming it as chaos get us closer to a solution.

    • Rich

      Typical of democrats, so called “progressives”, and liberals – you seek to enact political change by labeling. Your full-on government medical administration will be incredibly chaotic and costly, but your first manipulative step is to label what you consider the opposition as chaos.

  4. Sally

    I believe that a single-payer system, Medicare for all, is the best choice. A big reason for my choice is that there would be less confusion, Simplicity in acquiring and implementing health insurance has to be a blessing to many. I am 73. I was lucky to always have very good private health insurance, and now of course Medicare. For some people it has not been as effortless. This is a thoughtful and balanced article.

  5. Carlos

    This article is spot on. There is a false belief in this country that single payer would add more bureaucracy when the reality is the opposite. Health insurance companies do not add any value to our health care system, they are just a middleman whose main purpose is not to provide care but to make profits by actually denying it. That is, in part, what causes the insane level of bureaucracy that the current system has. Single payer does not mean a government take over of health care, is just a more common sense way to fund the system. Only in a few countries like Canada or the Uk the government controls the system and owns the hospitals, but in most European single payer countries, the delivery remains both private and public, just like in the US and they have a choice of hospitals and doctors in the same way we do here. With a single payer you would create a wider pool of patients with pure community rating and prices would actually go down as the government would have a better ability to negotiate prices with the providers than individual health insurance companies. That explains why the US expends twice as much per ca pita in health care than most western countries and yet has no universal coverage. The only reason we do not have a single payer yet in the US is because of the influence of big money in politics. We need a government that represents our interests, not those of the wealthy corporations.

  6. anka

    Inequalities in health care is really a terrible thing. I encountered this in my life and I really recommend it to anyone. I hope that something will change in this regard.

  7. Kathy Forte

    So Harvard thinks that a giant, anonymous federal bureaucracy would give all of us improved health care. It’s sort of like “if you like your doctor, you can keep your doctor.” Obamacare made our medical system worse, not better. Let’s restore health care to the place closest to the patient and doctor, back to the states and let the power of the people as expressed in a local, free market, where people are accountable for their decisions. Health care is out of control because there are too many government bureaucrats and anonymous insurance functionaries taking money out of the system.

    • Fred

      Your comment has been cloned from other right-wing responses throughout the years. I’m afraid you are a bot. Nonetheless, I’ll call out your stupidity.

      What system could be closer to patient-doctor than single payer? Do you prefer a system where insurance is determined by an employer, the deals that employer has with health insurance companies, the deal those companies have with certain doctors, and the deal those doctors have with drug companies? Is that your idea?

      To discuss “free market” and “people accountable for their decisions” in a healthcare discussion shows you don’t understand economics. I make choices when buying a phone or a car; if I’m having a heart attack I don’t give a damn about the free market.

      Please go spew your right-wing nonsense somewhere else.

      • madelyn Simms

        Spew? please. Any Government agency is inept as demonstrated in MediCare, Medical and EBT, IRS, Dept of Justice, State Dept. and let’s not leave out the Postal Service and the Veterans Administration – to name just a few.
        Please keep the Government far far away from the taxpayer as possible.

  8. Steve Ambrose

    It is important to understand that just because 58% favor a single health payer plan for U.S. healthcare, doesn’t mean you are polling people who understand U.S. healthcare. Just ask the people that voted for Brexit, and may well come to regret it.

    If the U.S. STARTED OUT with single payer for all, it would have been easier and perhaps more fair. However, I also wonder just how much medical advance we would have made without the growth of publicly owned companies in this system. Those shareholder dollars paid or great advances. The flip side is that it was shareholder money, and that means driving profit, instead of better patient-based outcomes, such as satisfaction and customer service.

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