The label of “single-payer” health care tends to hide the reality that many choices would still need to be made. For example, a “single payer” plan could involve the government providing a voucher for a standardized health insurance plan, or it could offer choices between insurance plans provided by private firms. It could involve supplementary private health insurance: for example, the single-payer Medicare plan is often supplemented with “Medi-gap” private policies. A “single-payer” plan could be funded out of general tax revenues, or by charging insurance premiums that might vary by age or in some other way. A “single-payer” plan might have had most healthcare providers as government employees, or as employees of private firms. A “single-payer” plan could be run at the national level, or at a regional or state-by-state level. It could involve the same price-and-payment structure across the country, or allow for substantial variations across areas.
The eminent health care economist Victor R. Fuchs, who is acutely aware of these distinctions and many others, nonetheless tackles the question in “Is Single Payer the Answer for the US Health Care System?” in a “Viewpoint” essay for the Journal of the American Medical Association (published online December 18, 2017). He focuses on how single payer might affect three outcomes: the number of uninsured, US health outcome, and the cost of healthcare.
On the issue of covering the uninsured, Fuchs writes (footnotes omitted):
“Regarding the uninsured, single payer in almost any form could achieve universal health care insurance coverage. But so could many less-comprehensive reforms. Despite the success of the ACA [Affordable Care Act] in increasing the number of individuals in the US who have health insurance, approximately 25 million US residents remain uninsured. Universal coverage requires (1) subsidies for individuals who are too poor or too sick to acquire insurance at actuarial correct premiums, and (2) compulsion (ie, a mandate) for everyone else to participate and implicitly contribute to the subsidies. No country achieves universal coverage without subsidies and compulsion. The United States could achieve universal coverage relatively promptly if it were willing to adopt these 2 principles. Public attitudes toward subsidies and compulsion have been assessed by analyzing answers to a Pew Research Center survey of the US population, which included almost 2000 adults. A modest majority favored subsidies only, and a modest majority favored compulsion only. There was not, however, a majority who favored subsidies and compulsion.”
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