Single Payer Health Care Emerging As a Discussion Topic

Thursday, August 24, 2017 | Larry Sobal

Single Payer Health Care Emerging As a Discussion Topic


With the Republican plan to repeal and replace the Affordable Care Act (ACA) seemingly dead in the water, the question of “what’s next” weighs heavy on the minds of elected officials and the overall population. One conversation that seems to be emerging is whether it is time to consider single payer health care.

As I tried to explain in a blog post a few weeks ago (The single payer vs universal coverage conundrum), many people confuse the two health care models. But we now seem to have a growing dialogue about a true single payer model, and some recent activity suggests that single payer health care is not altogether unfathomable.

Single payer health care is a controversial idea; a recent Merritt Hawkins survey indicates that 42% of physicians are strongly in favor of a single payer system, while 35% are strongly opposed. This matches another recent survey by Reaction Data that shows 41% of physicians strongly in support for a single payer system, but also that 44% of employers and, surprisingly, 46% of payers are also are in favor of this concept.

Public support for single payer health care is apparently much smaller. On one hand, 60% of Americans believe it’s the government’s responsibility to provide “universal health coverage,” representing a major shift in opinion since 2013, according to an analysis published in The New England Journal of Medicine. But this is significantly larger than a recent Pew Research poll indicating only 33% of the U.S. public favors a “single payer” approach to health insurance. This percentage is up 5 points since January and 12 points since 2014.

Is this just a knee-jerk reaction to the dysfunctional conversations in the House and Senate of the past few weeks related to the Republican Senate health care bill? Or are people thinking that it’s time to take a totally different approach and begin serious debate on single payer health care. After all, Senate Majority Leader Mitch McConnell (R-KY) said it is time for the Senate to move on from health care reform. While other senators are attempting a bipartisan approach to stabilizing health insurance marketplaces, and President Trump is pushing for another ACA repeal attempt in September, the fact is that the next steps in health care reform are unclear.

A recent survey indicates that 42% of physicians are strongly in favor of a single payer system, while 35% are strongly opposed.

One person who thinks it is time to introduce single payer health care is Senator Bernie Sanders (I-VT), who has started his single payer health care campaign for “Medicare for All," with digital ads to gather voter support. The ads will direct supporters to Sanders’ website, where they can sign on to his bill. Sanders is currently finalizing the bill and creating a campaign strategy around it.

So is single payer health care a realistic option for America?  To some, it’s the greatest idea since price supports for agriculture: a government assumes its citizens’ health care choices, paying every cost and minimizing all guesswork. To others, it’s an infringement on individual autonomy, the transfer of private decisions about health to a taxpayer-funded bureaucracy.

It’s important to remember that advocacy for a single payer system in the U.S. is not new. In the fall of 1945, just after the end of World War II, recently inaugurated President Harry Truman addressed Congress with a plea for a national health care system. The American Medical Association opposed the idea, and it eventually faded away. Incremental steps did continue throughout the decades. Medicare and Medicaid were established in 1965, essentially becoming a de facto single payer system for certain groups of the population – senior citizens, disabled, young children and the poor.

Though the idea of single payer health care has never gained much traction in the U.S., there are a few examples of true single payer health care from around the globe. In his bestselling book, The Healing of America: A global quest for better, cheaper and fairer health, author T. R. Reid explains that there are three predominant health care systemic models in place in westernized countries. They are:

  1. The Bismarck Model — Providers and payers are private and it uses private health insurance plans, usually financed jointly by employers and employees through deductions. Unlike with the U.S. health insurance industry, these plans cover everybody, and they don’t make a profit. Medical services and fees are regulated to keep costs down. Examples include Germany, France, and Japan and, like the U.S., insurance is generally offered through an employer.
  2. The Beveridge Model — Programs are provided and financed by the government, through tax payments. There are no medical bills and care is provided by both private and public doctors and hospitals. The government, as the sole payer, controls what doctors can do and what they can charge. Examples are Great Britain, Italy, Spain, most of Scandinavia and Hong Kong. The U.S. equivalent would be the VA and Indian Health Service.
  3. The National Health Insurance (NHI) Model — The providers of health care are private, but the payer is a government-run insurance program that every citizen pays into. As a single payer covering everybody, the national insurance plan tends to have considerable market power to negotiate for lower prices. NHI countries also control costs by limiting the medical services they will pay for or by making patients wait to be treated. Examples are Canada, Taiwan, and South Korea. The U.S. equivalent would be Medicare.

How far the single payer discussion goes will be interesting to watch. As for me, I am a strong proponent of the EMBRACE plan as a functional model for U.S. health care. Where do you stand?


Illustration: Lee Sauer


Larry SobalLarry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems. His weekly blog post comes out on Thursdays and can be accessed at


About the Author
Larry Sobal

Larry Sobal, MBA, MHA, is CEO of a yet-to-be-named cardiology practice which is transitioning from employment to an independent physician group effective January 1, 2019. He has a 37-year background as a senior executive in physician practices, consulting, medical group leadership, hospital leadership and health insurance.

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