Single-payer is great but it's not the only option

By Matthew Ward
Former 40th District Resident & Expatriate

As an American who has lived in two countries with universal health care (UHC) systems, one thing I find odd is the common assumption in the US that other developed countries have single-payer systems. When discussing possible alternatives to the ACA, it's quite common to hear American political pundits declare that single-payer is the alternative, rather than an alternative, to the ACA. A common variant to this theme is "Medicare-For-All" is the only thing that will ever work.

Now, while I like single-payer healthcare systems, it's really hard for me to agree that "Medicare-For-All"/single-payer is the only workable model. You see, I live in Japan, which is one of many developed countries that has UHC but not single-payer, and I'm a huge fan of the system here. To be fair, I've also lived in Taiwan, which has a single-payer system, and am a huge fan of that system too, but in many ways, I feel that the models presented by countries like Japan or the Netherlands may well be more viable for the U.S. than Canadian or Taiwanese-style single-payer. 

So why do Americans think of "single-payer" as the only alternative to the ACA? It appears to me that Americans have come to use the term "single-payer" as a generic term for "health care funded primarily by taxes," a description that does loosely apply to most UHC systems used worldwide. However, one problem with this assumption is that it glosses over a lot of important differences that we will need to understand if we are to expand the ACA into a UHC system or try to create a new system in the event that the ACA is repealed.  

With that in mind, here are a few common universal health-care models and some simple descriptions:

1). Single-Payer: One public entity collects and pays fees, with only a minor and optional role for private insurance. Classic example: Taiwan.

2). Public Multi-Payer: A number of public and quasi-public entities collect and pay the fees. In some cases, these entities may include employer or industry-run non-profit health societies, thus retaining a strong role for employer-based coverage. However, like single-payer, private insurance has only a minor and optional role.  Classic example: Japan.

3). Two-Tiered: A public entity or entities pays part of health care costs (for example, catastrophic care) but people are required to buy heavily regulated and standardized private insurance plans for other expenses. Classic example: The Netherlands.

4). Insurance Mandate: Everybody is simply required to buy private insurance, though the insurance packages and fees are so heavily regulated that they essential represent one standard national package, and subsidies ensure that everyone can afford to do this. Classic example: Switzerland.

Keep in mind that this is a generalization: Almost every UHC system is unique and many systems are hybrids to a degree. Also, none of these descriptions relate to "socialized medicine," which refers to situations in which the government owns and runs the actual health care providers, as opposed to the means of funding health care. For a variety of reasons, full-on socialized medicine is extremely unlikely to be implemented in the US in the foreseeable future.  

The ACA is most like #4 currently, though it's not yet universal, and already has some elements of #2 and #3 due to the Medicaid expansion. If it had a full-on public option, it would be a hybrid, though the public option could then gradually be expanded into a single-payer system. Another possibility is that the public option might end up working in tandem with expanded Medicare and Medicaid systems to form a universal multi-payer system. A third possibility would be the US government regulating the price and conditions of private insurance, pharmaceuticals, and medical procedures to the point where the ACA becomes a Swiss-like universal insurance mandate system. In all possible systems, much greater government control over the price of medical care would be required, especially if the system ended up being more tax-based.  

Of course, also it's possible that an entirely new system could be created that would bypass the ACA. Worth noting though: very few UHC systems were created out of full cloth: Most evolved out of existing systems, which is why many are hybrid and very few exactly match the systems of other countries. There is a good reason for this: Despite the fact that in the rest of the developed world both the left and the right generally support UHC, creating a heath-care system is enormously complicated and difficult, and about half of the attempts to create single-payer systems in particular worldwide ended up in failure.  

Because of this reality, I strongly feel that we should fight to preserve the ACA for future expansion. Expanding the ACA into a universal system is a more plausible path than creating a new system. It already contains several plausible paths to UHC, and even Democratic attempts to replace it could take years or fail entirely. Meanwhile, judging by the AHCA, any Republican plan is almost guaranteed to be a disaster.

Above all, we Americans should demand the UHC that the rest of the developed world enjoys, but we should recognize the variety that exists in viable health-care systems, and avoid being too ideological or picky about the form the system takes in the US.  


Matthew Ward was raised in the 40th District and a native of Lopez Island. He currently lives with his wife and two children in Osaka, Japan, where he can be found listening to Taiwanese metal and working as an English instructor.