People mean different things when they speak of single payer. Taiwan is the only true single payer system in the world. Our closest neighbor to the north is often describes as a single payer, but in Canada, there are 13 provincial and territorial health plans, with the federal government providing financial support. Moreover supplementary private insurance is growing in Canada and is important in most countries. Most doctors are private and hospitals are tightly-regulated government-funded institutions.

Single payer is different from universal healthcare. Universal healthcare implies that everyone has access to healthcare. Single payer suggests the government pays for the whole thing, so that the entire show is run centrally. So you can have a single payer that supports for-profit private facilities and doctors, or you could have a government-owned and administered health system. Moreover physician services, hospital care, long-term care, social services, community services, medications, mental health and dental care can all be funded by different mechanisms. Sometimes portions are not funded at all.

As in Canada, France has self-employed physicians billing a single payer. But there are gaps and balance billing is permitted, so 90% of the French carry supplementary private insurance. Except for people on public assistance, the patient pays the full bill for out-patient care and are very quickly reimbursed by the government. this allows some degree of market forces to influence prices, but generally prices are dictated by an official government fee schedule. Hospitals are entirely paid for at public (government-run) hospitals that account for 65% of French facilities. . The private hospitals are funded by a blend of public and private insurance payments.

Because supplementary insurance is a big part of the French healthcare system, it resembles a tiered medical system, with one set of rules for those on public assistance and another for those who can afford private supplementary insurance.

England of course has the NHS which covers about 90% of people. It is a classic two-tier system with 10% of the people carrying supplementary insurance. Most countries that offer universal healthcare have statutory tax-funded heath plans supplemented by private insurance. This includes Australia, New Zealand, Japan, Brazil, Denmark and many others. Many lower-income countries offer universal healthcare access to government-run facilities which offer limited services.

Germany has the oldest statutory health system that goes back to Bismarck in 1883, but there are hundreds of payers; insurance companies (sickness funds) that are highly regulated, much like utilities. Individuals have the choice to opt out of the public system and substitute private insurance, which 12% of Germans do. This is a two-tier multi-payer system.

Israel mandates that everyone sign up with one of four non-profit health plans funded by income taxes. Out of pocket expenditures account for 22% of healthcare spending, so copays are high.

In Sweden, local and regional authorities pay for all care, so technically, there are 21 different payers. In Norway, counties, municipalities and the central government share responsibilities for payments to different sectors, like GPs, specialists and hospitals. The Netherlands runs a hybrid public/insurance scheme where everyone is enrolled in the public system and about 80% supplement with private insurance.

India offers free healthcare to everyone at government operated facilities. These are not necessarily well-funded and most people use the parallel private system. Only 37% of Indians have insurance. Both access and quality of care vary tremendously from state to state.

Singapore has multiple funding streams, including one for large hospital bills, a health savings account and a safety net. People use their savings account to purchase insurance and to purchase services directly. Singapore relies on market mechanisms to keep costs down.

Japan has a mandated universal coverage from one of 1400 employment-based plans and 47 regional plans for the unemployed and elderly.

Taiwan is the only true mandated single-payer system in the world, where the central government funds private physicians and hospitals. There are still copays and out-of-pocket payments except for select populations, like government employees and low-income populations.

So there are a lot of ways to skin the healthcare cat. Designing a healthcare system that includes universal coverage is a slippery, squirmy sausage-making process.

The only way to secure universal healthcare is to mandate that everyone contributes tax revenue and has access, whether they want to or not. Opting out is problematic if people can opt back in when they become ill. That’s like calling the insurance company after the house is on fire. In the language of actuaries, this is called “adverse selection.”

There is good reason to make sure there is universal coverage, but single payer is problematic for reasons we will go into in the next post. The distinction is of extreme importance as we shall see.

Universal healthcare is going to be a political issue again under the Biden administration and probably will be for the foreseeable future.

Before anyone talks about healthcare, they should define their terms. I define healthcare as the large system that is supposed to deliver actual care related to health. This care is usually delivered by health professional like physicians, nurses, therapists and others.

Healthcare is about insurance, Medicaid and Medicare, hospital systems, health economists, policy-makers and so on.

Providing health care is complicated, but the systems of healthcare are complex, in a technical sense.

Universal healthcare is a system where nobody goes without some form of coverage. One way of accomplishing this is single payer. Paradoxically in the US, people are talking about multiple single payers; one for the military and the VA, one or the poor, perhaps one for the elderly, although expansion of Medicare or Medicaid to the general public is one way to achieve a large single payer that coves the majority of Americans. That’s where “Medicare for All” comes in. What most people mean by single payer is the elimination of health plans and other middle men who finance health care. Some people refer to single payer as a true one payer for the entire country, much along the line of the French system.

I define insurance as an agreement with a private or public entity that protects against financial catastrophe by assuring compensation for losses in return for a premium. In the US, we cannot speak of health insurance since it has become a financing mechanism for every virtually type of care, no matter the cost. What we call health insurance is merely a mechanism, for funding care. Low price services are covered which makes them more expensive and raise premiums. The administrative cost is high; think of $20 to get the average claim out, compared to a $20 brace. Now it’s a $40 brace.

It is better to talk of these as health plans, which are prepaid based on an actuarial estimate of total annual expenditures for a given individual or group of individuals. The premium is set at about 1/3 above the average (technically 1 standard deviation above the mean.) This means the insurance company will win two years about of three, There are a lot of ways to maniputale this estimate and the set price of a premium.

Some people, myself included, refer to universal access to health care. To me this implies that everyone can get to a doctor. Some may have to pay, if they can afford it, but there would be financial support and resources for those who could not. The level of support would depend on income and the potential cost of a specific treatment. But here we are getting ahead of ourselves. Universal access implies some sort of blend of true insurance with out-of-pocket expenditures.

Now that we’ve defined our terms, we can then talk about the pros and cons of single payer. That will be the subject of the next post.

It may be time to reboot the old blog. My social media presence has increased and the discussions have become more intense. More importantly the tendency for people to twist my words and misrepresent my position has become intolerable.

A case in point has involved my departure from Vaccinate Washington. In a discussion with my co-founder, I expressed the need for caution in establishing COVID-19 vaccine mandates for children. Maybe it’s because she is a teacher, but she responded with great hostility and dismissiveness.

It seems that the political polarization I saw coming in my last blog has deteriorated to the point that everyone is consciously deciding to misinterpret anyone who introduces a bit of a grey area into their discourse.

For example, just prescribing caution about children’s vaccine mandates provoked a “medical freedom” activist to contacted me with an invitation to be on his podcast. I didn’t think that was wise.

I am a radical centrist, part of the alt-center. I won’t easily allow myself to be mischaracterized.

So the plan is to start writing a couple of blog posts a week and to look for media mentions from the past couple of years and back date them. I may well transfer all the posts from the past that are currently hidden. This blog was active from about 2007 to 2016 under the moniker “The Physician Executive.”

Keep your eyes on this space as I start posting more and varied media, both old and new.