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Single-payer nightmares in Canada and the United Kingdom -- Single-payer healthcare in the United States -- Single-payer plans under consideration

Cost shifting, in which governments transfer the cost of certain health care services to patients or private insurance companies, is increasing rapidly, and Dr. Christopher Carruthers thinks it will spell an end to Canada's single-payer system. The signs are already there: the private sector is offering more services and employers are keeping a closer eye on the health care system as they begin to pay a bigger share of the costs. The result, says Carruthers, is that government influence is bound to diminish as the private sector tries to fill voids created by governments that are trying to live within their fiscal means.

There are formidable institutional obstacles to passing a single-payer health program in the United States. Advocates should consider incremental improvements that may better match legislative realities. There are three potential directions for incremental coverage policy. One possibility is to build on the successes of the Affordable Care Act; this might include rolling back regulatory changes, further incentivizing Medicaid expansion, enhancing coverage in the Affordable Care Act marketplaces, and imposing regulations on private employer-based insurance to ensure that all Americans have access to affordable coverage that provides adequate financial security. A second direction is to offer more publicly sponsored insurance options, which might involve offering a public option to those eligible for marketplace coverage, creating a Medicare or Medicaid buy-in program, lowering the eligibility age for Medicare, or developing a public plan that serves as a default for those who do not choose to buy alternative private coverage. A third direction is to build on federalism, offering states incentives to expand coverage. Federal and state legislators could also consider incremental cost-containment steps, such as rate setting.

US political debates often refer to the experience of "single-payer" systems such as those of Canada and the United Kingdom. We argue that single payer is not a very useful category in comparative health policy analysis but that the experiences of countries such as Canada, the United Kingdom, Spain, Sweden, and Australia provide useful lessons. In creating universal tax-financed systems, they teach the importance of strong, unified governments at critical junctures—most notably democratization. The United States seems politically hospitable to creating such a system. The process of creation, however, highlights the malleability of interests in the health care system, the opportunities for creative coalition building, and the problems caused by linking health care finance and reform. In maintaining these systems, keeping the middle class supportive is crucial to avoiding universal health care that is essentially a program for the poor. For a technical term from the 1970s, "single-payer health care" has proved to have remarkable political power and persistence. We argue it is not a very useful term but the lessons from such systems can be valuable for those contemplating movement toward universal health coverage in the United States.