Moving Towards Medicare for All: Lessons from International Single-Payer Systems for the United States
Creators: name: Elkins, Andrew
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2018

description: The United States is the only rich democratic country that does not have a universal healthcare system. In other nations, all (or nearly all) individuals receive health care directly from government programs or are covered by public insurance programs or heavily regulated private insurance. Even with the ACA, about 30 million Americans remain uninsured. In addition, the US spends more on healthcare than any other nation and has poor population health outcomes (Etehad, 2017). With the introduction of the Expanded & Improved Medicare for All Act (H.R. 676) in the House of Representatives and the Medicare for All bill (S.1804) in the Senate in 2017, Democrats have laid the foundations for a potential path to a single-payer system in the US. In 2018, the Center for American Progress released its plan, Medicare Extra For All. It differs from current single-payer legislation by expanding Medicare Advantage but making the purchase of coverage from the US government optional. This plan would also maintain employer and private insurance, and require patient cost-sharing (CAP, 2018). Despite current proposals’ poor prospects for passage right now, the debate over a single-payer system is likely to intensify in the run-up to the 2020 election. Support for Medicare for All is growing among Congressional Democrats. S. 1804 has 16 co-sponsors and H.R. 676 has 120, respectively. Public support, too, is growing. In a poll by the Pew Research Center in June 2017, 60% of the public believes that the federal government is responsible for ensuring that every American is provided with health care coverage, and 33% now favor a single-payer approach; up 12 percentage points since 2014 (Kiley, 2017). In a similar poll, the Kaiser Family Foundation (2017) reported a modest increase in support for a single-payer health plan from 50% to 53% between 2016 and 2017. An April, 2018 poll from the Washington Post and the Kaiser Family Foundation showed similar results but indicated that nearly 75% of Democrats and 54% of Independents now support a single-payer system (Guskin, 2018). Considering the rising prominence of Medicare for All and the potential implications of 2020, it is possible to imagine that the US could begin the process of moving towards a single-payer system in coming years. If a single-payer system becomes a serious option, it will be important to grapple with design choices in operationalizing a Medicare for All system. As US reformers contemplate these choices, they can learn much from other nations’ experiences with single-payer arrangements. The goal of this study is to consider lessons from the experiences of the United Kingdom, Canada, and Taiwan in operating their single-payer systems. These systems were chosen in order to explore how a single-payer arrangement works in a variety of settings. Their successes and failures give us the opportunity to learn about the challenges of operating a single-payer system which could give reformers insight into how a Medicare For All system could be designed. Lessons on the adjustment of revenue streams, the evolution of cost controls, efforts in delivery reform and quality improvement, and the role of private insurance are critical to considering the design of our own single-payer system. By highlighting the tradeoffs made in other nation’s arrangements, lessons will be identified in order to make recommendations for a single-payer system in the US.