How Single-payer Stacks Up: Evaluating Different Models of Universal Health Coverage on Cost, Access, and Quality.

Described as "universal prepayment," the national health insurance (or single-payer) model of universal health coverage is increasingly promoted by international actors as a means of raising revenue for health care and improving social risk protection in low- and middle-income countries. Likewise, in the United States, the recent failed efforts to repeal and replace the Affordable Care Act have renewed debate about where to go next with health reform and arguably opened the door for a single-payer, Medicare-for-All plan, an alternative once considered politically infeasible. Policy debates about single-payer or national health insurance in the United States and abroad have relied heavily on Canada's system as an ideal-typical single-payer system but have not systematically examined health system performance indicators across different universal coverage models. Using available cross-national data, we categorize countries with universal coverage into those best exemplifying national health insurance (single-payer), national health service, and social health insurance models and compare them to the United States in terms of cost, access, and quality. Through this comparison, we find that many critiques of single-payer are based on misconceptions or are factually incorrect, but also that single-payer is not the only option for achieving universal coverage in the United States and internationally.

Devolving authority for health care in Canada's provinces: 4. Emerging issues and prospects.

Devolution or authority for health care is evaluated in the context of 3 objectives of provincial governments--community empowerment to garner new allies for health care restructuring, service integration to create a true "system" and conflict containment as spending is cut. Devolved authorities cannot pursue each of these objectives with equal vigour because they must balance the competing pressures from their provincial government, their providers and their local citizens. Each devolved authority accommodates these pressures in its own way, through different trade-offs. Appointed board members are generally well intentioned in representing the interests of their entire community but are unlikely to overcome formidable barriers to community empowerment in health care. Unless future board elections attract large and representative voter turnouts, they may fragment board members' accountability (by making them more accountable to multiple interest groups) rather than solidify it (by making them more accountable to the community). Although boards have integrated and rationalized parts of the institutional sector, integration of the community sector is hampered by structural constraints such as the lack of budgetary authority for a broader scope of services, including physicians' fees and drugs. Devolved authorities will deflect blame from provincial governments and contain conflict only while they believe that there is still slack in the system and that efficiency can be improved. When boards no longer perceive this, they are likely to add their voices to local discontent with fiscal retrenchment. Continuing evaluation and periodic meetings of authorities to share experiences and encourage cross-jurisdictional policy learning are needed.

Reform of the Quebec healthcare system.

This article briefly describes issues surrounding the reform process in Quebec and discusses its major thrusts--regionalization, definition of healthcare objectives, strengthening frontline services and greater use of outpatient services--and their effect on institutions which must above all come to terms with the reduction of the provincial deficit. Fewer human resources, longer waiting periods, institutional autonomy and the creation of integrated networks are some of the issues of current concern to the Quebec healthcare community.