States as Policy Laboratories: The Politics of State-Based Single-Payer Proposals.

Although the focus for most single-payer advocates is in Washington, DC, and on proposals for Medicare for all, there are also efforts in a handful of states to enact a state-based single-payer program. Moreover, the odds of legislative passage are better in a state like New York than at the federal level.Even if enacted, however, state-based single-payer proposals face a distinct set of obstacles, including (1) the need to obtain federal permission (via waivers) to repurpose federal dollars, (2) the federal Employee Retirement Income and Security Act, and (3) the burden of state-only action in an interconnected 50-state economy.The most likely result of the energized single-payer movement will be incremental public insurance expansions at the federal and state levels, including state programs to permit the uninsured to buy into the Medicaid program. Such an outcome is consistent with the most plausible path (incrementalism) to a US version of universal coverage.

Lessons for the United States From Single-Payer Systems.

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.

Political Accommodations in Multipayer Health Care Systems: Implications for the United States.

Current interest in a single-payer approach to universal health care coverage in the United States has also triggered interest in alternative multipayer approaches to the same goal.An analysis of experiences in Germany, the Netherlands, Switzerland, and Israel shows how the founding of each system required a distinctive political settlement and how the subsequent timing, content, and course of the reforms were shaped by political circumstances and adjustments to the founding bargain in each nation.Although none of these systems is directly transferable to the United States, certain parallels with the American context suggest that a multipayer approach might offer a model for universal coverage that is more politically feasible than a single-payer scheme but also that issues associated with risk selection and other potential inequities would remain.

Single-Payer Health Care in the United States: Feasible Solution or Grand Illusion?

The adoption of a single-payer health care system, a recurring dream of progressive American reformers, now enjoys sustained attention in the run-up to the 2020 national elections. Some compelling arguments support the case for single payer, and its political prospects may indeed be on the rise, but myriad obstacles beset it, and a full-throated Democratic endorsement of it carries disquieting risks.

Considering "Single Payer" Proposals in the U.S.: Lessons from Abroad.

Issue: When discussing universal health insurance coverage in the United States, policymakers often draw a contrast between the U.S. and high-income nations that have achieved universal coverage. Some will refer to these countries having "single payer" systems, often implying they are all alike. Yet such a label can be misleading, as considerable differences exist among universal health care systems. Goal: To compare universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance; and role of private insurance. Methods: Data from the Organisation for Economic Co-operation and Development, the Commonwealth Fund, and other sources are used to compare 12 high-income countries. Key Findings and Conclusion: Countries differ in the extent to which financial and regulatory control over the system rests with the national government or is devolved to regional or local government. They also differ in scope of benefits and degree of cost-sharing required at the point of service. Finally, while virtually all systems incorporate private insurance, its importance varies considerably from country to country. A more nuanced understanding of the variations in other countries' systems could provide U.S. policymakers with more options for moving forward.

What can the Canadians and Americans learn from each other's health care systems?

Numerous papers have been written comparing the Canadian and US healthcare systems, and a number of health policy experts have recommended that the Americans implement their single-payer system to save 12-20% of its healthcare expenditures. This paper is different in that it assumes that neither country will undertake a significant philosophic or structural change in their healthcare system, but there are lessons to be learned that are inherent in one that could be a major breakthrough for the other. Following the model in Canada and in Western Europe, the USA could implement universal health insurance so that the 32.0 million (2015) Americans still uninsured would have at least minimal coverage when incurring medical expenditures. Also, the USA could use smart cards to evaluate eligibility and to process health insurance claims; these changes resulting in an estimated 15% reduction in US health expenditures without adversely effecting access or quality of care. Such a strategy would result in the eventual loss of 2.5 million white-collar jobs at hospitals, physician offices and insurance companies, a long-term economic gain. Only a few would agree with the statement that Canada already functions with a multi-payer reimbursement system as evidenced by (1) a federal-provincial, tax-supported plan, administered by each of the provinces, providing universal coverage for hospital and physician services and (2) roughly 60% of its residents receiving employer-paid health insurance benefits, underwritten primarily by investor-owned plans, that are less than effective to reimburse for pharmaceuticals, dental and other healthcare services. What could be learned from the USA and particularly from Western European countries is possibly implementing an approach, whereby at least upper-income Canadians could opt out of their federal-provincial plan and purchase private insurance coverage - being eligible for far more comprehensive "private" benefits for hospital, physician, pharmaceutical, dental and other healthcare services. Aside from generating billions of additional needed revenues from the private sector, it could (1) help eliminate long waits for non-emergent physicians' care by appointing newly minted specialists to their medical staffs; (2) offer prompt admissions for elective cases to "private" wings of hospitals; (3) increase available funding for what is currently an undercapitalized system; (4) enhance the system's sluggish operations; and (5) encourage more competition among various providers. Although such a two-tier approach, such as available in the USA and elsewhere, is politically dead on arrival in Canada today, private insurance being already legal and commonly available there. Interestingly, this recommended solution is utilized in most western European countries where there is a higher percentage than in Canada of public (versus private) funding of their total health expenditures. Because of various vested interests, attempts to implement any of the aforementioned proposals will undoubtedly result in considerable political rancor. There is greater likelihood, however, that the Canadians because their need to be more effective and efficient in their delivery of care, and their overall long-term fiscal outlook will agree to the further privatization of their healthcare system before the Americans will mandate universal access, use the smart card to process insurance eligibility and claims or will impose price controls on high-tech services and on pharmaceuticals. Copyright © 2016 John Wiley & Sons, Ltd.

What Can US Single-Payer Supporters Learn From the Swiss Rejection of Single Payer?

On September 27, 2014, Swiss voters rejected a proposal to replace their system of about 60 health insurance companies offering mandatory basic health coverage with a single public insurer, the state, which would offer taxpayer-funded coverage of all medically necessary care. The Swiss and the U.S. media, academia, and business sectors, from conservative and liberal camps, interpreted the results to mean a rejection of single payer and a preference for a privately run system, with important implications for health reform in the United States. While on the surface mainstream interpretations appear reasonable, I argue that they have little basis on fact because they rely on assumptions that, while untrue, are repeated as mantras that conveniently justify the continuation of a model of health insurance that is unraveling, less conspicuously in Switzerland, dramatically in the United States. To make my case, I describe the dominant narrative about Swiss health care and mainstream interpretations of the latest referendum on health reform, unpack the problem within these interpretations, and conclude by identifying what lessons the Swiss referendum contains for single payer advocates in the United States in particular and for those who struggle for social and economic rights more generally.

The Affordable Care Act versus Medicare for All.

Many problems facing the Affordable Care Act would disappear if the nation were instead implementing Medicare for All - the extension of Medicare to every age group. Every American would be automatically covered for life. Premiums would be replaced with a set of Medicare taxes. There would be no patient cost sharing. Individuals would have free choice of doctors. Medicare's single-payer bargaining power would slow price increases and reduce medical cost as a percentage of gross domestic product (GDP). Taxes as a percentage of GDP would rise from below average to average for economically advanced nations. Medicare for All would be phased in by age.

Medicare for All - If It Were Politically Possible - Would Necessarily Replicate the Defects of Our Current System.

Medicare for All, ideally implemented, could offer powerful advantages over our current health care financial system. Unfortunately, the political obstacles to such a system are formidable and are likely to remain so for decades. More to the point, a politically viable single-payer system would not replace our currently dysfunctional health care politics. It would be a product of that same legislative process and political economy and thus be disfigured by the same interest group politics, path dependence, and fragmentation that Laurence Seidman rightly laments.

The Little State That Couldn't Could? The Politics of "Single-Payer" Health Coverage in Vermont.

In May 2011, a year after the passage of the Affordable Care Act (ACA), Vermont became the first state to lay the groundwork for a single-payer health care system, known as Green Mountain Care. What can other states learn from the Vermont experience? This article summarizes the findings from interviews with nearly 120 stakeholders as part of a study to inform the design of the health reform legislation. Comparing Vermont's failed effort to adopt single-payer legislation in 1994 to present efforts, we find that Vermont faced similar challenges but greater opportunities in 2010 that enabled reform. A closely contested gubernatorial election and a progressive social movement opened a window of opportunity to advance legislation to design three comprehensive health reform options for legislative consideration. With a unified Democratic government under the leadership of a single-payer proponent, a high-profile policy proposal, and relatively weak opposition, a framework for a single-payer system was adopted by the legislature - though with many details and political battles to be fought in the future. Other states looking to reform their health systems more comprehensively than national reform can learn from Vermont's design and political strategy.

Changing healthcare capital-to-labor ratios: evidence and implications for bending the cost curve in Canada and beyond.

Healthcare capital-to-labor ratios are examined for the 10 provincial single-payer health care plans across Canada. The data show an increasing trend-particularly during the period 1997-2009 during which the ratio as much as doubled from 3 to 6 %. Multivariate analyses indicate that every percentage point uptick in the rate of increase in this ratio is associated with an uptick in the rate of increase of real per capita provincial government healthcare expenditures by approximately $31 ([Formula: see text] 0.01). While the magnitude of this relationship is not large, it is still substantial enough to warrant notice: every percentage point decrease in the upward trend of the capital-to-labor ratio might be associated with a one percentage point decrease in the upward trend of per capita government healthcare expenditures. An uptick since 1997 in the rate of increase in per capita prescription drug expenditures is also associated with a decline in the trend of increasing per capita healthcare costs. While there has been some recent evidence of a slowing in the rate of health care expenditure increase, it is still unclear whether this reflects just a pause, after which the rate of increase will return to its baseline level, or a long-term shift; therefore, it is important to continue to explore various policy avenues to affect the rate of change going forward.

Is the swiss health care system a model for the United States?

Both supporters and critics of the Patient Protection and Affordable Care Act (ACA) have argued that it is similar to Switzerland's Federal Law on Health Insurance (LAMal), which currently governs Swiss health care, and have either praised or condemned the ACA on the basis of this alleged similarity. I challenge these observers on the grounds that they overlook critical problems with the Swiss model, such as its inequities in access, and critical differences between it and the ACA, such as the roots in, and continuing commitment to, social insurance of the Swiss model. Indeed, the daunting challenge of attempting to impose the tightly regulated model of operation of the Swiss model on mega-corporations like UnitedHealth, WellPoint, or Aetna is likely to trigger no less ferocious resistance than a fully public, single-payer system would. I also conclude that the ACA might unravel in ways unintended or even opposed by its designers and supporters, as employers, confronted with ever-rising costs, retreat from sponsoring insurance, and workers react in outrage as they confront the unaffordable underinsurance mandated by the ACA. A new political and ideological landscape may then ensue that finally ushers in a truly national health program.

Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system.

BACKGROUND: Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE: To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS: This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS: T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS: Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.

Ditching the single-payer system in the national health service: how the English Department of Health is learning the wrong lessons from the United States.

Reforms to the British National Health Service introduce major changes to how health care will be delivered. The core elements include the creation of new purchaser organizations, Clinical Commissioning Groups, which unlike their predecessors will be able to recruit and reject general practices and their patients without geographical restriction. The Clinical Commissioning Groups are to transition from statutory bodies to freestanding organizations, with most of their functions privatized and an increasingly privatized system of provision, In this paper, we explore the likely consequences of these proposals, drawing in particular on the experience of managed care organizations in the United States, whose approach has influenced the English proposals extensively. We argue that the wrong lessons are being learned and the English reforms are likely to fundamentally undermine the principles on which the British National Health Service was founded.