Differences between universal coverage and single payer systems


Health care reform has been an ongoing debate in the United States for decades. Two terms are often used in discussions: universal health coverage and single payer. They are not the same, even though people sometimes use them interchangeably.

Although single-payer systems generally include universal coverage, many countries have achieved universal or near-universal coverage without using a single-payer system. Let's take a look at what these two terms mean and some examples of how they apply around the world.

Universal coverage

Universal coverage refers to a health care system in which everyone has health insurance. This can be accomplished through a public health insurance system, a private health insurance system, or a combination of both.

According to the US Census Bureau, 26.1 million people in the US were uninsured in 2019. This is far less than the 45.6 million people who were uninsured in 2012, prior to Most of the Affordable Care Act (ACA) passed, but this is clearly not universal coverage. Over the years, the lack of universal health coverage has set the United States apart from other equally developed countries .

By contrast, there are no uninsured Canadian citizens; its state system provides universal coverage. Thus, Canada has universal health coverage, but the United States does not.

However, it is important to note that among the uninsured population in the United States , there are a significant number of undocumented immigrants who are not eligible to purchase (even at full cost) health insurance in exchange and are not eligible for Medicaid . the government system does not provide insurance for undocumented immigrants.

Single payer system

Secondly, A single payer system is a system in which the government is responsible for paying insurance benefits with funds collected through the tax system. Therefore, the state is the only (that is, the only) payer.

Currently, the single payer system is used by at least 17 countries, including Norway, Japan, Great Britain, Kuwait, Sweden, Bahrain, Brunei, Canada, United Arab Emirates, Denmark, Finland, Slovenia, Italy, Portugal, Cyprus, Spain . and Iceland.

But single payer systems can also be implemented without reaching the entire population. Therefore, a country may have one or more single payer programs, but still not achieve universal coverage. This is what we see in the US, with a combination of single payer coverage for some people, private coverage for others, and tens of millions of people without coverage at all.

Medicaid is sometimes called a single payer system, but it is actually funded jointly by the federal and state governments. So while it is a form of government funded health insurance, the funding comes from two sources rather than one.

People who are covered by employer sponsored health plans or individual U.S. health plans (including ACA eligible plans sold on health exchanges ) are not part of the single payer system and their health insurance is not It is run by the government. … In these markets, hundreds of individual private insurance companies are responsible for paying members' claims.

Two-tier systems: government plan complemented by private coverage

In most cases, universal coverage and single-payer systems go hand in hand because a country's federal government is the most likely candidate to run and pay for a healthcare system that reaches millions of people.

It is difficult to imagine a private entity, such as an insurance company, with the resources or even the general inclination to create a nationwide health insurance system.

However, it is entirely possible to provide universal coverage without a complete single payer system, and many countries around the world have done so. Some countries have a two-tier system in which the government provides basic health care through a single payer system and secondary coverage is available for those who can afford a higher level of care.

Two-thirds of Canadians, for example, purchase additional private insurance for dental, vision, and prescription drugs because the government plan does not provide these benefits. And in France, almost everyone has additional coverage that pays for medical expenses (deductibles and copayments) that they would otherwise have to pay with a government plan.

This is similar to Medigap coverage in the United States for people with Original Medicare . The government provides coverage for Original Medicare, but does not limit out-of-pocket expenses. Therefore, most Original Medicare beneficiaries rely on some form of additional coverage: employer or former employer, Medicaid, or privately purchased Medigap. (Note that Original Medicare is made up of Medicare Part A, which covers hospital care, and Medicare Part B, which covers outpatient / therapeutic services; most members get Part A at no premium , but there is a monthly Part B premium).

Socialized medicine

Socialized medicine is another phrase that's often mentioned in conversations about universal coverage, but this model actually takes the single-payer system a step further. In the socialized medicine system, the state not only pays for medical care, but also operates hospitals and hires medical personnel.

A country may adopt a single payer approach (that is, the government pays for health care) without a socialized medicine approach.

The UK's National Health Service (NHS) is an example of a system where the government pays for services and also owns hospitals and hires doctors.

But in Canada, which also has a universal single-payer system, hospitals are privately owned and doctors do not work at the state level. They simply bill the government for the services they provide, just like America's Medicare program.

A major obstacle to any socialized medical system is the government's ability to effectively fund, manage, and update its standards, equipment, and practices to deliver optimal health care.

Calls to the US

Some experts have suggested that the United States gradually reform its current health care system to provide a publicly funded social safety net for the sick and the poor (a kind of expanded version of the Medicaid ACA expansion ), while requiring that those in better health buy their own policies wisely and financially …

However, the political stalemate over the Affordable Care Act over the past decade makes it hard to imagine that such a proposal will receive enough support for adoption. But it is technically possible to build a system that provides universal coverage and at the same time has multiple payers.

While it is theoretically possible to have a national single payer system without universal health coverage, this is highly unlikely because the federal government will undoubtedly be the only payer in such a system. If the US federal government were to adopt such a system, it would not be practical for them to exclude any citizen from health insurance.

Regardless, a growing number of Congressional officials are calling for the establishment of Free Health Care for All, a proposal widely supported by supporters of Vermont Senator Bernie Sander in his presidential campaigns.

Although the term Medicare for All is often used to describe a program under which the U.S. government will provide coverage to all U.S. citizens, several approaches have been proposed and all of them will include more reliable coverage than the Medicare program. current. … These approaches have been mistakenly labeled "socialist" by many Republican members of Congress, but none of the current Medicare for All proposals will include socialized medicine.

World Health Insurance

The Organization for Economic Cooperation and Development has 38 member countries. Most have reached universal coverage, with 100% of the population covered by basic health services. But in seven countries (Chile, Estonia, Hungary, Mexico, Poland, the Slovak Republic and the United States), less than 95% of the population has comprehensive health insurance.

According to the latest US Census data, only 92% of the US population was insured in 2019. The United States is at the bottom of the OECD countries in terms of the percentage of the population covered by health insurance, but it also spends far more of its GDP on health care than any other member country.

Let's take a look at the different ways that some countries have achieved universal or near-universal coverage:


Germany has universal coverage but does not use a single payer system. Instead, everyone who lives in Germany must have health insurance. Most employees in Germany are automatically enrolled in one of the more than 100 non-profit "health insurance funds" paid for by employee and employer contributions.

In addition, there are private health insurance plans, but only about 10% of German residents opt for private health insurance .


Singapore has universal coverage and large health care costs are covered (after deductible) by a public insurance system called MediShield. But Singapore also requires everyone to deposit between 4% and 10.5% of their income in a MediSave account.

When patients require routine care, they can withdraw money from their MediSave accounts to pay for it, but this money can only be used for certain expenses, such as government-approved drugs.

In Singapore, the government directly subsidizes the cost of health care rather than the cost of insurance (unlike the approach taken in the United States with coverage purchased through the ACA health exchanges , which subsidizes the cost of insurance doctor). As a result, the amount people have to pay for their health care in Singapore is much less than in the American model.


Japan has universal coverage but does not use a single payer system. Coverage is provided primarily through thousands of health insurance plans that compete under the Mandatory Health Insurance System (SHIS).

Residents must sign up for coverage and pay premiums for current SHIS coverage, but there is also the option to purchase private supplemental health insurance.

By implementing a less burdensome single payer model (rather than the separate public, private, and private government-linked health insurance schemes used in the United States), governments like Japan are better able to streamline their national health care services.

United Kingdom

The UK is an example of a country with universal coverage and a single payer system. Technically speaking, the British model can also be classified as socialized medicine, as the government owns most of the hospitals and employs healthcare providers.

Funding for the UK National Health Service (NHS) comes from tax revenue. If desired, residents can purchase private health insurance. It can be used for routine procedures in private hospitals or for faster access to care without waiting times that would otherwise be required for non-emergencies .

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