In this highly political season health care in general- and the Affordable Care Act [ACA] in particular- are frequent points of attack and counter-attack between the different campaigns.
The conversation has become all the more interesting with the candidacy of Senator Bernie Sanders and his call for a single payer system (or “Medicare for all”).
Unfortunately, many of us are not well informed about different ways to pay for healthcare coverage and provide medical care.
Talking heads, politicians, and regular people such as us tend to throw around the terms “universal coverage,” “single-payer health care,” and “socialized medicine,” without much distinction between them.
I think it would be useful if we all at least had some shared definitions and examples while we have this very important debate about what is best for our country.
Universal Coverage refers to a system where every legal resident of a country has insurance for health care. The underlying principle behind “Universal Coverage” is that with insurance people have better access to medical treatment.
The insurance may be from the government or private companies, and the care itself could be from either a government-controlled system or private providers.
Regardless, there has to be some governmental involvement in achieving Universal Coverage, through a mandate for insurance, or other legislation determining to “whom the universal health care should be provided, the type of coverage that is included, and the type of care that is provided.”
As of 2009- the year the ACA was passed- “thirty-two of the thirty-three developed nations had universal health care, with the United States being the lone exception.” But as you will see, that does not mean that all of the other countries had (or currently have) government controlled healthcare.
Universal coverage can be obtained by:
- insurance mandates,
- two-tier programs, or
- single-payer systems.
1. Insurance Mandates
In insurance mandate countries the government has required everyone to obtain insurance coverage, whether through the government, private companies, or a combination of both.
Nothing in this type of system is contrary to private health care providers. Insurance coverage is mandatory, but the care itself is not necessarily provided by the government in government owned facilities.
As stated by President Obama, the goal of the Affordable Care Act (“Obamacare”) was to achieve Universal Coverage through an insurance mandate. The decision by many states to not expand Medicaid (and other loopholes in the law) have left the actuality in this country short of that goal, but the original ACA plan of expanding Medicaid nationally, requiring individuals to have insurance (whether through their employer or individually), and protecting Medicare was designed to achieve- for the first time– a universally insured American population.
Other examples of countries with an insurance mandate include Germany and Switzerland.
2. Two-Tier Programs
In some other countries the government requires every citizen to have basic insurance coverage (through the government) to cover catastrophic circumstances such as accidents and major illnesses, but also allows their citizens to choose whether to purchase supplemental insurance (or health savings account) for more routine care. These are known as “Two-Tier” systems.
It is important to note that in these systems there are privately operating hospitals, physicians and other providers.
For examples think Ireland, Israel and Singapore.
3. Single-Payer Systems
When a government is paying all the bills, that money comes through taxation.
It is important to understand that in a single-payer system there can still be privately run hospitals and independent physicians. The payment comes from one source- but the care does not necessarily have to. Think France, or our own Medicare program.
So What Is “Socialized Medicine?”
In a socialized system the government “owns and operates health care facilities and employs the health care professionals, thus also paying for all health care services.”
By definition this would constitute a single-payer system, but unlike the examples given above- in a socialized system the single entity not only pays for the care, but owns the system where the care is delivered.
As examples, think England and the United Kingdom, or here in this country, the VA System.
Which System Provides “Free” Healthcare?
If I can underscore one point that is frequently lost in the conversation about different healthcare delivery and payment systems, none of these models constitute “free” care.
In every system people are paying, whether directly to their provider, or through paying taxes.
Keep the Debate Raging!
How best to provide (and pay) for healthcare in this country is an important debate that extends back to the mid-1800’s.
I hope some clarity about the terms can make it a more productive conversation!
Want to Know More?
The history of the desire of some to achieve Universal Coverage in the United States is a long and very interesting one, as is the quest for a single-payer system. An excellent history is available from the Physicians for a National Health Program here.
Medicare and Medicaid are both parts of the “Three-Layer-Cake” envisioned by President Johnson to achieve universal healthcare in this country. To get a glimpse into the tortuous political process that was required to pass that legislation in 1965, I highly recommend this article in the New Yorker.
Would you like to know more about the single-payer proposal being floated by Bernie Sanders- and the arguments for and against it? Stay tuned for my next Fontenotes!