Cover: What Is Single-Payer Health Care?

What Is Single-Payer Health Care?

A Review of Definitions and Proposals in the U.S.

Published in: Journal of General Internal Medicine, [Epub May 2017]. doi: 10.1007/s11606-017-4063-5

Posted on Jun 1, 2017

by Jodi L. Liu, Robert H. Brook

Research Question

  1. Single-payer health care systems have been proposed at both the federal and state levels in the United States, but what does "single-payer" really mean?


Single-payer systems have been proposed as a health care reform alternative in the United States. However, there is no consensus on the definition of single-payer. Most definitions characterize single-payer as one entity that collects funds and pays for health care on behalf on an entire population. Increased flexibility for state health care reform may provide opportunities for state-based single-payer systems to be considered.


To explore the concept of single-payer and to describe the contents of single-payer health care proposals.


We compared single-payer definitions and proposals. We coded the proposal text for provisions that would change how the health care system functions and could impact health care access, quality, and cost.

Main Measures

The share of proposals that include changes to the financing, pooling, purchasing, and delivery of health care; and possible impact on access, quality, and costs.

Key Results

We identified 25 proposals for national or state single-payer plans from journal and legislative databases. The proposals typically call for wide-ranging reform; nearly all include changes across the financing, pooling, purchasing, and delivery of health care services. Many provisions aiming to improve access, quality, and cost containment are also included, but the proposals vary in how they plan to achieve these improvements. Common provisions are related to comprehensive benefits, patient choice of providers, little or no cost sharing, the role of private insurance, provider guidelines and standards, periodic reviews of the benefits package, electronic medical records and billing, prescription drug formulary, global budgets, administrative cost thresholds, payment reform and studies, and the authority to implement cost-containment strategies.


Single-payer systems are heterogeneous. Acknowledgment of what is considered as single-payer and the characteristics that are variable is important for nuanced policy discussions on specific reform proposals.

Key Findings

  • Despite their primary definition as a financing mechanism for universal coverage, single-payer proposals vary in the changes they would pursue to improve health care access, quality, and cost containment.
  • Of the single-payer proposals reviewed for this study, about half involved no cost sharing.
  • Details on how a given single-payer system would contain costs and reimburse providers are critical characteristics that are often unspecified.
  • Meaningful policy discussions on a given single-payer proposal should clearly define which provisions are at play.

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