Single-Payer Healthcare vs. Universal Coverage

Table of Contents
View All
Table of Contents

Healthcare reform has been a topic of debate in the United States for decades. Two terms often used to discuss it are universal healthcare coverage and the single-payer system. Yet "single payer" as a definition doesn't always offer clarity when describing specific policy proposals.

Although it's often used to describe "Medicare for all" plans, or refer to a type of socialized health care, the truth is that it does not have a one-size-fits-all meaning. Single-payer systems generally include universal coverage, but many countries do this without a single-payer system.

This article delves into what the two terms mean, including their similarities. It offers some examples of how these healthcare delivery systems are implemented around the world.

Universal Coverage vs. Single-Payer System

Verywell / Laura Porter

Pros and Cons of Universal vs. Single-Payer System

Universal coverage refers to a healthcare system where every individual has health coverage. This can be accomplished under a government-run health coverage system, or a private health insurance system, or a combination of the two.

According to the U.S. Census Bureau, there were 28 million people in the U.S. who had no health insurance coverage in 2020. While the Affordable Care Act (ACA) of 2010 has extended coverage to millions of people, it is not the universal coverage provided in many developed countries.

Single-Payer System

A single-payer system is one in which the government is responsible for paying healthcare claims, using money collected via the tax system. The government is the only "single payer." This is true in at least 17 countries, including Japan, Canada, United Arab Emirates, Italy, and Iceland.

Single-payer systems also can be implemented without covering the entire population. A country can have one or more single-payer programs and still not achieve universal coverage. This is true of the U.S., with its combination of single-payer coverage for some people, private coverage for others, and tens of millions of people who have no coverage at all.

In the United States, Medicare and the Veterans Health Administration are examples of single-payer systems. 

Medicaid is sometimes referred to as a single-payer system, but it is actually jointly funded by the federal government and each state government. Although it's a form of government-funded health coverage, the funding comes from two sources rather than one.

Many people are covered under employer-sponsored or self-purchased health plans in the U.S., including those sold on the health insurance exchanges. This means hundreds of private insurance companies are paying their members' claims, and are not part of a government single-payer system.

Two-Tier Systems: Public Plans and Private Coverage

In most cases, universal coverage and a single-payer system go together. The federal government is the entity that administers and pays for a healthcare system that covers its population.

However, countries like Canada and France operate two-tier systems that provide basic care via a single-payer system. Secondary coverage is available for those who can afford a higher standard of care.

This is similar to Medigap policies sold to people covered under Original Medicare in the U.S. Many people with Original Medicare rely on supplemental coverage to cover out-of-pocket costs.

What Is Original Medicare?

Original Medicare is comprised of Medicare Part A, which covers inpatient care, and Medicare Part B, which covers outpatient/physician services. Most Medicare enrollees get Part A without a premium, but there's a monthly premium for Part B.

Socialized Medicine

Socialized medicine is another phrase that is often mentioned in conversations about universal coverage, but this model actually takes the single-payer system one step further. In a socialized medicine system, the government not only pays for health care but operates the hospitals and employs the medical staff.

A country can adopt a single-payer approach, meaning the government pays for medical care, without fully embracing socialized medicine.

In the United States, the Veterans Administration (VA) system is an example of socialized medicine, but Medicare is not.

The National Health Service (NHS) in the United Kingdom is an example of a system in which the government pays for services and also owns the hospitals and employs the doctors.

But in Canada, which also has a single-payer system with universal coverage, the hospitals are privately operated and doctors are not employed by the government. They simply bill the government for the services they provide, much like the American Medicare program.

The main barrier to any socialized medicine system is the government's ability to effectively fund, manage, and update its standards, equipment, and practices to offer optimal health care.

Pros and Cons of Single-Payer Health Care

Single-payer healthcare systems arise from different policy models. What they have in common is that federal governments are responsible for financing the system, with the goal of providing care to the entire population. Among the drawbacks of a single-payer system are budget resources needed to achieve this goal, including tax collection, and the challenge of providing access to quality health care across diverse geographic areas and demographic groups.

Challenges in the United States

Some experts have suggested that the U.S. should incrementally reform its current health care system to provide a government-funded safety net for the sick and the poor. In some ways, the approach is similar to a broader application of the ACA's Medicaid expansion adopted in some states. It would mean that healthier, more affluent Americans would still need to purchase their own policies.

It is possible to have a U.S. single-payer system without also having universal health coverage. This has remained unlikely because the federal government would need to be the single payer. The political will in the U.S. has not favored a system in which an individual citizen would be excluded from health coverage in this way.

The ongoing political gridlock over the Affordable Care Act in the U.S. limits how such a proposal might gain enough support for legislation to be enacted. It is technically possible to construct such a system, which would provide universal coverage while also having multiple payers.

A number of U.S. legislators have called for the establishment of "Medicare for All," a proposal introduced by U.S. Senator Bernie Sanders of Vermont during his presidential campaigns. For example, there were 121 cosponsors of the Medicare for All Act of 2021 in the U.S. House of Representatives.

The term "Medicare for All" is often used to describe a program under which the U.S. government would provide coverage to all American citizens. What different proposals have in common is that they would offer more robust coverage than the current Medicare program provides.

Although opponents of "Medicare for All" proposals typically label them as socialized healthcare, none of the current proposals actually rely on or incorporate socialized medicine.

Health Coverage Around the World

The Organisation for Economic Co-operation and Development (OECD) includes 38 member countries. Most of them have achieved universal coverage with 100% of their population covered by core health benefits.

In 2021, the OECD reports that 90% of the U.S. population was eligible for core healthcare services. This is lower than the OECD average of 98% among its member nations.

According to recent U.S. Census data, less than 92% of the U.S. population was insured in 2020. The U.S. is near the bottom of the OECD countries in terms of the percentage of its residents with health coverage, but it also spends far more of its GDP on health care than any of the other member countries.

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

Germany

Germany has universal coverage but does not operate a single-payer system. Instead, everyone living in Germany is required to maintain health coverage. Most employees in Germany are automatically enrolled in one of more than 100 non-profit "sickness funds," paid for by a combination of employee and employer contributions.

Alternatively, there are private health insurance plans available, but only about 10% of German residents choose private health insurance.  

Singapore

Singapore has universal coverage, and large health care expenses are covered (after a deductible) by a government-run insurance system called MediShield. But Singapore also requires everyone to contribute 4% to 10.5% of their income to a MediSave account.

When patients need routine medical care, they can take money out of their MediSave accounts to pay for it, but the money can only be used for certain expenses, such as medications on a government-approved list.

In Singapore, the government directly subsidizes the cost of health care rather than the cost of insurance (in contrast with the approach that the United States takes with coverage purchased through the ACA health exchanges, in which the cost of the health insurance is subsidized). As a result, the amount people have to pay for their health care in Singapore is much lower than it would be under the U.S. model.

Japan

Japan has universal coverage but does not use a single-payer system. Coverage is mainly provided via thousands of competing health insurance plans in the Statutory Health Insurance System (SHIS).

Residents are required to enroll in coverage and pay ongoing premiums for SHIS coverage, but there is also an option to buy private, supplemental health insurance.

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

United Kingdom

The United Kingdom is an example of a country with universal coverage and a single-payer system. Technically speaking, the U.K. model can also be classified as socialized medicine since the government owns most of the hospitals and employs the medical providers.

Funding for the U.K. National Health Service (NHS) comes from tax revenue. Residents can purchase private health insurance if they want to. It can be used for elective procedures in private hospitals or to gain faster access to care without the waiting period that might otherwise be imposed for non-emergency situations.

Summary

Universal coverage refers to any approach that ensures that all of a country's residents (in most cases, only those who are legally present in the country) have health coverage. The coverage can be provided under a government-run program or a system of private health insurance or a combination of the two.

Single-payer health coverage refers to a system in which one entity pays for residents' medical services. In most cases, the payer will be the country's government, using funds collected via taxes. In the U.S., Medicare and the VA system are both examples of single-payer health coverage, as they're funded by the federal government.

But the U.S. does not have universal coverage, nor does it have a single-payer system available to all residents.

A Word From Verywell

It's common for the terms single-payer and universal coverage to be conflated. But it's simple enough to remember the difference if you keep in mind that single-payer means there's just a single entity paying for medical care (in most cases, a country's government).

Universal coverage, on the other hand, just means that coverage is universal, and that everyone in the country (or at least everyone who is legally present) has health coverage. But that doesn't mean that medical care has to be provided by the government; universal coverage can be achieved with a private insurance system or a combination of a public and private system.

Was this page helpful?
11 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Liu JL, Brook RH. What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S. J Gen Intern Med. 2017 Jul;32(7):822-831. doi:10.1007/s11606-017-4063-5

  2. Keisler-Starkey, Katherine; Bunch, Lisa N. U.S. Census Bureau, Current Population Reports. Health Insurance Coverage in the United States: 2020.

  3. World Population Review. Countries With Single Payer.

  4. Cubanski, Juliette; Damico, Anthony; Neuman, Tricia; Jacobson, Gretchen. Kaiser Family Foundation. Sources of Supplemental Coverage Among Medicare Beneficiaries in 2016.

  5. King B, Spadaro A, Schiff G, Rodriguez-Monguio R, Jordan AO, Flaherty L, et al. The American Public Health Association Endorses Single-Payer Health System Reform. Med Care. 2022 Apr 26. doi:10.1097/MLR.0000000000001722

  6. Congress.gov. H.R. 1976 - Medicare for all act of 2021.

  7. Organisation for Economic Co-operation and Development. Health at a Glance.

  8. All About Berlin. Public and private health insurance in Germany: how to chose?

  9. Inland Revenue Authority of Singapore. Compulsory and Voluntary Medisave Contributions.

  10. Zhang X, Oyama T. Investigating the health care delivery system in Japan and reviewing the local public hospital reformRisk Manag Healthc Policy. 2016;9:21–32. doi:10.2147/RMHP.S93285

  11. United Kingdom, National Health Service. An Introduction to the NHS.