Key design components and considerations for establishing a single-payer healthcare system
Congressional interest in substantially increasing the number of people who have health insurance has grown in recent years. Some Members of Congress have proposed establishing a single-payer healthcare system to achieve universal health insurance coverage. In this report, the Congressional Budget Office describes the primary features of single-payer systems, as well as some of the key considerations for designing such a system in the United States.
Establishing a single-payer system would be a major undertaking that would involve substantial changes in the sources and extent of coverage, provider payment rates, and financing methods of healthcare in the United States. This report does not address all of the issues that the complex task of designing, implementing, and transitioning to a single-payer system would entail, nor does it analyze the budgetary effects of any specific bill or proposal.
About 29 million people under age 65 were uninsured in an average month in 2018, according to estimates by CBO and the staff of the Joint Committee on Taxation. Although a single-payer system could substantially reduce the number of people who lack insurance, the change in the number of people who are uninsured would depend on the system’s design. For example, some people (such as noncitizens who are not lawfully present in the United States) might not be eligible for coverage under a single-payer system and thus might be uninsured.
Although single-payer systems can have a variety of different features and have been defined in many ways, healthcare systems are typically considered single-payer systems if they have these four key features:
· The government entity (or government-contracted entity) operating the public health plan is responsible for most operational functions of the plan, such as defining the eligible population, specifying the covered services, collecting the resources needed for the plan, and paying providers for covered services;
· The eligible population is required to contribute toward financing the system;
· The receipts and expenditures associated with the plan appear in the government’s budget; and
· Private insurance, if allowed, generally plays a relatively small role and supplements the coverage provided under the public plan.
In the United States, the traditional Medicare program is considered an example of an existing single-payer system for elderly and disabled people, but analysts disagree about whether the entire Medicare program is a single-payer system because private insurers play a significant role in delivering Medicare benefits outside the traditional Medicare program.
Medicare beneficiaries can choose to receive benefits under Part A (Hospital Insurance) and Part B (Medical Insurance) in the traditional Medicare program or through one of the private insurers participating in the Medicare Advantage program. Those private insurers compete for enrollees with each other and with the traditional Medicare program,
