Module 3 discussion

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Single-payer Systems – What Works (and What Doesn’t Work) Outside of the United States

After researching a country (outside of the United States) with a single-payer health care system, share a summary of information regarding how the single-payer system works in that country of your choice. Include both the specific benefits and specific drawbacks of the system. Look at the discussion board to see what countries’ information has already been posted, and choose a country that is not posted yet to ensure a wide variety of examples for us to review. Your summary should be a concise 200-word response, using peer-reviewed sources to find facts to support your points.

EYE ON WAsHINgtON

Ken Perez

What would be the price tag of “Medicare for All”? It’s an
important question, given current bills under consideration
in Congress, the primacy of healthcare thus far in the
2020 presidential election campaign and general public
support for the Medicare for All concept.

On Feb. 27, Rep. Pramila Jayapal (D-Wash.)
introduced the Medicare for All Act of 2019 in the
House. The bill was touted as an improved version
of prior bills proposed in the Senate by Sen.
Bernie Sanders (I-Vt.) in 2013 and 2017. Not to be
outdone, on April 10, Sanders and 14 of his
Democratic colleagues in the Senate introduced a
bill with the same title as the Jayapal bill.

In general, the Medicare for All bills would create
a federally administered single-payer healthcare
program that would provide comprehensive
coverage for all Americans, across the entire
healthcare continuum. All physicians would be
effectively in-network, and there would be no
deductibles, copayments or cost-sharing
requirements of any kind.

Public attitudes
Many Americans support the idea of Medicare for
All. According to polls conducted by the Kaiser
Family Foundation, public backing in 2019 for a
single-payer system averaged 56% from January
through April.a Similarly, a survey of 2,000 
U.S. registered voters conducted from April
30 through May 5 by RealClear Opinion Research

a. Kaiser Family Foundation, “Public opinion on single-payer,
national health plans, and expanding access to Medicare
coverage,” June 19, 2019.

found 55% in support of Medicare for All.b

However, a January Kaiser Family Foundation
Health Tracking Poll found that 60% would
oppose Medicare-for-All legislation if it would
require most Americans to pay more in taxes.
Perhaps even more concerning — because it
indicates a lack of understanding of the funda-
mentals of the Medicare-for-All concept — 60%
would oppose such legislation if it would threaten
the current Medicare program and 58% would
oppose it if it would eliminate private health
insurance companies.

the cost of a single-payer system
Citing the lower per-capita costs of healthcare in
other industrialized countries that have single-
payer systems, Sanders contends that national
health expenditures (NHE), which totaled
$3.5 trillion in 2017, would actually amount to
$6 trillion less over 10 years under his plan
compared with the current system.c Currently,
the federal government’s spending on healthcare
amounts to roughly one-third of NHE, about
$1.1 trillion, funding Medicare, Medicaid, the
Children’s Health Insurance Program, health
insurance subsidies and related spending, and
veterans’ medical care.d

Unquestionably, under a single-payer system,
the federal government’s expenditures for
healthcare would increase significantly. Sanders
posits that $16.2 trillion would be the implied

b. Cannon, C.M., “Poll: ‘Medicare for All’ support is high—but
complicated,” RealClear Politics, May 15, 2019.
c. Friedman, g., “What would sanders do? Estimating the
economic impact of sanders programs,” Jan. 28, 2016.
d. Congressional Budget Office, “the budget and economic
outlook: 2019 to 2029,” January 2019.

single-payer concept for u.s. healthcare
requires close fiscal scrutiny

14 August 2019 healthcare financial management

expected increase in federal expenditures over a
10-year period under his plan.e However, several
analyses have concluded that federal expendi-
tures would rise by significantly more than
Sanders projected, and NHE would be higher
under Medicare for All than under the present
multi-payer system.

The Urban Institute, a left-center think tank, has
concluded that federal expenditures would
increase by about $32 trillion over 10 years
(2017-2026) — roughly twice what Sanders
projected — and NHE would, in fact, increase, not
decrease, by $6.6 trillion over the same 10-year
period. Notably, the Urban Institute’s projection
incorporates “provider supply constraints faced
by current Medicaid enrollees,” which means not
all increased demand for healthcare would be met
under the program.f

Emory University professor of health policy
Kenneth Thorpe has concluded that, under the
Sanders plan, federal expenditures would rise by
almost $25 trillion over the same 10 years.g To put
the Urban Institute and Thorpe projections in
perspective, total federal expenditures in fiscal
2019 will be roughly $4.5 trillion.

In July 2018, Charles Blahous, a senior research
strategist at the Mercatus Center at George
Mason University, estimated that the Sanders
plan would increase federal expenditures by
$32.6 trillion during its first 10 years of
implementation.h

On May 22, Congressional Budget Office deputy
director Mark Hadley testified at a House Budget
Committee hearing on Medicare for All. Although
Hadley declined to provide a cost estimate for the
legislation, he noted that the changes required to
implement a single-payer system “could

e. sanders, B., “Options to finance Medicare for All,” accessed
June 22, 2019.
f. urban Institute, “the sanders single-payer health care plan,”
May 2016.
g. thorpe, K.E., “An analysis of senator sanders’ single payer
plan,” Jan. 27, 2016.
h. Blahous, C., “the costs of a national single-payer healthcare
system,” July 30, 2018.

significantly affect the overall U.S. economy” and
be “potentially disruptive,” and he cautioned that
“the amount of care supplied and the quality of
that care might diminish.”i

Lessons from the states
Four states have tried to garner public support for
a single-payer system, but their plans all fell apart
because of concerns about their programs’ high
costs and requisite financing. In 1994, Califor-
nia’s Proposition 186 was rejected by 73% of
voters. Similarly, in 2002, Oregon’s Measure
23 was voted down by 79% and in 2016, 79% of
Colorado voters rejected Amendment 69, a
universal healthcare proposal.

Shedding light on the potential tax implications
of a single-care program, in 2014, Vermont’s
then-Gov. Peter Shumlin, a Democrat who had
famously championed a single-payer system,
abandoned his drive after concluding that 11.5%
payroll assessments on businesses and sliding-
scale premiums of up to 9.5% of individuals’
income “might hurt our economy.”j

A shift to a single-payer system
requires rare objectivity
The divergence between the desire for a single-
payer system and equally strong opposition to
the tax increases to fund it is emblematic of the
human condition: Our wants often exceed our
ability or willingness to pay. Ultimately, policy-
makers and other stakeholders — especially
voters, who generally are less aware of the fiscal
realities associated with Medicare for All —
must consider the downside risks and weigh
the benefits of a single-payer system against
alternative uses of public resources, from
spending on other programs to avoiding signifi-
cant tax increases.

i. sullivan, P., “CBO: Medicare for All gives ‘many more’
coverage but ‘potentially disruptive,’” The Hill, May 22, 2019.
j. Wheaton, s., “Why single payer died in Vermont,” Politico,
Dec. 20, 2014.

Ken Perez is vice president of healthcare policy, Omnicell,
Inc., Mountain View, Calif., and a member of HFMA’s
Northern California Chapter.

hfma.org August 2019 15

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

ww.sciencedirect.com

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2

Available online at w

Public Health

journal homepage: www.elsevier .com/puhe

Review Paper

Single-payer or a multipayer health system: a
systematic literature review

P. Petrou a,*, G. Samoutis b, C. Lionis c

a Pharmacy Program, Department of Life and Health Sciences, School of Science and Engineering, University of

Nicosia, Nicosia, Cyprus
b St George’s, University of London Medical Programme, Delivered in Cyprus by the University of Nicosia Medical

School, Cyprus
c Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece

a r t i c l e i n f o

Article history:

Received 18 July 2017

Received in revised form

18 April 2018

Accepted 9 July 2018

Available online 5 September 2018

Keywords:

Health system

Single payer health system

Multipayer health system

Universal health coverage

Health Insurance

* Corresponding author.
E-mail address: [email protected] (P.

https://doi.org/10.1016/j.puhe.2018.07.006
0033-3506/© 2018 The Royal Society for Publ

a b s t r a c t

Objectives: Healthcare systems worldwide are actively exploring new approaches for cost

containment and efficient use of resources. Currently, in a number of countries, the critical

decision to introduce a single-payer over a multipayer healthcare system poses significant

challenges. Consequently, we have systematically explored the current scientific evidence

about the impact of single-payer and multipayer health systems on the areas of equity,

efficiency and quality of health care, fund collection negotiation, contracting and budget-

ing health expenditure and social solidarity.

Study design: This is a systematic review based on Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) guidelines.

Methods: A search for relevant articles published in English was performed in March 2015

through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing

and Allied Health Literature, Medical Literature Analysis and Retrieval System Online

through PubMed and Ovid, Health Technology Assessment Database, Cochrane database

and WHO publications. We also searched for further articles cited by eligible papers.

Results: A total of 49 studies were included in the analysis; 34 studied clinical outcomes of

patients enrolled in different health insurances, while 15 provided a qualitative assess-

ment in this field.

Conclusion: The single-payer system performs better in terms of healthcare equity, risk

pooling and negotiation, whereas multipayer systems yield additional options to patients

and are harder to be exploited by the government. A multipayer system also involves a

higher administrative cost. The findings pertaining to the impact on efficiency and quality

are rather tentative because of methodological limitations of available studies.

© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Petrou).

ic Health. Published by Elsevier Ltd. All rights reserved.

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2142

Introduction

Universal healthcare coverage is ‘the most powerful concept that

public health has to offer’.1 The redistribution of health risks lies

at the core of a universal coverage health system (UCHS),

thereby protecting the citizens who are in the greatest need of

healthcare services.

Despite the diversity in the design of health systems

worldwide, all health systems have the same desired attri-

butes of efficiency, trustworthiness and affordability.2 The

healthcare system can be defined by three functional pro-

cesses: (i) service provision; (ii) financing and (iii) regulation,

which must be governed by the following principles: (a) eq-

uity; (b) financial protection and (c) efficiency and quality,

respectively.3,4

The payer type, whether single payer or multipayer, is a

highly debatable issue for any country contemplating

healthcare reforms.4,5 A single-payer health system is

delineated by universal and comprehensive coverage, while

the payer is a public entity. A multipayer healthcare system,

on the other hand, features two or more providers in charge

of administrating the health coverage. This assumes that a

certain level of competition exists and usually the rules of

competition, along with the basic principles of healthcare

coverage, are demarcated by a governmental body. Cyprus

and Ireland are examples of two European countries without

a UCHS.6 In Cyprus, a parliament-approved National Health

System has not been implemented because of concerns

about its fiscal sustainability and the lack of consensus

among social stakeholders and health professionals. Out-of-

pocket payment (private expenditure that does not include

copayments in the public healthcare sector) exceeds public

funding, while the ability of people to fund their healthcare

has been compromised because of the financial crisis and the

reduction of household disposable income.6 The public

healthcare sector has been severely strained, while the

financial recession had impaired affordability for private

sector health services, whose costs burden patients, thus

exposing them to potentially catastrophic expenditure. The

current situation begs for the introduction of a universal

coverage health system (UCHS). This systematic review aims

to enable informed decision-making in the context of Cyprus’
healthcare sector, while still being relevant to an interna-

tional audience, as many countries are actively pondering

reforms to improve their healthcare systems.

Objectives

The objective of this article is to systematically investigate

current scientific evidence about the impact of the single-

payer and multipayer health system on the areas of equity,

efficiency, quality of care and financial protection through a

systematic literature review.7

Methods

Based on the available literature and the theoretical back-

ground of universal coverage framework,4,8 the term health

protection, a major determinant in the context of a UHCS,

encapsulates:

a) Equitydtimely access not linked to employment status or

ability to pay;

b) Efficiency and high-quality health caredproviding the

highest possible level of health with the available

resources;

c) Financial protection against catastrophic health expendi-

ture, which can be further stratified into the following

categories:

� Fund collection, which is a policy norm.9 Fund collection

is a weak stand-alone tool, unless accompanied by

pooling of contributions and cross subsidisation of

health costs.

� Social solidarity.

� Negotiation, contracting and budgeting, comprising the

efficient use of health resources. This includes the se-

lection of providers and implementation of cost-

containment measures and even performance targets.

� Health expenditure that provides the funds to meet the

health needs of the population.

Studies reporting at least one of the aforementioned health

protection parameters were included in the review.

Search strategy

Our research strategywas to look for (a) original and published

studies (randomised controlled trials, observational, quanti-

tative, qualitative, meta-analyses); (b) published between 01

January 1980 and 28 February 2015; and (c) studies that discuss

single-payer and multipayer health systems, efficiency, soli-

darity, cost risk sharing and quality of care.

We searched the following databases: Excerpta Medica

Databases, Cumulative Index of Nursing and Allied Health

Literature, Medical Literature Analysis and Retrieval System

Online through PubMed and Ovid, Health Technology

Assessment Database, Cochrane database and WHO publica-

tions. We also searched for further articles cited by eligible

articles.

Screening process

The screening process was conducted in two stages: first, the

titles and abstracts were screened by the lead reviewer to

exclude distinctly irrelevant references. If the abstract did not

provide sufficient data to enable selection, full articles were

reviewed. Second, full-text manuscripts were screened for

compliance with inclusion criteria of the review by two in-

dependent reviewers. Disagreements were resolved by dis-

cussion or by consulting with the lead reviewer.

We adopted the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) statement for reporting

systematic reviews andmeta-analysis in health care10 (Fig. 1).

The PICO terms are the following:

1) Population: beneficiaries enrolled in health systems

2) Intervention: single payer vs multipayer health system

3) Comparison: single payer vs multipayer health system

Records iden�fied through
database searching

(n = 888)

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in
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ed
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ib
ili
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Addi�onal records iden�fied
through other sources

(n = 126)

Records a�er duplicates removed
(n = 898)

Records screened
(n = 898)

Records excluded based
on �tle

(n = 703)

Full-text ar�cles assessed
for eligibility

(n = 195)

Full-text ar�cles excluded,
with reasons:

Not related (n = 107)
Perspec�ve (n=11)

Not sufficient data (n=28)

Studies included
n=49

Fig. 1 e Flow Diagram of literature review of single-payer vs multipayer health systems using Preferred Reporting Items for

Systematic Reviews and Meta-Analyses (PRISMA).

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2 143

4) Outcomes: equity, solidarity, costs, efficiency, risk pooling,

contracting negotiation and budgeting.

We used theMedical Subject Headings terms: ‘ Single Payer

System’, ‘Healthcare Disparities/statistics & numerical data’,

‘Insurance, Health/classification’, ‘System, Single-Payer’,

‘Single-Payer Plan’, ‘Insurance Coverage/statistics & numeri-

cal data ’, ‘Health Insurance, Voluntary’ ‘Insurance, Voluntary

Health’, ‘Group Health Insurance’, ‘Insurance, Group Health’,

‘Reimbursement, Health Insurance’, ‘Third-Party Payments’,

‘Payment, Third-Party’, ‘Payments, Third-Party’, ‘Third Party

Payments’, ‘Third-Party Payment’, ‘Health Insurance Reim-

bursement’, ‘Insurance Reimbursements, Health’, ‘Re-

imbursements, Health Insurance’, ‘Third-Party Payers’,

‘Payer, Third-Party’, ‘Payers, Third-Party’, ‘Third Party Payers’,

‘Third-Party Payer’, ‘Health Program, National’, ‘Health Pro-

grams, National’, ‘National Health Program’, ‘Program, Na-

tional Health’, ‘Programs, National Health’, ‘National Health

Insurance’, ‘Health Insurance, National’, ‘Insurance, National

Health’, ‘National Health Insurance, Non-U.S.’, ‘Health Ser-

vices, National’, ‘National Health Service’, ‘Service, National

Health’, ‘Services, National Health’, ‘National Health Ser-

vices’, using Boolean operators (AND, OR).

Data collection

Data relating to study characteristics, such as study popula-

tion, outcome measures and analysis undertaken, were

extracted on a data extraction form by the lead reviewer and

independently checked for accuracy by two independent re-

viewers, individually. Disagreements were resolved by dis-

cussion or by consulting with the lead reviewer.

Study selection

We identified 888 potentially eligible articles and an additional

126 through other sources (including snow-ball citations of

the included articles). Deduplication led to 898 articles of

which 703 were excluded based on title and 195 were further

assessed for eligibility. A total of 112 were further excluded

being unrelated to the study topic, 11 were perspective arti-

cles, while 24 more did not provide sufficient data. In the end,

49 studies were included in the analysis, including 34 with

quantitative end-points and 15 with qualitative end-points

(Fig. 1, Table 1 and Supplementary Table 1).

There were 20 studies focussing on the USA and four on

Germany. Two compared the USA with Canada and two were

Table 1 e Assessment of qualitative studies.

Authors, year, reference Author objectives or aims Population (participants, diagnoses,
gender, age)

Outcomes measures and analysis
undertaken

Assessment
criteria CASPa

Abiiro and Allegri, 20148 Dimension of universal health coverage Global perspective Humanitarian, legal and economic

approach

1,2,3,4,6,7,10

Besstremyannaya, 201344 Managed competition in health insurance

systems in central and eastern Europe

Regulated competition among multiple

health insurance companies in central

and eastern Europe

Quality indicators (infant and under-five

mortality etc.)

1,2,3,4,7,8,9,10

Blanchet and Fox, 201352 Prospective, institutional stakeholder

analysis for Vermont’s single-payer

system

Questionnaire based in Vermont for

stakeholders

Attitude for the comprehensive health

reform

1,2,3,4,5,6,7,8,9,10

Chollet et al., 200261 Feasibility study for introduction of single

payer in Maine

Population module that estimates

Maine’s, (USA) population by sex and age

Cost, financing and economic impact

module

1,2,5,6,7,8,9,10

Duijmelinck Mosca and van de Ven, 201555 Switching between insurers: benefits and

costs

Dutch consumers (1091 respondents) Relevance of the different switching

benefits and costs in consumers’ decision
to switch the insurer

1,2,3,4,6,7,9,10

Geyman, 200565 Review paper Qualitative Comparison between single vs public 1,2,3,5,6,7,8,10

Hussey and Anderson, 200340 Comparison of single- vs multipayer

system

Systematic review Equity, risk pooling, financing and

contracting

1,2,3,4,5,6,7,8,10

Mikkers and Ryan, 20145 ‘Managed competition’ for Ireland: the

single- versus multiple-payer debate?

Qualitative Effective managed competition 1,5,7,8,9,10

Preker, 199862 Policy paper Qualitative (European Union [EU]) Strength, weakness and areas of

improvement of EU health systems

1,2,3,4,5,6,7,8,9,10

Reinhardt, 200746 Perspective Qualitative Review of single- vs multipayer system 7,10

Thomson and Mosialos, 57 Insurance choice Framework in Germany and the

Netherlands

The impact of opting out on equity and

efficiency

1,2,5,6,7,8,9,10

Vetter and Boecker, 201253 Describe introduction of a single payer in

Dubai

Qualitative Policy analysis framework 1,2,5,6,7,8,9,10

Wendt, Frisina and Heinz, 20094 Classification of health systems Conceptual comparison of health systems Financing, service provision and access to

health care

1,2,3,4,6,7,9,10

Van de Ven, Beck, Van de Voorde et al.,

200759
Risk adjustment and risk selection Qualitative study across Belgium,

Germany, Israel, the Netherlands and

Switzerland

Comparison of risk equalisation schemes 1,2,3,4,5,6,7,8,9,10

Van de Ven, Beck, Buchner et al., 201343 Efficiency and affordability Belgium, Germany, Israel, the Netherlands

and Switzerland

Assessment of efficiency and affordability

in five European countries

1,2,3,4,5,6,7,8,9,10

1. Was there a clear statement of the aims of the research? (Consider � What was the goal of the research? � Why it was thought important? � Its relevance).

2. Is a qualitative methodology appropriate? (Consider � If the research seeks to interpret or illuminate the actions and/or subjective experiences of research participants � Is qualitative research the

right methodology for addressing the research goal? Is it worth continuing?).

3. Was the research design appropriate to address the aims of the research? (Consider � If the researcher has justified the research design [e.g. have they discussed how they decided whichmethod to

use?]).

4. Was the recruitment strategy appropriate to the aims of the research? (Consider � If the researcher has explained how the participants were selected � If they explained why the participants they

selected were the most appropriate to provide access to the type of knowledge sought by the study � If there are any discussions around recruitment [e.g. why some people chose not to take part]).

5. Was the data collected in a way that addressed the research issue? (Consider � If the setting for data collection was justified � If it is clear how data were collected [e.g. focus group, semi-structured

interview etc]. � If the researcher has justified the methods chosen � If the researcher has made the methods explicit [e.g. for interview method, is there an indication of how interviews were

conducted, or did they use a topic guide]? � If methods were modified during the study. If so, has the researcher explained how and why? � If the form of data is clear [e.g. tape recordings, video

material, notes etc] � If the researcher has discussed saturation of data).

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p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2 145

performed with a global perspective. One study dealt with a

basket of European Union (EU) countries (Germany, Denmark,

the Netherlands, Belgium, Luxemburg, France, the UK,

Ireland, Italy, Greece, Spain, Portugal and Austria). One study

referred (separately) to Switzerland, the Netherlands, Puerto

Rico and Taiwan. Among the studies that referred to specific

health conditions, six concentrated on oncology, four on car-

diology, three on orthopaedic operations, one on trans-

plantation and one on sepsis. Three studies focussed on

disparities in waiting times pertinent to insurance type.

Among the 15 qualitative studies, two referred to a group of

five countries (Belgium, Germany, Israel, the Netherlands and

Switzerland) and two to the USA. Among the remaining

studies, one dealt with EU countries, one combined the

Netherlands and Germany, one assessed Dubai, one focussed

on central and eastern Europe, one on theNetherlands, one on

Ireland, while the others had a global framework.

Data items and critical appraisal

Two reviewers independently assessed the scientific quality

using Cochrane Risk of Bias tool and the Critical Appraisal

Skills Programme (CASP) tools (Table 1 and Supplementary

Table 1, respectively). Disagreements were resolved by dis-

cussion or by consulting with the third (lead) independent

reviewer.

Discussion

Equity

Equity is a fundamental pillar of health systems and it encom-

passes timely access, equivalence of care and absence of

avoidable or remediable differences among groups of people,

pertinent to distinct social, economic, demographical or

geographical criteria.11,12 Persistent differences in the health

status due to socio-economic status constitute amajor concern

across developed countries.13 Health inequalities escalate to

significant health disparities, which were primarily reported in

the oncology sector. Four out of the six studies that investigated

cancer patient outcomes in single-payer vs multipayer health

system settings, indicated that the insurance type was inter-

weaved with survival. Among these, one study reported that

certain insurances were correlated with advanced stage colo-

rectal cancer diagnosis, which leads to lower relative survival.14

McDaid et al. concluded that the outlined variability of out-

comes of lung, colorectal, prostate and breast cancer could be

attributed to insurance type.15 One study regarding breast

cancer evinced that within a multipayer system, patients with

private insurances presented with statistically significant

smaller tumours, compared with public beneficiaries.16 Robins

andNiu reached thesameconclusion for colorectal, breast, lung

cancer and non-Hodgkin lymphoma.17e19 Nevertheless, two

studies did not find significant differences in breast, cervical

and colorectal cancer.20,21

Three studies reported on orthopaedic care. Among these,

two attested a significant association between income-related

health insurance and hindered access tomedical care, leading

to impaired functionality after hip replacement therapy.22,23 It

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2146

was also observed that there was a statistical difference

among several types of health insurance; patients covered by

non-commercial insurance be in a disadvantaged position

regarding their referral to rehabilitation services. Martin et al.

in 2012 also reported that the payer type was statistically

significantly associated with disparate joint arthroplasty

outcomes.24

Two more studies reported data on sepsis and lung

transplantation. O’Brien et al. argued that risks of sepsis-

associated death varied by insurance cover.25 In the same

vein, Allen et al. found a statistically significant correlation

between survival of lung transplant recipients and insurance

type.26 Two studies reported on paediatric data indicating

disparities between asthma management and insurance type

among children,27 and some payer types demonstrated

diverging results contingent on the neonatal and post-

neonatal period.28

Three studies reported findings from Germany. Lungen

et al. stated that for five specific specialist examinations, pa-

tients enrolled with statutory health insurance (SHI) waited

3.08 times longer for an appointment, comparedwith patients

with private health insurance (PHI).29 Kuchinke et al.

concluded that private insurance patients in Germany have

statistically significant lower waiting times in a sample of 485

hospitals.30 Adding to this, Scwiertz et al. concluded that

exacerbated discrimination in waiting times between SHI and

PHI beneficiaries, is -paradoxically-related to better financial

performance of the hospitals.31

Four studies reported data in the cardiology sector. The

insurance type also proved to determine the use or not of

drug-eluting stents.32 Moreover, Laux et al. also stated that PHI

patients are more likely to be prescribed newer antihyper-

tensive agents.33 Two of these four studies reported conflict-

ing data with regard to the association of the payer type and

outcomes of cardiac surgery.34,35

Finally, Taiwan’s recent shift to a single-payer design ver-

ifies that a single-payer system culminates to equal access to

healthcare substantiated by high public satisfaction rate.36

Efficiency and quality of health care

Quality in health is a multifactorial process and it has been

interlaced with performance management, goal setting

through health indicators, academic detailing and introduc-

tion of guidelines.37 In general, the private sector is perceived

to bemore efficient than the public sector. There is an attempt

to extrapolate this in the health sector, but this is highly

challenged.38 Geyman concluded that private hospital costs

are 3e13% higher, employ fewer nurses and death rates are

6e7% higher compared with public hospitals.38 In specialised

units, such as dialysis centres, private centres reported 30%

higher death rates compared with public units, while prema-

ture discharge from private hospitals was also observed. And,

if we assume that fragmentation hinders efficiency improve-

ment, we have to take into consideration that in the US, a

sample of 2000 patients with depression were enrolled in 189

different plans with 755 different policies.39 Moreover, high-

quality healthcare implies that extrinsic factors such as

employment status and payment status should not affect the

quality of provided services. The assumptions have exceeded

the body of evidence and no differences in outcomes were

observed in a study between single-payer and multipayer

systems.40

A single-payer system with a centralised data mining

procedure is more likely to be able to glean and analyse health

indicators, while the direct comparability of providers will

presumably nurture patients in informed decision-making

and concomitantly will engage providers in an efficiency-

enhancement saga.41 Additionally, public single-payer sys-

tems are depleted of a profitmotive. Although thismay reduce

overall costs of the system, it also nullifies incentives for ef-

ficiency improvement of their operation framework. In this

notion, a multipayer system may be more efficient. Never-

theless, the rather oxymoron finding of underinvestment in

high-quality care because of enhanced competition between

insurers was reported, as quality improvement projects in

hospitals run by a specific health insurance will also benefit

the patients enrolled with a competitive insurance.42 In the

same context, it was also reported that patients with private

insurance give more favourable evaluations to their physi-

cians (P < 0.001) compared with patients enrolled to SHI.

Competition enhancement among purchasers was proved

to be a rather unattainable target across a cluster of EU

countries,43 while Besstremyannaya reckoned that the

increased competition between private insurances in Russia

did not lead to an improvement in the quality of care.44

Financial protection

Fund collection
A single-payer system can explore synergies with tax-

collecting structures at a marginal cost, which concomi-

tantly comprises disadvantage in countries with significant

tax evasion.45 In tandem, a single-payer system can also be

‘pitted against other government priorities’, and it is an easy

target on fund reduction.46 It is also vulnerable under a hostile

government due to its interdependence with government

structures. Finally, amultipayer system requires replication of

several individual mechanisms, from each payer, which

further ramps up not only the total costs but also the

complexity factor. Apart from this, fund collection is consid-

ered to be easier.

Negotiation, contracting and budgeting
Competitive forces in health are flawed because its main at-

tributes entail asymmetry of information, barriers of entry

and no potential substitution effect.47 This is frequently

overseen by people who endeavor to compare the health

market with other commodity markets. Nevertheless, some

unique and controversial attributes of the healthmarket, such

as healthcare’s positive externalities, point out the impor-

tance of proper access for patients to the necessary healthcare

services. Inequalities in access may be further exacerbated by

the market, while they are rarely remedied by it.48 Therefore,

contracting of public good’s services such as health services

could have negative effects if the operational framework is not

liable to constitutional scrutiny and does not abide by legal

and ethical accountability.49

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2 147

Contracting
A multipayer system is a market-oriented approach and it

perceives health as a commodity.50 Feldman contented that

a single-payer system deems health as a public good, which

will be underprovided for in a multipayer system.51 Multi-

payer systems can offer patient-centred packages, an attri-

bute that is debated because several authors demonstrated

that a service rarely fits just one patient, but it usually suits a

collection of patients of similar sociodemographic charac-

teristics.47 Moreover, a multipayer system may accommo-

date risk-averse individuals, for example individuals who

oppose high deductibles and cost sharing. Multipayer

schemes assume beneficiaries as temporary contractors,

which stems out of its own subsistence. The downsize of

this characteristic is that preventive policies that usually

yield later in time are rather unlikely to be reimbursed

because the current beneficiary may change supplier by the

time intervention becomes cost-effective. Adversely, a

single-payer system does have a strong spur to apply

screening and preventive programmes.52 This was epitom-

ised in Abu Dhabi’s preventive programme ‘cradle-to-grave’,

which encompasses this long-term commitment between

payer and beneficiary.53

A single-payer scheme assumes that patients are not

adequately informed to make rational choice and they are

presumed as passive recipients.40,46 Consequently, the pro-

vider’s response to the consumer’s expectations is not corre-

lated to the improvement in patient’s utility. The lack of the

required information from the patient perspective is not

problematic, while the lack of proper evaluation of that in-

formation by the patient is what matters the most. A single-

payer scheme overcomes this issue by offering the entire

spectrum of health services.49,51

The health market is an oligopoly due to high barriers of

entry, pertinent to costs, medical licensure and expertise.2,4

Therefore, bargaining power shifts to suppliers and erodes

the power of buyers. This feature can be exploited by current

providers to raise their effective costs and even erect barriers

for other providers to enter the market. Some other factors

also contribute to the establishment of the health market as

substantially less than perfect. Producers of health such as

hospitals can influence prices, which will lead to failure of the

market.41 This power escalates if the hospital is established as

a monopoly or a centre of excellence, and under this

assumption, it will not lead to a Pareto efficient outcome.8,9

‘Pareto optimality’ describes the allocation of resources in

the most efficient way for one party, without harming other

involved parties in the same field (i.e. other hospitals or other

beneficiaries).31 This will also probably cascade to profit

maximisation and to stagnation of efficiency improvement

because there is no need to explore efficiency as an approach

to reduce costs because this can be achieved by maximising

profit through the pricemaker attribute, thus exploiting the

position in the market.

Insurances subsidise high-risk individuals using utility and

resources from low-risk individuals. Nevertheless, if the cross

subsidisation surges, this creates an incentive for insurances

to selectively shift low-risk enrolees to new contracts.

Therefore, when insurances apply the practice of offering new

contracts to low-risk individuals, this leads high-risk patients

to a premium spiral.54

Additionally, free mobility between insurances, without

financially burdening the patients, which supposedly is the

hallmark of a multipayer system, also negatively affects high-

risk patients. This is attributed to the high cost incurred, the

lack of available options or underwriting and fear of rejection.

While free selection of insurance constitutes the benefit of a

multipayer system, recent findings cast light to in-

consistencies of this because one-fifth of responders

expressed the concern that their age and health status would

impede contracting with a new insurance.55 Most countries

strived to make the market more transparent either through

making the package prices publicly available and/or through

the introduction of uniform benefits package and making

available comparative information on the price of the benefits

package. However, most availed to disseminate adequate

comparative information on the quality of health services.56,57

A single-payer health system provides a single authority

with all the negotiating power. This leads to an increased

level of competition among providers.55,57,58 On the contrary,

multipayer systems target different group of patients by

segregating their schemes. The multipayer system will also

lead to fragmentation of the market, which will augment the

power of providers. If the market is heavily regulated, as in

Russia and the Netherlands, market distortion may take

shape. In Russia, this has led to insurances being merged and

for the premiums to increase.44 In the Netherlands, this has

led to consolidation of pharmacies, and fears were expressed

for even more to come.5 This will compromise the level of

care to the insured. Market competition is not a solution, and

the degree of competition among insurers affects their per-

formance. Overall, in a single-payer health system, the in-

surance provider is better placed to counteract the negative

effects of the market power of the suppliers and the agency

failures.

Three studies assessed the mobility across payers, perti-

nent to contracting. One study reported that in Germany and

the Netherlands, the choice of public or private coverage vio-

lates equity in funding, aggravates the risk for the public sector

and waives the incentives for efficiency enhancement in the

private sector.57 To the same direction, the second study

delineated transaction costs, learning costs, ‘benefit loss’

costs, uncertainty costs, the costs of (not) switching provider,

and sunk costs, as potential barriers.55 These switching costs

hamper transfers for as many as half the population who do

not switch insurances, an aspect magnified for people with

comorbidities. This cascades to the lack of incentives for

further investment in high-quality health care, relevant to

these people, because their mobility is impeded. Finally, a

study in Switzerland concluded that as the number of pro-

viders expands, the willingness of patients to switch between

providers diminishes, thus perpetuating the creation of sig-

nificant price differences even for homogeneous products.58

The multipayer system can also selectively contract with

some providers who satisfy a specific need of their target

group, usually low cost or some exclusive treatments, which

act as a differentiating point. The multipayer system may

strive for excellence in a specific healthcare speciality,

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2148

capitalising on risk adjustment, which, paradoxically, in some

cases can be profitable.59 This opposes integration and health

continuity, which are fundamentals of health care today. Se-

lective contracting entails the notion of a substantial coverage,

but it may not extend over life-threatening conditions that are

the most significant reason for obtaining a health insurance,

thus avoiding the catastrophic expenditure possibility. Selec-

tive contractingwas also associatedwith a significant distance

to access health care by Martin et al.24 Evidence from the

Netherlands also indicated that insurances attempt to ‘enforce

a joint purchase of basic and supplementary insurance’, thus

splitting the cost.54 One out of four health insurances offer

supplementary insurance if patients are already enrolled with

a basic one, while 40% of all insurances who do not apply the

previous rule, use surcharges instead on beneficiaries who opt

only for supplementary insurance.54

Finally, contracting with a single payer is a much more

simple and straightforward process and does not allow devi-

ation from provided bundle of services. From a payer

perspective, a single-payer system applies minimal barriers

compared with screening in a multipayer system.

Health expenditure
A single-payer system has lower administration costs,

through economies of scale, which implies that its cost

advantage arises (actual costs per unit declining) with

increased output, which is ascribed to the optimum usage of

its resources. Therefore, by capitalising on its bargaining

monopoly power, it can negotiate lower prices.60e62 This has

to be monitored because it can backlash if prices fall below a

feasibility threshold for providers: either by induced demand

or by reducing adoption of innovation.63

The Vermont’s single-payer feasibility study forecasted

that under a single-payer system, expenses may temporarily

rise due to its universal coverage, but they will be offset by

the reduction of administrative costs.64 The conclusion has

also been confirmed by the South Korea paradigm, in which

the country shifted its healthcare system to a single-payer

scheme, thus resulting in a reduction of managerial costs

(from 8.5% in 1997 to 2.4% in 2008), attributed to the stand-

ardisation of operational processes. Taiwan’s shift to a

single-payer system led to savings that have largely offset

the incremental cost of covering the previously uninsured

people, offering at the same time greater financial risk

protection.36

A single-payer system gravitates to less use of copayment

and deductibles which was proved to impede access to health

care for low- and middle-income patients.65 Multipayer sys-

tems imply the duplication of structures; therefore, it is

obvious that this would be feasible only under a minimum

number of beneficiaries and this will also lead to soaring

administrative costs as in the case of the USA administration

costs ($US 400 billion of a total health expenditure of $US 1.6

trillion in 2003).66

Risk pooling
Health insurance dispenses risk among individuals, thus

elaborating a safety net for people in need. Although risks can

be highly unpredictable at the personal level and consequent

health expenditure can be catastrophic for the individual, a

large sample leads to predictable risk which can be distributed

between low- and high-risk enrolees.67

Risk pooling is interrelated with adverse selection, a phe-

nomenon where one member of the transaction is less

informed than the other. In the case of health insurance, an

insurer may not disclose all his medical history, while an in-

surance organisation may increase fees, or ask for more

medical examinations from high-risk individuals.54 This is

spawned by an asymmetrical flow of information between the

two parts. Patients at a higher risk will be more likely to need

health coverage, while insurance will try to identify exact

health status of potential beneficiaries. Therefore, in a single-

payer system, all patients, regardless of their risk and health

status, will be enrolled in the same scheme. On the contrary, a

multiple-payer setting will unavoidably perpetuate to a

diversified portfolio of schemes: expensive and complete

coverage for people at high risk and cheaper but minimal, and

potentially catastrophic, coverage for low-risk individuals.

This is better described by cream skipping or cherry picking, the

policy of screening and identifying high-risk individuals and

excluding them by offering disproportionate high fees, or, on

the contrary, focussing on low-risk individuals by offering

them attractive schemes.59 In any of the aforementioned

cases, patients with chronic diseases and high-risk in-

dividuals will have to pay more, leading to the inverse law

paradigm.68

If adverse selection is left unchecked, it can lead to a pre-

mium death spiral, where high-risk individuals gravitate to

plans with richer benefits, which escalates to the point that

plans are no longer financially sustainable, further com-

pounded by the preference of low-risk patients to opt out and

pursue lower cost alternatives. Multipayer health insurance

tries to waive this uncertainty and all adjoined risks through

risk adjusters. Risk adjusters (risk equalisation) redistribute

resources among fragmented patient pools. It is a resource-

demanding process, both in human and monetary terms. It

can be complicated, while it can be only partially effective. To

grapple meaningfully excess risk, demographic data, medical

history, ex-post utilisation, currentmedical condition, chronic

illness, urbanisation, and diagnostic cost groups are used to

adjust the risk. Demographic data are the easiest to collect,

but their projecting power is low. Therefore, selection of

appropriate adjusters must reflect the ability to gather data

and risk of manipulation of data. An optimum risk adjuster is

still an unmet objective.

Risk equalisation can be performed either ex-ante, thus at

the beginning of the financial year, or ex-post, which is done

at the end of the financial year. The downsize of risk equal-

isation in a multipayer system is that the weaker the risk

adjusters are, the higher the possibility of costly patients (i.e.

suffering from chronic diseases) being averted by private in-

surances and burdening the public insurer, which will have to

be subsidised by the government.2 Conversely, a potent risk

equalisation may support the implementation of effective

chronic disease management programmes as an incentive to

the insurer to reduce the cost of the chronic diseases.67

Social solidarity
Social solidarity embeds the social cohesion and interdepen-

dence among themembers of a geographically, ethnologically

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2 149

or socially defined group. The sense of solidarity can also be

expanded to accommodate the sense of responsibility and

giving to vulnerable groups of the society, such as the elderly,

disabled, socially and financially deprived and persons with

chronic, life-threatening and orphan diseases.

Social solidarity is expressed as a form of exclusion from

contribution either to the fund and/or to the point of care. This

assumes that their costs will be shifted and spread across the

other beneficiaries. Progressive contribution to health funds is

a concept that better fits the concept of solidarity: people who

are wealthier contribute a higher amount of money, which

without financially affecting them can be used to finance

others. This bridges the gap between rich and poor benefi-

ciaries, primarily by alleviating financial burden from the

poorer and subsidisation of the health costs of low-income

individuals. A single-payer system may better serve solidar-

ity because a multipayer system perpetuates to fragmented

patient pools. Usually patients in amultipayer systemwith an

annual income above a specific threshold are allowed to apply

for a PHI, while patients with lower income can only contract

with public insurance.29 The use of premiums on a disease

basis, as applied in multipayer schemes, does not seems to

serve social solidarity. On the contrary, Taiwan’s paradigm

underpins that solidarity in healthcare financing is more

prominent under a single-payer system.36

Conclusion

This systematic review identified that there is not a gold

standard contingent to a UHCS, and the payer type is highly

pertinent to each country’s characteristics, public policies,

social coherence and national structure. Thus, country-

specific cultural, institutional and sociodemographic factors

are imperative and decisive factors for an effective payer-type

selection3 (Table 2).

Current evidence accentuate that a single-payer system is

more equitable to patients than a multipayer system, mainly

Table 2 e Type of payer among European countries.

Country Payer type Efficiency of system

Austria Multi 9th Fre

Belgium Multi 21st Fre

Czech Republic Multi 48th Fre

Denmark Single 34th Par

Finland Single 31st Yes

France Multi 1st Par

Germany Multi 25th No

Greece Single 14th No

Hungary Single 66th Yes

Ireland Single 19th Par

Italy Single 2nd Yes

Malta Single 5th Par

The Netherlands Multi 17th For

Norway Single 11th Yes

Portugal Single 12th Yes

UK Single 18th Yes

Spain Single 7th Par

Sweden Single 23th No

GDP, gross domestic product.

because of access and its progressively financing pattern.

Multipayer systems use premiums collected by the patients,

which constitutes a regressive pattern. This can also comprise

their differentiating point because they may compete for the

direct premium part of the funding.54,69

A single-payer health system can also effectively

distribute risk throughout a large risk pool. The risk distri-

bution must be regulated under a multipayer system on the

basis of relative claims made by policy holders, which pro-

vides that insurances with high payouts will receive addi-

tional funds. This aims to waive any incentives to deter high-

cost individuals.

In a single-payer system, the government is the single

payer, an attribute that while it augments single-payer’s bar-

gaining power, it may also emerge as a drawback under a

hostile or inefficient government. In this case, a multipayer

systemwould be better-off. The ability of a multipayer system

to provide tailor-made healthcare coverage based on the in-

dividual’s characteristics intertwines with the adverse selec-

tion, which is also linked to the individual’s characteristics.

Adverse selection can be avoided, usually with highly so-

phisticated risk-adjustment programmes, a factor that in-

flates costs. This accentuates why multipayer systems seem

to be costlier, mainly imputed to increased administration

costs.

Although there is some evidence that a single-payer system

is more likely to sustain solidarity and equity, this review is

inconclusive in fully supporting it. Moreover, there is an indi-

cation that the single-payer system lacks the motive for effi-

ciency enhancement, in contrast to multipayer systems.

Finally, current paradigms from recent reforms in several

countries corroborate that a single-payer system is a preferred

scheme, albeit the selection must be compatible with each

county’s policies and governance pattern. The ability to collect

revenue, expertise in risk adjustment and diversity of popu-

lation are merely some of the issues that may influence

setting selection.

Gatekeeping Health expenditure (% GDP)

e access 10.8

e access 10.5

e access (referral for hospitals) 7.5

tially 11.1

9

tially 11.6

11.3

9.1

7.9

tially 8.9

9.2

tially

hospitals 11.9

9.3

10.2

9.4

tially 9.3

9.5

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2150

Five-year outlook

The sustainability of health systems worldwide is going

under a stress test, which is expected to intensify as life ex-

pectancy increases, culminating to the proliferation of

healthcare needs. In the context of hovering financial

recession, health systems will be faced with the dubious

tasks of satisfying increasing needs with constrained re-

sources, a ‘do more with less’ approach. The constant

introduction of new medicines, with higher costs and un-

certainty apropos their clinical effectiveness, further aggra-

vates the feasibility of health systems to adequately provide

health care, especially in the current era, which is charac-

terised by easy dissemination of information to the public.

Moreover, an ageing population, will surge expenditure for

social care.

This implies that health agencies will scrutinise the payer

type of their health systems, with the ultimate task to further

enhance their efficiency. This becomes even more complex in

tandem with the current refugee crisis in Europe, the worse

since the end of World War II, which has seen millions of

people, the majority presenting with physiological and phys-

ical conditions, migrating to Europe. Because asylum seekers

and refugees are entitled to free medical care in almost all

European countries, this mounts the pressure for continuous

research and ensuing refinement of health system functions,

primarily the payer type.

Author statements

Ethical approval

This article does not contain any studies with human partici-

pants or animals and therefore does not require ethical

approval.

Funding

No funding was received.

Competing interests

The authors declare that they have no conflicts of interest.

Appendix A. Supplementary data

Supplementary data related to this article can be found at

https://doi.org/10.1016/j.puhe.2018.07.006.

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  • Single-payer or a multipayer health system: a systematic literature review
    • Introduction
      • Objectives
    • Methods
      • Search strategy
      • Screening process
      • Data collection
      • Study selection
      • Data items and critical appraisal
    • Discussion
      • Equity
      • Efficiency and quality of health care
      • Financial protection
        • Fund collection
        • Negotiation, contracting and budgeting
        • Contracting
        • Health expenditure
        • Risk pooling
        • Social solidarity
      • Conclusion
    • Five-year outlook
    • Author statements
    • Ethical approval
    • Funding
    • Competing interests
    • Appendix A. Supplementary data
    • References
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