What do we mean by “single payer”?

Aaron’s post this morning prompted some back-and-forth emails between the two of us over what he and I mean by single payer. He called Medicare “single payer.” I disagreed because there are many plans (FFS Medicare + Medicare Advantage, not to mention Part D and supplements) so providers are paid by multiple payers.

But Aaron had a point that, supplements aside, all of Medicare is predominantly taxpayer financed, which is also a characteristic of single payer. (Actually, even including supplements, I believe claims are predominantly taxpayer financed, but I don’t have the figures to prove it.) In contrast, according to the CBO and as Aaron posted, Rep. Paul Ryan’s vision for Medicare would lead to a program that was not predominantly taxpayer financed. In time, beneficiaries would pay the lion’s share of premiums.

So, what are all the things we mean by “single payer” and to what extent is today’s Medicare “single payer”? To what extent is Rep. Ryan’s vision? My list:

  • Single payer as (largely) tax-financed benefits. Today’s Medicare: yes. Rep. Ryan’s vision: no.
  • Single payer as one source of payment for providers. Today’s Medicare: no. Rep. Ryan’s vision: even more “no” if FFS Medicare loses popularity, which is what I would expect.
  • Single payer as one set of benefits and prices, nationally, for beneficiaries. Today’s Medicare: no, but yes for FFS. Ryan’s vision: no, and less so if FFS enrollment dwindles.

What else?


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