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Health Reform for Beginners: The Difference Between Socialized Medicine, Single-Payer Health Care, and What We'll Be Getting


I've been meaning to write this post for some time. The words "socialized medicine" and"single-payer health care" get thrown around with such gleeful abandon that they've both become a bit unmoored from their actual meanings. In the American health-care debate, they tend to refer to "whatever the Democrats are proposing." But that's not what they mean.

Socialized medicine is a system in which the government owns the means of providing medicine. Britain is an example of socialized system, as, in America, is the Veterans Health Administration. In a socialized system, the government employs the doctors and nurses, builds and owns the hospitals, and bargains for and purchases the technology. I have literally never heard a proposal for converting America to a socialized system of medicine. And I know a lot of liberals.

Single-payer health care is not socialized medicine. It's a system in which one institution purchases all, or in reality, most, of the care. But the payer does not own the doctors or the hospitals or the nurses or the MRI scanners. Medicare is an example of a mostly single-payer system, as is France. Both of these systems have private insurers to choose from, but the government is the dominant purchaser. (As an aside here, unlike in socialized medicine, "single-payer health care" has nothing in particular to do with the government. The state might be the single payer. But if Aetna managed to wrest 100 percent of the health insurance market, then it would be the single payer. The term refers to market share, not federal control.)

Socialized medicine is far outside any discussion we're having. Single-payer medicine has a genuine constituency but is also a vanishingly unlikely outcome. But the promiscuous use of the terms has created a rather confused population. "Socialized medicine" is the thing we don't have. In some case, it's the thing we don't like. The graph atop this post comes from a poll conducted by the Harvard School of Public Health. They found that Americans actually preferred socialized medicine to our system. Or take this question, about our current system:


You're reading that right. About 30 percent of Americans think HMOs are socialized medicine. Which implies a couple things. First, the term "socialized medicine" has been diluted beyond all meaning. Second, it's no longer considered a terrifying outcome. And third, nothing that's this amorphous -- and actually preferred by a plurality of the population -- is likely to prove a terribly effective attack against health reform. Socialized medicine has become such a stand-in for "not this system of medicine" that it's begun to look good in comparison.

Meanwhile, what we're actually going to get is not socialized medicine or single-payer health care. It's a hybrid system. Private insurers, hopefully competing with a public option. Private doctors and private hospitals. Government regulation and subsidies. It's going to be complicated and messy and inefficient and hopeful and the product of a strange mix of corporate preferences and public compassion and latent populism. It will, in other words, be a uniquely American system, and hard to describe with a single epithet.

By Ezra Klein  |  June 9, 2009; 11:09 AM ET
Categories:  Health Reform For Beginners  
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"It will, in other words, be a uniquely American system, and hard to describe with a single epithet."

I don't know. "Brought to you by GlaxoSmithKline" seems to work fairly well.

Posted by: DemosthenesofPaeania | June 9, 2009 11:50 AM | Report abuse

EK: "Single-payer health care is not socialized medicine. It's a system in which one institution purchases all, or in reality, most, of the care."

The practical difference from the patient's point of view is minor. If there were to be one government entity setting prices and the terms of care coverage, it would essentially have all decision-making authority over the patient's care, and would in effect own the system.

Posted by: tomtildrum | June 9, 2009 11:50 AM | Report abuse

Why didn't you quote the Post's own poll?

Here is a question from a Washington Post - ABC poll:

"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"

62% favored Medicare for All; 33% were opposed. That's pretty decisive. And this is with the facts suppressed. Other questions in the poll show that the 62% supporting the universal program mostly believe it will cost more when it will cost less. They believe they won't be able to pick their doctor when Medicare allows much more freedom than most private plans. They believe there will be long waiting times when this is a myth. And still they support a universal plan like Medicare for All by 2 to 1.

Len Charlap
Princeton, NJ

Posted by: lensch | June 9, 2009 11:57 AM | Report abuse

Great article! If you would like to help pressure Congress to pass single payer health care please join our voting bloc at:

Posted by: letsgobuffalo | June 9, 2009 12:11 PM | Report abuse

I could be incorrect, but isn't France a Co-Payer system since most people have complimentary insurance provided by the private market? Or is the fact that France guarantees a base level of insurance to everyone what makes it single payer?

Posted by: EricthePoliticalHack | June 9, 2009 12:17 PM | Report abuse

like so many americans, i have real fear over maintaining good health and hoping to be able to afford my health care plan.
it is really frightening.
and yet, even if obama has the best of intentions, considering the state of our economy, considering what would be involved in dismantling the insurance and pharmaceutical companies...and the wall of opponents against "socialized medicine," i just dont think it is realistic to expect that we are going to have a radical change, all at once.
i just cant imagine that will happen.
a few months ago, i remember hearing president obama say that the united states is an ocean liner, not a speedboat.
i wish progress would be faster....for perfected health care, for improvement and stabilization in the economy,for alternative energy, for troop withdrawals, for the people of gaza......but turning this country around, when there are large percentages of people who believe any improvement in health care is socialized medicine...when there are people that turn a blind eye to what happened to dr tiller, when there are people who still dont believe in global warming, when newt gingrich still gets thundering applause for saying that we are being a pagan nation and that obama's hope for change in israeli policy is a fantasy, and members of congresss are still entwined with all manner of ironcclad special interest groups, i just feel that the forces against progress are still so contemptuous and powerful, it is going to be a long, slow, uphill battle, under the very best of circumstances.
i hope that i am wrong.

Posted by: jkaren | June 9, 2009 12:19 PM | Report abuse

Media Matters found that as far back as the 1930s -- with respect to at least 16 different proposals -- conservatives have volleyed attacks on progressive efforts at health-care reform with the clich├ęd -- and false -- label of "socialized medicine."

Posted by: inquirium | June 9, 2009 12:23 PM | Report abuse

Is it correct to call France a single-payer system?

I've heard many single-payer advocates in the U.S. call it that, but PNHP and other sources describe it as a multipayer or "multipayer, non-profit" system. Private insurance is actually delivered through several independent sickness funds that rely on a combination of premiums, employer contributions and government funds. The French government does have a major role in negotiating prices for services and regulating the funds, but the sickness funds are technically independent.

Correct me if my recollection is wrong.

Posted by: Isa8686 | June 9, 2009 12:25 PM | Report abuse

EricthePoliticalHack raises a good point -- a lot of countries have guaranteed gov't coverage supplemented by private insurance policies / providers. My favorite example is Hong Kong -- one of the world's most pro-capitalist markets but also near-free government-administered health insurance (plus some private facilities / specialists) available to anyone with a work visa. It's hard to find a single label that covers the whole thing.

I'd also like to suggest a possible topic of future inquiry: I read recently that Sweden has no-fault malpractice insurance. State regulators put a price on everything (which America already does to some extent with disability payments), and then claims for medical complications are paid from a fund to which all physicians contribute. Saves us from Wyeth v Levine, damage awards decided by medically unqualified juries of our peers, and misaligned incentives for, say, Caesarians v natural births. Where else have they reformed malpractice insurance and what does it look like there?

Posted by: _rusty_ | June 9, 2009 12:31 PM | Report abuse

The differences in terminology in the story are minimal, I agree with the bloggers. But nice try.

The sad thing is just how ignorant Obama is. How can you even talk about keeping costs down when you support a for-profit system? Hey stupid man, that's where the "profit" goes, into salaries and payoffs. YOU HAVE NO RIGHT TO DICTATE TO A PRIVATE FOR-PROFIT COMPANY, HEALTH INSURER OR OTHERWISE, TO GIVE UP ITS PROFITS. It's AGAINST THE LAW. IT MAY BE A LESS THAN DESIRABLE LAW, BUT IT IS THE LAW. Boy, are you dumb. This is why you are getting into trouble with the GM and Chrysler bailouts. Or you are just LYING to us again thinking we are buying your crap. You either accept big for-profit business or you don't. You can't control it and they will NEVER "reform" willingly.

Obama, you really need to fail on this. You will be denied a victory because you are a fake, supporting fake reforms. Fake, Fake, Fake.

And, sure, some people may want to keep their private health insurance, especially if their employer is paying. They want to drive SUV's also, and use too much plastic. But how much better would it be to create another JOB. THATS ANOTHER THING THIS DUMASS POTUS DOESN'T CARE ABOUT, OR UNDERSTAND. JOBS.

And if you, Obama, think you are going to dump more requirements on struggling businesses or private individuals, then you really deserve the HEAP OF SHAME that is coming your way. You are TRULY a failure, in every way.

By the way, how's that stimulus coming? And the mortgage help? You stink.

Posted by: tropicgirl | June 9, 2009 4:41 PM | Report abuse

Ezra, YOU need a beginner's lesson in health care overseas. Under an NHS general medical services contract, the general practitioner is an independent contractor, not an employee, and the NHS "reimburses general practitioners (GPs) for providing primary health care services." It doesn't own the GPs or their practices as the "means of production." Patients "can choose from any hospital that meets NHS standards," and the "list includes many private hospitals as well as all NHS providers. Between them they offer everything from treatment for cataracts to open-heart surgery." In addition, the "European Court of Justice has decided that the NHS should reimburse patients for medical treatment overseas if they have faced an 'undue delay' for surgery at home." The NHC certainly does not own French or German hospitals or surgeons.

Posted by: hubert3 | June 9, 2009 6:37 PM | Report abuse

Wow, seems like a well-balanced, informative column on health care system options. How refreshing. And, again, well-done. The public option and the Obama Plan are not entities to be feared, except for those who 1) have an industry position that could be threatened, or 2) have a political base that is anti-Obama to the end. We have so much to learn in the health care areas from other countries. Hopefully, the ideas will continue to flow. Hopefully, we will see health care reform in the U.S. in 2009.

Posted by: crossingsg | June 16, 2009 9:04 PM | Report abuse

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