Pursuit of Truthiness

my gut tells me I know economics

Archive for October 2019

Which Countries Have Single-Payer?

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This seems like the kind of question that should have a straightforward, generally agreed-upon answer. But right now, it doesn’t.

I can only find a single attempt to answer it, from a random blogger whose original post describing the methods seems to have disappeared. This should really be a job for a big respected organization like The WHO or OECD, but barring that, I can be the next random blogger to update the answer.

There are two challenges to getting a good answer to “which countries have single-payer?”: choosing a good operational definition of “single-payer”, and then researching every country’s health-care system to see if it qualifies.

First, the definition. Literal single-payer would mean there is a single entity, presumably a national government, that pays 100% of health care expenses; but this would imply no countries currently have single-payer, since every country has some out-of-pocket spending:

OECD Chart: Health spending, Out-of-pocket, % of health spending, Annual, 2016

At the other extreme, a broad definition would count any country with universal government-sponsored insurance, even if it covers so little that most spending still comes from individuals or supplemental private insurance. Other important questions are whether any private insurance can exist, and whether all spending has to go through the national government or if many states/provinces operating their own insurance systems still counts as “single”.

Some day I will state 5+ alternate definitions of single-payer and do the deep institutional research to say whether each of the 188+ countries qualifies based on each of the 5+ definitions, the sort of deep dive that was done for 12 countries here. But today, you aren’t getting the thorough answer, you’re getting the quick answer, because today I decided its ridiculous that no one has provided any real answer.

So my working definition of single-payer, which doesn’t make the most sense but has the great virtue that it can be calculated quickly from existing data, is:

Single-payer: A country has a “single-payer” health system if at least 75% of health spending is done through government.

Why 75%? I originally thought 90% made sense, then looked at the WHO health expenditure data and saw that this would only count 6 countries. In the archetypical single-payer system, the United Kingdom, only 79% of expenditure is from government, and so 75% is the lowest round-is number that will count the UK. Even this doesn’t count Canada (69%), but I can’t bring myself to put the bar below 70. If you want to make your own map with a different cutoff, the Excel file with 2016 government spending as a % of all health spending is here.

Single-Payer Health Care Map


Source: Calculated from 2016 WHO Global Health Expenditure Database

Update: The WHO numbers for government spending do not include compulsory social insurance programs that many people would consider part of government spending (see table 7.2 here for an explanation of these and other spending categories; basically “social insurance” is tied to individual contributions to a fund, like in Medicare, though in the case of German sickness funds this is really stretching the ‘single’ in single-payer). If I add “social insurance” and “government schemes” together, several more countries hit 75%+ of spending:

Alternate Single-Payer Map (Includes Social Insurance)


Source: Calculated from 2016 WHO Global Health Expenditure Database

It’s worth repeating one more time, these are preliminary numbers made using a definition that prioritizes ease of calculation over accuracy, and I encourage others to make their own maps, especially if you have the time or resources to study the institutional details of every country.

Written by James Bailey

October 16, 2019 at 10:14 am