Single-payer health care
Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs. Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the UK). The term "single-payer" thus only describes the funding mechanism—referring to health care financed by a single public body from a single fund—and does not specify the type of delivery, or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.
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Single-payer health insurance collects all medical fees, then pays for all services, through a "single" government (or government-related) source. In wealthy nations, this kind of publicly managed insurance is typically extended to all citizens and legal residents. Examples include the United Kingdom's National Health Service, Australia's Medicare, Canada's Medicare, and Taiwan's National Health Insurance.
The standard usage of the term "single-payer health care" refers to health insurance, as opposed to healthcare delivery, operating as a public service and offered to citizens and legal residents towards providing near-universal or universal health care. The fund can be managed by the government directly or as a publicly owned and regulated agency. Some writers describe publicly administered health care systems as "single-payer plans". Some writers have described any system of health care which intends to cover the entire population, such as voucher plans, as "single-payer plans", although this is uncommon usage.
Worldwide health care systems 
Many nations worldwide have single-payer health insurance programs. These programs generally provide some form of universal health care, which are implemented in a variety of ways. In some cases doctors may be employed, and hospitals run by, the government such as in the United Kingdom. Alternatively the government may purchase healthcare services from outside organizations. This is the approach taken in Canada.
Health care in Australia is provided by both private and government institutions. The Minister for Health and Ageing, currently Tanya Plibersek, administers national health policy, elements of which (such as the operation of hospitals) are overseen by individual states. The current system, known as Medicare, was instituted in 1984 and coexists with a private health system. Medicare is funded partly by a 1.5% income tax levy (with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme that considerably subsidises a range of prescription medications.
Health care in Canada is delivered through a publicly funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act of 1984. The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and his or her physician. Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses health care to be involved in billing and reclaim. Private insurance is only a minimal part of the overall health care system.
Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, except in British Columbia, the only province to impose a fixed monthly premium which is waived or reduced for those on low incomes. There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care. There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for pre-existing conditions.
Pharmaceutical medications are covered by public funds for the elderly or indigent, or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Canadians do wait for some treatments and diagnostic services. Survey data shows that the median wait time to see a special physician is a little over four weeks with 89.5% waiting less than three months. The median wait time for diagnostic services such as MRI and CAT scans is two weeks, with 86.4% waiting less than three months. The median wait time for surgery is four weeks, with 82.2% waiting less than three months. In addition, there is concern of a "brain drain" as high-quality medical graduates leave Canada for better-paying careers in the U.S.
Healthcare in Taiwan is administrated by the Department of Health of the Executive Yuan. As with other developed economies, Taiwanese people are well-nourished but face such health problems as chronic obesity and heart disease. In 2002 Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population. In 2002, there were a total of 36 hospitals and 2,601 clinics in the country. Per capita health expenditures totaled US$752 in 2000. Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 (or US$951 in 2009); 64.9 percent of the expenditures were from public funds. Overall life expectancy in 2009 was 78 years.
The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health-care funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004. NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many health care providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.
United Kingdom 
Healthcare in the United Kingdom is a devolved matter, meaning England, Northern Ireland, Scotland and Wales each have their own systems of private and publicly funded healthcare, generally referred to as the National Health Service or NHS. Each country having different policies and priorities has resulted in a variety of differences existing between the systems. That said, each country provides public healthcare to all UK permanent residents that is free at the point of need, being paid for from general taxation. In addition, each also has a private healthcare sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.
The individual systems are:
- England: National Health Service
- Ireland: Health and Social Care in Northern Ireland (HSENI)
- Scotland: NHS Scotland
- Wales: NHS Wales
United States 
A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (H.R. 676, also known as "Medicare for All") but none have achieved more political support than 20% congressional co-sponsorship. The national system would be paid for in part through taxes replacing insurance premiums, but also by savings realized through the provision of preventative universal healthcare and the elimination of insurance company overhead and hospital billing costs. An analysis of the bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year. Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventative health care. Preventative care can save several hundreds of billions of dollars per year in the U.S., because for example cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal. Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, may serve as living models supporting federal single-payer coverage.
National policies and proposals 
Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease. Government is increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on individuals' medical care in 2004. However, studies have shown that the publicly administered share of health spending in the U.S. may be closer closer to 60% as of 2002. According to Princeton University health economist Uwe E. Reinhardt, U.S. Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) represent "forms of 'social insurance' coupled with a largely private health-care delivery system" rather than forms of "socialized medicine." In contrast, he describes the Veterans Administration healthcare system as a pure form of socialized medicine because it is "owned, operated and financed by government." In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the RAND Corporation reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients currently using United States Medicare.
The United States National Health Care Act (or the "Expanded and Improved Medicare for All Act," H.R. 676), is a bill introduced in the United States House of Representatives by Representative John Conyers (D-MI). The bill had 88 cosponsors in 2009. The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. Under a single payer system, all medical care would be paid for by the Government of the United States, ending the need for private health insurance and premiums, and probably recasting private insurance companies as providing purely supplemental coverage, to be used when non-essential care is sought.
The bill was first introduced in 2003, when it had 25 cosponsors, and has been reintroduced in each Congress since. During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act. H.R. 676 was expected to be debated and voted upon by the House in September 2009, but was never debated. Advocates who remained staunchly for single-payer health care as the ultimate vote and passage of the America's Affordable Health Choices Act of 2009 loomed, tried to present HR 676 as a viable alternative to the Affordable Health Care for America Act, H.R. 3962, but were ignored, and even in some cases arrested by police during various nationwide debate events, and the bill itself never received significant public support.
The Congressional Budget Office and related government agencies scored the cost of a single payer health care system several times since 1991. The General Accounting Office published a report in 1991 noting that "[I]f the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs [10 percent of health spending] would be more than enough to offset the expense of universal coverage.” The CBO scored the cost in 1991, noting that "the population that is currently uninsured could be covered without dramatically increasing national spending on health" and that "all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured. A CBO report in 1993 stated that "[t]he net cost of achieving universal insurance coverage under this single payer system would be negative" in part because "consumer payments for health would fall by $1,118 per capita, but taxes would have to increase by $1,261 per capita" in order to pay for the plan. A July 1993 scoring also resulted in positive outcomes, with the CBO stating that, "[a]s the program was phased in, the administrative savings from switching to a single-payer system would offset much of the increased demand for health care services. Later, the cap on the growth of the national health budget would hold the rate of growth of spending below the baseline." The CBO also scored Sen. Paul Wellstone's American Health and Security Act of 1993 in December 1993, finding that "by year five (and in subsequent years) the new system would cost less than baseline.
State proposals 
Several single-payer state referendums and bills from state legislatures have been proposed, but with the exception of Vermont, all have failed.
California attempted passage of a single-payer bill as early as 1994, and the first successful passages of legislation through the California State Legislature, SB 840 or "The California Universal Healthcare Act" (authored by Sheila Kuehl), occurred in 2006 and again in 2008. Both times, Governor Arnold Schwarzenegger vetoed the bill. State Senator Mark Leno has reintroduced the bill in each legislative session since.
In 2007, the Health Care for All Illinois Act was introduced and the Illinois House of Representatives' Health Availability Access Committee passed the single-payer bill favorably out of committee by an 8–4 vote. The legislation was eventually referred back to the House rules committee and not taken up again during that session.
Massachusetts had passed a universal health care program in 1986, but budget constraints and partisan control of the legislature resulted in its repeal before the legislation could be enacted. Question 4, a nonbinding referendum, was on the ballot in 14 state districts in November 2010, asking voters, "[S]hall the representative from this district be instructed to support legislation that would establish health care as a human right regardless of age, state of health or employment status, by creating a single payer health insurance system like Medicare that is comprehensive, cost effective, and publicly provided to all residents of Massachusetts?" The ballot question passed in all 14 districts that offered the question.
The Minnesota Health Act, which would establish a state-wide single payer health plan, has been presented to the Minnesota legislature regularly since 2009. The bill was passed out of both the Senate Health Housing and Family Security Committee and the Senate Commerce and Consumer Protection Committee in 2009, but the House version was ultimately tabled. In 2010, the bill passed the Senate Judiciary Committee on a voice vote as well as the House Health Care & Human Services Policy and Oversight Committee. In 2011, the bill was introduced as a two-year bill in both the Senate and House, but did not progress. It has been introduced again in the 2013 session in both chambers.
In September 2011, Governor Brian Schweitzer announced his intention to seek a waiver from the federal government allowing Montana to set up a single payer health care system. Governor Schweitzer was unable to implement single-payer health care in Montana, but did make moves to open government-run clinics and, in his final budget as governor, increase coverage for lower-income Montana residents.
The state of Oregon attempted to pass single payer health care via Oregon Ballot Measure 23 in 2002, and the measure was rejected by a significant majority. Previous bills, including the Affordable Health Care for All Oregon Act, have been introduced in the legislature but have never left committee. The Affordable Health Care Act may be reintroduced in the 2013 session.
Vermont passed legislation in 2011 creating Green Mountain Care. When Governor Peter Shumlin signed the bill into law, Vermont became the first state to functionally have a single payer health care system. While the bill is considered a single-payer bill, private insurers can continue to operate in the state indefinitely, meaning it does not fit the strict definition of single-payer. Representative Mark Larson, the initial sponsor of the bill, has described Green Mountain Care's provisions "as close as we can get [to single-payer] at the state level."
Public opinion 
Advocates for single payer point to support in polls, although the polling is mixed depending on how the question is asked. Polls from Harvard University in 1988, the Los Angeles Times in 1990, and the Wall Street Journal in 1991 all showed strong support for a health care system compared to the system in Canada. More recently, however, polling support has declined. A 2007 Yahoo/AP poll showed a majority of respondents considered themselves supporters of "single-payer health care," and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all." Polls by Rasmussen Reports in 2011 and 2012 showed pluralities opposed to single payer health care.
A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan." Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare."
Advocacy groups 
Physicians for a National Health Program the American Medical Student Association and the California Nurses Association are among advocacy groups that have called for the introduction of a single payer health care program in the United States. A study published in the Annals of Internal Medicine found that 59% of physicians "supported legislation to establish national health insurance" while 9% were neutral on the topic, and 32% opposed it.
See also 
- Health care reform debate in the United States
- International comparisons of health care systems – tabular comparisons of the US, Canada, and other countries not shown above.
- The Kucinich Amendment, an amendment to the America's Affordable Health Choices Act of 2009 which would have empowered the Secretary of Health and Human Services to waive the federal law that pre-empts state law on employee-related health care.
- National health insurance
- Publicly funded health care
- Public health insurance option ("the public option")
- single-payer, Merriam Webster Dictionary
- Medical Subject Headings thesaurus, National Library of Medicine."Single-Payer System" Year introduced: 1996, (From Slee and Slee, Health Care Reform Terms, 1993, p106)
- Frank, Robert H. (2007-02-15). A Health Care Plan So Simple, Even Stephen Colbert Couldn’t Simplify It, By ROBERT H. FRANK. New York Times, February 15, 2007. Retrieved from http://www.nytimes.com/2007/02/15/business/15scene.html.
- Aguirre (August 6, 2012). "In British Emergency Room, 'There's No Card To Show; There Are No Bills'". NPR. Retrieved August 9, 2012. Text " Jessica Camille" ignored (help)
- Public vs. private health care CBC, December 1, 2006.
- "Overview of the Canada Health Act".
- "Provincial/Territorial Role in Health".
- CIHI p.91
- Diagnostic tests defined as the following: non-emergency magnetic resonance imaging (MRI) devices; computed tomography (CT or CAT) scans; and angiographies that use X-rays to examine the inner opening of blood-filled structures such as veins and arteries.
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- "Taiwan country profile". Library of Congress Federal Research Division. March 2005. Retrieved 2008-05-04. This article incorporates text from this source, which is in the public domain.
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- 'Huge contrasts' in devolved NHS BBC News, 28 August 2008
- NHS now four different systems BBC 2 January 2008
- BUPA exclusions bupa.co.uk, accessed 23 February 2009
- Krugman, Paul (June 13, 2005). "One Nation, Uninsured". The New York Times. Retrieved December 4, 2011.
- Physicians for a National Health Program (2008) "Single Payer System Cost?" PNHP.org
- Hogg, W.; Baskerville, N; Lemelin, J (2005). "Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis". BMC Health Services Research 5 (1): 20. doi:10.1186/1472-6963-5-20. PMC 1079830. PMID 15755330.
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- "State-Based Single-Payer Health Care — A Solution for the United States?" New England Journal of Medicine 364;13:1188-90, March 31, 2011
- HealthCare.gov: What is Medicare?.
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- "Letters: For Children's Sake, This 'Schip' Needs to Be Relaunched", Wall Street Journal, July 11, 2007, Uwe E. Reinhardt and others.
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- "House Reps Introduce Medicare-for-All Bill" Becker's Hospital Review, Feb. 14, 2013
- H.R. 676
- "Single Payer Gets A Vote (Updated)". Daily News (New York). July 31, 2009.
- "H.R. 676: United States National Health Care Act or the Expanded and Improved Medicare for All Act (Govtrack.us)". Retrieved December 1, 2009.
- “Canadian Health Insurance: Lessons for the United States,” General Accounting Office, June 1991.
- Universal Health Insurance Coverage Using Medicare’s Payment Rates, Congressional Budget Office, December 1991.
- “Single-Payer and All-Payer Health Insurance Systems Using Medicare’s Payment Rates” Congressional Budget Office, April 1993.
- “Estimates of Health Care Proposals from the 102nd Congress” Congressional Budget Office, July 1993.
- S.491, American Health Security Act of 1993, Congressional Budget Office, December 1993.
- "The California Single-Payer Debate, The Defeat of Proposition 186 – Kaiser Family Foundation". Kff.org. Retrieved November 20, 2011.
- "Healthcare for All Bill Passes — Governor Threatens Veto".
- Marin Independent Journal: "Leno reintroduces single-payer health plan." March 15, 2009.
- Latest News on SB 801 | Senator Mark Leno.
- "Illinois General Assembly Bill Status: HB 311".
- New York Times: State Referendums Seeking to Overhaul Health Care System. June 11, 2000.
- "Boston Globe: Ballot Questions (2010)". Boston Globe. Retrieved November 20, 2011.
- WBUR: Non-Binding Measure On Single-Payer System Passes In All 14 Districts. November 4, 2010.
- Committee on Health, Housing and Family Security Minutes, January 16, 2009.]
- Video of Senate committee session in which the bill was passed out of committee.
- Minutes of the House Health Care and Human Services Policy & Oversight Committee, February 25, 2009.
- Video of Senate committee session in which the bill was passed on a voice vote.
- Audio of House Health Care & Human Services Policy and Oversight Committee proceedings.
- Senate - Bill Number 0008.
- House - Bill number 0051.
- Senate - File number 18.
- House - File number 76.
- Missoulan: Schweitzer wants statewide universal health care program. September 28, 2011.
- Reuters: Brian Schweitzer, Montana Governor, Sees Big Savings With New State Health Clinic. September 30, 2012.
- Missoulan: Schweitzer's final budget proposal boosts education, health care. November 15, 2012.
- November 25, 2002, General Election Abstract of Votes
- Statesman Journal: Demonstrators urge universal single-payer health care system. February 5, 2013.
- Central Penn Business Journal: State senator introduces Pa. health care plan. October 13, 2011.
- Co-sponsorship Memo Family and Business Health Care Security Act. Office of Representative Tony Payton, June 20, 2012.
- Lancaster Online: Universal interest in health care. January 13, 2008.
- "Vt. Senate approves single-payer plan – WCAX.COM Local Vermont News, Weather and Sports". Wcax.com. April 26, 2011. Retrieved November 20, 2011.
- Politico: Vermont could be first in line for single payer. September 17, 2012.
- American Medical News: Vermont approves universal health program. May 16, 2011.
- "Michael Moore claims a majority favor a single-payer health care system". PolitiFact. Retrieved November 20, 2011.
- Harvard/Harris poll: Robert J. Blendon et al., “Views on health care: Public opinion in three nations,” Health Affairs, Spring 1989;8(1)149-157.
- Los Angeles Times poll: “Health Care in the United States,” Poll no. 212, Storrs, Conn.: Administered by the Roper Center for Public Opinion Research, March 1990
- Wall Street Journal-NBC poll: Michael McQueen, “Voters, sick of the current health –care systems, want federal government to prescribe remedy,” Wall Street Journal, June 28, 1991
- Health Affairs, Volume 20, No. 2. "Americans' Views on Health Policy: A Fifty-Year Historical Perspective." March/April 2001. http://content.healthaffairs.org/content/20/2/33.full.pdf+html
- AP/Yahoo poll: Administered by Knowledge Networks, December 2007: http://surveys.ap.org/data/KnowledgeNetworks/AP-Yahoo_2007-08_panel02.pdf
- TIME MAGAZINE/ABT SRBI – July 27–28, 2009 Survey: http://www.srbi.com/TimePoll4794_Final_%20Report.pdf
- Rasmussen Reports: Rasmussen Reports. January 1, 2010. Retrieved November 20, 2011.
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- "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance". Physicians for a National Health Program.
- Chua, Kao-Ping (2006), Single Payer 101, Reston, Virginia: American Medical Student Association, retrieved 11 April 2012
- Single-payer, or Medicare for all, is the way to go[dead link] from the California Nurses Association / National Nurses Organizing Committee.
- Carroll AE, Ackerman RT (April 2008). "Support for National Health Insurance among U.S. Physicians: 5 years later". Ann. Intern. Med. 148 (7): 566–7. PMID 18378959.
- Citizen action or resource groups
- Single-Payer Healthcare Resources. A collection of links to primers, national/state resources, comparisons to other nations, bills/terminology, etc.
- Healthcare-NOW!. A nonprofit advocacy group for single-payer healthcare.
- Progressive Democrats of America Advocates for single-payer system.
- Physicians for a National Health Program. Advocates for single-payer system. Extensive source material from peer-reviewed journals.
- Single Payer Action. Activist nonprofit organization supporting single-payer universal healthcare.
- Single Payer Central. An independent/unaffiliated central clearing house of information (groups, legislation, etc.), for single-payer.
- Articles, books, and broadcast programs
- Five myths about health care around the world "For people over 65, we're Canada ... for the tens of millions without insurance coverage, we're Burundi or Burma" by T.R. Reid, a former Washington Post reporter.
- Institute of Medicine Committee on the Consequences of Uninsurance. Hidden costs, value lost: uninsurance in America. Washington, D.C.: National Academies Press, 2003. Frequently cited monograph.
- Sick Around the World: Can the U.S. learn anything from the rest of the world about how to run a health care system? from Frontline, PBS.
- Single Payer Healthcare Now. An activist blog supporting single payer healthcare
- States Moving Towards Comprehensive Health Care Reform in the U.S., The Henry J. Kaiser Family Foundation.
- The Case For Single Payer, Universal Health Care For The United States
- The Socialists Are Coming! The Socialists Are Coming! by Phillip Boffey. Editorial on U.S. "socialized medicine" in the military, the Veterans Health Administration, and Medicare, The New York Times, September 28, 2007.
- Whither a health-care solution? Oh Canada BusinessWeek, March 21, 1994, by William C. Symonds, article in a business journal writing favorably about single payer.
- FAQ and summaries by NGOs favoring single payer
- Get the Facts on Health Care Reform Single-payer solution myths and facts from Public Citizen.
- Report Card on Single-Payer and Public Option from PDA and Healthcare-now comparing, contrasting, and grading the two proposals.
- Single-Payer Myths; Single-Payer Facts summary from PNHP.
- What is Single-Payer Healthcare? from Healthcare-Now.org (expanded from PNHP with additional information)
- News feeds
- Latest news and analysis about current and upcoming State based single-payer legislation in United States