One of the most publicized rifts between the Democratic Party’s pragmatist wing and its populist wing is the disagreement over which type of health care system the US should pursue. Some on the populist left have brazenly declared that anything short of the most comprehensive single-payer system in history would amount to a worthless half-measure. Some take it even further. To advocate for anything less, they say, is morally comparable to murder. You’ll often hear, “If every other country on earth can do it, why can’t we?”

This is a common claim made by health care reform advocates on the modern American left (particularly supporters of Senator Bernie Sanders)—that “every other major country” has adopted a form of “Medicare for All.” While it is true that most of the developed world outside of the US has invested in some form of universal health care, it’s plainly false that Sanders’s maximalist version of single-payer is the norm. Many of the countries that single-payer advocates frequently point to have, in fact, built and maintained highly functional multi-payer systems.

Universal Private Coverage

It may surprise some M4A purists that several countries have achieved universal coverage through a system that relies entirely on private insurance. Take, as examples, the health care systems of Switzerland and the Netherlands. In both countries, people are required to purchase insurance from private providers. While coverage for lower-income residents is heavily subsidized, many Swiss and Dutch are still required to pay premiums and copays as a form of cost sharing. These systems resemble souped-up versions of the Affordable Care Act.

Good regulation is a key factor in these systems’ success. The Swiss insurance companies that cover basic medical care (not including things like vision and dental) are required to operate like non-profit organizations, while supplementary for-profit insurance can be purchased to cover other needs. The cost of medical procedures and prescription drugs is considerably lower compared to what US providers are allowed to charge (more on that later). Also, unlike the US, Swiss insurance is not tied to employment, giving consumers of health care a greater breadth of options.

Switzerland not only outperforms the US, but also many of its European neighbors when it comes to health outcomes, with among the highest life expectancies in the world.

Hybrid Systems

Many more countries insure their citizens through a combination of public and private options.

Germans and Australians can choose to get their health insurance either through a public option or a more specialized private option. In Germany, all citizens making below a certain income are automatically covered by public insurance (known as “sickness funds”) while wealthier Germans and self-employed Germans can choose to buy into private plans. In both countries, the public options are more popular, though either option comes with some trade-offs.

This type of system is similar to what many center-left think tanks and Democratic politicians in the US have proposed: a Medicare-like option that all Americans could choose to opt-into. This would mean that low- and middle-income earners could pay little to nothing for their health care, and that private insurers would be incentivized to lower their prices in order to compete.

Other countries, such as Japan and France have implemented a system that is essentially single-payer up to a point, with the government covering roughly 70-80% of a person’s medical costs, and the remainder paid either out-of-pocket or by private coverage. France has frequently been rated the highest in the World Health Organization’s health care rankings.

Singapore has an especially unique system, which combines government and market forces unlike any other. At first glance, the city-state’s streamlined system resembles single-payer. Most hospitals are public, and the state does provide some of the funding. At the same time, Singaporeans are required from early in their career to pay into private health savings accounts. This may seem like a non-starter for Americans, who already pay through the eyes for health care, but an important consideration here is that, like most other countries, medical prices are much lower in Singapore than what Americans have grown accustomed to. Singaporeans pay far less per capita compared to the US. Their system also includes different tiers of coverage with an extremely cheap catastrophic coverage plan (called “Medishield”) which, while voluntary, covers about 90% of the population. It’s a complex but seemingly efficient system that even some right-leaning health care wonks can appreciate.

There are numerous advantages to these hybrid systems. One is that they don’t require the same level of taxation to fund them compared to single-payer systems. Another is that maintaining a profit-motive probably does lead to greater medical innovation and thus better health outcomes over time. Senator Cory Booker was right when he pointed out that almost every country still has some form of private insurance in place, and that this is not inconsistent with the goal of affordable health care for all.

The Truth About American Health Care

Acknowledging this reality can be difficult for single-payer absolutists, who have been led to believe that insurance companies are public enemy number one when it comes to health care. But an abundance of evidence points away from insurance companies as the source of America’s high health care costs. In reality, health care providers (i.e., physicians and hospitals) are generally the ones bleeding us dry and getting away with it.

This is important. Part of the reason private insurance systems are so much more equitable in other countries is that there are regulatory structures in place that keep prices reasonably low. Appealing to technocratic regulatory reform doesn’t exactly stoke passion in voters the way that pie-in-the-sky promises do (Pete Buttigieg learned this the hard way). But when it comes to something as vital as health care, results should matter more than rhetoric.

Misguided Messaging

Single-payer advocates love to promote the following talking point:

“Nobody really likes their health insurance, they just like their doctors.”

It makes intuitive sense. People are more likely to form a bond with another human being attempting to heal them than they are to form any kind of meaningful connection with some faceless company.

But this message is still misguided, given that the lobbying power of doctors and hospitals is one of the primary reasons why Americans pay so much for health care. That doesn’t mean that your family doctor is a villain, or that big insurance companies are really saints who care deeply about the wellbeing of ordinary people (it’s worth remembering that prior to the ACA, insurance companies could still reject some of the sickest among us). It simply means that any industry, once large enough, will try to rig the system in its favor if allowed. America’s problem of outrageously high medical bills should be attacked at its source.

Furthermore, while most Americans are not in love with their insurance companies, polling data show that a majority of Americans do actually like their existing plan. Forcing them off of it, therefore, is understandably unpopular.

Single-payer advocates will often respond to this by saying something to the effect of, “But your employer can force you off your plan whenever they want!” True, hence the case for having another option available. If people hate it when their boss kicks them off their plan, why would we expect them to love it when the government does? Because public trust in government is so high?

We Have Made Progress, and We Can Make More

The health care reform efforts of the Obama administration have already done a lot of good for a lot of people, but much remains to be achieved. The US still pays more for worse outcomes relative to many other countries.

US politicians should certainly continue pushing for a more equitable health care system in which nobody has to live with the fear of ruinous medical debt. It is encouraging to see that this position has become fairly mainstream within the Democratic Party, with even moderates like Joe Biden now supporting a generous public option.

It’s crucial for us to acknowledge that one health care system doesn’t necessarily rule them all. In reality, every version has its costs and benefits. That being said, the US system today is heavier on the costs and lighter on the benefits. But there’s every reason to believe that it can be improved! True health care reformers should be willing to take whatever path is most likely to be achieved in the near future. Our collective wellbeing depends on it.