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.