Monday, March 4, 2019

A Short Glossary of Terms Used In Health Care Reform Debates

By Sarah Fontenot

Editor's Note: This article was previously published on the author's website,

Earlier this month I released my Fontenotes Beyond the Slogan “Medicare for All.” The response illustrated how much confusion there is over titles used to describe various political arguments for revising our health care delivery system.

“Universal Coverage,” “Insurance Mandates,” “Two-Tier Insurance,” “Single-Payer System,” and “Socialized Medicine,” are bandied about as both endorsements and attacks- but does everyone agree on what those labels mean? There really shouldn’t be controversy about the terms- they each have definitions and examples- which I will share with you here.

Health care promises to be a critical issue in the next election (only 620 days away!). If we can’t use words consistently, we have no hope for a constructive debate on this vital topic. 


Please read on-

 – Sarah

Universal Coverage

Universal Coverage (often called “Universal Health Care”) refers to a system where every legal resident of a country has insurance for health care. The underlying principle behind “Universal Coverage” is that with insurance people have better access to medical treatment.

The insurance may be from the government or private companies, and the care itself could be from either a government-controlled system or private providers.

Regardless, there must be some governmental involvement in achieving Universal Coverage, through a mandate for insurance, or other legislation determining to “whom the universal coverage care should be provided, the type of coverage that is included, and the type of care that is provided.”

The Affordable Care Act (“Obamacare”) was the first successful legislation in America that attempted to achieve Universal Coverage; I say “attempted” because even if it was fully implemented (and it was not), the ACA missed the mark of insuring all Americans. 

The goal of the ACA underscores how unique the USA is in not insuring its populace. As of 2009,­ the year the law was passed­ “thirty-two of the thirty-three developed nations had universal health care, with the United States being the lone exception." 

What that means is all those other countries have fully insured populations. Presumably, patients in these countries worry about what news they will get in their doctor’s office- in America, people worry as much about the news they will get in their billing statement.

Universal Coverage can be obtained by:

  1. Insurance Mandates,
  2. Two-­Tier Programs, or
  3. Single-­Payer Systems

1. Insurance Mandates

In insurance mandate countries the government has required everyone to obtain insurance coverage, whether through the government, private companies, or a combination of both.

Nothing in this type of system is contrary to private health care providers. Insurance coverage is mandatory, but the care itself can be in private hospitals or doctor offices. These systems do not necessarily require medical treatment to be only in government-owned facilities.

As stated by President Obama, the goal of the Affordable Care Act (“Obamacare”) was to achieve Universal Coverage through an insurance mandate. The decision by many states to not expand Medicaid (and other loopholes in the law) have left many people uninsured, but the original ACA plan of expanding Medicaid nationally, requiring individuals to have insurance (whether through their employer or individually), and protecting Medicare was designed to achieve  – for the first time  a universally insured American population.

Examples of countries with an insurance mandate include Germany and Switzerland.

2. Two­-Tier Programs

In some countries, the government requires every citizen to have basic insurance coverage (through the government) to cover catastrophic circumstances such as accidents and significant illnesses but also allows their citizens to choose whether to purchase supplemental insurance (or health savings account) for more routine care. These are known as “Two-­Tier” systems.

The “Two-Tiers” moniker points to the reality that the wealthier citizens will purchase more insurance for (presumably) better care, but even the poorest will have the basic medical care assured by their government.

It is important to note that in these systems there may be privately operating hospitals, physicians and other providers. The Two-Tier refers to payment- not quality of care (although- again- money is likely to create that dichotomy as we see here in the U.S.A.)

For examples of Two-Tier systems look at Ireland, Israel, and Singapore.

3. Single­-Payer Systems

In a single payer system, one source purchases all health care. Arguably this could be a private entity, but in reality, this happens through a nation’s government.

When a government is paying all the bills, that money comes through taxation. No country offers free care- the public pays for it either in the exam room or through taxes.

Please note that in a single­payer system there can still be privately run hospitals and independent physicians. The payment comes from the government (or other entity), but the care does not necessarily have to.
For illustrations think of France or our own Medicare program.

What is “Socialized Medicine?"

A Socialized Health Care system starts with Universal Coverage but involves far more government involvement. Under a socialized system, the government pays for all the care- and also delivers that care in hospitals and facilities the government owns and operates. All the physicians, nurses and other health care professionals are government employees- from birth to death every patient encounter is with the government.

In other words, Socialized Medicine starts with a single-payer as we just discussed, but it adds the other side of the coin- the distribution of the medical care itself. 

Warnings of “Socialized Medicine” are rampant in the debates surrounding various current “Medicare for All” proposals, were equally strident during the passage of the ACA, and resonate back to advertisements against Medicare by Ronald Reagan in the mid-1960s.

All three times the pundits were incorrect. Medicare in 1965 did not result in a government take-over of providers, Obamacare did not shut down hospitals or require physicians to give up their private practices, and none of the “Medicare For All” proposals currently floating about- not even the most extreme  will result in a system where care is delivered in hospitals and facilities the government owns and operates.

To call any of these “Socialized Medicine” is just wrong- it is not a correct use of the term.

For accurate examples of Socialized Medicine, think England and the United Kingdom, or our very own VA system.


I hope this serves as a quick glossary of words we will all hear incessantly through this election cycle.

The concepts are very detailed and knotty- the terms are not.

Want to Know More?

  1. In 1986 EMTALA (The Emergency Medical Treatment and Labor Act) was passed- requiring any Emergency Room that accepted Medicare (and as a practical matter they all do) to provide medical screening and stabilizing care for any person who comes into the ER for care, regardless of their ability to pay.

    ER personnel are not even supposed to ask if the patient has insurance before they receive the screening. However, care under EMTALA is not free- which is frequently misunderstood by the public and politicians.

    For more information about EMTALA- as well as some consequences to ERs and providers- the American College of Emergency Physicians [ACEP] has a Fact Sheet here.
  2.  If you are interested in how other countries pay for- and deliver- health care there is an excellent interactive guide here from the Commonwealth Fund. Not only is the information on each countries’ health care system quite detailed- it covers far more countries that most resources I have seen (Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, Taiwan, USA). I highly recommend this resource!
Sarah Fontenot is an adjunct professor at Trinity University in San Antonio, author of the Fontenotes Newsletter, and popular speaker who brings clarity to health care legal and policy issues.  

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