Opinion: We’re Sliding Towards Single Payer

By John Hood

RALEIGH — North Carolina is about to become the 40th state to expand its Medicaid program under the Affordable Care Act. The bill drew huge, bipartisan majorities of legislators.

Republican leaders resisted expansion for years, arguing that the promise of permanent 90% funding from Washington was either implausible or fiscally irresponsible. They no longer feel that way. I still do. The federal government’s current deficits are unsustainable. Either some future Congress and presidential administration will get serious about closing them — in which case states should expect that 90% Medicaid match to go away — or federal debt will reach economically ruinous levels.

That said, North Carolina’s Medicaid-expansion debate does illustrate that conservatives and progressives may agree on a major health-care initiative while maintaining very different long-term goals. Virtually all conservatives accept that health plans with massive government funding and regulation — in the form of Medicare, Medicaid, and heavily subsidized exchange plans — are here to stay, but can coexist alongside a robust market for health plans that are substantially private in funding and control.

Many progressives, by contrast, see this new Medicaid expansion as merely another step to their ultimate goal of a single-payer system. The next steps will be to lower the eligibility age for Medicare, for example, and to expand Medicaid coverage for long-term care.

In my view, we’ve spent the past two decades sliding down the slippery slope to Medicare/Medicaid for all. It’s time for conservatives to put on our spiked shoes and try to find a stopping place before it’s too late.

That means articulating a clear, attractive, practical alternative that preserves the maximum amount of choice, competition, private innovation, personal responsibility, and fiscal restraint. Fortunately, we don’t have to invent such a system from whole cloth. We can learn from the best practices of other countries.

Contrary to popular belief, single-payer systems aren’t standard among other industrialized countries. Many rely on a combination of government and private health care arrangements to extend universal access to basic medical services. Some of these systems are arguably more pro-market and less heavily subsidized than ours is.

The Foundation for Research on Equal Opportunity (FREOPP) has just published its latest World Index of Healthcare Innovation. Its scholars use a wide array of data to rate health care systems on four criteria: quality, choice, technology, and fiscal responsibility.

Switzerland won the top ranking in the 2022 index, as it did in the previous two years. The Swiss system is based on competing private plans, not a government monopoly. In fact, only one of the six highest-ranking countries on the FREOPP index has a single-payer system.

“Private insurance systems empower patient choice, and create room for insurers to organically evolve their benefit designs without having to wait for politicians or regulators to act,” the FREOPP scholars write. “In addition, universal private systems tend to be more fiscally sustainable, because countries can means-test their subsidies and phase them out as one ascends the income scale.”

The United States doesn’t just outspend the rest of the developed world on health care. We already spend more tax dollars on health care than most of our peers do. That’s because we subject so little of our government subsidy to means-testing. Wealthy seniors and poor seniors get essentially the same Medicare coverage. And one of our largest subsidies — excluding employer-sponsored health insurance from taxable income — actually benefits upper-income households more than lower-income households, since the latter face lower marginal tax rates and are less likely to be enrolled in group health plans in the first place.

So, whether you agree or disagree with the North Carolina legislature’s decision to expand Medicaid, it’s time for serious thought about what happens next. At the state level, conservatives ought to fight for greater choice and competition among medical providers. At the federal level, conservatives ought to replace our current, inefficient system of tax subsidies with something fairer and fiscally sustainable.

If we don’t, the slope towards a single-payer system will only get slipperier.

John Hood is a John Locke Foundation board member. His latest books, Mountain Folk and Forest Folk, combine epic fantasy with early American history (FolkloreCycle.com).


  1. Medical care is not a right. It is a combination of service provided by workers and products manufactured by more workers. Nothing in this world is free. This is a form of welfare and socialism which gives no incentive for work and paying your own way. In other words, being responsible and a productive part of society. Charity is great and needed greatly, but it is not under the realm of the government to provide. Keep going down this avenue and we will become a nation of dependent weaklings. Loving others is a hard thing to practice in real life. No wonder we have fallen away from God as we continue to put more and more trust in government instead of our Creator.

    • Carl, Being a Fear Mongering Hypocritical Hateful so called Christian who pushes their idol worshipping beliefs on other, is also not a right. But some how it’s ok to be a hypocrite. Another RW opinion from John Hood and the hatred filled John Lock foundation.

  2. Physicians for a National Health Program:

    “Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands. Under a single-payer system, all residents of the U.S. would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.

    Over $500 billion in administrative savings would be realized by replacing today’s inefficient, profit-oriented, multiple insurance payers with a single streamlined, nonprofit, public payer.

    Premiums would disappear, and 95 percent of all households would save money. Patients would no longer face financial barriers to care such as co-pays and deductibles, and would regain free choice of doctor and hospital. Doctors would regain autonomy over patient care.”

    Full article: https://pnhp.org/what-is-single-payer/

    • I fostered a few children who were on government assistance- Medicaid. It wasn’t too hard finding doctors and dentists in our area. However, the MENTAL HEALTH options were absolutely horrendous!
      I don’t love paying insurance costs, co-pays, and non-covered expenses. However, I would much rather pay those costs than have my taxes increase to cover the inefficiencies and ineffectiveness that would certainly be the result of a government-run universal healthcare system.

  3. Yhe only way to stop the slide is to end SOCAILism Security, Medicare, Medicare, and federal grants. The RINOs in congress need to go! #VoteOutIncumbents

  4. From the Declaration of Independence-

    “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

    So, based upon that document-

    I cannot pursue happiness without liberty.

    I cannot pursue liberty without my life.

    I cannot pursue life without ….. healthcare.

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