Everything You Wanted to Know About Single-Payer Health Care But Were Afraid to Ask

The Maryland Senate heard testimony last week on a measure that would establish a single-payer health system, a “Medicare for all” system in which everyone automatically qualifies for care, with the state picking up the tab.

Sen. Bernie Sanders (I-Vt.) advocated for a single-payer system at the national level during his presidential campaign. Former NAACP president Benjamin T. Jealous, a Democratic candidate for governor, is a full-throated supporter, and another Democratic candidate, attorney James L. Shea, has also said a single-payer system ultimately makes the most sense, though he believes the solution should come at the federal level.

Single-payer advocates argue that too many Americans still lack access to quality care; critics contend the price associated with universal, government-funded health care would be prohibitive.

Last week, the National Nurses Union endorsed the Maryland bill, calling it “a more humane, comprehensive health system based on patient care and need, rather than ability to pay.”


Sen. Paul G. Pinsky

Maryland Matters reporter Bruce DePuyt talked with Sen. Paul G. Pinsky (D-Prince George’s), lead sponsor of SB 1002, the Healthy Maryland Act of 2018. A lightly edited and condensed version of their conversation appears below.

Maryland Matters: What’s the case for a single-payer health system in Maryland?

Sen. Paul G. Pinksy (D-Prince George’s): We still have many people in the state and around the country who are uninsured. At some point we’re going to have to look at some other options. We might as well solve the problem, rather than putting more Band-Aids on it. Canada and most of Western Europe have gone to a system that’s mostly not-for-profit, and I think that’s what we need to do.

MM: How would it work?

Pinsky: The way it works is they roll everything into one fund, in some ways like Medicare. It would be Medicare for everybody. It would be a quality program that includes what is mostly expected in a private insurer. They would roll in Medicare, Medicaid, your private insurance, ACA, everything. They’d take all the funds from all of those. They’d figure out what the universal budget would be. And they’d do it as a tax, a fee, maybe a bump in the income tax that’s paid once, hopefully progressive, or it would be a payroll tax, done once like Medicare.

There wouldn’t be any co-pays or deductions.

MM: Advocates of a single-payer system claim there are some cost-savings to be realized.

Pinsky: So, right now Medicare has an administrative cost of 3 percent. For the private insurers, it’s 16 percent. So right away you save 13 percent. You’re not paying for advertising because it’s not the marketplace. You’re not paying for lobbying. You’re not paying for a whole lot of things. So right away, off the top, you save 13 percent.

Doctors would no longer need support staff who are filling out 12 forms for 12 insurance companies. You don’t need to be worrying about co-pays and deductibles. And so at the end of the month [a doctor would say] we saw these 500 people or 1,000 people with these 50 CPT [current procedural terminology] codes, these other people were treated for something else. You enter the information into the system, it goes to one place, and one check comes back — and it’s done.

MM: What gets covered?

Pinsky: In my bill, I list what is covered. It’s dental, it’s vision, it’s outpatient, it’s mental health care. And we have a study for long-term care because that’s expensive and it’s complicated.

But the idea with single-payer, as it is in Canada, is that if you want to expand what’s covered, which means you’re raising a tax, it becomes a public-policy issue, rather than being decided by United Health, or other insurers, and that’s a difference. Because if you take out the profit motive, you take out all the competing administrative costs, you save a lot of money.

MM: A lot of people like the coverage they have and will worry about a big change like this.

Pinsky: If you’re middle class, you can get good care. But we have one of the most expensive per-person costs in the world, and sadly, our outcomes are not better than a lot of countries that have cheaper costs.

A lot of people in our current system get great care. But a lot of people don’t. And we’re wasting a lot of money. And we could insure that everyone gets good care.

Canada’s single-payer system started in one province. And then it went to the next province and the next province, and now it’s national. And they have one-payer. The government runs it. It’s like Medicare for all.

In Sen. Bernie Sanders campaign, he talked about single-payer. Now I think there are 17 U.S. senators who are co-sponsoring Sanders’ bill. So there’s more momentum now.

MM: What’s the fiscal note? I assume it’s eye-popping.

Pinsky: Well, we don’t put it in there. We say you have to set up a universal budget, and then you have to raise revenue to take care of it. In previous years I’ve said it should be this tax and this much money, but modeling all this is way beyond the Department of Legislative Services’ abilities. So we leave that aside. We just said there will be a system. You have to get the federal waivers. It wraps all the money together and says what is covered.

I acknowledge we’re unlikely to get a waiver from this president. But I wanted to take the conversation to a more serious level. Would I prefer national legislation? Of course. But I don’t see it. But if a state could do it, if we could get a Democratic president who would approve a waiver, maybe we could replicate Canada.

We’re the only state in the country that has an all-payer system for its hospitals. In other words, we do not have any charity hospitals. If you’re sick and uninsured you can go into any hospital and get care. In a lot of states, they say you have to go to a charity hospital. And the way it works is, if you have uncompensated care, all hospitals pay into a pool and the ones providing care to the uninsured get reimbursed. We got the waiver for that like 30 years ago, and we’re the only state that does it. We have, over time, done some unique things.


  • Senator Paul Pinsky deserves congratulations for his progressive and compassionate vision. Many citizens cannot afford basic care much less the numerous costs associated with medical services. Many cannot pay for the prescriptions they need. As long as we have a commodity-based health care system, it’s a system of winners and losers. There are any number of health care systems that provide universal coverage with subsidized out of pocket in other countries the US and Maryland can explore. Within hours of passing the tax bill with eye-popping deficits, the majority R. party identified Medicare, Medicaid(and Social Security) programs to cut, programs that enjoy immense popularity and assist millions of citizens. Look at the enormous amounts of money the industry donates to Congress, and we can see why serious reform has stalled in the past. Time for a change!

  • Brian Michael Doherty

    Kudos to Paul Pinsky! Great bill which deserves cosponsors from Montgomery County delegation.

  • Hold the phone! I have a health savings account and love it! I’m an educated and active consumer with private health insurance and there are hundreds of citizens just like me. Single payer would be a disaster.

    • sydney jacobs jacobs

      Jon – good for you. Too bad what YOU have is not available to millions of other people. Our private, for profit insurance is already a disaster, and becoming more untenable every day. You think you are an “educated, active consumer?” If that was true, you’d know that you are actually paying significantly more than under a universal coverage program. Stop thinking only about yourself and consider how much better off ALL of us would be if NO ONE had to worry about having access to quality, affordable care.

    • Martin Reisinger

      Jon – the current system is untenable. For the past four years, the average increase for our family’s premiums was 25% – 2018’s was 38%. This year’s premium is $21K for a CareFirst Bronze plan with a $13K deductible (their least expensive plan for two healthy adults). This seems like a tax to me; it is certainly a burden.

      From the American Academy of Actuaries: “Pooling risks together allows the higher costs of the less healthy to be offset by the relatively lower costs of the healthy, either in a plan overall or within a premium rating category. In general, the larger the risk pool, the more predictable and stable the premiums can be.” Pool the risks, eliminate the profits and dividends, reduce the wastes — the expenses, per individual and overall, will go down. Bernie and Paul are correct in their argument for a single payer system.

  • Thank you Sen. Pinsky. I couldn’t agree more. Our current system is held together with a multitude of quick fixes. It is a system designed to insure providers get paid, regardless of price charged not to insure citizens get care. There is a bill being pushed before the Maryland Legislature that would fine folks who do not have insurance, regardless of the cost. Those of us who work for small business are stuck in low premium high deductible plans we dare not use even if we get sick. And forget about family coverage. Cost for me to add my husband goes up over 7x’s the individual rate and their is no employee plus one. This disqualifies us right off the bat for a subsidized silver plan or any subsidy for that matter. We’re also over 50, so costs for individual bronze plans currently hover in the $600 + per month range ($726 for a Kaiser plan). Now, to add insult to injury, politicians, health care providers and insurers want to fine me $700. Really, Jon, I had what you had until the recession forced me out of my well paid job with great benefits which included a health fund just like you. No one is immune from layoffs. I lost my job, my insurance and over $10,000 in my health fund. I never thought it would happen to me after 31 1/2 years, i hope you have better luck

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