A Short Glossary of Terms Used
in The Healthcare Reform Debate
“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 is no 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 (less than 20 months from now!). If we can’t use
words consistently, we have no hope for a constructive debate on this vital topic.
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.1
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 health care should be provided, the type
of coverage that is included, and the type of care that is
provided.”2 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.3
The goal of the ACA underscores how unique this country
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.”4
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:
24 Dallas Medical Journal May 2019
1) Insurance Mandates
In insurance mandate countries, the government requires
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
healthcare 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.
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 wealthier citizens will purchase more insurance for
(presumably) better care, but even the poorest citizens will
have the basic medical care assured by their government.
Again, in these systems there may be privately operating
hospitals, physicians and other providers.
It is worth noting that 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 US.)
For examples of two-tier systems, look at Ireland, Israel,
and Singapore.4
3) Single-Payer Systems
In a single-payer system, one source purchases all health
care.5 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.
Note that privately run hospitals and independent
physicians can still be available in a single-¬payer system.
The payment comes from the government (or other entity),
but the care is not necessarily provided by the government.
For illustrations think of France or our own Medicare
program.4
What is “Socialized Medicine?”
A socialized healthcare system starts with Universal
Coverage but consists of far more government involvement.6
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,
by Sarah Fontenot, JD
1. Insurance Mandates
2. Two-Tier Programs, or
3. Single-Payer Systems