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The case for single-payer, explained in 3 charts

New York has a single-payer plan, and the numbers add up this time.

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

I hope you aren’t sick of single-payer projections yet. RAND has a fascinating new one, looking at a New York plan for universal coverage.

First, the specifics of the New York Health Act:

  • Every resident would be covered by the New York Health program.
  • Cost-sharing would be effectively eliminated for all residents, and almost all services would be covered — with the exception of long-term care.
  • The state’s single-payer program would be paid for through a combination of existing federal and state health care funding, plus new payroll taxes and a progressive tax on non-payroll income like stock dividends.

The RAND study’s big-picture findings read like a state-level version of George Mason University’s analysis of Bernie Sanders’s Medicare for All bill:

  • Federal funding would be about the same because of the way the program is structured, but New York state’s health care spending would increase fivefold over 10 years, versus the projected status quo.
  • However, overall health care spending in New York would go down slightly, about 2 percent, even as more services and more people are covered.

But RAND gets a little more granular and helps to answer some of the questions about winners and losers that will likely define the single-payer debate, should we ever have one in Washington.

A couple of charts explain as well as I can what single-payer in New York might look like in 2031.


As you can see, New York would be spending a modest amount less on health care after 10 years under single-payer than it would under the status quo, according to the RAND projections. $15 billion isn’t really that much in the grand scheme of things, as crazy as that sounds.

However, that same spending will cover more people and more services, and more of it will be spent on health care. RAND finds that New York would be spending $23 billion less on administration and $9 billion more on health care services under this single-payer plan.

Here’s another good chart:


One thing sticks out most to me: New Yorkers would be spending half as much money out of their own pockets when they go to the doctor or get a prescription under single-payer than they would under the current system: $23 billion versus $52 billion.

The other thing this chart helpfully illustrates: New tax payments would almost perfectly replace the premiums that people and their employers pay right now for private health insurance. It’s not quite an exact match, but it’s very close: $195 billion for premiums versus $210 billion in new taxes.

Then there is the question of who is paying for this new system. RAND’s conclusion is pretty simple: “We find that payments for health care would be more progressive under the NYHA [New York Health Act] than under the status quo.”


Basically everyone making under 1,000 percent or less of the federal poverty level — about $120,000 for an individual or $250,000 for a family of four in 2018 — would pay the same or less if you look at everything from their out-of-pocket spending to taxes they pay that fund health care.

A family making 139 percent of the poverty level (the Medicaid expansion cutoff) would see their spending drop from $2,700 to $1,300 under single-payer. Families who make 500 percent of the poverty level would have their spending cut from $10,000 to $6,400 on average.

Wealthier families might spend a lot more, though. The families making more than 2,000 percent of the poverty level would see their spending (a lot of this is taxes) increase from $141,700 on average in 2022 under the status quo to about $218,000 under the New York Health Act.

That is a genuine trade-off. Single-payer proponents’ support turns on the idea that health care is a human right, even for the less fortunate. So this might be a trade-off they are willing to make.

In fact, in total, if you look at the RAND research, it outlines what you could imagine as the pillars of the argument for single-payer health care:

  • We would spend less money overall, while spending more on actual health care and covering more people and services.
  • Any new taxes would be effectively replacing the premiums you and your employer already pay.
  • Yes, some higher-income people would pay more, but the working and middle classes would save money.

This comes with caveats, as any projection does. It assumes single-payer would be able to substantially cut payments to providers without reducing access to care. It assumes New York Health won’t cover long-term care, which is very important as our population gets older and very expensive.

But I think between the RAND and the George Mason studies this week has shown that there is at least a case to be made for single-payer. The question will be whether its supporters can artfully make it — and whether the people find it persuasive.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.

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