Ok, we know, ideological juices are already flowing having seen the words “single-payer” in the title. As Americans, we have been trained, in an almost Pavlovian way, to equate single-payer with the much-maligned and much-feared social and economic system called socialism. In fact, many confuse the tenets of socialism with the even more dreaded communism. Americans believe that anything short of a free market will take away our liberties and bankrupt the country. But wait, before we sit back and smugly dismiss the whole idea as one of those liberal hare-brain ideas, let’s consider some inconvenient facts from the rest of the world:

Single-payer is alive and doing well, thank you, in such “socialist” countries as Canada, the U.K., France, Japan, South Korea, and Switzerland. We purposely didn’t include Sweden, Denmark, and other countries in Northern Europe in the list of single-payer countries, since the term “Swedenization,” has been used to demonize everything that deviates from the Right’s laissez-faire orthodoxy. Never mind that Sweden has had for a long time a conservative government. As had a slew of the other countries.

So why don’t these countries “repeal and replace” their single-payer system? The answer is simple: Because they work! European Conservatism hasn’t gone off the rails; rather, they conserve what works and change what doesn’t. Unfortunately, for some U.S. conservatives, that means sacrificing ideological purity on the altar of, God forbid, pragmatism.


Our experience

We have traveled widely for both through our work and the occasional medical incident abroad where we have had countless opportunities to interact with patients and doctors in many different countries. Despite their inevitable gripes about minor issues, the unanimous verdict is that they wouldn’t change the system—by and large, it is working for them. When they talk about healthcare in the U.S., the reaction ranges from disbelief to downright derision.

healthiest countries as of 2012Ah, you must be thinking, that may be true, but we have the best system in the world in terms of quality, right? Certainly, some of our politicians keep repeating this mantra. But what about the facts? In terms of being healthy, we rank behind Hong Kong, Italy, Australia, Japan, and Israel. And as number 33 on the list, we’re right behind the United Arab Emirates, Kuwait, and the Czech Republic and just ahead of Bosnia and Herzegovina and Bahrain. So, let’s not delude ourselves about “American Exceptionalism” when it comes to healthcare. It’s not unpatriotic to acknowledge the reality that we are exceptionally bad in this area.

We know that it can be difficult to translate statistics into “kitchen table” terms. What would living under a single-payer system really be like? So when we received this email, written by an American who moved to Israel (number 6 on the list of healthcare quality), forwarded to us by a friend, we thought, what a great way to help people understand the truly social nature of “socialized” medicine. We know that it can be difficult to translate statistics into “kitchen table” terms. What would living under a single-payer system really be like? So when we received this email, written by an American who moved to Israel (number 6 on the list of healthcare quality), forwarded to us by a friend, we thought, what a great way to help people understand the truly social nature of “socialized” medicine.


Letter from an ex-pat

“As an ex-pat/dual citizen living under a single-payer health care system myself, I thought it would be a good idea to share with the community what life is like under single-payer health care from my perspective as a man with a family, a tax-paying teacher, and a football player (don’t laugh).”

“Here’s basically the system in Israel:

  • Healthcare is predominantly paid for through the government.
  • Everyone receives a certain, basic “basket” of services based on their age (children get free basic dental care, people over 90 years old get free home health aids, etc.).
  • Everyone pays into the system or has someone pay for them, based on income.
  • The basic payment structure is similar to what Sen. Sanders proposes for the U.S. Workers pay between 3% and 9% of their salary (progressively based on income) and employers pay a similar matching percentage. We do not have to negotiate for health insurance when applying for a job.
  • There are four quasi-private healthcare providers.
  • They open clinics and have affiliate doctors and hospitals throughout the country. A doctor can work for a company’s clinic, or work privately and decide whether or not to accept the customers of each of the four companies.
  • All four companies provide the same basic standard of care for similar prices.
  • What about competition? Each company wants as many subscribers as possible. So they have to get the best doctors to provide the best care, the best equipment and offices, and availability in the most communities.
  • The four companies have options for supplemental insurance above and beyond the basic basket. This includes, dental, long term care, discounted hospital stays, discounts on private (non-plan) doctors, alternative medicine, and fertility services.
  • There is private insurance available, also above and beyond the basic basket.

But how does this work in real life?


What we pay

bituach leumiMy wife is a post-doctoral fellow, or a graduate student according to the government. She is paid by stipend. And she does not pay anything for health insurance. The government wants to encourage graduate study (especially in the sciences) and covers the cost of basic healthcare for graduate students at this level. Neat!

I am a high school teacher. Not on the high end of the income scale. I pay 3% of my income to the Bituach Leumi (national insurance). My employer pays a matching percentage. That comes out to, maybe $2,000 per year. Compare this with the $1,000 per MONTH I was spending in the U.S. for catastrophic care. But more on that later.

We opted to purchase the highest-available supplemental plan with our health insurance. The price is based on age. For two 30-ish adults and two kids, it costs 260 shekels per month (or about $60 per month) for a family of four. What do we get for this? You’ll see…


As a father

If you have kids, you know they go to the doctor a lot. Even healthy kids get colds, viruses, broken bones, and cavities. My local clinic is down the street from my house, maybe a 3-minute walk. But my wife didn’t like any of the pediatricians there, so we take them to a private doctor who is affiliated with our insurance company (also a 3-minute walk from the house). She is considered the premier pediatrician in our very large city. Her daughter also happens to be in my daughter’s class.

We’re in the doctor’s office at least once a month for one kid or another. Kids share germs more than they share toys. For the 20 or so visits we’ve made in the last 21 months, we’ve paid nothing out of pocket. Nothing. Not one shekel. We walk into the doctor’s office (sometimes with an appointment, sometimes without), show our insurance card, get an exam and great care, and walk out. No bills.

Prescriptions? You do have to pay for these. I think we pay 10 shekels ($2.50) for antibiotics. I don’t think I’ve paid more than 40 shekels ($10) for anything ever at the pharmacist.


As a football player

I took up competitive, full-contact, football at the age of 35. Having no athletic skill, this wasn’t a terribly good idea. But I had the time of my life (I’m writing a book about it). But with competitive sports come injuries. Aside from sprains and bruises, I broke my finger…twice. Both times I needed surgery.

Don’t you have to wait months for appointments with specialists under socialized medicine? HELL NO! The first time I broke my finger, I went online and made an appointment for an orthopedist in my insurance group for a couple of days later. He happens to be British. The appointment was free. He sent me for an x-ray…downstairs. I got it immediately, went back upstairs, and my x-ray was on his screen. Total cost: 36 shekels ($9) for the x-ray.

Now I needed a hand surgeon. Here’s where it got a bit complicated. The best hand surgeon in the country (a French woman) happened to work at the hospital where my wife works. I called the hospital…6 months for an appointment! That can’t be right. Turns out, the hospital has a “private” clinic that can schedule an appointment with the surgeon THAT SAME DAY. But for how much? First visit was 1,000 shekels ($250). Expensive, but not tragic.

Well, when I got to the appointment, I was told to take the receipt to my insurance provider for reimbursement. A few days later I did (walked into my local clinic and handed the paper to the receptionist). A few days after that, 600 of the 1000 shekels appeared in my bank account. The appointment was only $100. YAY, supplemental insurance!

I needed surgery. It was scheduled for the next week. I needed two days in the hospital, the best hospital in the country in their shiny, new wing. Out of pocket cost for the surgery, hospital stay, medicines, etc.? 260 shekels ($60)!!! That was it. I walked in, paid the $60, and everything else was covered. Again, YAY supplemental insurance!

The surgery was a success. Follow-up visits were covered.

I broke my finger again a year later. Same results. Same doctor. Same hospital. This time, I was out-of-pocket 400 shekels ($100) for the surgery and the stay. And that was covered by my football team’s insurance.


”You’re a healthy male. What about women, the elderly, and the poor?”

This I only know anecdotally. My wife is very into alternative medicine. She has visited herbal medicine doctors, massage, acupuncture, and half a dozen other specialists that I don’t understand. We paid maybe $20 per visit at most. All of it is covered by our insurance.

Having babies? We haven’t had one in this country. But from what I know, maternity care is free universally. And you get a payment from the government (like $6,000) when the baby is born. There is also 3-6 months of paid family leave. Compare this with the $12,000 I paid in the U.S. when my son was born (that was with the $1,000 per month insurance).

The poor? They have basic care. The unemployed pay between $5 and $20 per month for their coverage. Senior citizens do not pay for basic care, as far as I know.


How does this work for entrepreneurs?

We’re the “start-up nation.” One of the reasons we lead the world in technology innovation and starting new businesses is that we don’t worry about health insurance. A person is free to leave their employer for greener pastures knowing that they will always have the same healthcare for the same price. They’re also covered if they’re unemployed.

Striking out to start a new business is also fear free. You will always have health insurance whether you succeed or fail. If you succeed, you know the cost of healthcare for yourself and your employees. We complain about a lot of things. But the cost of healthcare for businesses is generally not a problem. There is no complex search or negotiation. We pay a fixed percentage. And if we don’t like it, we can elect leaders who will change the percentage!


What else makes the program work?

Efficiency. There are no billing and coding staff personnels. Everything is done with computers (and fax?) without middlemen.

No paper files. Everything is electronic. Swiping your insurance card provides any doctor, clinic, or provider access to your records. So the rooms of paper files do not exist. Also, you don’t need to bring or send your medical records anywhere. This improves care and reduces staffing.

When you visit the doctor’s office, you swipe your card at the kiosk and get a number. You wait your turn (if you have an appointment, it’s almost no wait), and you go in and see the doctor. No multiple nurses to repeat your symptoms to. You just see the doctor. Clinics and offices have a receptionist to help you, and that’s about it.


Is everyone happy?

Of course not! No system is perfect. There are holes that we’re working to patch up. Doctors and hospitals are hit and miss as they are in any system. Sometimes they suck. Some regions don’t have enough facilities or medical personnel. Some of the common medical opinions are antiquated and standards haven’t been updated in 50 years.

Like in the U.S., elections matter. Healthcare is always an issue and various parties offer various improvements. The current Health Minister is a chareidi (ultra-orthodox) man. While you’d think he wouldn’t care or be capable of running this department, much of his constituency is very poor. And he has been focused on delivering better care to children and families. The benefits have been felt by all families.


Can this work in the U.S.?

There are MANY differences between the U.S. and Israel. I’ll narrow it down to three:

  • Population: There are only 8 million people here. There’s no reason the program can’t be scaled up, but four companies may not be enough. They would be enormous businesses. Turning existing insurance companies into limited-profit competitors for your business (paid for by the government) might be a viable workaround.
  • Lifestyle: Israelis tend to be more active and have a healthier diet. We have lower instances of heart disease and diabetes. We have much lower obesity. That alone reduces healthcare costs. Americans would benefit from a massive campaign to improve healthy lifestyles.
  • Culture: Israel was founded as an essentially socialist state. Government school, healthcare, and other services were there from the beginning. Only recently (within the last 30 years) have we moved towards capitalism. The U.S. is coming at this from the opposite direction. Americans have to be able to trust the system for it to be implemented. Given the enormous influence of insurance companies, drug companies, and the medical lobby, it will be a hard sell.

But we’ve done hard things before.”

So what’s not to like? Am I missing something obvious?

First posted on Epic Times on 02/22/16.

Pat Salber, MD, MBA and Dov Michaeli, MD, PhD
Patricia Salber, MD, MBA (L) is the Founder and Editor-in-Chief of The Doctor Weighs In. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare. Dov Michaeli, MD, PhD (R) loves to write about the brain and human behavior as well as translate complicated basic science concepts into entertainment for the rest of us. He was a professor at the University of California San Francisco before leaving to enter the world of biotech. He served as the Chief Medical Officer of biotech companies, including Aphton Corporation. He is now retired and enjoys working out, following the stock market, travelling the world, and, of course, writing for TDWI.


  1. I am not making any statements regarding the American health care system. As a proud Canadian I want to share that the Canadian single payer health care system has treated me very well and I am overall quite satisfied. In fact I am grateful that the timely provision of urgent and specialized medical care has saved my life, twice.
    Our system is not perfect and often we wait for several hours at the Emergency Department depending on our needs as determined by a triage team. However, for urgent medical services we are treated very quickly.
    For elective surgeries we face waiting lists, but they are relatively short. I am currently on a two month waiting list for a total knee replacement. I consider that period reasonable and when my surgery is delivered my cost will be zero. No one in Canada goes bankrupt due to a catastrophic illness.
    I personnaly love my health care system even though it is not perfect.

  2. Yes,.. this is all just wonderful but who actually owns the medical facilities and businesses. In the U.S, some practices are privately owned and must be paid in order to cover overhead like staff salaries. Here in the US, Medicaid pays my billing at 17 cents on the dollar. If that is single payer, then expect ….. nothing but trouble. Medicaid has not raised fees here in Illinois in 27 years. kw


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