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p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2
Available online at www.sciencedirect.com
Public Health
journal homepage: www.elsevier.com/puhe
Review Paper
Single-payer or a multipayer health system: a
systematic literature review
P. Petrou a,*, G. Samoutis b, C. Lionis c
Pharmacy Program, Department of Life and Health Sciences, School of Science and Engineering, University of
Nicosia, Nicosia, Cyprus
St George’s, University of London Medical Programme, Delivered in Cyprus by the University of Nicosia Medical
School, Cyprus
Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece
article info
Article history:
Objectives: Healthcare systems worldwide are actively exploring new approaches for cost
Received 18 July 2017
containment and efficient use of resources. Currently, in a number of countries, the critical
Received in revised form
decision to introduce a single-payer over a multipayer healthcare system poses significant
18 April 2018
challenges. Consequently, we have systematically explored the current scientific evidence
Accepted 9 July 2018
about the impact of single-payer and multipayer health systems on the areas of equity,
Available online 5 September 2018
efficiency and quality of health care, fund collection negotiation, contracting and budgeting health expenditure and social solidarity.
Study design: This is a systematic review based on Preferred Reporting Items for Systematic
Health system
Reviews and Meta-Analyses (PRISMA) guidelines.
Single payer health system
Methods: A search for relevant articles published in English was performed in March 2015
Multipayer health system
through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing
Universal health coverage
and Allied Health Literature, Medical Literature Analysis and Retrieval System Online
Health Insurance
through PubMed and Ovid, Health Technology Assessment Database, Cochrane database
and WHO publications. We also searched for further articles cited by eligible papers.
Results: A total of 49 studies were included in the analysis; 34 studied clinical outcomes of
patients enrolled in different health insurances, while 15 provided a qualitative assessment in this field.
Conclusion: The single-payer system performs better in terms of healthcare equity, risk
pooling and negotiation, whereas multipayer systems yield additional options to patients
and are harder to be exploited by the government. A multipayer system also involves a
higher administrative cost. The findings pertaining to the impact on efficiency and quality
are rather tentative because of methodological limitations of available studies.
© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author.
E-mail address: petrou.pa@unic.ac.cy (P. Petrou).
0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2
Universal healthcare coverage is ‘the most powerful concept that
public health has to offer’.1 The redistribution of health risks lies
at the core of a universal coverage health system (UCHS),
thereby protecting the citizens who are in the greatest need of
healthcare services.
Despite the diversity in the design of health systems
worldwide, all health systems have the same desired attributes of efficiency, trustworthiness and affordability.2 The
healthcare system can be defined by three functional processes: (i) service provision; (ii) financing and (iii) regulation,
which must be governed by the following principles: (a) equity; (b) financial protection and (c) efficiency and quality,
The payer type, whether single payer or multipayer, is a
highly debatable issue for any country contemplating
healthcare reforms.4,5 A single-payer health system is
delineated by universal and comprehensive coverage, while
the payer is a public entity. A multipayer healthcare system,
on the other hand, features two or more providers in charge
of administrating the health coverage. This assumes that a
certain level of competition exists and usually the rules of
competition, along with the basic principles of healthcare
coverage, are demarcated by a governmental body. Cyprus
and Ireland are examples of two European countries without
a UCHS.6 In Cyprus, a parliament-approved National Health
System has not been implemented because of concerns
about its fiscal sustainability and the lack of consensus
among social stakeholders and health professionals. Out-ofpocket payment (private expenditure that does not include
copayments in the public healthcare sector) exceeds public
funding, while the ability of people to fund their healthcare
has been compromised because of the financial crisis and the
reduction of household disposable income.6 The public
healthcare sector has been severely strained, while the
financial recession had impaired affordability for private
sector health services, whose costs burden patients, thus
exposing them to potentially catastrophic expenditure. The
current situation begs for the introduction of a universal
coverage health system (UCHS). This systematic review aims
to enable informed decision-making in the context of Cyprus’
healthcare sector, while still being relevant to an international audience, as many countries are actively pondering
reforms to improve their healthcare systems.
The objective of this article is to systematically investigate
current scientific evidence about the impact of the singlepayer and multipayer health system on the areas of equity,
efficiency, quality of care and financial protection through a
systematic literature review.7
Based on the available literature and the theoretical background of universal coverage framework,4,8 the term health
protection, a major determinant in the context of a UHCS,
a) Equitydtimely access not linked to employment status or
ability to pay;
b) Efficiency and high-quality health caredproviding the
highest possible level of health with the available
c) Financial protection against catastrophic health expenditure, which can be further stratified into the following
Fund collection, which is a policy norm.9 Fund collection
is a weak stand-alone tool, unless accompanied by
pooling of contributions and cross subsidisation of
health costs.
Social solidarity.
Negotiation, contracting and budgeting, comprising the
efficient use of health resources. This includes the selection of providers and implementation of costcontainment measures and even performance targets.
Health expenditure that provides the funds to meet the
health needs of the population.
Studies reporting at least one of the aforementioned health
protection parameters were included in the review.
Search strategy
Our research strategy was to look for (a) original and published
studies (randomised controlled trials, observational, quantitative, qualitative, meta-analyses); (b) published between 01
January 1980 and 28 February 2015; and (c) studies that discuss
single-payer and multipayer health systems, efficiency, solidarity, cost risk sharing and quality of care.
We searched the following databases: Excerpta Medica
Databases, Cumulative Index of Nursing and Allied Health
Literature, Medical Literature Analysis and Retrieval System
Online through PubMed and Ovid, Health Technology
Assessment Database, Cochrane database and WHO publications. We also searched for further articles cited by eligible
Screening process
The screening process was conducted in two stages: first, the
titles and abstracts were screened by the lead reviewer to
exclude distinctly irrelevant references. If the abstract did not
provide sufficient data to enable selection, full articles were
reviewed. Second, full-text manuscripts were screened for
compliance with inclusion criteria of the review by two independent reviewers. Disagreements were resolved by discussion or by consulting with the lead reviewer.
We adopted the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement for reporting
systematic reviews and meta-analysis in health care10 (Fig. 1).
The PICO terms are the following:
1) Population: beneficiaries enrolled in health systems
2) Intervention: single payer vs multipayer health system
3) Comparison: single payer vs multipayer health system
Iden fica on
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2
Records iden fied through
database searching
(n = 888)
Addi onal records iden fied
through other sources
(n = 126)
Records screened
(n = 898)
Full-text ar cles assessed
for eligibility
(n = 195)
Records a er duplicates removed
(n = 898)
Studies included
Records excluded based
on tle
(n = 703)
Full-text ar cles excluded,
with reasons:
Not related (n = 107)
Perspec ve (n=11)
Not sufficient data (n=28)
Fig. 1 e Flow Diagram of literature review of single-payer vs multipayer health systems using Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA).
4) Outcomes: equity, solidarity, costs, efficiency, risk pooling,
contracting negotiation and budgeting.
We used the Medical Subject Headings terms: ‘ Single Payer
System’, ‘Healthcare Disparities/statistics & numerical data’,
‘Insurance, Health/classification’, ‘System, Single-Payer’,
‘Single-Payer Plan’, ‘Insurance Coverage/statistics & numerical data ’, ‘Health Insurance, Voluntary’ ‘Insurance, Voluntary
Health’, ‘Group Health Insurance’, ‘Insurance, Group Health’,
‘Reimbursement, Health Insurance’, ‘Third-Party Payments’,
‘Payment, Third-Party’, ‘Payments, Third-Party’, ‘Third Party
Payments’, ‘Third-Party Payment’, ‘Health Insurance Reimbursement’, ‘Insurance Reimbursements, Health’, ‘Reimbursements, Health Insurance’, ‘Third-Party Payers’,
‘Payer, Third-Party’, ‘Payers, Third-Party’, ‘Third Party Payers’,
‘Third-Party Payer’, ‘Health Program, National’, ‘Health Programs, National’, ‘National Health Program’, ‘Program, National Health’, ‘Programs, National Health’, ‘National Health
Insurance’, ‘Health Insurance, National’, ‘Insurance, National
Health’, ‘National Health Insurance, Non-U.S.’, ‘Health Services, National’, ‘National Health Service’, ‘Service, National
Health’, ‘Services, National Health’, ‘National Health Services’, using Boolean operators (AND, OR).
Data collection
Data relating to study characteristics, such as study population, outcome measures and analysis undertaken, were
extracted on a data extraction form by the lead reviewer and
independently checked for accuracy by two independent reviewers, individually. Disagreements were resolved by discussion or by consulting with the lead reviewer.
Study selection
We identified 888 potentially eligible articles and an additional
126 through other sources (including snow-ball citations of
the included articles). Deduplication led to 898 articles of
which 703 were excluded based on title and 195 were further
assessed for eligibility. A total of 112 were further excluded
being unrelated to the study topic, 11 were perspective articles, while 24 more did not provide sufficient data. In the end,
49 studies were included in the analysis, including 34 with
quantitative end-points and 15 with qualitative end-points
(Fig. 1, Table 1 and Supplementary Table 1).
There were 20 studies focussing on the USA and four on
Germany. Two compared the USA with Canada and two were
Table 1 e Assessment of qualitative studies.
Authors, year, reference
Author objectives or aims
Population (participants, diagnoses,
gender, age)
Abiiro and Allegri, 20148
Dimension of universal health coverage
Global perspective
Besstremyannaya, 201344
Managed competition in health insurance
systems in central and eastern Europe
Blanchet and Fox, 201352
Prospective, institutional stakeholder
analysis for Vermont’s single-payer
Feasibility study for introduction of single
payer in Maine
Switching between insurers: benefits and
Regulated competition among multiple
health insurance companies in central
and eastern Europe
Questionnaire based in Vermont for
Chollet et al., 200261
Duijmelinck Mosca and van de Ven, 201555
Systematic review
Preker, 199862
Review paper
Comparison of single- vs multipayer
‘Managed competition’ for Ireland: the
single- versus multiple-payer debate?
Policy paper
Reinhardt, 200746
Thomson and Mosialos, 57
Insurance choice
Vetter and Boecker, 201253
Describe introduction of a single payer in
Classification of health systems
Framework in Germany and the
Mikkers and Ryan, 20145
Wendt, Frisina and Heinz, 20094
Van de Ven, Beck, Van de Voorde et al.,
Risk adjustment and risk selection
Van de Ven, Beck, Buchner et al., 201343
Efficiency and affordability
Qualitative (European Union [EU])
Conceptual comparison of health systems
Qualitative study across Belgium,
Germany, Israel, the Netherlands and
Belgium, Germany, Israel, the Netherlands
and Switzerland
criteria CASPa
Humanitarian, legal and economic
Quality indicators (infant and under-five
mortality etc.)
Attitude for the comprehensive health
Cost, financing and economic impact
Relevance of the different switching
benefits and costs in consumers’ decision
to switch the insurer
Comparison between single vs public
Equity, risk pooling, financing and
Effective managed competition
Strength, weakness and areas of
improvement of EU health systems
Review of single- vs multipayer system
The impact of opting out on equity and
Policy analysis framework
Financing, service provision and access to
health care
Comparison of risk equalisation schemes
Assessment of efficiency and affordability
in five European countries
1. Was there a clear statement of the aims of the research? (Consider What was the goal of the research? Why it was thought important? Its relevance).
2. Is a qualitative methodology appropriate? (Consider If the research seeks to interpret or illuminate the actions and/or subjective experiences of research participants Is qualitative research the
right methodology for addressing the research goal? Is it worth continuing?).
3. Was the research design appropriate to address the aims of the research? (Consider If the researcher has justified the research design [e.g. have they discussed how they decided which method to
4. Was the recruitment strategy appropriate to the aims of the research? (Consider If the researcher has explained how the participants were selected If they explained why the participants they
selected were the most appropriate to provide access to the type of knowledge sought by the study If there are any discussions around recruitment [e.g. why some people chose not to take part]).
5. Was the data collected in a way that addressed the research issue? (Consider If the setting for data collection was justified If it is clear how data were collected [e.g. focus group, semi-structured
interview etc]. If the researcher has justified the methods chosen If the researcher has made the methods explicit [e.g. for interview method, is there an indication of how interviews were
conducted, or did they use a topic guide]? If methods were modified during the study. If so, has the researcher explained how and why? If the form of data is clear [e.g. tape recordings, video
material, notes etc] If the researcher has discussed saturation of data).
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Geyman, 200565
Hussey and Anderson, 200340
Population module that estimates
Maine’s, (USA) population by sex and age
Dutch consumers (1091 respondents)
Outcomes measures and analysis
6. Has the relationship between researcher and participants been adequately considered? (Consider If the researcher critically examined their own role, potential bias and influence during (a)
Formulation of the research questions (b) Data collection, including sample recruitment and choice of location How the researcher responded to events during the study and whether they considered
the implications of any changes in the research design).
7. Have ethical issues been taken into consideration? (Consider If there are sufficient details of how the research was explained to participants for the reader to assess whether ethical standards were
maintained If the researcher has discussed issues raised by the study [e.g. issues around informed consent or confidentiality or how they have handled the effects of the study on the participants
during and after the study] If approval has been sought from the ethics committee).
8. Was the data analysis sufficiently rigorous? (Consider If there is an in-depth description of the analysis process If thematic analysis is used. If so, is it clear how the categories/themes were
derived from the data? Whether the researcher explains how the data presented were selected from the original sample to demonstrate the analysis process If sufficient data are presented to
support the findings To what extent contradictory data are taken into account Whether the researcher critically examined their own role, potential bias and influence during analysis and selection
of data for presentation).
9. Is there a clear statement of findings? (Consider If the findings are explicit If there is adequate discussion of the evidence both for and against the researchers arguments If the researcher has
discussed the credibility of their findings [e.g. triangulation, respondent validation, more than one analyst] If the findings are discussed in relation to the original research question).
10. How valuable is the research? Hint: Consider If the researcher discusses the contribution the study makes to existing knowledge or understanding e.g. do they consider the findings in relation to
current practice or policy?, or relevant research-based literature? If they identify new areas where research is necessary If the researchers have discussed whether or how the findings can be
transferred to other populations or considered other ways the research may be used.
Critical Appraisal Skills Program (CASP) qualitative checklistdthree options available as a reply: yes, cannnot tell and no. Inclusion of checklist number in the table implies a positive answer.
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2
performed with a global perspective. One study dealt with a
basket of European Union (EU) countries (Germany, Denmark,
the Netherlands, Belgium, Luxemburg, France, the UK,
Ireland, Italy, Greece, Spain, Portugal and Austria). One study
referred (separately) to Switzerland, the Netherlands, Puerto
Rico and Taiwan. Among the studies that referred to specific
health conditions, six concentrated on oncology, four on cardiology, three on orthopaedic operations, one on transplantation and one on sepsis. Three studies focussed on
disparities in waiting times pertinent to insurance type.
Among the 15 qualitative studies, two referred to a group of
five countries (Belgium, Germany, Israel, the Netherlands and
Switzerland) and two to the USA. Among the remaining
studies, one dealt with EU countries, one combined the
Netherlands and Germany, one assessed Dubai, one focussed
on central and eastern Europe, one on the Netherlands, one on
Ireland, while the others had a global framework.
Data items and critical appraisal
Two reviewers independently assessed the scientific quality
using Cochrane Risk of Bias tool and the Critical Appraisal
Skills Programme (CASP) tools (Table 1 and Supplementary
Table 1, respectively). Disagreements were resolved by discussion or by consulting with the third (lead) independent
Equity is a fundamental pillar of health systems and it encompasses timely access, equivalence of care and absence of
avoidable or remediable differences among groups of people,
pertinent to distinct social, economic, demographical or
geographical criteria.11,12 Persistent differences in the health
status due to socio-economic status constitute a major concern
across developed countries.13 Health inequalities escalate to
significant health disparities, which were primarily reported in
the oncology sector. Four out of the six studies that investigated
cancer patient outcomes in single-payer vs multipayer health
system settings, indicated that the insurance type was interweaved with survival. Among these, one study reported that
certain insurances were correlated with advanced stage colorectal cancer diagnosis, which leads to lower relative survival.14
McDaid et al. concluded that the outlined variability of outcomes of lung, colorectal, prostate and breast cancer could be
attributed to insurance type.15 One study regarding breast
cancer evinced that within a multipayer system, patients with
private insurances presented with statistically significant
smaller tumours, compared with public beneficiaries.16 Robins
and Niu reached the same conclusion for colorectal, breast, lung
cancer and non-Hodgkin lymphoma.17e19 Nevertheless, two
studies did not find significant differences in breast, cervical
and colorectal cancer.20,21
Three studies reported on orthopaedic care. Among these,
two attested a significant association between income-related
health insurance and hindered access to medical care, leading
to impaired functionality after hip replacement therapy.22,23 It
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was also observed that there was a statistical difference
among several types of health insurance; patients covered by
non-commercial insurance be in a disadvantaged position
regarding their referral to rehabilitation services. Martin et al.
in 2012 also reported that the payer type was statistically
significantly associated with disparate joint arthroplasty
Two more studies reported data on sepsis and lung
transplantation. O’Brien et al. argued that risks of sepsisassociated death varied by insurance cover.25 In the same
vein, Allen et al. found a statistically significant correlation
between survival of lung transplant recipients and insurance
type.26 Two studies reported on paediatric data indicating
disparities between asthma management and insurance type
among children,27 and some payer types demonstrated
diverging results contingent on the neonatal and postneonatal period.28
Three studies reported findings from Germany. Lungen
et al. stated that for five specific specialist examinations, patients enrolled with statutory health insurance (SHI) waited
3.08 times longer for an appointment, compared with patients
with private health insurance (PHI).29 Kuchinke et al.
concluded that private insurance patients in Germany have
statistically significant lower waiting times in a sample of 485
hospitals.30 Adding to this, Scwiertz et al. concluded that
exacerbated discrimination in waiting times between SHI and
PHI beneficiaries, is -paradoxically-related to better financial
performance of the hospitals.31
Four studies reported data in the cardiology sector. The
insurance type also proved to determine the use or not of
drug-eluting stents.32 Moreover, Laux et al. also stated that PHI
patients are more likely to be prescribed newer antihypertensive agents.33 Two of these four studies reported conflicting data with regard to the association of the payer type and
outcomes of cardiac surgery.34,35
Finally, Taiwan’s recent shift to a single-payer design verifies that a single-payer system culminates to equal access to
healthcare substantiated by high public satisfaction rate.36
Efficiency and quality of health care
Quality in health is a multifactorial process and it has been
interlaced with performance management, goal setting
through health indicators, academic detailing and introduction of guidelines.37 In general, the private sector is perceived
to be more efficient than the public sector. There is an attempt
to extrapolate this in the health sector, but this is highly
challenged.38 Geyman concluded that private hospital costs
are 3e13% higher, employ fewer nurses and death rates are
6e7% higher compared with public hospitals.38 In specialised
units, such as dialysis centres, private centres reported 30%
higher death rates compared with public units, while premature discharge from private hospitals was also observed. And,
if we assume that fragmentation hinders efficiency improvement, we have to take into consideration that in the US, a
sample of 2000 patients with depression were enrolled in 189
different plans with 755 different policies.39 Moreover, highquality healthcare implies that extrinsic factors such as
employment status and payment status should not affect the
quality of provided services. The assumptions have exceeded
the body of evidence and no differences in outcomes were
observed in a study between single-payer and multipayer
A single-payer system with a centralised data mining
procedure is more likely to be able to glean and analyse health
indicators, while the direct comparability of providers will
presumably nurture patients in informed decision-making
and concomitantly will engage providers in an efficiencyenhancement saga.41 Additionally, public single-payer systems are depleted of a profit motive. Although this may reduce
overall costs of the system, it also nullifies incentives for efficiency improvement of their operation framework. In this
notion, a multipayer system may be more efficient. Nevertheless, the rather oxymoron finding of underinvestment in
high-quality care because of enhanced competition between
insurers was reported, as quality improvement projects in
hospitals run by a specific health insurance will also benefit
the patients enrolled with a competitive insurance.42 In the
same context, it was also reported that patients with private
insurance give more favourable evaluations to their physicians (P < 0.001) compared with patients enrolled to SHI. Competition enhancement among purchasers was proved to be a rather unattainable target across a cluster of EU countries,43 while Besstremyannaya reckoned that the increased competition between private insurances in Russia did not lead to an improvement in the quality of care.44 Financial protection Fund collection A single-payer system can explore synergies with taxcollecting structures at a marginal cost, which concomitantly comprises disadvantage in countries with significant tax evasion.45 In tandem, a single-payer system can also be ‘pitted against other government priorities’, and it is an easy target on fund reduction.46 It is also vulnerable under a hostile government due to its interdependence with government structures. Finally, a multipayer system requires replication of several individual mechanisms, from each payer, which further ramps up not only the total costs but also the complexity factor. Apart from this, fund collection is considered to be easier. Negotiation, contracting and budgeting Competitive forces in health are flawed because its main attributes entail asymmetry of information, barriers of entry and no potential substitution effect.47 This is frequently overseen by people who endeavor to compare the health market with other commodity markets. Nevertheless, some unique and controversial attributes of the health market, such as healthcare's positive externalities, point out the importance of proper access for patients to the necessary healthcare services. Inequalities in access may be further exacerbated by the market, while they are rarely remedied by it.48 Therefore, contracting of public good's services such as health services could have negative effects if the operational framework is not liable to constitutional scrutiny and does not abide by legal and ethical accountability.49 p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2 Contracting A multipayer system is a market-oriented approach and it perceives health as a commodity.50 Feldman contented that a single-payer system deems health as a public good, which will be underprovided for in a multipayer system.51 Multipayer systems can offer patient-centred packages, an attribute that is debated because several authors demonstrated that a service rarely fits just one patient, but it usually suits a collection of patients of similar sociodemographic characteristics.47 Moreover, a multipayer system may accommodate risk-averse individuals, for example individuals who oppose high deductibles and cost sharing. Multipayer schemes assume beneficiaries as temporary contractors, which stems out of its own subsistence. The downsize of this characteristic is that preventive policies that usually yield later in time are rather unlikely to be reimbursed because the current beneficiary may change supplier by the time intervention becomes cost-effective. Adversely, a single-payer system does have a strong spur to apply screening and preventive programmes.52 This was epitomised in Abu Dhabi's preventive programme ‘cradle-to-grave’, which encompasses this long-term commitment between payer and beneficiary.53 A single-payer scheme assumes that patients are not adequately informed to make rational choice and they are presumed as passive recipients.40,46 Consequently, the provider's response to the consumer's expectations is not correlated to the improvement in patient's utility. The lack of the required information from the patient perspective is not problematic, while the lack of proper evaluation of that information by the patient is what matters the most. A singlepayer scheme overcomes this issue by offering the entire spectrum of health services.49,51 The health market is an oligopoly due to high barriers of entry, pertinent to costs, medical licensure and expertise.2,4 Therefore, bargaining power shifts to suppliers and erodes the power of buyers. This feature can be exploited by current providers to raise their effective costs and even erect barriers for other providers to enter the market. Some other factors also contribute to the establishment of the health market as substantially less than perfect. Producers of health such as hospitals can influence prices, which will lead to failure of the market.41 This power escalates if the hospital is established as a monopoly or a centre of excellence, and under this assumption, it will not lead to a Pareto efficient outcome.8,9 ‘Pareto optimality’ describes the allocation of resources in the most efficient way for one party, without harming other involved parties in the same field (i.e. other hospitals or other beneficiaries).31 This will also probably cascade to profit maximisation and to stagnation of efficiency improvement because there is no need to explore efficiency as an approach to reduce costs because this can be achieved by maximising profit through the pricemaker attribute, thus exploiting the position in the market. Insurances subsidise high-risk individuals using utility and resources from low-risk individuals. Nevertheless, if the cross subsidisation surges, this creates an incentive for insurances to selectively shift low-risk enrolees to new contracts. Therefore, when insurances apply the practice of offering new 147 contracts to low-risk individuals, this leads high-risk patients to a premium spiral.54 Additionally, free mobility between insurances, without financially burdening the patients, which supposedly is the hallmark of a multipayer system, also negatively affects highrisk patients. This is attributed to the high cost incurred, the lack of available options or underwriting and fear of rejection. While free selection of insurance constitutes the benefit of a multipayer system, recent findings cast light to inconsistencies of this because one-fifth of responders expressed the concern that their age and health status would impede contracting with a new insurance.55 Most countries strived to make the market more transparent either through making the package prices publicly available and/or through the introduction of uniform benefits package and making available comparative information on the price of the benefits package. However, most availed to disseminate adequate comparative information on the quality of health services.56,57 A single-payer health system provides a single authority with all the negotiating power. This leads to an increased level of competition among providers.55,57,58 On the contrary, multipayer systems target different group of patients by segregating their schemes. The multipayer system will also lead to fragmentation of the market, which will augment the power of providers. If the market is heavily regulated, as in Russia and the Netherlands, market distortion may take shape. In Russia, this has led to insurances being merged and for the premiums to increase.44 In the Netherlands, this has led to consolidation of pharmacies, and fears were expressed for even more to come.5 This will compromise the level of care to the insured. Market competition is not a solution, and the degree of competition among insurers affects their performance. Overall, in a single-payer health system, the insurance provider is better placed to counteract the negative effects of the market power of the suppliers and the agency failures. Three studies assessed the mobility across payers, pertinent to contracting. One study reported that in Germany and the Netherlands, the choice of public or private coverage violates equity in funding, aggravates the risk for the public sector and waives the incentives for efficiency enhancement in the private sector.57 To the same direction, the second study delineated transaction costs, learning costs, ‘benefit loss’ costs, uncertainty costs, the costs of (not) switching provider, and sunk costs, as potential barriers.55 These switching costs hamper transfers for as many as half the population who do not switch insurances, an aspect magnified for people with comorbidities. This cascades to the lack of incentives for further investment in high-quality health care, relevant to these people, because their mobility is impeded. Finally, a study in Switzerland concluded that as the number of providers expands, the willingness of patients to switch between providers diminishes, thus perpetuating the creation of significant price differences even for homogeneous products.58 The multipayer system can also selectively contract with some providers who satisfy a specific need of their target group, usually low cost or some exclusive treatments, which act as a differentiating point. The multipayer system may strive for excellence in a specific healthcare speciality, 148 p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2 capitalising on risk adjustment, which, paradoxically, in some cases can be profitable.59 This opposes integration and health continuity, which are fundamentals of health care today. Selective contracting entails the notion of a substantial coverage, but it may not extend over life-threatening conditions that are the most significant reason for obtaining a health insurance, thus avoiding the catastrophic expenditure possibility. Selective contracting was also associated with a significant distance to access health care by Martin et al.24 Evidence from the Netherlands also indicated that insurances attempt to ‘enforce a joint purchase of basic and supplementary insurance’, thus splitting the cost.54 One out of four health insurances offer supplementary insurance if patients are already enrolled with a basic one, while 40% of all insurances who do not apply the previous rule, use surcharges instead on beneficiaries who opt only for supplementary insurance.54 Finally, contracting with a single payer is a much more simple and straightforward process and does not allow deviation from provided bundle of services. From a payer perspective, a single-payer system applies minimal barriers compared with screening in a multipayer system. Health expenditure A single-payer system has lower administration costs, through economies of scale, which implies that its cost advantage arises (actual costs per unit declining) with increased output, which is ascribed to the optimum usage of its resources. Therefore, by capitalising on its bargaining monopoly power, it can negotiate lower prices.60e62 This has to be monitored because it can backlash if prices fall below a feasibility threshold for providers: either by induced demand or by reducing adoption of innovation.63 The Vermont's single-payer feasibility study forecasted that under a single-payer system, expenses may temporarily rise due to its universal coverage, but they will be offset by the reduction of administrative costs.64 The conclusion has also been confirmed by the South Korea paradigm, in which the country shifted its healthcare system to a single-payer scheme, thus resulting in a reduction of managerial costs (from 8.5% in 1997 to 2.4% in 2008), attributed to the standardisation of operational processes. Taiwan's shift to a single-payer system led to savings that have largely offset the incremental cost of covering the previously uninsured people, offering at the same time greater financial risk protection.36 A single-payer system gravitates to less use of copayment and deductibles which was proved to impede access to health care for low- and middle-income patients.65 Multipayer systems imply the duplication of structures; therefore, it is obvious that this would be feasible only under a minimum number of beneficiaries and this will also lead to soaring administrative costs as in the case of the USA administration costs ($US 400 billion of a total health expenditure of $US 1.6 trillion in 2003).66 Risk pooling Health insurance dispenses risk among individuals, thus elaborating a safety net for people in need. Although risks can be highly unpredictable at the personal level and consequent health expenditure can be catastrophic for the individual, a large sample leads to predictable risk which can be distributed between low- and high-risk enrolees.67 Risk pooling is interrelated with adverse selection, a phenomenon where one member of the transaction is less informed than the other. In the case of health insurance, an insurer may not disclose all his medical history, while an insurance organisation may increase fees, or ask for more medical examinations from high-risk individuals.54 This is spawned by an asymmetrical flow of information between the two parts. Patients at a higher risk will be more likely to need health coverage, while insurance will try to identify exact health status of potential beneficiaries. Therefore, in a singlepayer system, all patients, regardless of their risk and health status, will be enrolled in the same scheme. On the contrary, a multiple-payer setting will unavoidably perpetuate to a diversified portfolio of schemes: expensive and complete coverage for people at high risk and cheaper but minimal, and potentially catastrophic, coverage for low-risk individuals. This is better described by cream skipping or cherry picking, the policy of screening and identifying high-risk individuals and excluding them by offering disproportionate high fees, or, on the contrary, focussing on low-risk individuals by offering them attractive schemes.59 In any of the aforementioned cases, patients with chronic diseases and high-risk individuals will have to pay more, leading to the inverse law paradigm.68 If adverse selection is left unchecked, it can lead to a premium death spiral, where high-risk individuals gravitate to plans with richer benefits, which escalates to the point that plans are no longer financially sustainable, further compounded by the preference of low-risk patients to opt out and pursue lower cost alternatives. Multipayer health insurance tries to waive this uncertainty and all adjoined risks through risk adjusters. Risk adjusters (risk equalisation) redistribute resources among fragmented patient pools. It is a resourcedemanding process, both in human and monetary terms. It can be complicated, while it can be only partially effective. To grapple meaningfully excess risk, demographic data, medical history, ex-post utilisation, current medical condition, chronic illness, urbanisation, and diagnostic cost groups are used to adjust the risk. Demographic data are the easiest to collect, but their projecting power is low. Therefore, selection of appropriate adjusters must reflect the ability to gather data and risk of manipulation of data. An optimum risk adjuster is still an unmet objective. Risk equalisation can be performed either ex-ante, thus at the beginning of the financial year, or ex-post, which is done at the end of the financial year. The downsize of risk equalisation in a multipayer system is that the weaker the risk adjusters are, the higher the possibility of costly patients (i.e. suffering from chronic diseases) being averted by private insurances and burdening the public insurer, which will have to be subsidised by the government.2 Conversely, a potent risk equalisation may support the implementation of effective chronic disease management programmes as an incentive to the insurer to reduce the cost of the chronic diseases.67 Social solidarity Social solidarity embeds the social cohesion and interdependence among the members of a geographically, ethnologically 149 p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2 or socially defined group. The sense of solidarity can also be expanded to accommodate the sense of responsibility and giving to vulnerable groups of the society, such as the elderly, disabled, socially and financially deprived and persons with chronic, life-threatening and orphan diseases. Social solidarity is expressed as a form of exclusion from contribution either to the fund and/or to the point of care. This assumes that their costs will be shifted and spread across the other beneficiaries. Progressive contribution to health funds is a concept that better fits the concept of solidarity: people who are wealthier contribute a higher amount of money, which without financially affecting them can be used to finance others. This bridges the gap between rich and poor beneficiaries, primarily by alleviating financial burden from the poorer and subsidisation of the health costs of low-income individuals. A single-payer system may better serve solidarity because a multipayer system perpetuates to fragmented patient pools. Usually patients in a multipayer system with an annual income above a specific threshold are allowed to apply for a PHI, while patients with lower income can only contract with public insurance.29 The use of premiums on a disease basis, as applied in multipayer schemes, does not seems to serve social solidarity. On the contrary, Taiwan's paradigm underpins that solidarity in healthcare financing is more prominent under a single-payer system.36 Conclusion This systematic review identified that there is not a gold standard contingent to a UHCS, and the payer type is highly pertinent to each country's characteristics, public policies, social coherence and national structure. Thus, countryspecific cultural, institutional and sociodemographic factors are imperative and decisive factors for an effective payer-type selection3 (Table 2). Current evidence accentuate that a single-payer system is more equitable to patients than a multipayer system, mainly because of access and its progressively financing pattern. Multipayer systems use premiums collected by the patients, which constitutes a regressive pattern. This can also comprise their differentiating point because they may compete for the direct premium part of the funding.54,69 A single-payer health system can also effectively distribute risk throughout a large risk pool. The risk distribution must be regulated under a multipayer system on the basis of relative claims made by policy holders, which provides that insurances with high payouts will receive additional funds. This aims to waive any incentives to deter highcost individuals. In a single-payer system, the government is the single payer, an attribute that while it augments single-payer's bargaining power, it may also emerge as a drawback under a hostile or inefficient government. In this case, a multipayer system would be better-off. The ability of a multipayer system to provide tailor-made healthcare coverage based on the individual's characteristics intertwines with the adverse selection, which is also linked to the individual's characteristics. Adverse selection can be avoided, usually with highly sophisticated risk-adjustment programmes, a factor that inflates costs. This accentuates why multipayer systems seem to be costlier, mainly imputed to increased administration costs. Although there is some evidence that a single-payer system is more likely to sustain solidarity and equity, this review is inconclusive in fully supporting it. Moreover, there is an indication that the single-payer system lacks the motive for efficiency enhancement, in contrast to multipayer systems. Finally, current paradigms from recent reforms in several countries corroborate that a single-payer system is a preferred scheme, albeit the selection must be compatible with each county's policies and governance pattern. The ability to collect revenue, expertise in risk adjustment and diversity of population are merely some of the issues that may influence setting selection. Table 2 e Type of payer among European countries. Country Austria Belgium Czech Republic Denmark Finland France Germany Greece Hungary Ireland Italy Malta The Netherlands Norway Portugal UK Spain Sweden Payer type Efficiency of system Gatekeeping Health expenditure (% GDP) Multi Multi Multi Single Single Multi Multi Single Single Single Single Single Multi Single Single Single Single Single 9th 21st 48th 34th 31st 1st 25th 14th 66th 19th 2nd 5th 17th 11th 12th 18th 7th 23th Free access Free access Free access (referral for hospitals) Partially Yes Partially No No Yes Partially Yes Partially For hospitals Yes Yes Yes Partially No 10.8 10.5 7.5 11.1 9 11.6 11.3 9.1 7.9 8.9 9.2 GDP, gross domestic product. 11.9 9.3 10.2 9.4 9.3 9.5 150 p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1 e1 5 2 Five-year outlook The sustainability of health systems worldwide is going under a stress test, which is expected to intensify as life expectancy increases, culminating to the proliferation of healthcare needs. In the context of hovering financial recession, health systems will be faced with the dubious tasks of satisfying increasing needs with constrained resources, a ‘do more with less’ approach. The constant introduction of new medicines, with higher costs and uncertainty apropos their clinical effectiveness, further aggravates the feasibility of health systems to adequately provide health care, especially in the current era, which is characterised by easy dissemination of information to the public. Moreover, an ageing population, will surge expenditure for social care. This implies that health agencies will scrutinise the payer type of their health systems, with the ultimate task to further enhance their efficiency. This becomes even more complex in tandem with the current refugee crisis in Europe, the worse since the end of World War II, which has seen millions of people, the majority presenting with physiological and physical conditions, migrating to Europe. 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