One of the most frequent arguments that Sen. Bernie Sanders (I–Vt.) makes in favor of single-payer health care is that other countries have universal, government-financed health care systems, so the United States should be able to have them as well. This is often declared with a sort of grumpy indignation, as if the existence of other systems is the final word in any debate on the issue. It is not really an argument so much as a declaration that single-payer is easy, and there is no real argument to be had. 

So it wasn’t exactly a surprise to see the following Sanders tweet show up in my timeline this morning: 

What’s notable about this tweet, however, is that Sanders links to a feature-length report by Vox‘s Dylan Scott on how Taiwan converted to a single-payer system in the 1990s. Scott’s piece is smart, thorough, and sharply observed, and I’d encourage everyone to read it—because, if anything, it shows just how difficult implementing and sustaining a single-payer system would probably be, even under relatively favorable conditions. 

As a newly formed democracy, Taiwan worked with well-known health policy scholar and single-payer advocate Uwe Reinhardt (who died in 2017) to build its system, which relies on a government-run insurance system to finance the majority—though not all—of the country’s health care. Some private insurance is available to cover additional benefits. 

As is often the case with government-run health care systems, the country determined that cost-control measures would be necessary, so it set up a system of relatively modest premiums and copayments. Eventually, at Reinhardt’s recommendation, the system converted to “global budgets” in which the government negotiates payments for providers based on a capped amount of total spending. 

Already, the differences between Taiwan’s system and the Sanders plan are apparent: Sanders’ Medicare for All bill calls for no copays and no premiums and effectively outlaws private insurance as we know it. It is substantially more generous than Taiwan’s system, which means it would be substantially more expensive. 

Yet one of the big themes of Scott’s piece is that Taiwan’s health care providers believe their system is too generous to patients. Even with copayments and premiums in place, Taiwan’s patients heavily utilize the system. This, Scott writes, has “predictable downsides: Hospitals get crowded in Taiwan. The capacity of health care providers to attend to everyone in need can be stretched pretty thin.” As a result, some patients face long lines, and limited access to expensive treatments.  

Doctors and other health care providers are frequently exhausted and have a much less favorable view of the system than the rest of the public. “I believe we are too kind to our patient[s],” a health economics professor at National Taiwan University told Scott, “which is not a good thing, actually.” Health officials believe that the copayments and premiums are, if anything, too low; one top health official said he planned to propose increasing them following an election. 

Taiwan’s system, in other words, is less generous and less radical than the system Sanders has campaigned on. And unlike the United States, which has a vast and complex network of health care providers and public and private financing, Taiwan started from something like a blank slate—without the embedded complexities and pathologies of the American system. 

Yet in the quarter-century it has existed, Taiwan’s health care system has nonetheless struggled with sustainable financing and utilization issues. And it has pitted doctors against patients, resulting in overworked caregivers and pressure to raise costs on individual users. 

Although Scott notes that in Taiwan, these difficulties “aren’t treated as an indictment of national health insurance,” they should certainly serve as a caution tale for anyone thinking of trying out a similar system here in the United States, where aggressive cost-control measures often fail, and where health care providers have considerable political power—in part because they have the trust and backing of the public.  

Indeed, before he died, none other than Uwe Reinhardt, the health policy expert who helped design Taiwan’s system, warned that single-payer probably wouldn’t work in the United States. “I have not advocated the single-payer model here,” he told Ezra Klein, then of The Washington Post, “because our government is too corrupt.” Doctors and providers, he argued, have too much political power.

There are inherent limits to the ability of one country to adopt another country’s system; Taiwan’s system probably tells us more about how a similar system in the United States would struggle than it does about how it would “surely” succeed. As Klein observed “Reinhardt’s argument is a reminder that the simple fact that a policy worked in another country does not mean it will work in this country.” It’s a useful reminder—and one that Bernie Sanders could stand to hear.