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The 2018 Washington State Legislature directed WSIPP to conduct a study of single-payer and universal health coverage systems. Our interim report discussed policies to promote universal health care, outlined health care coverage and expenditures in Washington, examined potential effects of implementing single-payer health care, discussed challenges to implementing it, and summarized characteristics of national and state single-payer proposals. Our final report examines universal coverage and single-payer systems in other high-income countries, which have achieved universal coverage and substantially lower health care spending than the US. These other countries, both single- and multi-payer, have mechanisms to control the prices of medical services and pharmaceuticals. They have lower insurer administrative costs and, in the case of single-payer countries, lower provider administrative burdens. These countries also have, to varying degrees, limited the utilization of some high-margin procedures and advanced imaging and discouraged the diffusion of medical technologies and drugs that have modest or uncertain effectiveness. Individuals in these countries have fewer financial barriers to health care and more equitable access to care across income groups than in the US. Finally, the higher US health expenditures do not translate to better health outcomes and quality of care for the entire population.