The United States does not have a healthcare system. There are several. Medicare is a single-payer option with mostly private provision and some alternative administrative choices with an overview of secondary private health insurance overlays. The Indian Health Service is comprehensive in Beveridge. Kaiser is a unique private system with almost complete vertical integration. Tricare is a social insurance model with limited private provision. Employer-based health care is privately funded (with a generous tax break on said provision), privately administered (subject to millions of pages of regulation) and privately delivered (with minor exceptions for state-funded hospitals, etc.). Then we have health sharing which is explicitly not health insurance, but involves “voluntary” bearing of costs by members, often bound by religious beliefs.
Then you have the growing option of cash-based health care where providers take all comers, but only those who can put money on the barrel because the paperwork is too expensive. And of all the ways healthcare is administered in this country, this and the VA are the only ones that don’t cover the full spectrum of benefits (at least not yet).
I worked for most of them. All are systems larger than several small European countries. All are significantly more expensive than similar delivery mechanisms overseas. All suffer from intrusive and costly interference from politicians and bureaucrats which, in my experience, results in active degradation of patient care.
There is no good way to pay for health care in the United States. Chances are, if you name an option, someone has failed to get the necessary buy-in at the state level. If you have a list of essential features, there is almost certainly an option that has already tried it.
Changing who signs the checks seems to make a very small difference. We’re looking for crumbs focusing on whether the overall model should be more Kaiser or more IHS or more Medicaid.
The far greater impact are the patients. We need $500 chairs in the waiting room, to make sure those with a BMI >50 won’t see them crumble under their weight. We had to order a larger CT scanner a few years ago when it was deemed unacceptable to send patients to the zoo for imaging. Opioid use means I have to detail a lot of hot bodies to manage withdrawal patients. I need an order of magnitude warmer bodies for suicide watch than my predecessors demanded at the time according to the records (and for “low risk” suicide watches I can use telesitters to watch multiple patients). I need a lot of social work hours because once the patients come to the ER I have to deal with the total lack of contact with social services that they have had while they were homeless. The psychiatric population is a permanent revolving door where I can make them basically normal (albeit weakly functional) with the help of urgently needed antipsychotic drugs, but I will see them relapse once they are on the streets and interrupting care (and will have their best long term recovery only once they have victimized enough “good” people to be imprisoned). And, of course, I need an order of magnitude more expensive home healthcare because everyone is single and separated from the rest of humanity (most single patients over 30 say not having anyone who can learn to change dressings, for example).
And, despite all this, the survival rates of health-matched controls are excellent. Are you diagnosed with lung cancer? You survive longer and better in the United States than your doppelganger in Britain or France. Do you need a hepatitis C liver transplant? Get it here if you want lower rejection chances.
American health care is starting with sicker patients and no amount of shrewd planning about signing checks or transferring patients will change that.