The problem isn't necessarily that it's a semi-private market, it's that for the vast majority of people it's tied to their employer.

The only for most Americans to have a choice in their health insurance is when they get to pick between the plans from either husband's or the wife's employers.

The biggest disappointment of the Republican alternative to Obamacare was not coming up with a way to sever that tie.

> disappointment of the Republican alternative to Obamacare was not coming up with a way to sever that tie.

Since that tie is also maintained by large amounts of political donations, it's going to be a hard one to break.

But tying it to an employer allows for group rate bargaining with the insurance company. I'm no expert in insurance, but I imagine there's very few instances where an individual will be able to negotiate a better rate for comparable coverage than they would get as part of a group.

Sure it cuts down on individual choice, but it should theoretically be the most cost efficient method, both for the employees and the insurance company.

It's inefficient in the first place that groups are limited to employees within a given employer instead of entire insurance customer bases or broad product based policy groups. It is very much not a cost efficiency to introduce employer sub groupings of customers.

Employer-based plans typically have lower premiums because they are, by definition, groups of working-age and (in most cases) working people. They are younger and less sick, so insurance costs are lower. (Dependents are typically more expensive.) This is the reason that companies, once they reach a sufficient size, self-insure, because they are carving out their younger and healthier population from the broader population. Plus, there are savings gained from administrative costs as well.

Selection of plans or providers is not the problem, especially with the current popularity of PPO plans.

I have a really hard time believing that somehow companies self-managing healthcare administration is more efficient than a large group consisting of the entirety of an insurers customers let alone vs. nations with universal healthcare or even ones with single payer private healthcare. And that doesn't even address the many small businesses which need to pay for "individual" plans as if there weren't larger groups with which to distribute the risk.

Even the marketing act of splitting up all these groups up as you describe is a huge waste. Now you have to shop the differences, the companies have to explain the differences, and everyone (insurance co, health provider, patients) gets to track multiple different groups with different rules. It's all a waste compared to fewer larger distributed risk pools - which is the whole point of insurance.

High marginal tax rates incentivizes employers to offer health care benefits instead of salary. This is a main reason why health care has been so closely tied to insurance. Either tax the benefits at the marginal rate, or reduce the marginal rate to liberate health care from employment.

By technical I don't mean unrelated to the question of who pays. It's certainly related. But, I think it's a mistake to spend too much time on the macro-level "medical care as a right" or "free markets."

Most medical markets (including the US') have large free market & "social" elements. I don't think moving one way or another along that axis would move the needle in a predictable way. That would be decided by the more detailed points. That's what I mean by technical