If you define single payer that broadly, ok. I'll just mention that Japan gives you your choice of about 2,000 insurance providers, which advertise extensively.

> I'll just mention that Japan gives you your choice of about 2,000 insurance providers, which advertise extensively.

How does all of this additional overhead provide more value to the consumer at the end? How are they actually differentiated?

I'm not sure (possibly because I read the book years ago). The other two countries handle it differently.

Japan's healthcare cost is the lowest of the three though, at 5% GDP, despite an aging population of heavy smokers. So there doesn't seem to be that much overhead.

Despite Japan's aging, heavy-smoking population, Japanese people tend to be very healthy for reasons that aren't necessarily related to their healthcare system.

And Americans tend to be overweight and unhealthy. Access to healthcare doesn't automatically shift culture to live a healthier lifestyle (and I suspect it might even do the opposite).

The paper considers that hypothesis and rejects it, honing in on prices not utilization as the problem. Indeed its title is "It’s Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt"

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05144

It would be great if gym memberships could be made free for everyone. I bet it would even be cheaper in the long run to buy an Equinox membership for every American than it would be to do nothing.

Free gym memberships are unlikely to result in higher use. I've had multiple workplaces where gym is free and I've rarely used it, thankfully, I am blessed with a skinny physique and parents who inculcated good food habits. In fact, places which charged for gyms explicitly saw slightly higher usage since some folks logic went, since I am paying for it, I might as well get my money's worth.

American health care plans are starting to offer financial incentives for maintaining fitness.

Which seems a bit like a tragedy of the commons situation.

In that insurance company X is paying me for later life benefits that may be reaped by insurance company Y that I have 40 years from now.

We need to hurry up and get to baseline genetic risks, then directly rebate insured out of a central pot if they exceed their expected fitness metrics.

Due to Japan's "metabo law", adults are required to get their waistlines measured every year and those who exceed the recommended limit have to get treatment.

https://mic.com/articles/84521/japan-has-cut-obesity-to-3-5-...

I don't necessarily agree with that policy, however it does appear to be effective in cutting healthcare causes. In the US a large fraction of our healthcare expenses are due to chronic conditions related to obesity.

Germany has a split system between mandatory government healthcare and voluntary private healthcare, once you pass a certain income threshold (about 80% above average income) or are self-employed.

There are differences. The voluntary insurance usually pays 2x to 3x of the mandatory one and covers more treatments that are seen as optional by the government insurance. E.g. physiotherapy is covered by government insurance only for clear indications while private insurances might cover it as a precautionary measure in many more cases. Also private patients can usually skip some waiting time (e.g. days instead of a few weeks).

But (nearly) everyone is covered, government or private, and can go to the doctor without worrying about money.

Even the government insurance isn't a single entity, but you can choose between multiple providers. All charge the same 14.6% of pre-tax income (capped at ~55k income) plus an additional 0.7% to 1.x% depending on the provider. They also compete on additional services. E.g. my provider adds a free professional tooth-cleaning per year and free travel-vaccination among other things.

> Also private patients can usually skip some waiting time (e.g. days instead of a few weeks).

See, now, that just really doesn't sound like a good idea to my ears. Why should someone be forced to sit through weeks of suffering while a handful of others don't, for the sole reason that they have more money to throw at the problem? I can understand buying better or more thorough treatment, or buying treatment from more expensive providers I guess, but line jumping via money just seems immoral when it comes to health care.

Why do you think line-jumping is more immoral than getting worse treatment? In one case you just have to wait in non life-threatening and non-urgent cases (you only have to wait if you actually can wait). In the other case you are actually in a worse physical or mental position.

This is like if the whole town is on fire, but you have enough money to pay the fireman to save your house first. Priority access to universal needs shouldn't be given based on personal wealth. I wonder if the people who wrote this line jumping into law qualified for the public or private insurance.

No, it's not. This analogy would only apply for shorter wait times in emergency cases. And that's not true and I explicitly said that. Everyone gets the same wait time in emergencies and urgent cases. But a significant amount of cases can actually wait.

It's more like your car broke down and you have to wait longer than the guys who pay extra to get a same-day repair. But if you are a taxi driver and depend on it, they repair it anyway on the first day.

The private insured patients also sponsor better treatment for the government insured patients.

It's a good compromise (and I'm saying that as someone who is government insured) and there is law in place like a maximum of 3 weeks wait time for a specialist appointment.

There actually are private firefighting companies which homeowners or insurers can pay to save their houses first.

https://www.businessinsider.com/california-wildfires-private...

> universal needs

Not everyone agrees Person A's needs should be paid for by other people. The system described (that pays for everyone, but treats people that can afford it better) may be a reasonable compromise to those people.

That sounds like the UK system, where everyone gets NHS, but those that want to spend £1k a year extra or whatever get private healthcare (BUPA etc)

Yet everyone uses the roads, schools, and safety paid for by everyone to ultimately get to their advantaged economic position. Healthcare is a public effort just like any of the above, and no one should suffer unequally due to class favoritism being built into public efforts. We shouldn't compromise with people who lack the humanity to see this.

To be clear, I'm in favor of everyone having healthcare. To some extent, I'm playing the devil's advocate here. Also to some extent, I think getting from where the US is to everyone having healthcare is a very difficult trip to make. That being said...

- There is no way to support roads without everyone supporting them for everyone. It's not possible to pay for "just the roads I use". - Educating the next generation helps everyone. - Keeping someone else healthy does not help me in any real way (I disagree with this, but it is a viewpoint that can be had).

It does help you in a real way just as existentially as educating the next generation helps everyone. A healthy population is an economically productive population, and ensuring people get preventative care on time prevents strain on emergency services and saves the whole system money. In fact, this is how private insurance works too, your regular bill pays for other customers services, yet private insurance is somehow not viewed with the same contempt by conservatives.

It is already illegal, yet practiced widely because the burden of proof is on the patient that cannot look into the doctor's records because of privacy.