The most efficient system would be direct payments only.

The downside is only the very roch can afford expensive medical emergencies.

But with insurance individuals get to pull the value of future premium payments forward to pay for large expenses in the present. There’s also a degree of socialization.

The downside is there will always be an overhead.

Government health care is insurance writ large and has the same tradeoffs, just on a larger scale.

> Government health care is insurance writ large

I would argue that it has even more tradeoffs; unlike private insurance, it's usually both mandatory and a monopoly, and that can go very wrong very quickly.

The US system is extremely overregulated and preventing true competition, even though US insurance is private, so there aren't really any good data points to compare, though.

Public systems can work very well and I can’t name one system which went downhill very quickly.

Exactly, the NHS is only going downhill because the dominant ideology among MPs has been that the NHS is the first place to get gutted for cheap savings. A lot of very efficient systems were removed and farmed out for "cheaper" private systems, that end up being rather costly in the long term with respect to increased error, price rising, and all the myriad ways incompetence and explicit money-grabbing messes with healthcare. They gutted the administration systems and now doctors have to work overtime on the weekends just to get their notes in the system, and now because doctors are overworked, they're putting more work into the hands of the incredibly underqualified PAs. And on top of all of this, repeated mismanagement of the money that is distributed to the NHS — including, of all things, incredibly inept bartering, putting hospitals on a "target system" where underfunded hospitals are given less money for not hitting targets, etc. It's a complete joke, but every step was damned near deliberate for the case of farming public money into the pockets of the friends of MPs.

The problem with the system in the USA is that paperwork can make all the different in costs. The burden is on the individual to comprehend all the implications of their choices. These choices are beyond do I want my ailments addressed.

Often, people in situations where they require healthcare are least able to assess the implications of their choices, as well. It is very literally praying on the sick.

You could provide every American with extremely robust healthcare for a trillion dollars a year. Probably less as you allocated resources based on need.

We choose to spend that on the military. Basically you can choose guns or butter, we choose guns and empire. Whether that is a “correct” decision is an exercise for the reader.

The US spends more on healthcare than arms.

You could argue for lower defense spending, but there’s a hard lower limit (which is unknown) and if you cross that threshold, the world changes for the worse very quickly.

The rules-based order is underpinned by tanks and planes and nukes. Diplomacy is a layer of abstraction over violence and potential violence.

Medicare costs $800 billion/year and only covers 20% of the population. They are on average the most expensive 20%, but I doubt you’re going to cover all the rest for another $200 billion.

Medicaid is another almost $1 trillion/year.

I've resorted to calling this kind of breathless fearmongering out for what it is. There are too many people suffering too greatly in the existing system to be civil at the expense of maintaining the fictions of libertarian idealogues.

Hyperfixation on an idealistic interpretation of real-world dynamics will always be thought-terminating. In the dichotomy of map vs territory, the map is definitionally a cliche. We can be better than that.

With many insurance companies there are lot of coordination costs.

Government "insurance" has several advantages:

- it has a much larger pool of insured, which reduces overall risk, and thus can have lower premiums/taxes

- there is no need for profits, which again lowers costs

- providers only have to deal with a single "insurer", which significantly reduces complexity of getting paid. Patients no longer have to waste time filling out paperwork about their insurance provider, and dealing with misunderstandings and miscommunication about whether they are insured, who they are insured by, etc.

- You no longer have to worry about if your preferred provider is "in network". Which also removes needless beurocracy.

- There is more of an incentive to care about longterm health, because the government will pay for all healthcare over the life of the patient. This used to be the case for private insurance, back when people stayed with the same employer, and same insurance company for most of their life. But now, insurance companies just want to minimize costs while you are with them, which probably won't be that long.

- Employers no longer have to waste time and resources providing health insurance for employees, and employees no longer need to spend time, energy, and anxiety on "open enrollment" every year.

Furthermore, you can have rich people and big companies pay for a good portion of it, through taxes

One interesting thing i would like to see would be for costs like Medicare not be borne by businesses on a per job basis but rather just part of their tax liability (note: requires first fixing the loopholes that mean large corporations pay no taxes).

Reason being that it disincentives job creation, by making it more costly to hire in America. Arguably all businesses and people benefit by keeping people alive longer, and therefore the companies which employ more people but make less profits shouldn’t pay more towards that goal. Let giant but very profitable companies with fewer employees pay too.