The conflict, then, would seem to be between regulatory capture and insurance company profits and you won't have one without the other, at least in this set up. To say that one exists purely as good guy and the other purely as villain is unrealistic. And if you had less of one than the other you might run into more abuses of one type or another. There's probably a better way, structurally, to set it up. I agree that focusing on healthier lifestyles is a way out.
I still think single payer seems to be the superior solution as long as there exists the freedom to take an alternative route. Coercion doesn't have to be part of the plan. There are far too may people without adequate health insurance and it's not getting better. I have medicare and I'm not complaining. I also pay out of pocket for alternative practitioners. Can you have a form of socialized medecine and also maximize freedom of choice? I don't see that they are mutually exclusive. Again, there are examples of other countries that seem to have better numbers and, I think, also some freedom of choice. I haven't heard of a purely private model of health care working anywhere in the world.
I think the good guys are the producers--i.e., the doctors and nurses. The villains are the people who take the value created by the doctors and nurses and try to get a piece of the action without adding any value to the overall health care delivery system.
In this formulation, the villains are the government and a portion of the insurance industry.
I don't really have an answer to what would
work. I can only observe what we have learned doesn't
As a suggested approach, perhaps the government could provide coverage for everyone that only kicks in when a person hits $50,000 or so in medical expenses in a given year. The insurance industry would provide coverage for medical expenses between $5,000 and $50,000, and there would be a premium for this coverage. Everyone would be responsible for self-insuring the first $5,000 of annual expenses, and this should keep the premiums on the $5,000-$50,000 coverage pretty low.
It's sort of like the current HSA/HDHP setup, except the government would pay everything over $50,000 in annual expenses. Since few people have expenses in excess of $50,000 per year, the government would actually be providing health care to a relatively small population of sick/injured people, premiums would be lower, and people would be able to negotiate and shop for the first $5,000 in annual spending. Since most families are going to average $5,000-$15,000 in healthcare expenses per year, this arrangement would provide a meaningful insurance component, while also allowing a premium structure that isn't outrageously expensive.
In the setup I am proposing, insurance rates would be set by age band, and if you are in that age band you would pay the premium for that age band, regardless of your own health situation, and anyone who wanted to buy insurance could buy it without answering any health questions.
I don't have an answer to the problem of waiting until you get sick to buy insurance, and I agree that this is a thorny problem. Maybe provide that for people who choose not to buy insurance and later get sick and have bills they cannot afford to pay, they become indentured servants to the state and once their health improves enough they are moved to a labor camp where they work off their medical bills. The longest stay in the camp would be two years, since the largest bill would be $45,000, since the government pays everything over $50,000, and the first $5,000 wouldn't have been paid by insurance in any case. That comes out to working off about $22,500 per year, which is probably about right. I have to think that this arrangement would be a strong incentive to maintain health insurance, and I wouldn't have a problem if the government subsidized the cost of coverage for poor or disabled people.