The public insurance option won't really work since it doesn't treat the core problem with the system. There is no fair market for goods. The market hasn't found the price for physician services as goods. Whether they are contractors, or employees, or whatever isn't the problem.
The typical solution when a monopoly is overpriced is that a competing firm enters the market to challenge the current cost structure. They may succeed, they may fail, but the change the market, imperceptibly at first, but ultimately they can revolutionize the system. This is currently not possible due to insurmountably high costs of entry. To create a completely new vertically integrated healthcare provider is ridiculously expensive due to the insane legal, legislative and incentive environment. No sane businessman would touch this system, even with its high profitability.
The government is still the solution to the problem, just not by applying a band-aid 1,990 page insurance triage. The current generation of AMA Lobby supporters, physicians, etc... are not going to approve any change to the way the system works. It is just to lucrative for them. In a free market economy, they would be destroyed by their shareholders if they didn't. The only thing left in this particular industry is for the government to directly compete with them.
Instead of aid, legislation, and obscure and complex incentives, allow the government to create an entity that directly recruits Med Students and offers them high salaries, about 30~50% more than the current average being offered by other providers. Even at that salary rate, probably somewhere around $300,000 per year, the costs of running this system would be a minor fraction of the currently allotted 2020 national healthcare bill. The costs would diminish continuously, in much the same way as a normal company's costs diminish as they innovate in efficiency.
Sign the students, and any other professional physicians to long term contracts, between 5 and 10 years. Basically treat them like athletic talent. Take all legal responsibility away from them, take all of the management tasks away from them and give them the ability to just work on the problem, the patient. This focus alone should improve outcomes by 25%. The key to this is to completely ignore the current incumbent provider community, unless they want to work within the system.
Then, within this particular structure, put students directly to real meaningful work with senior students or physicians, not the hazing that happens currently. Provide clear decision support systems that provide recommendations as opposed to CYA legal blah, mandatory treatments and tests. This will help to create some consistency, since you are putting less experienced Doctors in front of patients in some cases, but it will allow stars to shine.
Then, let them innovate, allow them to submit ideas to improving workflows and efficiency and take them seriously. Let these students own, drive, and change the organization. This will go a long way to retaining talent. Secondly on top of their plush salaries, offer them a bonus structure that is tied to what we as a country ultimately want. Solid outcomes at an efficient cost. Give them software tools to easily see the outcome of an individual patient alongside the cost to the system. Quarterly provide meaningful bonuses for improvements in either efficiency or outcomes. These two things should be equal. This will facilitate a dynamic environment that is responsive to changes in COGS basically, but where docs can make the choice to burn a bit more money if they think the outcome would be better. Keep the choice with the physicians, not with the bureaucracy. The in-the-trenches physicians still, and will always, know better than any non-practicing doctor or legislator what needs to be done. Keep the decision support systems transparent so that prosumer patients could question the logic of the decisions that the physician is making on their behalf. Use email and telephone to actually talk to people and answer questions. That would cut down on probably 15% of office visits.
For the first few years, this would be fairly expensive, but the effect on the market would be swift, and within 10 years would drop the cost of healthcare dramatically. The first effect would be to incent people who would have chosen other careers, but that want to help people live better lives, to seriously consider going to medical school, instead of making a web startup. The pool of talented, caring, individuals would increase in med school.
Another significant effect would be that competing providers would have to drop their costs, and change the way they pay doctors to be competitive. Medicare, along with all of the other insurance providers would prefer sending patients to this vertically integrated nationwide clinic / hospital system. Their cost structures would adjust to reflect this, plans allowing patients to see any physician would be probably 20x the cost of going to the government's clinic.
Malpractice insurance would increase hugely in cost since most doctors coming out of med school would opt for this deal and not need it, since demand would not be there, costs would likely increase for those physicians not working for the system.
If the fees are higher, the physician's cost for service would be significantly greater and the average person could not afford a plan that would cover them. If the provider were super awesome, they could probably scare up enough high-end clients to have a comfortable lifestyle and create a few jobs by doing it the old-way, but these places would be health boutiques basically and not mainstream.
Since most of the procedures from these places would not be covered by any insurance, consumers would have to directly pay. Even with the boutique health providers, the direct payment for services rendered would control costs.
Physicians would have to reduce their margins in order to retain patients, some hospitals would innovate and be able to attract quality talent at a lower cost, some may go out of business, but ultimately providing an alternative like this would force the market to function properly.
How would we pay for this? Obviously we'd have to raise taxes. However, we would be paying for a functional system that would start to dump money back into the hands of business owners in the form of dramatically reduced plan costs to the business, and consumers. Those returns would dump into the GDP since business and consumers would be likely to spend money on other goods and services.
I don't personally like deficit spending, but it could be funded that way, over 10 years the system would more than pay for itself.
Basically this is single payer healthcare, but in the most American way possible. You introduce an innovative, well capitalized competitor to the monopoly offering better service at lower prices. The market then will do what it does best, seek efficiency and profits. TANSTAAFL, we'd have to pay up front, but we'd create millions of jobs, fix the system, and once again be a model for the free-market system. Ultimately it would make sense to IPO the company and let it ride, but that would have to be after 20 years or so, and it would have to be regulated as heavily as a California utility company, but it would be an independent company that others could compete against. The goal is just to return the efficiency and sanity of the free-market to healthcare. I, in my naivete can easily make proposals, but I think this just might work.
