the economic structure of health care in other places just isn't what all too many people think it is. There's a large part of the American political class insisting that this is just obvious. We should have a national, single payer, health care financing system. And the amazing thing about this is that so few countries actually do that. And most of those countries who are thought to have better health care systems than the US don't do that either.
There are indeed national health care systems out there--but they tend not to be single payer. And there are single payer systems out there, or close enough at least--but they tend not to be national. Which is something that we really ought to be thinking about, no?
Take it as read that the US system isn't as good as it could be. And also that we might want to propose something to make it better. So, we're agreeing that something must be done. /My point here is just that the economics of what we should do might well not be the same as the economics of that national single payer system we're urged to implement.
This has been sparked by this piece from last weekend in the NYT:
Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it
OK, let's also take it as read that the Finnish system works. And it does too, it's a pretty good system, as are those in Sweden and Denmark to my certain knowledge. But the bit that concerns me is that nowhere in the piece is a very important qualifier mentioned. So too it's not mentioned in the bulging letters page this weekend.

Those three Nordic systems are not national systems at all, although they are all single payer. It is the municipality which collects the money, the tax, to pay for health care. And it's the municipality which then spends that money too. I maintain that this is rather why those Nordic social democracies work too. The Danish national income tax rate is 3.76%. No, that's 3 point 76%, not 37.6%. The top Danish national income tax rate is 15%. The place the money really gets gouged is at the level of the commune--that can be as small as 10,000 people and is thus a much, much, smaller unit than an American county. That money is raised locally and spent locally and that, I insist, is why people are happy enough that they've got to pay so much in tax.

I've called it the Bjorn's Beer Effect:
Instead they have what I call the Bjorn's Beer Effect. You're in a society of 10,000 people. You know the guy who raises the local tax money and allocates that local tax money. You also know where he has a beer on a Friday night. More importantly Bjorn knows that everyone knows he collects and spends the money: and also where he has a beer on a Friday. That money is going to be rather better spent than if it travels off possibly 3,000 miles into some faceless bureaucracy. I give you as an example Danish social housing or the vertical slums that HUD has built in the past. And if people think their money is being well spent then they're likely to support more of it being spent.
In the end, local collection and spending of taxes is likely to lead to people being willing to pay higher taxes.
That's not how anyone is proposing some notional single payer system in the US is going to work, is it? Rather, the vision is of one bureaucracy collecting all the money from 320 million people and then doling it out again on a national basis. And the sums would be eyewatering - $2 trillion sounds about right. 10-12% of GDP is that roughly right number for providing full health care to everyone.
Other systems are mentioned as well:
A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.
Note the very careful indeed wording there. Universal government guided health care--for those systems are not single payer. Holland, Germany and Switzerland all have mandatory insurance systems from private sector insurance companies. Germany has some 130 of them for example.
Again, please note I'm not trying to talk about whatever the US should or should not do. I'm making an observation about the economics of systems which seem to work in other places. The exemplars we're all asked to look at are not national, universal and single payer. They tend to be either almost hyper-local in their financing if they're single payer or if they're national then they use insurance companies--they're multi-payer. My assumption would be that both single payer and national is just too inefficient. There's neither local pride nor profit lust keeping the system efficient.
There are indeed national and single payer systems out there, most notably the National Health Service in Britain. That's very fair, very equitable, but performs horribly on "mortality amenable to health care" which is otherwise known as curing people of what ails them. That's not a recommendation