This is Part 6A in BrokeCon by Design, a series on how American systems are rigged against regular people. Part 1: USA! USA! USA! | Part 2: The Words That Stop You From Thinking | Part 3: Follow the Money | Part 4: The Healthcare Trap | Part 5: Employer-Based Health Insurance: Modern Serfdom
Part 5 ended on a question: who benefits from making you flinch when someone says “socialism”? The cheap answer is insurance companies, pharma, and the lobbyists they keep on retainer, and that answer is correct, and Part 5 already named them. What I want to do here is the unsexy version of the conversation. Walk through what the not-socialist countries actually do. Put an American version of it on the table. Then look at the standard objections next to the data and see which ones survive.
No vignettes. No imagine-if-you-woke-up-tomorrow scenarios. Just the plumbing.
What the Not-Socialist Countries Are Actually Doing
Every other wealthy country has solved this problem. They didn’t solve it the same way. There are three rough flavors.
Single-payer (Canada, the UK, Taiwan). One public insurer pays the bills. Doctors and hospitals are still mostly independent. The UK’s NHS goes one step further and runs the hospitals directly. Funded through taxes. No bills for medically necessary care.
Social insurance (Germany, France, Japan, the Netherlands). Mandatory coverage through nonprofit or tightly regulated sickness funds. Premiums are based on income, not on whether you’ve been sick. Funded through a mix of payroll contributions and general revenue. The state sets the rules and the prices.
Regulated private insurance (Switzerland). Everyone buys insurance from competing private insurers. Insurers can’t deny coverage, can’t price by health risk, and have to offer a defined benefit package. The government subsidizes premiums for people who can’t afford them and caps what insurers can charge.
Those are three pretty different setups. What they have in common: everyone is in, no one is one diagnosis from bankruptcy, and the country spends far less than the United States does on roughly any health outcome you want to measure. The 2024 numbers, from CMS for the US and OECD for the others (as reported by the Peterson-KFF Health System Tracker in March 2026):
| United States | Peer-country average | |
|---|---|---|
| Health spending per person, 2024 | $14,775 | $7,860 |
| Health spending as share of GDP, 2024 | 17.2% | 11.2% |
| Life expectancy at birth, 2024 | 79.0 yrs | 82.7 yrs |
| Share of population uninsured, 2024 | ~8% | 0% (universal) |
The next-highest spender after the US is Switzerland, at about $9,800 per person — close to $5,000 a head less than us. The Commonwealth Fund’s 2024 ranking of ten wealthy health systems put the US dead last on overall performance. Dead last on access, equity, and outcomes. We are not in the same conversation.
None of these countries are doing magic. They’re doing the boring things: negotiating drug prices instead of accepting whatever Pfizer puts on the invoice, running one billing system instead of a thousand, and treating health coverage as a universal floor instead of a job-shaped benefit. The US is the only wealthy country that decided not to do the boring things.
What an American Version Could Look Like
There are three live American paths. They’ve all been proposed by sitting members of Congress in the last few years. None of them are theoretical.
Path 1: Medicare for All
Sanders’ bill. Expand the existing Medicare program to cover everyone, fold in dental, vision, hearing, long-term care, and prescription drugs, eliminate premiums and out-of-pocket costs at the point of care, and fund it through some combination of payroll taxes, income taxes, and capital gains. Private insurance shrinks down to supplemental coverage, the way it does in Australia.
This is the most ambitious option and the one that gets called “socialism” the loudest, even though the structure (public insurer, private doctors) is closer to Canada than to the actually-socialist UK. The CBO modeled five different versions in 2020 and estimated that, depending on design choices, national health spending in 2030 would land somewhere between $0.7 trillion lower and $0.3 trillion higher than projected. Most of CBO’s scenarios save money. Independent analyses (Urban Institute, RAND, Mercatus) cluster across a similar range, with the conservative end skeptical and the progressive end projecting larger savings. The point is that “Medicare for All is unaffordable” is not a thing the actual budget scoring says. It’s a thing the talking points say.
Public support is real but soft. KFF’s long-running tracking shows majority support for the idea in the abstract — usually somewhere in the 53–60% range — that softens once people are told their taxes will go up, even when they’re also told their premiums and deductibles will go to zero. Which they would.
Path 2: A Public Option
Government-run Medicare-style plan, sold on the ACA exchanges, available to anyone who wants it. Private insurance keeps existing and competes with it. You can buy in if your employer’s plan is too expensive, or if you’re self-employed, or if you just want to.
This is what the Biden campaign ran on. It’s the more popular cousin of Medicare for All, polling in the high 60s in KFF surveys, including a meaningful chunk of Republicans. It doesn’t end employer-based insurance. It just gives people an exit ramp. If the public plan undercuts the private ones on premiums — which it probably would, given the administrative overhead spread — you eventually drift toward something like Australia’s system: public option as the default, private insurance as the upsell for people who want a private room or faster elective surgery.
The reason this hasn’t happened isn’t public opposition. It’s industry opposition, which is a thing Part 5 already covered.
Path 3: Regulated Multi-Payer
Keep private insurance. Regulate it so it can’t do the things it currently does. This is the Switzerland/Netherlands model, and it’s the path that gets the least airtime in the US precisely because it doesn’t fit the “socialism vs. free market” frame the industry prefers to fight on.
In practice it means a standardized essential benefits package every insurer has to offer, community rating (one premium per region, not 50 different prices based on your medical history), strict caps on administrative spending, real price controls on drugs and procedures, and income-based subsidies so the premium never eats more than a defined share of your paycheck. The ACA was a half-step in this direction. A full step would be the rest.
Switzerland’s version still spends more than any other peer country, but it spends a third less than we do, covers everyone, and consistently ranks above the US on outcomes and satisfaction. It is not a free market. There is no free market in healthcare anywhere on earth that produces good results, because consumers can’t price-shop an unconscious ambulance ride.
A Modest Proposal: Make Them Use It
Whichever path you pick, here’s the trick that would speed it up by about a decade.
Tie the healthcare that members of Congress receive to the healthcare available to the median American household in their district. Same plan. Same network. Same deductible. Same prior authorization phone tree at 4:55 on a Friday. No Office of the Attending Physician on standby in the Capitol basement. No Tricare-style supplemental cushion. Whatever your constituents have to navigate, you navigate too, and you keep navigating it for as long as you hold the seat.
This isn’t a serious legislative proposal in the sense that it’s going to pass. Members of Congress would have to vote for it, and Congress voting to take away its own perks ranks somewhere between “ferret learns calculus” and “Pat Robertson endorses drag brunch” on the list of plausible events. It’s a serious proposal in the diagnostic sense. The reason American healthcare reform moves at the speed of a senator’s mood is that the people writing the law are functionally exempt from the consequences. Align the incentives and you’d see a public option on the floor inside of a year.
The fact that it would never pass is the diagnosis.
The Objections, In Order Of How Often I’ve Heard Them
“We can’t afford it.” We currently spend $14,775 per person per year on healthcare. The peer-country average is $7,860. We are the most expensive system in the developed world by a country mile, and we are getting worse outcomes for the money. The question isn’t whether we can afford universal coverage. We’re paying for it already, in the most inefficient possible configuration. The question is whether we can afford to keep this. The CBO’s 2020 single-payer modeling found most design options reduce national health expenditure, not increase it.
“The wait times will be terrible.” The US already has wait times. They’re just hidden inside a different mechanism. Roughly a quarter of American adults report skipping a recommended test, treatment, or prescription in the past year because they couldn’t afford it. That is a wait time. It’s a permanent wait time. In Canada and the UK, you might wait six weeks for a non-urgent specialist appointment. In the US, plenty of people wait the rest of their lives. Emergency care is fast everywhere; elective care is slow in places that ration by capacity. The US rations by wallet. Those are the choices.
“Government can’t run healthcare.” Medicare runs healthcare for 65 million people right now. The VA runs hospitals. Medicaid covers about 80 million. The Indian Health Service exists. Tricare covers active-duty servicemembers and their families. These are all government-run or government-financed health systems that have been operating for decades inside the United States. They are not perfect. They are also more popular than private insurance by every customer satisfaction measure I can find. The argument that the government can’t do something it is currently doing is not really an argument.
“Innovation will die.” Most of the basic research behind modern drugs is funded by the NIH, which is to say by you, with tax dollars, before any private company patents the result. The mRNA platform behind the COVID vaccines came out of decades of NIH-funded work and a small German biotech (BioNTech). Insulin was discovered in Canada. The CT scanner came out of British EMI. Heart-valve surgery, IVF, keyhole surgery — all developed in countries with universal coverage. American drug companies are not the world’s laboratory. They’re the world’s most successful marketing operation, with RAND finding that US brand-name drug prices run roughly 4 times those in peer countries. What we call innovation is sometimes just the price.
“Rationing.” Your insurance company has a prior authorization department. That is a rationing department. They call it something else because “rationing” is the word we use when other countries do it. The denials you can’t appeal, the in-network/out-of-network distinction, the formulary that doesn’t cover the drug your doctor prescribed — rationing, rationing, rationing. Universal systems ration too. They mostly ration on medical necessity. We ration on the bottom line of a publicly traded company. Pick your rationer.
“Socialism.” Part 5 covered this. The fire department isn’t socialism. Roads aren’t socialism. Medicare, the program that turns 60 this year and that 90-plus percent of seniors say works for them, isn’t socialism either. The word does a job in American political conversation that has nothing to do with its definition. The job is to stop the sentence before it ends.
So Why Don’t We Have It
Not because it doesn’t work. Every other wealthy country has running, audited, well-documented evidence that some version of it works. Not because we can’t afford it. We are already overpaying by trillions for worse outcomes. Not because people don’t want it. Public support for both the public option and Medicare for All sits between “majority” and “crushing majority” depending on how the question is asked.
We don’t have it because the industries that profit from the current arrangement — insurance, pharma, hospital chains owned by private equity — spent close to three-quarters of a billion dollars on federal lobbying in 2024 alone, on top of the campaign donations and the revolving door and the think-tank funding and the “grassroots” coalitions whose grass turns out to be Astroturf. Part 5 already named who that money goes to and why it works.
The solutions are not the hard part. The solutions are sitting on a shelf, fully assembled, tested in eleven other wealthy democracies, ready to be adapted to American conditions. The hard part is the politics, and the politics are hard because a small number of people are making an enormous amount of money on the current setup.
Which, weirdly, brings us to who else is paying for that setup — not just you, not just your family. American businesses. Including the ones loudly explaining on cable news that universal coverage would ruin them.
That’s Part 6B.
Sources
Per-capita health spending and GDP share: CMS National Health Expenditure Accounts 2024; OECD Health Statistics 2025, as compiled by Peterson-KFF Health System Tracker (March 2026 release). Life expectancy: CDC NCHS for the US (79.0 years, 2024); Eurostat, Statistics Canada, Australian Bureau of Statistics, UK ONS, Japanese MHLW for peer countries; comparable-country average reported by Peterson-KFF. System rankings: Commonwealth Fund, Mirror, Mirror 2024. Single-payer cost modeling: CBO Working Paper 2020-08, “How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems Based on Medicare’s Fee-for-Service Program.” Drug-price comparisons: RAND Corporation, International Prescription Drug Price Comparisons, 2022 data, published 2024. Public-opinion polling: KFF Health Tracking Poll, multiple waves. Uninsured rate and ACA Marketplace enrollment: KFF analysis of the 2024 American Community Survey and Census Bureau data. Lobbying figures: OpenSecrets, 2024 health sector totals.
Even that's Odd 
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