At least one country already has a health care plan roughly similar to the one President Obama and the Democrats have proposed, with universal coverage, a mandate that everyone buy insurance and a major role for private insurance companies: Switzerland.
So I used part of a recent vacation to head for the Swiss Alps to observe the system in practice.
Jean-Oscar Meile runs a tidy one-man practice in Melide, a suburb of Lugano in Switzerland's Italian-speaking south. He is quick to say he's not a spokesman for Swiss doctors, the government or anyone else. But he has about 1,000 patients, as varied as bankers, fashion designers, rural woodcutters and immigrant laborers.
"We've got a lot of problems," he told me last week. "Costs are going up. Nobody wants to pay for them. The politicians want us to drive a Mercedes, but they're only willing to pay for a Volkswagen. ... The system was better a few years ago, before there was so much regulation."
Still, he added, "I think we have the best system in Europe. All the American doctors I know complain about your system and are jealous of ours."
Here's how the Swiss system works: Everyone is required to buy basic health insurance from one of several private companies; the government subsidizes the cost for low-income families. Consumers can choose any insurer and go to any doctor — more choice than most Americans now enjoy. The government prescribes what the policies will cover, sets the price and tells doctors what they can charge for every medical procedure. Doctors are free to do whatever they feel is called for, order up any test and prescribe any approved medication. But if a doctor's billings exceed the regional median by too much, he or she will get a "blue letter" — a bill from the government demanding the return of some of those fees.
By world standards, Swiss medicine is very good. The average infant born in Switzerland can expect to live to almost 82, more than three years longer than the average American baby. Swiss patients don't wait long for treatment either. "If you need an MRI, I can arrange one tonight or tomorrow," Meile said. And they pay a lot less than Americans do. About 11 percent of the Swiss gross national product goes to health care, against about 16 percent of the U.S. GNP. Per person, that worked out in 2007 to roughly $4,417 in Switzerland and about $7,290 per person in the United States, according to the Organization for Economic Cooperation and Development.
That makes Switzerland's system a lot cheaper than U.S. medicine, but it's not cheap in the eyes of many Swiss. In fact, the Swiss pay out-of-pocket costs that are higher than the U.S. average. This year, the basic Swiss health insurance policy cost an average of about $3,800 per adult older than 25, with a deductible of about $300 for the year and a co-payment after that of 10 percent (up to a ceiling of about $700). Next year, the premium will rise by about 9 percent. Some employers pick up a big chunk of the premium, but not all.
The unrelenting rise in costs has been the single biggest disappointment in the Swiss universal coverage system, which was created by landmark reform in 1994. To Meile and others, the basic reason is evident: The well-insured Swiss use a lot of medical care — too much, in fact. They visit their doctors more frequently than Americans do. They often ask for tests or pharmaceuticals that they've heard about from friends. And nobody wants to tell them "no."
"People come in with back pain and ask for a CT scan," he said. "We have hypochondriacs who come in every month and ask for an EKG. The (doctor) is going to get blamed either way. If he orders the test, it's too expensive; if he turns down the patient, the patient might switch doctors."
The price structure creates another quirk, he noted. In January, when people have that deductible to pay, "nobody comes to the doctor." But by December, when many patients have hit the out-of-pocket ceiling, doctors' appointments are effectively free. "That's high season for us," Meile said.
The average general practitioner in Switzerland, he said, makes about $150,000 a year, but cardiologists and other specialists can make $300,000 or more.
"That's not a complaint," he added. "We're not starving. We're probably the best-paid doctors in Europe. Not everyone can be a millionaire."
Here's what struck me most about Meile's practice: All of his patients have the same basic insurance policy, banker and woodcutter alike (although the affluent ones buy supplemental insurance that covers private hospital rooms and dental care). None of them has to worry about going broke because of medical bills.
And here's what struck me about his clinic: Except for the German-language health posters, it could have been a doctor's office anywhere in the United States — receptionist's desk, X-ray room, EKG machine, mini-lab. With one exception: no billing department, no bookkeepers. The insurance system is so simple that Meile handles all the billing himself. Charges go to insurance companies electronically and are paid within 10 days.
So what can be learned from all this?
One lesson of Switzerland's experience is that near-universal coverage is possible without a government-run "public option." Swiss health insurance is provided entirely by private companies, even for the elderly. (In that sense, it's less "socialized" than U.S. medicine: There's no government-run Medicare.) By law, the basic insurance plans are nonprofit, but companies use them to attract customers to their for-profit lines of business.
Another lesson: Cost containment is very, very difficult — especially if, like Obama and his Swiss colleagues, you've promised voters that they'll still get all the care they want.
A third lesson: Don't expect miracles. The Swiss are still working the bugs out of their system 15 years after it was enacted. They still haven't covered everyone, and illegal immigrants are a continuing problem.
Still, they get medical care as good as or better than that of the United States, at a cost that's significantly smaller. They must be doing something right.