We've all known for months now that we're not really uniquely American, that really we're all Swiss at heart [where's Krugman been? China? oh, wait], but it's bordering on laughable to call either RomneyCare or the pending DemoCare 'plans' Swissified. More like Swiffered maybe, as in the deformers reformers are going to wipe the floor with those of us who need health care.

Krugman is right about one thing, we'd be better off if we were Swiss, expensive as their system is: $750/month for a family, over $1000/month if you add all the bells and whistles. Still, according to the OECD, the Swiss spent $4417 per person in 2007, while we spent $7290. Who wouldn't want to slash their health care spending by 40%?

Just how Swiss are we going to become? We at chez hipparchia are fans, as you can see, but I'm thinking not very.

First off, we're going to slash spending by a whopping 2%, but with those savings happening in only ~40% of health care spending, it's more like slashing the budget by 1% [or less]. Looks like we're in no danger of losing our Uniquely American title on this score.

Second, we're going to have subsidies, so that ordinary people can afford this hugely expensive promise to pay our medical bills. The Swiss make everyone buy private insurance, but they subsidize the premiums for their lower income folks, we can too.

If you were a median household in the US in 2007, you had 2.59 people and made $50,740, which looks like it could put you at just over the 300% FPL line. Depending on what comes out of conference, the definition of affordable for you means somewhere between ~8% and 12% of your gross [before taxes] income spent on premiums, and up to $10,000 out-of-pocket spending [if your household is a family]. So affordable health care is ~30% of your before-tax income. Yay.

If you were a median household in Switzerland in 2007, you had 2.22 people and made $60,288. And you paid about 10.3% of that income in taxes, premiums, and out-of-pocket spending for your health care. Fewer people, higher income, lower health care spending for them; more people, lower income, [much] higher health care spending for us. Srsly, about as Swiss as we're going to get is the yodeling you'll hear from the public once they find out they've been had.

Oh, btw, that $10,000 maximum out of pocket doesn't include out-of-network spending, at least not in HR 3200 right now. Go out of your network and you'll pay whatever those doctors and hospitals decide to charge you. Which is as good a segue as any into point three. Does this sound like adequate protection from medical bankruptcy to you? Cuz, it sure doesn't to me. Even the conservatives in Switzerland would be scandalized:

The conservative Swiss President calls health care “a right,” and says it would be a “scandal” for the Swiss to experience medical bankruptcy, as many do in the U.S.

Next, how are we going to control costs? Besides the backroom deals, I mean, and wringing the waste out of Medicare and Medicaid, of course [ooooh! more mopping metaphors!]. Can't afford the insurance if we can't afford the care it's supposed to be paying for.

Why, we're going to rely on competition! Hell, even Paul "Why markets can’t cure healthcare" Krugman thinks that competition with a public option will help control costs:

That’s why I and others believe that a true public option competing with private insurers is extremely important: otherwise, rising costs could all too easily undermine the whole effort.

Dang, must be some good bud.

But lots of countries have public/private mixes in their insurance systems! cry the proponents of SwifferCare. And frequently they go on to stretch this to public insurance competing with private insurance. Which happens in lots of countries, no?

No. We can point to Germany and Australia, and that's about it. Even there, the competition is limited.

In Germany, about 85% of the population is in the public plan[s], whether they want to be there or not, and the other 15% [the richest, the self-employed, some others] have the choice of going with either public or private insurance. About half of them stick with the public insurance. Interesting factoid: a poll of those 'forced' into the public plan has 22% wishing they could go private and 58% preferring to stay in the public plan.

Australia is a bit weirder. Back in the 70s, their government instituted a more-or-less Canadian-style Medicare system. A later, more right-wing government tried to re-privatize it. The result is that today Australians can opt for either private or public insurance for hospitalization, and get some public subsidy to buy private hospital insurance. About 45% of Australians elect to go private. Some competition. I wonder how many would do so if there were no government subsidies for that decision.

Public systems with wimpy private options. Now there's a compromise I could support.

Circling around to the beginning for one last point [finally!], here's the Wonk Room's bit of silliness that I quoted in my Uniquely ... Swiss post:

In other words, American reforms would look a bit like the Swiss health system in which the government “leaves the provision of health care and health insurance in private hands” but creates a marketplace within which insurers can compete on price, and not avoid insuring the sickest patients.

Insurers in Switzerland compete on price?

No, says Uwe Reinhardt, the Swiss aren't all that price-sensitive in their health care decisions. No, says Timothy Jost, the Swiss often buy their health insurance as a package, with other insurance, and may keep their health insurance just because they also got a really good deal on, say, house insurance. And furthermore, insurance companies in both Switzerland and the Netherlands do engage in cherry-picking [attempting to avoid the sick], even though the risk adjustment schemes and regulations are supposed to discourage [or outlaw] the practice.

So why is the Swiss health care / health insurance system affordable?

It's the prices, Stupid.

Insurance is affordable because care is affordable, and care is affordable because, for all practical purposes, the government tells the doctors and hospitals and drug companies and insurance companies what they can charge.

Not only is it really that simple, but that's what all the other countries do too: France, Canada, Germany, Japan, ... [to greater and lesser extents].

It's worth noting that Germany is into managed care, and some of the other countries are fiddling with it around the edges, but most are heavily fee-for-service. Plus, Japan allows doctor-owned hospitals.

Not that we're going to do that, or even contemplate doing that. No, we're going to talk people out of wanting more care. And we're going to top it up with pay-for-performance, giving doctors and hospitals more money for spending less money on patients' care. Ceiling Cat knows, we could never ask fatcat CEOs to cut back, for instance. That would be unAmerican.

All this and I get to wait until 2013 too.

Oh well, somebody said banana peels would do.