[HourglassFR]

I would ass a fourth reason: health is a very much a public (as in collective) issue, not a sum of individual medical problems. Something that is fundamentally at odds with the dominant ethos of how to deal with problems in america in the past 50 years or so.

[otikik]

That is what I was trying to convey on my second point, but perhaps I didn't do a good enough job at it. Yes as a European I see it as a mere "efficiency" thing. My (admittedly, very simplistic) thinking goes like this:

> In a population of 1000 perhaps 10 will get a Really Bad Health Issue that requires Really Expensive Treatment that costs 100. So those 1000 people pool their resources up and each pays 0.1 so that if they happen to be one of the unfortunate 10 they are covered. Given that this is a shared risk for those 1000 people, the higher possible entity (the state) is put in charge.

It seems the Americans thinking starts the other way around:

> Anything public is awful and should be avoided at all costs. I'd better take my chances with a private entity (even if that means grouping with another 100 people instead of 1000, and that the private entity takes one cut, so we end up paying 2 each instead of 0.1) because the alternative is just awful.

... But then they are fine with having a very well publicly-funded military and police departments.

[mapremap]

A risk pool being split among multiple companies doesn't actually increase the average amount that each group would have to pay. For the group of 100 in your example, only one tenth of a person is going to have to get one tenth of the expensive treatment, so each one still has to pay 0.1. As long as each underwriter has a sufficiently large group to ensure that the average cost incurred by its members is sufficiently close to the population average, the relative sizes of those groups isn't going to affect their members' premiums. Insurance administration is not an economy of scale so competition in the marketplace would ensure downward pressure on prices. In contrast, a state provider would have little incentive to cost-cut or innovate since they wouldn't have to earn people's business, and any public option would necessarily be attempting to balance the interests of multiple groups (such as public sector unions/government employees, health care providers, and health care consumers) at the expense of the consumers whose interest would have been prioritized in a competitive market. Taking that into consideration, it's doubtful that the lack of shareholders in a public system would represent enough of a benefit to actually lower costs for consumers. Americans have enough experience with poorly managed government programs to intuitively understand that a socialized health care system isn't going to be an improvement over our current system.

And yes, since national defense and law enforcement are desirable services that can't be provided by a competitive market, we are fine with the government providing those specific services in a constitutionally-limited way. That preference is actually more ideologically consistent than your preference to socialize our healthcare system unless you're going to advocate for abandoning capitalism entirely.