Andrew Tsang's recent piece, An Abominable Creature, hit me in a way few articles do. Not because of its politics or moral framing, but because of its structural diagnosis. It recognizes, bluntly, that the “creature” we call American healthcare isn’t sick — it has already failed — at least, at the structural level.

After 45 years living and working inside this "anti-health" system — a system incapable of delivering “good health as a life boon” to virtually all citizens — I'll say it again: the system isn’t breaking. It’s already broken.

• Employer costs are no longer sustainable.

• Employee costs are no longer sustainable.

• Citizen out-of-pocket costs are no longer sustainable.

• Government costs are no longer sustainable.

And here’s the kicker that almost no one in benefits and healthcare acknowledges: even if every cost-mitigation program reached a “critical mass” of engagement and participation - and success - employer health plans only touch about one-third of total national health expenditures. A system that fragmented cannot be stabilized from the inside.

The 2/3rds of American healthcare expenses that don't run through employers....are squeezing employers....mercilessly.

There are only 4 viable global healthcare delivery and financing models
Since the article addressed a couple of other systems around the world, it got me wondering: How do those systems finance care, structure risk, and organize delivery at scale - at at least half the cost that we do?

I've recapped how each of these works; emphasis: recap! Not an in-depth analysis!

1. The Beveridge Model (National Health Service style)

Countries: UK, Spain, Nordics, New Zealand
Structure: Tax-funded, government-run, publicly delivered.

PROS:

• Lowest administrative costs on earth

• Universal access, simple entitlement

• Strong primary-care foundation

CONS:

• Vulnerable to political underfunding

• Wait-time bottlenecks when budgets lag

• Public delivery misaligned with U.S. provider culture

This can't become America’s path — structurally or culturally.

2. The Bismarck Model (Social Health Insurance)

Countries: Germany, France, Belgium, Japan, Netherlands
Structure: Mandatory universal insurance via payroll-funded sickness funds; private hospitals; regulated multipayer.

PROS:

• Excellent access and clinical quality

• Private delivery fits U.S. norms

• Universal but still choice-driven

CONS:

• Heavy regulatory lift to build

• Requires cultural buy-in to mandatory insurance

• Payroll-financed systems strain as societies age

As best as I can tell, this is the most structurally compatible “fully developed” alternative for the U.S. — but it requires regulatory, cultural, and administrative scaffolding we simply don’t have yet.

3. National Health Insurance

Countries: Canada, Taiwan, (partially) South Korea
Structure: One national insurer, private delivery, universal coverage.

PROS:

• Monopsony bargaining → strong price discipline (the insurer effectively controls the market)

• Simpler financing model

• Extremely low administrative waste (Taiwan is the world leader)

CONS:

• Not scalable to nations as large, fragmented, and decentralized as the U.S.

• Vulnerable to wait times if budgets fall behind demand

• The U.S. would end up with 50 mini-NHIs, defeating the whole structural purpose

Canada and Taiwan work because they’re smaller, more cohesive polities. Their architecture cannot simply be air-dropped into a nation the size and complexity of the United States.

4. The U.S. Hybrid — The Anti-Health System

What America has is not a health system. It is an anti-health system: a structurally incompatible fusion of employer insurance, individual markets, Medicare, Medicaid, and VA pockets — all running on different rules, incentives, and cost structures.

PROS:

• World-class specialty medicine

• Highly innovative clinical ecosystem

• Certain delivery segments are globally unparalleled

  

CONS:

• Highest costs on the planet

• No coherence, no unified purpose

• Administrative waste that no amount of “innovation” can meaningfully clean up

Fragmentation is not a bug — it is the architecture.

The most realistic fix: a Medicare-for-All OPTION (MFAO)
Here’s the part people miss: Medicare works. The rails exist. The billing systems exist. The provider networks exist. The benefit structure works. And employers already understand it.

A Medicare-for-All Option (including employers) would allow:

• Individuals to buy into Medicare

• Employers to select Medicare as one of their group health options

• Everyone else to keep what they have

No demolition. No forced migration. No ideological upheaval.

And crucially:

MFAO does not eliminate the insurance industry. It preserves the majority of existing roles — underwriting, analytics, care management, network design, actuarial work, claims operations — while simply shifting the foundation onto a more coherent chassis.

• Supplemental health programs? Still available.

• Voluntary benefits? Still available.

• Care-management solutions? Still available.

• Private plans? Still available.

MFAO is a coherence layer, not a replacement layer.

The Bismarck model could expand on MFAO — but only after MFAO exists

Bismarck systems offer:

• negotiated national fee schedules

• regulated multipayer alignment

• universal mandatory participation

• long-term coherence and cost stability

But you can’t jump from anti-health-system → Bismarck in one leap. We'd need a universal floor first. We'd have to have administrative alignment. We'd have to have transparency. We'd have to have cultural familiarity.

MFAO could be the bridge, with a Bismarck-style system as some possibly "greener grass."

So, what now?
The dam is not cracking — it has already burst. Costs, demographics, chronic disease, employer fatigue, and citizen burnout are converging faster than the system’s architecture can bear.

We need coherence, not ideology. MFAO is the first structurally sane step in that direction.
And if we take it, maybe — someday — a Bismarck-style evolution becomes possible.

The last word
We have to stop pretending the anti-health system can be saved. It can’t. The future starts by laying a floor that actually holds.

~Mark Head

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