Here's another approach to solving universal health care. Let's start with the Rethuglican position: We have universal service; it's called the emergency room. Pretty stupid, right? Expensive as all hell, and it doesn't provide all of needed care. But they've conceded that something can be provided, even though its cost is shifted to others, not properly covered. And they love big deductibles.
We also have some free clinics for the uninsured, and Medicaid. Nobody openly wants to do away with those.
Now let's add the most important and popular provisions that Democrats want. One is protection against medical bankruptcy. Another is real universal coverage.
And in the interests of realpolitik, let's keep some role for both the private insurance industry and employer-based coverage.
Let's put those two together. There's actually a new, old solution staring us in the face.
Let's start with the basic plan. Say, let's call it Americare. Everyone from the poorest pauper to The Donald gets a certain amount of coverage automatically. You get an annual checkup at a government-funded clinic. (This is to control costs, vs. letting preventive care all slide.) You get hospital coverage, though not necessarily at the most expensive hospital of your choice. You get access to emergency care. No mandate to purchase anything else, but Americare costs are covered by an increase in the Medicare payroll tax.
The payment scheme makes this progressive.
If you're eligible for Medicaid, that covers you. It remains in place, perhaps expanded, and covers more than the basics. No big deductibles, of course, since it's for the poor. So no big changes. Medicare too, is basically unchanged for those over 65; that's sacred and it is already an example of this type of plan. It's a public plan often supplemented by private coverage.
Above Medicaid eligibility levels, then the Americare deductibles are means-tested. They phase in with income. (It's progressive in both directions; higher income people pay more tax and have a higher deductible.) No extra Americare payments are needed over and beyond the payroll taxes, nor are there other explicit (or state) subsidies. Its goal is to prevent bankruptcy, not to replace all private insurance. So while everyone gets a checkup, everything else (prescription drugs, hospitalization, office visits, etc.) is subject to the potentially-high deductible. So the deductible would be something like 15% of your annual income minus the FPL. If you make $100k/year, it would be something like $12k. But no lifetime or annual payments cap -- this is national catastrophic-care coverage.
If you're employed, then your employer can buy you additional coverage as a benefit. A good employer will want to provide this. The cost won't be anywhere near today's level, though, because the really high costs are covered by Americare. So the benefit private insurance plan could cover office visits, the deductible portion of a hospital visit, the deductible portion of prescription drugs, eyeglasses, health clubs, etc.
If you're self-employed or don't get employer coverage, you should still be able to buy additional coverage. The big risk to the carriers from pre-existing conditions, of having a person sign up when they have a huge expense coming, is removed by Americare. So they shouldn't need to play the games they do now, and shouldn't be so averse to some regulation to make this extra insurance available without restriction (pre-existing conditions), and to make them actually pay claims (no recission). Since age-rating is a problem for those 50-65, maybe the Americare deductible (the gap that private insurance covers) could phase down as you approach full Medicare coverage, to limit the private companies' exposure and make market rates affordable.
This is not a new system. It is an update of what the US basically had in the 1940s. Medical care wasn't as expensive then -- to be blunt, people died more -- but the well-to-do went to nicer hospitals than the poor, but the poor still had "City" or "County", and charity clinics. The employer-based system we have now grew out of WW II wage controls. Labor was suddenly in short supply, and employers couldn't raise wages, so they competed for labor by adding fringe benefits. Medical insurance was the biggie.
Labor and medical conditions are totally different now but inertia preserves the system. So let's just go back to a different American system, one that leaves a role for employers and insurers but which guarantees no bankruptcy and provides at least some universal care. It's a better plan than what either house of Congress has now, and could even draw some bipartisan support.