As an enemy of the Affordable Health Care Act, I want something else, yet I see the need for universal health care.  So, here I outline what I believe would be a sustainable and fair system of health care that would cover every citizen and would work in the United States.  I believe it would be far superior to Obamacare, if designed according to these principles.  It’s modeled after but differs from the Australian Medicare System, established 1984.  Link: Health Care Australia.  Australian Medicare covers 20 million people, or about a fifteenth of the number of people in the US.   I chose Australia because their system is more recent than the UK’s, it seems to work, and I suspect Aussies in the mass are a bit more rational than Americans.

Any universal health care system needs to satisfy the following goals:

1. It needs to provide a reasonable level of care;
2. It should be affordable for the patients, properly remunerate providers and hospitals, and be sustainable for the public purse;
3. It should be free or nearly so for the poor and of moderate cost to the middle class.  The wealthier population should not be covered;
4. It should be designed to minimize fraud and cheating by the public and by providers;
5. It should allow competition from the private sector;
6. It should not impose unnecessary regulations and restrictions;
7. It should cover all aspects of health care including physican services, hospitals, pharmacy, rehabilitation, hospice, and long term care;
8. It should cover major medical expense;
9. It should make some provision for pre-existing conditions.
10. It should totally replace the current Medicare, Medicaid, Federal Employees Health Plan, and Tri-Care plans, as well as care for inmates of federal prisons.  Like them, it should be funded from the public treasury with revenue from special taxes.    Except where lives are at risk, providers should not treat any person without ability to pay.  Hospital emergency rooms should no longer be clinics for the poor and uninsured. 

My plan:

1. Issue a National Health Card (NHC) to every citizen or family requesting it.  It would be assigned a unique number.  Providers would charge fees to this number.  Duplicate cards would be given on request to each family member.  Family members would use a suffix on the NHC number to establish which patient is being served.  Each card would contain magnetic identification information,  as well as essential medical information such as blood type, chronic medical conditions, and date of birth.
2. Establish a centralized health record in a national database accessible only by providers.  This is similar to the database provided for in Obamacare.  It should contain photos and fingerprints as well.
3. Establish a health tax: say 2% off the top of all income.  No deductions, all would pay, including businesses.  The percentage is only a suggestion and would be adjusted as necessary to fully fund the National Health System (NHS).  The tax on business would be exactly equivalent to a sales tax, as businesses would pass the tax on to their customers.   Exceptions: food sales, medical expenses, and utilities would not be taxed.   Real estate and auto sales would not be taxed.
4. Establish means testing: single persons with more than (I suggest) $100,000 income and couples with more than $170,000 income would not be eligible for NHC benefits.  They would need to purchase insurance or self-insure.  Persons with incomes up to three times the poverty level (3X poverty) would receive full benefits; above that level, benefit amounts would progressively decrease so that patients would have to pay more from their own resources.   Means testing parameters are only a suggestion and could be adjusted.  Means would also be tested by evaluating the patient’s net worth.  If more than $250,000 but less than $500,000, an NHC+ card is issued regardless of income less than 3X poverty.  The card for someone who earns more than the poverty threshold would be an NHC+ card for which there would be two levels of deductible.  The member would pay all charges up to say, $1000, and half of all charges above $1000 and less than $3000.   NHS would pay the remaining charges.
5. A patient with a NHC who earns less than 3X poverty pays nothing at a hospital or clinic.  The NHS is billed by the provider, but does not pay the provider until the encounter is authorized by the patient.   With an NHC+ card, the patient pays any due amounts to the NHS. 
6. Patients are free to take  out insurance to pay for their medical care, or to pay the percentage deductible. 
7. The NHS would also pay for nursing home, rehabilitation, in-home, mental illness confinement, and hospice care on the NHC card.  It would also provide prescribed medical devices. 
8. A patient who loses income and net worth may apply for an NHC anytime within a year.  The means test is applied annually; the NHC must be renewed annually.

Notes:

1. Some health services would not be covered by the NHC, including: cosmetic procedures, sex change, abortion, sexually transmitted diseases, contraception, and conditions caused by drug/alcohol abuse.  Cosmetic repair procedures would be paid for injury or illness related disfigurement.
2. The Department of Defense would still provide health care for military personnel without change.  Civilian employees and contractor personnel posted outside of the United States would be treated by the military health service, but Tri-Care would go away. 
3. The Veterans Administration and the Indian Health Service would continue unchanged.
4. The President and Vice-Presidential health plans would not change.  The health plan now available to Congress would be eliminated.
5. Medicare, Medicaid, Tri-Care, and FEHP (Federal Employee Health Plan) will be totally eliminated.  The changeover might require as much as a year or more to implement.
6. Once voted into law, no amendments, modifications, exemptions, exceptions, or rebates to the plan may be granted without being passed by a two-thirds majority vote of Congress and an endorsement by the President.
7. The greatest potential for defrauding the NHC is in fraudulent billing by doctors, clinics, hospitals, and other approved providers.  For this reason, my plan would require a three  entity approach to provider reimbursement.   During a medical encounter, the provider will swipe the patient’s NHC to obtain current eligibility, and give the patient or representative a receipt with provider number, encounter number, and date.  The provider will render a statement of billed services, itemized by patient, to the NHS.  The NHS will forward it by mail or email to the patient (or designated representative) who would have to affirm the service was provided and return it with the receipt or the receipt information to the NHS, responding within thirty days.  If properly authorized, the NHS will forward payment to the provider, who eventually would be paid even if the patient failed to respond.   This system may prove too cumbersome, but there may be a workable variation.
8. If a patient or representative fails to respond within thirty days, their NHC would be invalidated and they would be subject to a fine to reinstate it.  The medical provider will receive payment as if the charge had been authorized.
9. The NHS will investigate discrepancies.  If fraud by a provider is proven and the patient or representative has authorized an invalid statement, the patient or representative would be subject to prosecution.  If the patient denies the charge the NHS would charge it back to the provider, who could submit it to adjudication at their discretion.
10. Providers will be free to decline service to anyone who cannot prove capability to pay, without legal liability, providing the patient is not in immediate danger of death.  Prudent business practice would allow providers to take a deposit of credit card, cash, or proof of insurance from patients they do not know.
11. It might be wise to take some of the revenue from the taxes and use it to subsidize education for more doctors and nurses.
12. There will be a need for an arbitration process for patient-provider disputes, and a limitation in malpractice awards.  Malpractice should be redefined as deliberate injury or gross negligence.  Remembering that medicine is more art than science, no physician who has diligently worked to help the patient should be penalized if the result is unfortunate.
13. The NHS will set reasonable fee schedules for each service to prevent providers from overcharging.  The NHS should take care to allow providers to thrive and prosper.
14. Data collected during the billing process would allow extensive computer analysis to detect provider fraud, patterns of unnecessary services, and excessive charges for supplies and equipment.   
15. Patients who walk in without an NHS card can give information to allow the provider to pull up their NHS record.  Undocumented non-citizens or persons with expired visas would be treated, but the police will be called, who will arrest and turn them over to the INS for deportation.  Non-citizens with work permits will be able to purchase an NHC good for two months, paying a fee of about $30.  Travelers entering the US will need to be insured.

In effect, the NHC would be a means-tested national health insurance plan funded by taxes, but it would not substantially dictate the fee schedules of providers, and would allow insurance companies to still provide services.  Patients would be free to choose any doctor or hospital who will accept them.  The only acceptable reason for providers to reject new patients is lack of capacity to treat them.  Doctors and hospitals would be free and encouraged to provide services outside of the NHC system.  If the tax rate is set at the proper level to balance revenues vs. expenditures, it will not drain the public treasury or add to the federal deficit.

Direct payment by the NHS might be controversial.  Many schemes try to generate competition through insurance.  My plan has some competitive pressure due to deductible payments for NHC+ members, who will pay two thirds of the first $3000 themselves, and would therefore be wise to accept providers with reasonable rates.  I believe these features of the plan will help to reduce costs: malpractice redefinition and award limits; deductibles, reduction in unpaid provider fees, and possibly subsidized medical education to train more doctors and nurses.    

Universal health care in the United States will be very difficult to sell, because the American public has been accustomed to high cost but has received high quality care.  The crazy patchwork of care programs we have now (individual insurance, provider unpaid, Medicare for the old, Medicaid for the poor, Tri-Care for the military, Federal Employee Health Plan for the federal employees, etc. ) is what we’re used to, and other than individual insurance, most of the cost is paid by the federal government — directly or indirectly.  The idea of more taxes to pay for a health care system is abominable, yet those taxes are built into our tax bill now.  I believe my proposed system would actually reduce health care costs, because unpaid provider costs would decline, and this would bring provider fees down. 

A final comment: the NHS tax should be set at a level to fully fund the system.  It might cost quite a bit to start.  Yet, Australia is currently taxing at 1.5 %.