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That's what some universal systems already do. I was reading up on Singapore. There is a baseline of insurance for hospital stays, but it's in a ward with 6 other patients in the same room.

If you want something better (and there are tiers), you pay more. You can buy insurance policies that pay for the more comfortable stay.

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Another place in SEAsia where it’s single payer but while everyone (legally employed persons) people who want good treatment go to private hospitals because of expertise, availability and the ability to get private rooms.

The same in Fiji.

We have universal health care, but anyone is of course free to forego that and pay (or use their private insurance) for a private room rather than a ward, or just go to a private hospital instead.

I don't understand the debate about this in the US. It's as if the rich assume that things will change for the worse for them if universal health care is enacted.

What about middle class people who can't afford private care but fear that the socialized healthcare system will be of worse quality than what they currently have?

They have a hard decision. Unlike the US they are allowed to be an adult.

You can look at austria to see that that doesn't happen.

An MRI cost me about 0€.

A 4000€ test which tests for nearly any rheutmatic diseases markers and the visit to the hospital for that test cost me 0€, both things got done within two weeks.

Even if you are poor and want to go to a private doctor it will cost you not nearly as much as in the usa. For me it was about 100€, for one visit and that was on the higher end.

Socialized healthcare is always cheaper.

I can buy an out of pocket (uninsured) MRI test in the US for less than $500. With a little bit of negotiation I could probably get it down to $300. An insured MRI can be free too depending on the plan.

My mom is a doctor, she worked ICU, ER, etc, board certified in 10 states and holds a medical license in 3 countries(yes, she did residency three times, it's a long fascinating story for another time). Eventually she decided to open a private practice for family medicine bec it was less stress, but she's got tons of experience, and is highly regarded, and she charged less than $40 a visit for the uninsured. She would spend ages talking patients out of procedures that were harmful or simply unnecessary. You got high end care from her each time.

The gist of this is: you have no idea what you're talking about and individual anecdotes don't prove one system is better then another.

I'll just add as food for thought: nothing is free, avg effective tax rate in EU is 50%

Avg ETR in the US is less than 30%.

Perhaps they should be taught about capitalism.

If there is demand for private healthcare affordable to the middle class, the demand will be met with supply.

And if that fails, they should be taught about democracy.

That if it turns out that socialised healthcare doesn't work for most Americans most of the time, then the country can revert to the system it currently has.

The bulk of the (public) opposition is from people who like their employer provided insurance. We'll soon learn if the mood changes, due to pandemic induced high unemployment.

It doesn't matter if the mood changes. Democratic voters are in the mood for medicare for all already and biden is the democratic candidate. This is america, the public mood isn't a factor.

Last I looked at the polls - before coronavirus stole all the attention - Democratic primary voters were split roughly evenly between single payer (M4A) and public option, in polls where the distinction was highlighted.

It’s not that their care will get worse, it’s because their care gets worse due to “those people” getting better care. Source: my in-laws.

> It's as if the rich assume that things will change for the worse for them if universal health care is enacted.

Well, it depends on the implementation, but Bernie Sanders has been on record numerous times as stating that his Medicare-for-All proposal would absolutely ban private insurance. Elizabeth Warren is another Democratic front-runner who indicated that she's on board with that, though her proposals didn't necessarily reflect it.

For what it's worth, the M4A _plan_ from Bernie's camp that I've seen didn't actually specify that it would eliminate private insurance, but he's also been keen on reminding us that he wrote it, and knows best what's in it.

So while it seems unlikely to me that political reality in America would prohibit banning private insurance, there are definitely those who espouse banning it for the greater good, so perhaps that fear isn't wholly unwarranted.

For what purpose would they not ban it?

To be clear, I misspoke in my closing sentence, and intended to say "It seems likely to me that the political reality in America would prohibit banning private insurance" -- but got mixed up in my negatives and now it's too late to edit.

That said, answering your question, they would presumably not ban it because a) the aforementioned arguments upthread make it pretty silly to do, and because b) it seems impossible to me that banning a wholly legal service just because it competes with the government would ever be deemed as constitutional.

Well, not ever -- but not today, and not with the direction that the Supreme Court has been taking for decades now in regards to government power. Licensure seems possible, but I think even prohibitive licensure intended to dissuade private entities from competing with the government would be tossed out, and we already have such programs for insurance providers anyway.

It's a slight misstatement to say that any of the M4A plans would have "banned private insurance." None of them prohibit supplemental coverage that would be secondary to Medicare.

This doesn't apply to procedures that are covered, though, does it? Like, a private plan that provides higher-quality / reduced wait times for all services you'd normally get from the public system.

Regarding the implementations I was talking about, the private market would exist exclusively for elective procedures "like cosmetic surgeries." [0]

For any of the services covered by Medicare. Quoting the Kaiser Family Foundation, "private insurance would be prohibited from duplicating the coverage under Medicare."

[0] The full quote here is "If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries. That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries."

[1] - https://www.bloomberg.com/news/articles/2019-07-05/harris-ke...

> For any of the services covered by Medicare. Quoting the Kaiser Family Foundation, "private insurance would be prohibited from duplicating the coverage under Medicare."

That's correct. Supplemental insurance can still cover copays and other out of pocket expenses. It can also cover procedures not covered by Medicare.

Now, tell me, how is that "banning private insurance" if insurance companies can still sell those policies?

From a Bernie Sanders interview with NPR.

Q: "Does private insurance go away under Medicare for All?"

A: "Yes, it does, because you're not going to a have a need for private insurance"

A tweet[1] from Bernie Sanders: You're damn right we're going to get rid of greedy health insurance companies.

CNBC describes Bernie Sanders plan as "Bernie Sanders is pushing a “Medicare for All” bill, which would create a government-run program and end private insurance."[2]

The Hill's headline covering Bernie's policy is "You're Damn Right Health Insurance Companies Should Be Eliminated"[3] and references a quote in an interview from MSNBC in which Bernie says universal health care can't be achieved "unless you get rid of the insurance companies."

So feel free to quibble over the nuances of what "eliminate," "end," and "abolish" mean as much as you like, but if you're a person who is concerned that your private insurance is going to be eliminated, and you're listening to Bernie Sanders talk about it, it seems like his statements would reinforce that fear.

[1] https://twitter.com/berniesanders/status/1111363118867927040...

[2] https://www.cnbc.com/2019/07/18/these-2020-democrats-want-me...

[3] https://thehill.com/policy/healthcare/436033-sanders-youre-d...

Why are we still talking about Bernie Sanders?

His ideas are still relevant, even if his candidacy is not.

Nonetheless, the fact remains, no M4A plan proposed by any candidate in the 2020 race would disallow insurers from offering supplemental coverage. Bernie is just simplifying for purposes of making himself understood to the general public. Nobody would "need" private insurance under his plan:

> In other words, while Sanders' plan doesn’t ban supplementary coverage from private insurers, it does offer such generous coverage by the government that there's not much room left for private coverage to fill any gaps. This is the logic upon which both conservative critics — and supposedly nonpartisan mainstream reporters and pundits — hang the logic that Sanders' plan would "ban" private coverage. It's a dramatic "gotcha" question.... [0]

You're essentially reinforcing a right wing talking point that completely mischaracterizes what Bernie's M4A plan actually does.

---

[0]: https://theweek.com/articles/850638/no-really-wants-ban-all-...

Whether he's simplifying or restating seems orthogonal to my point, which is that people who are worried that things are going to change and if they'd like to "just go to a private hospital instead," well - if Bernie is to be believed - in his vision of America, those may not be allowed to exist.

Where did anyone, Bernie included, say that private hospitals would not be allowed to exist?

Firstly, it's implied when he proclaims that companies shouldn't be profiting off of health care. But to answer the question less obliquely, here's a quote of him saying it (from Politifact):

"I could whack pharmaceutical companies, and I don’t need Medicare for All to do it, but I do need Medicare prices for all to deal with what the real profits are — whether you call them profits or not — which is hospitals."

https://www.politifact.com/factchecks/2020/jan/15/bernie-san...

Where does that say private hospitals shouldn't exist? All it implies, and which the article explicitly states, is that private hospitals will have to deal with making lower profits under M4A, which is obvious.

You're reaching. Why are you trying to push a right wing spin on M4A, when studies show that it would reduce costs and increase access to care?

I'm not pushing a spin at all. I care approximately zero about the current healthcare debate or its future direction. I think my initial statement was apolitical and factual. If it's being interpreted otherwise, that's by inference, not implication.

But to the point of why people might be wondering about changes to their healthcare policies, well, perhaps it's because they've been listening to the politicians. If folks would like to obliquely sidestep what I feel was a rather small, simple point and have an argument about efficiency gains in healthcare, you're free to, but I'm not trying to participate in that argument.

Edit: Actually, consider this my last post on the topic at hand, as I'd rather not engage in any argument where reputably sourced facts and direct quotes are regarded as "right wing spin."

Mischaracterizing M4A as a policy is what I'm considering "right wing spin," not "reputably sourced facts and direct quotes." Yours are exactly the words I would expect to hear from scaremongers in Washington telling people M4A "takes your freedom of choice away." If you can go to any doctor or medical facility and have your coverage accepted, and also have as much supplemental coverage as you want, again, how is that "banning private insurance," or "banning private hospitals?" Please explain.

> Mischaracterizing M4A as a policy

I did not do that

> Yours are exactly the words I would expect to hear from scaremongers

I quote the author and it's scaremongering? Yeah, count me out of this conversation altogether. You've uncharitably interpreted what I'm saying, and are doubling down on the sort of rhetoric I explicitly stated having no interest in.

You are spreading deliberate falsehoods. That is literally the definition of "mischaracterizing." As for "scaremongering," or "right wing spin," do you have a better word for amplifying the "you're going to lose your freedom of choice" meme by saying private insurance and private hospitals would be banned?

And, as for the conversation, you were supposed to be out already. It would be better if you stayed out rather than amplifying false statements. If you want to critique M4A, then quote the actual policies put out, not the rhetoric.

a) I'm not spreading falsehoods.

b) I've made no critiques of M4A.

c) You're wrong to the point of malice, perhaps deliberately.

I didn't say that any of the M4A plans would ban private insurance. That doesn't change the fact that Bernie has stated that his M4A plan would, even where the plan he's put forward doesn't show that.

I think it's fair (if a bit naive) to take politicians at their word on occasion. Moreover, I think it's more than a bit disingenuous to assert that plans that are disallowed by law from competing with Medicare services still being allowed to exist for only elective operations as "not banning them." If I disallowed Netflix from streaming any videos longer than a minute in length, I guess technically I have not banned Netflix, but in practice, I have totally banned Netflix, and that's exactly the scale of disallowance we're discussing here.

Your analogy is false, though. A more correct one would be "Netflix is allowed to show all initial movies in a franchise, but sequels are fair game to anyone."

Do you understand the difference between primary and secondary / supplemental insurance coverage?

I don't believe that my analogy is false, or that supplemental coverage would be allowed for the kinds of care being provided by M4A. I think perhaps a more on-the-nose analogy would be that "Netflix is not allowed to distribute anything that Apple TV is distributing or claims to distribute."

Again, I'm not making the claim that it's what's in the policy, but it's what Bernie has said, and others have echoed. Reasonable people can disagree on what policies are practicable or likely, but if you're a person who believes their health insurance might change based on those statements, then it seems like a warranted fear.

Part of it is because the “Medicare for All” proposal outlaws private insurance.

No, it does no such thing. Because there isn't one single "Medicare for All" proposal. There are a variety of plans proposed under that title, and only some would do away with private insurance. Many are some flavor of opt-in, granting access to the ability to buy into Medicare in the same way current Medicare recipients choose their level of coverage and pay accordingly, while leaving private insurance intact.

M4A gives everyone, rich or poor, the same base standard of coverage. And if you want coverage for other things that aren’t included under Medicare then you can get supplemental private insurance for it. That’s absolutely not outlawed.

If that's the case then they really screwed up with the term "single payer", and a lot of Bernie's own supporters were wrong. Lot of crap all over reddit about ending private insurance for the last year.

It’s not the case, but it’s apparently still not worth engaging with the Bros.

The big difference between the two camps that I see is that one side recognizes the cost benefit of their position and the other side doesn't.

Price controls on healthcare (socialization) has positive and negative impacts. The positive impact is universality. Everyone gets approximately the same basic level of care. In some countries you might be able to pay for a nicer room, or quicker service, but generally speaking it's all the same. The downside is that price controls stifle innovation. That's just basic mainstream economics and is the case in every industry, not just healthcare. The trick about stifling innovation is you don't feel it immediately. On day 1 of the price controls, the rich are about the same but the poor are better off. On year 50 of the price controls, everyone is worse off because of all of the innovation that never came to fruition.

I never hear advocates of universal healthcare have an adult conversation that they are trading long term benefits for short term gains. I think that's a reasonable position to hold, but if we just pretend that it's all benefits and no cost we're not having an adult discussion. It's not as if one side is right and one side is wrong. Once we accurately discuss the economics, it's easier to understand that this is a very difficult moral decision and not the trivial one that is sometimes portrayed in the political sphere.

My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.

1.) Your theory assumes that the cost difference at the hospital goes toward innovation. It ignores role of public money that goes into research. It is also not analyzing where the money are actually going.

2.) With this theory, if it is true, you are basically volunteering American patients to pay for innovation worldwide. That is quite a bad deal for quite a lot of American people.

3.)

> My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.

They have also different interests. Good cost benefit tradeoffs for one group is often very bad deal for another group.

1) No it doesn't

2) America doesn't have to let this happen. We could charge other countries for our innovations or otherwise demand reciprocation.

3) For people rich enough to have serious political power, the short term price difference is negligible or perhaps even cheaper under price controls.

On the other hand, right now, only the rich, or those with good enough medical insurance (if your co-pay is more than you make in 6 months, are you really insured ?), have access to the expensive treatments. On a universal heathcase system, whatever the form it may take, more people would have access those expensive options. Is it better to sell your treatment to more people but at a smaller price tag, or to fewer people at a bigger one ? I guess the economics depend on each treatment.

Fostering innovation is of course important. Which is why you can deduct a lot of your R&D expenses from your taxes. Again, each country has its own tax code, so generalization might not be possible, but in a lot of cases, the hard work of finding new drugs is funded by the citizens, through tax breaks or research grants. The public sector, via universities and public labs, is a major player (although not the only one, of course) in the medical field.

Let's not forget that forcing people to stay with their employer to maintain insurance coverage is also a way to stifle innovation. How many of those workers could have and would have started a business, if not for the fear to loose everything in case of medical issues ? Surely the republicains would love to remove those kind of barriers to worker movement and innovation, wouldn't they ?

The universal healthcare system obviously isn't free. Altough some studies, and real life examples elsewhere in the world, showed it wouldn't be the money pit some imagine, it certainly doesn't run on love and compassion and fresh water only. The taxes in my country can show you that. But the social benefits and the peace of mind I enjoy are, in my very own and somewhat biased opinion, worth the cost.

The peace of mind and knowledge that everyone gets taken care of no matter what is worth the world to me.

The "no matter what" in this case is that more people suffer and die for all time into the future so that fewer people can suffer and die today. That's a steep price to pay because the future and the amount of suffering people in it is functionally infinite. I think as long as you're willing to say that out loud and really mean it we've had a principled and honest discussion.

I feel like all you've done is point out exactly the cost in the cost/benefit analysis I gave. You pointed out that some treatments are expensive without acknowledging the high price encouraged it to be invented in the first place. Nor did you acknowledge that the patents will eventually expire and then that treatment will tend to become available to basically everyone.

We're talking about changing the velocity of innovation. Let's do a thought experiment about what innovations might be missing today if we implemented price controls everywhere in the globe 50 years ago. We might be missing the HPV vaccine leading to many cases of cancer for women. We might not have CRISPR. We might not have HIV treatments. High prices, profits, however you wish to put it, incentivized people to create these thing and go through the extremely difficult process of bringing them to market.

Now that's just a thought experiment about the past. It's impossible to know exactly what would have happened then, just like it's impossible to imagine the things that won't get invented 50 years from now. But we do know, according to basic mainstream economics, that price controls change the velocity of innovation. Since the velocity decreases, the farther you go into the future the more harm you cause through the lack of innovation.

I'm glad you brought up the fact that healthcare is tied to your employer. If you look up the history of this situation, you can see that it's the result of price controls enacted by the government on wages. Dumb things happen when we implement price controls.

The drugs/treatment you mentioned where all developped thanks to public contributions, not purely private research.

HPV vaccines were first developed by the University of Queensland in Australia [1] and further improved by the the University of Queensland, Georgetown University Medical Center, University of Rochester, and the U.S. National Cancer Institute [1].

CRISPR was discovered by several researchers from the University of California, Berkeley, the Broad Institute of Harvard and MIT [2].

The public helped in the discovery of those treatments (through tax payer subsidies), and as such, in my view, are entitled to some kind of retribution. Having a form of universal healthcare, where the public can put pressure on companies to decrease the price of different treatment, is exactly that.

Regarding the velocity of innovation, I don't think it is hurt by a universal healthcare system. Everyone has access to those treatments, and so the profit on each instance of the treatment can be lowered while keeping the same total profit for the company manufacturing the pills.

What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?

Even if some treatments, like drugs, can be made generic, and through that, have their price descrease in the futur, what about medical procedure ? Hip replacement won't suddenly or magically become cheaper in 5 years. Look at the price of stitches in the USA (For patients without health insurance, stitches typically cost $200-$3,000 or more, depending on the provider, the injury and the complexity of the repair [3]).

I do not propose to slash the profit of pharma companies. Like you said, academic studies consistently show that a reduction in current drug revenues leads to a fall in future research and the number of new drug discoveries [4]. Forbidding them one way or another to make a profit would be a net negative on the long term. But were our differences arise are in the implementtion of this principle. You propose, and correct me if I misunderstood, to let them set the price, and those how can will buy it. I propose to contain the cost so that all who need can afford it. The net result could be the same.

Price controls, like other types of controls, are a necessary evil in lots of case. It would be cheaper to allow companies to pollute everything and everyone, but we decided that society as a whole is better off with environmental controls. It would be cheaper to not test all those drugs and just let the market sort out which pills are working and which ones are dangerous, but we decided against it.

[1] https://en.wikipedia.org/wiki/HPV_vaccine#History [2] https://time.com/time-person-of-the-year-2016-crispr-runner-... [3] https://health.costhelper.com/stitches.html [4] https://itif.org/publications/2019/09/09/link-between-drug-p...

>The drugs/treatment you mentioned where all developped thanks to public contributions, not purely private research.

There's no such thing as a new drug that reaches the market without massive investment from private companies to do things like pay for FDA certifications, drug trials, etc. These are different categories of activities besides research. I don't think we're in conflict here.

>What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?

What is the point to avoid discovering ways to create insulin altogether just because some people might not be able to afford it while the patent is active? What are the regulatory hurdles preventing generics?

>Hip replacement won't suddenly or magically become cheaper in 5 years.

Regulatory capture by medical unions is a separate topic.

>I propose to contain the cost so that all who need can afford it. The net result could be the same.

The net result is NOT the same if the new treatment is never created in the first place. That's the whole point.

>Price controls, like other types of controls, are a necessary evil in lots of case.

Again, this whole thread is about making sure we acknowledge the "evil" part, which is long term increase in death and suffering but short term reduction in death and suffering. After that, you can decide on your own whether or not things are "necessary."

> stifle innovation

The most innovation I am seeing coming up from the US health system these days is in finding ways to extract more wealth.

Innovative things like "let's make a cartel, increase the price of insulin by 1000%, and use some of that money to buy politicians so they don't stand in our way".

That's not how insurance works, expensive insurance has a lower max out of pocket.

What you are talking about is that rich people don't need insurance at all. They just pay out of pocket.

That is how health insurance works in New Zealand.

If you want private health insurance for say $50 a month[1], then insurance gives access to procedures more quickly and the rooms are much nicer than the public health care system. It may give access to rare but expensive procedures.

If you don’t want insurance, then the default is the public healthcare system, which is paid for by taxes. You will usually be in a ward with other patients. You pay small amounts on use (to prevent abuse, and even those amounts are reduced to nearly free if you are poor). The level of care is reasonable, but can be slow for non-urgent elective surgery, and extremely expensive procedures are not available. The public healthcare system handles ongoing chronic conditions much better than a private system could.

[1] You can see a quote from https://www.southerncross.co.nz/ if you give your age, gender and tick whether you smoke. Note that Southern Cross is a nonprofit co-op, most premiums get returned to members (on average, less an approx 10% administrative overhead).

That system looks terrible for handling cancer and pre-existing conditions.

As opposed to one where everyone avoids medical care at all costs to avoid extortionate bills?

I don't think there is any system like that in first world countries. The US isn't like that if that's what you're insinuating

Please look around you a little more. My buddy separated his shoulder snowboarding in Tahoe. He had a full time (40 hours a week) job at the time, but it didn't provide healthcare.

He couldn't afford to go to hospital, so never did. I was visiting from Australia at the time and was utterly horrified, having no idea the US worked like that. Now years later his shoulder is still screwed.

Of course people in the US avoid going if at all possible, it's horrendously expensive, and medical bills are the number one cause for bankruptcy in the US [1]

In a stack of OECD countries (all the other ones?) nobody has ever gone bankrupt from medical bills, because that's impossible.

[1] https://www.thebalance.com/medical-bankruptcy-statistics-415...

Person doesn't have insurance and injured themselves doing a risky activity, and can't afford treatment. If it's really bad, why not use bankruptcy, I can't imagine this person has anything valuable given the history you described.

Or use physical therapy, it's cheap.

What is insurance for? To cover risk of something bad happening. The bigger the pool paying for it, the less impact to any one person to cover all the risk.

Now imagine that was scaled up to a whole country. That's New Zealand. Check out the Accident Compensation Corporation. All medical costs related to accidents are automatically covered!

But who pays the costs! Everyone, via levies. How much? $2000 on a $150K IT income.

But how do you control costs? Who is entitled? Who is at fault? Surprise! It's a no-fault accident insurance system that covers all accidents.

In exchange for that, we gave up our right to sue in accidents for medical damages. Why pay a lawyer when they're not required?

I guarantee the average US worker that makes 150k (not an avg salary) pays more then 2k in SSI taxes that cover Medicaid. They pay all over again for private healthcare, probably in the 6k range if they don't have kids.

Sorry, but is this a good example?

There are people that cannot afford insulin. THAT is a problem. But the fact that he took a risk, for fun, and suffered the consequences, rather than having everyone paying for it? That sounds a bit reasonable...

Note: important that the risk is voluntary, optional and recreational rather than professional. Why would the collective bear the costs, in those circumstances? Why is that fair?

So you think it's fair for someone to spend 2.5% of their income on a flu test when they have good reason to believe they may have COVID-19?

Do you mean monthly or annual?

If monthly, the answer is still no, but only because testing for covid is a significant public good.

Otherwise, yes, sure?

It is an unpredictable, low probability event, with not so big an impact (the payment, I mean, not covid)

It absofuckinglutely is. If you don’t see that you may want to check whether your perspective is informed entirely by a (quite rich) bubble.

Cancer is not an elective surgery and gets treated with urgency. Across the Tasman Sea with a very similar system my father had bowel cancer removed the day after diagnosis in the public system and spent most of the recovery in no state to miss a private room.

All NZers get treated for cancer or pre-existing conditions, within the funding limits of the health system.

Severe health problems don’t bankrupt NZers, and you are not locked into a job just to (a) keep your insurance, or (b) keep your insurance benefits.

How many recently unemployed in the US have lost cover for their pre-existing conditions?

I expect you can find the benefits list document for Southern Cross, if you wished to check out the details of cover for cancer or pre-existing conditions.

The most expensive plan for my family (2 parents and a young child) is $367 a month. Equivalent coverage in the US would be thousands of dollars.

I do not know the New Zealand system, but I suspect the base level of care is still covered by public funding and the insurance is only covering optional extras (like private rooms).

They still pay taxes, though.

Germany allows people to opt out entirely, although there are a bunch of conditions and limitations. Most people don't, so the public system can still pay for itself.

Sadly in germany it's rather difficult to switch between public and private or no insurance. Or rather, it's very difficult to get back on a public insurance once you're private or self-insured. The best you can hope for is pulling it off once, maybe twice.

That doesn't seem unreasonable.

If you're avoiding paying into a system because you don't want to claim from it then letting you hop back on whenever you need it would destroy the system very quickly.

It's not that easy, luckily, if you're self-insured and have to take the service of a doctor, you can't switch just like that. It takes about a year of paper exchange with everyone involved to switch cleanly. Even then, any costs you started paying for from before will still have to be paid unless you're below a certain income bracket (or declare bankruptcy).

So if you were self-insured and broke a leg, then decided to switch back to insurance, you'd still be on the hook for the costs of the ongoing physiotherapy until it is healed back up. The insurance doesn't have to actually pay anything that happened before a switch (switching from public to public insurance or private to private doesn't have this limit, private to public and the other way round but you don't pay, your old insurance pays).

I'd wager that is by design, and one of the ways they keep people from avoiding insurance when young and healthy, and then getting it when old

It's possibly one intention, though there are already laws that prevent you from going back to public insurance if you're over 55 years old as well as if you're over a certain income limit.

The only universal way to switch is to marry someone in public insurance.

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