Professor William Hsiao, the Harvard economist, has helped design health care systems for more than a dozen nations. He says the creation of a national health care system involves political, economic, and medical decisions, but the primary decision to be made is a moral one.

Defending his medical and unemployment insurance schemes in 1884, Bismarck argued that “the greatest burden for the working class is the uncertainty of life. They can never be certain that they will have a job, or that they will have health and the ability to work. We cannot protect a man from all sickness and misfortune. But it is our obligation,

the French for-profit hospitals tend to specialize in certain illnesses and procedures.

But the 2010 reform law did little to reduce the fragmentation of American health care; if anything, it will give us a system that is even more complex.

The most distinctive lesson we could take, though, from Canada’s health care system is the key point of the Tommy Douglas saga: Universal health care coverage doesn’t have to start at the national level. Once Douglas established free hospital care in a poor rural province and made it work, the demonstration effect drove other provinces to do the sa

Since the premium is a percentage of pay, the premium stays the same, no matter which fund a worker chooses. And yet there is heated competition among these nonprofit insurance plans. Some compete by promising to pay all claims within five days; some offer benefits beyond the basic package, like exotic Asian therapies or free neonatal nursing care

But no other country relies on for-profit insurance companies to pay for basic health care.

“But our Krankenkassen compete because the executives earn more money, and higher prestige, if they have a larger pool of insured members.

The ethical issue of universal coverage—Professor Hsiao’s “first question”—was not part of the conversation.