From this matrix, there are four groups of people:
Group 1
These people can afford insurance and buy it. It might be a strain on the budget but these people realize it is a good idea to have health insurance and thus try their best to buy it and do so.
Group 2
There are those who can't afford it but want to buy it. They want to be responsible but because of a combination of low income and high insurance premiums they are unable to buy. Some people in this category qualify for Medicaid and thus wind up in Group 1. But some don't qualify for Medicaid and can't afford health insurance.
Group 3
Some people actually earn enough money to buy health insurance but for whatever reason do not buy health insurance.
Group 4
Sadly, there are people who belong to this group who are unable and unwilling to buy health insurance.
Thus, the 46.3 million uninsured fall into one of the three categories of uninsured.
How does one help move people from the three other boxes into box one?
One idea of how to help the folks in the 3 uninsured boxes is to blow up the matrix and have the government run the whole thing. There are two ways the USA can do this:
(1) Nationalize health care providers
Just as the Federal government took over airport security in creating the TSA, the Federal government could directly hire and pay the salaries of health care professionals and run hospitals and clinics. An example of how this works in the USA is the VA medical system for the veterans.
(2) Nationalize health insurance
Under this approach, doctors and hospitals are paid from a government run insurance plan. We have some experience with this approach as Medicare is the USA nationalized health insurance for senior citizens. Also, Medicaid is a variant where Federal and States organize health insurance for the poor.
Thus, in the USA, some aspects of health care delivery and insurance are already nationalized and so some believe the nationalization should be extended so that all health care/health insurance be brought under one system.
However, for now, the question remains what will happen to health care as run by private entities. They are regulated at state and federal levels and the recent health bill expands those regulation.
I don't know how the regulatory climate compares to electrical utilities. One could make the comparison that both are essential services that should be heavily regulated and are. The debate is what degree of regulation.
If one retains private entities in the provision of health care, how does one address the 3 boxes of the matrix of uninsured?
One way is to provide vouchers to those who need help to buy insurance. Food stamps are essentially vouchers to buy food. Why not develop a program for the purchase of health insurance?
Instead of government agencies that run Medicare and Medicaid, why not trim their responsibilities to determining eligibility and issuing vouchers to those who qualify?
Of course to pay for those vouchers, the money committed to Medicare and Medicaid would have to be transferred to the voucher program and additional taxes might still be needed to cover people in group 2.
But what about group 3?
The stick of an insurance mandate may or may not survive legal challenge. But even if the mandates are eventually upheld, how does one enforce them? At what level of monetary fines will someone in group 3 decide to buy insurance? In the end, the uncompensated care provided to group 3 individuals is cost shifted to group 1.
As for group 4, they will remain in the realm of uncompensated charity care no matter what is done and their costs shifted to group 1.
Ultimately, even in a nationalized system, there is "cost shifting" because those who pay higher taxes are subsidizing those who pay less taxes. Thus, in my mind "cost shifting" is something that will always exist no matter what system is devised.
The dream of equal access to high quality health care is nice to strive for but unrealistic. The rich could always find a way to buy better services. Thus, the practical goal should be to design a system that maximizes access to a reasonable level of quality. Alas, the definition of reasonable quality is hotly debated.
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