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I started my solo IM practice in 1955.The elderly were charity cases, but fees were small, and tests rare and cheap. 10 years later medicare came in and elderly patients became a profit source for practitioners, many of whom abused the system . The elderly could afford surgery, and because it was universal single payer, everyone paid into the system his whole working life- still does.
The problem arose when medicine became commodicized. about 25 years ago. Paul Starr in his "Social Transformation of American Medicine' summarized it- medial practce went from a cottage model betwen patient and doctor- to an industrial model- insurance companies as owners, doctors as workers and patients as product. soto keep investors happy and profits rising, primary care doctors increasingly became hamsters on a wheel, seeing 5 patients in an hour.
It makes no sense to have for profit insurers.There is no realistic competition. Senator Grassley's state has one insurer for 75 % of its population. They insurers spend 15-20% on administration as compared to medicare's 3%, and spend huge amounts of money to deny claims.With 360 HMO's the system is hopelessly complex.
The most effective and cost effective HMO's are nonprofits like Kaiser-Permanente, Geisinger,Mayo. The best hospital system , with best IT, is the VA.Andwith 36 million onMeicare, and 1 in 5 children on medicaid, we canthust start over with grand declarations of principle. We have an aging population with increasingly expensive diagnosis and treatment. No one can pay for MI'sandstents and cabgs and HER testing and avastin- it mustbe done with general insurance, andit has to bepid for with higher taxes. soit hasto be more efficient, with comparative effectiveness systems.