Universal Access to Affordable Healthcare, without Medicare for All.

HomeHealth PolicyUniversal Access to Affordable Healthcare, without Medicare for All.
November 2, 2026

The discussion about universal access to affordable healthcare usually stops at Medicare for All. Most Americans don’t realize that there are many different approaches to achieve that goal, and Medicare for All is only one.

So this week, let’s look at the two countries with the best health outcomes in terms of life expectancy and maternal mortality and how they achieve universal healthcare: Switzerland and Japan.

Switzerland and Japan both cover everyone. Neither one runs a single government insurance plan. In both countries, your coverage comes through one of many insurers, and your care comes mostly from privately owned hospitals and clinics. On paper, they are closer to the American system than Canada or the UK will ever be.

And yet, according to the OECD, Switzerland spends about $9,960 per person on health care. Japan spends about $5,790. That is 42 percent less, for a population that is older and lives longer.

Same basic architecture. Very different bill. The difference is not who sells the insurance. It is who sets the price.

One honest caveat before we start. Switzerland’s insurers are true private companies, though they cannot profit on the basic plan. Japan’s are a patchwork: about 1,400 employer run health insurance societies, a national association for small business workers, and plans run by cities and prefectures. Under Japanese law the employer societies are public corporations, not private businesses in the American sense. But they are not one government payer either. Both countries prove the same thing: you can keep many insurers and still get universal coverage. Japan proves something more. You can keep many insurers and still get low prices, if the government sets them.

Same format as last week. Four variables: what it costs per person, who pays and how, how long you wait, and how care gets rationed. The goal is not to tell you what to think. It is to show you the trade offs clearly enough that you can decide for yourself.

How Switzerland works

Switzerland made health insurance mandatory in 1996. Every resident must buy a basic plan from one of a few dozen insurers. The benefits in that basic plan are identical everywhere, set by law. Insurers must accept everyone, and they compete on price and service.

Here is what makes it feel different from America. Your employer is not involved. You buy the plan yourself, the way you buy car insurance. Premiums are community rated: they vary by canton, age group, and the deductible you choose, but not by your health and not by your income.

That last part matters. A cashier and a bank executive in Zurich pay the same premium for the same plan.

The numbers for 2027, announced by the Federal Office of Public Health in September:

Then there is cost sharing. Adults choose an annual deductible, called a franchise, between CHF 300 and CHF 2,500. After that you pay 10 percent coinsurance, capped at CHF 700 a year. At the standard deductible, your maximum out of pocket is CHF 1,000, plus a small daily hospital charge.

To help with premiums, the federal government and the cantons pay subsidies. Roughly three in ten residents receive one.

And prices? Switzerland does have a national fee schedule for outpatient care. A new one, called TARDOC, took effect in January. But the dollar value of each service is negotiated between doctors, hospitals, and insurers, canton by canton, with government approval. It is a negotiated system among stakeholders, not a price the government dictates. Remember that distinction. It is the whole story.

How Japan works

Japan has had universal coverage since 1961. Like Switzerland, it uses many insurers, more than 3,000 of them. Which one you belong to depends on your job.

  • Large employers run their own health insurance societies. There were 1,383 of them as of 2023.

  • Small and midsize employers put their workers into one national association, Kyokai Kenpo.

  • Public servants have their own mutual aid associations.

  • Everyone else, including the self employed, retirees under 75, and the unemployed, joins National Health Insurance run by their city and prefecture.

  • People 75 and older move into a separate plan for the elderly.

For workers, the premium is a share of wages split evenly with the employer. In Kyokai Kenpo the national average is about 10 percent of pay, so the worker pays about 5 percent. Unlike Switzerland, premiums are tied to income.

At the point of care, there is no deductible. Most people pay 30 percent coinsurance on everything: visits, hospital stays, drugs. Young children and lower income older adults pay less.

Thirty percent sounds steep. Here is what keeps it from being ruinous. Japan’s high cost medical expense benefit caps what a household pays each month, based on income. For a middle income patient under 70, the cap is ¥80,100 plus 1 percent of costs above ¥267,000. On a ¥1 million hospital bill, the patient pays about ¥87,430, not ¥300,000. After three months at the cap in a year, the cap drops further.

Now the part that matters most. Every covered service, drug, and device in Japan has one price, set nationally by the government. The fee schedule applies to almost all providers and is revised every two years. Drug prices are surveyed and cut on a regular schedule. Doctors and hospitals cannot charge more. Insurers cannot negotiate less.

That is the lever Switzerland does not pull. Both countries have many insurers. Only one of them has a single national price list that the government writes.

Trade off one: what it costs per person

Start with the OECD’s 2024 figures, adjusted for differences in purchasing power so the countries can be compared fairly:

Switzerland is expensive by any standard except ours. Japan is not.

And Japan gets its number while running the oldest population on earth. Its people use more care, not less. Japanese patients see a doctor about 12.8 times a year, roughly twice the OECD average. Japan has the most hospital beds per person in the OECD, and the longest hospital stays. It has more MRI machines per person than any country, 52 per million, compared with 39 in the U.S.

So how does a country that uses that much care spend so little? Price. Look at one service.

These are older figures. The Japan number was reported by NPR in 2009, and the Swiss and American numbers come from a KFF comparison using 2014 data. The exact prices have moved since. The ratio has not.

Drugs follow the same pattern. In 2023, new drugs in Japan sold for about 40 percent of U.S. prices. Japan also lowers drug prices on a regular schedule after launch, so the price of a brand name drug falls over its life rather than rising.

One fair note. Japan’s spending is low per person, but not low as a share of its economy. It spends 10.6 percent of GDP on health, above the OECD average of 9.3 percent. Some of that is age. Some of it is that Japan’s economy has grown slowly. Either way, Japan did not get cheap care by skipping care. It got it by paying less for each piece.

Trade off two: who pays, and how it feels

Last week the question was taxes versus premiums. Here it is something more basic: is your premium tied to your income, or not?

Let me run a family of four through each system: two adults, two children.

Switzerland, 2027 average premiums:

  • Two adults at CHF 487.60 a month, two children at CHF 128.10

  • Total: about CHF 14,800 a year, or roughly $17,700

  • Employer share: none

  • Cost sharing: up to CHF 1,000 per adult at the standard deductible, more if you chose a higher deductible to lower your premium

  • Same premium whether the family earns $60,000 or $600,000, before subsidies

Japan, employer coverage:

  • Premium: roughly 10 percent of wages, split evenly, so about 5 percent from the worker and 5 percent from the employer

  • For a household earning the equivalent of $100,000: about $5,000 from the worker, about $5,000 from the employer

  • Dependents are covered under the worker’s premium

  • Cost sharing: 30 percent coinsurance, no deductible, with a monthly cap tied to income

United States, employer coverage, for reference:

  • Average family premium: $26,993, with the worker paying $6,850

  • Cost sharing: deductibles and copays that vary widely, often thousands

The Swiss model is the most transparent of the three. You see the full price of your coverage every month, because nobody hides it in your paycheck. That transparency is also why it stings. According to federal figures, Swiss households spend an average of 14 percent of their income on premiums. In June 2024, voters were asked to cap premiums at 10 percent of income. They said no, 56 percent to 44.

Switzerland also leans heavily on patients at the point of care. In 2024, 21.3 percent of all health funding came straight from households in cost sharing and out of pocket payments. Two thirds of the system is paid for by households, either directly or through premiums.

Japan spreads the cost differently. Premiums rise with income, and taxes cover a large share. In one breakdown using 2013 data, premiums paid for about half of the insurance system, tax funded subsidies about 38 percent, and patient charges about 12 percent. The 30 percent coinsurance looks harsh on paper, but the monthly cap does most of the protecting.

If you are a lower income family, Japan is gentler. If you are a high earner, Switzerland is cheaper for you than it is for your neighbors. That is a values choice, not a technical one.

Trade off three: wait times

Last week I said long queues are not a law of nature in universal coverage. These two countries are the proof.

Switzerland has some of the shortest waits in the developed world. In the Commonwealth Fund’s international surveys, 13 percent of Swiss adults waited two months or more for a specialist, compared with 46 percent in Canada. Only about 1.3 percent of Swiss residents report an unmet medical need, well under the OECD average of 3.4 percent. Switzerland has 4.5 practicing doctors per 1,000 people, above the OECD average.

That is what $9,960 per person buys. Capacity. Plenty of doctors, plenty of scanners, and patients who can see a specialist without much delay.

Japan gets fast access a different way. There are no gatekeepers. Patients can walk into a clinic or a hospital outpatient department, often without a referral, and be seen the same day. Japan does not take part in the Commonwealth Fund survey, so I cannot give you a clean side by side number. But queueing for a first visit is not Japan’s problem.

Volume is. Japan has fewer doctors per person than the OECD average, and they see far more patients. The OECD estimates Japanese doctors handle more than 4,500 consultations each per year, among the highest of any country. When a fee schedule pays a modest amount per visit, the way to keep a practice open is to see a lot of people quickly.

So Japan trades the waiting room for the exam room. You get in fast. You may not get long.

Trade off four: what price controls cost, and who gets rationed

Last week I wrote that the tension at the heart of Medicare for All is payment rates. Set them too low and capacity shrinks. Set them high enough to protect capacity and the savings shrink.

Japan is what it looks like when a country chooses low prices and holds the line for decades. It works. And right now, it is straining.

Hospitals are losing money. Fees are set by the government and revised every two years. When inflation and wages rose, hospitals could not raise prices to match. In the fiscal 2024 revision, the main portion of fees, the part that covers staff, rose only 0.88 percent. The result:

The government responded. For fiscal 2026 and 2027, it agreed to raise the main portion of fees by an average of 3.09 percent a year, while cutting drug prices again. Notice how it happened, though: a negotiation between the health and finance ministers, decided at the top. The price of care in Japan is a political decision, made centrally, every two years.

New drugs are skipping Japan. Low launch prices and scheduled price cuts make Japan less attractive to drugmakers. Only 20 novel medicines launched in Japan in 2023, less than half the U.S. total. The industry group PhRMA counts 245 new medicines launched in the U.S. or Europe from 2014 through 2023 that were not available in Japan. That is an industry source with an interest in higher prices, so read it with that in mind. But the Japanese government itself now calls this “drug loss” and has made fixing it a policy goal.

Japan rations by volume and by price cuts. You will rarely be told no, and rarely asked to wait for a first visit. But your visit may be short, your hospital may be understaffed, and the newest cancer drug may not be on the market yet.

Switzerland rations by price. Not at the clinic door, mostly, but at the premium bill. When households spend 14 percent of income on premiums, the easiest way to lower the bill is a higher deductible, up to CHF 2,500. That means the families most squeezed by premiums are often the ones most exposed when they actually get sick. Even inside one of the best performing systems in the world, the pressure shows up where it does here: in the monthly budget.

So neither system escapes rationing. Switzerland pays for capacity and asks households to carry the bill. Japan holds down the bill and asks providers to carry the strain.

The model, side by side

Here is the whole thing on one page, three systems measured the same way.

United States

  • Spending per person: more than $14,880 (OECD, 2024)

  • Insurers: employer plans, individual market, Medicare, Medicaid

  • Who sets prices: negotiated plan by plan, plus Medicare’s administered rates

  • What you pay: average family premium $26,993, worker pays $6,850, plus deductibles

  • Wait times: 31 days to schedule a new appointment in big metros; short specialist waits if well insured

  • How care is rationed: price, prior authorization, coverage gaps

Switzerland

  • Spending per person: about $9,960

  • Insurers: private, nonprofit on the basic plan, everyone buys individually

  • Who sets prices: negotiated between providers and insurers, approved by government

  • What you pay: flat premiums, about CHF 14,800 a year for a family of four in 2027, plus a deductible of CHF 300 to 2,500

  • Wait times: among the shortest in the world; 13 percent wait two months or more for a specialist

  • How care is rationed: price, through premiums and deductibles, softened by subsidies for about three in ten residents

Japan

  • Spending per person: $5,790

  • Insurers: more than 3,000, mostly employer and community based, assigned by your job

  • Who sets prices: the national government, one fee schedule for everyone, revised every two years

  • What you pay: about 5 percent of wages from the worker and 5 percent from the employer; 30 percent coinsurance with a monthly cap

  • Wait times: little queueing for a first visit, no referral needed; short visits and heavy doctor workloads

  • How care is rationed: volume and time, hospital finances, and delayed access to some new drugs

Read across any line and the pattern is the same. Switzerland and Japan agree on the structure: mandatory coverage, many insurers, private providers. They disagree on one thing, who decides the price. The gap between them is about $4,000 per person per year. Age, wealth, and wages all play a part, but price is the biggest single reason.

Where that leaves us

If you want universal coverage without a single government plan, Switzerland shows it can be done. Everyone covered, short waits, excellent care, private insurers competing for your business. It is also the second most expensive system in the world, and the Swiss are fighting about premiums every single fall, the way we fight about open enrollment.

If you want universal coverage at a lower price, Japan shows that too. But Japan’s savings do not come from its insurers. They come from a government that writes one price list for the entire country and makes everyone follow it.

That is the part of the debate we skip. Americans tend to argue about who should hold the insurance card: a private company or the government. Switzerland and Japan suggest that is the wrong fight. The bigger lever is who sets the price, and how hard they hold it.

And Japan shows the cost of holding it hard. Hospitals in the red. Doctors seeing patient after patient. New drugs arriving late or not at all. Those are real costs. The people dismissing them have usually never had to staff an emergency department on a fixed budget.

But the people dismissing price controls entirely have usually never had to explain to a patient why the same MRI has a different price at every building in town.

The honest version of this debate sounds less like “public versus private” and more like this: How much do we want to pay for each MRI, each office visit, each hospital day? Who decides? And how much capacity are we willing to give up to get there?

Those are not slogans. They are price lists. And that is where this debate should be happening.

Sources

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