> We will soon have a tiered system - if it already isn't here That has indeed been the case in the U.S. for years. The three most common health-insurance stru

> We will soon have a tiered system - if it already isn't here That has indeed been the case in the U.S. for years. The three most common health-insurance structures, EPOs, PPOs, and HMOs, each have very specific lists of doctors who accept "in-network" coverage (they differ largely on the terms by which you can pay out of pocket to go "out of network"). How big those lists are and what kinds of doctors they include is pretty noticeably correlated with price: the cheapest insurances don't get you access to a wide range of top-quality "in-network" doctors. And there are a handful of boutique clinics and surgeons who don't take any packages at all. (There's an additional negative impact of this "networks" system in that companies seem to change networks semi-regularly as they renegotiate packages, and people change networks when they change jobs, which interrupts continuity of care.) Where I live now (Denmark) the whole system is just run publicly, except for a handful of elective things (non-reconstructive plastic surgery, etc.), which are allowed to be done in private practice since they aren't properly considered part of the healthcare system. That removes the possibility of any tiering among "regular" care, and somewhat simplifies bureaucracy (plus, kids can keep the same doctor throughout their childhood, not having to switch every few years). I wouldn't actually mind a multi-tiered system, though, as long as the "free" tier can maintain sufficient quality. I particularly don't mind differences in amenities (if people are willing to pay a lot to go to boutique hospitals that have luxurious private suites, like some of the medical-tourism-oriented hospitals in Jordan offer, that's fine). Tiering does have potentially bad consequences for the quality of the free tier, but to me those consequences are what matter more than the tiering itself, i.e. if System A provides everyone level-7 quality healthcare, while System B provides everyone level-8 quality healthcare and those who pay extra level-9, I'd prefer System B despite its inequality, due to the higher absolute standard of its generally-available care. In terms of your worry of doctors dropping out of the insurance system to make higher incomes, I think that is something to watch out for, although afaict the big monetary lure currently isn't to keep the same general profession but go out-of-network, but rather to leave "regular" healthcare entirely and go to super-premium boutique stuff like plastic surgery, IVF treatments, sports medicine, etc., which is where the real "superstar doctor" money is. Some of this may be because it's harder to become a superstar doctor in areas like cancer treatment without being at a top research hospital, and research hospitals tend to see themselves as having a public-service (rather than income-maximization) mission, which impacts their policy decisions. If necessary the government could also probably lean on those kinds of hospitals (places like M.D. Anderson, Johns Hopkins, etc.) by adding strings to NIH funding.