In the purest sense, health insurance should be burden sharing. Everyone pays the same amount for coverage, and everyone receives appropriate care, regardless of individual cost. It is pure and simple "socialism", and the objective is that everyone gets that appropriate care while the burden of cost is "shared" equally or proportionately based upon ability to pay. For such burden sharing to be truly a "social program", membership in the population receiving the care and paying for the benefit must be mandatory for everyone in the society.
In many areas of what might be considered "social programs" in the US, however, the cost burden and/or delivery burden is administered and collected by competing entities. And sometimes, the competing entities are really the right and left hand of the same organism. In this environment, we find "burden shifting". That is where the cost and/or delivery of social services is shifted from one subset of the population or entity to another. I would offer two examples:
A while back, the commander of a Naval Hospital received an award for the cost saving to the regional Naval budget realized by closing the hospital's emergency room and directing the sailors, dependents and retirees to the nearby civilian hospital some 20 miles away. For active service members, of course, the cost of civilian emergency room care would be borne by the regional budget, at a per patient rate higher than at the Naval hospital. But for the dependents and retirees, the cost would be shifted to TRICARE, and these potential patients outnumbered the active duty sailors by about 5 to 1. Thus, a net saving to the Naval Hospital. The decision was made on budgetary terms alone, and with no coordination with the local hospital or ambulance service, who saw the population they were to serve for emergency services more than double. Lost in the joy the regional medical command expressed over this exercise in creative accounting was that the true payer of the bill for this care was the US taxpayer, who would ultimately pay more for civilian care than that at the Naval hospital. I won't even begin to try to evaluate the effect on overall quality of care to the residents of family housing who's emergency room services just moved 15 to 25 miles further away. The end result is that the Captain got an MSM, the taxpayer had to pay more for less and patients had to travel further for care.
The second example is more recent. Miami Charity hospital found that it could no longer afford to provide free scheduled dialysis services to the indigent. However, these same patients could, when their medical state reached a sufficiently high level of danger, go to the emergency room for dialysis, which would be paid for by the State, at a rate much higher than for the cost routine treatment. So, by putting the patients at constant and recurring medical risk/danger, Miami Charity could shift the burden of indigent dialysis from their benefactors to Medicaid, and even pick up some extra bucks doing so.
In the main, the US health care industry is based on burden shifting, not burden sharing. Since there are multiple insurers and multiple populations in the pool, it is "sound business practice" to shift burden to keep the costs for any specific population pool down. Since insurers could terminate someone's coverage, that burden could be shifted to public assistance and/or the patient. Since employer provided insurance is based on a pretty well defined population, actuarial data could tailor premiums for that population and only that population, without regard to the cost of care for the general population from which the insured were drawn. Since some populations could afford higher priced care than others, providers could raise prices for health care to what the market could bear, and it would be spread . Of course, once an appendectomy, for example, is bench marked to a new higher price, pressure comes to bear for all appendectomies to carry the same price.
But burden shifting isn't just the domain of government entities. Employers include the cost of health care insurance in their operating expenses, passing that cost on to their customers. Remember all the bruhaha about the embedded cost of the "Gold Plated Health Insurance" in the price of a US union-made car when Detroit went down the tubes? Well, the consumer began to bitch about their fellow Americans shifting the burden of their health care to their fellow American. Why? Because it became visible, for one reason. My neighbors here in Greece were puzzled over how health insurance can be "Gold Plated", as to them, you are either insured and receive health care or you aren't. Try to explain deductibles to someone in Europe, and their eyes glass over.
Health care isn't the only arena where burden shifting takes place in the US. It is not uncommon for states to rely on ear marks and pork to ease their internal tax burdens. Let the folks in all the other states help pay for our roads and schools in MS. Get a state or federal grant to bring our sewers up to decent sanitary standards in our town in NY. And the burden gets shifted from one sub-population to the other. But the fact is, we are all paying for it, and sooner or later the piper has to be paid, and when that happens, it's typically a catastrophe, as is the impending case with health care. We have run out of sub-populations to shift the burden to.
What's really insane about paying for health care through burden shifting is that when it's included in the commercial price of goods and services, we not only pay the direct cost, but the enterprise's desired profit goal throughout the chain of distribution. So if health care costs $1,000 per vehicle for GM, as so often cited, GM will add X% to it's total cost to meet their profit goal, and the consumer will pay $1,000 plus X% to fund GM insurance beneficiaries. Why $1,000? Because GM can only shift that burden to buyers of their cars. Buy a Mercedes, and you may very well be getting a car made by a beneficiary of national health care and a much more efficient health system, and much less of the burden is shifted to you.
And all of this so that we can fool ourselves into thinking that we are not paying for someone else's benefits!