"Fancy" healthcare is cosmetic surgery. Everyone pays that out of pocket. Otherwise, second tier healthcare is what? Where the providers are overworked and underpaid, where getting treatment is hit or miss?
I would see the public safety net health care as being no frills, and the private system as providing whatever the patient is willing to pay for (directly, or through payment by his/her insurer, which the patient obviously pays for indirectly). In the public safety net care you would expect to see:
-- Wards with 4-6 patients per room. This was the standard in years past, it's not clear why patients today have a greater requirement for privacy than our grandparents did. This is common in military health care, does not seem to adversely affect treatment.
-- Physicians/providers who are government employees, or directly contracted by the government at a fixed wage. (Reduced incentive for unnecessary procedures. This is also common in military health care, does not appear to adversely affect treatment). This step alone would likely cut costs a lot.
-- Treatment of some types is not available. This would include :
---Cosmetic surgery (restorative, post traumatic injury treament would be covered).
--- Fertility treatment
--- There would be age-based and expected-outcome-based limits on expensive care. A 90+ year old would not get $250,000 of cutting-edge inpatient oncology treatment at taxpayer expense. A 30 year old in good health otherwise might get this care. In a ward.
--- The 9+ month wait for knee replacements experienced in other countries? Our safety-net care might have similar waits.
- The government-supplied would include mandatory vaccinations and healthy-living counseling. It
might also include mandatory drug testing (I realize this is controversial. But, drug use definitely is a risk factor for all kinds of medical conditions, and if taxpayers are footing the bill, then it is not unreasonable to ask some questions that are directly pertinent. It's only mandatory if you want somebody else to pay for your care.)
To say we are a "rich nation" and that we should provide certain things for everyone blurs a couple of points that are significant, I think.
-- The
individuals in our nation are prosperous. The government is broke. To provide these benefits requires taking something from individuals against their will.
-- Our people are prosperous because our system is designed to reward initiative and hard work. Other systems have been tried, they do not result in prosperity. To the degree that our system continues to allow individuals to prosper from their efforts, we'll continue to prosper as a nation. To the degree we disincentivize hard work (e.g. through increased taxes) and provide the same services to everyone (e.g. health care that is the same, by law, no matter how productive you have been), we should expect our prosperity as a people to decline.