In US public policy, all roads lead to healthcare. Remorseless pressure on public spending? Blame Medicare. Economic insecurity? Fear of losing health benefits is a chief cause. Stagnant wages and worsening inequality? Look to the cost of employer-provided insurance. This failing system is a national scandal not just in its own right, but because of its proliferating fiscal, economic and political implications.

For many workers without employer-provided insurance, the cost of cover is now prohibitive. The average cost for a family is $12,000 (€7,700, £6,100) a year (roughly a quarter of median household income before tax) and rising handsomely in real terms. If you have cover provided by your employer, losing your job means losing your insurance. The unluckiest – especially those with a dreaded “pre-existing condition” – may then face ruin. This vastly amplifies the anxieties colouring the election and driving the US towards an increasingly strident anti-business, anti-trade outlook.

Even those with employer-provided insurance and no fear of losing it are unhappy, because the cost is eating up their wages. It is so high and rising so fast that many workers can expect pay rises or continued coverage, but not both. If you add the cost of insurance to wages, the pay of low- and middle-income workers has not in fact been stagnant. Concerns about living standards and widening inequality are linked to health policy.

Standards of care for those with access are superb, but the price is stunning. The US spends 16 per cent of its gross domestic product on health. Most of that is private, but even what the government spends exceeds, in per capita dollars, all Britain’s outlays (National Health Service and private spending combined). Yet aggregate US health outcomes are poor. By no stretch of the imagination does the US system deliver value for money.

But how to fix it? The best of recent books on this question is happily the shortest and clearest and comes out this month. I think it has the answer. The proposal laid out in Healthcare, Guaranteed (Public Affairs, $14.95) by Ezekiel Emanuel (an oncologist, bioethicist and noted health policy scholar) has convinced me. Whether it will convince others is in doubt for reasons I will come to. But if you are going to read one book on the subject, make it Mr Emanuel’s.

He points to employer-provided insurance as a critical defect in the US system. Inequities, inefficiencies and avoidable insecurity all flow from this model, which itself is a result of the $200bn tax break lavished on employers. In this he agrees with Senator John McCain who wants to give everybody tax relief for health insurance, regardless of who buys it. Senators Hillary Clinton and Barack Obama rely on employer-provided insurance and suggest ways of compelling or encouraging it.

Mr Emanuel also wants truly universal coverage. Here he parts with all three presidential candidates. Mr McCain’s plan is feeble: a subsidy to the low-paid (in the form of a refundable tax credit), but no clear solution to the pervasive problem of uninsurable “bad risks”. Mrs Clinton’s subsidies-plus-mandate is better, but would fall short of universal coverage (witness Massachusetts, which has tried a variant of her scheme); Mr Obama’s subsidies-without-mandate has the same defect, only more so.

Mr Emanuel proposes a universal healthcare voucher, entitling every citizen to privately-provided insurance, with standard benefits equal to those enjoyed by members of Congress. Insurers would be forbidden to deny coverage to any citizen, regardless of pre-existing conditions. They would be reimbursed by the government with a risk-adjusted premium for every enrolee – taking account of age, sex, pre-existing conditions and other factors using a formula to be determined by a new National Health Board. The system would start by covering the uninsured and those covered by their employers; in due course it would absorb Medicaid and Medicare.

This is not a single-payer plan: competition among insurers and health plans would be crucial to its success. But competition would revolve not around denying coverage by excluding bad risks, but around providing good results. To that end, companies would have to report detailed information on their performance and quality of service.

This is not a new idea. France’s mostly excellent system has similarities. But the presentation of the case has never been so concise or clear. Why then will it get nowhere? Because Mr Emanuel wants his scheme to be financed through a value added tax of 10 per cent, dedicated exclusively to the purpose. This instantly consigns the idea to the realm of the politically impossible – but bear with me a moment longer.

At least consider that Mr Emanuel might again be right. Total spending on health would come down under his proposal. What consumers in the aggregate paid in the new tax they would get back in savings on premiums (for the self-insured), higher wages (for those with employer-provided insurance) and cuts in other taxes. Best of all, the new tax would finally attach accountability to growth in overall healthcare costs. The country could resist the endless creep of health-cost inflation, or else resolve to pay a higher (broadly based) tax to meet it. The health budget could not keep growing, as at present, through sheer inattention.

In politics, being right is never enough. But if Mr Emanuel’s excellent proposal finds no takers, readers of his book will still have a clearer sense of what has gone wrong in US healthcare and of how and why the proposals of all three presidential candidates are certain to fall short.

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