One of the underlying conditions that have made the U.S. economy’s current sickness so painful is the country’s crippled health-care system. “System” may be too good a word for it. It’s really a make-do patchwork of institutions, public and private, that leaves many people with no coverage and many more with too little.

Even before the economic downturn, 47 million Americans had no health insurance. Because most of those who have lost their jobs have also lost their health insurance, that number is certainly higher today. Meanwhile, an increasing number of those still lucky enough to have insurance are struggling with rising premiums and copayments. About half of all personal bankruptcies are now caused by medical expenses, and of the people in that half more than three out of four go bankrupt despite having health insurance. In 2007, the United States spent $6,697 per capita on health care—the most in the world and about twice the average spent by other wealthy countries.

If this were the price of good health, Americans might be expected to put up with it. In fact, our expensive system does not produce very good results. Overall, we rank thirty-seventh in health outcomes according to the World Health Organization. Our survival rates for many kinds of cancer are lower than those of most Western European countries. We don’t live as long as the Canadians or the French or most other Europeans. And according to a study in the journal Health Affairs, every year there are approximately one hundred thousand deaths in the United States that could have been prevented by proper medical care. None of the other eighteen industrialized countries included in the study had a higher rate of preventable death.

These statistics are nothing to be proud of, and yet lobbyists for the pharmaceutical and health-insurance industries continue to brag that ours is the best system in the world. For a long time their appeal to national vanity and ignorance seemed to work. When President Bill Clinton proposed a plan for health-care reform in 1993, the lobbyists went to work on Capitol Hill and flooded the airwaves with risible attack ads about how terrible it would be if “socialized” medicine kept Americans from choosing their own doctor. The Clinton plan died, partly from self-inflicted wounds, and health-care reform disappeared from the national agenda for the next fifteen years.

Now we may finally be ready to address the problem, if only because it has gotten so much worse. According to a 2007 CBS poll, 55 percent of Americans would prefer “having one health-insurance program covering all Americans that would be administered by the government and paid for by taxpayers.” A 2008 poll found that 59 percent of U.S. doctors now support a single-payer system, in which the federal government would directly provide health-insurance to all Americans. Not long ago, Barack Obama agreed with them. “I happen to be a proponent of a single-payer health-care program,” he said in 2003. “[W]e may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, we have to take back the House.”

Having taken back all three, Democrats have since decided, not unreasonably, that a single-payer system is too ambitious—at least for now. It would mean the forced obsolescence of the entire health-insurance industry, which employs 2 million people in the United States and contributes huge amounts of money to politicians in both parties. We might be better off without it, but it won’t disappear overnight. For this reason, and because many Americans are nervous about losing the little coverage they have, major reform will have to be gradual. That’s why Obama and some congressional Democrats have proposed a health-care plan that allows people to keep their private insurance if they’re satisfied with it. If they aren’t—or if their employer doesn’t offer private insurance and they can’t afford to buy it on their own—there would be a public option available to them.

Predictably, the insurance companies are opposed to this option, which would give Americans a chance to discover the advantages of a nonprofit insurance system with less administrative overhead and more bargaining power. (Health-insurance companies spend more than 30 percent of their costs on administrative expenses; Medicare spends just 2 percent. So much for the idea that bureaucracy is a problem peculiar to the public sector.) For all their bluster about the virtues of the free market, health-insurance companies are desperately afraid that, given the choice, many Americans would choose the insurance offered by the government.

They have good reason to be afraid. But congressional Democrats and the Obama administration have reason—and now a mandate—not to let serious health-care reform get sidetracked once again.

May 26, 2009

Related: The Editors, "Primary Care"
Daniel Callahan, "America's Blind Spot"