More Americans lack health insurance today than at any time since the start of Medicare and Medicaid in the mid 1960s. Despite the economic boom of the 1990s the number of uninsured continued to increase, and millions more will lose coverage when the economy flattens.Three-quarters of the uninsured are children or working adults, and several million poor women and children lost coverage when the Clinton administration slashed welfare rolls in the mid 1990s, despite promises that former welfare recipients could continue their Medicaid coverage.

Meanwhile, workers are paying a higher share of premiums (and larger co-payments and deductibles) as firms shift costs onto employees.Seniors have also faced rising out-of-pocket costs.While the uninsured face the gravest problems, few Americans have adequate coverage.Most who need long term nursing home care pay out-of-pocket until they are impoverished and qualify for Medicaid; private insurance covers only 7% of nursing home costs.Nearly half of all bankruptcies involve illness or medical debts.

Choice has also narrowed with the increasing intrusion of market forces in medicine.42% of privately insured adults were offered only one choice of health plan.Patients rarely switch health plans voluntarily; three quarters of those changing plans are forced to by their employer or because they changed jobs.

Lack of coverage, insurance hassles, and other problems paying for care endanger the health of millions.Many of those with no, or poor, coverage forego care for potentially life-threatening symptoms such as chest pain or a breast lump.HMOs often erect barriers to care, even in emergencies.For terminally ill patients and their families the burden of illness is often compounded by financial suffering.Women frequently delay prenatal care because they're uninsured or unable to pay.

While millions of Americans are denied needed care, 300,000 hospital beds lie empty every day, and health policy leaders warn of an impending surplus of physicians.Meanwhile a growing army of health bureaucrats struggles to keep sick patients away from idle health care resources and personnel.

Recent health policies have encouraged market-based strategies - an expanded role for investor-owned firms, reliance on competition to control costs and streamline care, and the emergence of managed care.HMOs profit from healthy patients, and provide care for them on a par with fee-for-service medicine.But sick lower-income patients face a 21% higher risk of dying in HMOs than in fee-for-service, and elderly people with chronic conditions also fare poorly in HMOs.Surveys show that sick HMO patients face substantial barriers to care, and HMOs alsoscore poorly in consumer satisfaction surveys (38).

Several studies demonstrate that sick patients receive poor quality care in HMOs.Stroke patients covered by HMOs receive less specialist care than fee-for-service patients, get less rehabilitation care, and more often end up in nursing homes.Medicare HMO patients needing homecare receive fewer visits and have worse outcomes than similar patients covered by the traditional Medicare program.HMOs in New York selectively refer heart surgery patients to the hospitals with the highest surgical death rates, presumably because those hospitals give HMOs a price break.

HMOs often undertreat people with mental illnesses.Depression is less likely to be recognized, appropriately treated or improved even in good HMOs than in fee-for-service settings.Many HMOs and employers subcontract mental health services to for-profit managed mental health care firms that routinely provide substandard care.Less than one-third of primary care physicians report that they can always or almost always obtain high-quality mental health care for their patients.And psychiatric care's share of total health benefits has fallen by nearly half in the past decade.

Contrary to widespread perceptions, Medicare's costs have risen less than those of private insurers (where managed care has predominated).While market enthusiasts push Medicare to enroll seniors in HMOs, an AARP study shows that few seniors could make informed HMO choices; the sickest and frailest are most vulnerable to being duped.

As managed care has come to dominate health insurance, for-profit HMOs have eclipsed non-profit plans.Yet the non-profit plans that are losing out in the marketplace rank higher on every quality measure collected by the National Committee for Quality Assurance.Physicians favored by managed care, those who see more patients per hour, deliver worse care.And physicians omit needed tests and treatments for patients covered by capitation contracts that reward physicians for doing less.Primary care doctors are increasingly pushed to provide complex specialty care that exceeds their knowledge or capabilities.Perhaps most disturbing, doctors face mounting pressure to avoid sick (hence unprofitable) patients.Even most physicians who participate in capitation payment schemes believe they're unethical.HMOs sometimes explicitly forbid doctors from criticizing the plan or telling their patients how they are paid.More often, HMOs use the threat of "delisting " (effectively, firing) doctors who provide too much expensive care or otherwise fail to toe the corporate line.

Some do well under managed care - notably the CEOs of large health care firms.Their incomes ultimately derive from patients' premiums; overhead and profit consumes as much as one-third of premiums in the major for-profit plans.Misbehavior in search of profit is predictable; HMO executives owe first allegiance to their shareholders.In the 1850s, Aetna profited from slavery, and now pleads that such behavior was perfectly legal.More recently Cigna has deleted anti-tobacco information from subscriber newsletters at the behest of Philip Morris.And several major insurance firms hold large investments in tobacco.

Other firms that profit from care have also demonstrated a flexible sense of morality.The two largest investor-owned hospital chains have admitted to illegal schemes to pad their incomes.But even when not engaged in unlawful behavior, for-profit hospitals cost more and provide worse care.In communities whose medical market in dominated by investor-owned hospitals, health costs are higher and rising faster than in areas dominated by non-profits.Much of the excess costs of for-profit hospitals are due to higher administrative costs; expenditures on clinical personnel are actually lower than at non-profits.Death rates at for-profit hospitals are 7% higher than at comparable non-profit hospitals, and have been for at least a decade.

Poor quality has also been endemic among other types of for-profit health facilities.Nursing homes, most of which are investor-owned, have been plagued by low quality care and chronically poor staffing.For-profit dialysis clinics have high death rates, low transplant rates, and less use of the optimal type of dialysis (peritoneal) for children.Canadian dialysis clinics, virtually all of them non-profit, provide better care at lower cost.In sum, investor-owned health facilities provide inferior care at inflated prices (86).

Drug companies are the largest for-profit health care firms.In the past decade drug costs have soared.In the U.S., where firms have escaped the price regulations prevalent in other nations, drug prices are outrageous, fueling drug firm profits that outstrip any other industry.

International experience proves that universal coverage is feasible and improves health.Every other developed nation assures health coverage for the entire population.Our infant mortality rate, among the lowest in the world in 1950, is now disturbingly high.We trail other nations on life expectancy, and score poorly on measures of premature death.Meanwhile, our health costs per capita are nearly double those of any other nation, and rising more rapidly.Indeed, GOVERNMENT spending on health care in the U.S. exceeds TOTAL health spending in any other nation.

Yet Americans have fewer physician visits and lower hospital use per capita than other nations.Surveys of English-speaking countries show that Americans face the greatest barriers to care.

As the U.S. was implementing Medicare and Medicaid in the mid 1960s, Canada was putting in place national health insurance.The Canadian Government offered the provinces substantial funding for universal, comprehensive, publicly administered coverage.Within one year of the program's start-up, the proportion of patients with serious symptoms who saw a doctor increased sharply.Infant mortality - which had long been higher than in the U.S. - fell rapidly, and has remained below the U.S. level.While universal healthcare has not erased inequalities in health, it has ameliorated them.Even poor infants in Canada have death rates below the U.S. average.

Despite waits for some specialized care, studies continue to find that quality of care for Canadians is at least as good as the care received by INSURED Americans (though Canada spends far less).Depressed Canadians receive more professional help, and more appropriate care than their American counterparts.Canada has lower surgical death rates than the U.S., and lower cancer death rates for potentially curable tumors.Seniors in Canada actually get more of most types of physician care than American seniors.In sum, despite spending roughly half what we do, Canadians enjoy better health, the security of universal coverage, and a system that is relatively free of bureaucracy and constraints on patient choice.

National health insurance has effectively contained costs in Canada - perhaps too effectively.Canada's health care costs have been flat since the mid 1990s.Canada's single payer system greatly simplifies administration, cutting insurance overhead to about 1% (vs. 15% of premiums in the U.S.) and reducing bureaucratic costs for hospitals and doctors.Overall, Canada saves about $857 per capita annually on bureaucracy alone.

Americans pay a great deal for healthcare - funding princely incomes for executives and investors - but patients are denied care or forced to struggle to get what they need, and market values increasingly intrude in the examining room.Like people in other nations, Americans want a system that assures care when we need it at an affordable price, that engenders trust and respect, and affords patients choice.A universal, tax-funded, non-profit national health program organized like Canada's - though better funded - could achieve these goals.Congress' General Accounting Office, and many private-sector studies, have concluded that bureaucratic savings would offset the costs of expanding coverage.Projections that national health insurance is affordable gain credibility because every other developed nation has universal coverage while spending far less than we do.We already have in place the facilities and human resources needed to provide care to all Americans.

Surveys have consistently shown wide popular support for universal coverage, though political leaders' views reflect the more conservative convictions of the business community.Indeed, most medical school facutly and deans now favor single payer national health insurance.Yet Congress and most state legislatures are swayed by the massive donations that come largely from the wealthiest Americans.As a result, policy debate is dominated by options that protect HMOs, insurers and the drug industry.

Once, health policy wonks preached the gospel of market competition and managed care, fortelling a dawning age of efficient, consumer-responsive care.Today, the catechism of market fundamentalism is less believable.After two decades of market-driven health policy, costs are again soaring, coverage is contracting, and HMOs have joined tobacco firms in the basement of public esteem.

Reality has swamped zealots' arguments for market solutions.Now a poisonous nihilism is their defense."Yes, things are bad.But there is not alternative (TINA)."TINA claims come in two flavors: (1) Any reform that would extend coverage, bridle HMO's power, or improve quality of care would break the bank.And: (2) Though affordable, high quality national health insurance is theoretically feasible, it is politically inconceivable; the opposition is too rich, our democracy too weak.

The first of these arguments is demonstrably false.The second challenges us to prove that democracy works - that what's good for our nation, and popular with the American people can become the law of the land.