A growing part of the U.S. population, together with many health professionals, have become concerned about problems in our health care system. Health care costs continue to rise, unabated, several times faster than the cost of living, rendering medical insurance and health care unaffordable for millions of low- and middle-income families. Despite a booming economy in the 1990s, 45 million Americans are uninsured, and tens of millions are underinsured. Many people delay or avoid seeking needed care, which creates higher rates of preventable morbidity, hospitalizations, and death among this group compared with well-insured, more affluent Americans. All market-based incremental efforts over the past 30 years have failed to contain health care costs, while the private insurance industry has gained from its high administrative charges and profits—about 30 percent of the health care dollar.¹

Rising costs have forced employers to move toward defined-contribution health care coverage for their employees, and away from the defined-benefits approach started in the 1940s. The employer-based health insurance system is starting to fall apart, providing less coverage at more cost to less than two thirds of the U.S. workforce, and then only if these employees work full time.

Because a managed-care strategy has failed to control health care costs over the past 20 years, the current administration and stakeholders in the market-based system now favor consumer-directed health care (CDHC) to contain costs. Under the guise of “personal responsibility and choice,” the concept of CDHC places more financial responsibility on individuals and their families for their own health care decisions through increased cost-sharing. It is well established, however, that increased cost-sharing leads to adverse outcomes for many people who cannot afford necessary care. Supporters are energetically pursuing CDHC without regard for its hazards: many Americans avoid preventive care, delay needed care, and do not take their medications when even small copayments are imposed.^2–4 One half of insured adults with high-deductible health plans experience debt problems.⁵ Three out of four insured adults who declare bankruptcy do so because of medical debts.⁶ Moral hazard, as the premise underlying CDHC, holds that the insured overuse health care services. But, it fails to recognize other factors that have greater impact on health care inflation, such as new medical technologies and the aging population.

The current health care system is not sustainable and needs structural reform. Four basic alternatives exist on the state and federal levels: the status quo with small incremental changes; employer mandate, whereby employers are given incentives to offer health insurance to their employees; individual mandate, whereby individuals are expected to acquire their own insurance coverage and take more responsibility as prudent buyers of their own health care; and a system of social insurance (single-payer).¹ Reputable studies in California, Vermont, Massachusetts, and Georgia have demonstrated that a single-payer system could save money while offering coverage to everyone.^7–11

A national study¹² has shown that a single-payer system could provide all necessary care for Americans while saving more than $200 billion a year, largely through administrative simplification and not-for-profit financing. Single-payer health insurance is a more accountable system and would enhance access, cost containment, and quality of care. The money exists in the system ($1.8 trillion) and could be rechanneled to direct patient care. Patients and their families would gain improved affordability and access to care. Employers would have healthier workforces, allowing them to compete better in global markets. Physicians and other providers would have markedly reduced administrative overhead in dealing with single-buyer coverage instead of over 1,000 private insurers.

Family medicine has a mixed track record concerning health care reform. On one hand, it has a rich legacy of public service, and is the best-distributed specialty in American medicine, serving urban, suburban, and rural areas. Family physicians also are the mainstay of public safety-net programs in community health centers, the Indian Health Service, and other underserved settings. In its earlier years, family medicine was a counterculture force for health care reform.¹³ On the negative side, however, the field has recently charted its own future with the Future of Family Medicine report, which calls for “universal access” but leaves in place an enormous and wasteful for-profit private health insurance industry.¹⁴ We cannot have it both ways, as the California Health Care Options study has shown.⁷ Under CDHC, millions of Americans do not have adequate financial security to cover the costs of their necessary health care. In Massachusetts, for example, Blue Cross is marketing a preferred provider organization (PPO) plan with deductibles up to $5,000 for individuals and up to $12,500 for families.¹⁵

Incremental “reforms” of our market-based system have failed and will continue to fail until we have the political will to establish a new system based on universal access, affordability, comprehensiveness, quality, sustainability, and accountability. If we do not educate ourselves on system problems and alternatives, we fail our patients, their families, and the public interest. Now is the time to advocate for effective system reform or become part of the problem. The choice is ours, and our field could yet play a major role in leading the country toward social justice and a better health care system for all.

editor’s note: The Future of Family Medicine report¹ was published in the March 2004 issue of the Annals of Family Medicine. An editorial² in the January 1, 2005, issue of American Family Physician updated readers on the progress of the Future of Family Medicine project. In this editorial, Dr. Geyman offers a different viewpoint about what is ailing the American health care system, and his recommendations for reform.