The healthcare system in the United States is eroding. Costs are rising too fast. More and more people lack health insurance. Companies are dumping or shrinking employee health plans. Deductibles and copayments on medical services are rising.
That's the widely agreed-upon scene.
Yet chances are slim that Americans will go for a far less expensive "single payer" health system, as in Canada, Britain, or Australia, anytime soon.
"The issue is not likely to be given a fair examination," says Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health, Boston. "There is a cultural resistance to even considering this very serious option."
Since the healthcare system is "sort of collapsing," Stephanie Woolhandler, co-founder of Physicians for a National Health Program (PNHP), expects "a lot more discussion" of a single-payer system after the congressional elections Tuesday, especially if the Democrats win at least one house in Congress. In such a system, the government pays the bills from hospitals and physicians.
Doctors Woolhandler and Blendon basically agree on why change is resisted.
Many Americans are cynical about government, distrusting its ability to provide a competent healthcare system. They prefer a market-based system with a high degree of individual choice.
Moreover, self-interested groups have political clout. Health insurance companies, pharmaceutical firms, private hospitals, and Wall Street investors in the healthcare industry "aren't going to go quietly into the night," says Blendon.
The drug industry usually ranks as the most profitable. In 2002, it made a 14 percent return on assets; the Fortune 500 made a median of 2.3 percent.
When voters in California and Washington considered single-payer systems for their states in the 1990s, opponents outspent proponents 12 to 1, and the proposals died by a huge majority.
Students from other industrial nations tell him that the US is unique in the degree of power that moneyed interests wield in politics, says Blendon.
"A single-payer system is inevitable," holds Dr. John Geyman, president of the 14,000-member PNHP. "It is just a matter of time."
Polls find at least 60 percent of Americans want public financing of the $2 trillion healthcare system, something that would work the way Medicare does for older citizens. Government would foot much of the bill from private hospitals and physicians.
But in opposition are many of the 1,500 private insurance firms. They seek to make more money for shareholders by cherry-picking healthy customers and avoiding those with costly chronic illness, Dr. Geyman charges. He cites a former editor of the New England Journal of Medicine, Dr. Arnold Relman, who warned in 1980 of the "medical-industrial complex" and its hold on Washington, echoing President Eisenhower's reference to a "military-industrial complex."
Those in the healthcare industry fear more government regulation, more interference. They don't want the government to restrain prices for drugs or other medical services, as systems in other industrial countries do.
The US spends 15 percent of its gross national product on healthcare, of which 31 percent goes for administrative costs. Canada spends about 10 percent of GDP on a universal healthcare system, 1.3 percent of it for overhead..
Woolhandler is hopeful about a single-payer system because of what she calls a "slow-motion collapse" of employee-sponsored health coverage as health costs rise and competition in a globalized economy increases.
Blendon, though, figures it will take a major healthcare crisis, perhaps including hospital closings and doctors becoming unavailable to many patients, before the political powers will launch an effort at real reform.
"Will the situation get so bad we have to do something about it?" asks Daniel Callahan, international programs director at the Hastings Center, a bioethics research body in Garrison, N.Y. "We have not yet reached that point."
There is no strong leadership in Congress or the White House for radical change in the healthcare system. Further, some 80 to 85 percent of Americans today get decent medical healthcare, Mr. Callahan estimates. Those who are satisfied with the system are unlikely to urge reforms to help the less fortunate.
Despite polls indicating sympathy for the plight of 46.6 million without health insurance, the majority "is not willing to put their wallet where their mouth is," says Callahan.
But the system continues to weaken.
Over the past six years, family health insurance premiums have risen on average about 69 percent, more than six times the increase in the median earnings of workers (about 11 percent), finds Families USA, a Washington group championing healthcare consumers.
"This is not sustainable," says the group's executive director Ron Pollack. "More and more people are being driven out of healthcare insurance.... More and more people find it unaffordable."
What may move the issue onto the front burner again is that in 2020 there will be about twice as many elderly in the nation, forcing up healthcare costs.
Healthcare will be a top issue in the 2008 election, Mr. Pollack predicts.