What's wrong with U.S. healthcare?

1. Over forty-three million people - 16 percent of the American people - are uninsured.

The number keeps going up - it's now the highest it's been since the mid-sixties, when Medicare and Medicaid were passed. Children make up about a quarter of the uninsured. Three out of four of the adults who are uninsured or were uninsured recently are in working families, according to a survey by the Commonwealth Fund.

Not only is this inhumane, it ultimately hurts all of us. The uninsured go without needed care until their condition reaches the point of an expensive emergency. And in the end, we all absorb the cost. As long as insurance is tied to employment, a high percentage of Americans will go without coverage.

2. Many who are insured have inadequate coverage and big out-of-pocket expenses.

Under our system, insurance companies have every reason to limit our care and increase our co-payments and deductibles. HMOs are famous for refusing to cover necessary hospital stays, denying people coverage for emergency room visits, and balking at medically necessary procedures and therapies. In 1996, over 20 percent of HMO enrollees said they had problems getting treatment; less than half think their HMO would cover a serious illness.

For this lousy service, we are paying more and more out of our pockets. Between 1988 and 1996, the share of healthcare premiums paid by employees in small firms went from $408 to $2100 a year for family coverage. Seniors who are covered by Medicare are in the same boat: In 1977 they paid about 12 percent of their income in out-of-pocket health costs. In 1994, they had to devote 23 percent of their income to healthcare.

3. The so-called "managed care" revolution of the past decade has been a disaster.

Managed care and HMOs turned out not to be the solution to our healthcare problems. They're only making it worse. As recently as 1995, 59 percent of Americans thought managed care was "a good thing," according to a Harris poll. By 1997, its was down to 44 percent. Only 33 percent thought managed care improves the quality of healthcare.

The government has been pushing hard to get Medicaid and Medicare enrollees into HMOs. But HMOs try to skim off the healthiest of these patients, and underserve those who do sign up. Medicare enrollees who have a fee for service plan report far better access to care than those in HMOs. That's because HMOs only get a fixed premium from Medicare to provide care - and so they provide as little care as possible. Now, many HMOs across the country, having discovered that they couldn't make as much money off the elderly and disabled as they had hoped, are abandoning Medicare and Medicaid patients.

4. Our healthcare system wastes money on profits and administration.

For all our complaints about coverage and accessibility, we pay almost twice as much per capita on healthcare in this country than anywhere else. And the cost is still rising faster than anywhere else. Prescription drug costs are expected to rise over 13 percent this year. And the Congressional Budget Office predicts premiums will go up 5.5 percent this year. In California, where HMOs dominate the market, premium increases are in the double digits.

The Department of Health and Human Services has just come out with an estimate that by 2007, healthcare will absorb 16.6 percent of the nation's total output (or gross domestic product) - up from 13.6 percent last year. For comparison: In Canada, it's about 9 percent. And everyone's covered.

Spending money on healthcare is a fine social goal. But one of the main reasons our system is so expensive is that it has to support profit-hungry HMOs. Do we really want our healthcare dollars to be spent on insurance processing and profits? At US Healthcare, for instance, 26 percent of each premium dollar goes to overhead and profit. This is the same HMO that takes the prize for CEO compensation: US Healthcare's top executive has a $1 billion golden parachute!

Meanwhile, we are losing public hospitals at an alarming rate as they are bought up by both for-profit and non-profit conglomerates. These giant institutions lack direct accountability to the public. And in hot pursuit of their bottom line, they systematically cut patient care and slash staff.

5. Our healthcare system pits caregivers against patients.

The conglomerates that control our healthcare system put pressure on doctors to hold back on care they know their patients need. They force nurses to take part in strategies aimed at getting patients out of hospital beds before they are ready. Our system should allow healthcare providers to concentrate on our care, not on profit margins.