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Br J Gen Pract. 2009 June 1; 59(563): 458.
PMCID: PMC2688062

All for one, but more for me

A learned friend of mine told me that health care is the next US economic bubble. He said that when the housing and dot-com bubbles burst, the first hit were those with vulnerable mortgages and speculative stocks. The collapse then rumbled through the rest of society and the world. When the healthcare bubble bursts, everyone in the country will be hit and it will not be pretty.

For the past decade, polls showed that the American public feels health care needs a major overhaul. Everyone feels vulnerable. No one understands the current system. For the past 5 years, even insured Americans found their personal share of costs increasing for everything from doctor visits to drugs to emergency care. Those who have lost their health insurance are unable to purchase comparable individual or family insurance of any type.1 In a bit of disingenuous political solidarity, the CEO of the trade association that represents US health plans, sometimes referred to as the Evil Empire, recently admitted that, due to a pre-existing condition, even she might not be able to afford individual insurance in an open market. Now Darth Vader is feeling our pain.

President Obama, despite all the other economic issues he faces, has persisted in putting healthcare reform at the centre of his legislative and political agenda. He should. He is regularly trying to educate us that the cost of health care for those who have it and the cost to society of those who do not is not sustainable. Our current situation is crushing families, stifling innovation and creativity, and making the country less competitive through the overhead of employer-linked health care. Now everyone seems to agree with him, even the Republicans, the hospital lobby, the insurance lobby, the pharmacy lobby, the business community, senior citizens, and … doctors. Doctors voted in the majority for Obama in November.

But, the econometrics are the same in health care as in society as a whole: there are large and increasing disparities in hospital, pharmacy, insurance, and physician income. Formerly not-for-profit health insurance companies like Blue Cross/Blue Shield have converted to for-profit status. Spin-off hospitals for ‘special’ problems, from cosmetic surgery to orthopedics to pain management have been carved out and been hugely profitable. Family doctors are designing ‘concierge practices’ (their own description) offered to a higher class of patient who, one supposes, promises to behave and not become ill.

But hold on. The bubble. Healthcare costs and profits have always risen in the 40 years since the beginning of Medicare and Medicaid. Hospitals have made more money, insurance companies have made more money, share holders of those companies (which underpin a lot of mutual funds and retirement) have made more money, and doctors, despite our complaints, have made a lot more money, with marginal improvements in quality. There is a widespread belief that the market will only bring more, not less, to health care. When have you heard ‘what goes up can only continue to go up’ recently? From Bernie Madoff?

When a national health programme with universal coverage comes about, the US will have to get to grips with the idea of a budget for health care and a limit to growth. That is when the for-profit house of cards will start to collapse. Nobody in health care or the public has ever considered the fact that, to achieve the goal of universal coverage, there will be less, not more, for most systems (hospitals, doctors, pharma) who currently benefit from health care. I have not heard the word rationing or any euphemism for it in healthcare discussions. I doubt anyone will. It is the third rail of medicine.

But without a redistribution of the revenues in the current system, whether through controlling costs and/or increasing tax revenues, we will never get to health care for all — even a modest amount of care. I can only imagine the consternation that will greet the pollster who asks hospital administrators and procedural specialists how much of their current income they are willing to sacrifice to create greater support for primary care; or asks insurance executives what percentage of company profits they are willing to forgo to broaden coverage for all; or asks appliance manufacturers or pharma which of their products they are willing to submit to regulation or to a national formulary; or the pollster who asks insured older Americans which of their current benefits they are willing to forgo to help those who have nothing, have something.

The sad truth is that we are not prepared to deal with the demands of the commonweal. We are a nation that has grudgingly admired greed, seems surprised when it is exposed, and gets angry with those accused of it, without really changing the rules that makes greed possible. As the economy sinks, the casinos are more crowded than ever. The extraordinary hopefulness that Barack Obama brings to discussions of health care, energy, or education comes from his belief that the direction we have been going in for 50 years really has to change. At this point, the country agrees with him, despite forces, including doctors, aligned against anything other than incremental change. In his Nobel Prize speech, William Faulkner wrote of ‘man's soul, a spirit capable of compassion, sacrifice, and endurance.’2 If the US can become a country that returns to those old verities, we have a chance for substantive healthcare reform by the end of the year. One can hope, can't one?


1. Center for Studying Health System Change. Living on the edge: health care expenses strain family budgets. Washington, DC: Center for Studying Health System Change; 2002. (accessed 8 May 2009) [PubMed]
2. Faulkner W. The Nobel Prize in Literature 1949 banquet speech.

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners