An article in the Oct. 25, 2001 edition of the Journal of the American Medical Association (JAMA) put it simply: “Although the U.S. health care system is often touted as one of the best in the world, disparities exist in quality of care received by different populations, in different regions, and across different institutions and clinicians … availability of insurance coverage does not automatically lead to high-quality care.”

Faced with a situation where the number of uninsured is increasing daily and now approaches 40 million, it is easy to understand why the health-care movement has been focused on gaining access to health services via the “single payer” movement and other efforts such as extending Medicare to everyone without health insurance. The major shortcoming of both is that they are not linked to the delivery of health services.

But, as the JAMA article said, “being insured does not guarantee access to all services and all clinicians and institutions. Certain services may not be covered, certain physicians and hospitals may not be included among those participating in a plan or contracting with it, a provider may be unwilling to accept payment fees. Cost-sharing requirements may deter patients from seeking care. While these limitations may result from cost-cutting efforts to make insurance more affordable, collectively they represent another potential drop in the conversion of available insurance into quality care.”

How better to describe the failure of the U.S. system, where workers gain health insurance from a hodge-podge of insurance options provided by labor contracts and/or employers. In the final analysis the system benefits the insurance companies, pharmaceutical companies and the rest of the for-profit providers. Or, put another way, it is total failure.

Under the National Health Service in the United Kingdom and, to a lesser extent systems in France and many other countries, the government’s commitment to providing access to health care combines financing health care at government-owned hospitals and community-based clinics as well as at other facilities.

In those countries the public money spent to provide access to health services remains in the public sphere. In the U.S., the single-payer proposal and expansion of Medicare, both important advances, will use taxpayer money to pay for mostly private, for-profit hospital, clinic and physician services. Quality is not monitored in this system.

The U.S. system of providing health care has a sharp racist edge, especially when applied to provision of specialty services. Disparities across different populations have become a source of public policy concern. Researchers have documented, for example, that African Americans undergo fewer coronary procedures than do whites and that African Americans with early-stage lung cancer are less likely than white patients to undergo surgery, a factor that may explain much of the difference in lung cancer survival rates between these groups.

The struggle to improve the quality of health care, that is, the care of those already insured, when combined with the efforts to gain coverage for the uninsured, will dramatically expand the overall movement for national health legislation. It will help bring the labor movement, Medicare and Medicaid recipients into the struggle for everyone’s needs. The simple logic of this proposal slides past too many health policy “experts,” who would rather focus only on the financing of health insurance.

That latter approach is too narrow to generate a mass movement to force Congress to act. Obviously, Congress must be pressured to pass legislation outlawing the most abusive of these practices.

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