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Louise Brown was an accountant with a 25-year history of diabetes. Her physician taught her to monitor her glucose at home, and her health coach helped her follow a diabetic diet. Her diabetes was brought under good control. Diabetic retinopathy was discovered at yearly eye examinations, and periodic laser treatments of her retina prevented loss of vision. Ms. Brown lived to the age of 88, a success story of the US health care system.

Angela Martini grew up in an inner-city housing project, never had a chance for a good education, became pregnant as a teenager, and has been on public assistance while caring for her four children. Her Medicaid coverage allows her to see her family physician for yearly preventive care visits. A mammogram ordered by her family physician detected a suspicious lesion, which was found to be cancer on biopsy. She was referred to a surgical breast specialist, underwent a mastectomy, was treated with a hormonal medication, and has been healthy for the past 15 years.

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INTRODUCTION

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For people with private or public insurance who have access to health care services, the melding of high-quality primary and preventive care with appropriate specialty treatment can produce the best medical care in the world. The United States is blessed with thousands of well-trained physicians, nurses, pharmacists, and other health caregivers who compassionately provide up-to-date medical attention to patients who seek their assistance. This is the face of the health care system in which we can take pride. Success stories, however, are only part of the reality of health care in the United States.

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EXCESS AND DEPRIVATION

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The health care system in the United States has been called “a paradox of excess and deprivation” (Enthoven & Kronick, 1989). Some persons receive too little care because they are uninsured, inadequately insured, or have Medicaid coverage that many physicians will not accept.

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James Jackson was unemployed for more than a year but unable to qualify for Medicaid because his state did not expand Medicaid under the 2010 Patient Protection and Affordable Care Act. At age 34, he developed abdominal pain but did not seek care for 10 days because he had no insurance and feared the cost of treatment. He began to vomit, became weak, and was finally taken to an emergency room by his cousin. The physician diagnosed a perforated ulcer with peritonitis and septic shock. The illness had gone on too long; Mr. Jackson died on the operating table. Had he received prompt medical attention, his illness would likely have been cured.

Betty Yee was a 68-year-old woman with angina, high blood pressure, and diabetes. Her total bill for medications, which were only partly covered under her Medicare plan, came to $200 per month. She was unable to afford the medications, her blood pressure went out of control, and she suffered a stroke. Ms. Yee’s final lonely years were spent in ...

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