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Illustration by Elon Sharton-Bierig

Health care…what care?

by Melissa Suran
June 10, 2009


Photo illustration by Melissa Suran/MEDILL

President Barack Obama is no longer treating repair of our country’s severely broken health care system as an elective procedure – he’s rushing it to the emergency room.

Just a few days ago, Obama acknowledged the urgency of providing adequate health care to all Americans. Instead of leaving the problem to Congress as he originally planned, Obama decided to take matters into his own hands, promising to push harder for legislation to get the country’s health care system to finally reform. Of all the change he promised to bring to Washington, for millions of Americans, this one is the most critical.



CHAPTER I: Who gets coverage. Better yet, who doesn’t?

I’ve known Deanna Casper since we were kids in middle school. We share many of the same interests: Baseball (although she’s a Cubs fan – I’m a Yankees girl), Broadway musicals, Anderson Cooper 360, you name it. We attended the same school, celebrated holidays together, traded goofy jokes. Despite everything we have in common, however, a fundamental difference divides us. I can afford adequate health insurance in the U.S. Casper can’t. 

With a baby on the way, she’s staying in Israel so she and her baby will get the care they need.

Casper, 22, once was one of about 46 million people, or one in three Americans under 65, who can’t afford health insurance in the U.S., where it is not considered a human right.

Casper and her husband of almost a year, Eli Casper, are expecting their first child on June 17. Now living in Jerusalem, where she has been since last winter, Casper said she finally has access to health care.

“When I came to Israel, the day I became a citizen I was automatically put onto their health insurance,” she said. “My monthly insurance is $8 a month and I have the best medical coverage you can buy.”

According to Casper, getting on an Israeli plan is incredibly easy.

“I don’t need any tests, they didn’t ask me any medical questions, I was automatically guaranteed coverage,” Casper said. “In America with a lot of health insurance, you have to agree not to be pregnant, or they won’t cover you, like you have to promise that you won’t get pregnant for a year.”

Although Casper did not qualify for free coverage in the U.S., a select few here are eligible, including people with leprosy and people with renal failure.

So why is that?

“It’s just historical accidents,” said University of Pennsylvania bioethicist Dr. Arthur Caplan, 59. “For example, people with leprosy got care because people were afraid of it spreading.”

Yet there is another group of people who are guaranteed free health care by law – prisoners.

Since prisoners have protection under the constitution not to be treated cruelly or unusually, they obtain the right of health care.

“The average citizen does not have anybody looking out to make sure they’re not treated in a cruel, unusual way,” said Caplan, who has a doctorate in the history and philosophy of science. “You can forget about the homeless guy at the footstep of the hospital and you can dump him in the street.  There’s no constitutional protection because he’s not under the care of the state.”


CHAPTER II: A model country

Israel, as almost every other westernized country besides the U.S., operates under a universal health care system – a single-payer system in which one source, such as an insurance company or the government, finances the country’s health care.

The models are confusing and people frequently fail to distinguish key differences among the plans. When the government is the sole provider of health care coverage and does it through taxpayer dollars, that’s the national model. The universal model offers a blend of public and private coverage funded by a single entity that may or may not be the government. Socialized medicine is publicly funded and the government directly provides all heath care services. This model is a form of universal coverage.

Israel has operated a universal system since the country’s establishment in 1948. According to the Israel Ministry of Foreign Affairs, the country has a population of nearly 6 million people and their health care costs are 8.7 percent of the country’s gross national product, or the total value of all goods and services. Health insurance is mandatory and every citizen has the choice of registering under one of four health insurance plans, known in Israel as sick funds.

The U.S. is another story. The U.S. Census Bureau estimates more than 304 million people live in the U.S. On June 2, the White House released a report showing health care costs as 18 percent of the GDP or gross domestic product, the market value of all goods and services in the nation. It projected the cost to rise to 34 percent by 2040. In 2007 the National Coalition on Health Care concluded that people living in the U.S. spent more than $2 trillion on health care costs and at this rate, it expects heath care spending to reach more than $4 trillion by 2017. No other westernized country even comes close.

One source of the disparity is the high cost of doctor visits here. In Israel, doctor salaries are significantly lower than in the U.S. Yes, the cost of living is also lower in Israel, but wages still are exceptionally modest. The average salary of a doctor in the U.S. is more than $100,000. The average Israeli doctor makes a little more than $36,000 a year.

Dr. Michael Geist, 51, the director of intermediate cardiac care in the electrophysiology service at the Wolfson Medical Center in Holon, Israel, said the country’s health care model works more efficiently than the capitalist U.S. system in part because of lower doctors’ salaries.

“In Israel, a lot of the time you have to work outside of the hospital to augment your income,” Geist said.

He noted that doctors in Israel have fewer adjuncts at work. Geist doesn’t have a secretary or a physician’s assistant. He does all his work himself.

“I’m the director of a unit and some of my fellows and students who are now heading clinics in the U.S. or Canada, in my position, would have secretaries and a lot of other things,” Geist said.

But he said the quality of health care in Israel is excellent, with physicians who have comparable training, research and publishing records to those of U.S. physicians. He said Israeli doctors also have more job security.

“My hospital is a government hospital, but that doesn’t matter,” Geist said. “After a few years, after you finish medical school and your internship, you get a permanent position.”

Of course, the best part of the Israeli health care system is the coverage for its citizens. At all income levels, the only requirement is that you pay 5 percent of your salary. That’s it. There are four Health Maintenance Organizations, or HMOs, in Israel in which a citizen may enroll. Individuals may also switch coverage from one HMO to another. Everyone receives basic health benefits under the HMO and if a patient requires hospitalization, the patient is fully covered under the plan. The same goes for services such as prenatal care, cardiac bypasses and abdominal operations.

Patients pay a small fee for visiting a doctor, which is limited for every quarter, or three-month increment. For example, each time you go to a doctor, for the first time in a quarter, you pay between $4 and $5. The patient is liable to pay up to about $150 a quarter for medication. If medication costs are higher, you don’t pay extra.

“I’m the director of a pacemaker unit, so when a patient comes in and needs a pacemaker, I don’t even check what HMO the patient belongs to, they all get the same (treatment),” Geist said.

Geist also said he feels terrible for the millions of Americans who can’t afford health care.

“It’s the most primitive system in the Western world,” he said. “Pure capitalism doesn’t work as you’ve seen on Wall Street in the last couple of years. Some people (in the health care system) are making quite a lot of money on the lives of other people. It’s an immoral country.”

Although the chief criticism of a single-payer system is the waiting lines for crucial medical attention, Geist said there are no waiting lines for urgent procedures.  Patients may wait for non-life threatening ones, such as knee operations and the wait for some is painful. But he said if you come to the hospital and need surgery, you will get it the same day or the next day depending on the urgency of the situation.

Casper said she also has never heard of waiting lines in Israel. Although there are waiting lists for MRI scans, if you need immediate medical attention, you can get faster treatment.

“Eli was hit by a bus two years ago and he needed an MRI and he got help right away,” Casper said. “He was unconscious…he wasn’t even on a list and he wasn’t even on national insurance – he wasn’t a citizen.”

Of course, in order to ensure this kind of quality coverage for everyone, everybody has to bend a little.

Casper said the compromises for patients are small. In Israel, unless you pay more for a doctor, a midwife delivers your baby.

After she delivers her newborn, Casper will be resting in a small recovery room with two other new mothers. The baby will not be allowed to sleep with her, so she will have to get up in the middle of the night to feed it.

“You have to go down to the cafeteria to eat food, they don’t bring the food to you, which is okay,” Casper said. “You probably should be walking around after you have the baby.”

Although she was apprehensive about the experience at first, Casper said after speaking with a midwife, she felt more confident.

“New mothers in America are treated like princesses,” she said.

That is, if they can afford health insurance.

But not everyone can afford health insurance, let alone crucial medications.

Casper pays 12 shekels, or about $3 a month, for her medicine. Her mother who still lives in the U.S. pays $80 a month – for the same medication.

Because drug costs are so high in the U.S., Casper said her mother purchases medication through Isramed, an organization that acts as a “medicinal marketplace” that sells discounted medicine and medical equipment from Israel to people who can’t afford their medicinal expenses – in countries like the U.S.

It’s obvious that the U.S. is lagging behind the rest of the developed world when it comes to health care. Caplan said we should look at the country that was the first to implement universal health care back in the 1880s – Germany.

When it comes to health care, “it’s a payroll tax, which I like, and deducted out of a paycheck,” he said. “Health prevention is the emphasis and it’s not government run – it’s government regulated.”

And if you are unemployed, you are still guaranteed health care.


CHAPTER III: We all have a right to life…right?

So everyone needs health insurance – that’s a fact. But is health care a human right? And does it matter?

Dr. Nirav Shah, 32, a lecturer in the University of Chicago’s Department of Medicine, said it’s not about human rights.

“It’s not clear what a human right is,” said Shah, who is also an attorney. “When we think of a human right, we think of a corresponding obligation.”

Shah believes that we have to approach health care from a cost-effectiveness analysis perspective – that is, comparing the costs and effects of opposing actions. Those in charge need to determine how much money is available and how to allocate it based on a variety of factors and decisions. Should the money go toward treatment or prevention? How much should go toward each cause? Do you treat the mother with terminal cancer or the child in a permanent vegetative state?

“It’s difficult to falsify a human rights claim, we have no common way to argue about that,” Shah said. “My way of making decisions is where we can argue what will get more bang for the buck.”

Shah said the question of whether health care is a human right is separate from the “who should pay for it” question. For example, the question of whether the country should fund a district hospital or a health care center to function as a vaccination kiosk is not a question of human rights.

“It’s easy and fulfilling to say that everyone should have as much health care as possible and refugees should be fed and everyone should have access to health care because it’s a human right,” Shah said. “Making trade-offs in cost effectiveness analysis, that’s hard.”

Dr. Laurie Zoloth, 59, a bioethicist at Northwestern University, doesn’t think trade-offs have anything to do with whether people ought to get health care.

Zoloth, who worked as a clinical nurse prior to becoming a bioethicist, is no stranger to the health care world.

“I think that claiming rights should mean more,” said Zoloth, who has a doctorate in social ethics. “Yes, it is a human right, but that means it is a human duty to provide that right, for rights do not exist unless there is a corresponding duty on someone’s part.”

Amnesty International, an organization that won a Nobel Peace Prize in 1977 for promoting peace and human rights, defines a human right as any basic right or freedom that all people are entitled to, “regardless of nationality, sex, national or ethnic origin, race, religion, language, or other status.” The government also may not interfere with human rights. Although countries like Canada call health care a human right, according to this definition, that isn’t exactly correct.

But under the United Nations’ Universal Declaration of Human Rights, Canada and Israel would seem to be right on target in their health care policies. The declaration says everyone is born free with equal rights and dignity and is entitled to equal protection under the law. Additionally, “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control…Motherhood and childhood are entitled to special care and assistance.”

The U.S. does not seem completely to embrace this doctrine.


CHAPTER IV: We need change

Not everybody thinks that the U.S. should move toward a national model.

Dr. Brad Cohen, 48, a gynecologist at both Saint Peter’s University Hospital and Robert Wood Johnson University Hospital in New Brunswick, N.J., said there are many alternatives to the dysfunctional system we deal with now.

“I’m very against a national health care system,” Cohen said. “It would be costly, not administered right. You’re allowing the government to do something that you could do better yourself.”

Instead, Cohen said, he would require all Americans to purchase some form of health care plan, similar to requirements in Massachusetts.

“We should move toward a universal health care system – everyone should be forced to have some coverage.”

Obviously, this comes down to a question of choices. If you have to purchase health care, what package do you buy? What’s your price limit? What, if anything, would you need to give up for the package that is critical to your needs?

“Universal means some form of insurance coverage, so it’s not costing the rest of us to provide health care for them,” Cohen said. But “many people are stuck with bills they can’t afford, and that is criminal.”

Dr. Marshall Chin, 46, the director of a diabetes research center at the University of Chicago, said it’s a no-brainer – universal health care is essential.

“I think people will acknowledge that the root causes of these disparity issues (in health care) are more fundamental society issues having to do with, for example, poverty and education,” Chin said.

He said the nation needs to address the societal issues in addition to moving to universal coverage.

Caplan believes health care must be accessible for everyone and it is more than possible to guarantee every person a basic package similar to what members of the military get. This package should include prenatal care, vaccinations, dental care, eyeglasses and hearing aids.

“It’s those parts of health care that let us get around in our lives and function as members in society,” Caplan said. “If you can’t see, can’t hear, can’t walk, can’t breathe well, you can’t compete in the marketplace.”

That doesn’t mean that everyone can get whatever they want. Caplan said he wouldn’t include drugs for a dying cancer patient that would prolong his life for three weeks.

“I think we have to agree as a country that not everybody is going to get the same medical care, but I don’t care, I want people to have the basic package now, we’ll worry about the frills and the luxury items later,” Caplan said.

Although Shah is very adamant about not converting to a universal model, he also believes that everyone should receive health care.

“It’s not okay that people don’t have health care, I want as much health care for all Americans as possible,” Shah said. “What I don’t want is it to lead to shortages.”

Shah insisted that people who purchase less attractive plans should not be able to receive the same quality of care as people who purchased better plans.

“It’s not fair for people who bought the Ford treatment to say they want the Rolls Royce treatment,” Shah said. “Let individuals decide what they should not spend money on. That means that some people will sign up for worse policies, and that’s worse treatment, but it’s not unfair. What’s unfair is saying I’m going to save an extra $100 for five years of physical therapy and then you get in that accident.”

Shah said there are many levers we can pull to get those who are uninsured health care. For example, Shah said the government should provide a 100 percent credit for all health care expenses more than $1,000.

“It should come right off of your tax bill,” Shah said. “Maybe we should even provide tax credits and deductions to doctors who treat unemployed patients.”

Dr. Steven Wajsgras, 53, a retired podiatrist in Northwest Indiana, said the biggest problem with the U.S. health care system is fraud.

“In America, it’s all about making money,” he said.

According to Wajsgras, patients don’t really watch what they’re spending for doctor visits--and doctors who work on a fee for service basis have no incentive to provide fewer services..

“If you walked into McDonald’s and they charged you $9,000, you would go ‘what?’ but if you go to the hospital and they bill you $9,000" for treatment, you shrug it off because your insurance company will cover it, he said.

Wajsgras said in the end, it’s easier to charge people more for insurance than to fight fraud.

According to Cohen, the problem is that the U.S. has no competing market. He said through a cost-effective market, we would have our pick of doctors, hospitals and insurance companies.

“In a true consumer-driven health care system, it would be survival of the fittest,” Cohen said, who also holds a master's in business administration. “It would be a better system because you will get better care that you hand-picked and it will probably be cheaper.”

He said once again, the issue comes down to choices. If we had more choices, the competition would increase. The first step is to replace large hospitals with specialty centers for illnesses ranging from diabetes to depression as well as centers that work only as maternity wards.

“By causing enough competition, the options available become greater, the quality is better and the cost goes down,” Cohen said. “Right now, it’s survival of the fittest, so the big money is going to big hospital centers.”

Although Cohen is a doctor by trade, he believes that doctors’ salaries need to be cut.

“A lot of people are nervous,” he said. “I think there’s always going to be room for good quality people in the field. I think that the best among us will always do well. You won’t be the wealthiest person in the world, but if that’s what you went into medicine for, you went into it for the wrong reasons.”

Zoloth shares Cohen’s view that doctors are grossly overpaid and need to take pay cuts.

“It's everyone's duty to act responsibly and make sure that everybody has proper care,” said Zoloth, “We all make choices and if needed, we need to sacrifice some luxuries in order to ensure that everyone has the access to the health care they need.”

Zoloth also thinks people need to start taking better care of themselves to reduce costs for such preventable illnesses as type 2 diabetes or heart disease or high blood pressure linked to obesity and lack of exercise.

Shah argued that people tend to forget that America has the most responsive health care system in the world, along with the best survival rates for illnesses such as cancer.

This is true – but only if you have access to care.

“When we’re talking about the time waiting for a coronary bypass graft (in other countries), there’s an old line during the Communist era in Russia – two guys are waiting in line for bread. There might not be any bread at the front of the line, but at least it’ll be free,” Shah said. “My uncle in London has three blocked arteries and is on a waiting list, so he’s going to die. Here, if your grandma needs new arteries or a hip replacement, then she’ll get them.”

That is, if Grandma is insured.

Although she doesn’t support socialized medicine, Health and Medicine Policy Research Group executive director, Margie Schaps, 54, said the U.S. needs to turn to a universal health care model.

“Everything else we’ve tried has not been proven to reduce costs or the number of uninsured people,” said Shaps, whose Chicago organization advocates for delivering health care to everyone, particularly the underserved, through advocacy and health policy formulation. “We did one thing to reduce the number of kids uninsured, but not adults. We predict there will be 50 million uninsured by next year.”

Right now, 20 to 30 cents of every health care dollar is spent on administrative costs for paperwork, overhead insurance costs and high executive salaries. Schaps said if we worked off a single-payer system, there would be enough money to provide health care to everyone. Currently, Medicare, one model of single-payer and the nation’s largest insurance company, spends 3 to 5 percent of its budget on administrative costs.

“We don’t have endless money but there is adequate money to provide what people need,” she said. “If we could cut spots by 20 percent, we could provide everyone with health care.”

The White House Council of Economic Advisers June 2 issued a report on the economic case for health care reform concluding that “by reducing inefficiency in the current system” the nation could lower health care costs by about 5 percent of the GDP.

The advocates agree there’s room for cuts.

“We cannot do an MRI for every little thing,” Schaps said. “We need tort reform so that doctors don’t fear lawsuits against them.”

And that’s only the tip of the iceberg.

Dr. Monica Vela of the University of Chicago believes that health care should be provided to all – and the only way to do that is to make it a right and an entitlement.

“I don’t think that that means society is obligated to provide anything and everything," Vela said. “It does little good, and in my opinion harm to promise open-ended health care at the expense of other social goods and services, like housing, education or protecting the environment.”

Vela said we need to implement the right to health care in “a nuanced way within the confines of our political system.”

Obviously, we haven’t figured out how yet, and Vela is pessimistic that it will happen in the near future.

“It comes down to a very American style or way of thinking to provide more and more without necessarily stopping along the way to check for what other resources are at risk,” Vela said. “Providing state of the art health care at end of life and beginning of life is wonderful to be able to do but if we were to focus on preventive health care I think we could make the same dollar stretch much farther.”

Nevertheless, there are going to necessary budget cuts across the board.

“I suspect it’s going to be the business administration and the drug companies that will likely take on higher cuts to sustain the current health care system,” Vela said.

The same will have to go for doctors. I asked Vela if she would approve of doctors, including herself, taking deeper pays cut if it’s for the good of the system.

Her response, “absolutely." 

CHAPTER V: Ensuring Insurance

Although many may feel outraged that criminals get basic coverage while millions of law-abiding citizens do not, Schaps said prisoners are an important set of people to include when it comes to health care.

“We (the Health and Medicine Policy Research Group) do unpopular things, like we look for health care for prisoners,” Schaps said. “Now our focus is on girls who are in prison.”

According to the U.S. Department of Justice, the number of female prisoners has increased 1.7 percent from 2007 to 2008. The Women’s Prison Association released statistics showing that the female prison population increased 757 percent between 1977 and 2004 and continues to be the fastest growing incarcerated population.

“The public doesn’t care about prisoners and laws have gotten tighter and tighter about sentences and the prison health system has deteriorated,” Schaps said. “It’s an area that cries out to us for progressive reform.”

Because people in prison are more likely to carry infectious diseases such as tuberculosis and HIV, treating confined inmates – nearly all who eventually go back to their communities – makes sense.

“We believe that when people are in prison it’s a fabulous time to address health issues because they are captive by definition,” Schaps said.

And granting health care to everyone, providing treatment for mental illness and drug addiction, could also lower incarcerations rates.

“That’s the piece of the puzzle that would keep people out of the prison system,” Schaps said. “Most kids are in there because of mental illness and substance abuse, and I think we’ve been completely irresponsible as a country in addressing these issues.”

Schaps’ organization not only advocates for health care for prisoners, but for everyone.

“I think having one’s health is fundamental to life, liberty and the pursuit of happiness,” Schaps said.

The organization’s founder and chairman, Dr. Quentin Young, 85, started his organization in the early ‘80s after practicing at Cook County Hospital, the hospital on which the television show “ER” was modeled. Working at County as chairman of the Department of Medicine gave Young a window into what really poor people were going through.

“By the time I finished at Cook County Hospital, there were still many problems with underinsurance and racial problems,” said Young, who became a doctor in 1947. “By 1981, I knew there were all kinds of serious health care problems and that’s when the Health and Medicine Policy Research Group was founded.”

Young said for a very long time, many African-Americans were denied the health care they deserved. While he acknowledged that much progress has been made today, Young said we still have a long way to go, especially since long-term care is an emerging issue.

The elderly population is another rapidly growing group, with more people in need of support in their later years. Young’s organization is working on a project to bring health care to the elderly as well as to disabled people by using people in their own communities as resources.

“It’s better than stockpiling people in nursing homes,” Young said. 


CHAPTER VI - If it’s broke, fix it!

Obama recognizes the urgency for health care, as he noted in his weekly address on June 6.

“Even when I’m abroad, I’m firmly focused on the other pressing challenges we face, including the urgent need to reform our health care system,” Obama said. “If we do nothing, everyone’s health care will be in jeopardy.”

On Feb. 17, Obama signed a bill in conjunction with his stimulus package allocating more than $1 billion for comparative effectiveness research, also known as CER. According to the Congressional Budget Office, this sort of pragmatic research is intended to compare various health care models to determine if the risks of certain treatments and health care procedures outweigh the benefits. It also attempts to answer questions regarding what works best for certain individuals and under what conditions. For example, if you administer radiation or chemotherapy to a cancer patient, the therapies have harmful side effects and risks but may extend a patient’s life. CER tries to assess the benefit of the therapies as weighed against the risks.

Another example is determining whether to prescribe pills or perform open-heart surgery for people with heart disease. Should we go ahead with a bypass, which may not increase some patients' life expectancy, according to Chin, and costs tens of thousands of dollars, or is it just as cost-effective and health-effective to put that person on medication?

Shah believes although Obama signed the bill, our current system is still riddled with problems.

“(Obama signed the bill,) that’s great, but what does that mean to say we have a human right to health care in an era of rationing?” he asked. “Does that mean everyone gets a bare minimum?”

In 2001, The Institute of Medicine released a report called Crossing the Quality Chasm, which defined the pillars of quality health care. According to Chin, one of the most important pillars is equity, noting that everyone should have access to high quality health care.

“It’s a fundamental component to the definition of quality of care,” Chin said.

Of course, the place to get the ball rolling is Washington D.C.

“Washington needs to do something and figure out what the solution is in terms of universal coverage that will be politically viable,” Chin said. “Something will come out of Congress and I think there’s a good chance that this will be the time that it actually passes.”

Congress has mandated the Agency for Healthcare Research and Quality since 2003 to report on health care progress in the U.S. every year. Despite the jolly people pictured on the cover of the 2008 National Healthcare Quality Report, the rest of the content wasn’t so happy.

We may not have it now, but the folks in Washington continue to promise that someday soon everyone will have access to health care. Nevertheless, once people have access to coverage, how do we ensure that they have access to high quality care?


CONCLUSION – This is not the end.

With the number of those in dire need of adequate health care on the rise, we need health care reform sooner rather than later. Not only do we have 46 million uninsured, but there are also the forgotten 25 million who are underinsured.

Obama acknowledged that our broken health care system is a contributor to the country’s budget deficit, and at this rate, within 10 years, a dollar out of every five we earn will be spent on health care. He said his ideas for reforming the system will change that.

“If you like the plan you have, you can keep it. If you like the doctor you have, you can keep your doctor too. The only change you’ll see are falling costs as our reforms take hold,” Obama said.

Great. We love change, Obama. So please change it already.

The problems with our system have been the focus of public attention for some time now. For many, Michael Moore’s film “Sicko” comes to mind. It’s hard to forget a scene where someone has to choose which of two severed fingers to keep because he can’t afford to have both of them sewn back on for a grand total of $60,000.

In 1986, Congress passed the Emergency Medical Treatment and Labor Act, also known as EMTALA, which was supposed to ensure that patients would receive emergency medical attention whether or not they could pay for it.

It only applies, however, if the patient has a life-threatening medical condition – not a severed-off finger or two.

Just because ER doctors can turn patients down, should they? You would think that the U.S. could do better. Democrats have promised health care reform before Congress adjourns for the year. Those needing health care are hoping they succeed.

I saw a button not so long ago that read, “Our national health plan: DON’T GET SICK!”

For those 46 million uninsured Americans, not getting sick is their only option.