We’ve all heard friends and co-workers say "I can’t afford to get sick." For many, this isn’t just about meeting a deadline at work or school. Millions of Americans worry about whether they can pay their medical bills, or whether they can get care at all. Even those with good health insurance worry about the bureaucracy and complexity of the system.

Consider these facts:

• The amount the average American pays for insurance premiums and out-of-pocket costs rose by 50 percent between 2000 and 2005, from an average of $6,200 to $9,100 per person.
  
  
• Some 47 million Americans, roughly 15% of the population, don’t have health insurance at all.
  
  
• Unpaid medical bills are the nation’s leading cause of personal bankruptcy.
  
  
• Our country’s total health care bill is projected to hit $4.3 trillion by 2017 and account for about one-fifth of the total economy. That’s double the $2.1 trillion we spent in 2006.

Health care costs in the United States are hurting individuals, government and businesses. What makes this problem harder to solve is that there isn’t just one cause behind it. There are a lot of reasons for these astronomical sums, including:

• Technological advances. Science keeps coming up with new cures, which are wonderful – and expensive.


• An aging population. As 78 million baby boomers hit retirement age, they’re going to be subject to the extra medical needs everyone faces as they get older.


• It’s hard for most people to tell how much their health care really costs. Most people who have insurance only pay part of the cost through co-pays, deductibles or employee contributions – the insurance company pays the rest, and the patient may or may not ever see a bill. And since different insurance plans negotiate different deals withproviders, the bills for two people with the same illness could be quite different. Many experts say that since the patient isn’t bearing the real cost, there’s no incentive to control costs.


• General inefficiency. Since the U.S. health care system isn’t really a single system but a combination of private insurance plans and government programs, that means different forms and different rules for every situation. (The United States spends more than $400 billion a year in health care paperwork, more than three times per capita what Canada spends.) Some experts blame factors like high compensation for health care companies and providers and medical malpractice lawsuits.


• Unhealthy lifestyles. Americans may not be taking good enough care of themselves, with rising obesity rates and falling exercise levels.

The United States spends far more per capita on health care than any other nation, and yet some critics argue Americans aren’t getting their money’s worth. Despite tremendous gains in health and average longevity, from 47 to 77 years since 1900, measures of U.S. medical well-being lag behind those of several dozen other nations (Japanese life expectancy, for example, is nearly five years longer than Americans’.) A RAND Corporation study found that only half of the treatments that Americans receive are considered "best practices."’

Most Americans (about six in 10) get their health coverage as an employee benefit. As a result, the number of uninsured people tends to swing up and down with the economy, as employers lay off or cut back in hard times. Low-income people and young adults are most likely to be uninsured. Those without insurance are 25 percent more likely to die during any given year than those with insurance. And of course, even though people with employer provided insurance only pay a fraction of their health costs, it’s far from free – the Kaiser Family Foundation reports the average family premium is more than $12,000 per year, of which employees pay roughly one-quarter. The government does play a major role in providing health care, through programs for the elderly (Medicare), the poor (Medicaid) and low-income children, as well as through veterans benefits and insurance for federal employees and their families.

In fact, the federal government currently pays for about 45 percent of the nation’s health care bills. The government also provides substantial tax breaks ($225 billion total) for employers who provide insurance. People who aren’t covered by an employer or the government can still buy health coverage from an insurance company on their own – but relatively few do. Individuals end up paying the highest rates, because businesses usually negotiate a cheaper group rate.

This makes the rising cost of health care a challenge for government, businesses, families and individuals. Businesses are increasingly worried about the cost to their bottom line. General Motors, for example, says it spent $5.6 billion covering its 1.1 million employees in 2006, and claims health costs added $1,500 to the sticker price of every car it makes. While very few businesses said they intended to drop health benefits in 2008, one in five said they were likely to raise employee premiums, according to a Kaiser Family Foundation survey.

For the government, health care costs may become a budget-buster. The combination of the aging baby boom generation and rising costs makes Medicare the most worrisome part of the federal budget. Medicare spending will be about $400 billion in 2008. Medicaid and children’s health spending will be around $216 billion, and state Medicaid costs are likely to be about $160 billion. All of these numbers are projected to double within a decade. But controlling costs brings up fundamental questions of fairness. Few topics are as potentially controversial as setting limits on health care. When managed care companies became popular in the 1990s, there was intense debate over their attempts to control costs and approve procedures. Yet some limits may well be needed if we’re going to control costs.