Everyone complains about the American healthcare system. Co-pays, formularies, reimbursement requirements, and doctor referral rules are part of the expanding bureaucracy that patients must navigate. Businesses struggle to contain the ever rising price of health insurance for employees and retirees. Federal, state, and local governments forecast ballooning deficits as they tally the costs of healthcare promises already made to the Baby Boom generation. Yet, despite all the money spent, and the sense that America remains the world leader in medical discovery and innovation, healthcare outcomes for too many of our citizens are dismal.

Some of the statistics are familiar. Despite our unequalled wealth, we have among the lowest life expectancies in the developed world, among the highest rates of infant mortality, and perhaps the worst record in providing affordable care to the poor. Forty-five million Americans lack any sort of health insurance. Our system also seems woefully inadequate in encouraging preventative medicine. Last year’s flu season revealed a wholly broken system for producing adequate amounts of vaccine, with only two sources of supply available, one domestic and one foreign.

There is no shortage of proposals for repairing the system’s failings. The most common today involve adding a large dose of market economics to the way we allocate care. Individuals, it is argued, have little reason in the current system to discriminate among healthcare choices because they don’t directly incur much of the costs of those choices. This leads to expensive overuse of healthcare resources. This is the motivation behind the new healthcare savings accounts made available by legislation and the trend of rising co-pays among employer sponsored plans. Indeed, U.S. corporations, under the rising pressure of global competition, have been leading the way in finding new ways to place more of the costs of healthcare directly on the backs of their employees.

 But while the market system is at the core of America’s extraordinary wealth generating economy, market based approaches probably aren’t  the cure for what ails American healthcare. First, the bulk of healthcare resources are consumed by the seriously ill. Anyone in that category seeks care based on need, not price. Only an inability to pay would discourage those truly in need from obtaining the best care available. Would anyone who requires a heart bypass choose to skip the procedure because the current price seemed too steep? Or, alternatively, does anyone seek out chemotherapy because the price is right even though they are free of disease? These choices don’t fit the standard market framework which relies on consumer choice. Second, and more critically, market systems only work if we allow high prices to exclude those unwilling and or unable to pay. With all the talk about letting the market make healthcare more efficient, who is ready to proclaim that those who cannot afford care should simply be denied it?

Amidst the many loudly voiced opinions for reforming our healthcare system, one constituency remains oddly silent. American businesses seem either to avoid the public debate wholly, or to defend decisions to aggressively transfer the burden of healthcare expenses to their employees in order to serve their shareholders. But this approach can hardly be in the long term interest of most businesses. On the one hand, companies like General Motors are sinking under the burden of providing health benefits that none of their foreign competitors are required to provide. On the other, successful companies like Wal-Mart, by avoiding paying adequate benefits, have narrowed their pool of interested employees to those desperate enough to accept a job that lacks this most crucial benefit. In doing so they have left many workers to rely on welfare programs, and have damaged their corporate reputations. Indeed, Wal-Mart’s stingy benefits policy recently inspired Maryland’s legislature to mandate that the company pay far more generous healthcare benefits.

Shouldn’t American business be shouting for a solution that takes healthcare out of its hands? Surely this would improve the position of our most labor intensive businesses in the era of globalization. Wouldn’t a system that recognizes that healthcare is a universal right—guaranteed by government as a matter of social policy, rather than an employment benefit—be more sensible in a society as wealthy as ours?

This could be a defining moment. Business could take a public stand on healthcare policy that would serve its own interests while setting in motion the political will to address this most pressing social problem. But business remains mostly silent, perhaps sensitive to traditional political alliances or trapped by a reflexive assumption that the market should solve the problem.

—B. Apfel