Ruth Thorlby on the price of healthcare in the US

Ruth Thorlby

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For a new arrival to the US, embarking on the Health Foundation's Harkness Fellowship in New York, it is hard to take in the full litany of facts about the 46 million Americans with no health insurance.

Lack of insurance costs lives: 18,000 deaths in the non-elderly population were attributed to it in 2000. Uninsured people are more likely to be in worse health and, if they survive beyond 65, need more costly healthcare when they qualify for state-funded insurance for the elderly. This system, combined with the safety net for the very poor, costs more as a proportion of GDP than many other countries spend on covering their entire populations.

A comparative international survey of public attitudes by the Commonwealth Fund in 2007 found that twice as many Americans as Britons felt their healthcare system had so much wrong with it that it needed to be completely rebuilt.

More recent polls suggest that as many as eight in 10 Americans now believe the system needs "fundamental change or complete rebuilding".

As Americans head to the polls to elect a new president next week, there is a strong likelihood that whoever they choose will try to reform this dysfunctional healthcare system. Although concern about healthcare has been displaced by worries about the economy, both presidential candidates have made clear their determination to tackle the twin challenges of lack of affordable healthcare for millions of Americans and steadily rising costs of healthcare as a whole.

Some analysts have pointed to the similarities with the 1992 election, when both candidates' pledges reflected a similar public appetite for reform of the healthcare system.

But the failure of the Clinton administration's health reform programme casts a long shadow and experts here expect a much more incremental approach this time. Economic uncertainty will mean Congress will be even more wary of any bill that demands too many federal dollars. The evidence that universal healthcare coverage will, in the long run, reduce costs is still patchy and it is too early to see results from the handful of home-grown examples.

So what will happen to those uninsured Americans, whose ranks are likely to swell as the recession takes away the jobs that provide the bulk of health insurance? It will mean more pressure on the "safety net" providers, the hospitals and health centres that cater for all those with no insurance.

But on a visit to one of New York's public hospitals, I found the atmosphere was not yet one of crisis. In this most unlikely of environments, they have been imaginative at finding funding and encouraging staff to innovate in improving care for a challenging group of patients. Sure, high-level policy change would help, they said, but in the meantime, quality improvement for the poorest goes on.

Over the next few months, I plan to share some of the innovation that has come from those delivering services to some of America's most disadvantaged communities.