The US is one of the richest countries in the world - but on basic measures of health, like life expectancy, it lags behind many poorer countries.
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Crash penalty is harsh - Hamilton ... As the state of Massachusetts pioneers a new scheme to increase state involvement and get everyone insured, the BBC's Jill McGivering asks whether it could be a model for the rest of the country.
Massachusetts General Hospital in Boston is private, making most of its money from patients' fees.
A tour of the facilities is certainly impressive. It bristles with multimillion-dollar technology.
But it could be more efficient. Dr David Torchiana, a hospital chief executive, told me paperwork eats up a vast amount.
"We send bills to probably about 25 different payers," he said.
"Every one of them has a different set of rules. If you printed out our regulations around billing for radiology studies, it would be a pile of paper seven inches thick."
'Crazy' system
That sort of waste disturbs those who see chronic imbalance in the US system.
Americans spend more than twice as much per person on health as the British. Yet more than 40 million Americans - about 10% of the population - are completely uninsured.
John McDonough, who heads consumer lobby group Healthcare for All, describes the system as "crazy".
"All of the incentives right now in our system reward healthcare providers for the volume of services they provide," Mr McDonough said.
"So, all the rewards come from more procedures. The more talking you do, the more time you waste and the less money you make."
The effect is that people with money have treatments they may not need and see specialists when a more junior doctor would do.
At the other end of the scale, the poor can't afford even the basics.
'Brave attempt'
Now Massachusetts is introducing pioneering new reforms which give the poor a much needed safety net.
It makes health insurance mandatory for all. Anyone who fails to buy it faces a tax penalty. It helps those who can't afford insurance by providing subsidised or even free cover.
"We have taken the exiting system, and we have said we're going to try to fill in all the holes," says Jon Kinsdale, the programme's executive director.
"Altogether we've enrolled about 340,000 newly insured in the last 18 months."
It doesn't create a totally level playing field. Private insurance companies still play a central role.
Mr Kingsdale admits that the rich will still end up with better quality health care than the poor.
But it is a brave attempt to address gaps in US healthcare without trampling on a core US value: freedom of choice.
'Shared responsibility'
The scheme has some enthusiastic supporters.
I went to one of Boston's poorer neighbourhoods to attend a church service.
Several worshippers here now have health insurance for the first time, and they say it has made a huge difference in solving chronic health problems and catching early potentially life-threatening conditions.
The preacher, Reverend Hurmon Hamilton, sees the Massachusetts reforms as a model for the rest of the country.
"We're all mandated to get health insurance," he said.
"There's a role for the government to play, in terms of subsidising those who are poor. There's a role for employers to play. And then there's a role for insurers to play. So, it's shared responsibility. That's how this country is going to have to figure it out," Hurmon Hamilton said.
There is one problem: paying for the programme has only been possible because of extra cash from the federal government.
So, its survival is very dependent on political will. All eyes, then, on the presidential elections in November.
(BBC)
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