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Living in Bozeman, Montana, it’s hard to grasp the full extent of our health care crisis. We have adequate care here, though if one is uninsured, he might be well-advised to avoid it. And surely there is an underbelly here I am not seeing – the waiters and cooks and unemployed, pre-Medicare retirees and low-income self employed who don’t have insurance. Let the market work, they say, and it will fix all these woes. How? They don’t say. Osmosis.

I’m in the middle of a book, Sick, by New Republic editor Jonathon Cohn. It’s well-written and interesting. Cohn starts each chapter by introducing us to individuals with medical problems, and then deftly takes us to the larger problems and back again. It’s compelling reading on an unpleasant subject.

Most of the problems center on our insider-outsider based rationing system, where the very best coverage goes to those with insurance or Medicare. What is left over covers our ever-increasing working class and poor sectors – lousy care or no care with financially stressed hospitals morphing into collection demons. All of this while George Bush attempts to fix malpractice, as if.

Cohn gives what seems to be an objective history of health care in the United States, from the early days of the insurance concept to the pricey private companies that now eat up our health care dollars. He’s not anti-insurance by any means, and gives full credit to the wonderful work that Blue Cross Blue Shield has done over the years until their recent conversion to for-profit status. Catholic hospitals have performed miracles over the years, but are stressed now as they attempt to remain viable while competing with for-profit corporations that can be selective about who they choose to treat. And Medicaid and S-chip have performed a valuable service, though they are underfunded and under financial pressure in every state.

Back to Bozeman, and my own insulation from the giant nationwide quagmire. In a middle chapter, Cohn takes us to Los Angeles, where state and local government attempt to help with the problem inadequate health care for the underclasses. Here’s the seamy side:

Glorida Montenegro had been experiencing a stomachache for several days, and was hoping it would just go away. But when the pain became intense, she feared it might be a real emergency, and she went to the only hospital she knew would take her: County. As Gloria tells it, a member of the staff – Gloria doesn’t remember whether it was a doctor, a nurse or somebody else – asked her about her condition and instructed her to sit tight, offering some Maalox to settle her stomach for the time being. Then Gloria waited. And waited. Ten hours passed, and as Gloria looked at the woman sitting next to her – who appeared to be bleeding from a miscarriage – she decided it might be another ten hours, or more, before the hospital finally got around to her. She had her husband take her back home, and she eventually recovered; but she still got a bill for nearly $1,000. After persuading the hospital to reduce it by a few hundred dollars, she ended up paying it over several months.

Gloria and her husband work two jobs that do not offer insurance, and make in total about $25,000 per year. Market solutions abound – right? Why, they can simply make more money by getting raises or taking on second and third jobs, or can buy private insurance from a wide array of choices – oh, wait, think again. There are only so many hours in a day, they have a child, and the insurance is beyond their means, and anyway, Tony, her husband, has diabetes, and no self-respecting insurer would touch him even if he could afford the coverage.

Anecdotal? Yes, of course. Typical, Yes, emphatically so. In 2003 a group of frustrated doctors claimed that at least four patients in LA County had died because of long waits for hospital beds. A subsequent study found they would have died anyway, but also cited horrifying cases of waits of 25 hours or more up to seven days for access to a hospital bed for conditions ranging from tuberculosis to AIDS to schizophrenia.

That’s medical care for the underclasses. They don’t get regular checkups, and don’t go to the doctor for minor ailments. When something is wrong, they go to the emergency rooms, which are fitfully overcrowded. The waits are interminable. If they are lucky, there won’t be a bill, as there is compassion in our strapped society. But hospitals, trapped by the ever-burgeoning uninsured population, cannot afford to care for them for free and are getting tough about payment. There’s a cadre of attorneys now who do nothing but enforce collection on people like Gloria.

In the end, people live with ailments, forego drugs and treatment, and die prematurely because our system is broken. And the market cannot fix it. The market is doing what it does quite well – we have a first-class system of health care for insiders. I can currently afford insurance (though Blue Cross is saying they need a 32% premium increase from me – I may be on the outs) – I get excellent care. I’m one of the lucky ones.

Let the market work, and this system will continue to get worse, and will eventually crash. It is crashing right now. What galls me is the attitude I encounter, most recently from Dave Budge, that all of the problems of our system are caused by government, and if left alone, the market would fix it.

Quite the opposite.