Unlike every other industrialized country, America does not have a national system of public health insurance. Instead, intense lobbying by insurance companies over decades has left us with a patchwork system. Medicare, Medicaid and the Veterans Administration are public plans that cover seniors, the poor and veterans. Most other Americans get employer-provided private plans of varying quality, but the number of people covered by employers is shrinking as more and more employers decide they cannot afford to even offer coverage.

As fewer and fewer employers provide quality coverage, more and more middle-class families are vulnerable when catastrophe strikes. Today, more than half of all personal bankruptcies are due to medical bills. Every 30 seconds, someone files for “medical bankruptcy.”

Why are costs skyrocketing and squeezing working families? The administrative costs for private insurers are approximately four times the size as those for Medicare. That’s because instead of providing coverage to all who need it, private insurers have a layer of bureaucracy to “cherry pick” their customers. They take on people who are less likely to get sick and deny coverage to people with pre-existing conditions. The uninsured often turn to expensive emergency rooms for their medical care, driving up costs for everyone. Furthermore, there’s been no incentive to move towards electronic medical records, which would help prevent wasteful spending on unnecessary medical procedures.

Insurance companies, HMOs and private providers do compete with one another. But without standards for high quality, the competition is over who can avoid insuring the sick and the elderly—and who has a better system to deny health care to people who need it. This kind of competition has led to byzantine paperwork, soaring costs and massive waste, not affordable choices for all Americans.

Letting private insurance companies dictate the terms of our health care system simply hasn’t worked. They haven’t covered everybody. They haven’t kept costs reasonable. They haven’t given us good choices.