Health insurance—we’re hearing a lot about it lately. If you have it—good, reliable insurance that covers everything you need—you don’t even believe about insurance. Your employer has already done the legwork for you. But if you don’t have insurance, if you’re one of the 47 million Americans who have lost their insurance because of layoffs, or pre-existing conditions, or self-employment, the subject of insurance looms large.

The truth about American Health Insurance is that it is now a luxury item. Though arguments abound as to whether it’s a ‘right’ or a ‘responsibility,’ the truth is that insurance coverage in our country hangs by a thread. The cost of premiums and copayments have increased so noteworthy that only large corporations or government entities can ‘negotiate’ in order to regain the best prices. And their covered employees are so large a group that the risk is spread over a broad number of age groups and health situations.

We are often told that tiny business is the engine for job creation in our country, and has been for decades. Yet, small businesses are the most vulnerable to the prohibitive costs of health insurance. Often, a business is started with just one person—or perhaps with one person, his or her spouse, or partner. That can qualify as a ‘group’ for insurance, but if one of those people has a serious, previously-diagnosed condition, it will bump their ‘group’ into a considerably higher premium level. Often the self-employed go without insurance, hoping to insert it into the business budget later, but higher health insurance premium costs can outstrip profit gains, so that it never does quite fit into the budget. And they continue to go without insurance.

On an industry forum I subscribe to, I recently read agonized comments and requests for advice about health insurance. If you mediate small business is doing fine with the current system, you are terribly mistaken. Foremost in the minds of those with miniature, fledgling businesses is the health insurance coverage for the owner and his or her family. Often, this cost so taxes the profit margin that the only choice left to preserve the tiny business is to fall coverage for employees altogether, That invariably affects the quality of employees a business can attract. It then becomes a vicious circle—the business can’t derive the employees it needs, or can’t retain them for long—which then affects the productivity of the business—which then affects the bottom line of the business—which then makes it even more impossible to afford the health insurance coverage it needs to attract long-term employees.

The ‘pre-existing condition’ is also a dilemma that is calm with us, and may even be so narrowly defined as ‘previous surgery’ or past mental health condition. If you try to shop around for health insurance, hoping to score a better price, you may find your condition under an ‘exclusion’ for a number of years. So in effect, you won’t be covered for that which you most need coverage to inaugurate with!

Other problems afflict our health care coverage, such as increasing deductibles and copayments, that drive ordinary, hard-working and insurance-covered individuals into bankruptcy court—and ‘non-covered procedures’ that have the families of desperately-ill individuals on the phone with insurance companies and dispute resolution boards when they should be attending to the patient himself.

We are often told that we have ‘the best health care system in the world,’ and it is—for those who are included fully in it. For others, the struggle to break into that ‘best system in the world’—or to make that system work for them—is a daily, monthly, or quarterly battle. And the number of those who are not included in that system grows daily. There are those who also tell us that it would be too expensive to cover all Americans in a national healthcare plan. Yet other countries find a ways to do it. And our government spends hundreds of billions on other projects of dubious necessity.

We should all be aware that our current system of healthcare is failing too many Americans, and will continue to fail even more in the future. It is affecting our productivity as a nation, and our savings rate as a population. It is affecting our future—slowly, inexorably—and there may come a time when we are ‘forced’ to something drastic. It would surely be better if we made the change to a new system thoughtfully and systematically, instead of under the threat of health insurance collapse. These are the choices we have. Let us hope we have the courage and creativity to tackle the problem. Those qualities are, after all, our strengths as Americans.