The United States ranks among nations with the highest per-capita incomes and most advanced medical technology. But many Americans say they cannot afford or get access to health care. The issue is high on the agenda for Democratic Party candidates hoping to replace President Bush next year, prompting renewed debate about who should pay for health insurance.

Most Americans get their health insurance through their employers, but there is no requirement that every American have such insurance.

With the skyrocketing cost of health care, more U.S. businesses are reducing the benefits they pay for employees' health insurance as a way to save money. That means employees are paying more of their health costs. Many can no longer afford it. More than 40 million Americans are without health insurance, and the number continues to grow, as does concern over the situation.

Pat Schoeni is executive director of the National Coalition on Health Care, a non-partisan group working to address problems in U.S. health care. "We at the National Coalition on Health Care feel it is basically a broken system, and a system that is getting worse all the time, and not getting better," she said.

Her organization prepared a study that shows health care spending in the United States, already the highest in the world on a per-capita basis, will soon double to over $2.6 trillion. At the same time, health insurance premiums rose this year eight times faster than general inflation, the largest one-year surge in premiums in more than a decade.

Much of the rise in the cost of health care is attributed to more intensive care, the use of new and expensive technology, especially for the 120 million Americans who are chronically ill, and the rapidly growing number of elderly Americans.

What to do about the situation has become a key political issue. Democrats who are seeking their party's nomination for president next year are unveiling their own health care reform plans, and they all call for giving the government a greater role in providing health insurance.

For example, Congressman Dick Gephardt of Missouri advocates universal coverage. "This is a moral issue," he says. "It is immoral to have anyone without health insurance in this country."

Senator Joseph Lieberman of Connecticut takes a different angle. "I am going to have a plan that I will introduce in the next couple of weeks, which would guarantee every American worker, if you lose your job, God forbid, you are not going to lose your health insurance," he says.

But major health care reform has been elusive in the United States. Part of the reason, analysts say, is that the insurance companies, which donate generously to lawmakers' campaigns, do not want to lose the profits they make from their private plans. The other reason is that many Americans who have health insurance fear they will lose benefits under reform.

"The reason we do not have major health care reform is a function of the fact that most people are already well-insured, and, therefore, really do not stand to gain much personally from the extension of health insurance coverage to others," explains Henry Aaron of the Brookings Institution. "On the cost side, one person's health care expenses are another person's health care income."

The medical industry agrees reform is needed. The American College of Physicians calls for building on existing government health care programs, using a more private approach. The organization's president, Dr. Munsey Wheby, advocates combining subsidies, tax credits, and more competition among health plans to lower cost and expand access. "We would hope this would provide more choice by allowing individuals to choose from a variety of health plan options," says Dr. Wheby. "This is something that I think has an appeal to the American public."

Nearly a decade after Congress defeated an ambitious Clinton administration plan to reform the health care system on grounds it was too bureaucratic, lawmakers are taking a more incremental approach. They are focusing on making prescription medicines more affordable to Americans.

The politically influential U.S. pharmaceutical industry defends the high prices, saying they are necessary to pay for the high cost of research.

But lawmakers, with election year politics on their minds, are looking for ways to bring down prescription drug costs. Earlier this year, the House of Representatives and Senate passed separate legislation to reform medicare, the government health care program for the elderly and disabled.

The $400 billion plans would help older and disabled Americans pay for prescription drugs. President Bush has urged both chambers to reconcile differences in the legislation, so he can sign it into law. "The lack of coverage for prescription drugs and many preventative treatments is a major gap in Medicare that denies some of our seniors the latest and best medicine," says President Bush.

The House also passed a bill that would allow Americans to import less expensive drugs from some 25 nations.

Opponents expressed concern the measure would jeopardize patient safety by allowing diluted, expired, tainted or even terrorist-engineered fakes across U.S. borders, and would deprive U.S. drug companies of money for research.

The bill's future is unclear, as 53 Senators signed a letter objecting to the fact the measure denies the administration the chance to establish the safety of the program.

In the meantime, as the November 2004 election draws closer, the debate over how to expand health care access and reduce its cost is expected to get louder.

This report is part of VOA's series on world health.