I know who can fix our broken health care system -- and who can't:

* Not presumptive Republican nominee John McCain. He proposes a tax credit of $5,000 per family to encourage us to buy private health insurance.

* Not Democratic presidential candidate Hillary Clinton. She proposes universal health insurance supported by tax credits.

* Not Democratic presidential candidate Barack Obama. He proposes a mix of public and private health insurance with government subsidies to those who don't qualify for government insurance plans such as Medicaid.

I say, let Wal-Mart Stores (WMT, news, msgs) do it. Hold your guffaws. Stifle your impulse to scoff. Control those sputters of rage.

Wal-Mart has done more to expand coverage and lower costs in the past year than any government program to come out of Washington in the past 10 years. And I'd bet the new programs that this company -- known for stiffing its own part-time workers on health care benefits -- has announced in the past year will do more to expand coverage and cut costs than anything likely to come out of a McCain, Clinton or Obama first term.
Government programs, rising costs
The goal, everyone agrees, is to maximize coverage, heighten competition and cut costs. Good goals, all. About 47 million Americans now lack health insurance. Health care costs are rising far faster than general inflation. And health care is on track to consume 25% of U.S. gross domestic product by 2025. That would be up from 16% today and 5% in 1960. (For more on the health care squeeze and the candidates' proposed fixes, see our multimedia package "The Middle Class Crunch.")

If you really think the federal government is up to the task, consider the government's last venture into expanding coverage and cutting costs, the Medicare prescription drug program signed into law in 2003. The program, which went into effect in 2006, was budgeted at $400 billion over 10 years. By the time it had been up and running for a year, the cost estimates had climbed to $800 billion, according to Medicare.

Look at what's happened to costs in another federal program with a much longer history. Of the 44 million elderly and disabled covered by Medicare, 80% have their health bills paid by the traditional fee-for-service program. The other 20% get their Medicare benefits through private health plans that receive payments from Medicare.

These plans, now called Medicare Advantage plans, have been around for decades. And they've recently formed the backbone of many plans to fix U.S. health care by expanding coverage and cutting costs. The theory was that these privately run plans would provide the same services as Medicare at reduced costs -- and then put that money back into new services or reduced premiums or co-pays.
Industry 'consultation' narrows competition
But it hasn't worked out that way. A recent survey by the federal government of the private Medicare Advantage plans found they charge the government 17% more, on average, than it would cost Medicare to provide the same services. From 2009 to 2012, the government projects, the extra costs to the federal government will amount to $50 billion.

What's wrong? Why have programs designed to increase coverage and cut costs been only limited successes or outright failures? Because the competition that was supposed to unleash so many benefits and reduce costs has never really materialized.

These programs, like many government programs in other areas, were written in consultation with or in some cases actually by the drug and insurance industries. That "consultation" made sure any competition introduced wasn't too onerous. So, for example, the federal government -- the world's greatest purchaser of medical products and services -- is prohibited by law from bargaining with drug companies to get lower prices.

Letting Wal-Mart run the health care system would fix many of those problems. It's a company that understands how low prices can build market share and thus increase profits. Furthermore, it's a company with a culture of cutting costs that has shown no compunction in pushing suppliers to the wall over price. The Wal-Mart motto ought to be, "Make it cheaper, or we'll find someone who can." I'd love to see that attitude brought to bear in health care.

My wish isn't pie in the sky either. Wal-Mart has decided it can make money by applying its always-low-prices strategy to drugs and medical services. For example, in 2006, the company first rolled out a program to sell a long list of about 300 generic drugs for $4 a prescription. It added 24 more drugs to the list in 2007.
Broad expansion of a generic program
Then on May 7, Wal-Mart expanded that strategy. Customers can buy a 90-day supply of any of 350 generic drugs for $10. In addition, the company expanded its $4 generic program so it now applies to more than 1,000 over-the-counter drugs, about a third of the OTC drugs the company sells, including generic versions of such blockbuster drugs as Zantac and Claritin. And a 30-day supply of generic drugs for osteoporosis, breast cancer, hormone deficiency and other women's health problems will sell for $9.

By offering a 90-day supply -- exactly the same length of prescription the mail-order drug management companies offer -- Wal-Mart is going right at the heart of the drug management business. At $10 for a 90-day supply, the Wal-Mart price is below the co-pay many of its customers face if they have private or company insurance.

The addition of over-the-counter generics is aimed at another trend: the increasing practice of drug-benefit plans to refuse to pay for such medications. Once you can buy allergy medication Zyrtec without a prescription, some plans stop paying for it -- even though a 20-tablet box can cost $20 or more at the average drugstore.

Think any of these price points is a coincidence? Wal-Mart, I'd argue, has studied this market and knows where the price points and vulnerabilities are.

And Wal-Mart isn't stopping there. In April, it opened the first of its walk-in health clinics in stores in Atlanta, Dallas and Little Rock, Ark. This joint venture with local hospitals will build up the almost 80 clinics already in place in Wal-Mart stores. The goal is 400 co-branded clinics by 2010.

Lower costs, less paperwork
Again, the strategy reflects a close study of the vulnerabilities of the existing health care industry. The clinics will be low-cost, of course, charging just $45 for a get-well visit. That price is again below the co-pay in many health care plans.

And it gets even more attractive when you remember that it comes without all the paperwork so typical of the modern co-pay, deductible, delayed-reimbursement health insurance system. No appointment necessary, so harried consumers can get a kid vaccinated while shopping. No insurance necessary either. Got cash or a credit card? You can see a doctor.

And let me tell you, anyone who thinks this isn't an attractive way to deal with a minor problem -- for customers in every demographic and with every kind of health insurance -- hasn't tried to get an appointment to see an overworked doctor to check out what might be strep throat or an ear infection. I've got good health insurance, but I've used clinics like these in stores belonging to Wal-Mart competitors for exactly that kind of problem.

Wal-Mart's clinics also promise to be a major step toward the goal of a national network of electronic health records. Wal-Mart is part of a consortium of eight big employers, including AT&T (T, news, msgs) and Intel (INTC, news, msgs), that are putting their employees' health records online. And Wal-Mart is requiring that all of its in-store clinics use electronic health records to track the patients they treat. The software, from private company eClinicalWorks, keeps an electronic record on each patient that doctors in any Wal-Mart clinic can pull up easily at the next visit. The system also gives clinic practitioners diagnostic cues to aid in treatment.

This sounds like a big step toward the goal President Bush laid out in 2004 for most Americans to have electronic health records by 2014.
Spurring on the competitors
The best thing about letting Wal-Mart do it is that the company won't have to fix the health care system all by itself. Wal-Mart's entry into this field has already galvanized competition from retailers such as Target (TGT, news, msgs) and CVS Caremark (CVS, news, msgs).

Some, like Target, are matching Wal-Mart step by step. Some are arguably ahead of the giant retailer. Clinic operator MinuteClinic is a CVS subsidiary that operates more clinics than Wal-Mart has opened to date.

What Wal-Mart does, though, is take the game up another level. If you're playing against Wal-Mart, it's compete or die. Walgreen (WAG, news, msgs), Rite Aid (RAD, news, msgs), CVS and other drugstores have to run at full speed with their best ideas or get turned into roadkill. Same for Costco Wholesale (COST, news, msgs), BJ's Wholesale Club (BJ, news, msgs) and Target. Think e-health information companies such as WebMD Health (WBMD, news, msgs) haven't noticed? Especially when Google (GOOG, news, msgs) and Microsoft (MSFT, news, msgs) have recently launched Internet-based e-health services. (Microsoft is the publisher of MSN Money.)

And if all those companies are competing, that will force the drug makers, the insurance companies, the health care providers and the health management companies into motion, too. It won't be enough for these companies just to lobby in Washington anymore.
Evolving program for employees, too
There's more than a little irony in seeing Wal-Mart take the lead in the health care market in the United States. The company has received well-deserved criticism for the way its rules prevent part-time workers from receiving health insurance.

For example, part-time workers had to work at the company for two years before they were eligible for health insurance. In 2005, WakeUpWalMart found that 300,000 Wal-Mart workers and their families had received publicly funded health care -- because they didn't have any company insurance -- at a cost of $1.4 billion.

That's begun to change. The company has cut the waiting period on health insurance for part-time workers to 12 months. (For 2007, the company set a goal of having 50% of its employees covered by company health insurance. The national average at big companies in the United States is 63%.) Children of part-time workers will be eligible for company health benefits. And co-pays on generic medications for common conditions such as diabetes, hypertension, high cholesterol and infections have been reduced to $3 from $10.

Has Wal-Mart changed enough on the inside? No way. But you don't have to like the company to think it might be able to do what no one else has been able to do: fix health care in the United States.

I've been saying this for years. Nothing will happen until the corporations decide that we need change. Not exactly the way this article is talking, but they need to realize that universal health care would save them huge amounts of money. Then they can force the change, because the corporations rule America.

This doesn't sway me from seeing UHC as the most viable option. I'm open to other solutions, but this isn't that compelling just yet. I'd have to see how it would expand to anything beyond drugs and walk-in clinics. And I'd like to see what the downsides are as well.

• Competition forcing other health care providers to reduce their rates (same applies to prescription drugs program)
• Increase the acceptance of electronic records. Paper is the bane of the industry (and part of the reason administrative costs are so high)

The only concern I have about this is that many people might think of this as a substitution to health insurance and won't buy it even if they need it.

There is no guarantee that universal coverage will help corporations (or all other taxpayers) save money on health care.

It depends on how the system is set up. What the article talks about is something completely different (and the exact opposite of universal health care) - letting market forces fix the problem created by the government.

UHC would get corporations completely out of the health care business. The corporate beauracracy alone that would end as a result of UHC would save untold billions of dollars.

It would also allow people to move freely between jobs without having to worry about their coverage ending.

It depends on how the system is set up. What the article talks about is something completely different (and the exact opposite of universal health care) - letting market forces fix the problem created by the government.

So the government will run the hospitals? The government will make the drugs? The government will run the medical schools, medical equipment companies, pharmacies, nursing homes, etc.? Somehow I don't think so.

The article talks about how currently the government is not allowed to negotiate with pharmaceuticals on drug costs. How much money is that wasting? And why would the situation change if UHC is introduced?

And yes, I agree, there is a way to set up a universal system in the U.S. that would be cheaper than what we're paying now (but not cheaper than what a true market solution would accomplish). My point is that it's not a guarantee, but rather wishful thinking, given the U.S. government's track record on health care.

I'm not talking about the health care industry. I'm talking about corporations in general, who have to setup entire departments just to deal with employee benefits. That would all go away under a UHC system. Corporations would no longer have to deal with payroll deductions for health insurance, most worker's comp, or insurance companies at all.

Regardless of whether UHC is implemented, the government should be able to negotiate drug prices. The prohibition was a part of the Medicare law written by the pharmaceutical companies. Also, private citizens should be able to buy less expensive prescription drugs from Canada if they wish.

The current HMO model of denying care to maximize profits was promoted and established by the PRIVATE company Kaiser Permanente. And I don't deny that the government's half-measures have been part of the problem, but to deny the role of big insurance corporations and other big health care industry conglomerates in the problem is simply false.

i think the fact that every other industrialized country in the world has implemented a better and cheaper model for health care while still covering almost every citizen is proof enough of the concept. And I don't see why the US, the current administration notwithstanding, isn't capable of doing at least as well as Canada, Britain, or France. The key will be competent and visionary leadership.

Btw, as I'm sure you're aware, private health care and insurance does still exist in most of these countries, in much the same way that private schools still exist in America despite our public education system. So those businesses would not go away entirely.

And yes, I agree, other countries have successfully implemented universal coverage programs, but those countries have different government structures implications of which go far beyond health care issues. That has negative aspects as well (do you really think the government should be able to control how much a physician makes a year?).

I'm not worried the private health care and insurance companies at all. I think the industry is corrupt and needs a major kick in the ass - something that Wal-Mart might just do.