Because the United States, alone among the industrialized nations, has continued to base its health care on an employer provider model. Because health care in America is a profit driven enterprise structured to favor the bottom lines of insurance companies, health care providers and insurance firms alike are severely impacted by fluctuations in the economy. In the present recession the health care system is in increasingly deep trouble.

Because most Americans get their health care insurance coverage through their employers, when an economic downturn like the present one results in ever higher unemployment, many people lose both their jobs and their health coverage. If a person is not covered, or can only buy subsistence coverage, then he or she either must seek out free care (such as free clinics) or do without. Because high unemployment also means reduced tax revenue, state and local entities that are designed to help with health care costs must slash their budgets and deny care to more and more people. Programs such as COBRA, which allow people to continue their health insurance when they lose their jobs if they can pay the entire premium, only help a very few, since insurance is expensive and the incomes of the newly unemployed have plummeted.

Health care providers are feeling the impact. Many doctors are reporting a substantial increase in the numbers of people who can't pay their bills or their co-pays. For profit hospitals are seeing revenue declines as people of limited means put off elective surgeries or inpatient services. A 2009 survey by the American Hospital Association, discovered that 90% of community hospitals had scaled back staff or services, as well as capital improvements or technology upgrades due to decreased revenues. Medical practices are reacting much the same way, although some have responded to reduced patient traffic by keeping longer office hours instead of cutting back. The survey also discovered that many doctors are seeking opportunities for extra income such as on-call pay, or employment at the hospital. And of course, at the other end of the scale, subsidized services and low-cost services are being swamped with new patients.

For the insurance firms, the recession has not impacted their profitability in any great sense, although if the situation continues to degenerate, that might change. They have recourse to several modes of operation that can protect their bottom line, such as increasing rates, denying claims in greater numbers, or refusing to cover the more marginal customers (in terms of health risk) that can end up costing them. It's hard to see how this course of action can be sustained indefinitely, but then again, it's hard to see how the recession can continue as well.