The American health care system is a mess. That is the theme of this week’s JAMA, though in fact the sentence is pinched from the beginning of a paper in its sister journal, Arch Intern Med (p.433). That paper is well worth reading as a defence of the idea of tiered health care – though I remain appalled.

Here the first paper in JAMA (p.1063) shows that the current pattern of tiered health care in the USA ensures worse outcomes following myocardial infarction according to the ability to pay for drugs and services.

For chronic conditions too, outcomes vary according to the level of insurance (p.1073).

Whole sections of society – above all undocumented immigrants – have no official medical cover but do receive Emergency Medicaid (p.1085)

The answer must come from better physician leadership, according to an interesting and idealistic article by two non-physicians (p.1103).

Ah, if only. The present state of our own dear NHS offers the worst possible example. Physicians here are denigrated as self-interested, regarded as mere expensive pairs of hands, and disempowered by the ideology of the market (see Iona Heath’s Lancet editorial, p.866).