Unlike most western democracies, health insurance in the United States is provided by a haphazard mix of employer-based plans, Medicare for those over 65 or on social security disability or chronic renal failure, Medicaid under varying state-dependent rules for some low-income recipients and no insurance for tens of millions. Administrative costs, which include both the direct costs of the insurers and the indirect costs imposed on physicians and hospitals, make up nearly 25% of our bloated national health care expenditures.