EDITOR—In Charatan's news piece on “boutique medicine” in the United States he sketched out a problem that is a symptom of a healthcare system in trouble.1 As a medical writer and observer of American health care, I would say that the problem is even more worrying than Charatan described. Now we have a system that is faltering not only for the uninsured and underinsured but for the fully insured too. I worry that this problem might go unrecognised unless research and advocacy embarrass Congress to intervene.

Recently, a fully insured friend of mine was referred for a cardiology consultation. When he arrived at the doctor's surgery for a stress test he was told that the practice no longer took his insurance. He had his examination, as one last favour from the doctor, who warned him …