How do other nations run a health system?

27/09/2009
By Andrea Berggren
Special to The Denver Post

With the ongoing health care reform debate going full bore in recent weeks, it seems obvious that many people, while wishing for a better system, are also nervous about changing the current one. Perhaps these people see no need for an overhaul of the system. A more likely scenario, however, is that the average American isn't aware of the United States' place in the world in terms of health care.

Enter T.R. Reid's "The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care," which manages to present a dizzying array of pertinent facts and figures while also tempering the coldness of those numbers with personal experiences and thoughtful insights.

Reid wastes no time in the prologue, titled "A Moral Question," where he reports that all of the seven countries he researched for the book "concluded that everybody has a right to health care" while pointing out that these same countries, comparable to the U.S. financially, enjoy better national health statistics and also spend "far less" on health care than does the American system.

The statistics are sobering. Reid's extensively footnoted facts include that the U.S. has the highest infant mortality rate in the industrialized world (6.8 infant deaths per 1,000 births); that 700,000 Americans go bankrupt every year because of medical bills; and that the U.S., with more than 45 million uninsured at any given time, ranks high in the list of wealthy countries whose citizens must pay out-of-pocket to receive medical care. (Impoverished countries such as Cambodia and India are at the top of the list, with 91 percent and 85 percent, respectively).

Reid, a former correspondent for The Washington Post and former chief of its London and Tokyo bureaus, has done his homework plus extra credit during his travels for this book, visiting France, Germany, Japan, Britain, Canada, Taiwan and Switzerland and investigating their health care systems from the inside out.

His basic premise seems to be that no social changes can be made to an existing society without borrowing ideas from others. "The Healing of America" is dedicated to former President Dwight D. Eisenhower, who, as Reid points out, created the vast American highway system by imitating Nazi Germany's Autobahn.

In the book's second chapter, Reid provides an industry tutorial on the four prevalent models of health care in use around the world — the Bismarck Model, the Beveridge Model, the National Health Insurance Model and the Out-of-Pocket Model — and explains origins of each model while matching them with a current working system.

Only the United States seems to provide either none, or all four, of the models to its citizens, and Reid makes it clear that this isn't working so well. "All of the other countries have settled on one model for everybody, on the theory that this is simpler, cheaper and fairer," he writes. "With its fragmented array of providers and payers and overlapping systems, the U.S. health care system doesn't fit any of the recognized models."

What is perhaps most striking about this book is not simply that Reid comes to the debate prepared with numbers, but that he has tried each system personally, taking his "bum shoulder" first to his general practitioner in the U.S. and then to specialists, family doctors and even spiritual healers in India to suss out the pros and cons of each system.

From a full shoulder-replacement operation recommendation in the U.S. (cost unknown, dependant on which insurance plan he has) to discussions of similar and alternative therapies in France, to the realization that non-acute cases in Canada can be made to wait as long as 18 months for surgery, Reid spares no details.

Some countries don't come off as well as one might expect, such as Britain, which apparently holds to a gatekeeper policy. Reid attempted to request from his London doctor the full shoulder-replacement surgery and was told that as he has no chronic pain, the doctor could not refer him to a specialist and that a specialist would be turned down for such an operation as the government would not find it medically necessary.

This is similar to the HMOs in the U.S., which act as gatekeepers for coverage. The difference is that if one had the money to pay out-of-pocket in the U.S., one could get the surgery. The moral question Reid raises is: Is that a fair system? Should the rich enjoy the best health care while the poor go without any?

Americans seem divided on this issue. Unlike Switzerland or Taiwan, both of which switched to universal health care within the past two decades, and both of which had trouble persuading their populations to make a switch, the crux of the problem in the U.S. seems to be that Americans are still unsure that health care is a right: "In the rest of the world, this is considered unbelievably cruel," Reid writes. " 'Excuse me, Mr. Reid, but I don't understand your approach to health care,' a junior minister in Sweden's health department said to me. 'It seems to me that your country takes away the insurance when people most need it.' "

Reid assumes a friendly tone as he dispels the notion that a universal health care plan would be engaging in "socialism" by pointing out two basic flaws in that argument. "Many foreign countries provide universal health care of high quality, at reasonable cost using private doctors, private hospitals and private insurance plans," he writes. He also points out that both the Veterans Administration and Medicare enjoy enormous popularity among Americans.

Reid believes that the U.S. is opposed to any foreign health care system concepts because it is considered unpatriotic.

"The real patriot," argues Reid, "the person who genuinely loves his country, or college or company, is the person who recognizes its problems and tries to fix them."

Andrea Berggren is a Denver-based freelance writer and former Denver Post staffer.