Wednesday, September 16, 2009

The Healing of America

In honor of the constructive and collegial discussion of health-care reform going on in our nation's capital, I've just finished reading Washington Post correspondent T.R. Reid's new book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. I first heard about it in a great interview on NPR's Fresh Air.

This highly readable book illustrates with brutal clarity how out of step the U.S. is with other advanced nations. At the same time, Reid shows that we have several proven ways to simultaneously improve the accessibility of health care and reduce its cost--if we are willing to look outside our borders for guidance.

Reid divides the world's health systems into four types, noting that different groups in the U.S. already experience each one:

  • The systems that most resemble the widely reviled "socialized medicine" follow the "Beveridge model" of the National Health Service in the U.K.: the government runs both delivery and payment. The Veteran's Administration in the U.S. is similar.
  • In Canada, a government-run single payer (actually one for each province) pays private practitioners. The U.S. Medicare system follows this model.
  • The "Bismarck model" used in Germany and many other European countries, as well as Japan, requires everyone to get insurance from mostly private providers, generally with partial payment from employers, and most providers are also private. This is similar to the coverage many employed U.S. citizens get, but the insurers are non-profit and are required to take everyone and the fees for treatment are generally negotiated at the national level.
  • The "out-of-pocket" model is common in developing countries, where people get whatever care they can afford--and many get nothing. Millions of Americans get the same treatment.

Reid doesn't dismiss the downsides to the different approaches-- restricted options in the U.K, long waits for elective procedures in Canada, and merely middle-class pay for doctors in most countries. But at the same time, he notes that patients in these other countries are often completely free to choose their doctors--in contrast with the restrictive insurance-company networks in this country. And all of these countries have significantly lower costs, often half of per-capita costs in the U.S, partly because they spend much less on paperwork.

All the rich countries of the world have opted for universal coverage--except the U.S. For Reid, this moral question should be addressed first: "is access to health care is a basic right?" Or is it acceptable that tens of thousands of Americans die each year for lack of insurance? He thinks that trying to sell reform on cost alone, as the Clintons did in 1994, is misguided.

Nonetheless, Reid clearly expects that bringing everyone into a single plan will provide the joint sense of purpose and the negotiating leverage to reduce costs. Like waiting in line at the grocery store, it's a lot easier to accept limits if everyone is treated equally. Currently, even though the U.S. spends more than anyone on health care, it falls far short on measures such as life expectancy or infant mortality. We're not getting what we pay for.

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