The Isolationism of Health Reform

Why won’t Congress consider how other countries do it?

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The health care debate is, within mainstream political discourse, isolationism’s last refuge.

Every day Washington’s leaders tell us that we live in an interdependent world with a globalized economy. A butterfly beats its wings in Guangdong province, and four Wal-Marts materialize in Duluth. The peso plunges, and 30 Honda workers get laid off in Marysville. A coal-fired power plant belches carbon dioxide in Prague, and Lohachara Island sinks into the Bay of Bengal.

But change the subject to reform of the health care system, and the community of nations abruptly vanishes. No France, no Canada, no Germany, no Japan. Let there be no mention of any industrialized democracy save that of the United States, which is proud to claim 37th place in the World Health Organization’s rankings of the world’s health systems and 15th in the Commonwealth Fund’s ranking by avoidable mortality of 19 industrialized countries (the highest rank indicates the fewest such deaths). To achieve a better score would be unpatriotic!

The political establishment’s hubristic refusal to consider how other countries manage health care is encapsulated in the cliché “uniquely American,” which is what Sen. Max Baucus, D-Mont., the lead legislator on health care reform, says he wishes his bill to be. It therefore goes without saying that the finance committee Baucus chairs could find no place in this year’s exhaustive health care hearings for a single expert on how other countries achieve better health outcomes for their populations while typically spending, on a per capita basis, half what we do. When the finance committee releases its draft bill this week, it will be almost completely free of foreign influence.

Given this circumstance, I am sorry to report that T.R. Reid’s superb new book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, won’t hit bookstores until August, by which time the Obama White House and Congress hope to be finishing up their work on health reform. In the meantime, I would urge Penguin Press to sprinkle advance copies liberally throughout Congress, the White House, and the Health and Human Services department.

Ignore the title (which, apart from being Sunday-schoolish, was used 12 years ago by New Age spiritualist Marianne Williamson); a better one would be Sick Around the World, which is what Reid called the excellent Frontline documentary he hosted on this topic last year. Even better: Around the World With My Bum Shoulder. Engagingly, Reid frames his inquiry by seeking relief for his aching right shoulder, which he injured while serving in the Navy in 1972. A surgeon at Bethesda Naval Hospital fixed it by inserting a stainless-steel screw into his clavicle, but three decades later Reid could no longer swing a golf club and could only just barely replace a hanging light bulb. In a show of the same sunny resourcefulness he displayed as a foreign correspondent for the Washington Post, Reid uses his ailment as a vehicle to explore the world’s health systems.

Reid helpfully divides health care systems into four models:

Bismarck. As the name suggests, the Bismarck model is found in Germany—and also in Japan, France, Belgium, Austria, and, “to a degree,” in Latin America. Doctors, hospitals, and insurers are all private, and insurance is funded jointly by employers and employees, as it is in the United States. But the insurance companies are nonprofit, and coverage, fees, and medical services are all tightly regulated by the state.

Beveridge. Named for Lord William Beveridge, who with Aneurin Bevan created Britain’s National Health Service. Also found in Spain, Italy, Hong Kong, and much of Scandinavia. Instead of private insurers, the government pays all medical bills. Hospitals are typically owned by the government, and doctors are usually (though not always) salaried government employees.

National Health Insurance. A blend of Bismarck and Beveridge found in Canada, Taiwan, and South Korea. Hospitals and doctors are private, but the government pays.

Out-of-Pocket. The de facto system of the Third World. Since most of the population can’t afford health insurance, medical care is typically achieved through international charity or (most often) not at all.

Reid explains that for most working people in the United States, the health care model is a modified Bismarck in which insurance is for-profit and regulation is scattershot. Essentially, the United States has taken a workable foreign model and ruined it by rendering it “uniquely American.” Within the conservative subculture of the military (including veterans), the U.S. health care model is the highly pinko Beveridge. For everyone over 65, the model is National Health Insurance. (Medicare even got its name from Canada’s single-payer program.) For the 45 million Americans who have no health insurance, the model is Out-of-Pocket; for these unfortunate souls, Reid writes, the United States may as well be “Cambodia, or Burkina Faso, or rural India.”

As Reid drags his sore shoulder through France, Germany, Japan, the U.K., Canada, India, Taiwan, and Switzerland, two conclusions become inescapable. The first is that the health care systems of every one of these industrialized democracies have problems. The second is that (except for India’s) virtually all of these problems look trivial compared with the problems of the U.S. health care system. Most of the foreign medical professionals and politicians whom Reid interviews are well-aware of this and express horror at the mess the richest nation on earth has made of its health care system. Although no one comes out and says it, one senses that they wonder whether Americans place a lower value than they do on human life.

What sort of problems do these other countries suffer? In Switzerland, where there’s a feeling that costs are out of control, health care represents 11 percent of GNP, compared with 16 percent in the United States. Doctors in other industrialized democracies tend to grumble that they don’t make nearly enough money, and Reid suggests that in Japan they may have a point. In general, though, Reid finds that (outside of India) these foreign doctors manage to live well enough, especially when one considers how little they spend on malpractice insurance and how little debt they run up attending medical school. (In some places, medical education comes free of charge.) Whatever problems exist tend to fade quickly from memory when one considers that the populations in these industrial democracies typically live longer than we live in the United States and that medical catastrophe does not lead to the kind of financial ruin about which abortion-rights activist Kate Michelman wrote so harrowingly in the April 27 issue of The Nation. The only point I fault Reid for not mentioning is that cancer survival rates in the U.K. are comparatively low. Conservatives have tried to turn this into a broad condemnation of socialized medicine. But since survival rates for other industrialized European nations with what conservatives would consider socialized medicine tend to be comparable to those in the United States, the cancer-survival problem would seem to be U.K.-specific. Reid gets at this only indirectly when he puzzles over the U.K.’s unwillingness to provide prostate cancer screening to men over 50. (The U.K.’s long waits for elective surgery, another problem about which conservatives often complain, finally became a political liability for Prime Minister Tony Blair, who shortened them substantially, Reid reports.)

Whatever bill the Senate finance committee produces, it is all but certain that it will fall short of the international norm in two regards. It won’t get health care spending down anywhere near to what it is even in Switzerland, and it won’t provide the uninsured and the underinsured with anything close to the easy access to health care enjoyed in other industrialized countries. Reid tells me that Baucus last year brought him in to show his PBS documentary Sick Around the World to finance-committee members—in private. Afterward, Sen. Ken Salazar, D-Colo., who has since become interior secretary, noted that other countries saw a conflict between profits and health. How could the United States possibly persuade insurance companies to give up profits? Reid answered that Switzerland, home to many powerful insurance companies, had done it in 1994 when it adopted the Bismarck model. The insurers fought it tooth and nail, of course, but now they compete energetically to sign up people for basic care on a nonprofit basis because they constitute a customer base for supplemental insurance that they’re allowed to sell on a for-profit basis. This answer didn’t satisfy Baucus. “Perhaps you don’t know how much money [U.S. insurers] have,” he told Reid. (Judging from his campaign contributions—since 2005, Aetna alone has given him $45,250—Baucus knows all too well.)

Even PBS has a hard time pondering an America in which health insurers would work as nonprofits. In a follow-up documentary to Sick Around the World called Sick Around America, Karen Ignagni, the health insurers’ chief lobbyist, said that guaranteeing for-profit health insurance for all Americans would be just like what other countries did. Reid couldn’t let that stand without comment. The producers disagreed, and Reid ended up withdrawing from the project.

In 1994, the same year Switzerland embraced health reform (also the same year Hillary Clinton botched it), Taiwan decided its health system needed an overhaul. “People said, let’s do whatever the Americans do,” according to one member of the planning commission quoted in Reid’s book. After taking a closer look, though, this member says the commission decided:

American health care is not really a system at all. It’s a market. In a market, people with money can buy what they want and many people are left out. So we thought, no, we don’t want market-driven health care. We want a real system, something that covers everybody and doesn’t depend on how much money you have.

This is a rebuke to the United States in two respects. One, Taiwan couldn’t take seriously as a model for its own health system its strongest ally in the world, the country on whom it depends more than any other. Two, after rejecting the U.S. model, Taiwan did something the United States ought to be doing but isn’t. It carefully examined, in great detail, other health systems around the globe. (It ended up adopting the National Health Insurance, i.e., Canadian, model.) There may be no country on earth with a greater siege mentality than Taiwan—and for good reason. Nonetheless, Taiwan was able to peer over the parapet long enough to take note of how other countries managed their affairs and acted accordingly. Fortress America could learn a lesson or two from that.

And Reid’s shoulder? His U.S. doctors recommended extensive reconstruction, at likely cost of “serious pain, months of rehabilitation, and tens of thousands of dollars.” In the other countries, reconstruction was often offered as an option, but doctors told him he’d be much better off with steroid injections (Japan); physical therapy (France, where insurance will pay for a spa); acupuncture (Taiwan); a regimen of herbs, yoga, massage, and spiritual meditation (India); and merely learning to live with it (the U.K.). Reid opted not to get reconstruction, had some success with the steroids, and got no relief from acupuncture. The only treatment that led to “significant improvement,” oddly, was the folk medicine in India, for which he paid out of pocket. Reid does not make too much of this, and neither should you.