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PLOS BLOGS Speaking of Medicine and Health

Can we really fix US health care?

That’s the question that T.R. Reid, renowned correspondent for The Washington Post and a commentator for National Public Radio, set out to answer in his new book, called “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.”

Yesterday I heard Reid give a compelling talk at San Francisco’s Commonwealth Club.  The talk will eventually be broadcast on NPR, and televised on PBS, and I’ll add the links when they go live.

In researching his book, Reid visited industrialized countries worldwide, including France, Germany, Japan, and the UK, to see how their health systems compare with the American system (the US is the only developed nation on earth without universal health care).  He visited doctors, hospitals, and health ministries.  In a TV interview on ABC, Reid was described as a “Marco Polo” looking at health care around the world.

Reid said he set out on his global reporting journey to answer a simple question:

“How come the other advanced industrialized free market countries offer universal health care at half the cost?”

He then realized that in fact there were two other important questions that arguably have a moral theme: why do these countries offer universal care, and why doesn’t the US?

What he found, he said, was that different developed countries were able to offer universal health care through a variety of different models.

In his book, Reid writes that efforts to change the US health system “tend to be derailed by arguments about ‘big government’ or ‘free enterprise’ or ‘socialism’ – and the essential moral question gets lost in the shouting.”

“It’s not all socialized medicine in other countries,” he said during his talk. Many countries use private hospitals, private insurance companies, and private doctors.  Few countries have single payer systems.

Reid categorized health care systems into four different types, based on who pays for health care and who provides it.

The first, he said, is the British style “Beveridge” model, in which it is the government’s job to provide care, patients never get a bill from their doctor, and the government is both the provider and payer.  Taxes are high, he said, but in fact the taxes that people in Britain pay are half of what US citizens pay for their annual health insurance premiums.

The second, he said, is the German style “Bismarck” model, where universal health care is achieved through private insurance plans purchased through one’s employer (the cost of the premium is shared between employer and patient). Providers and payers are private entities but, unlike in the US, he said, health insurance companies in Germany must cover everyone and they don’t make a profit.

Third is a model that Reid calls the “national health insurance” model, as used in Canada, where the government is the payer and providers are private.

These first three models are all used to provide universal health care.

Finally, there’s the “out-of-pocket” model, used in about 140 countries in the developing world, where people only get care if they can pay for it.  “If your child is sick,” said Reid, “if you have money in your pocket, she gets treated and she lives.  If you don’t, she doesn’t.”

The US, said Reid, has all four models in its system.  For Native Americans, military, and military veterans, there’s a Beveridge model – these patients are treated through socialized, single-payer systems (such as the Veterans Administration system) by doctors who are government employees working in government-owned facilities.

If you’re over 65, you get care through a Canadian-type model, Medicare (with private providers and a public purchaser).

If you get your health care through employer-based insurance (as I do at PLoS), this is a Bismarck model.

Finally, the 45 million uninsured people in the US are forced to use an out-of-pocket model (“the same as in Afghanistan or Angola,” said Reid).  Tens of thousands of people in the US die every year because they are uninsured.

Reid commented that while the US has this mixed-model system, other industrialized nations decided to use just a single system.

When he traveled the world, Reid asked health ministers in nations with universal health care why they chose to have a single “one  size fits all” health system.  There were three answers.

First, using a single model means that administration is simpler and cheaper. The US, said Reid, spends 18-25% of health care costs on administration; the figure for France is 4%.

Second, using just one model means that these industrialized nations have an incentive to invest in preventive medicine,  since the ‘single-model health system’ is caring for patients from cradle to grave.  In contrast, in the US, most people stay with their health insurance company for an average of only 4.8 years (and insurance companies know that when their patients reach 65, the government will foot the bill for their care, so there is little incentive for these companies to provide preventive medicine).

Third, these countries “think it’s fairer if everyone has access to the same care at the same cost,” said Reid.  “Health care reflects a country’s moral values.”

Reid ended his talk by reflecting on these moral issues.  If a country doesn’t make a commitment to universal health care, as is the case in the US, he said, it means that there will be some people who can buy insurance and who will get great care, but tens of millions “don’t even get through the door” of the clinic or hospital.

“If we Americans could find the political will to cover everyone,” he said, “all the other countries could show us the way.”

During the post-talk Q and A, Reid said that there isn’t enough awareness in the US about the deaths caused by being uninsured.  “I think Americans are pretty generous and we care about our neighbors, but there’s a lack of awareness.”

Reid was asked for his thoughts on the current US health reform efforts, particularly the so-called “public option” (a government health insurance plan that would compete with private plans to keep costs down).

“No other country has a public option,” said Reid.  “They don’t need it.  They get there with regulation.”

In Germany, he said, regulations mean that insurance companies must insure every single person, these companies must pay all claims quickly, and patients can choose from between 200 companies offering plans.  In the US, said Reid, insurance companies are afraid of the public option (they are fighting to oppose it), but they have accepted that there will need to be some regulation to keep costs down.  However, they have not agreed to cap their administration costs nor to pay every claim.

While Reid said he thinks that a US health reform bill will pass this year, “the bill won’t get us to the standard of care we see in other countries.”  He urges major reforms, not incremental changes.

“It would be fairer to put everyone into a single system,” he said, and he would favor the US adopting a Canadian-type model.

“It takes a leader, a national commitment, to make a moral decision to cover everyone.”

Competing interests: I worked for 5 years as an NHS doctor in Britain and believe that a single payer Beveridge model provides the most equitable kind of health system.  I live in the US where I have employer-based health insurance, in which the premium is shared between me and my employer.  I’m a permanent resident of the US (not a US citizen), so while I cannot vote I am legally allowed to support and donate to political campaigns.  In the 2008 elections, I donated money to and volunteered for Obama’s presidential campaign, and donated to several congressional and senatorial candidates (all Democrats). I’m a member of Organizing for America, a community organizing project of the Democratic National Committee.

  1. I think single payer would be the way to go, wish Obama would ignore all the nut-jobs screaming socialism, comparing him to Hitler. Geesh! I think it’s apparent that neither our health industry nor our government are in it for our health, here. Not yet, anyway.

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