Book Review
Positive Perspectives
Two new books look at health care reform—one through an historic lens and the other through an international one.
Review by Charles R. Meyer, M.D.
Editor’s note: This is part of an ongoing series of articles on national health care reform.
Since President Barack Obama propelled health care reform into the national spotlight earlier this year, the machinery of American democracy has been grinding and clanging, attempting to construct a workable fix to a problem that threatens to break an already shaky economy. Buffeted by rhetorical vituperation and incessant politicking, the engine seems in danger of sputtering before the trip is completed. Solutions no sooner get proposed than critiques—reasonable and ridiculous—assault them, sending congressmen and senators scrambling for new ideas. Although not curative prescriptions, two recent books offer intriguing perspectives on American health care—one historical, one international—that might guide the next steps.
The themes of the 2009 health care brouhaha sound altogether familiar when reading David Blumenthal and James Morone’s study of the role of presidents from Franklin Delano Roosevelt to George W. Bush in promoting health care reform—health care being called a “crisis” during almost every president’s tenure, allegations that government involvement is “socialized medicine,” resistance by organized medicine and the insurance industry to many of the proposed changes, presidents deciding whether to use cloak-room persuasion or a national sales pitch to promote their ideas, and the American people sounding ambivalent and ambiguous about what they want from their health care system and what they are willing to pay for. What is not expected in The Heart of Power’s presidential history is that since Lyndon Johnson bullied Medicare and Medicaid through Congress in 1965 most major modifications of our health care system, including some overtly “liberal” proposals, have occurred during Republican administrations. Richard Nixon proposed a national health insurance plan that failed to pass Congress but became the basis for future Democratic offerings. Ronald Reagan signed a catastrophic health plan act that was repealed a few years later during his successor’s tenure. And George W. Bush presided over the single largest expansion of Medicare with the $400 billion Medicare Modernization Act that added prescription drug coverage as a benefit.
Blumenthal and Morone have advice for future presidents with plans for health care reform. Drawing heavily from LBJ’s success in passing Medicare legislation, the authors conclude that speed is essential, that presidents should concentrate on creating political momentum rather than the details of a specific bill, and that “presidents must be deeply committed to large changes such as health care reform.”
Looking for ideas for such large changes in the U.S. health care system and nursing a chronically sore shoulder, Washington Post journalist T.R. Reid traveled to seven countries to see how his medical problem would be handled in different medical systems and gained an understanding of how medical care is delivered and paid for in those countries. His global doctor shopping found three general models of health care delivery. In the Bismarck model found in Germany, Japan, and France, health care providers and payers are private entities, with health insurance plans financed by employers and employees and with government stepping in to help those without an employer. In the Beveridge model, found in Britain, Italy, Spain, and most of Scandinavia and named after the godfather of Britain’s National Health Service, health care is provided and financed by the government through tax payments. Medical treatment is a “public service, like the fire department or the public library.” In the national health insurance model epitomized by Canada, health care providers are private and paid through a single-payer, government-run insurance program funded by taxes.
Reid is blunt about the deficiencies he sees in the American health care system—700,000 people declaring bankruptcy yearly because of medical bills, the United States ranking 19th out of 19 developed countries in deaths before age 75 from conditions that could have been helped with effective medical care, U.S. life expectancy at age 60 being last among 23 countries, U.S. insurance companies denying 30 percent of all claims. But he doesn’t enthusiastically embrace any one of the medical systems he sampled. Instead, he attempts to dispel five myths about health care in other countries that circulate in the United States: that “it’s all socialized medicine out there,” that all other countries ration care with waiting lists, that foreign health care systems are wasteful bureaucracies, that health insurance companies have to be cruel, and that foreign health care structures would be “foreign” to American culture. The lessons Reid learned from other countries were that universal coverage is essential and that, at a minimum, the United States needs to untangle the rat’s nest that we call a “system”: “Any proposal for ‘reform’ that continues to rely on our fragmented structure of overlapping and often conflicting payment systems for different subsets of the population will not reduce the cost or the complexity of American health care.”
No system is perfect and most countries discussed in Healing feature trade-offs that many U.S. physicians would bridle at. Most systems that Reid studied regulate insurance companies, doctors, and hospitals more than the United States does. Some, like Canada, control costs through waiting lists for elective procedures. (In Canada, Reid would have had to wait one year for shoulder surgery that he could have had in a week in the United States.) And doctors in most countries make less money on average than in the United States (although, ironically, the most entrepreneurial physicians Reid encountered were in that den of socialism, Britain).
The health care sturm und drang rumbling across this country is not likely to quiet down soon. If legislation ever emerges from Washington, all of us will need perspective to understand and judge it. The Heart of Power and Healing of America help provide that. MM
Charles Meyer is a practicing internist and editor in chief of Minnesota Medicine.