TOPICS > Health

What the U.S. Can Learn From Health Care Abroad

October 7, 2009 at 12:00 AM EDT
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Gwen Ifill speaks with health experts about what the United States can learn from health care systems throughout the world.

JIM LEHRER: And now, Gwen Ifill looks at how the U.S. health care system compares to the Netherlands and those of other countries.

GWEN IFILL: And for that, we talk to two people with different points of view: Cathy Schoen, the senior vice president of the Commonwealth Fund, which does research on health policy; and Scott Atlas, a senior fellow at the Hoover Institution at Stanford University. He’s also the chief of neuroradiology at Stanford University.

Welcome to you both.

SCOTT ATLAS, Hoover Institution: Thank you.

CATHY SCHOEN, The Commonwealth Fund: Hi.

GWEN IFILL: Cathy Schoen, based on what we just saw Ray Suarez tell us about just one country, the Netherlands, what about what we just saw there — and he also did this last night, as well, telling us how it works — what’s transferable to the way we do things here and the way we can reform our health care system here?

CATHY SCHOEN: Gwen, thank you for having me on the show. I think, as you look at the Netherlands and other countries, every country has developed systems that come out of their own history, their own culture, and they’re building on them.

But the kind of ideas that are shared in common is, first, everybody is insured, everyone’s in continuously in the Netherlands, and they’ve made that a top priority. And what we’ve just seen with some of the examples is they’ve also really worried about primary care, getting in quickly to see the doctor, having a long-term relationship with the doctor. People have very long-term relationships in the Netherlands.

And when we’ve done surveys, we are struck by how quickly they get in when they need same-day treatment, much more quickly than in the United States. And as we just heard, there’s no trouble getting care after hours. So this emphasis on primary care as well as integrated care is critical.

And it’s not just the Netherlands. We see multiple countries that have strong insurance systems with good primary care spending far less. We’re spending about twice as much as every other country. And our outcomes are often not better (inaudible) and in some times worse.

So we really can look at that insurance system as being a foundation for the way the physicians are paid to push on prevention, primary care, rapid access when people need it, and a more integrated care approach.

GWEN IFILL: Scott Atlas, is what we see in these countries transferable to our system here?

SCOTT ATLAS: Well, I think that you have to be careful what you want to glean from other countries’ systems. Obviously, the Netherlands or places like Switzerland, they’re very different from the United States, both culturally as well as the homogeneity of the population, for instance.

But I think we can learn some good lessons from even the piece you just showed, where emphasis on preventive care is a priority. I think access to things like the clinics for minor illnesses as opposed to going into a high-powered emergency room, these sorts of things can be extracted and prioritized in our system.

Advantages of U.S. health care

GWEN IFILL: What is not transferable, Doctor?

SCOTT ATLAS: Well, what's not transferable, I think, is the idea, for instance, that primary care, at the expense of specialty care, should be emphasized. We are in an era right now where medicine is far more complex than ever, where the most -- the biggest advances in medical treatment are highly dependent on having access to sub-specialists, highly dependent on having access to innovative, less-invasive diagnoses and treatments, highly dependent on access to the newest cancer-curing drugs, for instance.

And their list goes and on. And these are things that have been lost in the shuffle. The fact is, the United States excels at these things, and that is reflected in superior outcomes from many of the serious diseases that are our priority.

GWEN IFILL: Cathy Schoen, does the U.S. actually have superior outcomes when you compare it to countries with systems like these?

CATHY SCHOEN: Well, I think one of the things that is startling is that, if we're spending twice as much, we should expect to see ourselves as real leaders, and we don't always. Sometimes our rates rival other countries, and sometimes we're marginally above.

On cancer outcomes for breast cancer, there are other countries that are right about where we are, just a little bit less, but we have been a leader. But we've fallen behind on asthma, mortality from asthma. We're well behind on infant mortality. We're behind on diabetes.

And, in fact, a recent study that looked at potentially preventable deaths before age 75 from conditions like diabetes, asthma, the screenable cancers, lung disease in children, young children, found that we went from 15th out of 19 countries to 19th, not because we didn't get better, but because they improved faster than we did, with a real focus on early preventive care and, yes, ready access to specialists care when you need it in a much more coordinated way.

Achieving universal care

GWEN IFILL: Scott Atlas, is it desirable or even -- or attainable to be able to cover as many Americans as many of these countries cover their own citizens without, say, access to a public option or allowing government to regulate far more strenuously than it regulates the industry now?

SCOTT ATLAS: Oh, I think it's absolutely a very important priority to allow people to have access to health insurance. But the way to do that is the question.

I feel that the access to health insurance should be access to health insurance that American citizens actually want to buy, that they make a value-based decision, rather than have government impose mandates on what is their idea, government bureaucrat ideas, about what needs to be covered, or rather than punish people with either fines or taxes...

GWEN IFILL: But what I was asking about...

SCOTT ATLAS: ... to pay for health insurance that they don't want.

GWEN IFILL: Pardon me. What I was asking you about was a public option which will give people the choice or whether federal regulation of industries like the insurance industry or the medical industry is something that is a way to achieve these goals, these outcomes?

SCOTT ATLAS: Well, I think that the public option, it's been shown -- there are many studies in the literature, but also in our own state-based experiments, that there's this phenomenon where the public option actually reduces the choices that Americans have. It doesn't increase the choices for health insurance.

There's a phenomenon called crowd-out, where, in fact, there's almost as many people get insured as those that were uninsured as -- actually, from the pool of people that were privately insured. So all you do is you shift a huge percentage of people that had private insurance on to the government tax payroll, basically. They're on the burden.

The problem with having government options as the -- it becomes the dominant insurer. And once government is the dominant insurer, then you -- there's only one way the government can force down health care costs. And the fact is that there's only one way to force it down, and that is by restricting access. And so if you want to have...

GWEN IFILL: That's all right. I didn't want to interrupt you, but I did want Cathy Schoen to have a chance to respond to that.

Making insurance markets work

p>CATHY SCHOEN: Gwen, as we look at other countries, I think we can actually learn a lot about making insurance markets work in the public interest. There are very rich example in the Netherlands, Germany, and Switzerland. They've actually made a decision to have multiple competing private insurance plans, but they do it in a far different way than we do.

Everyone has to be included, as we heard, in the Netherlands. You can't turn anyone down. The price will not vary except by the benefit package, whether you're sick or not sick. And when you open an array of choices in these countries, it's easy to choose, because you don't have to worry about insurance surprises, where there's just not a benefit that you really need that will be covered. There's much more uniformity.

And it makes these markets work. When people move, they look very hard at the overhead of insurance carriers, which is much lower than the United States. We're, bar one, the most complex. The McKinsey institute estimates that we spend about $90 billion per year in excess overhead just because of the complexity.

So I think we can see other models that don't completely replace the insurance system we have, but build on it, and a lot of the reforms Congress is now looking at would start to have exchanges like we see in these countries where there's a lot of choice. There's a lot of choice, but they compete on quality and price, not on turning down sicker applicants.

GWEN IFILL: OK, Cathy Schoen of the Commonwealth Fund and Scott Atlas at Stanford, thank you both very much.

SCOTT ATLAS: OK. Thank you.

JIM LEHRER: On our Web site,, Washington Post correspondent T.R. Reid and Commonwealth Fund President Karen Davis will answer your questions about health care coverage in countries around the world. That's on our "Global Health Watch" page.