T.R. Reid is a veteran foreign correspondent for The Washington Post, a commentator for National Public Radio and the author of nine books, including three in Japanese. He is currently working on his 10th book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, to be published by Penguin Press in the summer of 2009.
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- Health Care Systems -- The Four Basic Models
An excerpt from Reid's upcoming book on health care around the world.
- Related Video
- India: A Second Opinion
On assignment for FRONTLINE/World, Reid travels to India to see whether the ancient medicine called Ayurveda can help his ailing shoulder.
How did you choose the five countries featured in this report?
Two of our choices, Britain and Japan, were pretty obvious. I had lived in both countries, I had doctors there and knew the systems. I could speak the language, sort of, in both places.
Beyond that, we were looking for examples of each of the established models of health care systems. The U.K. uses the Beveridge model; Taiwan has chosen the Canadian-style National Health Insurance [NHI] model; Germany, Japan and Switzerland use the Bismarck model. We went to three Bismarck countries on the theory that these private-sector systems are more relevant to America than a British-style National Health Service.
I got interested in Taiwan because Taiwan's Health Ministry did what our film does; it traveled the world studying health care systems. In the end, Taiwan chose the Canadian model. We went to Switzerland because it is a ferociously free-market economy with politically powerful insurance and drug companies. But still, the Swiss managed to revamp their system, making it cheaper and fairer. We thought that might inspire Americans to believe that change is possible here, too.
You and your family lived in London and Tokyo; what was your experience with the health care systems there?
Our American family used the health care systems in Japan and Britain with considerable satisfaction. Fortunately, we never had a heart attack or cancer, but for the normal family medical problems -- flu, measles, broken bones, earache, etc. -- we got excellent care, with little or no waiting. During a trip to South Asia, I contracted a mysterious tropical disease that left me sick as a dog. When I got back to London, our family doctor diagnosed the problem precisely and found a fast cure.
In Japan, the prices were low; in Britain, there was no price at all. There was no bill! I loved that part of British health care.
In Japan my local government, Shibuya-ku -- it's a part of Tokyo -- sent me a card every year on my birthday, urging me to get a comprehensive physical. I could go to any doctor or hospital in Shibuya, and the whole thing was free. When I did it, they checked everything -- and I mean everything -- that a man my age might have to worry about. This was a terrific example of preventive medicine.
In your upcoming book about health care you write about the five countries in this FRONTLINE report, as well as a few others. What are some of the good ideas America could learn from other countries?
As we say in the film, the World Health Organization studied every health care system on earth and rated the world's richest country 37th in terms of quality and fairness. The top ranking in that survey went to France, so I went there to see what they are doing right.
The French private insurance system covers all 61 million residents of France, with excellent health results. There's no "in-network" or "pre-authorization"; you can pick any doctor or hospital in France, and insurance has to pay the bill. Doctors are required to post their prices on the wall of the waiting room, so the mystery of American-style medical billing is removed.
Everyone in France has a green plastic card, the carte d'assurance maladie. That card has completely replaced paper billing and medical records. The result: administrative costs of 3 percent, compared to 25 percent in the U.S.
While France has achieved 100 percent digital record keeping, the U.S. is years behind on this technology. President Bush has made it a national goal to have 50 percent of American health records in digital form by the year 2014. Who would have thought that France would clean our clock when it comes to high-tech innovation?
The Austrians, who seem to do everything with a clockwork precision, have a precise, modern health care system that is a model of careful organization and cost control. But I think Austria may be too small and not diverse enough to be a model for the U.S.
Canada's system is also pretty good. It has some notorious problems, including waiting lists, but I was impressed by Canada's relentlessly egalitarian approach to health care.
Yes, Canada is one country in particular that many Americans think about when they think of health care. Can you talk a bit about their system: how it's paid for, what works well, what needs fixing, and what we Americans get right and wrong when we talk about it.
Canada uses a National Health Insurance model; that means private providers but public financing. Everybody pays a premium to a single health insurer, run by the government. The Canadians call their system "Medicare," and in fact our system of Medicare for the elderly is a good example of the Canadian-style National Health Insurance model.
Canada's system started in a single province, Saskatchewan. The other provinces saw that it was working, and people demanded that it be expanded to the whole country. This suggests that if one American state set up a sort of Medicare-for-all system and it worked, then other states might demand the same kind of plan, and eventually we'd get a national system.
As we said in the film, the Taiwanese hired a professor at Harvard to study health care systems around the world and choose a model for Taiwan. In the end, they picked the Canadian model, on the grounds that it is cheaper and fairer than the for-profit insurance system used in the U.S.
Canada is fairly stingy in paying for health care; it spends about half of what we do, on a per capita basis. This leads to scrimping. That's why Canadians often have to wait to see a specialist or have elective surgery. Some Canadians respond by crossing the border to buy treatment in the U.S. But most Canadians accept the delays, because they are roughly equal for everybody. A scholar there put it this way: "Canadians don't mind waiting lines, as long as the rich Canadian and the poor Canadian have to wait about the same amount of time."
There was another recent documentary about health care around the world: Michael Moore's Sicko. Did you have that film in mind when you set out to make this report?
I thought Michael Moore did a good job in describing the shortcomings of the U.S. system. He didn't pay much attention to our strengths: the best medical education in the world, the most innovative research, the best equipped hospitals. He is an advocate and had a point to make.
But Sicko was disappointing when Moore went overseas. He seemed to feel that all foreign health care systems are the same, that they are all "socialized" and that they all work great for low cost. I'd say that's simplistic and wrong. We set out to take a more careful look at the different models in different countries. We saw their problems as well as their successes.
All five of these countries have achieved universal coverage for their citizens, but all five are grappling with rising costs as well. Is this simply a worldwide problem, or is there a fundamental difference between America's rising health care costs and those in other countries? Which countries may be better able to keep a lid on them, and why?
Health care costs are rising everywhere, largely because health care is getting better. Doctors routinely save lives now that would have been lost a decade ago. A lot of this is due to new technology, and new technologies cost money. We shouldn't complain about this. It's hard to imagine anything more worth our money than good health and longer, happier lives. But this is the reason all the countries we visited are struggling with rising costs for health care.
In countries where there is a single health care system -- and thus a single pool of money to pay for it -- it is somewhat easier to control costs. Britain's NHS often decides, for example, that it won't pay for kidney dialysis for a 90-year-old. That means somebody's grandmother will die, but at least Grandma and her relatives know that the money saved is going to be used to help some sick baby or some accident victim.
Limits like that are harder to impose in the U.S. because the money saved here doesn't necessarily help another sick person. If Aetna or United Health declines to pay for somebody's dialysis, the money saved is likely used for dividends to the stockholders or bonuses for the executives. That's a little harder to swallow for the relatives of the sick patient.
It was interesting to learn in the report that some of Switzerland's drug companies make one-third of their profits in the U.S. market. Are we subsidizing these other nations' prescription drugs, and what would happen if America clamps down on prices?
Yes, we subsidize the whole world. Americans pay more for pills than people in any other country. Sometimes, the same tablet made in the same factory costs $1 in the U.S. and 20 cents in Britain. If we could negotiate lower prices in the U.S., the drug companies would then try to raise prices overseas to make up for the lost revenues.
The pharmaceutical industry spends billions on research. Drug companies say they would have to reduce R&D if Americans paid less for their drugs, but the companies spend more on marketing than they do on research. In Switzerland, when the government started negotiating lower prices for drugs, the companies cut their marketing budgets and maintained the level of R&D.
For the first time since 1992, health care is, according to a Kaiser Foundation poll, a top-three concern for voters, after the economy and Iraq. Do you think that reform is going to happen this time?
Yes. I am confident that we're going to do it. I think Americans are ready for fundamental change, for two reasons.
First, our system is so expensive and inefficient that we can't afford it anymore. It's a big competitive disadvantage for U.S. industry. Second, Americans are too decent and too generous to accept a system that leaves tens of millions of our fellow citizens without access to health care. [According to the Institute of Medicine,] about 18,000 Americans die each year because they can't get the medical treatment that would save their lives. That's morally unacceptable.
So I think both the fiscal and the moral imperative will drive us to major change in 2009.
You note at the end of the report that none of the 2008 presidential candidates' plans really encompass the ideas you found abroad. Do you think there's a distinctly American approach that can solve the problems in our system?
To me, the candidates all seem to be tinkering at the margins of a system that needs fundamental change.
What we've learned overseas is that successful national systems have settled on one model -- be it Beveridge, Bismarck or NHI -- for everybody. This is fairer, cheaper and far more efficient than our badly fragmented crazy-quilt system.
I don't think the systems we see in our film are un-American. The British system -- the Beveridge model -- is the same system used by the U.S. Veterans Administration. If this is un-American, why do we use it for America's military heroes? And the Canadian system -- the National Health Insurance model -- is the model for Medicare. If it were un-American, would we use it for 36 million elderly Americans?
This is not the first project you've done that looked at how other nations address social issues differently -- and often with better results -- than the United States. Has this approach drawn criticism that you're being too hard on America?
Anybody who dares say that other countries do anything better than America is liable to be called unpatriotic.
I wrote a book, Confucius Lives Next Door, pointing out that East Asian countries in the Confucian cultural sphere have much lower crime rates than the U.S., more stable families, almost no single mothers. And when I went on talk radio to promote this book, the hosts would say, "You hate America," or, "Well, if Asia is so much better, why don't you just move there?"
In fact, facing up to your country's problems and trying to fix them is a sign of love for your country. The person who really cares about his college, his company or his country is the person who recognizes its shortcomings and tries to improve things. And one excellent way to do that is to study how other colleges, companies and countries have dealt with the same problem.
There are many cherished elements of American life that we copied from other countries: the Interstate Highway System (Germany), text messages (Finland), sushi (Japan), and American Idol (Britain). So it can't be unpatriotic to suggest that we could cure our ailing health care system by borrowing ideas from overseas.
This report is about health care, but it's also a travelogue of sorts. What was the most memorable moment from your travels in making this report?
I heard Big Ben toll the hours; I rode the bullet train past Mount Fuji; I ate leberwurst mit sauerkraut in Berlin; I flew a fighting kite on a beach in Taiwan; I strolled the breezy shore of Lac Léman with the president of Switzerland. All in all, a lovely trip.
For me, the best moment came at a new hospital in the fishing village of Jinshan, on the east coast of Taiwan. We went there with Professor Bill Hsiao of Harvard, the guy who designed Taiwan's new health care system. In the hospital lobby, we met a woman, Mrs. Lee. She told me that her mother got breast cancer in the 1980s, when Taiwan had no [national] health care system and Jinshan had no hospital. Her mother died. In the late 1990s, the daughter, Mrs. Lee, also got breast cancer. By then, Jinshan had the new hospital and a health care system that gave Mrs. Lee treatment. She is now completely recovered.
I pointed out Professor Hsiao. I said, "Right over there is the guy who set up the health care system that treated your cancer." So Mrs. Lee walked shyly over to Bill Hsiao; she gave him just a tiny, almost imperceptible bow. I thought it was a moving way for someone to say, "Thank you for saving my life."
Finally, in this report and your earlier one for FRONTLINE/World, you've sought non-Western treatments for your sore shoulder. How's it feeling? Has anything helped?
Thank you for asking. Last November, FRONTLINE/World showed a film in which I went to India to see if the ancient medical technique called Ayurveda could help my bum shoulder. I spent a lot of that film on a hard wooden table, undressed, being massaged with warm oil.
Ever since, people have been coming up to me on the street. Some say, "How's your shoulder?" Some say, "I saw you naked."
None of the non-Western treatments completely cured my shoulder, but then Western medicine hasn't done so, either. Ayurveda was definitely helpful, though. It gave me more movement and much less pain.
By the way, in Sick Around the World [watch it online] I keep my clothes on at all times.