Dear FRONTLINE,

I enjoyed the program. It supplies a lot of information about other countries' health care systems that is difficult to access and interpret.

I hope you can produce a sequel that will help guide us through the process of deciding what we want, and implementing it. The political problems are three: 1) There are powerful interests who will oppose change for financial reasons, 2) Most Americans are insured to some extent, and are afraid of losing something they value, and 3) Most uninsured are not ill, and are too busy and too unempowered to participate in the debate.

Frank Turner
Eugene, OR

Dear FRONTLINE,

This show was an excellent commentary on the current health care crisis that exists in the U.S. By the end of the program, I would have gladly accepted any one of the health care systems in the several countries visited with my deepest gratitude. Having been without regular health care or health insurance for many years, I am now eligible for an employer based health insurance plan but find that I am too poor to afford either the deductible or the co-payments, but not poor enough to qualify for the State funded managed care program. I agree with the consensus that health care is a basic human need and that everyone should have the right to good health care. Access to the health care system should be equal for all regardless of income level or ability to pay.

At the age of fifty-eight years, I would welcome our Government's involvement in mandating that change take place in the Health Care Industry and in helping to restructure and direct that change. Any of the health care systems implemented by those countries examined in this program would be an enormous improvement. The sooner the better.

Katherine Reidy
Tulsa, Oklahoma

Dear FRONTLINE,

Dear FRONTLINE,I noticed that the family physician in Germany, who makes a fraction of the income compared to family physicians in the US, did not have to pay for medical school. I am a medical student who will graduate with nearly $130,000 in student loans, most of which are accruing interest at 6.5%. If the US works to reform the healthcare system in a way that reduces income for doctors, it is important to also address the cost of medical education. As a future doctor, I don't mind the idea of being paid less if it means that we have improved our healthcare system. However, the amount of debt that medical students acquire and must repay is daunting!

Brigitte Smith
Madison, WI

Dear FRONTLINE,

Three major forces were covered in the multinational study and in the Frontline story: physicians, health care systems and settings/hospitals and payment/access mechanisms.

However, once again, the enormous service and profession that was entirely ignored, overlooked and taken for granted is that of professional nursing. The almost three million registered (professional) nurses in the US provide about 95% of all reimbursed health care services, given the 24 hour 7 day a week nature of much of nursing care.

However, nursing is afforded zero reportage in traditional media. Nurse experts are not consulted on any health care stories. Nursing research is rarely cited in health care stories, and nurses languish in unacceptable practice settings by virtue of their status as employees instead of as autonomous professionals.

Nursing is charged via social contract and statute to serve as a patient safety advocate, and it is the presence of nurses educated at a baccalaureate level or above which significantly impact patient morbidity and mortality rates.

No discussion of health policy or health care systems should ever exclude professional nursing, the scope of practice of nurses and the critical relationship professional nursing has with the health of individuals, families, communities and societies.

Failure to include nursing in health care discussions leaves the public uninformed about issues which have direct affects on their health. For example, the nursing shortage affects all health care services across all settings and patient populations.

The dearth of nursing faculty is a direct result of horrid work conditions and abominably low salaries - not even on a par with the most novice two year technical graduate in a first clinical position.

Clinical nurses do not have the opportunity to interact routinely with nursing researchers and educators. There is no formal educational requirement for nurses past licensure other than state by state diluted continuing education modules. And there is no mechanism for standardized curriculum development and implementation for novice nurses to have guided and mentored clinical practice. Orientation and training to employer policies and procedures is not standardized and serves the employer to the detriment of the nurses' clinical education and practice development.

Add to that the fact the nursing service leaders are no such thing. They are nurses selected and hired by patient care employers. These nurses exhibit corporate loyalty over loyalty to the nursing profession, their nurse colleagues and to patients. Indeed, the nursing managers and executives broke away from the national professional organization - the American Nurses Association - and formed the American Organization of Nurse Executives as a subsidiary of the American Hospital Association, which has direct and competing interests with nurses.

Until nurses have full autonomy to practice as professionals with publicly acknowledged legitimacy and authority over their own practice, patients suffer - preventable errors, preventable harm and preventable deaths. Nurses traditionally travelled to where patients are: tenements, rural areas, reservations, ghettos, and other areas where all other helping professionals loathed to tread. But in the unregulated free market, when nurses attempt to practice in areas which are not under-served or unserved, suddenly the physicians come out swinging accusing nurses of threatening the health of patients - and no one questions that assumption, which is spurious and is not based on any legitimate evidence.

Back to this story, though. In the links and references, there is not a single nursing related resource.

May I suggest a few?

The American Nurses Association http://nursingworld.org/The Online Journal of Issues in Nursing - hosted by the ANA at http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN.aspxThe National Institute for Nursing Research http://www.ninr.nih.gov/The American Association of Colleges of Nursing http://www.aacn.nche.edu/

Newton, MA

Dear FRONTLINE,

I think the most important question asked during the program is whether Health Care is a universal right. I venture to guess the majority of Americans would answer yes to that question.

The only reason we don't have Universal Health Care is because we are suckered into debating minutiae that inevitably distracts from the over-riding goal of Universal Health Care.

I propose we exert our democratic powers and demand a National Referendum much like Switzerland has done. If we make it crystal clear to our politicians that the majority of Americans want Universal Health Care, I'll bet you they will find a way to make it work.

Damien Vu
Los Angeles, California

Dear FRONTLINE,

Overall, I think this was an excellent program, showing what we might be able to learn from other countries, what they have done well, and what they have not done well. One comment I found troubling, that I think a rational health care system should not endorse, is the notion of alternative medicine such as homeopathy being included in a national health care system. I don't think the program was endorsing this, but it did seem to leave open the idea that homeopathy is a legitimate form of medical care, when in fact the scientific basis for homeopathy has long been disproven, no scientific study has ever found a legitimate method by which it could work, and no study has ever proven that it does in fact produce results beyond what can be accounted for with the placebo effect. I think that whatever health care system we have in this country, we should not be paying for health care charlatans whose methods have no scientific basis.

Arthur Nielsen
Seattle, WA

Dear FRONTLINE,

T. R., We knew each other in Tokyo 15 years ago. My recollection of the Japan healthcare system is not as favorable as portrayed in your excellent program. Doctors over-prescribe medications because they sell the drugs to patients and make a lot of money doing that. If you are 'somebody' you get excellent care. If you are not you get hustled through. You are not permitted to question a doctor, quite often not allowed to get second opinions. My Japanese friends tell me it is still that way. More than once in recent years I have been asked by Japanese to arrange medical appointiments in the US for individuals who have serious illnesses (I now live in Seattle). Birth control is discouraged because doctors make money on abortions. And so on. But I do respect you as a man of integrity and one of the best reporters I know, and hope all our political leaders read your book and watch the program.

Bill Franklin
Seattle, WA

Dear FRONTLINE,

Great program. Two points:

The routine denial of insurance coverage in the US due to a 'pre-existing condition' is more than a mere inconvenience or cost burden. It's a serious disincentive to sensible preventative care. Recently, I went to my doctor for a routine cholesterol test. I was told my liver enzymes were elevated, a possible indication of NASH, or Non-Alcoholic Steatohepatitis. Further tests confirmed that I have Fatty Liver, which should moderate if I lose weight and improve my diet.

These results are now part of my medical record, and make me a slightly elevated statistical risk for liver disease later in life. My doctor isn't worried - as long as I bet healthier, the matter should clear up.

In Canada, this won't affect my insurance coverage in any way. But in the US, a patient who inadvertently tested for Fatty Liver and/or NASH could well have their insurance coverage cancelled for a range of liver and endocrine problems, including cirrhosis.

The only way to avoid the possibility of contracting a 'pre-existing condition' is to avoid periodic physicals and medical tests. This makes no sense at all.

In public single-payer health care systems, there is no such disincentive to preventative care.

H. Hughes
Vancouver, BC , Canada

Dear FRONTLINE,

Cry me a river for the complaining medical students. U.S. physicians are a major contributor to the exorbitant cost of U.S. healthcare. Not only do physician fees account for 20% of healthcare, but physicians control nearly the remaining 80% of the remaining costs.

This "poor me" saw of medical student debt is a frequent refrain. A March 11, 2008 article in The Chronicle of Higher Education noted that the American Association of Medical Colleges and the American Medical Association had written a joint letter asking Congress to reverse the Department of Education's decision to end a program that has allowed new physician graduates to lower student loans and defer interest on their student-loan payments.

The article states that "in 2007 the average medical student graduated with $140,000 in debt, and the average first-year resident earned less than $45,000. Eliminating the provision, the letter warns, could discourage students from pursuing less-lucrative careers in medical education, research, public health, or primary medicine."

Give me a break. I borrowed $100,000 to earn a doctorate in healthcare administration (DBA-Healthcare) in September 2007 at the age of 57. I teach at a small college in Virginia, with four international campuses, where I earn $50,000 in base salary. I'd like to believe that what I am doing is working with the future healthcare leaders in the U.S. and around the world.

And I am not alone. There are many occupations where students have assumed substantial debt to earn terminal degrees. I personally cannot support carte blanche treatment of physicians who have been and continue to be bulwarks against universal healthcare in the U.S.

Let's replace the Neanderthal notion that physicians are "entitled" with one where physicians join equally skilled and indebted graduates who direct their time and talent to service to America.

Arlington, VA

Dear FRONTLINE,

Tom Reid has done a wonderful job of explaining health care systems in a way that the average viewer (non health care professional) can understand. What I think is most difficult to get across to the American public, is that due to the way we finance health care, what is delivered is often designed to meet the needs of the provider rather than the patient. Moreover, because we have relegated our health care to a market free for all, it has served to justify the class based bigotry that is now spreading to other institutions of American life. The resistance in our country to facing this situation, has fed a kind of cultural hubris, that has put us all at risk... For instance, we have public funding of policemen and firemen. Do we consider the NYPD to be socialized policemen? I also think we have rejected the notion of social goals, and as such are resistant to seeing our well being as part of a larger context. These are cultural values, that inhibit real healthcare reform. What brought national health care to Britain, was a war on their soil - a publicly observable, shared catastrophe. Let's hope we don't have to wait for that here...

Carole Bahou
New York, New York

Dear FRONTLINE,

When I lived on the West Bank (1991-2000), health care was available to all, without so much as a shekel if you didn't have the money. I sometimes wonder about this paradox. In the U.S. I can't get basic health insurance because it would cost me over $400/month (I'm over 60 and couldn't afford that), but in the West Bank I can walk into any clinic along with others and be seen and helped within a couple of hours, no questions asked.

Elaine Kelley
Portland, OR

Dear FRONTLINE,

Hello, first of all a very interesting program and many interesting comments to read. I would just like the comment on the issue of malpractice in other countries since I see a lot of Americans ask about this.

Here in Norway, and I believe it is the same in many other northern European countries you don't sue the doctor, nurse or surgeon directly for malpractice. You apply to what we call "Pasientskadenemda" which translates to something like "patient injury institute". Basically it is a government organ which pays you money if you were subject to malpractice. They will review if you are entitled or not. Usually it is standard procedure. It is obvious that you should be compensated. If it is not and you are denied payment you can sue them in court.

So basically physicians, nurses, surgeons etc are not sued personally in Norway. That doesn't mean there is no risk to them of course. They can be fired for negligence or have their license revoked.

Whether they can actually be sued in court or not personally I am not sure. It is simply not custom to do there. It is easier to simply apply for money from government. Since they provide the health care they are also essentially responsible for its outcome too.

As a side note I read that in Germany you don't sue the surgeon at a hospital for malpractice. You sue the hospital itself. Responsibility lies at the organizational level not the individual level.

Oslo, Norway

Dear FRONTLINE,

I think this show provided a good starting point for discussions on how to improve healthcare in the U.S. Some thoughts:

Employer based health care is a dinosaur in our present day economy. The average job lasts less than 5 years. Who can afford to pay premiums for personal plan or COBRA if there is a gap in employment? This actually discourages many possible entrepreneurs from taking risks to start their own business.

Why do people complain about taxes going up to pay for universal care? The average family insurance plan costs over $1000/mo. and doesn't cover all healthcare costs. It is also increasing nearly 10% per year. That equates to a 24% tax per year for a family making $50,000 per year and it doesn't include out of pocket expenses. The only way employers can reduce insurance costs passed on to employees is to provide cuts in coverage, which just means higher out of pocket costs for them.

Regarding malpractice costs, would a universal plan not include some type of cap on these costs for doctors. I believe that that is a sacrifice that would have to be made by patients to have universal care. Since the patient wouldn't be facing possible huge medical bills in the future, there would be no need to sue for future medical costs, thus reducing the need for malpractice.

Due to the dire need for doctors to care for our aging population, there should be free or greatly tuition for those that work in the system. They would have to accept lower salaries in return. More emphasis could be placed on educating and recruiting nurses, nurse practitioners and general practice physicians that can handle the bulk of health issues faced by patients.

The medical smart cards just make sense. With our aging population, we need a way to ensure that doctors don't have to rely on the memory of the patient for all meds taken and past health history. Also, the overhead costs saved from using a card and card reader versus massive file rooms and file clerks would be substantial. It would not take a huge education process to get the patients to use the cards and produce the cost savings. Most of us are used to using a card at the grocery store to get decent prices on food, why would it be so hard to do the same at the doctor's office.

J K
Knoxville, TN

Dear FRONTLINE,

Mr Reid,That was a fascinating, well done documentary. I appreciate the diverse backgrounds of the people you interviewed, and your choice of current healthcare systems to include. My hope for you (America as well)is that your poingnant prayer will be anwered after the next U.S. election.

I am an advanced-practice nurse in Denver currently working with Hospice/Palliative Care. I would be very interested to see a similar type story of how different countries view healthcare at the End of Life, and what are priorities in funding of the various systems throughout the world?

I also have one comment for the 1st year medical student from Baltimore. My AP nursing education cost me (and my colleagues) almost as much as you describe paying for medical school. Would you please find another shoulder to cry on, people do not enter the healthcare industry purely for financial gain. I am not advocating for MD's to be in debt, and surely they deserve a handsome salary-many hardworking americans would agree that a starting $80k/year is indeed "handsome". My exact sentiment goes to Hospital administrators and Insurance company executives, whom reportedly earn (on average) over $500k/year.

Denver, CO

Dear FRONTLINE,

I really enjoyed this program and I found it very informative on many things but as a nurse and part of the health care system I wonder what the effects are on nurses and other health care employees in these other countries. I am all for health care for everyone and I do think the US has some serious issues to be dealt with but I wish there was more information on other aspects of health care presented in this program. I also wish, as others have said, that there was more information on the treatments involved with long term health needs. Overall it was very interesting and topical but perhaps a second program answering more of these questions should be considered.

Portland, Maine