Aug. 24, 2009 -- It's a topic that has dominated the headlines and President Obama's time for months now: health care in America.
While the president's plan has recently come under fire from Republicans and voters alike, author T.R. Reid took a tour of other countries to explore their answers to the health care conundrum and find out how the U.S. could learn from their shortcomings and successes.
By talking to experts, from government officials to doctors, Reid discovered inspiration in the ways some countries can give their people quality health care at an affordable cost.
Read an excerpt of "The Healing of America" below, and head to the "GMA" Library for more good reads.
A Quest for Two Cures
Mrs. Rama came sweeping into my hospital roomwith the haughty grandeur of a Brahmin empress, wearing a salmonpink sari and leading a retinue of assistants, interpreters, and equipmentbearers. It wasn't exactly medical equipment they were carrying, becauseMrs. Rama wasn't exactly a doctor. Still, her professional services wereconsidered an essential element of the medical regimen at India's famousArya Vaidya Chikitsalayam, the Mayo Clinic of traditional Indian medicine.
Indeed, Mrs. Rama's diagnostic work is covered by Indian medicalinsurance. As she set up her equipment—on a painted wooden board,she carefully arranged a collection of shells, rocks, and statuettes ofHindu gods—Mrs. Rama told me that she was connected to the clinic'sDepartment of Yajnopathy, an ancient Indian specialty that roughlyequates to astrology. Her medical role was to ascertain my place in thecosmos; in that way, she could determine whether the timing was propitiousfor me to be healed. Any fool could see, she explained in matter-of-fact tones, that it would be a mistake to proceed with medical treatment if the stars in heaven were aligned against me.
For all her majestic self-assurance, Mrs. Rama did not immediatelyinspire confidence in her patient. After asking some basic questions, sheshuffled the stones and statuettes around her checkerboard and launchedinto my diagnosis. "In the summer of 1986, you got married," shedeclared firmly. Well, not exactly. In the summer of 1986, my wife andI celebrated our fourteenth wedding anniversary; by then we had threekids, a dog, and a minivan. "In 1998," she went on, "you were far fromhome and were treated for serious illness." Well, not exactly. OurAmerican family was, in fact, living in London in 1998; but in thatwhole year, I never saw a doctor.
Mrs. Rama kept talking, but I stopped listening. To me, the stonesand shells and statues all seemed preposterous. Still, I kept my mouthshut. If Indian medicine required yajnopathic analysis before healthcare could begin (and Mrs. Rama did eventually conclude that thetiming was propitious for treatment), that was fine with me. I was willingto go along, in pursuit of the greater goal. For I had traveled to theArya Vaidya clinic—it's in the state of Tamil Nadu, at the southern tipof the subcontinent, where the Bay of Bengal meets the ArabianSea—on a kind of medical pilgrimage. I was on a global quest, searchingfor solutions to two different health problems, one personal andone of national dimensions.
On the personal level, I was hoping to find some relief for my ailingright shoulder, which I bashed badly decades ago as a seaman, secondclass, in the U.S. Navy. In 1972, a navy surgeon (literally) screwed thejoint back together, and that repair job worked fine for a while. Overtime, though, the stainless-steel screw in my clavicle loosened; myshoulder grew increasingly painful and hard to move. By the first decadeof the twenty-first century, I could no longer swing a golf club. Icould barely reach up to replace a lightbulb overhead or get the wineglassesfrom the top shelf. Yearning for surcease from sorrow, I tookthat bum shoulder to doctors and clinics—including Mrs. Rama'schikitsalayam—in countries around the world.
The quest began at home. I went to a brilliant American orthopedist,Dr. Donald Ferlic, a specialist who had skillfully repaired anotherbroken joint of mine a few years back. Dr. Ferlic proposed a surgicalintervention that reflects precisely the high-tech ethos of contemporaryAmerican medicine. This operation—it is known as a total shoulderarthroplasty, Procedure No. 080.81 on the National Center forHealth Statistics' roster of "clinical modifications"—would require theorthopedist to take a surgical saw, cut off the shoulder joint that Godgave me, and replace it with a man-made contraption of silicon andtitanium. This new arthroplastic joint would be hammered into myupper arm and then cemented to my clavicle. The doctor was confidentthat this would reduce my shoulder pain—orthopedic surgeonstend to be confident by nature—but I had serious reservations aboutProcedure No. 080.81. The saws and hammers and glue made theprocedure sound rather drastic. It would cost tens of thousands of dollars(like most major medical procedures in the United States, the exactprice was veiled in mystery). The best prognosis I could get was thatthe operation might or might not give me more shoulder movement.
And when I asked Dr. Ferlic what could go wrong in the course of atotal arthroplasty, he was completely honest. "Well, you have all therisks that go with major surgery," he answered calmly. And then helisted the risks: Disease. Paralysis. Death.
With that, a certain skepticism crept into my soul about this hightechmedical intervention. I departed my American surgeon's officeand took my aching shoulder to other doctors, doctors all over theglobe. Over the next year or so, I had my blood pressure and temperaturetaken in ten different languages. I ran into a world of differentdiagnostic techniques, ranging from Mrs. Rama and her star charts toa diligent, studious doctor (we'll meet him in chapter 9) who told mehe couldn't possibly analyze my medical condition without tastingmy urine. In Taipei, an acupuncturist twirled her needles in my leftknee to treat the pain in my right shoulder. The shoulder itself wasexamined, X-rayed, patted, poked, palpated, massaged, and manipulatedin countless ways. Some of these treatments worked, more or less; aswe'll see in chapter 9, Mrs. Rama's colleagues at the chikitsalayam werehelpful. Others proved no help at all.
This was not a major disappointment, though, because that achingshoulder was really just a secondary impetus for my medical odyssey.It would be ridiculous, after all, to go all the way to the southerntip of India—not to mention London, Paris, Berlin, Tokyo, and soon—to get treatment for a sore shoulder that isn't, frankly, all thatsore. The stiffness is tolerable most of the time. I have another arm touse for changing lightbulbs or getting glasses off the shelf. I don't havea golf swing anymore, but even when I could swing a club I was arotten golfer.
So the shoulder was not my top priority. Rather, the primary goalof my travels was to find a solution to a much bigger medical problem.It's a national problem—a national scandal, really—that is underminingthe physical and fiscal health of every American. With help from manyscholars and the Kaiser Family Foundation, I traveled the world searchingfor a prescription to fix our country's seriously ailing health caresystem. As Nikki White's experience demonstrates, it's fundamentallya moral problem: We've created a health care system that leaves millionsof our fellow citizens out in the cold. Beyond the issue of coverage,however, the United States also performs below other wealthy countriesin matters of cost, quality, and choice.
Most Americans can remember when our politicians used toboast—and we used to believe—that the United States had "the finesthealth care system in the world." Today, any U.S. politician who daredto make that claim—it was last heard in a State of the Union addressin 2002—would be hooted out of the room. Americans generally recognizenow that our nation's health care system has become excessivelyexpensive, ineffective, and unjust. Among the world's developed nations,the United States stands at or near the bottom in most importantrankings of access to and quality of medical care. In 2000, when aHarvard Medical School professor working at the World HealthOrganization developed a complicated formula to rate the quality andfairness of national health care systems around the world, the richestnation on earth ranked thirty-seventh. That placed us just behindDominica and Costa Rica, and just ahead of Slovenia and Cuba. Francecame in first.
The one area where the United States unquestionably leads theworld is in spending. Even countries with considerably older populationsthan ours, with more need for medical attention, spend much lessthan we do. Japan has the oldest population in the world, and theJapanese go to the doctor more than anybody—about fourteen office visits per year, compared with five for the average American. And yet Japan spends about $3,000 per person on health care each year; we burn through $7,000 per person.
Health Expenditure as a percentage of GDP, 2005
Sources: OECD Health at a Glance, 2007; Government of Taiwan.
There's nothing particularly wrong with spending a lot of moneyon something important, as long as you get a decent return for whatyou spend. It's certainly not wasteful to spend money for effective medicaltreatment. If a dentist who was about to drill a tooth offered herpatient a choice between listening to pleasant music for free to lessenthe pain, or a shot of Novocain for $50, most people would pay for theshot and would probably get their money's worth. And there's nothingwrong with paying more for better performance. Those fifty-two-inchhigh-definition plasma televisions that people hang on the family roomwall these days cost five times what a top-of-the-line set would havecost ten years ago, but buyers are willing to shell out the extra moneybecause the enhanced viewing quality is worth the price.
When it comes to medical care, though, Americans are shellingout the big bucks without getting what we pay for. As we'll see shortly,the quality of medical care that Americans buy is often inferior to thetreatment people get in other countries. And patients know it. Surveysshow that Americans who see a doctor tend to be less satisfied with theirtreatment than Britons, Italians, Germans, Canadians, or the Japanese—even though we pay the doctor much more than they do.
You don't need an advanced degree in yajnopathy to recognize thatthe stars are aligned and the timing is propitious for the United Statesto establish a new national health care system. As Americans votedin the 2008 election, only 18 percent told the pollsters that the U.S.health care system was working well. Even American doctors, whogenerally do just fine, thank you, in financial terms, are unhappy withthe ridiculously cumbersome and unjust system that has built uparound them. And those Americans who want change in our system—which is to say, almost all Americans—are not willing to settle forminor tinkering or small-scale adjustments. Rather, 79 percent told thepollsters they want to see either "fundamental changes" or "a completeoverhaul."
The thesis of this book is that we can bring about fundamentalchange by borrowing ideas from foreign models of health care. For me,that conclusion stems from personal experience. I've worked overseasfor years as a foreign correspondent; our family has lived on threecontinents, and we've used the health care systems in other wealthycountries with satisfaction. But many Americans intensely dislike theidea that we might learn useful policy ideas from other countries,particularly in medicine. The leaders of the health care industry andthe medical profession, not to mention the political establishment, havea single, all-purpose response they fall back on whenever somebodysuggests that the United States might usefully study foreign health caresystems: "But it's socialized medicine!"
This is supposed to end the argument. The contention is that theUnited States, with its commitment to free markets and low taxes,could never rely on big-government socialism the way other countriesdo. Americans have learned in school that the private sector can handlethings better and more efficiently than government ever could. InU.S. policy debates, the term "socialized medicine" has been a powerfulpolitical weapon—even though nobody can quite define what itmeans. The term was popularized by a public relations firm workingfor the American Medical Association in 1947 to disparage PresidentTruman's proposal for a national health care system. It was a label, atthe dawn of the cold war, meant to suggest that anybody advocatinguniversal access to health care must be a communist. And the phrasehas retained its political power for six decades.
There are two basic flaws, though, in this argument.
1. Most national health care systems are not "socialized." As we'llsee, many foreign countries provide universal health care ofhigh quality at reasonable cost using private doctors, privatehospitals, and private insurance plans. Some countries offeringuniversal coverage have a smaller government role than theUnited States does. Americans switch to government-runMedicare when they turn sixty-five; in Germany and Switzerland,seniors stick with their private insurers no matter howold they are. Even where government plays a large role, doctors'offices are operated as private businesses. As we'll see inchapter 7, my doctor in London, Dr. Ahmed Badat, was nobody'ssocialist; he was a fiercely entrepreneurial capitalist whoregularly found ways to enhance his income within the NationalHealth Service. Many countries have privately ownedhospitals, some run by charities, some for profit; Japan hasmore for-profit hospitals than the United States.In short, the universal health care systems in developedcountries around the world are not nearly as "socialized" asthe health insurance industry and the American MedicalAssociation want you to think.
2. "Socialized medicine" may be a scary term, but in practice,Americans rather like government-run medicine. The U.S.Department of Veterans Affairs is one of the world's purestmodels of socialized medicine at work. In the Medicare system,covering about 44 million elderly or disabled Americans,the federal government makes the rules and pays the bills.And yet both of these "socialized" health care systems areenormously popular with the people who use them and consistentlyrate high in surveys of patient satisfaction. That'swhy President Obama has consistently promised to save bothgovernment-run systems, no matter what other changes hemakes in health care.
So the problem isn't "socialism." The real problem with thoseforeign health care systems is that they're foreign. That offends themind-set—sometimes referred to as American exceptionalism—thatsays our strong, wealthy, and enormously productive country is suigeneris and doesn't need to borrow any ideas from the rest of theworld. Anybody who dares to say that other countries do somethingbetter than we do is likely to be labeled unpatriotic or anti-American;I've run into that charge myself. Of course, this is nonsense. The realpatriot, the person who genuinely loves his country, or college, orcompany, is the person who recognizes its problems and tries to fixthem. Often, the best way to solve a problem is to study what othercolleges, companies, or countries have done. And the fact is, Americansoften do look overseas for good ideas. We have borrowed numerousforeign innovations that have become staples of American daily life:public broadcasting, text messaging, pizza, sushi, yoga, reality TV, TheOffice, and even American Idol.
The academics have a term for this approach to problem-solving:"comparative policy analysis." The patron saint of comparative policyanalysis was an American military hero who went on to become ourthirty-fourth president: Dwight D. Eisenhower. That's why this bookis dedicated to his memory.
When Eisenhower became president, in 1953, the key domesticissue was the sorry state of the nation's transit infrastructure. Almost allmajor highways then were two-lane country roads designed primarilyto get farmers' crops to the nearest market. Interstate travel was a torturousordeal, marked by rickety bridges and long stretches of mud orgravel between intermittent paved sections. As postwar America embracedthe automobile, it was clear that vast improvements were required.And most of the forty-eight states already had highway planson the books. For the most part, those blueprints called for networksof two-lane highways that would run through the downtown MainStreet of every city along the route. These were perfectly reasonableplans for the time. But Eisenhower, who recognized the value of comparativepolicy analysis, had a better idea.
As Supreme Allied Commander during World War II, Ike hadcommanded the long push by American and British soldiers towardBerlin after the D-day landings in June 1944. By the spring of 1945,the Allies had battled their way across France to Germany's westernborder. Eisenhower's strategic plan envisioned months of painful sloggingacross a shattered German countryside. But then his forwardcommanders reported an amazing discovery: a broad ribbon of highway,the best road system anybody had ever seen, stretching straightthrough the heart of Germany. This was the autobahn network, builtin the 1930s, which featured four-lane highways; overpasses and rampedinterchanges to avoid intersections; and rest areas for refueling everyhundred miles or so. Once Eisenhower's trucks, tanks, and troop carriersfound the superhighway, they moved much faster than Ike hadplanned. By early May of 1945, the war in Europe was over.
Those German roads came to mind when, in 1953, President Eisenhowerwas presented with rather timid plans for a two-lane highwaynetwork across America. "After seeing the autobahns of modern Germany,and knowing the assets those highways were to the Germans,"he wrote in his memoirs, "I decided, as President, to put an emphasison this kind of road-building. I made a personal and absolute decisionto see that the nation would benefit from it. The [American plans] hadstarted me thinking about good, two-lane highways, but Germany hadmade me see the wisdom of broader ribbons across the land." SoEisenhower built those "broader ribbons": a state-of-the-art networkdesigned to a single national standard, with four-lane divided highways;overpasses and ramped interchanges to avoid intersections; and restareas for refueling every hundred miles or so. There was considerabledebate about how to pay for this hugely ambitious engineering project.A giant bond issue was proposed. But in those more innocent times,it was considered irresponsible for the federal government to run uplarge debts; in the end, Ike settled on a highway trust fund financed bygasoline taxes.
Today, the interstates—formally designated the Dwight D. EisenhowerSystem of Interstate and Defense Highways—comprise 47,000miles of road, 55,500 bridges, 14,750 interchanges, and zero stoplights.The system has spawned such basic elements of American lifeas the suburb, the motel, the chain store, the recreational vehicle,the automotive seat belt, the spring-break trek to Florida, the thirtymilecommute to work, and, on the dark side, the two-mile-long trafficjam. It's one of the finest highway networks in the world—andnobody seems to care that the basic idea was copied from the Nazis.
Eisenhower, the pragmatic commander, was willing toborrow a good policy idea, even if it had foreign lineage. In the samespirit, my sore shoulder and I hit the road, looking for good ideas formanaging a nation's health care. But where should I look?