The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

There can be, in book reviews, a distressing tendency to bury the actual recommendation beneath the scintillating thoughts of the reviewer. (I have fallen prey to this myself. My thoughts are very scintillating.) Let’s not make that mistake here. You should buy this book. It is the clearest and most useful contribution to the ongoing health care reform debate I’ve read. And, unlike most books that are described as a “useful contribution,” it’s a good read, too.

The book’s clarity comes from its thesis: The way America does things is not the only way things can be done. That simple refusal to remain inside the strictures of America’s political debate — where the argument is over how best to cover everyone while offending no one and changing nothing — allows T. R. Reid to elegantly demonstrate how unnecessarily complex and inefficient and expensive and cruel our health care system really is.

Unlike so many other commentators, Reid does not do this by exhaustively explaining the mechanics of the American health care system and wagging his finger at its many mistakes. He does it by offering insight into other health care systems. In particular, he examines the French, Canadian, German, Japanese, and British systems, alongside the pushes for reform that recently gave Sweden and Taiwan brand-new health care systems.The result is a sort of health policy travelogue: Reid flies around the world, investigating the workings of these systems and asking doctors in each to recommend a course of treatment for the chronic pain in his shoulder. This latter effort could be gimmicky, but it actually proves helpful: It allows Reid to view the various arrangements from both the high altitude favored by wonks and the ground level experienced by patients.

Reid’s reporting results in two important contributions to the debate we’re having here at home. First, the national health care systems enjoyed by residents of every other developed country are superior to the fractured health care industry that serves Americans. They are cheaper, they cover everyone, and there is no evidence that they produce worse outcomes. Second, these national health care systems are all different. Some are socialized and some are not. Some are single-payer and some are not. Some are private and some are not.

This first fact is a particularly hard one to swallow. We’re America. We have the most highly trained doctors, the most astonishing medical equipment, that guy from House (although we imported the actor who plays him from Britain). We even spend the most, which is, in many areas of life, a sure sign of achievement. How can our medical system not be the envy of the world? This leads to a lot of strange rationalizations for the fact that we get less and spend more than every other country. But it shouldn’t. If there were two stores in your town, and one was twice as expensive as the other and tended to be out of things that 15 percent of the people needed to buy, you wouldn’t spend a lot of time concocting elaborate explanations for the superiority of the store that cost too much and couldn’t provide everyone with the goods and services they required. You’d go to the other store.

But it’s not just one other store. There are a variety of other business plans we could try. Reid groups the possibilities into four models. The Bismarck model, named for Germany’s Otto von Bismarck, is a private system in which the government shapes the rules of the market to make certain that everyone is covered and that basic rules of decency and consumer protection are followed. The Beveridge model, named for England’s William Beveridge, is a socialized system in which the governments owns the hospitals and employs the doctors and basically runs the whole thing. The National Health Insurance model is what’s traditionally known as single-payer, and it’s what we see in Canada: the government is the insurer, but the doctors and hospitals are private. And then the Out-of-Pocket model is what you have in developing countries: health services are available to those able to afford them.

None of these systems should be particularly alien to Americans. The Bismarck model is pretty close to what those of us with solid employer-based insurance experience. The Beveridge model is what our veterans enjoy in the Veteran’s Health Administration. The National Health Insurance Model is Medicare. And the Out-of-Pocket model is what the uninsured and self-employed face. But unlike other countries that have chosen a single system and worked to make it run smoothly, America has a confusing patchwork of different arrangements and models. We don’t so much have a store as a vast bazaar. And there’s a good reason that the bazaar model has given way to Target.

Choosing a system, however, is only the first step. You also have to implement it. Savings will not emerge as if by magic. In other countries, health care providers make less money. Doctors have lower salaries. Pharmaceutical companies see less in profits. Those will be tough political fights. Similarly, other systems sometimes — though not always — furnish patients with less in the way of treatments. That, too, is a choice. A system can be biased toward more treatment, less treatment, or neither. Our system is currently biased toward more treatment: Doctors make money every time they do something to you. Britain’s system is biased toward less treatment: Doctors lose money every time they do something to you. Other systems are somewhere in the middle. But Americans tend to believe that more medical care is better, even if the evidence doesn’t quite back that up, and they don’t like facing down the possibility that a new system would mean doctors might be more reticent with a pill or a surgery.

There are, in other words, hard decisions to be made. But they are decisions. Toward the beginning of the book, Reid says something quite radical: Letting people die or go bankrupt because they happen to be sick and happen to not have health insurance “is a fundamental moral decision America has made.” That is not, in general, how we see it. The more traditional view is that health care is a problem we simply haven’t solved. Not mustering the will or energy to solve that problem anytime during the 21st century is, however, a choice. A decision. It is to our discredit to fail. But it is in our power to change it. Others, as we can see, already have.