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. -- Ezra Klein
Ezra Klein writes on economic and domestic policy for The Washington Post, at http://voices.washingtonpost.com/ezra-klein. He has been an associate editor at The American Prospect and contributes to the group food blog the Internet Food Association.
Read an Excerpt
A Quest for Two Cures
Mrs. Rama came sweeping into my hospital room
with the haughty grandeur of a Brahmin empress, wearing a salmon
pink sari and leading a retinue of assistants, interpreters, and equipment
bearers. It wasn’t exactly medical equipment they were carrying, because
Mrs. Rama wasn’t exactly a doctor. Still, her professional services were
considered an essential element of the medical regimen at India’s famous
Arya Vaidya Chikitsalayam, the Mayo Clinic of traditional Indian medicine.
Indeed, Mrs. Rama’s diagnostic work is covered by Indian medical
insurance. As she set up her equipment—on a painted wooden board,
she carefully arranged a collection of shells, rocks, and statuettes of
Hindu gods—Mrs. Rama told me that she was connected to the clinic’s
Department of Yajnopathy, an ancient Indian specialty that roughly
equates to astrology. Her medical role was to ascertain my place in the
cosmos; in that way, she could determine whether the timing was propitious
for me to be healed. Any fool could see, she explained in matterof-
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 immediately
inspire confidence in her patient. After asking some basic questions, she
shuffled the stones and statuettes around her checkerboard and launched
into my diagnosis. “In the summer of 1986, you got married,” she
declared firmly. Well, not exactly. In the summer of 1986, my wife and
I celebrated our fourteenth wedding anniversary; by then we had three
kids, a dog, and a minivan. “In 1998,” she went on, “you were far from
home and were treated for serious illness.” Well, not exactly. Our
American family was, in fact, living in London in 1998; but in that
whole year, I never saw a doctor.
Mrs. Rama kept talking, but I stopped listening. To me, the stones
and shells and statues all seemed preposterous. Still, I kept my mouth
shut. If Indian medicine required yajnopathic analysis before health
care could begin (and Mrs. Rama did eventually conclude that the
timing was propitious for treatment), that was fine with me. I was willing
to go along, in pursuit of the greater goal. For I had traveled to the
Arya Vaidya clinic—it’s in the state of Tamil Nadu, at the southern tip
of the subcontinent, where the Bay of Bengal meets the Arabian
Sea—on a kind of medical pilgrimage. I was on a global quest, searching
for solutions to two different health problems, one personal and
one of national dimensions.
On the personal level, I was hoping to find some relief for my ailing
right shoulder, which I bashed badly decades ago as a seaman, second
class, in the U.S. Navy. In 1972, a navy surgeon (literally) screwed the
joint back together, and that repair job worked fine for a while. Over
time, though, the stainless-steel screw in my clavicle loosened; my
shoulder grew increasingly painful and hard to move. By the first decade
of the twenty-first century, I could no longer swing a golf club. I
could barely reach up to replace a lightbulb overhead or get the wineglasses
from the top shelf. Yearning for surcease from sorrow, I took
that bum shoulder to doctors and clinics—including Mrs. Rama’s
chikitsalayam—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 another
broken joint of mine a few years back. Dr. Ferlic proposed a surgical
intervention that reflects precisely the high-tech ethos of contemporary
American medicine. This operation—it is known as a total shoulder
arthroplasty, Procedure No. 080.81 on the National Center for
Health Statistics’ roster of “clinical modifications”—would require the
orthopedist to take a surgical saw, cut off the shoulder joint that God
gave me, and replace it with a man-made contraption of silicon and
titanium. This new arthroplastic joint would be hammered into my
upper arm and then cemented to my clavicle. The doctor was confident
that this would reduce my shoulder pain—orthopedic surgeons
tend to be confident by nature—but I had serious reservations about
Procedure No. 080.81. The saws and hammers and glue made the
procedure sound rather drastic. It would cost tens of thousands of dollars
(like most major medical procedures in the United States, the exact
price was veiled in mystery). The best prognosis I could get was that
the operation might or might not give me more shoulder movement.
And when I asked Dr. Ferlic what could go wrong in the course of a
total arthroplasty, he was completely honest. “Well, you have all the
risks that go with major surgery,” he answered calmly. And then he
listed the risks: Disease. Paralysis. Death.
With that, a certain skepticism crept into my soul about this hightech
medical intervention. I departed my American surgeon’s office
and took my aching shoulder to other doctors, doctors all over the
globe. Over the next year or so, I had my blood pressure and temperature
taken in ten different languages. I ran into a world of different
diagnostic techniques, ranging from Mrs. Rama and her star charts to
a diligent, studious doctor (we’ll meet him in chapter 9) who told me
he couldn’t possibly analyze my medical condition without tasting
my urine. In Taipei, an acupuncturist twirled her needles in my left
knee to treat the pain in my right shoulder. The shoulder itself was
examined, X-rayed, patted, poked, palpated, massaged, and manipulated
in countless ways. Some of these treatments worked, more or less; as
we’ll see in chapter 9, Mrs. Rama’s colleagues at the chikitsalayam were
helpful. Others proved no help at all.
This was not a major disappointment, though, because that aching
shoulder was really just a secondary impetus for my medical odyssey.
It would be ridiculous, after all, to go all the way to the southern
tip of India—not to mention London, Paris, Berlin, Tokyo, and so
on—to get treatment for a sore shoulder that isn’t, frankly, all that
sore. The stiffness is tolerable most of the time. I have another arm to
use for changing lightbulbs or getting glasses off the shelf. I don’t have
a golf swing anymore, but even when I could swing a club I was a
So the shoulder was not my top priority. Rather, the primary goal
of my travels was to find a solution to a much bigger medical problem.
It’s a national problem—a national scandal, really—that is undermining
the physical and fiscal health of every American. With help from many
scholars and the Kaiser Family Foundation, I traveled the world searching
for a prescription to fix our country’s seriously ailing health care
system. As Nikki White’s experience demonstrates, it’s fundamentally
a moral problem: We’ve created a health care system that leaves millions
of our fellow citizens out in the cold. Beyond the issue of coverage,
however, the United States also performs below other wealthy countries
in matters of cost, quality, and choice.
Most Americans can remember when our politicians used to
boast—and we used to believe—that the United States had “the finest
health care system in the world.” Today, any U.S. politician who dared
to make that claim—it was last heard in a State of the Union address
in 2002—would be hooted out of the room. Americans generally recognize
now that our nation’s health care system has become excessively
expensive, ineffective, and unjust. Among the world’s developed nations,
the United States stands at or near the bottom in most important
rankings of access to and quality of medical care. In 2000, when a
Harvard Medical School professor working at the World Health
Organization developed a complicated formula to rate the quality and
fairness of national health care systems around the world, the richest
nation on earth ranked thirty-seventh.1 That placed us just behind
Dominica and Costa Rica, and just ahead of Slovenia and Cuba. France
came in first. (For more about the WHO’s global ranking, see the
The one area where the United States unquestionably leads the
world is in spending. Even countries with considerably older populations than ours, with more need for medical attention, spend much less
than we do. Japan has the oldest population in the world, and the
Japanese go to the doctor more than anybody—about fourteen office
* * * * * * * *
HEALTH EXPENDITURE AS A PERCENTAGE
OF GDP, 2005
Sources: OECD Health at a Glance, 2007; Government of Taiwan.
* * * * * * * *
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.
There’s nothing particularly wrong with spending a lot of money
on something important, as long as you get a decent return for what
you spend. It’s certainly not wasteful to spend money for effective medical
treatment. If a dentist who was about to drill a tooth offered her
patient a choice between listening to pleasant music for free to lessen
the pain, or a shot of Novocain for $50, most people would pay for the
shot and would probably get their money’s worth. And there’s nothing
wrong with paying more for better performance. Those fifty-two-inch
high-definition plasma televisions that people hang on the family room
wall these days cost five times what a top-of-the-line set would have
cost ten years ago, but buyers are willing to shell out the extra money
because the enhanced viewing quality is worth the price.
When it comes to medical care, though, Americans are shelling
out 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 the
treatment people get in other countries. And patients know it. Surveys
show that Americans who see a doctor tend to be less satisfied with their
treatment than Britons, Italians, Germans, Canadians, or the Japanese—
even though we pay the doctor much more than they do.2
You don’t need an advanced degree in yajnopathy to recognize that
the stars are aligned and the timing is propitious for the United States
to establish a new national health care system. As Americans voted
in the 2008 election, only 18 percent told the pollsters that the U.S.
health care system was working well. Even American doctors, who
generally do just fine, thank you, in financial terms, are unhappy with
the ridiculously cumbersome and unjust system that has built up
around them. And those Americans who want change in our system—
which is to say, almost all Americans—are not willing to settle for
minor tinkering or small-scale adjustments. Rather, 79 percent told the
pollsters they want to see either “fundamental changes” or “a complete
The thesis of this book is that we can bring about fundamental
change by borrowing ideas from foreign models of health care. For me,
that conclusion stems from personal experience. I’ve worked overseas
for years as a foreign correspondent; our family has lived on three
continents, and we’ve used the health care systems in other wealthy
countries with satisfaction. But many Americans intensely dislike the
idea that we might learn useful policy ideas from other countries,
particularly in medicine. The leaders of the health care industry and
the medical profession, not to mention the political establishment, have
a single, all-purpose response they fall back on whenever somebody
suggests that the United States might usefully study foreign health care
systems: “But it’s socialized medicine!”
This is supposed to end the argument. The contention is that the
United States, with its commitment to free markets and low taxes,
could never rely on big-government socialism the way other countries
do. Americans have learned in school that the private sector can handle
things better and more efficiently than government ever could. In
U.S. policy debates, the term “socialized medicine” has been a powerful
political weapon—even though nobody can quite define what it
means. The term was popularized by a public relations firm working
for the American Medical Association in 1947 to disparage President
Truman’s proposal for a national health care system. It was a label, at
the dawn of the cold war, meant to suggest that anybody advocating
universal access to health care must be a communist. And the phrase
has retained its political power for six decades.
There are two basic flaws, though, in this argument.
So the problem isn’t “socialism.” The real problem with those
foreign health care systems is that they’re foreign. That offends the
mind-set—sometimes referred to as American exceptionalism—that
says our strong, wealthy, and enormously productive country is sui
generis and doesn’t need to borrow any ideas from the rest of the
world. Anybody who dares to say that other countries do something
better 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 real
patriot, the person who genuinely loves his country, or college, or
company, is the person who recognizes its problems and tries to fix
them. Often, the best way to solve a problem is to study what other
colleges, companies, or countries have done. And the fact is, Americans
often do look overseas for good ideas. We have borrowed numerous
foreign innovations that have become staples of American daily life:
public broadcasting, text messaging, pizza, sushi, yoga, reality TV, The
Office, and even American Idol.
- Most national health care systems are not “socialized.” As we’ll
see, many foreign countries provide universal health care of
high quality at reasonable cost using private doctors, private
hospitals, and private insurance plans. Some countries offering
universal coverage have a smaller government role than the
United States does. Americans switch to government-run
Medicare when they turn sixty-five; in Germany and Switzerland,
seniors stick with their private insurers no matter how
old they are. Even where government plays a large role, doctors’
offices are operated as private businesses. As we’ll see in
chapter 7, my doctor in London, Dr. Ahmed Badat, was nobody’s
socialist; he was a fiercely entrepreneurial capitalist who
regularly found ways to enhance his income within the National
Health Service. Many countries have privately owned
hospitals, some run by charities, some for profit; Japan has
more for-profit hospitals than the United States.
In short, the universal health care systems in developed
countries around the world are not nearly as “socialized” as
the health insurance industry and the American Medical
Association want you to think.
- “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 purest
models 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 are
enormously popular with the people who use them and consistently
rate high in surveys of patient satisfaction. That’s
why President Obama has consistently promised to save both
government-run systems, no matter what other changes he
makes in health care.
The academics have a term for this approach to problem-solving:
“comparative policy analysis.” The patron saint of comparative policy
analysis was an American military hero who went on to become our
thirty-fourth president: Dwight D. Eisenhower. That’s why this book
is dedicated to his memory.
When Eisenhower became president, in 1953, the key domestic
issue was the sorry state of the nation’s transit infrastructure. Almost all
major highways then were two-lane country roads designed primarily
to get farmers’ crops to the nearest market. Interstate travel was a torturous
ordeal, marked by rickety bridges and long stretches of mud or
gravel between intermittent paved sections. As postwar America embraced
the automobile, it was clear that vast improvements were required.
And most of the forty-eight states already had highway plans
on the books. For the most part, those blueprints called for networks
of two-lane highways that would run through the downtown Main
Street of every city along the route. These were perfectly reasonable
plans for the time. But Eisenhower, who recognized the value of comparative
policy analysis, had a better idea.
As Supreme Allied Commander during World War II, Ike had
commanded the long push by American and British soldiers toward
Berlin after the D-day landings in June 1944. By the spring of 1945,
the Allies had battled their way across France to Germany’s western
border. Eisenhower’s strategic plan envisioned months of painful slogging
across a shattered German countryside. But then his forward
commanders reported an amazing discovery: a broad ribbon of highway,
the best road system anybody had ever seen, stretching straight
through the heart of Germany. This was the autobahn network, built
in the 1930s, which featured four-lane highways; overpasses and ramped
interchanges to avoid intersections; and rest areas for refueling every
hundred miles or so. Once Eisenhower’s trucks, tanks, and troop carriers
found the superhighway, they moved much faster than Ike had
planned. By early May of 1945, the war in Europe was over.
Those German roads came to mind when, in 1953, President Eisenhower
was presented with rather timid plans for a two-lane highway
network 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 emphasis
on this kind of road-building. I made a personal and absolute decision
to see that the nation would benefit from it. The [American plans] had
started me thinking about good, two-lane highways, but Germany had
made me see the wisdom of broader ribbons across the land.”5 So
Eisenhower built those “broader ribbons”: a state-of-the-art network
designed to a single national standard, with four-lane divided highways;
overpasses and ramped interchanges to avoid intersections; and rest
areas for refueling every hundred miles or so. There was considerable
debate 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 up
large debts; in the end, Ike settled on a highway trust fund financed by
Today, the interstates—formally designated the Dwight D. Eisenhower
System of Interstate and Defense Highways—comprise 47,000
miles of road, 55,500 bridges, 14,750 interchanges, and zero stoplights.
The system has spawned such basic elements of American life
as the suburb, the motel, the chain store, the recreational vehicle,
the automotive seat belt, the spring-break trek to Florida, the thirtymile
commute to work, and, on the dark side, the two-mile-long traffic
jam. It’s one of the finest highway networks in the world—and
nobody seems to care that the basic idea was copied from the Nazis.6
Eisenhower, the pragmatic commander, was willing to
borrow a good policy idea, even if it had foreign lineage. In the same
spirit, my sore shoulder and I hit the road, looking for good ideas for
managing a nation’s health care. But where should I look?