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

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By TR Reid

Review by KM Tan, MD

Summer 2010 - Volume 14 Number 2

https://doi.org/10.7812/TPP/10-055

Though much has been written, few people are aware of US standings in international health care rankings: 31st in life expectancy, 37th in infant mortality, 34th in maternal mortality.1 A child in the US is two and a half times as likely to die by age five as in Singapore or Sweden. We spend more of our GDP (17% and rising) than any other country, and get much less than most first-world countries, who spend considerably less.¹

In The Healing of America, TR Reid takes us on a journey using the ingenious approach of offering his previously injured shoulder to comparatively assess several systems of health care.

In the US, he is offered expensive joint replacement with the potential risks of major surgery. In France and Germany, physical therapy is recommended; however, the same surgery, at low cost, is available. In England, he is given the advice to live with it: his predicament is not a priority. In Japan, traditional Chinese medicine, physical therapy, steroid injections, or surgery are offered at little cost. In India, he obtains significant relief with meditation, herbs, and massage.

Mr Reid posits most countries use one of four models: 1) the Bismarck model in Germany, Japan, France, Belgium, and Switzerland consists of private clinicians and insurers financed through payroll deductions overseen by the government; 2) Britain's Beveridge model is government-financed through taxes with government-owned hospitals and government-regulated physician payments, decried in the US as "socialized medicine"—Italy, Spain, and most Scandinavian countries follow this model; 3) in Canada, through taxes, the government funds single payer, or National Health Insurance, with private physicians and hospitals—Taiwan and South Korea have adopted this system; 4) the final model, appropriately called Out-of-Pocket, is found primarily in poor nations where only the rich get health care.

In the US, an amalgam of all four models prevails. Employer-based health insurance reflects the Bismarck model. The Veterans Administration is similar to the Beveridge model. Medicare, often criticized but ferociously defended, reflects the Canadian model. Our 45 million uninsured and the self-employed reflect the Out-of-Pocket system.

Mr Reid effectively illustrates the difference between our system of care and those of the nations he surveys. In the US, our patchwork of multiple alternatives, the most expensive in the world, omits care for 15% of the population. And yet, with stellar insurance or financial means, an American has access to some of the best available treatment and most advanced technological diagnostic equipment in the world.

Our Achilles' heel lies in our system of payment for volume services rather than for value. Physicians overprovide lest they be sued for not doing more. Thus, we spend 65% to 85% of the premium dollar on medical care, referred to as "medical loss."

Mr Reid clearly shows that the dominant theme in other countries is universal health care, where access is a national right and the choice of system reflects the ethics and values of that society. That is a bridge the US has yet to cross; we remain subject to a system in which 45,000 people die each year for lack of insurance—one person every 12 minutes—and 700,000 people face bankruptcy because of medical bills.² In all the other countries surveyed by Mr Reid, that rate is zero.

Ultimately however, physicians must assume some responsibility for the current state of affairs. The American public has been led to believe more care is always better. Thus any reform geared toward judicious use of cost-effective, evidence-based care is pilloried as rationing, notwithstanding that we already ration care based on wealth status.

Even with the passage of the 2010 Health Care Reform bill, until we change the mindset of Americans, costs will continue to spiral upwards. TR Reid's book is a welcome step along the road to rational change in our health care environment.

References

1. Kristoff ND. Unhealthy America [monograph on the Internet]. New York: The New York Times; 2009 Nov 4 [cited 2010 Apr 24]. Available from: www.nytimes.com/2009/11/05/opinion/05kristof.html.
2. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. Am J Public Health 2009 Dec;99(12):2289-95.