Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care - T R Reid "On September 11, 2001, some three thousand Americans were killed by terrorists; our country has spent hundreds of billions of dollars to make sure it doesn’t happen again. But that same year, and every year since then, some twenty thousand Americans died because they couldn’t get health care. That doesn’t happen in any other developed country. Hundreds of thousands of Americans go bankrupt every year because of medical bills. That doesn’t happen in any other developed country either."

This is probably a book everyone should read. It's a dispassionate look at health care systems throughout the world as Reid travels from one country to another to see how his shoulder would be treated and under what circumstances. To start a couple of basic facts: "most rich countries have better national health statistics—longer life expectancy, lower infant mortality, better recovery rates from major diseases—than the United States does.Yet all the other rich countries spend far less on health care than the United States does. . . .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. The Japanese go to the doctor more often than anyone else, yet their system costs only $3,400 per person; in the United States the cost is $7,400 per person annually. In Canada, the nation has decided that to be the most fair, people should have to wait equally. In Britain, the priority is that all health care should be free to everyone.

He begins by identifying the four basic types of mechanisms to pay for health care in the industrialized world. (He discounts the third world since those are all basically pay-as-you-go and available only to the rich.) Conventional wisdom tells us that these other countries depend on "socialized" medicine, yet that is incorrect. Ironically the only pure socialized medical systems exists in Cuba and the United States' VA system which is totally government funded, doctors are paid and employed by the government and veterans pay nothing for its services. Other countries are all a mix of private and public. How they are structured is related to the country's moral fabric.

The four systems are the Bismarck (a mix of public and private as in Japan, Germany, and Switzerland); in the Beveridge model there are no medical bills; rather, medical treatment is a public service, like the fire department or the public library, hospitals and clinics are often owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge. The British system is based on the Beveridge model. Canada's system is the third type, a national insurance plan which has elements of both Bismarck and Beveridge. The providers of health care are private, but the payer is a government-run insurance program that every citizen pays into. The last system is the pay-as-you-go in which there is no insurance and people pay for service out of their own pockets.

The United States has a mix of all. For those under sixty-five is a modified Bismarckian system for those lucky enough to be employed and have an employer-based system. Those over sixty-five have Medicare more similar to the Canadian system, and for many there is only the pay-as-you-go although most municipalities will not refuse treatment for emergencies which simply means the cost is allocated elsewhere, i.e. everyone else. One of the features of the so-called ObamaCare was to eliminate free-loading and have everyone, or most everyone pay for some form of health insurance. For Native Americans, military personnel, and veterans, we’re Britain, or Cuba. "And yet we’re like no other country, because the United States maintains so many separate systems for separate classes of people, and because it relies so heavily on for-profit private insurance plans to pay the bills. All the other countries have settled on one model for everybody, on the theory that this is simpler, cheaper, and fairer. With its fragmented array of providers and payers and overlapping systems, the U.S. health care system doesn’t fit into any of the recognized models."

A common complaint leveled against government health care programs is they ration, yet all systems ration. In this country it's done by insurance companies, in others it's done by ethical committees. Here, the decisions are applied inequality and depend on one's plan (and the quality of one's lawyer.) "made, often in secret, by scores of different insurance companies. One person may get coverage for a potentially life-saving operation, while the next person doesn’t. This may be a boon to the person with the more generous insurance policy, but it’s not particularly fair." Some form of rationing *must* be done in order to reduce costs. "Should the system spend its money to keep a ninety-five-year-old Alzheimer’s patient alive until he’s ninety-six? Should an ailing eighty-four-year-old get the same intensive treatment for breast cancer that is provided to an otherwise healthy forty-four-year-old? Should the health system, or the insurance plan, pay for Viagra? For Botox? In a health care system that offers universal coverage, these decisions tend to be made uniformly for everybody."

The U.S. spends the most on administrative costs and a system that organized everyone into one plan would clearly cut costs. Ironically, the charge that one system would reduce choice is not true. Other countries, in fact, offer patients more choice. Insurance plans in this country have discourage choice by building preferred networks. In most other countries patients can go wherever they want and see whomever they want since the structure for payment is the same throughout the country.

All countries are faced with rising health care costs and all face complaints about their systems. The grass is always greener.... The one constant is complaining. "The American economist Tsung-Mei Cheng has formulated, with tongue only partly in cheek, the Universal Laws of Health Care Systems: 1. “No matter how good the health care in a particular country, people will complain about it.” 2. “No matter how much money is spent on health care, the doctors and hospitals will argue that it is not enough.” 3. “The last reform always failed.”3 Everywhere I went on my global quest, I found that Cheng’s Universal Laws held true. But for all their problems, the other industrialized countries tend to do better than the United States on basic measures of health system performance: coverage, quality, cost control, choice. This was the most surprising and infuriating discovery of my global quest—that the United States of America performs so poorly in this fundamental area of human life. In industry, finance, music, science, arts, academics, athletics,Americans can match or surpass any other country. Why can’t we do that when it comes to health care?"

Read the book for part of the answer. Fascinating, yet ultimately quite depressing.