What can we learn from other countries?

For nearly two years, members of the Democracy for America healthcare task force have been writing monthly opinion pieces on the need for healthcare reform in our country. By now, readers should be well aware that the U.S. healthcare system is not only the most expensive among the developed countries of the world, but it has received low marks for outcomes. The World Health Organization (WHO) has ranked our system 37 for overall quality, well below the ranks of most other developed countries. Our poor outcomes are mainly because so many of us are not covered by health insurance, or are underinsured, and do not get the care they need.

What do we know about the healthcare systems of these other developed countries? How do they work? How are they paid for? What might we borrow from them? T.R. Reid­journalist, documentary filmmaker, and author­wrote a bestseller that describes his global quest for better, cheaper, and fairer healthcare. His book is called “The Healing of America.” Reid’s quest focused mainly on large countries with political, economic, and educational structures like ours: free­market democracies that have embraced the high­tech world. They include France, Germany, Japan, Great Britain, and Canada. He also examined Switzerland and Taiwan, which more recently reformed their healthcare systems. Reid’s knowledge is based in part on his research travels for this book and his Frontline documentary “Sickness Around the World.” It also comes from having lived, as a foreign correspondent, in several of the countries under study.

While every nation’s healthcare system reflects its history, politics, economy, and national values, Reid found that the systems of all the countries he examined had certain things in common. Let’s take a look.

A moral imperative. The foundation of every one of theses healthcare systems was not an economic issue but a moral one. Each of these countries firmly believes that healthcare is a basic human right. So to construct or improve their healthcare system, they first had to address the question: “How can we provide healthcare for everyone?” rather than “How can we save costs?”

Universal healthcare. Every resident in these countries­young and old, rich and poor­has healthcare coverage.The poor are subsidized or their fees are paid for entirely by the government. Universal access is both a moral and a practical issue. Having everyone in the system is essential to make a healthcare system cheaper and more effective. Universal coverage (along with less­expensive care) also improves the overall health of a nation. People in these other developed countries use their healthcare system more, making frequent preventive visits and getting diagnostic tests when indicated. Mandated coverage. With the exception of Germany, everyone must participate in the healthcare system, through taxes or by paying monthly premiums to a government insurance plan or a private insurer. (Germany exempts rich people from coverage, assuming that they can afford to pay for healthcare out of pocket. Even so, many wealthy residents choose to purchase some type of “sickness insurance” plan.) In several countries, private health insurance plans are financed jointly by employers and employees through payroll deductions. If you are unemployed or otherwise cannot afford to pay, the government pays for you.

Mandatory coverage ensures that the government or private insurance plans (whoever are the “payers” for services in that country) have a broad enough risk pool to keep them solvent.

Tight regulation. If private insurance companies are part of the national healthcare system, they are highly regulated and they cannot make a profit on basic healthcare coverage.They cover all “essential” healthcare needs­which often include massage, acupuncture, and other holistic treatments that are not typically covered in our own country. For­profit insurance companies have a place in many of these countries, notably for supplemental coverage. People use them to pay for elective procedures such as Botox treatments, to get a private hospital room, or to reduce waiting time for a non­emergency procedure.

The government also tightly regulates medical services and fees, and negotiates drug costs so that prices are consistent and transparent across the country.

Fees for service are generally low, so doctors and hospitals in these countries don’t make a lot of money. Still, doctors generally do quite well­enough to be among the upper middle class and sometimes higher. It helps that these doctors do not begin practice with mountains of debt. Medical school is often free or much less expensive than in the United States. Also, malpractice insurance is infinitely cheaper than what physicians pay in our country. And there are ways to increase income ­such as by making house calls to the sick, which is done by many doctors.

None of these countries experienced a mass exodus from medicine because of their universal healthcare system. Doctors may complain about their incomes (comparing them to those of U.S. physicians), but, Reid found, most doctors stay the course because they love practicing medicine, helping people be well and get well. Like their countrymen, they believe in “community” and “solidarity,” and healthcare as a human right. And the profession is highly respected in their countries. Rationing of care. In addition to regulation, another means of keeping healthcare costs down is to ration care to a degree.

Rationing is a bad word in the United States, but insurance companies here do it all the time, and they do not act uniformly or transparently. In the countries Reid studied, decisions about coverage are made uniformly for everyone, often by a governmental body acting transparently. Essential medical services are always covered when they make sense. For example, it may not make sense to perform surgery on a 95­ year­old Alzheimer patient to keep him alive one more year. People usually have to wait for elective procedures, but in most countries, you can purchase a supplemental policy that will pay for certain elective or non­emergency procedures more quickly, or for a more expensive drug, an elective diagnostic, or an experimental treatment not normally covered. In spite of rationing of care and often long waits for nonemergency treatment, whenever a referendum came up to change the healthcare system for whatever reason, it was voted down by large margins. Above all, people loved their system’s “fairness” to everyone.

Wide choice in providers and drugs. In the United States, many of us are restricted by our company’s insurance plan(s) and its “provider networks” and “approved formularies.” Other developed countries provide many more options so that a patient can go just about anywhere­or change insurance plans on short notice if necessary to go to a provider they want. While most people still have wide choice among doctors, hospitals, and drugs, in several countries they must take the insurance plan their employer or local government provides. National insurance plans like Canada’s, for example, require you to sign up with your provincial government’s insurance program.

Less cost and better outcomes. A unified healthcare system that applies to everyone is much easier to administer, more egalitarian, and far less costly than the complicated system we have in the United States. Judged by the quality of outcomes, WHO statistics show that these unified, universal healthcare systems rank very high. Reid points to the DALE measurement in particular: the Disability­Adjusted Life Expectancy scale, meaning healthy life expectancy. Ranked 24th for DALE, the United States, with the highest costs by far, stands below almost all other developed nations.

Reid encourages our country’s leaders to follow the example of Taiwan, another fiercely capitalistic country with a high­tech economy and rich and politically influential finance and insurance industries. Taiwan originally had a dysfunctional, “poor country’s” healthcare system­that is, it was paid for entirely out­of pocket. In the early 1990s, Taiwan conducted a thorough study of the healthcare systems of other developed countries. It then borrowed from them practices that would fit their country and culture today in order to create a uniform system that would cover everyone.

Whom did Taiwan hire to design its new system? It was none other than our own Professor William Hsiao, a healthcare economist at Harvard School of Public Health. Perhaps we could enlist Professor Hsaio to help us design a national healthcare system that incorporates the best practices abroad that fit our own country and culture.

Jeanne Duffy, Ph.D., has served as a college professor, an analyst and project manager for several corporations, and a college administrator. She is current chair of the Democracy for America healthcare task force.