One Injury, 10 Countries: A Journey in Health Care

One Injury, 10 Countries: A Journey in Health Care
By ABIGAIL ZUGER, M.D.
Copyright by The New York Times
Published: September 14, 2009
http://www.nytimes.com/2009/09/15/health/15book.html?th&emc=th


With all due respect to the seminar room, the boardroom, the hearing room and the Oval Office, a better vantage point than any of them for evaluating and redesigning our health care system is the hospital room (window bed, please).

The chair next to the bed isn’t bad, either.

Some of us perch on one or the other almost every day, observing the tangled mess that is our current system and mentally designing a dozen better alternatives. But for those who wind up in bed or a chair only when tragedy strikes, T. R. Reid’s new book provides an excellent substitute perspective.

Mr. Reid, a veteran foreign correspondent for The Washington Post, knows from personal experience that there are indeed a dozen better alternatives. International postings from London to Japan familiarized him with many of the world’s health care systems. Then a chronic shoulder problem offered the opportunity for an unusually well-controlled experiment: Mr. Reid decided to present his stiff shoulder for treatment around the world.

One shoulder, 10 countries. Admittedly it’s a gimmick, but what saves the book from slumping into a sack of anecdotes like Michael Moore’s 2007 documentary “Sicko” is a steel backbone of health policy analysis that manages to trap immensely complicated concepts in crystalline prose.

“The Healing of America” blends subjective and objective into a seamless indictment of our own disastrous system, an eloquent rebuttal against the arguments used to defend it, and appealing alternatives for fixing it.

Mr. Reid starts with a methodical clarification of terms. First: universal health care. Far from a single socialized system, the various plans other countries use to cover all their residents are quite distinct. Some are as private as our own, and most offer considerably more in the way of choice.

In Japan, and many European countries, private health insurers — all of them nonprofit — finance visits to private doctors and private hospitals through a system of payroll deductions.

In Canada, South Korea and Taiwan, the insurer is government-run and financed by universal premiums, but doctors and hospitals are private.

In Britain, Italy, Spain and most of Scandinavia, most hospitals are government-owned, and a tax-financed government agency pays doctors’ bills.

In poor countries around the world, private commerce rules: residents pay cash for all health care, which generally means no health care at all.

Similarly, what Americans often consider a single unique system of health care is an illusion: we exist in a sea of not-so-unique alternatives. Like the citizens of Germany and Japan, workers in the United States share insurance premiums with an employer. Like Canadians, our older, destitute and disabled citizens see private providers with the government paying. Like the British, military veterans and Native Americans receive care in government facilities with the government paying the tab. And like the poor around the world, our uninsured pay cash, finagle charity care, or stay home.

Our archipelago of plans means that those safe on a good island with good insurance can be delighted with the system, even as millions of invisible fellow citizens tread water or drown offshore. It means that those on a mediocre island are stuck there. It also means that not one single piece of the infrastructure — like record keeping, drug pricing and administrative costs — can be streamlined across islands in any meaningful way. Hence the expense, the inequity and the tragedy.

When Mr. Reid presents his shoulder to his own orthopedist in Colorado, the doctor is quick to recommend a shoulder replacement. It will cost his insurer tens of thousands of dollars (assuming it agrees to pay), with unknown co-payments for him. Risks include all those of major surgery; benefits include a restored golf swing.

The same shoulder gets substantially different reactions elsewhere in the world.

In France, a general practitioner sends him to an orthopedist (out-of-pocket consultation fee: $10) who recommends physical therapy, suggests an easily available second opinion if Mr. Reid really wants that surgery, and notes that the cost of the operation will be entirely covered by insurance (waiting time about a month).

In Germany, the operation is his for the asking the following week, for an out-of-pocket cost of about $30.

In London, a cheerful general practitioner tells Mr. Reid to learn to live with his shoulder. No joint replacement is done in Britain without disability far more serious than his to justify the expense and the risks, and if his golf game is that important, he can go private and foot the bill himself.

In Japan, the foremost orthopedist in the country (waiting time for an appointment, less than a day) offers a range of possible treatments, from steroid injections to surgery, all covered by insurance. (“Think about it, and call me.”)

In an Ayurvedic hospital in India, a regimen of meditation, rice, lentils and massage paid for entirely out of pocket, $42.85 per night, led to “obvious improvement in my frozen joint,” Mr. Reid writes, adding, “To this day, I don’t know why it happened.”

But the comparative merits of different orthopedic philosophies are secondary here: Mr. Reid’s attention is focused on a meticulous deconstruction of the history and philosophy of the policy decisions behind them.

Among health policy narratives, this book’s clarity, comprehensiveness and readability are exceptional, and its bottom line is a little different from most. Instead of rationalization and hand-wringing, Mr. Reid offers an array of possible solutions for our crisis. As the proverb goes (it is a favorite among policy wonks): “To find your way in the fog, follow the tracks of the oxcart ahead.” We have plenty of reasonable paths to follow.

And plenty of reasons to follow them. Mr. Reid’s underlying message of hope does not preclude an intensely satisfying quotient of moral outrage at the worst casualties of our system as it stands.

One is the uninsured working person, too rich for Medicaid, too poor for a standard insurance policy, at first too proud to acknowledge disability, and then too sick for the process that a formal declaration of disability requires. These are the people who die of treatable illness in our country.

And then there is the insured working person who discovers, with surprise, that health insurance is a for-profit industry, that the industry term for payment is “medical loss” and that the process of extracting payment for a dire health condition can turn into a bizarre game of “catch me if you can.”

A person’s last days can be spent in any number of ways. But on the phone pleading with an insurer, that’s only in America.