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

In `The Healing of America' TR Reid gives a tutorial on the basic types of health care systems in place around the world, and then tries to give an evenhanded analysis of what works in these systems and what doesn't. What gives the book its teeth though is his first-hand experience of health care systems in six different countries. In his quest, Reid brings a bum shoulder to these countries to find, as he puts it, `two cures': one for himself and one for the US health care system. There's no question something needs to be done to fix the US health care system. The idea that the richest and most technologically-advanced country would let people die because they can't get the care they need or go bankrupt because they get sick is absurd. That is why the current debate about health care reform is needed. The problem though is that's it's hard to know what we're looking at when filtered through politicians and the majority of the media coverage. They focus on the extremes, especially those opposed to reform who mischaracterize the systems in other countries as `socialized medicine'. In this context, Reid provides a useful voice to the debate- whether you agree with his prescriptions or not. He de-stigmatizes the systems of other countries and explains why we're not as far removed from them as we think. He shows us how other countries' systems are different, but also alike. Some `socialist' countries have private insurance and private doctors. In fact, Reid demonstrates how some countries actually have more choice than the US. In Germany for example, one can choose from hundreds of different insurance plans and go to any doctor, whereas US citizens are generally limited to one employer's plan and only `in-network' doctors. Some countries, like Britain, have government-run hospitals but private GPs. Some are single-payer, but most have multiple payers. Some plans are funded by private insurance, some by a government-run insurance fund, and others by general taxation. What is striking about these different variants though is that while some Americans rip these other systems, we here in America have forms of each of them. Medicare is run like Canada's system. Veterans are put through a system like Britain's. Americans with employee-sponsored plans are in a similar system as people in Germany. The difference is that those other countries provide health care more economically and more effectively than we do in America. Why? The answer lies in what they have in common. They all have a single, unified system, which allows administrative efficiencies. Ours is fragmented and riddled with administrative costs and perverse economic incentives. Their programs are all non-profit, so there's no need for insurance to cut coverage to maintain the bottom line as ours do. And they all provide universal coverage, which provides the economic incentive for preventative medicine. As Reid points out, the first question we need to ask ourselves is, do we think people should die due to lack of coverage? Or should people go bankrupt because they get sick? These are moral questions, and the US is the only rich developed nation that has so far said yes to them. Reid does gloss over some things though. He pays little attention to costs, seeing it as a problem solved once the profit motive is gone, universal coverage is agreed upon, and government price controls are in place. Besides showing a complete lack of economic understanding, this also skirts the fact that costs in other countries are also increasing. He does point this out but only says that their costs are so much lower than America's they can afford to let them rise. (For a more intelligent and nuanced analysis of the problem of cost in the US health care system and a unique idea for reform, see the article by David Goldhill in the September issue of `The Atlantic'.) He also polarizes the debate (like it needs more polarization) by getting into the `health care as a civil right' question. He was better-off sticking with his stronger, moral point because it's not at all inconsistent to think health care is NOT a civil right, but still have the moral conviction that everyone should have coverage. By putting these in black and white terms, he sounds like the European Socialist Liberal he had managed to avoid sounding like up to that point. Still, assuming he hasn't misrepresented anything in this book or provided inaccurate facts, this is important stuff. The health care debate is vitally important and I think every American should be armed with as much information as possible. That said, many articles by Reid and about this book have been published that will give you the basic facts outlined here. For most people, those articles should be enough. Only shell out for the book if you're interested in a deep dive on the subject.

Toward the end of the book, the author makes up a story that involves two American women of similar ages, but differing economic levels. Both have malignant tumors in the ovaries. For the woman with health care insurance, the tumor is found early, surgery is performed, and recovery is complete. For the woman without health care insurance, the malignancy is "discovered" at an emergency room examination, but the cancer has spread too far to be treated. The woman is sent home with pain pills to die. Per the author, no one is suggesting that the United States become an egalitarian society throughout. We expect differences in incomes and living standards. But all developed countries have decided to not tolerate inequality in health care. All except the United States. The result is that more than 20,000 U.S. residents die each year because they do not have health insurance and cannot get the coverage they need to live. This result, in itself, means that the richest nation in the world does not have the best health care system in the world. But author T.R. Reid feels that "the stars are aligned and the timing is propitious for the United States to establish a new national health care system." And the thesis of his book, he says, is "that we can bring about fundamental change by borrowing ideas from foreign models of health care." He has a bum shoulder, one that has been operated on and fixed in the past. As a guise to evaluate various health care models around the world, he seeks advice from each for his shoulder. In the end, he gets a variety of advice for his shoulder, but does not find one country that has the perfect system for the United States to adopt. What he does find are four basic models of coverage: 1) The Bismarck Model: Both health care providers and payers are private entities. Private health insurance companies, which are financed by employer and employee contributions, do not make a profit. There are tight controls on the costs of medical services and fees. (Germany, France and Japan use this model.) 2) The Beveridge Model: Health care is provided by the government. It is financed by taxes. All hospitals and clinics are owned by the government. Most doctors work only for the government. (Great Britain, Spain, Italy, most of Scandinavia, Hong Kong and Cuba use this model.) 3) The National Health Insurance Model: The providers of health care are private, but they are paid only by the government; thus, this is a single-payer system. The system is financed by monthly premiums. (Canada, Taiwan and South Korea use this model.) 4) The Out-of-Pocket Model: Those with money pay for medical care; those without money stay sick and/or die. The government is too poor and/or disorganized to provide universal health care. There are few or no private insurance companies or plans. (Approximately 160 countries in the world use this model.) Reid tells us that the U.S. uses all four models at the same time: 1) The Bismarck Model: Those who have employer-provided health insurance. 2) The Beveridge Model: Members of Congress, Native Americans, Veterans and active military personnel. 3) The National Health Insurance Model: Those under Medicare or Medicaid. 4) The Out-of-Pocket Model: The 45 million uninsured Americans (or more like the 80+plus million Americans who are without health care insurance at least one time in the year). And, he tells us that the first three models have the following in common: * There is a "moral imperative" that all residents have guaranteed health care coverage * All residents are covered by the same system, under the same set of rules * All are mandated to pay into the system, one way or the other * Basic health care must not generate any profit * Costs of services, procedures and drugs are controlled by the national government * There are health care horror stories under each model and each is challenged to control costs and to finance its system * The very rich have the means to get whatever health care treatment they want, wherever they want Per the author, some in the U.S. get the very best medical care possible, but the overall medical system is mediocre by world standards. And that is the rub. But we also pay about double, per resident, what other developed countries pay for our mediocre care. So, how is this possible? First, we pay far more for our doctors, nurses, hospitals and drugs than other countries do. But even if we reduced those costs significantly, he says, that would not be enough. No, per Reid, the biggest reasons for our high costs of health care are "the way we manage health insurance and the complexity of our health care system." Per Reid, "the U.S. private insurance industry has the highest administrative costs of any health payer in the world." He pegs it at about 20% of total costs and says other countries do it for far less: France: 5%; Canada: 6%; Taiwan: under 2%, as examples. Is there a simple solution? Per Reid, it's universal coverage, which he says is "an essential tool to control costs and maintain the overall quality of a nation's health." He adds, "The administrative patchwork (of the American insurance system) makes everything about American medicine more complex and more expensive than it needs to be." And he says only a national government has an inherent stake in preventive care. In the U.S., consumers change insurance companies every six years, on average, negating any interest or responsibility by them for preventive care. Looking at countries individually, he finds that the French go to doctors and take more pills than we do, yet their health care costs are about half of ours, per capita. In France, any resident can go to any doctor in the country; there are no "gatekeepers." Germany has one of the most expensive health care systems, but it is about 40% cheaper than the U.S. The government controls payments to doctors and hospitals. The basic model has been in place for 125 years. The Japanese consume health care like no other country, seeing doctors three times more than Americans, on average. Annual physicals are free, and residents expect to see a doctor without having to make an appointment. In Britain, all hospitals are owned by the government, and the British National Health Service is the largest employer in all of Europe. 85 percent of drugs are free of charge. Doctors do house calls, most health care is free, but there are waits to see doctors, and not all procedures and services are allowed. For example, there are no free annual physicals. There is no room here to talk about Canada, Taiwan or Switzerland, or the out-of-pocket countries. And, you'll have to read the book to find out what advice each country gives him for his bum shoulder. I can tell you that there is quite a variety of advice given. The bottom line is that the book takes you on a quick trip around the world to look at various health care systems, how they work, what their pluses and minuses might be, and what features each might have that the U.S. could adopt to improve its system. But, as I mentioned above, in the end, he does not find a single country with the model in place for us. And, he does not give us a composite model of what we need to follow, based on his findings from other countries. Sadly, he admits that the task of doing this became harder than he initially thought it might be. I highly recommend the book for its excellent core information and insight. The author, of course, did the excellent documentary for Frontline, called "Sick Around the World," which can be viewed in its entirety via the Internet. Watch that, if you don't get a chance to read the book.

Ever since the PBS documentary mentioned Reid's characterization of the different healthcare systems, I have been waiting anxiously for this book. Was well worth the wait. The fundamental thesis of the book is that the US healthcare system can and must learn and adapt ideas from various other healthcare systems - the idea is not radical at all. What is unique about this book is that Reid systematically and convincingly disproves the common arguments centered on the notions of "socialized medicine". A sub-text of this thesis is perhaps a bit more novel than his original thesis - US doesn't have a healthcare delivery problem, but has a significant problem financing it. This re-framing of the problem, clearly and deliberately divorcing the clinical resources/processes from the administrative (non-clinical) processes, is very helpful in focusing the arguments Reid wants to make. While one could argue that this re-framing is oversimplification and too biased against payers, it becomes to a open-minded reader that, at least in the US context, it is absolutely critical to view the economics side of healthcare first. Reid convincingly makes an argument that the "capitalistic" idealism US markets crave for and swear for are not channeled appropriately or are in fact, have the wrong incentive structure. Whether you agree with that viewpoint or not, the detailed global journey of Reid and his quasi-functional shoulder, helps a reader lead a vicarious patient life in a wide variety of settings, some more similar to the US than others. (Having grown up entirely in India, I certainly can relate to and think that the author's portrayal of India's healthcare system is accurate and presented in a matter-of-fact manner). The discussions often tends to be on administrative issues - getting an appointment, scheduling surgeries, who bills whom for what, and whether a patient ever sees a bill, etc. For each of the country discussed, Reid also provides a fairly good summary of the historical context of the healthcare systems and sometimes (a little bit tangentially) profiles of key persons involved in shaping that country's system. While such a narrative is very informative, I think the author missed an excellent opportunity to provide his thoughts on potential solutions (for example, from an information technology perspective - while he lauds the usage of health cards in Taiwan, Germany etc as key to cutting admin costs, he does little to highlight the significant clinical advantages that can be gleaned from the huge database). His focus on addressing the "that's socialized medicine" argument left him little room to take on another common argument theme - patient privacy. A reader would also have significantly benefited if the author had spent more time on analyzing the transformation challenges that countries that adopted significant reform went through and how they addressed them. The policy/ethics framing of the problem and the discussion with the renowned William Hsiao is very informative and thought-provoking. The discussion on the role of preventive medicine is insightful in that Reid makes a convincing argument as to why a healthcare economy with fractured for-profit players has no incentive in preventive medicine. The chapter "apple a day" is in itself well-worth the read. For a more enterprising reader, a thought exercise centered on the applicability of the ideas from this book with the hypotheses/assertions of The Innovator's Prescription: A Disruptive Solution for Health Care will be rewarding. Nevertheless, the book, provides a reader engaged in the current (directionless) debate in US on healthcare "reform", an excellent source of providing an unbiased, well-informed context with a very powerful nudge in trying to re-frame the discussion. The book will perhaps be best remembered for its systematic destruction of the "socialized medicine" arguments wide-spread in the US. An excellent read.

This book is not for the demagogically susceptible town-hall scaredy-cat; more than one's limbic system is required to take it in! This book informs the reader about other health care systems around the world. It gives historical accounts of how these other systems evolved into universal coverage systems. The author fairly coveys the pros and cons of the surprisingly different approaches different countries have taken to arrive at universal health care for their citizens. France, Germany, UK, Canada, Japan, Taiwan, and Switzerland are examined. Oh, if we weren't so proud to be able to learn from others…

A non-partisan, factual and well-researched book. Written by a true journalist who does his homework. Knows what he is talking about. To me, this one lays out the case well on why the US and this new administration in DC needs to really "redo" not just "revise" healthcare in America. Let's take our time and really get to the right answer. Not one that is just politically expedient for Obama and 2010 congressional election cycle. He's right it doesn't make sense that our healthcare system is so ineffective and costly - why does ours spend 20c of every dollar on non-medical stuff like paperwork, marketing, admin? Author also makes the point that socialized medicine terminology that has prevented true reform isn't actually true of foreign models. The US is more "socialized" than many of them already. This is a great book and must read if you care about the topic. (Learned a lot more reading this book than than watching the talking heads on CNN, Fox, etc.). BTW I have also read two other of Reid's books, Confucious Lives Next Door Confucius Lives Next Door: What Living in the East Teaches Us About Living in the West and The US of Europe The United States of Europe: The New Superpower and the End of American Supremacy - neither likely as popular given timing of this one - but both excellent reads and similarly well-researched.

I bought this book after reading Jacob Weisberg's review in Newsweek. It is the best thing on the subject for the following reasons: 1. It is well written even funny in places. 2. It is very informative. 3. It presents comparative data both as to health outcomes and also ways of paying for health care 4. It is non-partisan, even though by the end one wonders why we Americans are paying so much for health outcomes that are actually worse than any comparable country. 5. It is revealing as to the complexity of the US; for example, I didn't know that as many as 80 million Americans are already covered by systems nearly identical to the British or Canadian, i.e. medicaid, medicare, military, veterans and Department of Indian Affairs - who would have thought that? But 45 million others are not covered at all. Everyone else is covered, more or less, by insurance and so are the Germans, French and Japanese etc. But what a difference in the insurance systems! In the other countries you get insurance just like here EXCEPT THAT 1. you cannot be denied 2. you cannot be cancelled 3. everyone is covered and 4. your premiums are regulated by government which of course is what the entire debate is about. Because here the insurance industry is for profit and the premiums reflect that fact, the amazing fact that US health is the USA's largest industry by far, larger that the State of California, four times larger that the military, in fact US health would be the world's 8th largest country. No wonder the debate is so fierce. This excellent books set it all out readably and comprehensively.

I can't vouch for the accuracy of all of Reid's accounts, but as an American expat who lived in Germany and the UK for a total of 28 years, I can confirm that his descriptions of the health care systems in those two countries are both accurate and fair. The timing of this book is uncanny. Everyone who cares one whit about health care in the US should read it… and LISTEN to what it has to tell us.