The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care by T. R. Reid

The Barnes & Noble Review

There can be, in book reviews, a distressing tendency to bury the actual recommendation beneath the scintillating thoughts of the reviewer. (I have fallen prey to this myself. My thoughts are very scintillating.) Let's not make that mistake here. You should buy this book. It is the clearest and most useful contribution to the ongoing health care reform debate I've read. And, unlike most books that are described as a "useful contribution," it's a good read, too.

The book's clarity comes from its thesis: The way America does things is not the only way things can be done. That simple refusal to remain inside the strictures of America's political debate -- where the argument is over how best to cover everyone while offending no one and changing nothing -- allows T. R. Reid to elegantly demonstrate how unnecessarily complex and inefficient and expensive and cruel our health care system really is.

Unlike so many other commentators, Reid does not do this by exhaustively explaining the mechanics of the American health care system and wagging his finger at its many mistakes. He does it by offering insight into other health care systems. In particular, he examines the French, Canadian, German, Japanese, and British systems, alongside the pushes for reform that recently gave Sweden and Taiwan brand-new health care systems. The result is a sort of health policy travelogue: Reid flies around the world, investigating the workings of these systems and asking doctors in each to recommend a course of treatment for the chronic pain in his shoulder. This latter effort could be gimmicky, but it actually proves helpful: It allows Reid to view the various arrangements from both the high altitude favored by wonks and the ground level experienced by patients.

Reid's reporting results in two important contributions to the debate we're having here at home. First, the national health care systems enjoyed by residents of every other developed country are superior to the fractured health care industry that serves Americans. They are cheaper, they cover everyone, and there is no evidence that they produce worse outcomes. Second, these national health care systems are all different. Some are socialized and some are not. Some are single-payer and some are not. Some are private and some are not.

This first fact is a particularly hard one to swallow. We're America. We have the most highly trained doctors, the most astonishing medical equipment, that guy from House (although we imported the actor who plays him from Britain). We even spend the most, which is, in many areas of life, a sure sign of achievement. How can our medical system not be the envy of the world? This leads to a lot of strange rationalizations for the fact that we get less and spend more than every other country. But it shouldn't. If there were two stores in your town, and one was twice as expensive as the other and tended to be out of things that 15 percent of the people needed to buy, you wouldn't spend a lot of time concocting elaborate explanations for the superiority of the store that cost too much and couldn't provide everyone with the goods and services they required. You'd go to the other store.

But it's not just one other store. There are a variety of other business plans we could try. Reid groups the possibilities into four models. The Bismarck model, named for Germany's Otto von Bismarck, is a private system in which the government shapes the rules of the market to make certain that everyone is covered and that basic rules of decency and consumer protection are followed. The Beveridge model, named for England's William Beveridge, is a socialized system in which the governments owns the hospitals and employs the doctors and basically runs the whole thing. The National Health Insurance model is what's traditionally known as single-payer, and it's what we see in Canada: the government is the insurer, but the doctors and hospitals are private. And then the Out-of-Pocket model is what you have in developing countries: health services are available to those able to afford them.

None of these systems should be particularly alien to Americans. The Bismarck model is pretty close to what those of us with solid employer-based insurance experience. The Beveridge model is what our veterans enjoy in the Veteran's Health Administration. The National Health Insurance Model is Medicare. And the Out-of-Pocket model is what the uninsured and self-employed face. But unlike other countries that have chosen a single system and worked to make it run smoothly, America has a confusing patchwork of different arrangements and models. We don't so much have a store as a vast bazaar. And there's a good reason that the bazaar model has given way to Target.

Choosing a system, however, is only the first step. You also have to implement it. Savings will not emerge as if by magic. In other countries, health care providers make less money. Doctors have lower salaries. Pharmaceutical companies see less in profits. Those will be tough political fights. Similarly, other systems sometimes -- though not always -- furnish patients with less in the way of treatments. That, too, is a choice. A system can be biased toward more treatment, less treatment, or neither. Our system is currently biased toward more treatment: Doctors make money every time they do something to you. Britain's system is biased toward less treatment: Doctors lose money every time they do something to you. Other systems are somewhere in the middle. But Americans tend to believe that more medical care is better, even if the evidence doesn't quite back that up, and they don't like facing down the possibility that a new system would mean doctors might be more reticent with a pill or a surgery.

There are, in other words, hard decisions to be made. But they are decisions. Toward the beginning of the book, Reid says something quite radical: Letting people die or go bankrupt because they happen to be sick and happen to not have health insurance "is a fundamental moral decision America has made." That is not, in general, how we see it. The more traditional view is that health care is a problem we simply haven't solved. Not mustering the will or energy to solve that problem anytime during the 21st century is, however, a choice. A decision. It is to our discredit to fail. But it is in our power to change it. Others, as we can see, already have. -- Ezra Klein

Ezra Klein writes on economic and domestic policy for The Washington Post, at http://voices.washingtonpost.com/ezra-klein. He has been an associate editor at The American Prospect and contributes to the group food blog the Internet Food Association.

From the Publisher

Bestselling author T. R. Reid guides a whirlwind tour of successful health care systems worldwide, revealing possible paths toward U.S. reform.

In The Healing of America, New York Times bestselling author T. R. Reid shows how all the other industrialized democracies have achieved something the United States can't seem to do: provide health care for everybody at a reasonable cost.

In his global quest to find a possible prescription, Reid visits wealthy, free market, industrialized democracies like our own-including France, Germany, Japan, the U.K., and Canada-where he finds inspiration in example. Reid shares evidence from doctors, government officials, health care experts, and patients the world over, finding that foreign health care systems give everybody quality care at an affordable cost. And that dreaded monster "socialized medicine" turns out to be a myth. Many developed countries provide universal coverage with private doctors, private hospitals, and private insurance.

In addition to long-established systems, Reid also studies countries that have carried out major health care reform. The first question facing these countries-and the United States, for that matter-is an ethical issue: Is health care a human right? Most countries have already answered with a resolute yes, leaving the United States in the murky moral backwater with nations we typically think of as far less just than our own.

The Healing of America lays bare the moral question at the heart of our troubled system, dissecting the misleading rhetoric surrounding the health care debate. Reid sees problems elsewhere, too: He finds poorly paid doctors in Japan, endless lines inCanada, mistreated patients in Britain, spartan facilities in France. Still, all the other rich countries operate at a lower cost, produce better health statistics, and cover everybody. In the end, The Healing of America is a good news book: It finds models around the world that Americans can borrow to guarantee health care for everybody who needs it.

The Washington Post - Phillip Longman

Reid acknowledges that the health systems in the countries he studied have their own problems. He also admits that none has figured out how to contain the global long-term trend toward higher costs as populations age, the spread of Western lifestyle and diet causes an epidemic of chronic illness, and as expensive new medical technologies become available. But he does demonstrate that [critics] put forward a distorted image when they contend that other industrialized countries ration health care and constrain patients' choice of doctors, deny effective care and, in essence, provide socialized medicine. Reid shows us how other advanced countries easily combine universal coverage and government regulation with entrepreneurialism and respect for market forces to produce high quality, low cost health care—a simple empirical truth we can no longer afford to ignore.

Publishers Weekly

Washington Post correspondent Reid (The United States of Europe) explores health-care systems around the world in an effort to understand why the U.S. remains the only first world nation to refuse its citizens universal health care. Neither financial prudence nor concern for the commonweal explains the American position, according to Reid, whose findings divulge that the U.S. not only spends more money on health care than any other nation but also leaves 45 million residents uninsured, allowing about 22,000 to die from easily treatable diseases. Seeking treatment for the flareup of an old shoulder injury, he visits doctors in the U.S., France, Germany, Japan and England-with a stint in an Ayurvedic clinic in India-in a quest for treatment that dovetails with his search for a "cure" for America's health-care crisis, a narrative device that sometimes feels contrived, but allows him valuable firsthand experience. For all the scope of his research and his ability to mint neat rebuttals to the common American misconception that universal health care is "socialized" medicine, Reid neglects to address the elephant in the room: just how are we to sell these changes to the mighty providers and insurers? (Sept.)

Jacob Weisberg - Newsweek

In his new book The Healing of America, the journalist T. R. Reid employs a clever device for surveying the world's health systems: he takes an old shoulder injury to various countries. In the United States, a top orthopedist recommends joint-replacement surgery, costing tens of thousands of dollars. In France and Germany, doctors steer him instead toward a regime of physical therapy. In Britain, they tell him to go home. In India, he is treated, quite effectively, with herbs, massage, and meditation.

Reid argues we should follow other countries, where health care is fairer and cheaper and produces better results. He's right that we can learn much from practices elsewhere. But the lesson I took away from his book was somewhat different: health-care systems are not just policy choices, but expressions of national character and values. The alternatives he describes work not just because they're well designed but because they reflect the expectations and traditions of their societies.

Timothy Noah - Slate

Ignore the title (which, apart from being Sunday-schoolish, was used 12 years ago by the New Age spiritualist Marianne Williamson); a better would be Sick Around The World, which is what Reid called the excellent Frontline documentary he hosted on this topic last year. Even better: Around the World With My Bum Shoulder. Engagingly, Reid frames his inquiry by seeking relief for his aching right shoulder, which he injured while serving in the Navy in 1972. A surgeon at Bethesda Naval Hospital fixed it by inserting a stainless-steel screw into his clavicle, but three decades later Reid could no longer swing a golf club and could only just barely replace a hanging light bulb. In a show of the same sunny resourcefulness he displayed as a foreign correspondent for the Washington Post, Reid uses his ailment as a vehicle to explore the world's health systems.

Kirkus Reviews

A timely survey-filled with important lessons for the United States-of how other nations have created systems that provide universal health care for their citizens. Washington Post correspondent and NPR commentator Reid (The United States of Europe: The New Superpower and the End of American Supremacy, 2004, etc.) sees the health-care issue as a moral question to which all other technologically developed countries have responded well, creating affordable, effective systems. The author outlines four basic models: the Bismarck, in which both health-care providers and payers are private; the Beveridge, in which "health care is provided and financed by the government, through tax payments"; the National Health Insurance (NHI) model, in which the providers are private but everyone pays into a government-run insurance program; and the out-of-pocket model, in which the patient pays with no insurance or government help. Elements of all four are present in the United States. The author took his own health problem-a stiff, painful shoulder-to doctors in France, Germany and Japan to see how the Bismarck model worked; to Great Britain to assess the Beveridge model; to Canada to look at the NHI model; and to India, where the patient pays out of pocket. He also went to Switzerland and Taiwan, two countries that have recently reformed their health-care systems, to see how they accomplished major overhauls. Reid's personal experiences with doctors and hospitals make for entertaining reading-especially his encounter with Ayurvedic medicine-and his stories of patients who have been unable to get necessary health care are moving. More important, these anecdotes are embedded in solid research. The authorprovides a capsule history of each system, discusses its drawbacks as well as benefits and destroys some popular myths about so-called socialized medicine. Though he offers many image-shattering statistics that reveal how poorly the United States stacks up against other countries, the author's message is essentially optimistic: We can learn from the experience of other countries and use that knowledge to create a more efficient and humane system. A reasoned, well-balanced, highly readable account, especially welcome as the national debate over health care gets underway.

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For all her majestic self-assurance, Mrs. Rama did not immediately inspire confidence in her patient. After asking some basic questions, she shuffled the stones and statuettes around her checkerboard and launched into my diagnosis. “In the summer of 1986, you got married,” she declared firmly. Well, not exactly. In the summer of 1986, my wife and I celebrated our fourteenth wedding anniversary; by then we had three kids, a dog, and a minivan. “In 1998,” she went on, “you were far from home and were treated for serious illness.” Well, not exactly. Our American family was, in fact, living in London in 1998; but in that whole year, I never saw a doctor.

Mrs. Rama kept talking, but I stopped listening. To me, the stones and shells and statues all seemed preposterous. Still, I kept my mouth shut. If Indian medicine required yajnopathic analysis before health care could begin (and Mrs. Rama did eventually conclude that the timing was propitious for treatment), that was fine with me. I was willing to go along, in pursuit of the greater goal. For I had traveled to the Arya Vaidya clinic—it’s in the state of Tamil Nadu, at the southern tip of the subcontinent, where the Bay of Bengal meets the Arabian Sea—on a kind of medical pilgrimage. I was on a global quest, searching for solutions to two different health problems, one personal and one of national dimensions.

On the personal level, I was hoping to find some relief for my ailing right shoulder, which I bashed badly decades ago as a seaman, second class, in the U.S. Navy. In 1972, a navy surgeon (literally) screwed the joint back together, and that repair job worked fine for a while. Over time, though, the stainless-steel screw in my clavicle loosened; my shoulder grew increasingly painful and hard to move. By the first decade of the twenty-first century, I could no longer swing a golf club. I could barely reach up to replace a lightbulb overhead or get the wineglasses from the top shelf. Yearning for surcease from sorrow, I took that bum shoulder to doctors and clinics—including Mrs. Rama’s chikitsalayam—in countries around the world.

The quest began at home. I went to a brilliant American orthopedist, Dr. Donald Ferlic, a specialist who had skillfully repaired another broken joint of mine a few years back. Dr. Ferlic proposed a surgical intervention that reflects precisely the high-tech ethos of contemporary American medicine. This operation—it is known as a total shoulder arthroplasty, Procedure No. 080.81 on the National Center for Health Statistics’ roster of “clinical modifications”—would require the orthopedist to take a surgical saw, cut off the shoulder joint that God gave me, and replace it with a man-made contraption of silicon and titanium. This new arthroplastic joint would be hammered into my upper arm and then cemented to my clavicle. The doctor was confident that this would reduce my shoulder pain—orthopedic surgeons tend to be confident by nature—but I had serious reservations about Procedure No. 080.81. The saws and hammers and glue made the procedure sound rather drastic. It would cost tens of thousands of dollars (like most major medical procedures in the United States, the exact price was veiled in mystery). The best prognosis I could get was that the operation might or might not give me more shoulder movement. And when I asked Dr. Ferlic what could go wrong in the course of a total arthroplasty, he was completely honest. “Well, you have all the risks that go with major surgery,” he answered calmly. And then he listed the risks: Disease. Paralysis. Death.

With that, a certain skepticism crept into my soul about this hightech medical intervention. I departed my American surgeon’s office and took my aching shoulder to other doctors, doctors all over the globe. Over the next year or so, I had my blood pressure and temperature taken in ten different languages. I ran into a world of different diagnostic techniques, ranging from Mrs. Rama and her star charts to a diligent, studious doctor (we’ll meet him in chapter 9) who told me he couldn’t possibly analyze my medical condition without tasting my urine. In Taipei, an acupuncturist twirled her needles in my left knee to treat the pain in my right shoulder. The shoulder itself was examined, X-rayed, patted, poked, palpated, massaged, and manipulated in countless ways. Some of these treatments worked, more or less; as we’ll see in chapter 9, Mrs. Rama’s colleagues at the chikitsalayam were helpful. Others proved no help at all.

This was not a major disappointment, though, because that aching shoulder was really just a secondary impetus for my medical odyssey. It would be ridiculous, after all, to go all the way to the southern tip of India—not to mention London, Paris, Berlin, Tokyo, and so on—to get treatment for a sore shoulder that isn’t, frankly, all that sore. The stiffness is tolerable most of the time. I have another arm to use for changing lightbulbs or getting glasses off the shelf. I don’t have a golf swing anymore, but even when I could swing a club I was a rotten golfer.

So the shoulder was not my top priority. Rather, the primary goal of my travels was to find a solution to a much bigger medical problem. It’s a national problem—a national scandal, really—that is undermining the physical and fiscal health of every American. With help from many scholars and the Kaiser Family Foundation, I traveled the world searching for a prescription to fix our country’s seriously ailing health care system. As Nikki White’s experience demonstrates, it’s fundamentally a moral problem: We’ve created a health care system that leaves millions of our fellow citizens out in the cold. Beyond the issue of coverage, however, the United States also performs below other wealthy countries in matters of cost, quality, and choice.

Most Americans can remember when our politicians used to boast—and we used to believe—that the United States had “the finest health care system in the world.” Today, any U.S. politician who dared to make that claim—it was last heard in a State of the Union address in 2002—would be hooted out of the room. Americans generally recognize now that our nation’s health care system has become excessively expensive, ineffective, and unjust. 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. In 2000, when a Harvard Medical School professor working at the World Health Organization developed a complicated formula to rate the quality and fairness of national health care systems around the world, the richest nation on earth ranked thirty-seventh.1 That placed us just behind Dominica and Costa Rica, and just ahead of Slovenia and Cuba. France came in first. (For more about the WHO’s global ranking, see the appendix.)

The one area where the United States unquestionably leads the world is in spending. Even countries with considerably older populations than ours, with more need for medical attention, spend much less than we do. Japan has the oldest population in the world, and the Japanese go to the doctor more than anybody—about fourteen office

There’s nothing particularly wrong with spending a lot of money on something important, as long as you get a decent return for what you spend. It’s certainly not wasteful to spend money for effective medical treatment. If a dentist who was about to drill a tooth offered her patient a choice between listening to pleasant music for free to lessen the pain, or a shot of Novocain for $50, most people would pay for the shot and would probably get their money’s worth. And there’s nothing wrong with paying more for better performance. Those fifty-two-inch high-definition plasma televisions that people hang on the family room wall these days cost five times what a top-of-the-line set would have cost ten years ago, but buyers are willing to shell out the extra money because the enhanced viewing quality is worth the price.

When it comes to medical care, though, Americans are shelling out the big bucks without getting what we pay for. As we’ll see shortly, the quality of medical care that Americans buy is often inferior to the treatment people get in other countries. And patients know it. Surveys show that Americans who see a doctor tend to be less satisfied with their treatment than Britons, Italians, Germans, Canadians, or the Japanese— even though we pay the doctor much more than they do.2

You don’t need an advanced degree in yajnopathy to recognize that the stars are aligned and the timing is propitious for the United States to establish a new national health care system. As Americans voted in the 2008 election, only 18 percent told the pollsters that the U.S. health care system was working well. Even American doctors, who generally do just fine, thank you, in financial terms, are unhappy with the ridiculously cumbersome and unjust system that has built up around them. And those Americans who want change in our system— which is to say, almost all Americans—are not willing to settle for minor tinkering or small-scale adjustments. Rather, 79 percent told the pollsters they want to see either “fundamental changes” or “a complete overhaul.”

The thesis of this book is that we can bring about fundamental change by borrowing ideas from foreign models of health care. For me, that conclusion stems from personal experience. I’ve worked overseas for years as a foreign correspondent; our family has lived on three continents, and we’ve used the health care systems in other wealthy countries with satisfaction. But many Americans intensely dislike the idea that we might learn useful policy ideas from other countries, particularly in medicine. The leaders of the health care industry and the medical profession, not to mention the political establishment, have a single, all-purpose response they fall back on whenever somebody suggests that the United States might usefully study foreign health care systems: “But it’s socialized medicine!”

This is supposed to end the argument. The contention is that the United States, with its commitment to free markets and low taxes, could never rely on big-government socialism the way other countries do. Americans have learned in school that the private sector can handle things better and more efficiently than government ever could. In U.S. policy debates, the term “socialized medicine” has been a powerful political weapon—even though nobody can quite define what it means. The term was popularized by a public relations firm working for the American Medical Association in 1947 to disparage President Truman’s proposal for a national health care system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to health care must be a communist. And the phrase has retained its political power for six decades.

There are two basic flaws, though, in this argument.

1. Most national health care systems are not “socialized.” As we’ll see, many foreign countries provide universal health care of high quality at reasonable cost using private doctors, private hospitals, and private insurance plans. Some countries offering universal coverage have a smaller government role than the United States does. Americans switch to government-run Medicare when they turn sixty-five; in Germany and Switzerland, seniors stick with their private insurers no matter how old they are. Even where government plays a large role, doctors’ offices are operated as private businesses. As we’ll see in chapter 7, my doctor in London, Dr. Ahmed Badat, was nobody’s socialist; he was a fiercely entrepreneurial capitalist who regularly found ways to enhance his income within the National Health Service. Many countries have privately owned hospitals, some run by charities, some for profit; Japan has more for-profit hospitals than the United States. In short, the universal health care systems in developed countries around the world are not nearly as “socialized” as the health insurance industry and the American Medical Association want you to think.
   
   
2. “Socialized medicine” may be a scary term, but in practice, Americans rather like government-run medicine. The U.S. Department of Veterans Affairs is one of the world’s purest models of socialized medicine at work. In the Medicare system, covering about 44 million elderly or disabled Americans, the federal government makes the rules and pays the bills. And yet both of these “socialized” health care systems are enormously popular with the people who use them and consistently rate high in surveys of patient satisfaction. That’s why President Obama has consistently promised to save both government-run systems, no matter what other changes he makes in health care.

The academics have a term for this approach to problem-solving: “comparative policy analysis.” The patron saint of comparative policy analysis was an American military hero who went on to become our thirty-fourth president: Dwight D. Eisenhower. That’s why this book is dedicated to his memory.

When Eisenhower became president, in 1953, the key domestic issue was the sorry state of the nation’s transit infrastructure. Almost all major highways then were two-lane country roads designed primarily to get farmers’ crops to the nearest market. Interstate travel was a torturous ordeal, marked by rickety bridges and long stretches of mud or gravel between intermittent paved sections. As postwar America embraced the automobile, it was clear that vast improvements were required. And most of the forty-eight states already had highway plans on the books. For the most part, those blueprints called for networks of two-lane highways that would run through the downtown Main Street of every city along the route. These were perfectly reasonable plans for the time. But Eisenhower, who recognized the value of comparative policy analysis, had a better idea.

As Supreme Allied Commander during World War II, Ike had commanded the long push by American and British soldiers toward Berlin after the D-day landings in June 1944. By the spring of 1945, the Allies had battled their way across France to Germany’s western border. Eisenhower’s strategic plan envisioned months of painful slogging across a shattered German countryside. But then his forward commanders reported an amazing discovery: a broad ribbon of highway, the best road system anybody had ever seen, stretching straight through the heart of Germany. This was the autobahn network, built in the 1930s, which featured four-lane highways; overpasses and ramped interchanges to avoid intersections; and rest areas for refueling every hundred miles or so. Once Eisenhower’s trucks, tanks, and troop carriers found the superhighway, they moved much faster than Ike had planned. By early May of 1945, the war in Europe was over. Those German roads came to mind when, in 1953, President Eisenhower was presented with rather timid plans for a two-lane highway network across America. “After seeing the autobahns of modern Germany, and knowing the assets those highways were to the Germans,” he wrote in his memoirs, “I decided, as President, to put an emphasis on this kind of road-building. I made a personal and absolute decision to see that the nation would benefit from it. The [American plans] had started me thinking about good, two-lane highways, but Germany had made me see the wisdom of broader ribbons across the land.”5 So Eisenhower built those “broader ribbons”: a state-of-the-art network designed to a single national standard, with four-lane divided highways; overpasses and ramped interchanges to avoid intersections; and rest areas for refueling every hundred miles or so. There was considerable debate about how to pay for this hugely ambitious engineering project. A giant bond issue was proposed. But in those more innocent times, it was considered irresponsible for the federal government to run up large debts; in the end, Ike settled on a highway trust fund financed by gasoline taxes.

Today, the interstates—formally designated the Dwight D. Eisenhower System of Interstate and Defense Highways—comprise 47,000 miles of road, 55,500 bridges, 14,750 interchanges, and zero stoplights. The system has spawned such basic elements of American life as the suburb, the motel, the chain store, the recreational vehicle, the automotive seat belt, the spring-break trek to Florida, the thirtymile commute to work, and, on the dark side, the two-mile-long traffic jam. It’s one of the finest highway networks in the world—and nobody seems to care that the basic idea was copied from the Nazis.6 Eisenhower, the pragmatic commander, was willing to borrow a good policy idea, even if it had foreign lineage. In the same spirit, my sore shoulder and I hit the road, looking for good ideas for managing a nation’s health care. But where should I look?