liberty-weepingIn other words: America is unique and, some would argue, superior.

Well, duh. Every country is unique. And every country probably has some area in which it is (depending on your values) superior to other countries. Alas, in the area of taking care of our own, we are not doing all that well; which is why I like TR Reid’s idea of taking a serious and deep look at what other developed nations are doing for healthcare with the idea that we can do it just as well, if not better.

Let’s look at the four basic models of healthcare provision currently in use:

  • The Bismarck Model, founded by Otto von Bismarck in Germany in the 19th century. This is a privatized but non-profit multiple payer model.
  • The Beveridge Model, invented by William Beveridge in Britain. This is a public service like the police and fire department.
  • The National  Health Insurance System (NHIS) Model, which has elements of both Bismarck and Beveridge systems. It has private providers, but government run funds to pay out.
  • The Out-of-Pocket Model, which is used in the developing world. Basically, the rich get medical care, the poor don’t. Pretty simple.

Reid comments, “Of course the foreign models could work for Americans; they already do.”


Yes, it’s true. Each of these systems is in use in the US already and serves some segment of our population.

For example, for people over 65, we’ve adapted the Canadian NHIS model and even used the same name the system’s inventor gave it: Medicare. For those of us who get care through an employer (I get mine through Jeff’s employer, Apple), we’re using the Bismarck system (Germany and Japan). For the rest of our population, we’re using the Out-of-Pocket-System (OOPS). Huh. Now there’s an appropriate acronym. “Oops, sorry. You fell through the cracks.”

Why isn’t this working for us? Because it’s chaotic and piecemeal. And that is also why healthcare costs us more.

Here’s REALITY #5 to go with MYTH #5: All healthcare systems are not the same.

j0292026_2f597000There are a myriad variations on the basic theme that ALL residents of a country must be covered. My friend Moshe helped shed light on this by chipping in how the Israeli healthcare system (which Reid doesn’t address directly) works. Some systems have co-pays, others don’t. Some have the bill footed by taxes, others have premiums. (Remember Taiwan? $13 co-pays and $150 per month premiums.) Most provide free care to pregnant women and newborns. Some offer yearly checkups, others monitor health levels at every visit. Some countries assign the healthcare premium as a percentage of income, others let the insurance plans set their own rates (with oversight, of course).

The central principle is: EVERYONE MUST BE CARED FOR. What varies from nation to nation is how financing and delivery is handled.

This is a critical point: What keeps our healthcare from being as good as we want to believe it is, is the delivery system. That’s what’s broken. Our medical care here is great. Our delivery system sucks. Okay, okay—language. I mean, it’s broken.

Reid suggests that by studying the above models and variations and exploring their strengths and weaknesses, we can learn how to create our own universal healthcare SYSTEM. A unified system of just about any kind will cost us—as a nation and as individuals—far less than what we’ve got now because of a set of central realities:

  • A unified delivery system is far more efficient than a chaotic piecemeal one. This is true of any delivery system, not just healthcare. Look at industry: companies keep costs lower when they standardize.
  • A unified system makes it much easier to use digital record-keeping. You’ve seen those commercials where the guy’s getting an exam in front of a lecture hall full of docs whose experience with him is available on his current physician’s computer? They already have that in Japan, France, and Germany. I’ve seen it in some medical offices here. The ACA now mandates a move in that direction here, and the fact that insurers now must spend 80-85% of premiums on actual healthcare should create a greater incentive for efficiency.
  • A unified system eliminates the cost-shifting that a piecemeal system has. That is, if a hospital is underpaid by Medicare, it shifts the costs to other payers. With a unified system, there’s no need for this sleight of hand.
  • A unified system creates incentives for preventive healthcare. If you’ve got to take everyone, you have a vested interest in keeping them healthy. You can’t just remove them from the rolls.
  • A unified system is a powerful force for cost control. Reid notes that “Since the single healthcare system is the only buyer of medical services, it has enormous market clout.” (Evidence: An MRI costs $89 in Japan. It costs $1200 in the US or more, depending on where you have it done.)

My personal take on this: I had brain surgery in 1992 which necessitated follow-up visits. My neurophysician had me getting MRIs at a facility attached to Davis University. When my employer switched insurance plans, they insisted I get my MRIs at a less expensive mobile facility in our home town. Result? The inferior quality of the image from the portable MRI in Nevada City caused my doctor to have to schedule more MRIs and more frequent visits to get a baseline for comparison. So whatever money they saved with cheaper MRIs they spent in more frequent MRIs and visits to a specialist. That’s the sort of inefficiency a piecemeal system can cause.

Anyway, I’m all mythed out now but I’d like to close with this observation: The service is not the delivery system. Most countries rely on free-market service providers for healthcare, but not to pay for it. The fundamental difference between our “system” and the ones used by other countries is that their health insurance plans exist only to pay people’s medical bills, NOT to make a profit or pay dividends to investors.

work_med1I should add that when employers are not tasked with insuring their employees directly, their costs fall, as well, which puts them on a more equal footing with other international businesses. Right now, the fact that US employers have to offer insurance results in an uneven playing field when they compete against companies that don’t have to cover the cost of healthcare directly.

Food for thought: We have public policing, public fire departments, public schools. Why are we so averse to going public in one of the most critical facets of our existence?


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