What the U.S. can learn from other health care systems

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, it’s good to be back after a nice year end break
and let me wish all of our listeners a happy and healthy New Year as the
wheel turned again.

Margaret Flinter: Mark, let me add my voice to that chorus of Happy New
Year greetings and we hope that this year brings about a resolution to
our National Health Care Debate and that we can guarantee access to
those in need and provide a world class level of care for everybody.

Mark Masselli: That’s a great resolution. But will Congress be able to get
their resolutions resolved? It appears that the road will not go back to
the United States Senate as the Democrats lost their super majority on
Tuesday as the special election in Massachusetts sent a Republican to fill
the Senate seat long held by Senator Ted Kennedy.

Margaret Flinter: We had the reporter’s itch yesterday about the election
so we drove up to a small voting precinct about 30 miles outside of
Boston to get a feel for voter mood. It turned out that Massachusetts
voters were coming out in droves and like that postman they were going
to deliver message regardless of rain, snow or sleet that was falling the
voters’ mood had turned.

Mark Masselli: The results seemed like a bad dream as it was just one
year ago today that you and I were in Washington DC in a sea of millions
of excited celebrants witnessing history as President Obama was sworn
into o ! ce and the Democratic Party was riding a high.

Margaret Flinter: It really has the making of a Greek Tragedy as Senator
Kennedy had been the inspiration behind so much of the work around
health care reform for decades. Now with the loss of his seat it has the
Democrats again forced to recalibrate how to get health care reform
passed.

Mark Masselli: That recalibration has been percolating up for the past
week as the polls started to show that their senate strategy of counting
on a super majority was over. There appear a number of avenues that are
being explored with many variations on each of them but they boil down
to either having a house pass the senate bill as it is with no amendments

or attach a health reform bill to the budget bill which will only require 50
votes in the Senate or they could go back to the Senate and try to reform
the bill to attract Senator Olympia Snowe’s vote.

Margaret Flinter: Mark, I think you are right about a variation and if
House Majority Leader Steny Hoyer is any indicator of what might be in
play, he said yesterday that passing the Senate bill is better than nothing.
But this will be very hard for members of the house as the senate bill is
more conservative than the house version and it hurts some of the
house’s most important constituents.

Mark Masselli: But while it might be possible to resolve those issues
through the budget bill, what looms larger is that many Americans are
not happy that one party alone is passing such an important piece of
legislation and more importantly America’s major concern has shifted to
the economy and Democrats have not yet made a convincing connection
between those two issues.

Margaret Flinter: We have said it before this process was always going to
be a rollercoaster. We will keep you informed as the debate continues
but this week’s Conversations On Health Care will be interviewing
Washington Post correspondent T.R. Reid to discuss his new book about
health care systems around the world and what the US can learn from
that.

Mark Masselli: T.R. Reid’s book The Healing of America: A Global Quest
for Better, Cheaper, and Fairer Health Care explores health care systems
around the world in an e " ort to understand why the US remains the only
first world nation to refuse its citizens universal health care.

Margaret Flinter: No matter what the story you can hear all of our shows
on our website www.chcradio.com . You can now subscribe to iTunes to
get our show regularly downloaded or if you would like to hang on to our
every word and read a transcript of one of our shows, come visit us at
www.chcradio.com .

Mark Masselli: And as always, if you have feedback, Email us at
[email protected] we would love to hear from you. We are also
happy to announce a new member to the Conversations on Health Care
team, Loren Bonner, is our new producer and we are glad she has joined
our team. Let’s check in with her and hear our headline news.

Loren Bonner: Thanks Mark and Margaret. I am very excited to join the
team of Conversations on Health Care. I am Lorraine Barner with this
week’s headline news. Republican State Senator Scott Brown’s victory for
the Massachusetts State Senate Seat presented a big blow for Democrats
and the health care bill they have been working tirelessly to pass for
almost a year. Brown defeated Martha Coakley, the state’s attorney
general; Brown had 52% of the votes and Coakley 47% when the results
st
came in Tuesday night. Brown vowed to be the 41 vote in the Senate
against health care reform giving the senate republicans enough leverage
to filibuster the President’s health care overhaul. Hofstra University
Presidential Scholar Meena Bose says the loss of the senate seat will hurt
Democrats.

Meena Bose: This is a major setback for the Democratic Party, for the
Obama Administration, and for the administrations agenda for the next
year and it raises some serious questions about the fate of the democrats
in the November mid-term election.

Loren Bonner: Democratic leaders have been in rescue mode for some
days preparing for the defeat; top law makers said they were weighing
other options. The Brown victory forces the White House and
congressional leaders to decide how or whether to salvage their long side
health care overhaul. Democrats had hoped to deliver a health care bill
to President Obama before his State of the Union Address which is
th
scheduled for January 27 but rushing the bill carries political risks after
the Massachusetts upset as does letting it collapse. Although no formal
proposal has been taken to the House Leadership, the preferred plan B
for the moment would be to try to persuade House Democrats to approve
the health care bill that the Senate approved on Christmas Eve. This
would block the need for an additional senate vote and send the measure
directly to President Obama for his signature. House Majority Leader
Steny Hoyer said some health care reform is better than none.

Steny Hoyer: I think the senate bill clearly is better than nothing.

Loren Bonner: But the likelihood of this happening appears dim. House
Liberals opposed key di " erences in the senate version, a tax on high-end
insurance plan and less generous assistance to help low income
Americans by insurance. From a political and public relations standpoint,
o ! cials said it seemed better for House Democrats to set forward and
make the case that approving the senate bill would be better than having
no health care bill at all.

(Music)

Loren Bonner: Today we are happy to have T.R. Reid as a guest on our
show. Mr. Reid has an impressive career as a journalist. He is a
commentator on National Public Radio, a correspondent for the
Washington Post, and a health policy fellow of the Kaiser Family
Foundation. He has also written numerous books. His latest is called
The Healing of America: A Global Quest for Better, Cheaper, and Fairer
Health Care. The book emerged from months of travel for the 2008
frontline documentary Sick Around the World. As a lead correspondent,
Mr. Reid examined five other capitalist democracies looking for lessons
on health care delivery. He wanted to find out how other developed
nations fared on delivering health care and how it might serve America in
its search for a better system. Mr. Reid set out on his mission equipped
with two things. First, he wanted to know how other nations kept healthy
by spending less on health care. Almost all other countries have better
health results than the United States and they don’t spend nearly as much
on health care as we do. These countries have longer life expectancy
rates, much lower neonatal death rates, and better recovery rates from
major diseases. Second, Mr. Reid had a nagging shoulder injury. In the
United States a doctor recommended a costly invasive surgery but in
countries he traveled to he found the systems worked better in treating
his ailing shoulder. In France and Germany, doctors suggested physical
therapy; in England, they told him to go home and in India, they treated
him with herbs, massage, and meditation. Mr. Reid claims this is where
he found the greatest relief even after some initial skepticism. Health
care systems are not just policy choices but expressions of national
character and values. In The Healing of America, Mr. Reid presents four
di " erent models of medical care used around the world. Mr. Reid thinks
we can learn something from other countries on how they do health care,
and in doing so, perhaps we can begin to rethink some of our core
values. Mark and Margaret interviewed Mr. Reid about his new book.

Mark Masselli: This is Conversations on Health Care. We are speaking
with T.R. Reid author of the best selling book The Healing of America: A
Global Quest for Better, Cheaper, and Fairer Health Care. T.R. Reid,
welcome to the Conversations on Health Care. So most people with a
hurt shoulder would stick with a doc in their neighborhood, you decided
to take that shoulder to nine di " erent countries to see how their di " erent
systems of paying for health care would a " ect the diagnosis about the
shoulder kind of an unusual approach. How did doctors react to finding
you in their waiting room and what did they tell you?

T.R. Reid: Yeah I was really looking for two cures. I was hoping that
somebody might fix my bumped shoulder but I was also trying to figure
out what we could learn about running a health care system in those
countries because the fact is Mark all the other industrialized
democracies, all of them cover everybody with high quality care and they
spend half as much as we do on health care. So I was trying to figure
how do you that.

Margaret Flinter: In your book Tom you say there are basically four
di " erent models that those countries have used to get to that place of
providing universal care for people from Bismarck to out-of-pocket. And
you point out that in some ways United States has elements of all those
systems, can you tell us about those systems?

T.R. Reid: Yeah. One of the striking things is guess what it’s not all
socialized medicine overseas and in some countries like Britain, Spain,
Italy, government owns the hospitals, government employs the doctors,
government buys the bills and government pays the bills; I would call that
socialized medicine. But there are other countries where they cover
everybody with private doctors, private hospitals, and private insurance
that would be for example Germany, Switzerland, Belgium, Netherlands,
Japan, France to a degree; these are private systems. Germany has no
Medicare; people stay with private insurance cradle to grave. So I argue
that’s less socialized in the United States. Another model I call it the
National Health Insurance Model, it's kind of a mix, the providers, the
doc, the hospitals, the labs etc., are all private and then the payment
scheme, the insurance scheme is run by government so that’s kind of
what would you call that quasi socialized medicine that’s found in
Canada, Australia, etc. And then the fourth model is the most common
model because in the poor countries of the world there is no health care
system so that model is called the out-of-pocket model basically if your
child is sick and you have some money in your pocket to pay to the
doctor, she gets treated and if you don’t have any money she stays sick
or dies. It's brutal, it's simple and it’s a fact of life in about 150
countries. And the kind of a striking thing for an American is we have
got them all. If you are a veteran or a Native American, they live in Britain
for health care because the VA is exactly like Britain’s government run an
HS. If you are getting private health insurance through your employer,
you live in Germany. That’s the German model. If you are over 65 and
you go to private doctors but have government run Medicare insurance,
that’s the Canadian model. In fact when Canada invented that model,
they called it Medicare. And for the 40 million Americans or so with no

insurance, they live in Angola or Afghanistan, that’s the out-of-pocket
model right here in the richest country in the world, we have got them all.

Mark Masselli: As you said, private insurance companies play a valuable
role, an important role in almost all of the developed countries health
care systems such as Germany, Japan, France, Netherlands but they are
all nonprofit. It looks like a conflict between dividend paying, for-profit
health insurance and the administrative simplicity, cost control, fairness
and transparency. Here, in the US, it seems like the for-profit health
insurance is here to stay. How do you that a " ects our opportunities for
real health care reform?

T.R. Reid: All the other rich countries that use private insurance have
decided, as you say, there is a basic conflict between paying for people’s
health care and paying a dividend to investors you can't do both. That’s
not so unusual for America. Health insurance was born in America as a
nonprofit endeavor. Blue Cross and Blue Shield all started out as
nonprofit ways to help people with their health care. And then in the
‘70s and ‘80s the big insurance companies like United Health and Aetna
started buying up these State Blue Cross operations and turning them
into for-profit but that’s a relatively new development in America. There
are still some nonprofit health insurance companies in America but most
of the business is run by these big for-profit companies so as I say other
countries wouldn’t let it work that way.

Margaret Flinter: T.R. as a large primary care organization that converted
to electronic health records several years ago, Mark and I could relate to
your observations of going into doctors’ o ! ces in France or Germany and
finding no paper charts on the wall. In your book you talked about that
little sign you found in the o ! ces in France which I translate as we accept
la carte, a simple plastic card that every French citizen has with all their
health care information on it something we haven’t seen in the United
States yet and they have had that system since 1998. Can you tell us a
little bit about that and the impact it has on the health costs in the
country?

T.R. Reid: Yeah that system really works. It improves health care
because every provider you go to can see your record and know what pills
you are taking or what kind of treatments you have had. You know I am
sure you have seen this, you walk down the hall in an American hospital
and there is a woman walking along with a walker in one hand and her
big fat medical file in the other and papers are falling out of it or she
happens to forget it then the doctor doesn’t know what she’s got. So it

definitely provides for better care and it's vastly cheaper. I went to a 900
bed hospital in Canada that’s a pretty big hospital and they were giving
me a tour and I said where is the billing o ! ce, turns out the billing o ! ce
in a hospital that big in Canada is two part timers who come in the last
two days of the month that’s it. An American hospital that size would
have 200 people working full time on billing, shu # ing paper, filling out
forms. So if you design the system, you can really save hundreds,
hundreds of millions of dollars a year on administrative cost.

Mark Masselli: We are speaking with T.R. Reid, author of the bestselling
book The Healing of America: A Global Quest for Better, Cheaper, and
Fairer Health Care. You mentioned a few fundamental truths one every
system a country has the people will complain about it, doctors and
hospitals will always say they are not being paid enough and everyone
always thinks the last heath reform e " ort failed so there is no system that
is perfect. Is that why there is such a disconnect here in America and why
we saw the thousands of people out at town hall meetings last summer?

T.R. Reid: Well that’s certainly true. I mean most of the countries have
higher rates of satisfaction, they like their system better than Americans
do but yeah, the people are always complaining and I have never met a
doctor anywhere in the world who is paid enough they are all underpaid
and they are getting shafted by the system no matter what the system is.
The striking thing is, in the other countries, they are constantly adjusting
and fixing you know the French system I think is pretty good, it was rated
number one in the world by the World Health Organization. They have
health care reform every three-four years kind of regularly; we have got a
system that people are not happy with, it's not working and we can't
seem to reform it so figure that one out.

Margaret Flinter: T.R. back to the United States we have a fee-for-service
system that rewards procedures in volume but sometimes at the expense
of everything else and many people say that’s a fundamental problem
with our system. But you don’t seem to say that, you instead present a
variety of models, the fee-for-service models in France and Germany as
well as the total capitation model in Great Britain where the GP is really at
the center of care. Do you have a thought about the path forward in the
United States on this issue?

T.R. Reid: Well you are right. There is a big buzzword, let’s get rid of
fee-for-service but what I found as you say in a lot of countries, France,
Germany, Japan, Taiwan, they have fee-for-service systems that work
fine; I mean they cover everybody for about half the cost that we spend.

Here’s how you do it, are you ready, you pay less for those services. In
Japan, they decide which services they think are valuable and on those
ones they pay a decent fee for and if doctors are doing procedures or
diagnostic tests that the health ministry don’t like, they let them do it
they just don’t pay them much and guess what, the doctors do fewer.

Mark Masselli: I have really enjoyed reading about your pursuits of
helping your aching shoulder. I have a rugby injury and I am thinking
about going o " to that Ayurvedic treatment in India, an ancient healing
system based on helping the body heal itself, clearly it helped you. You
did not say much about the role of complimentary and alternative health
in the US system that we know is a multibillion dollar industry. How do
you think it fits into the United States’ system?

T.R. Reid: I think a lot of those so called complimentary approaches
work. In my case, as you say, I went to an ayurvedic treatment center in
India. They massaged my shoulder, my whole body as a matter of fact
with warm oil everyday for weeks it was wonderful. And although I
certainly didn’t expect it, I got improvement I got less pain and more
movement out of that treatment so I think these modalities work. Lots of
people swear by acupuncture, there is definitely room for them. And
other systems, Germany, Japan, for example, they just pay for everything
they are really wide open. In America, because the insurance companies
are so concerned of it paying a profit to their investors, they are much
less willing to be open to these modalities.

Margaret Flinter: In the prologue of your book you told us about Nicky
White, a young woman who died at 32 supposedly from lupus but really
from a combination of lupus and having no health insurance. You
mentioned talking to her doctor at a community health centre in
Tennessee. There are thousand heath centers across America with 70
million patients and probably a big expansion coming. Have you given
any thought to the role of community health centers in the emerging US
health care system?

T.R. Reid: Well they help but you need an insurance structure to pay for
them and that’s really the problem in America. This is the most
important di " erence between the US and the other countries I went to.
Those countries made a commitment from the beginning let’s cover
everybody. They said a rich country has a moral obligation to provide
health care for everybody. It's only the United States that lets people
su " er from treatable illnesses but not get treated because they can't
a " ord it and as you know the Institute of Medicine says about 22,000

Americans die every year with treatable diseases because they can't a " ord
a doctor. Other countries won't let that happen. Nobody dies in
Germany because they can't a " ord a doctor, zero. And a community
health center is an approach to that but you have got to pay for it and
that’s why you really need universal insurance coverage to bring in the
funds to pay to the people when they happen to get sick or get hurt.

Mark Masselli: You said to reach universal health care coverage we will
need an e " ort equivalent to Martin Luther King Jr. and President Lyndon
Johnson on civil rights a passionate, articulate, moral reformer, and a
hard driving canny politician to ram it through. How does President
Obama’s e " ort stack up against that standard?

T.R. Reid: I mean if you look at the bill they are going to get, they just
haven’t succeeded. They did not manage to concede the American
people that we have an obligation to cover everybody so I have been
really disappointed with the debate we had. I think once the President
started saying hey if you have good insurance don’t worry everything is
going to be fine, that was a losing argument as it turned out because that
made the whole thing selfish rather I think it would have been better if he
had said we are going to keep your insurance but the more important
thing is to see that all of our fellow citizens in America get health care
which is what we said about civil rights. This is the way they got the
universal coverage in the other countries, a leader reminded people that
their neighbors aren’t getting as good care as they are and we kind of
lost that point in our argument.

Margaret Flinter: And you made that point very compellingly and we
appreciate that. Let me ask you, you have shared many insights about
innovations in health care delivery around the world, any one or anything
that really excites you right now that didn’t make it into your book? Who
should our listeners be keeping an eye on?

T.R. Reid: Well the striking thing is there are lot of countries in the last
10-15 years that went from third world countries to exporters to
becoming wealthy countries and a lot of countries are moving towards
universal coverage. I don’t know if this makes Americans proud but our
neighbor to the south by the end of this year will have everybody
covered, they are going to have a universal coverage system they
basically adopted the Canadian model for that. Are you proud that
Mexico covers everybody and we don’t? And many countries with much
lower per capita income than the US has are moving towards universal

coverage. Hey, if Taiwan can do it, why can’t the United States of
America?

Mark Masselli: We have been speaking with T.R. Reid, author of the
bestselling book The Healing of America: A Global Quest for Better,
Cheaper And Fairer Health Care. T.R. Reid, thank you for joining us thing
morning.

T.R. Reid: Mark, Margaret, it’s been great, thank you.

Margaret Flinter: Thank you.

Mark Masselli: Each week, Conversations highlights a bright idea about
how to make wellness a part of our communities and everyday lives. This
week our bright idea focuses on community gardens as a way to improve
community members’ health while also fostering greater unity between
them. The modern concept of community gardens in urban and
suburban neighborhoods has been around since the 1940s when wartime
food shortages inspired the development of Victory Gardens. Usually
maintained by several families, these gardens provided communities with
fresh seasonal fruits and vegetables that were otherwise scarce and
expensive. These days, people are again seeing the tremendous benefits
that community gardens have to o " er. One such community is New York
South Bronx. The South Bronx is notorious for its public health problems
and gang violence but recently a group of residents have been working to
reverse those trends. This year, the area’s first community garden was
established known as La Finca Del Sur literally the farm of the south.
This urban garden is managed by women of color in the South Bronx
community. These women have transformed three acres of polluted open
lots into thriving source of fresh flowers and produce complete with a
farmers’ market, children’s programs, and a performance space for local
music and theater. La Finca Del Sur’s goal is to provide a " ordable fresh
organic food, encourage local economic empowerment and promote
health awareness. Now that the garden is operating at full capacity,
community members enjoy a wide variety of fresh flowers and produce
including mint, Russian sage, English thyme, red lettuce, green peppers,
flowering acacia and purple coneflowers. In addition to providing South
Bronx residents with often scarce fresh produce, the community garden
also plays a key role in a new health program at the local community
center. The point, this program works to teach youth about how to eat a
balanced diet using La Finca’s produce as examples of healthy foods. In
the South Bronx, the asthma rate is among the highest in the country and
the diabetes rate is the highest in the city. However programs like this

one are helping to change those statistics by providing students and their
families with both the education and resources to lead healthier lives.
Community gardens like La Finca Del Sur can be found thriving
everywhere from Seattle to Johannesburg, from St. Luis to Copenhagen.
Also, in support of these gardens and healthy habits they promote, the
US Department of Agriculture recently launched a program called Know
Your Farmer Know Your Food to encourage increased growing and
purchasing of local foods. As the positive health impacts of community
gardens become more widely known in the coming years, we can expect
to see more and more implemented across the country and around the
world. Growing community unity and good food, now that’s a bright
idea.

Margaret Flinter: This is Conversations on Health Care. I am Margaret
Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Loren Bonner: Conversations on Health Care, broadcasted from the
Campus of Wesleyan University at WESU, streaming live at Wesufm.org
and brought to by the Community Health Center.