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Paul Krugman The draft Democratic Party platform that was sent out last week puts health care reform front and center. “If one thing came through in the platform hearings,” says the document, “it was that Democrats are united around a commitment to provide every American access to affordable, comprehensive health care.” Can Democrats deliver on that commitment? In principle, it should be easy. In practice, supporters of health care reform, myself included, will be hanging on by their fingernails until legislation is actually passed. What’s easy about guaranteed health care for all? For one thing, we know that it’s economically feasible: every wealthy country except the United States already has some form of guaranteed health care. The hazards Americans treat as facts of life — the risk of losing your insurance, the risk that you won’t be able to afford necessary care, the chance that you’ll be financially ruined by medical costs — would be considered unthinkable in any other advanced nation. The politics of guaranteed care are also easy, at least in one sense: if the Democrats do manage to establish a system of universal coverage, the nation will love it. I know that’s not what everyone says; some pundits claim that the United States has a uniquely individualistic culture, and that Americans won’t accept any system that makes health care a collective responsibility. Those who say this, however, seem to forget that we already have a program — you may have heard of it — called Medicare. It’s a program that collects money from every worker’s paycheck and uses it to pay the medical bills of everyone 65 and older. And it’s immensely popular. There’s every reason to believe that a program that extends universal coverage to the nonelderly would soon become equally popular. Consider the case of Massachusetts, which passed a state-level plan for universal coverage two years ago. The Massachusetts plan has come in for a lot of criticism. It includes individual mandates — that is, people are required to buy coverage, even if they’d prefer to take their chances. And its costs are running much higher than expected, mainly because it turns out that there were more people without insurance than anyone realized. Yet recent polls show overwhelming support for the plan — support that has grown stronger since it went into effect, despite the new system’s teething troubles. Once a system of universal health coverage exists, it seems, people want to keep it. So why be nervous about the prospects for reform? Because it’s hard to get universal care established in the first place. There are, I’d argue, three big hurdles. First, the Democrats have to win the election — and win it by enough to face down Republicans, who are still, 42 years after Medicare went into operation, denouncing “socialized medicine.” Second, they have to overcome the public’s fear of change. Some health care reformers wanted the Democrats to endorse a single-payer, Medicare-type system for all. On the sheer economic merits, they’re right: single-payer would be more efficient than a system that preserves a role for private insurance companies. But it’s better to have an imperfect universal health care plan than none at all — and the only way to get a universal health care plan passed soon is to inoculate it against Harry-and-Louise-type claims that people will be forced into plans “designed by government bureaucrats.” So the Democratic platform emphasizes choice, declaring that Americans “should have the option of keeping the coverage they have or choosing from a wide array of health insurance plans, including many private health insurance options and a public plan.” We’ll see if that’s enough. The final hurdle facing health care reform is the risk that the next president and Congress will lose focus. There will be many problems crying out for solutions, from a weak economy to foreign policy crises. It will be easy and tempting to put health care on the back burner for a bit — and then forget about it. So I’m nervous. The history of the pursuit of universal health care in America is one of missed chances, of political opportunities frittered away. Let’s hope that this time is different. One more thing: if we do get real health care
reform, a lot of people will owe a debt of gratitude to none other
than John Edwards. When Mr. Edwards dropped out of the presidential
race, I credited him with making universal health care a “possible
dream for the next administration.” Mr. Edwards’s
political career is over — but perhaps he and his family
can take some solace from the fact that his party is still trying
to make that dream come true.
Why is Health Care for America Now Giving Up on
Real Reform?
Sandeep Jauhar, M.D. “I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates and a poster of an illuminated lighthouse that read: “Success doesn’t come to you. You go to it.” A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; his days, he said, will be “totally busy.” “Your days aren’t busy enough already?” I asked. The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals. He smiled wanly. “Just look at my eyes.” They were bloodshot. “This whole week I haven’t slept more than about six hours a night.” I asked when his work usually got done. It is never done,” he replied, shaking his head. “See this pile?” He pointed to five large manila packages on a shelf above his desk. “These are reports I still have to finish.” As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming. In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 3 percent said they were not frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey. “It will take real structural change in the work environment for physician satisfaction to improve,” Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.” Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens. “I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.” When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty. “But managed care is like a magnet attached to you,” he said. He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ” Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said. And it is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement. In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession. The dissatisfaction would probably not have reached such a fever pitch if reimbursement had kept pace with doctors’ expectations. But it has not. Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket. There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care. Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners. Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. Students who do choose internal medicine increasingly are forgoing primary care for subspecialty practices like cardiology and gastroenterology. “For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. As an internist, I have to worry about working up so many conditions — anemia, thyroid problems and so forth. There is no time to do it all in a day. “On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.” Many primary-care physicians have stopped seeing their patients when they are hospitalized, relying instead on hospitalists devoted to inpatient care. Internists have told me that it is prohibitively inefficient to drive to a hospital, find parking, walk to the wards, examine a patient, check laboratory tests and vital signs, talk to a nurse and write orders and a note — for just a handful of cases. They cannot afford to leave their offices long enough to do it. The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today. “Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.” A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients. But reimbursement cuts are only a small part of doctors’ woes today. “I was naïve,” Saeed Siddiqui said. “When I was a resident I thought it was enough to take good care of patients. But the real world is totally different.” Dr. Sandeep Jauhar, a cardiologist on Long Island, is the author of a new memoir, “Intern: A Doctor’s Initiation.” Editorial The relentless, decades-long rise in the cost of health care has left many Americans struggling to pay their medical bills. Workers complain that they cannot afford high premiums for health insurance. Patients forgo recommended care rather than pay the out-of-pocket costs. Employers are cutting back or eliminating health benefits, forcing millions more people into the ranks of the uninsured. And state and federal governments strain to meet the expanding costs of public programs like Medicaid and Medicare. Health care costs are far higher in the United States than in any other advanced nation, whether measured in total dollars spent, as a percentage of the economy, or on a per capita basis. And health costs here have been rising significantly faster than the overall economy or personal incomes for more than 40 years, a trend that cannot continue forever. It is the worst long-term fiscal crisis facing the nation, and it demands a solution, but finding one will not be easy or palatable. The Causes Varied and Deep-Rooted. Contrary to popular beliefs, this is not a problem driven mainly by the aging of the baby boom generation, or the high cost of prescription drugs, or medical malpractice litigation that spawns defensive medicine. Those issues often dominate political discourse, but they have played relatively minor roles in driving up medical spending in this country and abroad. The major causes are much more deep-seated and far harder to root out. Almost all economists would agree that the main driver of high medical spending here is our wealth. We are richer than other countries and so willing to spend more. But authoritative analyses have found that we spend well above what mere wealth would predict. This is mostly because we pay hospitals and doctors more than most other countries do. We rely more on costly specialists, who overuse advanced technologies, like CT scans and M.R.I. machines, and who resort to costly surgical or medical procedures a lot more than doctors in other countries do. Perverse insurance incentives entice doctors and patients to use expensive medical services more than is warranted. And our fragmented array of insurers and providers eats up a lot of money in administrative costs, marketing expenses and profits that do not afflict government-run systems abroad. Does It Matter? If citizens of an extremely wealthy nation like the United States want to spend more on health care and less on a third car, a new computer or a vacation home, what’s wrong with that? By some measures, Americans are getting good value. Studies by reputable economists have concluded that spending on such advanced treatments as cardiac drugs, devices and surgery; neonatal care for low-birth-weight infants; and mental health drugs have more than paid for themselves by extending lives and improving their quality. But if health care spending continues on its same trajectory, the United States will reach the point — probably several decades from now — where every penny of the annual increase in gross domestic product would have to go for health care. There would be less and less money for other things, like education, environmental protection, scientific research and national security, that may be equally or more important to the well-being of society. Governmental budgets will face the crisis even sooner. States are already complaining that they have to crimp other vital activities, like education, to meet soaring Medicaid costs. And federal spending on Medicare and Medicaid is surging upward at rates that will cause the deficit to soar. That means politicians will have to raise taxes, severely cut a wide range of other governmental programs, or chop back the health programs themselves. The question is: What can be done to lower both the high level of health care spending and its high rate of increase from year to year? The Solutions Geography. Pioneering studies by researchers at Dartmouth have shown enormous disparities in expenditures on health care from one region to another with no discernible difference in health outcomes. Doctors in high-cost areas use hospitals, costly technology and platoons of consulting physicians a lot more often than doctors in low-cost areas, yet their patients, on average, fare no better. There are hints that they may even do worse because they pick up infections in the hospital and because having a horde of doctors can mean no one is in charge. If the entire nation could bring its costs down to match the lower-spending regions, the country could cut perhaps 20 to 30 percent off its health care bill, a tremendous saving. That would require changing the long- ingrained practices of the medical profession. Public and private insurers might need to refuse coverage for high-cost care that adds little value. Stick to What Works. The sad truth is that less than half of all medical care in the United States is supported by good evidence that it works, according to estimates cited by the Congressional Budget Office. If doctors had better information on which treatments work best for which patients, and whether the benefits were commensurate with the costs, needless treatment could be junked, the savings could be substantial, and patient care would surely improve. It could take a decade, or several, to conduct comparative-effectiveness studies, modify relevant laws, and change doctors’ behavior. Managed Care. For a brief period in the 1990s it looked as if health maintenance organizations competing for patients and carefully managing their care might bring down costs and improve quality at the same time. The H.M.O.’s did help restrain costs for a few years. The problem was, doctors and patients hated the system, management became much looser, and the upsurge in costs resumed. Managed care techniques are creeping back into some health plans, especially for services apt to be overused, but too heavy a hand would most likely produce another backlash. Information Technologies. The American health care system lags well behind other sectors of the economy — and behind foreign medical systems — in adopting computers, electronic health records and information-sharing technologies that can greatly boost productivity. There is little doubt that widespread computerization could greatly reduce the paperwork burden on doctors and hospitals, head off medication errors, and reduce the costly repetition of diagnostic tests as patients move from one doctor to another. Without an infusion of capital, the transition from paper records is not apt to happen very quickly. Prevention. Everyone seems to be hoping that preventive medicine — like weight control, exercise, better nutrition, smoking cessation, regular checkups, aggressive screening and judicious use of drugs to reduce risks — will not only improve health but also lower costs in the long run. Preventive medicine actually costs money — somebody has to spend time counseling patients and screening them for disease — and it is not clear how soon, or even whether, substantial savings will show up. Still, the effort has to be made. The Milken Institute recently estimated that the most common chronic diseases cost the economy more than $1 trillion annually, mostly from lost worker productivity, which could balloon to nearly $6 trillion by the middle of the century. Disease Management. Virtually all policy experts want more careful coordination of the care of chronically ill patients, who account for the largest portion of the nation’s health care expenditures. Although that should improve the quality of the care they get, coordination may not cut costs as substantially as people expect. In some initial trials it has cut costs, in others not. Drug Prices. Compared with the residents of other countries, Americans pay much more for brand-name prescription drugs, less for generic and over-the-counter drugs, and roughly the same prices for biologics. This page believes it would be beneficial to allow Medicare to negotiate with manufacturers for lower prescription drug prices and to allow cheaper drugs to be imported from abroad. The prospect for big savings is dubious. Who Picks Up the Tab? Pay Providers Less. With doctors dreadfully unhappy under the heavy hand of insurers, it would seem shortsighted to make them even unhappier by cutting their compensation to levels paid in other countries. But many experts believe it should be possible to tap into the vast flow of money sluicing through hospitals, nursing homes and other health care facilities to find savings. Emphasize Primary Care. In a health system as uncoordinated as ours, many experts believe we could get better health results, possibly for less cost, if we changed reimbursement formulas and medical education programs to reward and produce more primary care doctors and fewer specialists inclined to proliferate high-cost services. It would be a long-term project. Skin in the Game. The solution favored by many conservatives is to force consumers to shell out more money when they seek medical care so that they will think harder about whether it is really necessary. The “consumer-directed health care” movement calls for providing people with enough information about doctors and treatments so that they can make wise decisions. There would most likely be some savings. A classic experiment by Rand researchers from 1974 to 1982 found that people who had to pay almost all of their own medical bills spent 30 percent less on health care than those whose insurance covered all their costs, with little or no difference in health outcomes. The one exception was low-income people in poor health, who went without care they needed. Any cost-sharing scheme would have to protect those unable to bear the burden. And consumer-driven plans have limitations. Most health care spending is racked up by a small percentage of individuals whose bills are so high they are no longer subject to cost sharing; they will hardly be deterred from expensive care they desperately need. Moreover, few consumers have the competence or knowledge to second-guess a doctor’s recommendations. Single Payer. Deep in their hearts, many liberals yearn for a single-payer system, sometimes called Medicare-for-all, that would have the federal government pay for all care and dictate prices. Such a system would let the government offset the price-setting strength of the medical and pharmaceutical industries, eliminate much of the waste due to a multiplicity of private insurance plans, and greatly cut administrative costs. But a single-payer system is no panacea for the cost problem — witness Medicare’s own cost troubles — and the approach has limited political support. Private insurers could presumably eliminate some of the waste through uniform billing and payment procedures. * * * By now it should be clear that there is no silver bullet to restrain soaring health care costs. A wide range of contributing factors needs to be tackled simultaneously, with no guarantee they will have a substantial impact any time soon. In many cases we do not have enough solid information to know how to cut costs without impairing quality. So we need to get cracking on a range of solutions. The cascade of knowledge flowing from the human genome project, new nanotechnologies and the advent of treatments tailor-made for individual patients may well accelerate, not mitigate, the rise in medical spending. If we want the benefits, we will need to make them affordable. David Lazarus I write a lot about healthcare reform. Now it's
personal. No, it's almost certain I got nailed because a
genetic time bomb finally exploded. So I had to quickly find a doctor who would take
insurance. My insurer's website had a directory of possible choices,
but you're essentially pulling a name out of a hat -- not the best
way to make decisions when your blood-sugar level is three or four
times normal. New
York Times Editorial Many Americans are under the delusion that we have
"the
best health care system in the world," as President Bush
sees it, or provide the "best medical care in the world," as
Rudolph Giuliani declared last week. That may be true at many top
medical centers. But the disturbing truth is that this country
lags well behind other advanced nations in delivering timely and
effective care. for a given
condition as defined by standard clinical guidelines and gave it
especially high marks for preventive care, like Pap smears and
mammograms to detect early-stage cancers, and blood tests and cholesterol
checks for hypertensive patients. But we scored poorly in coordinating
the care of chronically ill patients, in protecting the safety
of patients, and in meeting their needs and preferences, which
drove our overall quality rating down to last place. American doctors
and hospitals kill patients through surgical and medical mistakes
more often than their counterparts in other industrialized nations. Following thie editorial, THeNew York Times printed 8 letters to the Editor on August 14: To the Editor: —— Jane Bryant Quinn Prepare to be terrorized, shocked, scared out of
your wits. No, not by jihadists or Dementors (you do read "Harry
Potter," right?), but by the evil threat of ... universal
health insurance! The more the presidential candidates talk it
up, the wilder the warnings against it. Cover everyone? Wreck America?
Do you know what care would cost? Atul Gawande The documentary filmmake Michael Moore has more than few insufferable traits. He i manipulative, smug, and self-righteous. He has no interest i complexity. And he mocks the wea as well as the powerful. (Recall hi derision, in “Roger and Me,” for a impoverished woman in Flint Michigan, who slaughtered rabbit to make ends meet.) For all that, hi movie about the American health-care system, “Sicko,” is revelation. And what makes this especially odd to say is that the movie brings to light nothing tha the media haven’t covered extensively for years Few will be surprised, surely, to learn that insurance companies routinely deny people individual coverage, or jack up applicants’ rates, if they have diabetes or are obese or produced a weird blood-test result in the sixth grade. It’s just that a lot of us haven’t met those people, or seen what happens to them afterward. Moore makes sure that we do. Their travails are by turns depressing, blackly comical, and infuriating. There’s the twenty-two-year-old who was denied reimbursement for her cervical-cancer treatment because someone at her insurance company thought that she was “too young” to have the disease; the seventy-nine-year-old on Medicare who works picking up trash at his local Pathmark store to pay for the medicines that he and his wife need; the thirty-something-year-old who matter-of-factly sews up a trickling five-inch gash in his leg with kitchen thread, because he doesn’t have insurance to cover an emergency-room visit. These have become ordinary tales in America. Just this year, in my own surgical practice, I have seen a college student who couldn’t afford the radiation treatment she needed for her thyroid cancer, because her insurance coverage maxed out after the surgery; a breast-cancer patient who didn’t have the cash for the hormone therapy she needed; and a man denied Medicare coverage for an ambulance ride, because the chest pain he thought was caused by a heart attack wasn’t—it was caused by a tumor. The universal human experience of falling ill and seeking treatment—frightening and difficult enough—has been warped by our dysfunctional insurance system. “Sicko” doesn’t really offer
solutions. Yes, it visits France. But it doesn’t discuss
the difficulties of reforming a system that encompasses sixteen
per cent of the economy. It doesn’t investigate the tradeoffs
that universal health care will inevitably require. It’s
an outrage machine. Moore hopes that once people grasp the inhumanity
of our system we will replace it. But will we? The movie is so
effective in depicting the inhumanity that it makes our failure
to act seem baffling. Moore blames the familiar villains: insurance
companies, pharmaceutical-industry lobbyists, politicians. But
plenty of countries have private insurance—not
to mention politicians and lobbyists—and nonetheless have
health-care systems that cover all their residents, at a lower
cost, and with higher levels of satisfaction. Israel, the Netherlands,
and Switzerland all provide universal coverage through multiple
private insurers and, like Moore’s France, spend between
half and three-quarters of what we do. The finger of blame points
to an obstacle different from the one the movie suggests: us. Health care confronts us with a difficult test. We have never corrected failure in something so deeply embedded in people’s lives and in the economy without the pressure of an outright crisis. The welfare reforms of 1996 made changes that profoundly affected people’s lives, but only those of the poor, which was why voters supported the experiment. We adopted rules to protect clean water, clean air, and endangered animal species, but the costs seemed small and were largely hidden from taxpayers. In the past few months, John Edwards and Barack Obama have put forward coherent proposals to achieve universal or near-universal coverage. For the first time in a decade and a half, the prospects for reform seem genuinely promising. But the fight is about to begin. For example, Rudy Giuliani recently outlined a tax-credit-based health plan that would come nowhere near covering everyone; for one thing, he would let insurers continue to exclude people with preëxisting conditions. Its main purpose, it seems, is to let him attack other proposals as involving a big government takeover of medical care. If, in 2009, we actually swear in a President committed to universal health care, the fight will turn ugly. The plan most likely to gather broad support will look something like the Edwards/Obama approach, which would subsidize health insurance for everyone who does not receive coverage through work or through existing programs. It would provide a choice of private insurance options, as in the Netherlands, and would probably add a Medicare-like government option as well. And it would require Americans to obtain coverage for, at a minimum, their children. People on the right will attack the plan as a tax-and-spend nightmare, because it will have to include some mixture of increases in business and personal-income taxes. And they’ll say that it dictates your medical choices and gives government too much control. People on the left—Moore included—will attack the plan as a boondoggle for insurance companies, because it isn’t single-payer, and will say that it gives government too little control. Others will attack it for what it does or doesn’t do about malpractice litigation, birth control, acupuncture, and so forth. The debate will become angry and murky and mind-numbingly complicated, and the temptation will be to put off reform yet again. That’s exactly when you’ll need to remind yourself of what’s really at stake. So if, in the throes of the debate, you find yourself experiencing blurred vision, headache, and vertigo, here’s a prescription: go visit an emergency room, clotted with the uninsured, andsee what’s it like to try to get care. Or watch the movie. Either way, you’ll be outraged again. Deborah Burger What country endures such long waits for medical care that even one of its top insurers has admitted that care is "not timely" and people "initially diagnosed with cancer are waiting over a month, which is intolerable?" If you guessed Canada, guess again. The answer is the United States. Scrambling for a response to the popular reaction to Michael Moore's "SiCKO" and a renewed groundswell for a publicly financed, guaranteed single-payer health care solution, such as SB840, the big insurers and their defenders have pounced on Canada, pulling out all of their old tales of people waiting years in soup kitchen-type lines for medical care. But, here's the dirty little secret that they won't tell you. Waiting times in the United States are as bad as or worse than Canada. And, unlike the United States, in Canada no one is denied needed medical care, referrals or diagnostic tests due to cost, pre-existing conditions or because it wasn't pre-approved. U.S. waiting times are the elephant in the room few critics care to address. But, listen to what the chief medical officer of Aetna had to say in March. Speaking to the Aetna Investor's Conference 2007, Troy Brennan let these pearls drop: The U.S. "health care system is not timely." Recent statistics from the Institution of Healthcare Improvement document "that people are waiting an average of about 70 days to see a provider." "In many circumstances, people initially diagnosed with cancer are waiting over a month, which is intolerable." In his former stint as an administrator and head of a physicians' organization, he spent much of his time trying "to find appointments for people with doctors." Brennan's comments went unreported in the major media. But some reports are now beginning to break through, spurred by the debate "SiCKO" has spawned. Business Week reported (www.businessweek.com/technology/content/jun2007) that "as several surveys and numerous anecdotes show, waiting times in the United States are often as bad or worse as those in other industrialized nations -- despite the fact that the United States spends considerably more per capita on health care than any other country." A Commonwealth Fund study of six highly industrialized countries (www.commonwealthfund.org), the United States and five nations with national health systems (Britain, Germany, Australia, New Zealand and Canada) found waiting times were worse in the United States than in all the other countries except Canada . There's something else you probably don't hear about Canada. Substantial progress is being made. Most of the wait-time problems derive from funding cuts by conservative national or provincial governments, or from the siphoning off of resources by private providers. But precisely because the Canadian system is publicly administered, Canadians are able to force their elected officials to fix problems, or get voted out of office. Throughout Canada, there are multiple pilot programs that have succeeded in slashing wait times. Canada's latest statistics show that median wait times for elective surgery in Canada is now three weeks -- that's less time than Aetna's chief medical officer says Americans typically wait after being diagnosed with cancer. Canada also has no waits for emergency surgeries. It also doesn't have 44 million people who are uninsured because everyone has a national health-care card guaranteeing health care from any doctor or hospital they choose. And it doesn't burden those with insurance with rising deductibles or co-pays. A study reported by Health Affairs, a policy journal, for example, found that out-of-pocket costs to U.S. consumers jumped 76 percent this year over last year alone. Canada also surpasses the United States in a broad array of health barometers, including life expectancy, infant mortality rates, adult mortality rates, deaths due to HIV/AIDS, mortality rates for cardiovascular diseases and years of life lost to injuries and diseases, according to data from the World Health Organization and the Organization of Economic Co-operation and Development. No wonder some people are so afraid we'll learn the real comparative story about Canada's system -- and our own. Deborah Burger, R.N., is president of the California Nurses Association. Ken Terry While most large corporations still offer health insurance to their employees, the rapid growth of health costs is reducing their profitability and their ability to compete internationally. So some big companies want out. But they fear that if the government takes over health care -- a likely outcome if employers stampede for the exits -- they'll be subjected to onerous mandates or tax increases. So they're unalterably opposed to the kind of single-payer system that one California Senate bill would create. And they're just as likely to fight the new Democratic Senate/Assembly measure that would require employers to cover their workers or pay 7.5 percent of their payrolls into an insurance fund. The California Chamber of Commerce -- which takes a dim view of Gov. Arnold Schwarzenegger's health reform plan, as well -- strongly opposed an employer mandate two years ago, and the chamber led the successful effort to repeal the law that imposed it. What U.S. corporations really want to do, as shown by a recent proposal from the ERISA Industry Committee (ERIC), a lobbying group for big, self-insured companies, is to limit their health care liabilities without dropping their benefits (www.eric.org). ERIC would replace the current health insurance system, in which large employers pay medical bills themselves, with one in which competing regional "benefit administrators" would assume insurance risk for all individuals not covered by Medicare, Medicaid, other government programs, or non-participating firms. Every individual would be required to buy insurance from one of the local benefit administrators, which could be insurance companies, investment firms, banks, or other parties. Each benefit administrator would offer several health plans. An employer could pay the benefit administrators whatever it wanted to help cover its workers, or give each employee a voucher for that amount, and the employee would have to pay the rest. Thus, the company would have a fixed insurance premium and would no longer be responsible for health care costs. Another example of this "defined-contribution" approach is the contract that Goodyear Tire & Rubber Co. signed with the United Steelworkers Union last December after a two-month strike. Under the terms of the pact, Goodyear will transfer all union retiree health-care obligations to a trust fund under USW management. In effect, the union agreed to take on $1.2 billion (and perhaps more) in future health-care costs in return for $1 billion in cash and stock from Goodyear. GM, Ford and Chrysler's new owner, the Cerberus private equity firm, reportedly want to buy out their retiree health care commitments by making similar deals with the United Auto Workers. In less unionized fields, big employers are taking a different tack: They're passing on more costs to employees and rolling out "consumer-driven plans." Critics have assailed these plans as tax shelters for the healthy and affluent; they've also pointed out that the incentives they give consumers to spend less on health care often result in the avoidance of necessary care. What's less often noted is that, like the Goodyear deal and the ERIC proposal, consumer-driven plans are designed to help employers curb their health costs. Companies contribute a set amount to health savings accounts, and there's no requirement for them to raise their contributions over time. So even if the deductible in the associated high-deductible policy keeps getting larger, it's the worker, not the company, who will be on the hook for the difference between the deductible and what's in his or her HSA. There are many drawbacks to the employer-based system. As economists Alain Enthoven and Victor Fuchs note in a 2006 paper, it creates high administrative costs, limits wage increases, leaves many people without insurance and leads to "job lock." The ERISA Industry Committee seeks to alleviate some of these problems: for example, its approach would make insurance portable, reduce administrative costs and help self-employed people get coverage. On the other hand, many employees might discover they could no longer afford coverage comparable to what they have now. Wherever our health care system is heading, Americans should demand that employers pay their fair share for health care. The government-run and -managed health systems of Europe, Canada and Japan require employers to ante up; and if the United States decides to switch to a single-payer system, in which the government pays all of the bills, the same will be true here. Employers, as well as individuals, must make health-care contributions in proportion to their means. Only by sharing the pain can we start to build a better health care system. Ken Terry, a senior editor at Medical Economics Magazine, is the author of "Rx For Health Care Reform," which will be published in September by Vanderbilt University Press. Victorial Colliver Filmmaker Michael Moore might be onto something in his new documentary, "Sicko." These days, fewer Americans are buying the claim that the United States has the best medical system in the world. With polls showing that health care is Americans' top domestic concern, politicians are scrambling to propose reforms. Consumers are buying lower-cost online drugs from foreign sources, and some even become "medical tourists" to obtain affordable treatment in other countries. Studies show Americans aren't healthier, nor are they living longer than people in industrialized nations that spend half per capita of what we do on care. For example, a 2007 Commonwealth Fund study that compared the United States with five other nations -- Australia, Canada, Germany, New Zealand and the United Kingdom -- ranked the U.S. health system last. The study looked at access to health care, efficiency, equity and healthy living, among other measures. And a 2000 report by the World Health Organization, the most recent available from the U.N. organization, put the United States 37th out of 190 nations in health care services -- between Costa Rica and Slovenia. France was rated No. 1, the United Kingdom in the 18th spot, Canada at No. 30 and Cuba a couple of notches behind the United States in the 39th spot. In a New York Times/CBS poll conducted in March, health care ranked as the top domestic concern. And in "Sicko," Moore highlights Americans' disillusionment with their health care system, comparing it to systems in other countries, including France, Canada, Britain and Cuba. Many health experts say Moore might be glorifying other systems -- particularly the once in France. Still, they accept his argument that other nations are doing a better job than the United States in providing coverage for all residents and making sure people have access to primary care and preventive services. The United States has a private system for all but the poor and elderly. The countries lauded in "Sicko" have national systems funded primarily through the government. "We, unlike any other country, have 46 million people who are uninsured, and that raises a whole host of health and financial issues," said Ken Thorpe, professor of health policy at Emory University. Those issues are undermining the health of Americans, several studies have shown. While the United States may have cutting-edge medical technologies, many people lack access to such advanced care, limiting any positive health impact. "Ours is really is a sick-care system. We have tremendous technical capabilities to deal with people with serious illness," Thorpe said. He argues, though, that it is far more cost-effective to prevent people from getting sick or at least catch illnesses early through better monitoring. Karen Davis, president of the Commonwealth Fund, a nonprofit foundation that supports health care research, said many of the problems associated with poor primary care can be traced to the fragmented structure of our health care system. U.S. patients often have trouble seeing the same doctor on short notice, see multiple doctors who sometimes fail to communicate with one another and forgo care because they don't want to spend the money. "We tend to have more medical errors than other countries, in part because of this highly specialized, fragmented system," she said. "More things can go wrong and do go wrong." Moore's film has been criticized for showing the positive side of health systems in other countries while glossing over negative aspects. "There's almost only positive attributes about the British, the French and Cuban system. Invariably, no system is perfect. I think this sort of detracts from his credibility on these comparisons," said Stephen Zuckerman, health economist with the Urban Institute in Washington, D.C. Moore ignores the fact that private coverage still exists in most countries with nationalized health care. And he avoids showing solutions other than adoption of a government-funded system, often known as single-payer. "He's trying to be entertaining. But if the objective here is to kick off a serious study about the British and Cuba as an alternative to the U.S. system, you need a lot more than what was presented in 'Sicko,' " Zuckerman said. In "Sicko," Moore addresses one of the biggest criticisms of the Canadian system -- long wait times for care -- by asking patients in an Ontario emergency room how long they had to wait. All respond that they got treated quickly. But the Commonwealth Fund report found that both U.S. and Canadian patients were more likely to wait six days or more for an appointment. Waiting times for specialists or elective surgery were shortest in the United States and Germany. U.S. patients were less likely than Canadians to have to wait more than four hours in an emergency room, the report found. Moore also implies that care in Canada, Britain and France is virtually free. He dismisses claims that the French are overtaxed by showing the comfortable life of a French couple who even have money left over to travel. But la vie francaise isn't entirely en rose. The country has a high unemployment rate of 9 percent along with high taxes. In France, taxes amount to more than 44 percent of gross domestic product, compared with 26 percent in the United States, according to the Organization for Economic Cooperation and Development. Still, the United States spends a higher percentage of its gross domestic product on health than any other country -- more than 16 percent compared to France's 10.7 percent. The United States spends $6,102 per person in public and private funds compared with $3,159 per capita spending in France. Americans living in France generally praise the French system. Roderick Beck, a former New Yorker who moved to Paris this spring, said the profit motive that drives insurance companies as well as physicians is the central problem with the U.S. health system. "What are those insurance companies doing at the most fundamental level? Collecting cash and paying out benefits," said Beck, 45, who works for a telecommunications firm. "Governments using taxation and a simple health care card do that more efficiently than an insurance based system." Bruce Gain, 41, a U.S. journalist living in France since 2003, said the French system is better because the government strictly controls prices and the number of doctors per capita is much higher than the United States. "As far as access to medial technology goes, there are more doctors here to offer the latest treatments and drugs at affordable costs," Gain said. Davis, of the Commonwealth Fund, said the United States does not need to adopt nationalized health care to improve efficiency. For example, she said, the Netherlands has a well-developed system for after-hours primary care that would reduce emergency room visits. "There's a lot we can learn from other countries," she said. Unhealthy comparisons The World Health Organization in 2000 ranked the United States 37th out of 191 countries in health care services. U.S. life expectancy is nearly three years shorter on average than Canadians' and about two years less than that of the French. The United States spent more than $6,000 per person on health care in 2004, about double what France, Germany and Canada spent per capita. Sources: World Health Organization, United Nations, Organization for Economic Cooperation and Development Back to TopPaul Krugman These days terrorism is the first refuge of scoundrels. So when British authorities announced that a ring of Muslim doctors working for the National Health Service was behind the recent failed bomb plot, we should have known what was coming. "National healthcare: Breeding ground for terror?" read the on-screen headline, as the Fox News host Neil Cavuto and the commentator Jerry Bowyer solemnly discussed how universal health care promotes terrorism. While this was crass even by the standards of Bush-era political discourse, Fox was following in a long tradition. For more than 60 years, the medical-industrial complex and its political allies have used scare tactics to prevent America from following its conscience and making access to health care a right for all its citizens. I say conscience, because the health care issue is, most of all, about morality. That’s what we learn from the overwhelming response to Michael Moore's "Sicko." Health care reformers should, by all means, address the anxieties of middle-class Americans, their growing and justified fear of finding themselves uninsured or having their insurers deny coverage when they need it most. But reformers shouldn’t focus only on self-interest. They should also appeal to Americans’ sense of decency and humanity. What outrages people who see "Sicko" is the sheer cruelty and injustice of the American health care system sick people who can't pay their hospital bills literally dumped on the sidewalk, a child who dies because an emergency room that isn’t a participant in her mother’s health plan won’t treat her, hard-working Americans driven into humiliating poverty by medical bills. "Sicko" is a powerful call to action but but don’t count the defenders of the status quo out. History shows that they're very good at fending off reform by finding new ways to scare us. These scare tactics have often included over-the-top claims about the dangers of government insurance. "Sicko" plays part of a recording Ronald Reagan once made for the American Medical Association, warning that a proposed program of health insurance for the elderly the program now known as Medicare would lead to totalitarianism. Right now, by the way, Medicare which did enormous good, without leading to a dictatorship is being undermined by privatization. Mainly, though, the big-money interests with a stake in the present system want you to believe that universal health care would lead to a crushing tax burden and lousy medical care. Now, every wealthy country except the United States already has some form of universal care. Citizens of these countries pay extra taxes as a result but they make up for that through savings on insurance premiums and out-of-pocket medical costs. The overall cost of health care in countries with universal coverage is much lower than it is here. Meanwhile, every available indicator says that in terms of quality, access to needed care and health outcomes, the U.S. health care system does worse, not better, than other advanced countries even Britain, which spends only about 40 percent as much per person as we do. Yes, Canadians wait longer than insured Americans for elective surgery. But over all, the average Canadian's access to health care is as good as that of the average insured American and much better than that of uninsured Americans, many of whom never receive needed care at all. And the French manage to provide arguably the best health care in the world, without significant waiting lists of any kind. There's a scene in "Sicko" in which expatriate Americans in Paris praise the French system. According to the hard data they're not romanticizing. It really is that good. All of which raises the que0stion Mr. Moore asks at the beginning of "Sicko": who are we? "We have always known that heedless self-interest was bad morals; we know now that it is bad economics." So declared F.D.R. in 1937, in words that apply perfectly to health care today. This isn't one of those cases where we face painful tradeoffs here, doing the right thing is also cost-efficient. Universal health care would save thousands of American lives each year, while actually saving money. So this is a test. The only things standing in the way of universal health care are the fear-mongering and influence-buying of interest groups. If we can’t overcome those forces here, there’s not much hope for America’s future. Susan Brink, COMMENTARY |