Some 46 million Americans don't get healthcare because they can't afford to pay for it – will the government succeed in bringing in a more equitable system, asks DR CHARLES DALY
" . . . People have access to healthcare in America . . . you just go to the emergency room" – George W Bush, 2007
" American healthcare is . . . a market . . . people with money can buy what they want and many people are left out" – Chang Hong-Jen, Taiwanese health planner
ACCESS TO healthcare in the US is widely available, provided you have adequate health insurance, which is usually an employment perk; if you are over 65 and eligible for Medicare; if you’re in the military (current or retired); if you’re a Native American; if you’ve end-stage renal disease, or, surprisingly, if you’re in jail. Otherwise, you’re one of 46 million Americans with no access to healthcare – your health is seriously compromised and you may die from lack of proper care.
Even if you do go to the ER, if you’re not insured you’ll be turfed out as soon as you’re “stable”, and the ER is not there to provide primary and preventive care, or management of chronic disease.
If you lose your job, you usually lose your health insurance and you may lose your life. In addition, about 700,000 Americans are bankrupted every year by health bills.
Melissa Matthews, a prisoner, declined parole because she had cervical cancer. “If I’m in here, I can get treated,” she said. “If I’m out, I’m going to die from this cancer.”
College graduate Nikki White wasn’t so lucky. She developed lupus, an autoimmune illness. She was too “well off” to be eligible for care under welfare, too poor to pay for healthcare and medications, and insurance companies refused to take her on. She died from a condition that, though serious, is quite treatable.
In a recent book, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care, TR Reid, an American journalist who has experienced healthcare in countries as diverse as Britain and Japan, takes a critical look at his own country's disparate system, contrasts it with other systems, and makes suggestions as to how the US can make improvements.
There are four main systems of healthcare worldwide. In the Bismarck model, found in Germany and most of western Europe, comprehensive health insurance is provided by private doctors and paid for by private non-profit insurance companies. In the Beveridge model (after Lord Beveridge, the inspiration behind the NHS), all health costs are funded by general taxation. In the national insurance model, pioneered in Canada, everybody is covered by a government-run insurance scheme. Finally, there is the out-of-pocket scheme, whereby you don’t get any healthcare if you can’t pay for it, as is the case in most of the Third World and for 46 million unfortunate Americans.
No health system is perfect. Doctors are always complaining that they aren’t paid enough, hospitals always feel their budgets are inadequate, “the last reform didn’t work”, and the systems are always being adjusted, but in countries with comprehensive healthcare, the concept of patient exclusion on monetary grounds is anathema. Former British prime minister Margaret Thatcher promoted privatisation and feared nobody, but not even she would take on the NHS.
Traditional American opposition to healthcare reform is based on mistrust of “foreign” ideas and the fear of “socialised” medicine. What they don’t realise is that many of these alien concepts are already ensconced in American medicine. Workers with insurance are operating the Bismarck model. The military and veterans, Native Americans and patients with end-stage renal failure are treated by government employees in an NHS-type environment. The over-65s are all eligible for Medicare, based on the Canadian model.
Much of the cost of the US’s insurance schemes is administrative. Profit-making companies are adversarial by nature and will do anything to avoid paying a bill. Many doctors have secretaries whose sole function is to do daily battle with the insurance companies to ensure payment and reduce “denials”. In contrast, France’s admirable healthcare system is based on the Carte Vitale, a computerised card that simultaneously details the patient’s full medical history, organises billing in the consulting room, and cuts administrative costs to a minimum. Ironically, this software was developed in the US.
Even some Third World countries are realising the advantages of universal coverage. In 1994, as the Clinton bill was being scuppered in Congress (a bill that was bound to fail, based as it was on economic grounds rather than on equity), the small-island country of Taiwan, a newly industrialised and emerging democracy, decided to get away from traditional out-of-pocket payment and go for full healthcare. Within two years, Taiwan had one of the finest healthcare systems on the planet. South Korea and Singapore followed suit.
One Asian country is going in the opposite direction. China, which had the rudiments of a rural healthcare system, is now using its new wealth to promote urban centres of medical luxury at the expense of the peasantry. Although Reid doesn’t mention it, one modern industrialised country seems to be taking this route as well – the Republic of Ireland.
Most Americans agree that the current system is unsatisfactory and cannot continue indefinitely. There is enough capital and experience in the US to fund a comprehensive scheme. What is needed is a change of mind and attitudes.
Reid dedicates his book to Dwight D Eisenhower, who set up the impressive interstate freeway system, one of the US’s jewels, inspired by his experience of the Autobahnen during the Allied invasion of Germany in 1945. If an idea originated by the Nazis is acceptable in the US, surely all that is foreign is not bad.
Many US politicians, from Teddy Roosevelt to the Clintons to the late Ted Kennedy, have tried to bring comprehensive healthcare to all Americans, and to date all have failed. Barack Obama’s domestic legacy may yet be defined by whether he can bring full healthcare to all his fellow citizens, or whether he will join the list of heroic failures.
- The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, by TR Reid is published by The Penguin Press (US)
- Dr Charles Daly is a GP in Co Waterford
