PBS Frontline: 'Sick Around the World'
Wednesday, April 16, 2008; 11:00 AM
Frontline correspondent T.R. Reid was online Wednesday, April 16 at 11 a.m. ET to discuss his film "Sick Around the World," which examines how five other capitalist democracies -- United Kingdom, Japan, Germany, Taiwan and Switzerland -- deliver health care, and what the United States might learn from their successes and failures.
"Sick Around the World" aired Tuesday, April 15 at 9 p.m. on PBS.
The transcript follows.
Reid is a former chief of The Washington Post's London, Tokyo and Rocky Mountain bureaus, and also had stints covering Congress, national politics and four presidential elections for the paper. He is the author of eight books -- three in Japanese -- most recently "The United States of Europe: The New Superpower and the End of American Supremacy."
Philadelphia: Your excellent story has provoked many comments in my mind, but given our political contest, it seems appropriate to discuss what it takes to move the agenda in Washington. In Taiwan, you didn't mention that the opposition party -- the DPP back in the early '90s proposed national health insurance. It proved so popular that the KMT party also agreed, and so when the KMT won they were forced to enact what today has evolved into a true single-payer national health insurance program. Canada's NDP victory pushed for their health system in Saskatchewan back in the 1950s. So what political lesson can we learn from how countries obtain universal health care that could be relevant to the U.S.?
T.R. Reid: Hello, everybody. Thanks for watching our film. If you missed it (or fell asleep because I'm so boring), the documentary can be see at the Frontline.org web site.
In most countries that have revamped health care, the moral imperative was a driving political force. Switzerland decided it didn't want to be a society where 5% of the population was unable to see a doctor when sick. That feeling was strong enough to overcome the powerful political opposition of the drug and health insurance industries.
Taiwan was different. A poor country became rich almost overnight, and decided to build a rich country's system. But there, too, the choice -- for a single universal payment system, like Canada's -- was driven by concerns for equity.
In the U.S., I think two imperatives can lead us to change. First is the fiscal issue: Our system is too expensive for everybody. And second, is the same moral concern: Do we want to be a country where any of our neighbors has access to health care when they need it?
Minneapolis: What happens to the private insurance agencies and hospital systems when a country makes the change over to a national health care system?
T.R. Reid: In Switzerland, which switched to nonprofit in the '90's, the health insurance companies are still going strong. They can't make a profit on basic health insurance coverage, but they use the basic plans to draw in customers, to whom they can sell their supplemental (like Medi-gap) health insurance, plus life insurance, etc. The companies are all bigger today than they were when the switch was made.
Dover, Del.: I've heard that certain countries' health care systems have created "smart cards" for use as rapid health information identification when a citizen is admitted as a patient. Is there any tradeoff for the convenience of this service? How sophisticated is the information security in these programs?
T.R. Reid: I'm working on a book on health care systems in other advanced countries. I've seen the smart card in France (Le Carte Vitale), in Germany (gesundheitskarte), in Austria (E-Karte), and Taiwan.
You get two advantages from this system. First, paperwork is greatly reduced, and prices fall. Second, some medical errors can be avoided, because the doc can instantly see what other treatments and medication you've had.
San Luis Obispo, Calif.: Why don't we just expand Medicare, which has only a 2 percent overhead and with maybe a few tweaks could be the program that we need? Like HR 676?
T.R. Reid: Medicare for all strikes me as a viable approach. Perhaps the way to do it would be to maintain the private insurance companies, but let their customers (of any age) have the option of buying Medicare instead. This would force the private companies to cut their overhead costs and reduce premiums to hold onto customers.
My guess is that most people would migrate to Medicare, given the choice. But those who feel government-funded health care is un-American could stick with private insurance.
Some countries with single-payer systems allow people who prefer private coverage to buy it as an alternative. Generally, only about 3 percent to 10 percent of people do so.
New York: Brilliant reporting and analysis, thank you! My question is, do you think that the prayer you left at the temple in Japan will be answered within the next 10 years?
T.R. Reid: Thank you. You are a discerning viewer.
I left a prayer at the Meiji Jingu Shrine in Tokyo, asking for "Universal Health Care in the USA."
And you know what? I am confident we'll get there. I think Americans ready to make the change.
Anchorage, Alaska: Why do you think that politicians here can't or won't fix our health care system? Also, what did you think of Michael Moore's "Sicko"?
T.R. Reid: I think all Michael Moore films are entertaining. He's an advocate, not a reporter, so he gives us the information that advances his cause.
When Michael Moore's "Sicko" went overseas, it was simplistic and, frankly, wrong. It's not all "socialized medicine" in other countries. There are many private systems, and they are not all perfect. Every country is struggling with the rising cost of health care, and they all have problems.
Philadelphia: Why specifically is the French health system ranked No. 1 in the world? Why is it better than Germany or Switzerland, for example?
T.R. Reid: The World Health Organization hired a Harvard Prof., Christopher Murray, to create a matrix for rating all the world's health care systems (191 of them). He emphasized both "goodness" -- that is quality of care -- and "fairness" -- i.e., equality of access to care. The U.S. did fairly well on quality, but we had a rotten score on fairness, because millions of our fellow citizens are largely cut off from medical care.
France has excellent health results -- e.g., high quality -- and totally equal access at low cost for all 61 million of its people. Hence it was No. 1.
In my upcoming book, I think I'm going to end up arguing that Japan should have been rated #1. It has the best health statistics on earth, no waiting, absolutely equal access, and rock-bottom costs.
Boston: I am a first year medical student, in a class that will graduate with an average of $160,000 in debt. I agree with the thesis that health care is a right and our system is unfortunately a market. However, I wish you had addressed the giant difference in education costs. If our education isn't subsidized, we never will afford to work in considerably lower-paying systems. Please explain how you would face that issue.
T.R. Reid: In every country, we asked the doctors how much they paid to go to medical school. The most common answer was: zero. In Japan, the local community paid Dr. Kono to study medicine, so he came out ahead.
I think we definitely have the funds to subsidize medical education, so that no student pays more than $5,000 a year or so. Heck, Harvard and Yale could provide free education to all their med students just on the interest from their endowments.
If we are eventually going to limit medical costs, that's a necessary step. At least, all the other rich countries have agreed on that point.
Washington: Loved the show! Do you think the staffs of the current candidates made a point to watch it? One only can hope.
T.R. Reid: I strongly hope that the people who will be fixing our health care system are looking overseas for ideas. So far, though, the candidates only seem to mention health care in other countries when they savage it: "wasteful government-run socialized medicine." As our film showed, many countries use the private sector to provide and to pay for health care. And no country is as wasteful in this area as the U.S..
Inwood, N.Y.: What were the criteria to decide which countries would be examined? Was there any particular reason Canada was not included?
T.R. Reid: This is a common question, because Americans want to know the facts about Canadian health care.
We only had one hour. So we looked at Taiwan as an example of the Canadian approach. We liked Taiwan because we got good exotic pictures there, and because that country did what we are doing --looking around the world to get ideas for running health care.
In my forthcoming book (Penguin Press, early 2009), I spend a good deal of time on Canada.
Moral Imperative: In the film, while speaking to the Swiss president, you mentioned how in America "everyone has a right to an education, etc." yet we don't feel everyone has a right to health coverage. Yet education costs in the U.S. are skyrocketing probably at a higher rate than even health care costs. Isn't the heart of issue, really, the moral imperative question? In each country you visited, representatives pretty much echoed the same line: health care is a basic human right. Why is it so cumbersome for Americans to grasp this basic truism?
T.R. Reid: You got it. My fundamental conclusion is that any country's health care system is a reflection of its basic ethical values. In countries that have decided medical care is a human right, everybody has access to the doctor. Our country hasn't decided that, so millions of Americans don't get to see the doctor.
If we are to fix health care in the U.S., we first have to resolve the moral question: Do we feel a collective obligation to make sure than any American can get health care when she needs it?
Marshall, Mo.: How on earth will we ever have a single-payer health care system in this country as long as politicians are owned by big business, e.g. insurance and pharma?
T.R. Reid: John Edwards had an interesting idea when he was running for president: Cut off the health insurance plans covering members of congress in Jan. of 2009, and don't restore the coverage until Congress establishes universal coverage in the U.S.
But I don't think that is necessary. Members of congress respond to the people. If Congress decided in 2009 that Americans want fundamental change, Congress will provide it.
The argument of our film, and my upcoming book, is that there are excellent models we can draw from as we move toward fundamental change.
Coral Springs, Fla.: My wife and I watched your presentation last night. We are both nurses; can you say anything about how the nursing staffs of the hospitals in the countries you surveyed were able to make a living?
T.R. Reid: In every country I went to, as in the U.S., nurses are in short supply. Accordingly, nurses' pay has been going up, due to the law of supply and demand.
As countries try to limit costs of health care, they turn more of the job of treatment over to nurses. (In Britain, more than half the babies are delivered by nurse [practitioners, or midwives). This makes nurses even more necessary, and should raise their pay more.
Doctors/Lawyers: With the American Bar and the AMA such powerful lobbies, how can the U.S. possibly get both parties to agree that neither will make as much as they do now under the current system (the Tort Bar in particular)?
T.R. Reid: I think the AMA is ready for major change. Doctors basically are motivated by a desire to help people, and they can see that our cumbersome, unfair system is undermining their efforts. Some polls show that more than 60% of American docs are so fed up with the insurance industry that they favor a shift to a single-payer structure.
Malpractice cases are a plague for American doctors. It may make sense to put limits on these lawsuits. In terms of cost, though, the malpractice issue adds very little to the overall cost of care in our country. The big costs drivers are sheer inefficiency -- because our system is so fragmented -- and the huge administrative costs that the insurance industry takes out of the system before it pays any medical bills.
Kansas City, Kan.: Mr. Reid, in the U.S. there are big discrepancies in reimbursements for office visits and procedures. Does this disparity exist in other countries?
T.R. Reid: Most developed countries have a centrally negotiated fee structure, that applies across a province, a region, or a whole country. In all of Japan, there is one price for setting a broken arm; no doctor can charge more. Germany sets prices on a state-by-state basis, allowing some regional variation.
This seems to me to be fair to patients. And it makes the system vastly simpler to administer. An American hospital probably gets 25 different fees, depending on the insurance company and the plan, for setting a broken arm. It's expensive to keep track of all the rules, forms, and fees.
Washington: I enjoyed your program very much. I am a young lawyer cultivating an interest in health care law, and would love to learn more about the intersection of law and health care policy. Were there any specific legal issues you came across, and can you recommend any resources for additional learning on this subject?
T.R. Reid: The American malpractice system is a rich area for study.
Beyond that: Because health insurance companies are sometimes cruel to their customers --denying coverage, denying claims, rescinding the policy if the patient has a big bill -- there are also lawyers who specialize in going after health insurance companies. Which means the insurance firms need lawyers of their own to defend their practices.
I haven't studied this, so I can't recommend a text to you.
Medical Malpractice: You mentioned that in Germany, doctors aren't happy with their salaries. It seems that view is shared by the doctors you interviewed in other countries as well. However, you mentioned that in Germany at least, medical malpractice insurance rates are extremely low, and that medical school is free? Is that true across the board in the all countries you visited? Do doctors in these countries end up "netting" about the same as they do here when you factor in lower premiums and the absence of school loans?
T.R. Reid: My guess would be that U.S. doctors still make more than their counterparts in Germany, Japan, etc. Even after student loans and malpractice premiums, their net pay is higher.
Almost all the countries I've been to have free medical education, and minimal malpractice fees. Research my book, I have talked to dozens of doctors in 15 countries. Not one of the foreign doctors I talked to has ever been sued.
Trenton, N.J.: Mr. Reid -- your program was relentlessly critical of U.S. health care. Do you have anything good to say about your own country?
T.R. Reid: The U.S. has the best-educated doctors and nurses in the world. We have the most advanced hospitals, labs, and clinics. We have the most far-reaching research. And we are willing to spend more on health care than any other country.
With all those assets, we could have -- we should have -- the best health care system in the world. But we don't.
There is nothing unpatriotic about facing up to your country's problems and looking for ways to fix them. To me, making the effort to cure our sick health care system reflects a real love for the U.S..
Maryland: If I am not mistaken, one Japanese doctor in the film mentioned that 70 percent of the hospitals in Japan are about to go broke. Why do you still rate Japan as No. 1? Is Taiwan's a more balanced system in this regard?
T.R. Reid: I think Dr. Saito said that 50 percent of Japan's hospitals are operating in the red. This would be worrisome, except that costs are so low in Japan it will not take much more spending to make those hospitals whole again. I expect Japan will do what it takes. The Japanese are proud (and rightly so) of their health care system, and they won't let it fall apart.
Even if Japan increased spending on health care by hundreds of millions of dollars, it would still have a far cheaper and more efficient system than ours.
Houston: I was struck that in Switzerland, barely a majority originally wanted the universal health system, but now few would want a return to the private system of before. I understand that was also true with Canada. What changed the minds of those who originally opposed the change?
T.R. Reid: The key fact is: These new systems work. When Switzerland relied on U.S.-style for-profit health insurance, many people were denied coverage altogether. Many others had to fight constant battles with insurers to get their bills paid. Of course, those are the things Americans loathe about out insurance system.
In the new Swiss system described in our film, everybody has insurance, and the companies are not allowed to deny a claim. (In fact, they generally pay all claims within five days.) No wonder people are happier with this system than with what they had before.
If we were to go the Swiss route -- that is, keeping private health insurance, but with rules that require universal coverage and bar profit -- Americans, too, would be much happier about their health insurance. And if we get there, we will never go back to the cruel, costly system we have today.
Carrington, N.D.: This was an excellent, thought-provoking program and should be a must-see for all citizens of this country. It will be the citizens who force the change.
T.R. Reid: Thank you. Roughly 80 percent of Americans say they want to see "fundamental change" in our health care system. Most people think we should be able to run health care as fairly and as efficiently as the Taiwanese, the French and the Japanese do.
So I believe people will demand real change when the next president takes office. That should provide a tail wind that will get the job done -- if the new president is ready to do it.
Crestwood, N.Y.: How do they get rid of incompetent and dangerous doctors overseas?
T.R. Reid: Every health care system needs a process to police the performance of doctors and hospitals. Docs do make mistakes, and sometimes it is due to negligence. Our malpractice system is our effort to do that job.
Other countries do it differently. Britain has boards that review a doctor's records -- like tax auditors -- to see how successful she has been in treating patients. Germany sends a doctor-observer from a distant part of the country to spend time in another doctor's office and assess the quality of care. Japan has an official complaint system, where people can present a claim of bad treatment.
Minneapolis: I would have liked to see how the Arab world addresses health care. Is health care free in Dubai? Saudi Arabia? And do they cover the "guest workers" or just citizens? How about Egypt? Has Iraq step up its health care system along American or European lines?
T.R. Reid: In the world's poor countries, including those in the Mideast, the health care system is "Out of Pocket." People who can afford to pay for health care -- in money, crops, services, whatever -- can see a doctor. Those who can't afford it stay sick, or die.
The oil shiekdoms of the Mideast have established good health care systems, usually on the British or Canadian model, with government paying the bills. I decided these small, rich autocratic countries are not likely models for the U.S. to follow.
Cary, N.C.: Mr. Reid, if you could implement three specific changes to the U.S. health care system based on the information you gathered during your travels, what would they be?
T.R. Reid: If we stick with private insurance as the main source of payment in our system, we could follow the rules of other countries that use private insurance plans:
1. "Guaranteed issue." That means, the insurance companies have to accept every applicant. They have to pay every claim, without months of dispute. They are not allowed to factor in profit when setting their rate -- that is, basic health coverage is a non-profit endeavor.
2. And then, to make sure the insurance companies don't go broke following those rules, you have to require that everybody buy insurance. That gives the insurance company an adequate pool of rate-payers to keep the system in balance. People who decline to buy insurance are assigned to a company, and billed for the monthly premium.
3. Since those two rules would means everybody has health insurance coverage, you need some cost controls in the system to make sure the overall costs don't skyrocket. At present, the insurance companies negotiate costs with the docs and hospitals. I think some kind of central negotiation -- on the state, regional or national level -- might be a better mechanism. This gives enormous economic power to the source of funds, and keeps prices lower.
T.R. Reid: I'm grateful to everybody who watched our film and took part in this terrific discussion. Please let me shamelessly note that my book on this subject, "We're Number 37," will be published by Penguin Press early next year.
Our health care system is overpriced and unfair. We could and should have the world's best and fairest system. Please keep working for fundamental change, so we can get there quickly.
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