Lessons on universal healthcare

The United States, famously, is the only industrialized country without universal health care. For decades, the debate has centered around the best system to adopt: a government-run single payer system, national health insurance, or the free market. Barack Obama has said that health care reform is one of his priorities, but so far he’s been short on specifics.

Surgeon and writer Atul Gawande says one place to look is other countries who have universal health care coverage – and how they came to get it. Besides being a staff writer for "The New Yorker," Atul Gawande is also on the staff of the Brigham and Women’s Hospital and the Dana Farber Cancer Institute in Boston. His latest article, "Getting There from Here," is about how the US might go about getting universal health care.

Dr. Gawande explains why the United States is the only major industrialized country without universal health care: "The circumstances of our health system really seem to be rooted in World War II. During the war, when so many of our men went abroad to fight, the Roosevelt Administration froze salaries in place — more or less put in wage controls — but they let companies offer health coverage, private health insurance as a way to attract workers, and that became the basis for our health care system.  It’s this little accident of history, and it’s been accidents like that that have governed health care in many places around the world."

It was also World War II that led to national health care service in the UK. In his article in "The New Yorker," Dr. Gawande talks about the phenomenon that shows that certain things like health care, evolve based on small early events:

"The British are interesting, because the key meeting that determined the fate of the British health care system was not some policymakers meeting where they weighed all the options about whether you do it this way or that way, but instead it was the day that Britain declared war on Germany. The government realized they needed to fight a war where they had to prepare for air bombings of cities on a massive scale. Before long, they started a national emergency medical service. The next thing you knew, they were running blood banking and ambulance services, even facilities for fracture care and so on. The blitz came and wiped out a lot of the private sector hospitals and clinics, so by the end of the war the government realized in the devastation that they needed to offer a system of care for the post-war period that would cover people. And the obvious system was the one they had right there already, which was the government was already running large numbers of hospitals, had salaried many doctors, and they built on what they had."

Countries like Switzerland and Canada did not have these little accidents of history, but they created universal health care many years later after World War II. Dr. Gawande talks about how they pulled it off:

"Switzerland, for example, was a country that escaped World War II without the devastation that forced other countries like Britain and France to have to rebuild their health systems. So what they had in Switzerland instead was a very slowly developing locally based system of commercial health insurance plans, not that different from the United States.   And by 1994, when there was enough problems with people – just terrible stories of people who were falling between the gaps because the insurance companies weren’t covering very well, because some people didn’t have coverage and were simply not able to get the right kind of care, they reformed the health system. But again, they built on what they had.  They had no experience in public insurance, and so what they did was mandated that everybody have a private health insurance plan, but they also provided subsidies and regulations that limited the cost to consumers to no more than about 10 percent of income."

Dr. Gawande says the histories of the health care systems in the countries he’s studied informs how the US should go about providing universal health care:

"What I came away realizing is that everywhere looked to themselves to build on what they have. And if we did the same thing, if we looked to build on what we have, what we have are actually a series of reasonable choices. For example, we have a veterans’ health system that already runs 1200 hospitals, that has in recent studies not only the lowest costs per person of health care, but actually the highest quality results that we have – higher quality than people see through Medicare or through many private insurance plans.  And one option is to open that up and let other people join it. A second option is to open Medicare or Medicaid government programs that have been generally popular and successful.  A third option is to do something like what Massachusetts has done, which is to open private insurers to the public and in fact require people to obtain insurance through that kind of option, but subsidize it heavily especially for the poor.  Any of those options can actually be made to work and be made to work quite quickly. But it’s expanding the programs that we have and choosing the ones we think work the best, rather than imagining that what we’ll do is just blow up the existing system and put a new one in place." 

Dr. Atul Gawande’s article, "Getting There from Here" is in the January 26th edition of "The New Yorker." Dr. Gawande is a surgeon at the Brigham and Women’s Hospital and the Dana Farber Cancer Institute.  He also served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993.

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