Worldview

WORLDVIEW: Assume There's Morality

Joanne Kenen — Thu, 19 Nov 2009 21:16:00 -0500

Not many health writers -- not many writers of any ilk, for that matter -- can match T.R. Reid's ability to bring a light, witty touch to really serious topics. Like health policy around the globe.

Tom (that's what the "T" in "T.R." stands for) was the featured speaker at the Peterson Institute of International Economics today. Not the usual venue for the book tour for his best-seller, "Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care." Before his talk, he told me he was planning to stress the moral case for covering everyone. Not the approach, perhaps, that this particular crowd was used to hearing. Go ahead, I told him. It is, after all, a roomful of economists eating a free lunch.

And that's what he did.

Every rich western democracy (and a few of the not so rich and not so democratic ones), he said, covers everyone. We don't.

None of their systems are perfect. Like us, they wrestle with the rising price of pharmaceuticals and medical technology, and with the needs of an aging population. But they all cover everyone. It's time, he said, for us to do the same. It's been time for a long time.

Reid argued that health care is a basic human right -- a controversial notion in the United States, but received wisdom elsewhere. He threw in some economic lingo as well. Covering everyone (and everyone, he said, means everyone) also brings about efficiencie that make the system work better. He talked about "distributional ethics." Every American -- both Bill Gates and the guy who mows his lawn -- each have one vote. But they don't each have one yacht. Health care, he said, should be more like a vote than a yacht.

Nor does he believe (as some Americans seem to, judging from decibel level of our national health reform debate) that expanding coverage is a zero sum game. I get more, you get less. He argues that we can all get more. More efficiency. More morality. If we find the will, other wealthy industrialized countries can show us a plethora of ways.

Two New America colleagues have reviewed his book. Phil Longman in the Washington Post called the book " a service to his nation," Shannon Brownlee in the Washington Monthly wished he had written more on the lack of evidence behind some of the treatments widely used in the U.S. We liked the film Reid did for Frontline last year, "Sick Around the World" and we liked the book, a readable account of different national health systems interspersed with his own amusing but enlightening global search for a fix for his bum shoulder. How can you not like a book that has sentences like:

France [is] a mirror image of the United States when it comes to health care: Americans strongly dislike their national health care system but haven't found the political will to change it; the French are highly satisfied with theirs but change it all the time."

Or, after having his shoulder treated (quite successfully) by traditional healers in India, when he wrote:

When the front office at the Arya Vaidya Chikitsalayam handed me a detailed accounting -- dozens and dozens of pages listing every navarakizhi, every poojah, and ever ancient herbal medication I had experienced -- I realized instantly that my U.S. insurance company was never going to pay this bill.

He didn't care. His shoulder was better -- and he had lost nine pounds.

Reid's message is not always wry or witty. Far from it. At the beginning of his book, and again near the end, he writes about Nikki White. She died of lupus at age 32. Not because her disease was so severe or untreatable. But because once she became too sick to work, she lost her insurance. And once she lost her insurance, she got sicker. She could not get the treatment she needed until she was so sick that it was too late.

"No other rich country would have tolerated the inequality that left Nikki White dead," he wrote. Designing a health system is an economic question, a medical question, a political question, he acknowledged. But in the end, he concluded, " the primary decision to be made is a moral one."

WORLDVIEW: Switzerland's Success

Allison Levy — Wed, 11 Nov 2009 20:13:00 -0500

The Swiss might eat more chocolate per capita than people from any other nation in the world, but you wouldn't know it by looking at their health care stats.

Some say that Switzerland's health care system can provide inspiration, or serve as a model, for the restructuring of the U.S. health care system. Switzerland spends 10.8 percent, or $7,076 USD per capita (30 percent less than the U.S. spends per capita), of its gross domestic product on health care. They boast excellent health care service and enjoy long and healthy lives. Moreover, according to several indicators, the Swiss are healthier than Americans and are, as Nelson Schwartz of The New York Times reports, "generally happy with their system." (Switzerland does, however, still have high health care costs -- exceeded only by the United States and Norway.)

Harvard University's Regina Herzlinger, whom I listened to speak at an AARP and Swiss Embassy event last week, has done extensive research on Switzerland's health care system. In an article for the Journal of the American Medical Association (subscription only), she selects three U.S. states that have similar socioeconomic and population characteristics to Switzerland and demonstrates how the Swiss have lower health care expenses but equal or better health outcomes than the U.S.:

Switzerland guarantees quality health care coverage to all its residents, and does so without a government-run plan. It does not "resemble the model of bureaucratic, socialized medicine often cited by opponents of universal coverage in the United States." Instead, the Swiss rely on a public-private model that might be an appropriate template for policymakers in Washington to draw on.

The Swiss system has attracted attention because of "its use of an individual mandate combined with public oversight of the insurance market." The 1994 Health Insurance Law (that went into effect in 1996) requires that all residents of Switzerland purchase a private basic health insurance plan from one of the competing insurance companies. In return, the insurance companies must accept all applicants during the annual open-enrollment period and offer guaranteed coverage and renewal with community-rated premiums. Families can receive insurance subsidies from the government that vary depending on where they live. (About 35-40 percent of Swiss households receive a health insurance subsidy.)

Below are the main features of the Swiss health care system:

All insurers that offer the mandatory basic plan need to register with the Swiss Federal Office of Public Health. The health insurance market is decentralized and operates at the canton level (there are 26 cantons and each can have up to three regions.)
There is no group coverage, coverage for dependents or employer sponsored insurance; all plans are purchased on a per capita basis.
Most people purchase additional supplementary coverage for services excluded from the basic package (dental coverage, for example). Often times, an insurance company will have a non-profit branch that offers the basic plan and a for-profit branch that offers private, supplementary insurance.
Basic plans have a minimum deductible and coinsurance requirements; enrollees may opt for a higher deductible and obtain a reduced premium. (There is a minimum deductible of $225 and maximum deductible of $2,125. Once the deductible has been met, enrollees pay a 10 percent coinsurance rate with an annual maximum of $595. Maternity care and several preventive services are excluded from the deductible.) Switzerland tends to have relatively high out-of-pocket expenditures.
Aside from some variations in deductibles; individual insurers can vary premiums only according to age group (0-18, 19-25, 26 and older).
Insurance companies are free to set the prices for individual policies, but the Federal Office of Social Insurance has the power to reduce the price.
There is a risk equalization system that redistributes premium revenue among insurers according to the age and sex of their enrollees. This helps insurers with high-cost risk pools.
The Swiss have the option to change insurers each year during the annual open-enrollment period.

Many of the reform proposals floating around Washington mirror specific elements of the Swiss system. "The mix that Switzerland represents between private enterprise and general state regulations that make health care accessible to everyone is really an interesting example for the US," states Felix Gutzwiller, a senator and head of Zurich University's department of public health. Both the House and Senate health reform proposals, for example, include an individual mandate (with hardship waivers), government assistance for those that cannot afford insurance premiums, limits on age rating and prohibit coverage denials due to pre-existing conditions.

But as Uwe Reinhardt states in an article for JAMA, we "need not import another country's political system or social ethic to learn from the techniques they use to seek cost-effective health care." We can look to the Swiss system (and other European systems as well) for some good pointers on how to provide cost-effective, quality care to all Americans. The Swiss system represents American values of competition, choice and quality, and we may want to import some of their ideas -- and their chocolate!

WORLDVIEW: U.S. Lags In Primary Care

Meredith Hughes — Mon, 09 Nov 2009 20:40:00 -0500

The U.S. lags behind other leading industrial democraties in primary care, according to a new study from the Commonwealth Fund. The report, A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences, surveyed doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. It found the U.S. falls behind significantly in access to care, the use of payment incentives to improve health care quality, and utilization of health information technology.

Health IT. The U.S. lags behind every surveyed country except for Canada in health IT adoption. In the Netherlands, New Zealand, Norway, the U.K., Australia, Italy, and Sweden, over 90 percent of doctors use health IT, while in the U.S., only 46 percent of doctors use health IT. (It's worth noting that the U.S. has prioritized funding for health IT through economic stimulus package, and approximately $1.2 billion in grants has gone out to health IT development and implementation since data collection for this study concluded in July 2009.)

Cost. About half of U.S. doctors reported insurance restrictions were an obstacle to obtaining the treatment and medication their patients needed. More than half of U.S. doctors said their patients had difficulty paying for medication and care, more than any other surveyed country. Patients who struggle to pay for medical care are less likely to comply with treatment recommendations, and more likely to stay sick or get sicker. Millions of Americans go bankrupt every year because of medical debt.

Access. Only 29 percent of U.S. physician practices had arrangements to get patients reliable after-hours care -- which means many patients rely on costly visits to a hospital emergency room. In the Netherlands, New Zealand, the U.K., France, and Italy, more than 75 percent of physician practices had alternative arrangements. (Some examples of after-hours care arrangements include on-call clinicians and after-hours clinics.)

Financial incentives. The report found that other countries rely predominately on general practitioners or family practice physicians, in conjunction with primary care nurses. Primary care nurses counsel patients about healthy lifestyle choices, and help coordinate care of chronic conditions. In some countries, such as the Netherlands and the U.K., primary care doctors serve as gatekeepers for referrals to specialists. Elsewhere, patients and providers have financial incentives to rely on primary care. The U.S. offers few financial incentives to primary care doctors. Compared to 89 percent in the U.K. and 70 percent Italy, only 36 percent of U.S. doctors report receiving financial incentives. In many ways our payment system is geared to favor specialists with higher pay, and it discourages medical students with huge debts to go into the lower paying medical fields associated with primary care. We're facing a shortage of primary care physicians. On the other hand, one area the U.S. prevailed in was the wait time to see a specialist -- only 28 percent of doctors reported long waiting times for their patients to see a specialist, compared to more than 75 percent in Canada and Italy. However, the U.K. reported an even lower level of wait times to see a specialist -- only 22 percent.

Good primary care is the foundation for good health care. Research into primary care shows that good primary care leads to healthier populations, better health outcomes and lower costs. The U.S. has examples of both excellent and woefully inadequate primary care. The lack of a "strong primary care backbone" is the main difference between the U.S. and other countries, notes the Health Populi blog. Our reliance on internal medicine and pediatrics for primary care, coupled with very decentralized referral systems, makes the United States system of primary care uniquely different from the other surveyed countries. But as the study shows, that isn't necessarily a good thing.

WORLDVIEW: Dutch Improve Care and Cost Through Competition

Meredith Hughes — Wed, 07 Oct 2009 18:48:00 -0400

When the health care conversation heated up a year or so ago, a spate of articles focused on the Dutch health care system. In the Netherlands, everyone receives health coverage through a network of private insurers, and there is strict government regulation to ensure that everyone competes on a level playing field. We heard very little about the Dutch system for awhile -- but recently, there's been another round of reporting, including this piece from the NewsHour with Jim Lehrer.

The Netherlands passed major health reform in 2006. Most of the Dutch are "wealthy and healthy," reports the NewsHour, but the country has struggled with rising health care costs due to increases in the number of elderly and young immigrants from the developing world. When the Netherlands reformed its health care system, the country had similar goals to the U.S. -- lower costs in the long run, provide sustainable coverage to everyone, and unleash competition amongst private insurers, according to the NewsHour. (The Dutch have had near universal coverage since 1941, when the government introduced a mandatory health coverage plan for low and middle income citizens, according to Health Affairs).

The Netherlands has an individual mandate -- everyone is required to purchase insurance. The Dutch government subsidizes low income individuals so they can afford the premiums. Subsidies also exist in all versions of pending health reform legislation in the U.S., but how large the subsidies will be, and who will get them, is still a matter of contention for some lawmakers.

Rather than the "bronze, silver, gold, and platinum" plans in U.S. health reform legislation, the Netherlands offers plan to its citizens ranked on a scale of one to four stars. According to the NewsHour, everyone must buy a basic plan, for approximately $160 per month. There is no age-rating of premiums (you pay the same no matter how old you are) or denials based on medical history, what we call pre-existing conditions. Consumers may choose to pay more for services such as dental coverage, cosmetic surgery, or physical therapy.

Roger Van Boxtel, CEO of Menzel, one of the Netherlands' largest insurance companies, told the NewsHour,

There can be no discrimination if you're ill or old or young. We have to accept everybody. And I think that is one of the big differences with the United States. We have a level playing field, and we have to compete. We have to do our best to have good prevention programs, to innovate, and to buy health care with the providers, the GPs, the hospitals, the physical therapists. We make contracts with them every year, and we're seeking for the highest quality and the most efficient price.

Because everyone must have insurance and insurance companies must accept everyone, insurers are forced to compete on the quality of services they provide rather than on the cost of those services. In the Netherlands, if you don't like the quality of care you are receiving from your health insurer, you can switch to a different one. No insurer can turn you down for pre-existing conditions, so you are free to seek care from the insurer providing the highest quality (and at the same cost as your old plan!). To prevent a single health insurance company from getting overloaded with high risk patients, the Dutch government offers a "risk equalization fund." The fund reimburses companies taking on risky or costly patients, such as diabetics and cancer patients, reports the NewsHour.

According to the NewsHour, the Netherlands spends half as much money as we do on health care, and has a longer adult life expectancy and a lower infant mortality rate. As we illustrated earlier this week, the Netherlands ranked 8th overall in preventable deaths, while the U.S. was 19th (last place out of all wealthy industrialized countries). Dutch citizens are generally satisfied with their health care system and only spend seven percent of their income on health care.

Nor do they make the system work by skimping on necessary and effective care. Take the case of the Van Driel family, profiled by the NewsHour. When they began to suspect their son had autism, the Van Driel family moved from the U.S. to the Netherlands, Mr. Van Driel's native land. Thanks to their dual U.S.-Dutch citizenship, the Van Driels get coverage for their son's therapy, home visits, and even babysitters to help manage his condition. The Van Driel's feared the expensive therapy necessary to support their autistic son would bankrupt them if they remained in the United States. Mr. Van Driel told the NewsHour,

We didn't feel we had a choice. We felt we had our backs against the wall financially. We felt that we did have some money in savings, but not very much, and we felt that we were one treatment away from being bankrupt there.

The Netherlands laid the groundwork for a system that promotes choice and universal access, while the U.S. shows insight into quality integrated health care delivery systems, says Health Affairs. Though the health care system in the Netherlands is not perfect, it does demonstrate what health care coverage in the U.S. could be: affordable and sustainable for everyone, and built upon the values that Americans admire -- choice and competition.

WORLD VIEW: Globalized Mythbusting

Meredith Hughes — Mon, 24 Aug 2009 21:07:00 -0400

Do we have the best health system in the world? That's a complex question. A majority of Americans say the answer is ‘no,' but many are also terrified of the alternatives. Rather than let fear stifle the reform conversation, let's look at the facts -- just what are the alternatives? In The Washington Post this weekend, journalist and author T. R. Reid debunked myths about health care in the rest of the world.

Socialized medicine?

We hear a lot about Canada and Britain when we talk about health care around the world. Both of these countries have national health systems where the government pays for health care through tax revenue. But most Americans don't want a single payer system, and that's not where the current health care debate is taking us. There are other ways of creating high quality, affordable health care for all Americans. All other industrialized nations have found ways to provide health care coverage for all of their citizens, for less money per person than we're currently spending covering only some Americans.

Reid points out that universal coverage doesn't mean government-run. Germany, Japan, and Switzerland are among the nations that provide health care using "private doctors, private hospitals and private insurance plans." And for all the complaining about "government-run" care, it already exists in some parts of the U.S. system -- well-liked parts such as Medicare and the Veteran's Administration health system.

Choice vs. rationing

In Germany, a citizen can sign up for any of 200 private plans, says Reid. If they don't like the plan, they can switch without having to pay more in premiums. In France and Japan, you can't pick your plan (it's assigned based on your industry or employer), but you can see any doctor or health provider you want without having to worry about "out-of-network" rates or pre-authorization -- your insurance has to pay for any doctor you choose. It's true that you have to wait for non-emergency treatment in Canada, but this isn't true everywhere. In Japan, reports Reid, waiting times are so short some patients don't even bother scheduling appointments. They just drop in on the same day.

Foreign health care systems don't practice recission, (when insurers find a way to drop a customer when they get sick). Foreign companies must accept everyone (they can't deny coverage based on "pre-existing conditions") and can't cancel if you pay your premiums, reports Reid,

The key difference is that foreign health insurance plans exist only to pay people's medical bills, not to make a profit. The United States is the only developed country that lets insurance companies profit from basic health coverage.

Cost and innovation

Though the U.S. has some of the best educated medical professionals and most cutting-edge advanced hospitals in the world, we aren't responsible for many of today's most widespread the health care innovations. For example, hip and knee replacement surgery originated in France.

In Japan, patients see their doctor three times as often as Americans do, get twice as many MRIs and X-rays, and have longer life expectancy and higher rates of recovery from disease, reports Reid. Still, Japan spends less than half of what the U.S. spends on health care -- $3,400 vs. $7,000, per person annually. And, writes Reid,

Overseas, strict cost controls actually drive innovation. In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)

Patchwork health care

Reid calls the American system a "crazy quilt" -- we've got a little bit of everything in our system. Native Americans and veterans have a single payer system with no bills -- like the UK. People with private, employer-provided insurance split premiums between workers and employers, like in Germany. Medicare is like the Canadian system, where people see private health providers and pay premiums to a government-run plan. For those with no insurance, we're like a third world country, reports Reid, "In the world's poor nations, sick people pay out of pocket for medical care; those who can't pay stay sick or die." Hundred of thousands of Americans go into bankruptcy each year because of medical debt.

Reid says what we really need is organization in our health care system. He argues, "All the other developed countries have settled on one model for health-care delivery and finance; we've blended them all into a costly, confusing bureaucratic mess."

So it's time to fix it. Not by copying what works for another country, but by taking advantage of this unique moment in time to create an American health care system that works for Americans. Preserving what works in our system, and fixing what doesn't in ways that reflect the values that are important to us as a nation. We can have sustainable, affordable, quality coverage for all Americans without sacrificing important American values such as innovation, fairness, and choice.

(BTW we have T.R. Reid's new book The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care and we'll let you know what we think as soon as we have a chance to read it...)

WORLDVIEW: Fixing the Economy Means Fixing Health Care—In China?

Paul Testa — Tue, 16 Dec 2008 20:41:00 -0500

Extrapolating from the Kevin Bacon theory of health care and the economy one arrives at the fortune cookie corollary of international affairs, which states that any major issue is made more interesting simply by adding the phrase, ‘In China.'

For example, fixing the economy means fixing health care. It's true in the U.S. and as a piece in the current issue of Newsweek argues, equally true in China.

With an economic crisis of increasingly global proportions, the article argues China must boost its domestic consumption to maintain a desired level of economic growth. But efforts to stimulate the Chinese economy have been stymied by the country's high rate of domestic savings. The World Bank estimates the average household savings rate to be around 25 percent in China, substantially higher than most developed countries. The disparity is even more apparent when you look at net national savings rates across the G-20 (Below. Hat tip, Alejandra and New America's Asset Building Program)

Why is China too scared to spend? The answer Newsweek argues, is health care. As Cornell professor Huang Ming tells the magazine, the "‘[Chinese] save because they are frightened of getting sick.' The costs of illness can be ruinous. A better health-care system would unleash domestic spending and thereby boost employment."

Those fears are all too familiar to Americans for whom more than half of all bankruptcies and home foreclosures are caused by the high cost of health care. Ironically, 30 years after the reforms of Deng Xiaoping, China's economy looks more like the U.S. and so does its health care. Briefly:

Health care is unaffordable. Average out-of-pocket spending in China has risen from one-fifth of total health spending in 1980 to more than half in 2005.
Fee-for service payments at the nation's hospitals has led to overprescription and overutilization of services.(How do you say "Dartmouth Atlas" in Chinese?)
Employer-based health coverage fails to meet the needs of the population, while the individual market provides spotty coverage at best.
The primary care infrastructure is frayed with a particular shortage of rural doctors.

The parallels continue and the situation described in China seems as true for Brooklyn as it is for Beijing. Whether you subscribe to the economic tenets of Adam Smith or the political theories of Mao Zedong, succeeding in today's modern, integrated global economy requires an equally modern integrated system for delivering affordable, high-quality health care. The wealth of nations is increasingly dependent on the health of nations—in China, the U.S. and the world.

WORLDVIEW: Dutch Treat(ment) Running Way Ahead of Us

Julie Barnes — Fri, 21 Nov 2008 14:27:00 -0500

It is not every day the U.S. loses to the Dutch. Heck, even when our wooden-shod friends were favored in soccer over the U.S. in group play at the Olympics this summer, the U.S. came from behind to tie.

But when it comes to the quality of health care services, particularly taking care of people with chronic disease, the Netherlands runs way ahead of us.

So do Australia, New Zealand, France, Germany, the United Kingdom and Canada.

The Commonwealth Fund and Harris Interactive's 2008 survey of access and efficiency of health care services offered to chronically ill adults in eight industrialized countries provides yet more evidence that we in the U.S. do a terrible job of caring for patients with ongoing conditions. Despite far outspending the other seven countries surveyed, and despite high cost sharing even for insured patients, the U.S. was the hands-down survey loser. It's another reminder that our anachronistic system is designed to respond to acute, episodic illnesses, not prevent complications or deterioration of patients with chronic conditions.

The researchers surveyed about 10,000 people, most of whom were either in poor health or had experienced a serious illness or surgery in the previous two years. The Netherlands didn't top every category, but the United States almost always brought up the rear. Examples:

Skipping Care Because of Cost

Chronically ill U.S. adults were most likely to report forgoing needed care because of costs. More than 54 percent reported at least one cost-related access problem, like not filling a prescription or not visiting a doctor when sick. Twenty-nine percent of the U.S. patients surveyed were uninsured during the year.
The Dutch and the U.K. were the least likely to go without care

Can't Get Access to Timely Care

U.S. patients are the least likely to receive same or next-day access to care (a point we'd like to emphasize to all those skeptics of health reform out there who are always complaining that we'd have to wait for care)
The Dutch have no problem receiving same-day care, and have superb access during evenings and weekends

U.S. Uses ERs More

Chronically ill adults used hospital ERs more in the U.S., Canada and Australia than in the other five countries

More Medical Errors in U.S.

Lab and diagnostic test errors and delays in hearing about abnormal test results were significantly higher for U.S. patients than in other countries

Complaints About Wasted Time and Duplicate Tests

U.S. patients were significantly more likely to report wasted time because of poorly organized care and unavailable medical records or test results lead to unnecessary duplication of tests
The Dutch (and the U.K.) were the least likely to report time wasted and reported significantly better coordinated care

A couple of the things the United States does relatively well: timely access to specialist care and decent instructions after hospital discharge. Apparently, the French are particularly uninterested in touchy-feely post-surgery conversations, with 71percent of French patients reporting deficits in discharge instructions (e.g., after new medications are prescribed, there is a failure to warn of potential adverse drug interactions).

This was a powerful survey with important lessons:

Our primary care system —to use a clinical term — stinks. U.S. patients lack rapid access and ability to get care after hours.
We need medical homes. The absence of a strong primary care infrastructure and inadequate coordination of care leads to poor care. Just ask the people who have the most interaction with our health care system.
Insurance matters. U.S. patients either forgo care due to costs or can't afford to follow recommended care. What is so pathetic about this truth is that we are WAY outspending our foreign friends on health care.

Why are the Dutch winning the health care game? They have comprehensive insurance benefits and a strong primary care infrastructure. I'm not trading in my "Sex in the City"-inspired footwear for wooden shoes, but I'd still like us to follow in their health care footsteps.

WORLDVIEW: NPR Takes European Health Tour

Joanne Kenen — Thu, 10 Jul 2008 19:05:00 -0400

NPR's recent "Health Care for All" series went beyond a lot of the comparative reporting we've seen before, not just describing how various western European countries achieve and finance coverage for all, but also doing a few very specific case studies—comparing how a multiple sclerosis patient might fare in the U.S. versus Britain or how France treats cancer patients at home, or what the Dutch are doing about diabetes. They did take a good look at the Swiss system—often cited as a potential model for U.S. reforms. Our thanks to the Kaiser Family Foundation for assembling this list.The links will take you to both audio and text versions.

Britain

"Britain Weighs the Social Cost of High-Priced Drugs": The story examines how the British health care system limits coverage for certain treatments based on cost effectiveness to keep costs down and provide universal access to care (Silberner [1], NPR.org, 7/2).
"MS Patient Falls Into American Insurance Gap": The story examines the treatment and coverage of multiple sclerosis in Britain and the U.S. (Silberner [2], NPR.org, 7/2).

France

"France at Forefront of Free, Innovative Cancer Care": The story examines how the French health care system, which covers all residents, provides a broad range of cancer treatments, such as home care and experimental medications (Shapiro, "All Things Considered," NPR, 7/9).
"France's Model Health Care for New Mothers": The story examines how the French health care system provides women with generous paid maternity leave, in-home nurse visits at no cost and subsidized child care, a model with which the U.S. system cannot compete, according to two mothers featured (Shapiro, "Morning Edition," NPR, 7/10).

Germany

"Health Clinic Treats Germany's Few Uninsured": The story examines how German health clinics can meet the demand for care because only 0.2% of residents lack health insurance, compared with 18% of U.S. residents (Collins Sullivan, "Day to Day," NPR, 7/4).
"History of Tinkering Helps German System Endure": The story examines the history of the German health care system (Knox, NPR.org, 7/3).
"Keeping German Doctors on a Budget Lowers Costs": The story examines how the German health care system provides access to physicians, medications, technology, dental care, nursing homes and home care at a lower cost than the U.S., in part because the government requires physicians to adhere to a budget (Knox, "All Things Considered," NPR, 7/2).
"Most Patients Happy With German Health Care": The story examines how German residents have generous health insurance and often do not have to wait for elective surgeries or diagnostic tests (Knox, "Morning Edition," NPR, 7/3).

Netherlands

"In the U.S. and Holland, Diabetes Looks Different": The story examines how, although the Dutch health care system has similarities with a large HMO, the nation provides health care for all residents, with a focus on preventive care for those with chronic illness (Neighmond, NPR.org, 7/2).

Switzerland

"In Switzerland, a Health Care Model for America?": The story examines how the Swiss health care system could serve as a model for efforts by the U.S. to require the purchase of insurance while providing subsidies to those who cannot afford to purchase coverage (Rovner, NPR.org, 7/2).

WORLDVIEW: Evidence-Based Medicine vs Russian Salt Dust

Joanne Kenen — Wed, 18 Jun 2008 17:30:00 -0400

If you think we've got problems here in the U.S. developing evidence-based medicine, just think about the challenge in a place like Russia. Health writer and blogger Merrill Goozner just spent two weeks reporting in Russia, and we were fascinated by his piece on the Scientific American website.The problem, he writes, begins in the medical schools, where "young doctors receive almost no instruction on biostatistics, epidemiology and methods of decoding the evidence generated by clinical trials." Russian doctors make about $800 a month, meaning getting access to western medical literature is often out of reach (besides, it's in English). So while neither our health system nor our lawmakers have yet figured out how to stimulate more comparative effectiveness research (and how to get the research acted on), at least we aren't treating pulmonary patients with aerosolized salt dust in "cave-like rooms"—a practice that's been common in Eastern Europe for two centuries, but according to Goozner, never systematically studied.

WORLDVIEW: Health Care Complaints Sans Frontieres

Paul Testa — Fri, 30 May 2008 17:55:00 -0400

The Tour de France doesn't start until July, but Americans have already opened a substantial lead over some European compatriots when it comes to dissatisfaction with their home country's health care system, according to a new Harris Interactive poll, reported in today's International Herald Tribune.

Asked to describe their overall view of their country's health care system, 33 percent of Americans felt "the health care system has so much wrong with that we need to rebuild it," 50 percent believed there were some good things but "fundamental changes are needed to make it work better," and 12 percent said the system worked well and "only minor changes are necessary," (5 percent weren't sure).

Respondents from the five largest European countries were also dissatisfied with their health care systems, but they weren't as ready as some Americans to throw it all away and start over. This nifty little graph from the Tribune helps illustrate the comparison:

The poll also focused on issues of cost, standards, and efforts to improve health and wellness. Some quick highlights:

All of the countries agreed the costs of health care were rising too fast. Americans and Germans are most likely to agree (89 percent and 86 percent, respectively) that costs were rising too fast and also the least likely to feel that the standards and costs in their health care system corresponded to their needs and expectations.
The French are reasonably content (yes, you read that right). Nearly four in 10 of the French believed only minor changes were needed to their system. Further, France was the only country where a majority of the respondents believed the standards and costs of their system lived up to their expectations.
Health care is an issue of both shared and individual responsibility. Accompanying their dissatisfaction with their health care system, respondents identified on average five to seven steps they were taking to improve their own health and wellness. The most popular options: drinking more water and eating more fruits and vegetables. Americans were also focused on eating less fast food, while the Germans seemed far less worried about limiting their salt intake (19 percent) cutting out the snacks (15 percent) than their French neighbors (47 percent, and 62 percent respectively).