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Healthy examples

Plenty of countries get healthcare right.

The emergency room waiting area at Coney Island Hospital in Brooklyn. The hospital's emergency room receives about 60,000 patients a year. (Getty Images / Mario Tama) The emergency room waiting area at Coney Island Hospital in Brooklyn. The hospital's emergency room receives about 60,000 patients a year.
By Jonathan Cohn
July 5, 2009
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“I DON’T WANT America to begin rationing care to their citizens in the way these other countries do.”

That was Arizona Senator Jon Kyl, speaking last month about healthcare reform. But it could have been virtually any other Republican, not to mention any number of sympathetic interest groups, because that’s the party line for many who oppose healthcare reform. If President Obama and his supporters get their way, this argument goes, healthcare in America will start to look like healthcare overseas. Yes, maybe everybody will have insurance. But people will have to wait in long lines. And when they are done waiting in line, the care won’t be very good.

Typically the people making these arguments are basing their analysis on one of two countries, Canada and England, where such descriptions hold at least some truth. Although the people in both countries receive pretty good healthcare - their citizens do better than Americans in many important respects - they are also subjected to longer waits for specialty care and tighter limits on some advanced treatments.

But no serious politician is talking about recreating either the British or the Canadian system here. The British have truly “socialized medicine,” in which the government directly employs most doctors. The Canadians have one of the world’s most centralized “single-payer” systems, in which the government insures everybody directly and private insurance has virtually no role. A better understanding for how universal healthcare might work in America would come from other countries - countries whose insurance architecture and medical cultures more closely resemble the framework we’d likely create here.

Last year, I had the opportunity to spend time researching two of these countries: France and the Netherlands. Neither country gets the attention that Canada and England do. That might be because English isn’t their language. Or it might be because they don’t fit the negative stereotypes of life in countries where government is more directly involved in medical care.

Over the course of a month, I spoke to just about everybody I could find who might know something about these healthcare systems: Elected officials, industry leaders, scholars - plus, of course, doctors and patients. And sure enough, I heard some complaints. Dutch doctors, for example, thought they had too much paperwork. French public health experts thought patients with chronic disease weren’t getting the kind of sustained, coordinated medical care that they needed.

But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

The Dutch and the French organize their healthcare differently. In the Netherlands, people buy health insurance from competing private carriers; in France, people get basic insurance from nonprofit sickness funds that effectively operate as extensions of the state, then have the option to purchase supplemental insurance on their own. (It’s as if everybody is enrolled in Medicare.) But in both countries virtually all people have insurance that covers virtually all legitimate medical services. In both countries, the government is heavily involved in regulating prices and setting national budgets. And, in both countries, people pay for health insurance through a combination of private payments and what are, by American standards, substantial taxes.

You could be forgiven for assuming, as Kyl and his allies suggest, that so much government control leads to Soviet-style rationing, with people waiting in long lines and clawing their way through mind-numbing bureaucracies every time they have a sore throat. But, in general, both the Dutch and French appear to have easy access to basic medical care - easier access, in fact, than is the American norm.

In both the Netherlands and France, most people have long-standing relationships with their primary care doctors. And when they need to see these doctors, they do so without delay or hassle. In a 2008 survey of adults with chronic disease conducted by the Commonwealth Fund - a foundation which financed my own research abroad - 60 percent of Dutch patients and 42 percent of French patients could get same-day appointments. The figure in the US was just 26 percent.

The contrast with after-hours care is even more striking. If you live in either Amsterdam or Paris, and get sick after your family physician has gone home, a phone call will typically get you an immediate medical consultation - or even, if necessary, a house call. And if you need the sort of attention available only at a formal medical facility, you can get that, too - without the long waits typical in US emergency rooms.

This is particularly true in the Netherlands, thanks to a nationwide network of urgent care centers the government and medical societies have put in place. Not only do these centers provide easily accessible care for people who use them; they leave hospital emergency rooms free to concentrate on the truly serious cases. Tellingly, a Dutch physician I met complained to me that waiting times in her emergency room had been getting “too long” lately. “Too long,” she went on to tell me, meant two or three hours. When I told her about documented cases of people waiting a day, or even days, for treatment in some American emergency rooms, she thought I was joking. (In a 2007 Commonwealth Fund survey, just 9 percent of Dutch patients reported waiting more than two hours for care in an ER, compared to 31 percent of Americans.)

Dutch and French patients do wait longer than Americans for specialty care; around a quarter of respondents to the Commonwealth Fund survey reported waiting more than two months to see a specialist, compared to virtually no Americans. But Dutch and French patients were far less likely to avoid seeing a specialist altogether - or forgoing other sorts of medical care - because they couldn’t afford it. And there’s precious little evidence that the waits for specialty care led to less effective care.

On the contrary, the data suggests that while American healthcare is particularly good at treating some diseases, it’s not as good at treating others. (In some studies, the US did pretty well on cardiovascular care, not so well on diabetes, for example.) Overall, the US actually fares poorly on measures like “potential years of lives lost” - statistics compiled by specialists in an effort to measure how well healthcare systems perform. In a 2003 ranking of 20 advanced countries, the US finished 16th when it came to “mortality amenable to healthcare,” another statistic that strives to capture the impact of a health system. The Dutch were 11th and the French were fifth. These statistics are necessarily crude; diet, culture, and many other factors inevitably affect the results. But, taken together, they make it awfully hard to argue that care in these countries is somehow inferior. If anything, the opposite would seem to be true.

Critics of health reform frequently point to cancer as proof that American healthcare really is superior. And, it’s true, the US has, overall, the world’s highest five-year survival rate for cancer. But that’s partly a product of the unparalleled amount of government-funded research in the US - something healthcare reform would not diminish. Besides, it’s not as if the gap is as large or meaningful as reform critics frequently suggest. France (like a few other European countries) has survival rates that are generally close and, for some cancers, higher. Much of the remaining difference reflects differences in treatment patterns that have nothing to do with insurance arrangements and everything to do with idiosyncratic medical cultures. This is particularly true of prostate cancer, where a staggeringly high survival rate in the US seems to be largely a product of aggressive US treatment - treatment that physicians in other countries, and increasingly many specialists here, consider unnecessary and sometimes harmful.

None of this is to say that either the Dutch or French systems are perfect. Far from it. In both countries, healthcare costs are rising faster than either the public - or the country’s business interests - would like. And each country has undertaken reforms in an effort to address these problems. The French have started to introduce some of the managed care techniques familiar to Americans, like charging patients extra if they see specialists without a referral, while developing more evidence-based treatment guidelines in the hope that it will reduce the use of unnecessary but expensive treatments. The Dutch overhauled their insurance arrangements a few years ago, to introduce more market competition and reward healthcare providers - that is, doctors and hospitals - who get good results.

But cost is the one area in which France and the Netherlands are a lot like Canada and England: They all devote significantly less of their economy to healthcare than we do. The French spend around 11 percent of their gross domestic product on healthcare, the Dutch around 10. In the US, we spend around 16 percent. And, unlike in the US, the burden for paying this is distributed across society - to both individuals and businesses - in an even, predictable way.

Of course, reforming health insurance in the US isn’t going to turn this country into France or the Netherlands overnight, any more than it would turn the US into Britain and Canada. The truth is that the changes now under consideration in Washington are relatively modest, by international standards. But insofar as countries abroad give us an idea of what could happen, eventually, if we change our health insurance arrangements, the experience of people in Amsterdam and Paris surely matters as much as - if not more than - those in Montreal and London. In those countries, government intervention has created a health system in which people seem to have the best of all worlds: convenience, quality, and affordability. There’s no reason to think the same thing couldn’t happen here.

Jonathan Cohn is a senior editor of The New Republic, where he writes a blog called “The Treatment.” He is also the author of “Sick: The Untold Story of America’s Health Care Crisis - and the People Who Pay the Price (HarperCollins, 2007).