Learning from the Health Care Systems of Other Countries FREE

At the beginning of an election year in the United States, many are hoping that the election returns will be a clear mandate for health care reform. Not since 1992 has this prospect seemed so within reach. Then, many stars seemed to be aligned: The United States had been dealing with 14% annual increases in health spending and drug spending—and even greater increases in Medicaid spending. According to the polls, half of the country wanted health reform and felt it should be 1 of the 2 top priorities of the country. The incoming president had made health care reform his top priority, and his party controlled Congress. Indeed, the president followed through, and health care reform seemed inevitable. In the summer of 1993, a legislative aide to a prominent Republican congressman told me that his party felt as if it was in the path of a legislative avalanche. At best, it hoped to be at the bargaining table, to have a voice on issues that were important to their constituencies. The administration developed a complex plan. Many features of the plan seemed to reflect a memorable American College of Physicians (ACP) position paper on health reform, which Annals published (1). In the end, the president's plan went nowhere. Johnson and Broder's wonderful book The System tells the story of its downfall (2). It should be required reading during election season.

In some respects, the portents for action are less favorable in 2008 than they were in 1992. The rates of increase of health care premiums, drug spending, and Medicaid spending are considerably lower. The polls say that health care is still a major concern of the country, but fewer people believe that it is 1 of the top 2 issues facing the country. The situation may have to worsen before health care reform at the federal level has any serious prospects.

In fact, the outlook is pretty disturbing. The country seems headed for an unprecedented fiscal crisis if it can't control the costs of health care (3). Patients starting to feel the effects of the growing scarcity of primary care physicians, as fewer medical students choose careers in primary care and primary care physicians leave their practices (4). The number of uninsured Americans has risen by about 5 million since 1992, and the employment-based health insurance system is weakening under pressure from rising costs.

Of note, compared with 1992, the United States is farther down the path toward an infrastructure to support better care. The country has recognized the importance of electronic health records that can talk to each other, which was a key element in the remarkable success of health care reform in the Veterans Administration. The Internet, e-mail, and cell phones give us a communications infrastructure for better-coordinated health care. As a nation, we have become alarmed about poor-quality and unsafe care. Many health care provider systems are trying hard to get better, spurred on by the need to remain competitive in a world in which bad news about health system performance travels fast.

Reforming health care will not be easy, but it's not impossible. Other countries have done it, and they have lower costs and better overall system performance than the United States (5 - 7). That we can learn from their experience is the premise of an ACP position paper in this issue (8). This premise rejects the concept of American exceptionalism (the belief that the United States is unique among developed nations because of its historical credo, its evolution as a nation, and its unique institutions), as the authors rightly claim that we can and should learn from other countries. Written by ACP staff and J. Fred Ralston Jr., MD, for the ACP Health and Public Policy Committee and approved by the ACP Board of Regents, the article describes the U.S. health care system, compares it with those of other industrialized countries, and proposes changes that have worked in other countries. The article also recommends that the country seriously consider a single-payer system as another way to provide universal access to health care. Although countries have achieved universal access with pluralistic insurance systems, not unlike our own, both can achieve the greater end that should be our highest priority: equal access to basic health care for every citizen.

Annals will reprise the theme of learning how other countries are approaching the universal problem of high-quality health care at a reasonable cost. During 2008, we will publish a series of articles that describe the health care system of some exemplar countries. We will accompany each article by a commentary written by someone who knows the country's health care system and the U.S. health care system.

Successful national health care systems have taken several routes to paying for health care, but they share one essential characteristic: The government guarantees that every citizen will have health insurance. They have solved a problem that grows worse every day in the United States. Why do Americans tolerate a system that leaves one sixth of its citizens with poor access to basic medical care? When will we elect leaders who will erase this stain on our national character? Perhaps the example of other countries will motivate Annals readers to join ACP in demanding decisive action on universal coverage.

Harold C. Sox, MD

Editor