Thursday, August 27, 2009

U.S, Health System: Different Systems for Different Folks

U.S. Health System: Different Systems for Different Folks
And the dream lives on.

Senator Edward Kennedy, 1980

In Obama, Doctors, and Health Reform (IUniverse.2009), I wrote these words in the preface:

In a way, it is meaningless to talk of “universal health care. “ It may even be misleading to talk of a “national health system.” It is equally misleading to say we have a “non-system.” We have many systems –some public, private, state-wide as in Massachusetts, city-wide as in San Francisco, some regional as practicing in large organizations like the Marshfield, Geisinger, Mayo, Partners Health, Cleveland Clinic and other major health organizations.”

Thhe opinion expressed in that paragraph came back to me this week from three different sources.

• First was in interview with T.R. Reid, a journalist for National Public Radio. Reid has lived on three continents, has spent the last three years investigating various health systems, and has just written a book, The Healing of America: A Global Quest for Better, Chearer, and Fairer Health Care. Here is part of what Reid had to say,

I went all around the world for three years looking at different models of health care. It turns out we have them all right here in the United States. If you're a Native American or a veteran, you live in Britain. They get government health care and government hospitals from government doctors and they never get a bill. If you're an employed person sharing your health insurance premium with your employer, you live in Germany. If you're a senior and you buy Medicare insurance from the government and go to private doctors, you live in Canada. That's the Canadian model.
And if you're one of the tens of millions of Americans who can't get health insurance, well, you live in Malawi or Madagascar or Mali. We've got them all .”

• Second was an interview with Annie Proulx, author of Broke Back Mountain and numerous prize winning short stories and novels, in the Spring 2009 issue of The Paris Review, a literary magazine. Here is one of her comments.

The biggest difference between rural life in Wyoming and Vermount is the difference between liberals and conservatives. There are armfuls of liberal minds and ideas in Vermont, only scant handfuls in Wyoming. And Vermont is small, within a day’s drive of Montreal, New York, Boston, and those nearby urban centers that very much affect rural people, especially the rising tide of urbanites who mythologize Vermont as a rural paradise. Wyoming is huge and sparsely populated. The drives to Salt Lake City or Denver are long. Wyoming likes its isolation and clings to the ideal of the rugged individualism of the nineteenth century as its basic characteristic.”• Third was an interview with Toby Cosgrove, MD, a heart surgeon who is now CEO of the Cleveland Clinic, on the Public Broadcasting System (PBS) .

“One of the very important ways to improve care is to integrate the health care system and make it more efficient. And that means integrating not only the doctor with the hospital, which you saw a great example of here, but also integrating hospitals, so that not all hospitals are expected to be all things to all people, but rather to serve the community in a way that the community needs to be served, and then have the high specialty things located in places where you can get maximum practice and maximum efficiency. It's perfectly possible to expand that. It's not going to happen instantly.”


America is a vast continental nation with vast regional differences and different health systems. If nearly 100 years of failed efforts to institute a national system is any indication, a unified national system will continue to be a tough sell politically.

The dream of a universal system flounders because our complex system is a creature of our culture. This culture is why Americans prefer local solutions, why they reject federally mandated universal coverage with rationing, why they fear government mediocrity, why they feel capable of making their own health care decisions, why they seek equal and prompt access to high technologies, why they prefer pluralistic payment systems and rugged individualism to national uniformity.

U.S. health care is messy, as demonstrated in town hall free-for-alls. Health reform doesn't come neatly wrapped in one ideological package for all , but in multiple packages for different recipients. Freedom of speech, freedom of action, and freedom of choice are their rallying cries. American health care remains a set of subsystems. If you are in pne of these systems, health care can be great. If you do not fall into one of these systems, health care is often inadequate.
Richard L. Reece, MD, is a retired pathologist and a long time health reform commentator. His latest book is Obama, Doctors, and Health Reform (, a Barnes and Noble subsidiary , 2009), and his blog is

1 comment:

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