Why is it so hard to change the American health care system? And so much easier to change other countries’ systems?
I pondered this question recently while attending the Commonwealth Fund’s International Symposium on Health in Washington where our latest survey comparing primary care in eleven countries was discussed. I heard presentations describing changes that have been, or are being, implemented in England, France, Germany, Norway, Sweden, Switzerland, the Netherlands, Canada, Australia and New Zealand. In some cases, these are fundamental reforms in how medical care is delivered and how providers are reimbursed. Many of these countries can demonstrate real improvements in the quality of care and efficiency in their systems.
Evidence of how much more difficult it to improve this country’s system is provided by the OECD data from nineteen countries on the number of “deaths amenable to medical care,” that is deaths that could have been prevented by appropriate medical care. It is bad enough that the United States has dropped to last place – with the highest proportion of preventable deaths – of all nineteen countries measured. The data also show that all the other eighteen countries had lowered the number of preventable deaths over five years by much more than this country’s modest 4% improvement.
I would suggest that all of the following are reasons why it is easier, in some countries much easier, to reform their systems than it is to change ours:
- Their systems are so much simpler. Ours is much more complicated with our “thousand points of payment,” Medicare, Medicaid, Kaiser, the VA, the Mayo Clinic, HMOs, PPOs, and millions of employers and their different health plans.
- They already have universal coverage, so they can focus on improving quality, efficiency and cost containment without a huge ideological debate about the roles of government and the private sector.
- They have parliamentary systems, where their governments can usually win the votes of a majority of legislators and only a simple majority is needed. It is much, much harder for an American president to win enough votes in both houses of Congress, including a filibuster-proof sixty votes in the Senate, for controversial new legislation.
- Lobbies, representing special interests, are much more influential in this county.
- The power of money; elected officials in most other countries do not have to raise larger sums of money for their campaigns, and are therefore much less beholden to industries or professional groups.
- They only need a bare majority of votes in their legislatures. None of them have anything like the US Senate’s ability to filibuster.
Another factor that may also make a different is the influence of partisan news networks, especially Fox News, and of talk radio, that spread emotional and often misleading arguments, fuel populist feelings and dumb down the debate.
I should note here that the ease with which parliamentary systems can enact major reforms is not always a good thing. After World War II, Britain’s Labour government nationalized its substantial steel industry. It was then privatized (i.e. denationalized) by the next Conservative government, nationalized again in the 1960s and then denationalized in the 1970s – by which time it had been almost wiped out.
However, when we look at the difficulties our presidents since Theodore Roosevelt have had when trying to pass major health care reforms, one wonders if the uniquely American barriers to change and reform are really desirable.