That the American health care system needs reform is conventional wisdom. We are told anecdotally that having an appendectomy in France is performed efficiently and no bills ever appear. Ask someone in the United States with appendicitis and you probably will hear that it was performed efficiently here as well. However, as no bill is generated in France, it obviously is a better system. Michael Moore "proved" that in his film Sicko. But health care systems always have at least two kinds of individuals using them. One, like a patient with appendicitis, is pretty healthy and occasionally interacts with the system. The other, like a patient with chronic congestive heart failure, is chronically ill and needs complex coordinated care.

If the United States is headed for reform of its health care system similar to those experienced by other industrialized nations, it is worth knowing exactly how chronically ill patients feel about those health care systems. The Commonwealth Fund, an organization that is committed to health care reform, conducts a number of policy initiatives and studies to that end. It telephoned between 700 and 1200 individuals with at least two chronic conditions in eight industrialized countries. Regardless of your political orientation or your feelings about government-run health care, the chart below, published by the Commonwealth Fund, should give you pause. Given that there are substantial out of pocket expenses in the United States whereas there really is no bill in Canada or Germany, for example, it is pretty clear that there is a great deal of happiness out there in free-healthcare-land. The Commonwealth Fund chose to focus on the percentage of people in each country looking for a total rebuilding of the system as an argument that we really do need a total rebuild and that the U.S. system is in the worst shape. But clearly the desire for fundamental change is pretty widespread.


Now the "average" Canadian pays 42.6 percent of income in a variety of taxes. The average American pays 28.2 percent of income in a variety of taxes. The question then is whether that extra 14 or so percent of income that would go toward paying for a single-payer system (the stated end game of health care reform) is going to make Americans satisfied with their health care system? The Commonwealth Fund study does not give confidence.

The Massachusetts health care plan is an argument for health care delivery reform first and health care insurance reform second. This is because it is already bankrupting Massachusetts. We need a 5 to 10 year plan to fundamentally alter the mechanism of health care delivery. The president acknowledges this in various speeches but always goes back to conflating coverage of the uninsured with controlling health care costs. The two cannot happen together -- we must first control costs so we can pay for the coverage of the uninsured and prevent the future Medicare bankruptcy that looms over the nation.

And controlling costs by simply deciding to pay physicians and hospitals less while all of the regulatory requirements are in place, and while the current malpractice system is in place, and while their overhead costs are so high, will lead to colossal disruptions in the system. Hospitals will fail, physicians will be up in arms, and patients will be left in the middle. In 2006 there was a nationwide physicians' strike in Germany.

There is a need for modernization of health care delivery in every country on earth. The concerns voiced by critics about the current frenzy to produce health care reform legislation that covers the uninsured are criticized as merely attempting to maintain the status quo. Perhaps for some that is true, but to create a government directed health care system in the United States would be quite foolish when such systems are felt to be quite deficient by chronically ill patients in almost every other nation that has one.

Remember, there are always two consumers of health care. Those who rarely need health care will always prefer a system provided by the government and paid for by others or through their own taxes. Those who need ongoing complex care seem not to be very happy with such systems around the world. Why don't we seek a new and better way to do things rather than adopt the defective systems seen elsewhere?

Stanley Goldfarb MD is associate dean of clinical education at the University of Pennsylvania School of Medicine and a nephrologist.

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