What Hillary could learn from Canada and Germany - national health care - includes related article

Washington Monthly, March, 1994 by Susan Fitzgerald, Mark Jaffe

Josefa Hagel was resting comfortably in a bed at Schwabing Hospital in Munich. She had been there for nearly two weeks, but tomorrow she would go home.

The 92-year-old Hagel had been rushed to the hospital with the classic signs of a heart attack--shortness of breath and chest pains. But days of tests and monitoring revealed no serious problem. Hagel, a sprightly woman with gray hair and sparkling gray eyes, had spent her time at Schwabing, the oldest of Munich's municipal hospitals, in an austere, semi-private room with well-worn furnishings and no telephone or television.

Even so, as far as Hagel was concerned, Schwabing had served her well. The room was spotless. The medical staff had been attentive. "The doctors take the time to sit down and talk to you," she told an American visitor. And now she was well and going home. Her bill for the twoweek hospital stay would be $112--an $8-a-day insurance co-payment. The remainder of her charges--about $4,100--would be paid by Hagel's insurer, the Allgemeine Ortskrankenkasse, or AOK.

The AOK is the largest of the 1,200 non-profit, payroI1-financed "sickness funds" that comprehensively cover the health care of more than 90 percent of Germany's residents. The system was created in 1883 by Otto yon Bismarck, and the AOK was already 18 years old when Josefa Hagel was born. Through World War I, the Weimar Republic, the rise of Hitler, World War II, and the post-war economic boom, AOK was there to pay Hagel's bills. Through the birth of her children, three operations, and the death of her husband, AOK picked up the tab. "It always covered what was necessary," she said, surprised at a question about health insurance. "I've never had a problem. I've never thought about it."

Across the Atlantic, Joan Evans, a woman in a white, flowered nightgown, had been lying in Toronto's busiest emergency room for more than twelve hours after injuring her head in a fall. But since all of North York General's beds were filled, Evans had to bide her time until a room opened up.

She wasn't alone. All but two of the room's 19 curtained examining cubicles were filled. Four more patients lay in beds along the wall. And seven others, Joan Evans among them, were in a cluster of beds behind the nurses' station.

This happens a lot at North York, which is forced to strike a delicate balance nearly every day between patient demand and available resources. But Canadians are willing to put up with some inconveniences to pay for the comprehensive care they are guaranteed.

This was certainly true of patients in North York's emergency room this morning. Many were dozing. Some lay propped on pillows, reading magazines or books. One woman was knitting. An American reporter wandered from bed to bed, interviewing patients about the Canadian healthcare system. When the reporter came near Joan Evans, she blurted out: "We don't have socialized medicine. We have social responsibility."

Although she'd been waiting, Evans was here by choice. Under Canada's system, she could go to any hospital she chose. And many of the other hospitals probably had room, because on a given day, Toronto has 1,000 empty hospital beds. But Evans liked North York. She'd been here before, and this was where her doctor practiced.

Under Canada's tax-financed, single-payer system, Evans' red-and-white plastic card from the Ontario Health Insurance Plan entitled her to full medical treatment She knew she would get good care and that if she had to wait for a bed behind a more serious case, the decision would be made on medical, not economic, grounds.

Josefa Hagel and Joan Evans were deeply satisfied with their care. Surveys consistently find greater satisfaction among patients and doctors in Canada and Germany than in the United States. In those countries, health care is, as Princeton health economist Uwe Reinhardt says, "part of the cement of society."

This is not by chance. Both countries have consciously decided health care is a universal, public good. People who are poor receive the same high quality of care as people who are well off, and while the well off are able to buy amenities--a private room, television, a telephone-everyone is treated the same medically, treated well, and is certain that this equal treatment will be there.

"We see people having equitable access to affordable and appropriate health care regardless of geography, income, age, gender," said an Ontario Ministry of Health annual report. And, "In Germany, we operate under the social solidarity principle," explained Johann Fann, a top executive with the Bavarian AOK. "The rich pay for the poor, the young for the old, the well for the sick." Although both Canada and Germany are market-based economies, they have taken health care largely out of the marketplace. Unlike England, they do not have socialized medicine. The government controls overall spending, but hospitals and doctors operate independently of the government.

The Clinton administration says it wants the same goal, but it has proposed a radically different path for American medicine--a path that does not eschew the market but in fact embraces it. This is a risky exercise, for many of the problems that beset American medicine today-inferior care for the poor, spiraling costs, problems with insurance and bureaucracy--are products of market medicine. And remember that, compared to the U.S., Canada spends a third less per capita on health care and Germany spends 42 percent less. Yet both nations cover everyone for just about everything at high levels of quality.