The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care by T.R. Reid

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care Reviews

• 
  Alex Templeton

  This was one of the most infuriating books I've ever read. This was not because the book was bad, but because the points it laid out were so smart that I can't believe our policy makers and our population can really be so ignorant as to, well, ignore them. Reid visited different countries around the world that offer universal health care to their citizens. He discovers, in a nutshell, that not only are these systems not "socialist", but that they are far more efficient and cost-effective than any American system. Why? The primary reason, Reid argues, is that these countries have asked themselves what one scholar called The First Question, which is, essentially, is it a moral necessity for a government to provide health care for all of its citizens? France, Japan, Great Britain, and many other nations comparable to the United States in government, wealth, and power have all answered yes. Meanwhile, the United States operates under the morals of the almighty dollar, as the only country of its kind with a for-profit health care system that answers to its shareholders rather than to anyone else. This is a necessary book for all policy makers, although my cynicism doubts that many of them would be able to take off their blinders and/or get over their own profit motives.
• 
  Julie

  The upside of reading this book is that you will walk away with a clearer understanding of how different models of health care work, how massive reforms in health care have been undertaken recently and with success, and you will have the knowledge to debunk myths many Americans hold about health care systems outside of the United States.
  
  The downside of reading this book is that you may walk away and want to keep on walking- directly north to Canada, or to don your fins and cross the Atlantic or Pacific to join the ranks of those who receive excellent health care at minimal or no out-of-pocket costs.
  
  All of this, offered in 275 pages of succinct, clear and fascinating text. Anyone familiar with T.R. Reid's NPR commentaries as a correspondent in Japan and the U.K or his articles in the Washington Post will recognize his warm, engaging, self-effacing tone that is both professional and inclusive.
  
  Rather than prescribing solutions, Reid's central theme is that we can and must learn by example. There is nothing in universal coverage that precludes competition, choice, and access. It is highly probable that universal coverage would result in the United States spending less and providing better care, while increasing the quality of life and life expectancy of all. As a portion of GDP, the US spends significantly more than the nations featured in this book, yet ranks well below in life expectancy, and measures of quality, fairness and progressive financing of health care.
  
  Reid demonstrates again and again that the primary difference in the approach to health care between the United States- the only free-market, industrialized nation that relies on an out-of-pocket model- and those which offer universal coverage is a moral one. The countries he features have made the decision that access to health care is a basic human right and that government has a moral imperative to provide the same standard of care to all of its citizens, regardless of economic status.
  
  On the other hand, the United States has determined that only those who can afford health care have a right to it. We continue to support systems (insurance companies) that ration care, cherry-pick their consumers and routinely deny coverage to those who pay into their system, all while placing the burden of coverage on employers. Reid posits that medical facilities and the training of medical personnel in the United States are the best in the world. Too bad over 20,000 Americans die every year because they cannot access this superiority.
  
  We are foolish enough to listen to the pundits and talk-radio celebrities who decry "socialized medicine" without acknowledging that our nation's soldiers, veterans, Native Americans and those over 65 are all provided for by government-run, government-funded health care systems, one of which (Medicare) is a replicate of the Canadian system from which it takes its name.
  
  To those who may think that Reid is preaching to the choir, be assured that he paints a "fair and balanced" picture. The long waiting lists for specialized care in Canada and the underfunded facilities in Japan are two examples of significant stumbles in universal coverage.
  
  There is a bitter irony in pointing out that the same fearmongerers who warned that American life as we know it would be jeopardized if we did not pursue war in Iraq and continue it in Afghanistan are the same voices who cry out that the sky will crash down if we restructure our system to provide an equal standard of and access to health care for all our citizens. The immorality of these brutal stances makes me sick.
  
• 
  Eric_W

  "On September 11, 2001, some three thousand Americans were killed by terrorists; our country has spent hundreds of billions of dollars to make sure it doesn’t happen again. But that same year, and every year since then, some twenty thousand Americans died because they couldn’t get health care. That doesn’t happen in any other developed country. Hundreds of thousands of Americans go bankrupt every year because of medical bills. That doesn’t happen in any other developed country either."
  
  This is probably a book everyone should read. It's a dispassionate look at health care systems throughout the world as Reid travels from one country to another to see how his shoulder would be treated and under what circumstances. To start a couple of basic facts: "most rich countries have better national health statistics—longer life expectancy, lower infant mortality, better recovery rates from major diseases—than the United States does.Yet all the other rich countries spend far less on health care than the United States does. . . .Among the world’s developed nations, the United States stands at or near the bottom in most important rankings of access to and quality of medical care. The Japanese go to the doctor more often than anyone else, yet their system costs only $3,400 per person; in the United States the cost is $7,400 per person annually. In Canada, the nation has decided that to be the most fair, people should have to wait equally. In Britain, the priority is that all health care should be free to everyone.
  
  He begins by identifying the four basic types of mechanisms to pay for health care in the industrialized world. (He discounts the third world since those are all basically pay-as-you-go and available only to the rich.) Conventional wisdom tells us that these other countries depend on "socialized" medicine, yet that is incorrect. Ironically the only pure socialized medical systems exists in Cuba and the United States' VA system which is totally government funded, doctors are paid and employed by the government and veterans pay nothing for its services. Other countries are all a mix of private and public. How they are structured is related to the country's moral fabric.
  
  The four systems are the Bismarck (a mix of public and private as in Japan, Germany, and Switzerland); in the Beveridge model there are no medical bills; rather, medical treatment is a public service, like the fire department or the public library, hospitals and clinics are often owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge. The British system is based on the Beveridge model. Canada's system is the third type, a national insurance plan which has elements of both Bismarck and Beveridge. The providers of health care are private, but the payer is a government-run insurance program that every citizen pays into. The last system is the pay-as-you-go in which there is no insurance and people pay for service out of their own pockets.
  
  The United States has a mix of all. For those under sixty-five is a modified Bismarckian system for those lucky enough to be employed and have an employer-based system. Those over sixty-five have Medicare more similar to the Canadian system, and for many there is only the pay-as-you-go although most municipalities will not refuse treatment for emergencies which simply means the cost is allocated elsewhere, i.e. everyone else. One of the features of the so-called ObamaCare was to eliminate free-loading and have everyone, or most everyone pay for some form of health insurance. For Native Americans, military personnel, and veterans, we’re Britain, or Cuba. "And yet we’re like no other country, because the United States maintains so many separate systems for separate classes of people, and because it relies so heavily on for-profit private insurance plans to pay the bills. All the other countries have settled on one model for everybody, on the theory that this is simpler, cheaper, and fairer. With its fragmented array of providers and payers and overlapping systems, the U.S. health care system doesn’t fit into any of the recognized models."
  
  A common complaint leveled against government health care programs is they ration, yet all systems ration. In this country it's done by insurance companies, in others it's done by ethical committees. Here, the decisions are applied inequality and depend on one's plan (and the quality of one's lawyer.) "made, often in secret, by scores of different insurance companies. One person may get coverage for a potentially life-saving operation, while the next person doesn’t. This may be a boon to the person with the more generous insurance policy, but it’s not particularly fair." Some form of rationing *must* be done in order to reduce costs. "Should the system spend its money to keep a ninety-five-year-old Alzheimer’s patient alive until he’s ninety-six? Should an ailing eighty-four-year-old get the same intensive treatment for breast cancer that is provided to an otherwise healthy forty-four-year-old? Should the health system, or the insurance plan, pay for Viagra? For Botox? In a health care system that offers universal coverage, these decisions tend to be made uniformly for everybody."
  
  The U.S. spends the most on administrative costs and a system that organized everyone into one plan would clearly cut costs. Ironically, the charge that one system would reduce choice is not true. Other countries, in fact, offer patients more choice. Insurance plans in this country have discourage choice by building preferred networks. In most other countries patients can go wherever they want and see whomever they want since the structure for payment is the same throughout the country.
  
  All countries are faced with rising health care costs and all face complaints about their systems. The grass is always greener.... The one constant is complaining. "The American economist Tsung-Mei Cheng has formulated, with tongue only partly in cheek, the Universal Laws of Health Care Systems: 1. “No matter how good the health care in a particular country, people will complain about it.” 2. “No matter how much money is spent on health care, the doctors and hospitals will argue that it is not enough.” 3. “The last reform always failed.”3 Everywhere I went on my global quest, I found that Cheng’s Universal Laws held true. But for all their problems, the other industrialized countries tend to do better than the United States on basic measures of health system performance: coverage, quality, cost control, choice. This was the most surprising and infuriating discovery of my global quest—that the United States of America performs so poorly in this fundamental area of human life. In industry, finance, music, science, arts, academics, athletics,Americans can match or surpass any other country. Why can’t we do that when it comes to health care?"
  
  Read the book for part of the answer. Fascinating, yet ultimately quite depressing.
• 
  Brian

  This book was recommended to me by a friend a couple of years ago. After months and months of debating friends about the necessity of "Obamacare" (The PPACA or ACA for short), I decided it was finally time to pick up this book and get an idea of what others were doing in the health care arena. I know what I don't like about our system- cost, lack of access for those who don't have insurance or money. And, I know what I like- the availability of doctors and medicine and procedures as long as you able to pay. What I didn't know other than from some very biased perspectives- my right wing friends who say all "socialized" medicine is horrible with no choice and long lines- and smear jobs like the movie "Sicko" was what are others doing that is better than us? What can we learn from what other countries have done?
  
  T.R. Reid does an excellent and it seems objective job of summarizing the pros and the cons of each medical system he visits. And, there are pros and cons to each. None is perfect. If you're going to cover everyone at an affordable price, you cannot offer every procedure under the sun with no waiting. If you're going to have the absolute best care available with complete choice of doctors, hospitals, etc. you're not going to be able to cover everyone. What every system in the developed world seems to have in common, outside of the United States, is the will the moral imperative, that everyone will be covered.
  
  This book made me both hopeful and discouraged at the same time. Hopeful because other countries have made the change from where we are today to a more equitable and cost effective system where everyone gets covered and outcomes are actually better than they are here. However, I am discouraged because Americans seem to lack the will to cover everyone and American exceptionalism gets in the way of us looking to those who do it better and co-opting their ideas. We demonize the systems that are different from us and scare people about waiting periods or lack of access to certain things while we ignore the thousands who die each year here due to lack of access.
  
  The good news is there is a better way to do things and we don't have to reinvent the wheel. This book clearly lays out what is good and bad about our system and others. While it probably wouldn't make sense to copy anyone's system whole-hog and while we would like to preserve the best things about our system, we can take inspiration from others as we design a better system for us. There will be some sacrifice involved for some, but overall, there is a better way.
• 
  Preston Kutney

  I'm probably just a biased Canadian, but here is an excerpt from a great Malcolm Gladwell article that describes my opinion of the U.S. health care system:
  
  "One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system. Six times in the past century—during the First World War, during the Depression, during the Truman and Johnson Administrations, in the Senate in the nineteen-seventies, and during the Clinton years—efforts have been made to introduce some kind of universal health insurance, and each time the efforts have been rejected. Instead, the United States has opted for a makeshift system of increasing complexity and dysfunction. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world's median of $2,193; the extra spending comes to hundreds of billions of dollars a year. What does that extra spending buy us? Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average. Childhood-immunization rates in the United States are lower than average. Infant-mortality rates are in the nineteenth percentile of industrialized nations. Doctors here perform more high-end medical procedures, such as coronary angioplasties, than in other countries, but most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland all have more MRI machines per capita. Nor is our system more efficient. The United States spends more than a thousand dollars per capita per year—or close to four hundred billion dollars—on health-care-related paperwork and administration, whereas Canada, for example, spends only about three hundred dollars per capita. And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance. A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers."
  
  In this book, Reid gives an overview of the U.S. medical system, and compares it with other systems around the world. I really enjoyed it, and consider it a must-read for anyone interested in their own health.
• 
  Ana T

  The most important conclusion of the book goes ignored by its own author: almost all systems presented in the book are either flat out broke (UK, France) or a ticking time bomb squeezing doctors' pay or service availability to the limit (Japan, Canada). The only system that seems financially healthy is the Swiss - and it is not a coincidence that it is (by far) the most expensive of the ones analyzed. And I am saying this only using information from the book itself.
  
  In addition, not only it ignores the specifics of each case (Switzerland is a small and homogenous nation that can afford to send cash to patients and have them dutifully use the money to pay the hospital bill), but it also ignores the most pressing issue looming healthcare: it is getting prohibitively expensive. Biologics are already remarkably costly; what is going to happen when gene and cell therapies become widespread?
  
  
• 
  Sarah

  For those of us who have already reached the conclusion that the health care system in this country is laughable (in a devastating way), this little masterpiece beautifully clarifies what we already know. Our system is overly complex, sickeningly unequal and discriminatory, and grossly expensive. As a wealthy country in the industrialized world, we are the only nation that has not adopted universal health care of some kind. We are the only nation that allows for-profit insurance companies resulting in cruel denials, refusals, and astounding administrative costs. We pay millions more for less care, less coverage, and more red tape. Not to mention the thousands of citizen deaths due, literally, to the lack of health care coverage.
  
  Mr. Reid insightfully points out that many of the arguments tossed about in governmental debates are largely based in myth. The demonized term “socialized health care”, for example, is largely misconstrued and is now simply used as meaningless rhetoric.
  
  As this book succinctly argues, universal health care is ultimately an ethical decision. Moreover, other countries have clearly demonstrated that it is practical, effective, and highly functional. France, Germany, Japan; many countries spend a fraction of what Americans do and are able to provide coverage to all residents, provide efficient and effective preventive and acute care, and increase overall national health and satisfaction. Reid suggests that, as many governments have done in the past, we need to consider the elements of health care systems around the world; systems that are functioning well offer valuable information as we consider alternatives to our own dysfunctional non-system.
  
  There are immense hurdles to accomplishing something that seems so logical, however. Americans, if nothing else, are exceptionally skilled at making things much harder than they need to be.
• 
  Alex

  I came across this book by reading the author's other book, A Fine Mess, about tax systems around the world. The conclusion here is similar: US healthcare system as a whole is the worst out of rich countries, on pretty much all dimensions. But that's not new. Where this book shines is adding nuance and technical understanding of benefits and shortcomings of each system. If your view about US healthcare is like mine - shaped by late-night talk show jokes and attention-grabbing headlines - this is a great book to get better informed. I didn't know that the world has about four principal healthcare systems (Beveridge, Bismarck, NHI and out-of-pocket), didn't know that US actually has elements of each one of them in the country, and yet fails to cover tens of millions of people.
  
  While the numbers here are from 2010 (by then, Obamacare had just gotten approved, but the implementation hadn't kicked in), I would nevertheless highly recommend this book. Once you know the foundations, you can easily catch up with the latest numbers.
• 
  Michael Perkins

  WOW!
  
  
  https://www.nytimes.com/2021/04/28/op...
• 
  Matthew Hall

  This book was so great. With the conversation around how to fix healthcare in America ascendant, this book was a really great resource for thinking about changes to our system. TR Reid (back in 2009, pre-ACA days) visited seven different countries to investigate how they run their healthcare systems, and to think about ways in which we might overhaul the American healthcare system, which is both the most expensive in the world, and produces society-wide results which are middling at best, even while people with money can get excellent care.
  
  A few key takeaways:
  
  1) It's a great lesson for people on the left who crow about single-payer everywhere else in the developed world, without realizing that not every developed country has an explicitly single-payer system. True single payer exists (Great Britain, the US's VA system) where the government runs insurance and the hospitals and providers are all government employees, but it's one solution among many, and not necessarily the best.
  
  2) The Germans, French and Japanese (and US citizens with employer-based healthcare) take part in a Bismarckian system (yes, that Bismarck) that has large private non-profit insurance systems (sometimes tied to employers/trades but sometimes just nonprofits or run as unemployment insurance run by the local government). These systems cover everyone (no pre-existing conditions exclusions) but they are not cheap. (Cheaper than the US by GDP though).
  
  3) The French and Germans have an ID card system that has a person's whole medical history and people keep it on themselves like a debit card. This does a great job cutting down on bureaucratic costs to the system. However, I can see libertarians (and women who want to protect the privacy of their medical histories hidden from family/abusive spouses) having a problem with a history of medical procedures on one hackable, goverment-run record. Still, digitized records warrant consideration for cutting down bureaucratic costs.
  
  4) No developed country but the US has a for-profit insurance industry. They're often private, sometimes governmental, but always non-profit. They all spend less per capita and as a percentage of GDP than we do and have better outcomes. No developed country but the US seems to have ideological issues with individual mandates or pre-existing condition clauses.
  
  5) The notion that choice is gone in a single-payer system is only a half-truth. There may be lines in places like Canada or Britain, but in places like France and Germany they have as much choice as we do and there is no rationing of care. These are typically systems with private providers but non-profit/governmental insurers. Canada and the US have the Medicare/Medicaid model which has the government or Province running a single insurance pool, paying private providers/hospitals. These systems are cheaper, but they limit choice a bit.
  
  5) Places with Out-of-Pocket systems pay less as a part of the government budget (next to nothing) but have way worse outcomes. And they don't have our technology. (Reid got a month of Ayurveda treatment for his bum shoulder in India, paid $49 for OOP care and felt it helped more than anything else, so take that as you will.)
  
  The largest problem seems to be that the US healthcare system is suffering from FOMO-- we use iterations of true single-payer (VA) single-payer with private providers (Medicare/Medicaid), Bismarckian (employer-based insurance) and Out-of-Pocket systems (the 27.5 million people post-ACA who are still uninsured.) These uninsured people are driving up costs, but so are for-profit insurance companies. And because we can't just choose one of the other models to run with, we keep over-paying for bad results.
  
  We could expand Medicaid/Medicare or have more Medicaid buy-in programs, or increase subsidies/eligibility for subsidies on the market while simultaneously getting rid of for-profit insurance. Or hell, if you want to live in a sickly, disease-ridden hellscape, we could go to an OOP model. But we just need to choose one. The ACA managed to reduce the number of uninsured people but it was just a first step.
• 
  Thomas Ray

  The Healing of America, T.R. Reid, 2009, 277pp., ISBN 9781594202346, Dewey 362.10973, Library-of-Congress RA395.A3R435
  
  More than 85% of Americans say medical care is a basic human right. Americans /wrongly/ think anyone who needs care gets it. Each year, 22,000 Americans die of treatable ailments. pp. 217-218 (Also American Journal of Public Health, Dec. 2009, p. 2294
  http://pnhp.org/excessdeaths/health-i... )
  
  Prof. Uwe Reinhart wrote a /Journal of the American Medical Association/ article in 1997, asking, if a rich and poor child have the same illness, should they have the same chance of being cured. Physicians and lawyers responded savagely. "effete!" "class warfare!" "socialist propaganda!" "No!" "forced redistribution!" "costly political battles!" "the rich defend their wealth; the poor try to take it away!" ("Letters," /JAMA/, Mar. 11, 1998.) pp. 220, 267.
  
  The U.S. market transfers far more of our wealth to the insurance, pharmaceutical, and medical industries than any other country for two reasons: (1) The U.S. is the only place that relies on for-profit medical insurance--which spends vast sums denying coverage. (2) The U.S. hasn't used the clout of a large payer to demand limits to charges for treatment or drugs. pp. 35-36, 232-234. (Obama's Labor Day 2009 speech: "insurers should be free to make a profit."
  https://worleydervish.blogspot.com/20... )
  
  In the late 1980s, the Taiwanese president's office called Professor Hsiao, "asked me to lead a task force to give Taiwan a 21st-century health system. We had a conference. I required cabinet ministers to chair the various sessions. When you chair a meeting, you have to sit through the whole thing and listen. That's how you educate decision makers." pp. 169-170. Hsiao, /Getting Health Reform Right/.
  
  U.S. is #1 in deaths due to surgical or medical mishaps. p. 32.
  
  See Mary's 2009 blog,
  https://worleydervish.blogspot.com/se...
  
  
  
• 
  Katelyn

  Honestly, this book was just! so! good! and, to me, kind of life-changing. Not many people in the U.S. *actually* understand how healthcare works and we have all these misguided beliefs about how other nations that provide universal healthcare (and, it should be noted, whose healthcare systems are ranked high above our own) practice "socialized medicine" that are "wasteful", and result in "long waiting lists" and "limited choice". Not so! While I was angered and frustrated when exposed to the truth behind how crazily inefficient and unjust our healthcare system is, I also found hope in reading about programs implemented in countries like France and Switzerland and Taiwan that, admittedly, aren't perfect, but provide quality, affordable (or free) healthcare for all– while still spending much less on healthcare than the U.S.! (and often do so within the private sector! aka. not socialism.)
  
  Important/relevant things I've learned:
  - In the U.S., because they are for-profit, insurance firms spend a heck of a lot of time and money trying to figure out how to avoid paying medical bills; they hire adjusters and investigators to go through submitted claims looking for reasons to deny payment. U.S. insurance companies deny about 30 percent of all claims!
  
  - We have the most fragmented health care system in the developed world, with “providers” sending bills to a vast array of different payers: there's one system for Americans over 65, one for military personnel, a different one for veterans, a separate system for Native Americans and yet another for people with end-stage renal failure, one system for Americans under 16 living in poor families, one for people over sixteen in poor families, and scores of different private insurance plans. Each paying entity has its own distinct rules about what care it will pay for and how much it will pay. This is why, quite often, neither the buyer (patient) nor the seller (doctor) knows how much a particular treatment costs!
  
  - U.S. hospitals routinely deal with 20, 50, or a hundred different public and private payers. Middlemen compile the bills that doctors submit and shuttle them through the payment system. If the country could get the administrative costs of its medical system down to the Canadian level, the money saved would be enough to pay for health care for all the Americans that are uninsured.
  
  It doesn't have to be this way
  
  -In France:
  (1)“sickness insurance funds” are nonprofit entities, so their main concern is not providing a return to investors but, rather, paying for people’s health care. Every health facility is “in-network”; any patient can go to any doctor, any specialist, any surgeon, and any hospital or clinic– and the insurance MUST pay the bill.Since the French insurance funds don’t spend any money on marketing, filtering out unwelcome customers, reviewing and denying claims, paying dividends to stockholders, they are significantly more efficient businesses than American insurance companies.
  
  (2)Everybody must belong on a health insurance fund; it’s illegal to opt out, no matter how healthy you think you are!
  
  (3) The carte vitale- the “vital card” or “card of life”- contains the patient’s entire medical record, back to 1998! Everybody over age fifteen has this card- a child’s medical records are maintained on his mother’s card. All billing info- how much the patient owes, how much he paid the doctor as a co-pay, how much each of the insurance plans should pay back to the doctor and the patient- is transmitted to each of the relevant insurance plans. Insurance funds are required to pay him within 3 days. There is no expensive layer of administrative workers and paper handlers
  
  (4) The French do all this and still spends only about $3165 per capita each year, vs. the U.S.'s $7000 (which still leaves millions without coverage).
  
  This is just one example.
  
  Bismarck Model, Beveridge Model, and National Health Insurance Model have all been much more effective than U.S.'s fragmented quilt-like healthcare system with tons of overlapping entities.
  
  Other ideas/concepts to ponder on:
  -investing in public health is more impactful (saves more lives) than investing in high tech medical technologies (which, of course, are also important)
  -health care economics= tricky because you're measuring the values of lives and assigning them numbers (DALE, HALE, QALY, DALY)
  -preventative care! we need to do more of it!
  
  All in all, this book perfectly articulated many thoughts that had been scattered in the back of my mind for a while. It helped clarify and refine my opinions on healthcare, and was highly informative as well as honest and unbiased. I really appreciated the in-depth profile of healthcare systems from around the world (UK, Germany, France, Japan, Taiwan, Switzerland, Canada, India, etc.). I'm a strong believer that performing such a comparative analysis is absolutely essential to our discussions on how to "reform healthcare" in the U.S.
  
  {Down with American exceptionalism!}
• 
  Vincent

  My star ratings are always pretty pointless and arbitrary, but especially so here, mostly because my feelings of this book are extremely conflicted.
  
  Normal review
  
  A great high level overview/primer of healthcare systems both in the US and globally. Somewhat outdated with regards to the US, China, and other minor details. But his high level metrics for evaluating health care systems (focusing on choice, coverage, cost, quality) are sound and still applicable. Furthermore, most of the major flaws he identifies with the US system are still present. There's also an afterword specifically on Obamacare's impacts that is correct enough given the timing of this book's release.
  
  I would feel pretty good about recommending this to anyone who does not work in the healthcare field, but has an interest in learning about it and better understanding some of the inherent political discussions around healthcare. Additionally, I think it does a very good job of dispelling many politically manifested myths about our healthcare system and those in other countries. It does all of this without getting overly technical or "policy wonky," which I'm sure is good for most people.
  
  Personal gripes:
  
  The following are my personal issues with the book.
  
  1) Technical Detail and Analysis:
  Regardless of what I said earlier, I would have enjoyed more technical detail. Especially as it relates to other countries. There's a lot of high level stuff about other country's vastly lower admin, having/not having gatekeeping procedures, claim cost control, and different types of insurance/sickness funds. Yet, there's no deeper detail on how many of these things work in other countries, save comments like "they don't have as much paperwork or filing cabinets because of this global health card."
  
  I definitely believe that France and Germany's health chip vastly lowers their admin costs and is an unimpeachably great idea, but I would like to learn more about how the admin reduction on the insurance side gets moved to the governmental or outside vendor side. For example, they mention that France's health chip was designed by a US company. How does that cost affect France's admin costs? Does it require continual maintenance? Is it maintained by the US company who developed it? Does this create security concerns and if so how does the cost around that manifest? Health data security is a huge issue in the States so how does that look in other countries? The questions for one detail like this go on and on and on.
  
  Something like this can occur for so many different levels of healthcare both in the United States and other countries. Reid even briefly alludes to it when he says the UK's biggest employer is NHS. I've always thought a response point to the idea that single payer in the US will cause unemployment by erasing jobs for insurance companies, is that to some degree this will be offset by insurance companies and the jobs within effectively being absorbed by the government. Sure a reduction will still occur, but it's not like the total count of employees at health insurance companies will drop to zero. The government still needs people to process claims, respond to calls, manage care, reserve IBNR, price premium or taxes dependent on model, forecast, evaluate program spending and effects, etc etc. Naturally, there is an entire rabbit hole that can be traversed here. Discussion of more detailed and technical stuff like this is nowhere to be found in this book.
  
  I want to add that the two paragraphs I wrote out above are random thoughts that popped into my mind just now. There are thousands upon thousands of questions like the ones I posed above that are inherent in every healthcare system, and probably any large financial sector. These discussions and details really matter. History has taught us that single sentences in legal documents can have profound impacts on how a society operates or a person's day to day life.
  
  Regarding the US system, his lack of understanding of technical detail also limits his criticisms. There's a lot of sentences where I go "sure that's true, but it's missing an essential part." This is most prevalent in two of the main things he repeats a lot.
  1) Obamacare still leaves 23 million people uninsured.
  Yes, but why are they leaving those people uninsured? It's expressly because certain states refused to accept the Medicaid expansion and Exchange plans. This is crucial and would actually enhance the "moral question" he keeps coming back to. Obamacare permits for a system where the United States could have universal coverage, but it is blocked because of political interests and specifically people with political interests who fail his moral question.
  2) Individual mandate is needed to create a risk pool for insurers to have premiums to operate.
  Sure, but this ignores that the risk pool is largely unshared by insurers in the States. And what this really gets to is the evils of employer sponsored health insurance, which confoundingly goes unmentioned in this book. I don't want to turn a good reads review into a health policy analysis (although I guess I've already done that), but at a high level if you want to create an ideal risk pool that shares + lowers costs in an ideal way, you limit fragmentation of the risk pool as much as possible and one of the best ways to do that in the states is by blowing up employer sponsored health insurance. You don't need people to have an individual mandate as much as you need people insured and grouped together with everyone else. This is the real best way to create a proper risk pool for insurers/sickness funds. The individual mandate is one way to get there, but not the most essential.
  
  Granted, I don't think Reid had any interest in covering the sort of technical detail, rigor, and questions I outlined above. Very few people do, especially someone who is clearly just a journalist and not a healthcare expert or working in the field. It's very clear from the book's outset that finding the granular to mid sized detail within healthcare systems was not his goal. It certainly would have made his book less popular and more boring for most people. That said, if this book contained more of that sort of detail and discussion I would have embraced it much more. It might have even helped me look past my next and major critique.
  
  2. Racism:
  I'll start by saying that I don't think the book is aggressively racist or even intentionally mean spirited in that regard. I also don't think the majority of the racism in this book expressly detracts from the most important information (how healthcare systems work and where the US fails).
  
  That said, it would be fucking nice to read a book about comparative healthcare and to not be assaulted with weird white gaze microaggressions. Titling a chapter Bismarck on rice because it's in Japan was the first "huh, that's sort of weird" moment. Especially, when the rice part in the chapter title is never alluded to. Perhaps, if the rice had some deeper meaning like, it represented the thousands of sickness funds within Japan, maybe that would have made sense or been useful. (Although ultimately nonsensical). However, it clearly wasn't. It was legit just "They eat rice in Japan. And they have a Bismarck-esque system. So Bismarck on rice." You might think, this was just one chapter name of a book and probably not a big deal.
  
  However, shit like this just keeps happening with ole T.R. Calling dal bhat, dull butt is a joke that even 5th graders would feel stupid saying. The weird gaze and dismissiveness he has regarding non westernized medicine, even after it aided him, was also a bit annoying. I should probably reiterate that stuff like this isn't pervasive or non stop throughout the book. It mostly comes and goes, and is probably just symptomatic of living life as an old white man, but I still found it quite tiring. More irritating is that editing this stuff out would have been insanely easy, but clearly nobody gives a shit.
  
  Finally, the 3ish pages he wrote on Taiwan's history were beyond frustrating. He begins with "Taiwan is an island nation of 23 million Chinese people..." Fucking what? You wrote this in 2010 and didn't know that Taiwanese people are an identity to their own? Or that the indigenous people who still live there are not Chinese? You couldn't even write something like ethnically Han Chinese? (As an aside, a sentence this stupid is a real good example of how frustrating microaggressions can be.) He then begins his history of Taiwan with "The island was a province of China for centuries..." How in the world did you visit Taiwan, speak with Taiwanese people, meet Will Hsiao, get to age 60 something and beyond, and not figure out that China's province claim on Taiwan is tenuous at best? As he recites the KMT's invasion, there is no mention of martial law, white terror, massacre, attempted erasure of the Taiwanese language, or KGB influenced imprisoning of dissenters for nearly 40 years. The most derisive thing he says about the KMT is calling Shek a dictator. His crimes go far deeper than just being a dictator. Including threatening to fire on women and children during war. He begins to wrap up his barren and misleading summary of Taiwan's history with this trash, "Yet the old argument about who really rules the nation of China still resonates on Taiwan; the residents of this island are debating to this day about what their nation should be called." I cannot imagine missing the point about Taiwan's identity more. It isn't about the fucking name. It's about being clearly recognized as their own country, about not being under constant thread of being blown up by China, not being recognized by the WHO, and so much more.
  
  Now you might say, "why does this matter in a book about comparative healthcare? Didn't he describe the birth of Taiwan's NHI and function quite well in subsequent pages?" To the latter question, yes, he did a great job. It matters because Taiwan's unique identity and fabric are part of what allowed it to move to an NHI with such ease. When retelling the NHI's creation he analogizes the DPP vs KMT to Democrats vs Republicans. This is wrong and overly simplistic. Taiwan's response and fear of martial law permeates their political motivations and identity to this day. The spirit and influence of the indigenous people in Taiwan also matters and influences policy. Their own culture and identity as distinctly not part of China motivates as well. It was more than a political shell game, but an intrinsic part of Taiwanese identity and reaction to Chinese imperialism that lead to the creation of the NHI. More frustrating, is that the next section of the same chapter focuses on how Switzerland's nationwide identity of solidarity was a driving factor in it's development of a revamped universal healthcare system. Clearly, he gets that identity can drive a moral decision like healthcare as a right. But little care was taken to understand that when it came to Taiwan.
  
  Did this ruin the book? No, but as a Taiwanese American who's spent 30+ years of his life explaining to people Taiwan is not part of China, seeing another white man who doesn't care to figure it out was immensely frustrating. I understand that many Americans barely know Taiwan exists and that those who do probably can't even tell it's history as much as Reid. This isn't about getting everyone in the world to know or understand Taiwan's identity with breadth and detail, but rather the persistent frustration with lazy research and writing by those who come from racist institutions and don't care to know better. I imagine this book had editors, and I imagine all of them saw no issue with Reid's version of Taiwan's history, and that is the entire problem. Taiwan's history is seldom told in the West as a country with millions of Taiwanese and indigenous people before Japan and the KMT's arrival. These people, my parents, their parents, their grandparents, and generations before them are not acknowledged when White and Chinese people tell the story of our country. We were always there and we are Taiwanese.
  
  Summary:
  Anyway, I was going to give this book like 3 or 4 stars when I started writing this review, but as I've spent an hour or so writing this out and editing it. I'm realizing that the handful of racist microaggressions annoyed me even more than I realized. So I'm giving this one star.
• 
  Anna

  Reid examines America's health system within the context of the health systems of France, Germany, Japan, the UK and Canada (all universal systems). He also briefly looks at out-of-pocket systems, i.e. the third world and uninsured Americans. As a political scientist, my take on these issues is pretty much always institutional and political culture. Reid's jumping off point is the moral question "Should we guarantee medical treatment to everyone who needs it?" The answer to this question in a first world modern country should always be yes. It depresses me that the US should answer no to this question. Reid argues that public opinion shows that people in the US believe that all Americans should have access to medical care and that most people believe that everyone does have access (ERs for example). Personally, I don't believe that. From what I see around me there are plenty of people who believe in an old-fashioned concept of deserving and it really pisses me off.
  
  Reid does a nice job of comparing spending costs (the US, in 2005, spent 16.5% of GDP on health care compared to 11% in France, 10.4% in Germany, 10.1% in Canada, 8.4% in the UK and 8.1% in Japan) even though the US has a huge number of uninsured folks. Americans are not healthier nor do they live longer despite the huge expenditures. He also shows that administrative costs in the US are something close to 20% compared to about 6-7% in those other countries. Reid is clear that these other health systems are not socialized - doctors, hospitals, insurance companies are also likely to be private, and many countries include out-of-pocket costs to consumers too. And the most perfect socialized medical system in the world? Veterans in the US.
  
  Profit-making insurance companies are pointed to as much of the cause of the craziness of the American system - the bottom line is not treating people, it is not treating people because every procedure denied helps the profit and makes shareholders happy. It's infuriating that neither culture nor political institutions in the US deal with the inequity and expense of such a stupid system. Finally, as a person who believes that institutions matter, I was interested to read about Taiwan developing a new universal health care system and Switzerland reforming theirs to ensure universal coverage.
• 
  Jenny Leigh

  I started to read this book because I am currently studying comparative health care in Japan and wanted to gain a deeper understanding of its health care system. Reid's book was a bit disappointing for my purposes; it is clearly written by a journalist rather than someone who has worked in the health care field (or who even has above-average familiarity with health care systems). After establishing the primary models of global health care systems, he simply refers back to the model that he observes in his explorations of each system, sometimes using the exact same language. This style became uninteresting after a while, and I imagine didn't do justice to the nuances of these systems. While it does really hammer the point home about what these models are all about, it perhaps runs the risk of oversimplifying the circumstances, especially when Reid jumps from large-scale data to personal narrative with little in between.
  
  I found his narration somewhat frustrating as well. He weaves in his own narrative about seeking medical treatment during his travels to these countries, though given the lack of nuance in his writing, it's honestly unclear why he needed to be in these countries to recount the information that he does - a lot of it could probably have been gleaned from journal articles. Furthermore, particularly in his exploration of Japan and India he often uses cutesy, overwhelmed Westerner descriptions that are distractingly reductive of the cultures and countries he studies. This was probably most obvious in Chapter 9, when he explores out-of-pocket systems and just vaguely groups "Africa, South America, and South Asia" (144) together... after spending whole chapters at least attempting to specifically examine the systems of individual Western nations. All in all, this book is an excellent example of how little effort so many white male journalists need to exert to be considered thoughtful. I'd only recommend it as a primer.
• 
  Charlie Bray

  A sober review of the financial and health outcomes of healthcare systems around the world. I enjoyed the fact that the author, however he felt about the issues at hand, refrained from being moralizing and instead implored the reader to observe the facts and question why things must be the way they are in the US system. And by far my favorite aspect of the book was the author's running theme of dispelling the popular mythology of universal healthcare systems with nonprofit financing: that these are "socialized" systems that take massive redistribution and result in poorer outcomes for everyone (longer wait times, less choice, etc.). We instead see free-market providers and insurance plans acting under stricter guidelines and giving the patient far more choice and coverage in terms of primary care, with the cruelest aspects of the way we finance healthcare in the US removed from the equation. And an individual mandate to make a viable risk pool possible of course.
  
  What the author leaves his audience to wonder is, "where do my country's morals lie that we can't ensure every citizen's right to healthcare?" As well as, "where does my country's SENSE lie that we can't spend half as much on healthcare with a far more efficient and equitable system, to bring us in line with the majority of the developed world?"
• 
  Rachel

  OUTSTANDING. This book was so well written, so easy to understand, and so informative. I've always wondered how other industrialized, capitalist nations manage to make their healthcare systems work and this book explains it clearly using different countries as examples. Reid also dismantles all the garbage excuses we come up with about why "it would never work in the US." A fascinating, often enraging, sometimes depressing, and thoroughly engaging work.
• 
  C. Scott

  A really excellent bit of comparative analysis. I wish books like this existed for every subject. Reid takes the reader for a global tour of how healthcare works in other countries. The American healthcare system is frankly a disgrace. In the eyes of other developed nations we are a laughingstock. It is a scandal that the richest nation on earth can't find a way to meaningfully address this problem.
  
  Thanks to this book I now have a much clearer understanding of the most popular national healthcare systems on our planet: the Beveridge model, the National Health Insurance model, and the Bismarck model. Reid compares and contrasts the strengths and weaknesses of each and how different countries mix and match to find what works best for them. Surprise reveal? There are American examples of all three operating right in our midst. The evil commie Beveridge model (the British system named for William Beveridge where the government owns the hospitals) is basically the VA system used for treating American veterans. The grubby socialist National Health Insurance model (otherwise known as the Canadian single payer system) is how America's hugely popular Medicare system works. The Bismarck model (named for 19th century German conservative statesman Otto von Bismarck) is what the luckiest Americans have - insurance financed jointly by employers and employees. The difference is that in other Bismarck countries like Japan and Germancy insurance companies are non-profit and they must cover everybody.
  
  One interesting chapter deals with how both Switzerland and Taiwan moved from American style healthcare to universal coverage in the mid-1990s. This proves that it is possible to make systemic changes in the modern era.
  
  This is outside the parameters of the book, but I have to say, after reading this I am now certain that it is possible to have universal coverage in the United States that costs less than we are paying now. If it's possible to have better outcomes at a cheaper price who wouldn't take that deal? Any businessman would. Unfortunately it is the business community that provides the biggest barrier to change. Collectivism is viewed as a threat to capitalism. Profits would suffer. Stocks would plummet. We need to ask ourselves what is more important: Wall Street dividends or our health?
  
  The US is the only developed nation that runs healthcare for profit. The idea is that the profit motive and competition are supposed to give us the most efficient outcomes. But look around, is the American healthcare system giving us the best possible outcome? One study cited in this book says that 22,000 Americans a year die because they don't have health insurance. (Imagine for a moment that 22,000 Americans were killed by Al Qaeda every year. Do you think we could find the resources to save these lives then??) How can public health benefit from a system where thefirst priority is on retaining profits for shareholders? How can we have a healthy population when public health is only a secondary consideration?
  
  It is time for change. I feel that the best way to start moving toward that change is to educate yourself on what works and what doesn't. When it comes to understanding America's broken healthcare system and the functioning alternatives that exist in other countries - this book is a great start.
• 
  gwayle

  Among developed countries, America is a laughingstock when it comes to health care. Our pathetic system is ridiculously expensive—all for less coverage, lower life expectancy, higher infant mortality, more death for treatable illnesses, and more bankruptcy as a result of medical bills (people in other countries are horrified by this cruel fact of American life). Why is this?
  
  1. Universal coverage is a moral issue that America has never addressed head on; politicians always make this out to be an economic issue. Is health care a right or a commodity? Should poor people die for lack of access to health care? Because that is what happens. You have to be at death's door or in active labor to be guaranteed treatment at an emergency room. In this country, you have no basic right to the tests that will detect your cancer in time for life-saving treatment. So, the very first step is to be crystal clear on this moral issue. And if you want universal coverage, you'd better be prepared to insist on the individual mandate in spite of libertarian squawking.
  
  2. America has too many systems in place (private insurance, Medicare, Medicaid, VA, etc.), which increases doctors' administrative overhead (all the different billing systems) and de-incentivizes preventative care (i.e., why play the long game as a private insurer when you won't realize the savings because 65yos will switch to Medicare?). Conflicting systems also undermine the broad base that is ideal to efficiently fund insurance.
  
  3. For-profit insurance companies are evil. They emphasize shareholders' profit over effective and efficient financing of health care. In other developed countries, insurance is either government-run or the companies remain privatized but are run as nonprofits. For-profit leads to bloated administrative costs with huge departments devoted to denying coverage and rejecting and adjusting claims. 20 cents of every premium dollar you pay doesn't go to care. (Other developed countries keep administrative costs under 10%, sometimes well under.) There is simply no advantage to having for-profit insurance companies—except for the greedy, hell-bound shareholders of those companies. This system does not offer insurers more choices, and it does not operate more efficiently as a result of some magical thinking free market Darwinism.
  
  4. Astronomical medical school tuition, resulting in huge debt loads for young doctors, and an absurdly litigious culture that requires doctors to carry pricey malpractice insurance both skew the economics and result in defensive medicine—to patients' detriment.
  
  The good news is that other countries have worked through all of these issues to provide far less expensive care for all of their citizens. No system is perfect, but many boast more choice, shorter waits, and far better health-related statistics, not to mention patient satisfaction.
  
  As with his excellent book on tax reform, T.R. Reid offers clear explanations and an engaging narrative. I love him! I hope he writes many more nonfiction books on timely issues.
• 
  Kris

  I read this a few years ago and decided to re-read it since health care in America continues to be debated. Reid does a good job of explaining health care systems around the world. He says "There are some standard building blocks of health care system architecture that all developed countries (except the United States) have agreed on. By studying the blueprints and looking at these common principle, we can learn some important lessons about fixing the problems in our own health care system." I agree.
• 
  Emily Kaminsky

  This book was SO GOOD and it should be mandatory reading for everyone!
  
  Spoiler: the US healthcare system is ~the worst~
• 
  Rebecca

  Read. This. Book.
  
  It's a quick read, so quick you won't believe the amount of information it contains. It's also an easy read. With the central framing device of visiting individual countries to see their recommended course of treatment for a bum shoulder, Reid avoids a lot of dry fact-finding that might plague other books of its kind. Along the way he recounts the health care history of each country (France, Germany, England, Japan, Canada, and India) as well as outlining major points about health care in general.
  
  There are four major types of health care systems:
  
  1. The Beveridge Model - The UK is the prime example. The government pays for everything and it owns everything with doctors as government employees. Health care is a public service like a library or fire department.
  
  2. The Bismarck Model - Began with Germany and spread. Everything is private - both providers and insurers but with heavy regulations that ensure fixed fees and the providers themselves only exist to pay medical bills (i.e. non-profit).
  
  3. National Health Insurance - What we have here in Canada. The government is the insurance company. From a single point of payment, it's easy to set prices. Also not for profit. (Do you see a trend here?)
  
  4. Out of Pocket - What everyone outside of the industrialized world has, excepting the uninsured in the US. Care costs whatever the provider says it costs and you pay for it yourself if you can. If you can't, no care for you.
  
  The US likes all of these models so much it couldn't pick just one so you get to have all four! This means that prices are all over the place and administrative costs are somewhere around 20% of every dollar paid into the system. By contrast, most other countries with a health care system spend about 10% or less on administrative costs.
  
  All of the vignettes about the individual countries are interesting as well. France's carte vitale sounds awesome - I really hope Canada gets its own centralized, electronic medical filing system eventually. In Japan, there's no waiting even though the Japanese apparently love their health care so much that they show up 14 times a year on average for it all the while lingering in hospital longer anyone would ever dare in the West. England's NHS doesn't want you to pay any bills and it also wants you to keep a stiff upper lip when dealing with petty, niggling problems like a bad shoulder. Canada...well, Canada could use some improvements.
  
  Apparently, a Supreme Court (of Canada) ruling has come down in the case Chaoulli v. Quebec saying that yeah, actually, long wait times are in fact a violation of the Charter of Rights and Freedoms - long waits for care are in essence a denial of care and telling people they can't spend their own money for care is unconstitutional. The repercussions of this have not yet been realized for the entire country because the ruling only stands for Quebec right now, but I'm hoping that we'll see some changes soon. I think Canada should allow people to pay for care even though it creates the dreaded two-tier system. One of the main things people line up for here are orthopedic consultations and surgeries. While they may not be an emergency, loss of mobility and pain are still not something to take lightly.
  
  In the end, while different countries have different methods of administering their care, they all stick to a few general rules:
  
  1. Universal Coverage - Everyone is covered regardless of health or age. You cannot be denied care or insurance.
  
  2. Individual Mandate - everyone must buy insurance. Germany allows the richest to opt out of the system but they usually don't. England allows private insurance but only a few people take advantage.
  
  3. The system is there to care for people, not make money.
  
  4. Doctors aren't usually under the burden of giant student loans or crushing malpractice premiums. Most of the doctors in the countries examined had their schooling paid for by the government or (in Canada's case) the tuition is a fraction of what it is in the US. A year's worth of malpractice insurance for other places is about the same as a week's worth for the US and the doctors do not expect to be sued.
  
  5. Everyone still bitches about their own country's medical system even if it's #1.
  
  There's a lot more covered in the book everything from myths about the US system to the role of preventive medicine and keeping costs down. Sadly, Reid's conclusions about what would be best for the US do not match up to the bill that has passed, but maybe once everyone is used to the idea of universal coverage it can be overhauled to a greater extent.
• 
  Karyn

  Excellent discussion of what health care looks like around the world (spoiler alert: not all of it is socialized medicine - but much of it is cheaper and more equitably distributed). Only the U.S. spends 20% of cost going to paperwork (which doesn't actually help people heal). (Taiwan = 2%, Canada = 6%). Only the U.S. has made the ethical decision to allow people to die.
• 
  Jonna Higgins-Freese

  Reid researches how universal health care works in half a dozen different countries, exploding the myth of "American exceptionalism." The U.S. does NOT have the "best health care in the world" by any measure: not outcomes, not life span, not cost, not number of people covered. Reid points out that every other developed country except the US has answered the question: is health care a human right? with "yes."
  
  In the US, about 20,000 people a year die of treatable conditions because they don't have health insurance; 700,000 people go bankrupt due to medical bills (in countries with universal health insurance, those numbers are zero). We pay twice as much for health care as other countries (in terms of GDP) and get much less. France covers everyone, and has a longer lifespan and lower mortality rate, at half the cost in GDP.) A big part of this is for-profit health insurance, which makes it much less efficient (20% overhead) than other countries (around 3%, similar to Medicaid and the VA).
  
  "American health care is not really a system at all. It's a market." 170.
  
  He summarizes the different ways France, England, Canada, Germany, Japan, Switzerland, and Taiwan administer their programs. Some, like Canada, are the closest to the American idea of "socialized" medicine: the government owns the hospitals and pays the doctors. But it's not single payer, it's 13 payer -- it's run by the provinces according to federal standards. Others, like Germany and Japan, have private providers and health insurance, with the government paying the premiums for people who are out of work, etc. It was fascinating to learn how many different ways there are to organize health care that's fair, equitable, effective, and cheap -- once you decide it's a human right.
• 
  Bryan

  I realized how persuaded I was by this book at a recent dinner with a number of our friends in which a few of them expressed decidedly critical views of the new healthcare law. I had just finished this book earlier that afternoon and thus was undoubtedly under its influence, but I kept thinking how I have never read anything or heard anyone argue as persuasively in defense of our nation's current healthcare system as TR Reid does against it.
  
  And I was not just persuaded by it. I learned so much about the world from it. He has a very comfortable style, conversational without feeling casual or flippant. He teaches little history lessons about the major healthcare systems of the world and what we can learn from the other developed nations. His thesis is that the US has failed to make universal care to all its citizens a moral imperative; our patchwork system of multiple approaches to the provision and financing of healthcare is a proximate cause of thousands of Ameicans' deaths each year. He is not concerned with presenting solutions (though in his discussion of other nations' systems, many of those solutions suggest themselves), but to persuade us to accept our moral responsibility to ensure all Americans are covered. As his histories of other nations teach, that is the hardest part, but once accepted, each nation has found a way to make it work in a united system.