You could also link to T.R. Reid's Frontline piece, which visited places that don't often get mentioned in the healthcare debate (Switzerland, Taiwan).

He's working on a book related to the topic, too.

I've mentioned this before, though: the fundamental problem is American healthcare exceptionalism, the 'best in the world... where foreigners come for care' rhetoric. In the political debate, other countries currently exist solely as whipping-boys for healthcare comparisons, and even those who look at them for potential reform are wary of invoking foreign precedent: 'do it like the French' or even 'do it like the Swiss' doesn't sell.

So the tactical approach has to be similar to the Taiwanese model: pick and choose the aspects tested overseas that seem best suited to the US, and dress it up as a pure product of America.

"It's natural to look to England. It's just not all that useful. We will never have a situation in this country where you are not allowed to purchase your own care on the private market."

What on earth are you talking about? Private insurance is legal and easily available in the UK.

See, eg http://www.bupa.co.uk/

and with respect to funding of cancer drugs that the NHS won't pay for see http://www.bupa.co.uk/members/asp/members_news/articles/cancer_drugs.asp

There's a huge lesson lurking in the wings of the debate about health care change. Yes, wholesale reform is very difficult or perhaps impossible, given resistance to change and the embedded interests.

BUT, those who argue that we should incrementalize the future and take baby steps followed by other baby steps are fundamentally wrong in their reading of history, not just here in the US, but in all the developed countries. Our uniqueness, if that's what is is, is based on general ignorance and misleading special pleaders obscuring the facts and overemphasizing both our 'special' circumstances and the actual situation.

I'm greatly concerned that we will tweak around the edges, piling fixes and workarounds on top of each other and actually compound all the bad and strangle all the good from change.

Cancer is cancer. There isn't a German cancel treatment, or an Japanese one. While YMMV on incidence of diseases, we are all subject to the same biological facts.

just hang a right when you hit Michigan

What, Indiana? Damn your east coast media bias!

I don't really agree with this, Ezra, for a couple of reasons.

First, the Canadian system is built around federalism to some degree - the Federal government gives out money, in one form or another, to the provinces, who then actually administer the single-payer system. This is very similar to how it could and would be done in the US, since the US is also a federal system.

Second, while private insurance isn't allowed for the services covered under Canadian Medicare, it is allowed for those that aren't (like a lot of side stuff and some dental stuff, although it varies by province). It's hardly "no market involvement".

I could see the US evolving into something like that, sans the "no insurance for Medicare-provided services" rule (Americans don't seem to have a problem with wealth allowing people to get care first).

The positive function I've always seen comparisons to Canada/England playing is its blunting effect on claims that socialized medicine is incompatible with the Anglo/capitalist/common law system. It's easy to dismiss things that work for the French or the Swiss because of the obvious cultural gulfs- it's much harder to argue that our society will plunge into a totalitarian nightmare if we adopt a system that Steve in Toronto uses on his way home from watching a baseball game.

England does not equal the UK.

@ Hershel: True.

Let's bust out this handy chart again to keep our semantics in order.

Nice chart, but the British Isles should also include the Isle of Man, which is not part of any of the other categories. (In some schemes of things, that would also apply to the Channel Islands.)

Oh come on, the Isle of Man is just a myth. Everyone in America knows that ;)

Brett's right about Canada, although I'd probably add that much of the stuff you pay for or get through employer-provided insurance is kind of "so-what?"-ish (cosmetic stuff) or elite-ish (employer-provided insurance to pay for private or semi-private hospital rooms). Dental coverage is probably a good example of something that's a core health concern that's going to cost you a lot of money out-of-pocket in both the US and Canada.

I think the basic point, though, is that other than dental care, in Canada you can receive good medical care without entering private markets.

My family's mostly (but not entirely) in Canada and I live in the US but have dual citizenship, and my mom's generation is all starting to have similar health issues at the same time. It's been interesting to see how they've been handled for family members in the US vs. the ones in Canada. I've been enormously impressed with geriatric care (including things like the provision of geriatric social workers) in Ontario.

there could be a good reason for this - I'm no health care expert - but why not look at Australia? We have universal, government-provided coverage. Also private insurers, private hospitals, private treatments etc and a government subsidy for purchasing private health insurance. Our model has its problems and detractors, but the outcomes/expenditures are comparable with other developed countries and better than the US. And we speak English (really).

I've always wondered why the Australian system never gets brought up in the US discussion.

Oh come on James, everyone in America knows that Australia is just a myth.

You should turn that Health of Nations piece into a popular policy book on how to provide health care, kind of like MY's foreign policy book.

Having you on TeeVee talking about how they have private insurance in France AND unlimited doctor visits AND cover everyone AND still pay a third less than Americans would do wonders for the health care discussion in America.

You can even toss in some corny McCain quotes about Sarkozy to bipartisan things up a bit when praising France.

jamesa81 is on to something. The Australian system seems like it meets key goals (i.e. universal coverage). It also seems like the key features could be implemented from a political point of view (i.e. mandate insurance but provide acheap public policy, and give high income people incentives to take on private insurance.)

The main thing that doesn't seem likely are the price controls on pharmaceuticals.

I think Michael Moore hit on the right framing for this in Sicko: "Even France is doing health care better than us - on quality, cost, access and outcomes. Are we gonna let those Frenchies think they can outdo *us*? The USA? No way!"

I know the frustration of the UK focus in health care all too well.

To add to what Ezra says, the rest of Europe actually looks down on British health care, and the Brits are recluse to praise their own.

Just about their only consolation is "we're better than the States".

I would like to reiterate that England does not equal Britain.

The NHS is the National Health Service, the National referring to Britain, and so all the countries which make it up -- Scotland, Wales, Northern Ireland and England.

However, the Scottish Parliament and Welsh Assembly have considerable power to set health policy locally and so it's probably better to just do the comparison with England.

Reiterating, by the way, that the British and Canadian systems are very different indeed and that the UK has really quite a lot of private medicine operating alongside the NHS - often with the same doctors.

Actually Canada and the UK are completely different from each other.

UK (and Spain) is the extreme example of a true socialized system with the doctors and hosptitals all being employees of the state; like the VA system in the U.S.

Canada (Denmark, Norway, Australia, Taiwan and Sweden) as systems somewhat like the Single Payer proposal, where ther health insurance is publicly administered, but the delivery side is private and comptes with each other, with most physicians are in private practice.

See more:

http://www.pnhp.org/news/2008/june/international_health.php

Health care systems in the Organization for Economic Cooperation and Development (OECD) countries primarily reflect three types of programs:

1. In a single-payer national health insurance system, as demonstrated by Canada, Denmark, Norway, Australia, Taiwan and Sweden, health insurance is publicly administered and most physicians are in private practice. U.S. Medicare would be a single payer insurance system if it applied to everyone in the U.S.

2. Great Britain and Spain are among the OECD countries with national health services, in which salaried physicians predominate and hospitals are publicly owned and operated. The Department of Veteran's Affairs would be a U.S. single payer national health service system if it applied to everyone in the U.S.

3. Highly regulated, universal, multi-payer health insurance systems are illustrated by countries like Germany and France, which have universal health insurance via non-profit "sickness funds" or "social insurance funds". They also have a market for supplementary private insurance, or "gap" coverage, but this accounts for less than 5 percent of health expenditures in most nations.

Sickness or social insurance funds do not operate like insurance companies in the U.S.; they don't market, cherry pick, set premiums or rates paid to providers, determine benefits, earn profits or have investors, etc. In most countries, sickness funds pay physicians and hospitals uniform rates that are negotiated annually (also known as an "all-payer" system). Princeton economist Uwe Reinhardt calls Switzerland's "sickness funds" quasi-governmental agencies**

There is no model similar to sickness funds *** operating in the U.S., although they are often confused with the Federal Employee Health Benefit Program (FEHBP), which is simply a group of for-profit private insurance plans with varying benefits, rules, regulations, providers, etc. The 1993 Clinton health plan was an attempt to regulate private insurance companies in the U.S. to behave more like sickness funds, but the insurance industry defeated it.

Bottom line: The most important point for single payer advocates is that every country with universal coverage has a non-profit insurance system. No country uses for-profit, investor-owned insurance companies such as we have in the U.S. (although they do have a small role in selling "gap" coverage).

Notes:

* The three basic models are general outlines, and there are many examples of "mixed models" (e.g. although Sweden has national health insurance, the hospitals are owned by county government, a feature more common to countries with a national health service).

The Ezra knows what he is talkign about Fallacy

"We will never have a situation in this country where you are not allowed to purchase your own care on the private market. It won't happen, it's not under consideration, and it's not a plausible outcome of any plans being seriously examined."

You just never learn do you Ezra? Have you heard of something in America called Medicare? I think a few left leaning idiots are even proposing Medicare for all aren't they?

"Medicare beneficiaries have complete freedom to spend their money on medical services not covered under the Medicare program. However, the federal government effectively prohibits them from purchasing Medicare-covered services themselves.

The restrictions work by prohibiting physicians who engage in such arrangements from seeing any Medicare patients for two years. Since 97 percent of physicians participate in Medicare, and being cut off from Medicare patients would devastate a physician's practice, that prohibition effectively precludes most Medicare beneficiaries from ever paying for covered services themselves."

Current real world implications;

"the ban effectively eliminates beneficiaries' right to privacy, because it eliminates their ability to purchase covered services (e.g., psychiatric care) without creating a record in a government database. Privacy is a real concern: a recent Government Accountability Office report found that "47 percent of Medicare Advantage contractors reported privacy breaches within the past 2 years, as did . . . 42 percent of Medicare [fee-for-service] contractors."

To further refute your clueless claim;

" Similar threats to patient freedom have arisen at the state level. In 2006, the California legislature passed a universal coverage plan that provided, "No health care service plan contract or health insurance policy, except for the [state] plan, may be sold in California for services provided by the [state-run] system." Only a veto by Gov. Arnold Schwarzenegger (R.) prevented the California legislature from outlawing private health insurance for most medical services."

Will we be seeing a correction to this post or just bury it with all your other gaffes?

Stewart et al. v. Sullivan (1992)

United Seniors Association et al. v. Shalala (1999)

According to Ezra we have Judges trying cases over issues that don't exist. Do younot have access to google or yahoo search?

Something as simple as a "deny right to purchase own care" search would show you where totally off base.

Why does no one ever look at Japan?

It always seems they have the best health outcomes, as well as a mixed private/public system. Yet everybody focuses on Europe.

It's natural to look to England. It's just not all that useful. We will never have a situation in this country where you are not allowed to purchase your own care on the private market.

Ezra, this is utterly bogus. In my family alone, I had private health insurance provided as a benefit by my British employer (which I used for a surgical procedure with no out-of-pocket expenses), my mother paid for surgery to repair her shoulder when the NHS waiting list was 8-10 weeks long (and she's a retired schoolteacher), and my small business owner brother-in-law decided to pay for his own private health insurance because of the greater flexibility it offered in the timing of surgeries, treatments, etc.

So, please tell us again, how is this possible in a country you say we are not allowed to purchase our own healthcare?

The truth is hundreds of thousands of British people opt for private healthcare in the UK every year. And the kicker is, it's more affordable than much of the private care available in the States!