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Last Updated: Friday, 21 September 2007, 15:05 GMT 16:05 UK
The battle over wellness
By Tim Egan

Rudy Giuliani and Gordon Brown
Rudy Giuliani is against "socialised medicine"

Despite Rudy Giuliani's espousal of the US healthcare system over the UK's there are some who differ.

Not long ago, my friend Sheila got some bad news from her doctors. She's a runner, a salsa dancer - active in middle age - and a feisty New Yorker as well.

For some time, her hips had been bothering her. She felt like they were worn down, grinding. After much testing, the doctors told her she needed to have both hips replaced.

At the least, her dancing and running days were over. Worst, she might have trouble walking within few years. A very invasive surgery, with a long recovery period, was in the offing.

Sheila was stunned. How could this be? Hip replacements, she thought, were for much older people. Sheila has early onset arthritis and a genetic defect. The best remedy, she was told, was to have portions of her outer leg bones scraped away and replaced with titanium.

For a week, she was treated like a vacationer at a spa

Never one to accept bad news at first blush, she tried to find an alternative. What she discovered was a procedure in which worn hips are resurfaced - rather than cut away - with high-carbide cobalt chrome.

Sheila settled on this option as the best choice to stay active. But to her surprise, she also found that her American insurance carrier would not cover it. All along, she assumed she had gold-plated coverage. So sorry, the company bureaucrats told her in a formal letter of rejection. The procedure she wanted was considered experimental. Good luck.

Sheila decided to outsource her health care and she looked overseas. Now it's no secret to most Americans that the rest of the industrial world has more or less guaranteed medical care.

Laundry done

Michael Moore's latest film Sicko revels in the many advantages of state-funded health care in France, Canada and the UK. He spends half the movie with Americans who were denied a particular kind of care despite having insurance.

Then he goes to Paris, where he says to an American expatriate - a new mother - "I suppose they even do your laundry here". Cut to a scene of somebody doing the woman's laundry. Talk about rubbing it in.

Michael Moore's intent was to make us long for something that we don't have. He's a provocateur, of course, with no interest in showing the downside. But my friend Sheila found that an American could actually buy into overseas healthcare.

In the US healthcare is typically paid for by insurance

So, off she went to England to get one hip resurfaced in the land of socialized medicine. The other hip was not as bad, the doctors said, and could wait. She checked into the Royal Orthopaedic Hospital in Birmingham as a private patient.

For a week, she was treated like a vacationer at a spa, she said, and the operation was a complete success. The cost amounted to roughly the same as a high-end vacation - about $14,000 (7,000).

When Sheila returned, and eventually went back to jogging around the reservoir in Central Park and dancing to a latin beat on Friday nights, she was a changed woman in more ways than one. She became part of the political constituency calling for universal health care in the United States.

In the last few presidential elections, health care was an orphan issue - rarely mentioned, perhaps too complex to lend itself to easy sound bites. The candidates talked about gay marriage and terrorists.

Right or privilege?

On healthcare, they discussed only the peripheral issues, like drugs and veterans care but nothing big picture. Nothing about Our System versus everyone else's.

This time around, things are different. Virtually every major candidate for the presidency - Republican and Democrat - has a plan to greatly expand access to healthcare.

The Democratic frontrunner, Senator Hillary Clinton, unveiled her ideas this week.

The political lesson was - don't touch health care, it's a loser

"Health care is a right, and not a privilege," said the former First Lady. This line was an echo of something Franklin Roosevelt first said back in 1940, and it's deep in the DNA of most Democrats.

Senator Clinton's approach doesn't ditch the insurance companies - as some candidates on the left have called for. Instead it requires everyone to carry some kind of health insurance, just as everyone with a driver's license must have coverage.

It offers federal subsidies for those who can't afford it, and tax breaks for small businesses. The insurance companies would not be allowed to pick and choose who will covered, as they can now.

Republicans were quick to pounce on the Clinton plan. Hillarycare, they called it -- a recycled outline for "socialised medicine". They envisioned a nightmare of long waits in doctors offices and faceless bureaucrats with total control over people's medical decisions.

Big majority

The Republican approach, touted by candidates such as former New York Mayor Rudolf Giuliani, would offer tax breaks to encourage people to buy into the existing market.

Now the fact that most other candidates have a plan, with variations of the two approaches, suggests that the US may ultimately join the rest of the industrial world.

After all, polls show that a big majority of Americans want guaranteed healthcare for all. Even those who have the best of care question the wisdom of a system where profit-based insurance carriers make life and death decisions.

Those without healthcare tend to be poor, they don't vote, they work two jobs, they aren't organised, they don't lobby

But just because a majority wants change does not mean the change will happen. Remember the last time there was serious attempt to overhaul the American system? That was during the first year of the Clinton presidency, 1993, and Hillary, then First Lady, was in charge.

The plan was complex, and came under immediate fire. The insurance industry and other groups spent more than $100m (49.5m) to defeat it. Their centrepiece was an ad campaign featuring a fictional middle class couple - Harry and Louise - who didn't want to give up their sweet insurance coverage for the uncertainties of the Hillary plan.

These counter-punches crushed the Clinton proposal - even among fellow Democrats. And then, afterward - a long silence. The political lesson was - don't touch health care, it's a loser. And it's been 14 years since anyone tried to make a serious run at the issue.

Now, nearly 50 million Americans - essentially the population of England - have no health cover. And another 16 million are underinsured. Most of the insured rely on their employers but a lot of families pay $10,000 (5,000) a year or more - out of their own pockets - for the kind of basic care that only kicks in with a catastrophic illness.

Aggressive lobbying

For the 1.5 million Americans who go through bankruptcy in an average year, medical bills are the leading cause. For all of that, you would think there would be a loud and visible constituency for healthcare reform.

You would think there would large demonstrations, or at least aggressive lobbying for change. But there is very little. When you ask political strategists where is the counterforce to Harry and Louise, they shrug and offer several explanations.

Those without healthcare tend to be poor. They don't vote. They work two jobs. They aren't organised. They don't lobby. They have no money to influence the political system.

And besides, most middle class people like their benefits and don't want to rock the boat. All the insurance companies have to do is make an appeal to naked self interest - do you really want to give up your benefits to help 50 million people without coverage?

All of those explanations have worked in the past. But this time around, they may be outdated.

Employer burden

To the surprise of many, the constituency for change is coming from the powerful and the middle class. It's coming from Big Business and small business. General Motors, once considered to the most invulnerable fortress of corporate American, is crying for change - while bleeding red ink on its bottom line.

The cost of covering health care for all their autoworkers is such a burden that GM is having trouble making a profit. They want a new system.

Companies like Starbucks offer full healthcare for all their baristas - but they also complain about how much it cost for them to do it. Small businesses, where most new jobs are coming from, are being hit particularly hard. A family-run cafe opening next to - say, a Starbucks - can't possibly compete in the labour market without offering the same costly coverage to workers.

The story of my friend Sheila is but a drop in the ocean of anecdotes coming from people who already have insurance - and now want change. They share tales of denied coverage, or being forced to accept cheaper procedures, or being told that the operation they need to stay alive is - so sorry - experimental, and won't be paid for.

As for Sheila, she just came back from India, where she got that second hip resurfaced. She told me that a wonderful Indian doctor in a first-rate hospital did the operation for a third of what it had cost her in England.

And while she was recuperating, she had a nip and a tuck done for good measure, a small nod to vanity. So, in addition to being part of the political constituency for health care reform, Sheila has become quite the fan of globalisation.

Below is a selection of your comments.

Well written piece. Unless you lived this as I did, you would never understand it. The stranglehold of greedy insurance companies who make millions while questioning every medical decision you make is unacceptable and heartbreaking. Worst still, the control they have on the political structure of US is alarming. Tell me, in the Third World country, what name does the west call lobbying? Bribery and it is being done openly here. We shall see
Emeka Aninyei, Chicago, USA

The best friend I ever had, a successful lawyer from Chicago, lost her life to the health care system in the states. Do not get trapped into the 'grass is always greener over there' school of thought. If you really want to know what American health care is like, look to our own railways, where just like U.S. hospitals, cashflow comes before anything, including peoples lives.
Rob Jackson, Colchester

The Last thing we want is a nanny state such as they have in Europe. I agree we need immediate health-care reform, but not something which gives the government control and turns me into a number for a bureaucrat to create red-tape with. The government is too involved in my life as it is. What I want is control of my health-care. Not the insurance companies, not the government, but put the control in my hands! No socialized medicine for me thank you.
Sean , Orlando, USA

I personally envy the American healthcare system. The amount of money the NHS wastes on the elderly and the obese is obscene. If people had to pay for any health treatment they received, it would encourage people to work hard, and take care of themselves rather than assuming the state will pick up the tab.
James, UK

I am an American living in the UK now for over 2 years. I have had nothing but good experiences with the NHS, albeit very few experiences. My sister is ill in the US with a rare condition. She is only 29 years old, but shouldn't have to continue working, but she is because that is the only way she can still get treatment. Even with her insurance, she has attended a specialist hospital that isn't covered with her insurance even though it's her best chance at getting better. It makes me ill how if she lived in the UK she would have it a little easier.
Andrea Cousins, Micklefield, Leeds UK

I'm working in Taiwan at the moment and seeing a physiotherapist for some back problems. NT$450 - 7.50 - pays for six visits to a shiny brand new centre, and covers the costs of various treatments including ultrasound and traction. I never make an appointment. I never queue. My physio did her Master's Degree in Nottingham and is very knowledgeable and professional. I really can't fault the quality of treatment, or the cost. And it's all possible due to the National Health Insurance scheme operated in what is considered by many to be a developing country. I pay less for health care, including dental, in Taiwan than I did for basic cover in the USA. If a cheap manufacturing centre, with a weak tax-collecting system, like Taiwan can provide for its own people in this way then surely the USA can do better? It's simply a matter of political will.
Chris, Taipei, Taiwan

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