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Anne-Emanuelle Birn, ScD and Oliver Fein, MD

Anne-Emanuelle Birn is with the Robert J. Milano Graduate School, New School University, New York, NY. Oliver Fein is with the Office of Network Affairs, Weill Medical College of Cornell University, New York, NY.

Correspondence: Requests for reprints should be sent to Anne-Emanuelle Birn, Robert J. Milano Graduate School, New School University, 72 5th Ave, Room 503, New York, NY 10011 (e-mail: aebirn{at}newschool.edu).

	INTRODUCTION

TOP INTRODUCTION TIME FOR REFORM INTERNATIONAL PERSPECTIVES References

 

I love reform better than its modes.

Henry David Thoreau¹

The thing is, you can’t get private insurance for a price you can afford.

Patricia Nelson²

A lecture and workshop series titled "Rekindling Reform," held in spring 2002 in New York City, sparked this special issue of the Journal. The series was sponsored by a broad cross-section of health professional and health worker groups, advocacy organizations, unions, faith-based organizations, and university departments and associations. The "Rekindling Reform" Steering Committee³ wanted to understand the experiences of other countries in achieving universal health coverage. Such an understanding would, they hoped, provide a launching pad for renewed discussion of the alternatives in health care organization and financing needed to address the US health care crisis.

Why, one must ask, does health reform need rekindling at a national level, particularly given the debacle of the Clinton reform effort of the early 1990s? As the authors in this issue’s Rekindling Health Care Reform suggest, the problems that existed in the early 1990s persist today: More than 41 million remain uninsured; tens of millions more are underinsured, unable to get needed services owing to limits on their coverage; costs continue to rise at double-digit rates; and rampant profiteering persists. Indeed, there is a broad consensus—echoed by the voices of academics, advocates, business, labor, politicians, and provider groups represented in this issue—that the US health system is in dire need of reform.

	TIME FOR REFORM

TOP INTRODUCTION TIME FOR REFORM INTERNATIONAL PERSPECTIVES References

 
Almost a decade has passed since national health care reform was abandoned in favor of market-oriented reforms, patchwork governmental initiatives to cover the uninsured, and a shift of the health care cost burden from employers to employees. It has become clear that these efforts are not working. The idea of rekindling reform rises out of concern that policy discussions be elevated from the narrow focus on incrementalist approaches to a more comprehensive vision of health care reform in the United States. It is precisely because national reform has failed in the past that we must return to it now.

If the Rekindling Health Care Reform articles in this issue agree—like the American public—on the need for reform, they also share no consensus on the shape of reform or how to achieve it. Here is where cross-national accounts of the nature and politics of health reform processes in other countries pertain to policy discussions in the United States. Such comparative analysis has often been dismissed by US decisionmakers as irrelevant because of "US exceptionalism"—the notion that the United States’ historical trajectory, social makeup, and political institutions are unique. It is our belief, however, that the experiences of other countries presented here offer meaningful perspectives on reform that are frequently absent from political discussion in this country.

The country case studies included in the International Perspectives Forum in this issue range from nations that publicly finance health services (Canada and the United Kingdom) to those that have multiple payers in both the public and private sectors (France, Germany, Brazil, and Korea). Though Canada and the European countries began to implement national health systems more than half a century ago, their reforms remain an ongoing process. Having launched major health reform efforts much more recently, Brazil and Korea offer some surprisingly relevant experiences for the United States.

	INTERNATIONAL PERSPECTIVES

TOP INTRODUCTION TIME FOR REFORM INTERNATIONAL PERSPECTIVES References

 
While the country analyses offer a variety of historical trajectories and configurations of power in the polis, they present at least 3 common guiding points that US reformers of all stripes should take to heart. First, universality of coverage is a crucial dimension of a health system, both as an explicit principle and as the first order of policymaking activity. Second, each of these countries—indeed, all industrialized countries—recognize that there is a significant role for government in health policy making, whether as funder, regulator, or provider. Third, though most countries have a small private, market-oriented health care sector, profit-driven health care has grown very slowly. The public favors a health system that guarantees security. Other countries seek to limit the detrimental effects of for-profit market-driven health care on access, equity, and the public’s health itself. Additionally, though almost every country periodically declares itself in a financial crisis, all are able to control health care spending far more effectively than the United States.

Ultimately, this issue’s International Perspectives Forum reminds us that the usefulness of lesson drawing is not in providing prescriptions for policymaking. Instead, these international cases allow us to look on the political and social structures in the United States with a new eye to the local conditions needed for reform, however less than "lovable" the modes of reform may be.

As the historical pieces in this issue recount, notwithstanding sometimes valiant efforts, the US experience with comprehensive health care reform is the story of powerful interest groups’ blocking constructive reform efforts; the tendency of reformers to work only from the inside; and the focus of grassroots groups on single issue reforms, such as hospital desegregation, abortion rights, and access to AIDS drugs. What seems different today is that every sector of US society feels an increased level of health insecurity. Working people are concerned about shouldering ever larger premium costs. Students fear that new jobs won’t provide health insurance. The elderly are worried about the privatization of Medicare and the affordability of medications. The poor are distressed that Medicaid has become unreliable and subject to state budget crises. More and more of the public feel anxious about their health care coverage and are dissatisfied with the status quo. Perhaps now, just as Henry Sigerist observed in 1944,⁴ during a period of external security threats, health insecurity will breed a broad popular reform movement for universal, comprehensive health care. This incendiary moment may be just the time for rekindling reform. We hope that this issue of the Journal helps to stimulate discussion, and even action, toward universal health care reform in the United States.

Accepted for publication October 9, 2002.

	References

TOP INTRODUCTION TIME FOR REFORM INTERNATIONAL PERSPECTIVES References

 
1. Thoreau HD. Letter, March 27, 1848, to Harrison Blake. The Writings of Henry David Thoreau. Vol 6. New York: Houghton Mifflin; 1906:163.

2. Patricia Nelson. Quoted in: In Their Own Words: The Uninsured Talk About Living Without Health Insurance. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation; September 2000. Report 2207: xii.

3. The Rekindling Reform Steering Committee. Rekindling Reform: principles and goals. Am J Public Health. 2003;1:115–117.

4. Sigerist HE. Medical care for all the people. Am J Public Health. 2003;1:57–59.

This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Birn, A.-E. Articles by Fein, O. Search for Related Content PubMed PubMed Citation Articles by Birn, A.-E. Articles by Fein, O.