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Wednesday, March 11, 2009 | Sixteen years after Bill and Hillary Clinton tried to create a health care system with universal coverage, Barack Obama is back at it. He wants to avoid the mistakes the Clintons made, but leaves no doubt his goal is the same: to bring down healthcare costs and create a system where all Americans have health insurance.

It’s a tough time to introduce reforms more sweeping than anything since the New Deal. Banks are failing, markets collapsing, economies sinking, and Obama faces a deficit higher than anything since World War II. But it is that very crisis, throwing people out of work and leaving them without health care, that creates the urgency, he says. He thinks Clinton waited too long after his election. Relying on a 67 percent approval rating and large majorities in Congress, he wants to get the job done this year, which will be tough.

The ugly fact is that health care costs and coverage are worse in America than in any other industrialized nation. At $8,160, we will spend twice as much per capita this year as the average industrialized nation, and even at that have 47 million people uninsured. The problem is not the quality of our professionals — medical students come from around the world to study and work here. The problem is the system itself.

For 40 years, the medical, pharmaceutical and insurance lobbies, strong supporters of the Republican Party, have found ways to block any move beyond universal health care coverage for seniors, or Medicare. The GOP opposition is not hard to understand: A survey last year by the Harvard School of Public Health showed that two thirds (68 percent) of Republicans believe the U.S. health care system already is the best in the world, compared to only 32 percent of Democrats who hold that view.

It’s not hard to guess which party’s supporters have better health care coverage.

Obama has an advantage: The wretched Bush presidency delivered him a mandate Clinton never had. Obama is FDR to Bush’s Hoover. Still, just as Lyndon Johnson needed time and bi-partisan support to pass Medicare in 1965, so will Obama need both to succeed. Though public support for Medicare (69 percent) in 1965 was as high as it is for universal coverage today, the AMA lobby was strong enough to defeat the Medicare bill when it first came to a vote under Kennedy in 1962. Despite the Johnson landslide of 1964, it took Congress another 19 months to pass the bill.

People who’ve always had good jobs, good insurance and good doctors have rarely supported universal coverage. But with people losing jobs and insurance and with medical costs rising at twice the rate of inflation, attitudes are changing. Our existing system has too many moving parts, too many middle men and fee takers, excludes too many people and relies too much on employers, putting on them a direct burden that foreign competitors don’t have. The U.S. auto industry is an example.

Since the health care debate began seriously after World War II, the question has always been how to do it. The arguments against universal coverage have not changed: Quality will slip, costs will rise, waiting times will grow, rationing will be introduced and Washington bureaucrats will pick your doctor for you.

None of those things need happen if the changes are done right. I’ve lived and worked in two nations with universal coverage, France and Great Britain, and observed how each system evolved slowly, building on existing practices, until they achieved wide popular support. France, which has the top health care system in the world according to the World Health Organization, created its system over many years.

When I first began working in France in 1965, only the employed, their families and retirees were fully covered. Before I left a decade later, the self-employed had been added to the system, and it took several more decades to extend the system to all residents, including the unemployed. Calling it socialized medicine misses the point that coverage is in part financed by a payroll-tax on employers and employees, with funds funneled through private insurance companies.

One effect universal U.S. coverage could have is a fall in doctors’ salaries. For general practitioners (family care), the average U.S. doctor’s salary in 2005 was $140,000. In Britain it was $102,000, in Italy $60,000 and France $50,000. For Obama to succeed, especially given the size of budget deficits now anticipated, he must deal with costs. Hillary Clinton admits today that costs were a central reason the Clinton plan failed 15 years ago. Obama’s plan addresses costs with a variety of proposals, including taxing the wealthy and reducing payments to insurers, drug companies and hospitals. Congress will need to look carefully at his numbers, and Obama, unlike Bill Clinton, has invited Congress to improve his plan.

For the plan to work, it must follow the formula that has worked in other countries, that is, build on what already exists. For a country our size, you can’t start from zero. That means using proven parts of our existing system. Examples would be Medicare, the federal workers insurance programs and the veterans’ health care system with some 1,000 government-run health facilities around the nation.

Massachusetts introduced a state-wide universal health care system two years ago with elements that resemble Obama’s proposals. Obama calls for a public insurance program to compete with private insurers, one that requires employers either to contribute to their workers’ coverage or to the cost of the public plan. Such an idea borrows both from the French and the Massachusetts systems.

Done right, there’s no reason America can’t do what every other modern nation has already done. We’ve bucked the tide up to now, but rising costs and diminishing coverage are proof that our jerry-built system needs rebuilding before it collapses

James O. Goldsborough has written on foreign affairs for four decades, both from the United States and abroad, where he worked as a foreign correspondent for The New York Herald Tribune, International Herald Tribune and Newsweek magazine for 14 years, reporting from more than 40 countries. Visit his website here. Submit a letter to the editor here.

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