Diagnosing U.S. Health Care — and 'Sicko,' Too

DATE July 9, 2007 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Professor Jonathan Oberlander discusses film "Sicko"
and health care

TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

(Soundbite of "Sicko")

Mr. MICHAEL MOORE: There are nearly 50 million Americans with no health
insurance. They pray every day they don't sick because 18,000 of them will
die this year simply because they're uninsured.

(Soundbite of music)

Mr. MOORE: But this movie isn't about them. It's about the 250 million of
you who have health insurance, those of you who are living the American dream.

(End of soundbite)

GROSS: Michael Moore's film "Sicko" raises a lot of questions about the
quality of Americans' health insurance and compares our system to countries
like Canada, England and France, where everyone is insured and health care is
free. So we thought we'd pose some of the questions raised in the film to an
expert on health care policy and politics. My guest is Jonathan Oberlander.
He's an associate professor of social medicine and health policy and
administration at the University of North Carolina-Chapel Hill. He's also the
author of the book "The Political Life of Medicare."

Here's another clip from "Sicko," which is filled with examples of people who
have health insurance but still have problems getting covered for illnesses
and medical emergency.

(Soundbite of "Sicko")

Mr. MOORE: Laura Burnham was in 45-mile-an-hour head-on collision that
knocked her out cold. Paramedics got her out of the car and into an ambulance
for a trip to the hospital.

Ms. LAURA BURNHAM: I get a bill from my insurance company telling me that
the ambulance ride was not going to be paid for because it wasn't
pre-approved. I don't know exactly when I was supposed to pre-approve it, you
know. Like after I gained consciousness in the car, before I got in the
ambulance, or I should have grabbed my cell phone off of the street and called
while I was in the ambulance or--I mean, it's just crazy.

(End of soundbite)

GROSS: Jonathan Oberlander, welcome back to FRESH AIR.

Let's start with a short review of "Sicko." What did you think of the film?

Mr. JONATHAN OBERLANDER: He gets a lot right about the American health care
system, and really shows how the system doesn't work. He cuts a few corners
and leaves a few things out, which admittedly are hard to get in in a two-hour
format.

GROSS: Now Michael Moore presents the health care systems of France, England,
and Canada as better alternatives because everyone in those three countries
gets the health care they need for free. Which of those countries have you
studied most carefully?

Mr. OBERLANDER: Canada.

GROSS: So let's focus on Canada. Describe how that system works.

Mr. OBERLANDER: Canada is what's called a single payer system, and it's
really similar philosophically to American Medicare. Physicians are still
private in Canada. They are by and large not government employees. Many of
the hospitals are non-for-profit. And the difference is instead of having
lots of different private insurers, you just have one public insurer in each
Canadian province, just like we have one government program for the elderly in
the United States. And Canadians get that insurance regardless of whether
they're working or not working or where they live in Canada.

GROSS: So how is that system paid for?

Mr. OBERLANDER: Well, the Canadians pay for it primarily through taxes.
What's interesting about Canada as opposed to the US, is they really don't
rely on a lot of patient cost sharing or a lot of deductibles. In fact, that
is outlawed in the Canadian provinces, so this is a tax-based system. And as
someone says in the movie, really, the philosophy is from each according to
their own means, what they can afford to pay, and then they take out of the
system in terms of medical benefits according to their needs.

GROSS: So it's a progressive tax but you get whatever health care you need,
regardless of what tax you've paid.

Mr. OBERLANDER: Within limits. Within limits. And one of the things that's
not really part of the movie is that there are trade-offs in Canada and in
other countries, and the Canadians do set limits on what they spend for health
care. And while they have a terrific system, they've got their own problems.

GROSS: What are some of those problems? Let's start with the limits. What
are the limits that are set?

Mr. OBERLANDER: Well, they budget, and that's what most other countries do
when they decide how much to spend on health care. This is, you know, we talk
about the American system and we spend $2 trillion a year, which is the most
in the world by a long shot. And if you ask how do countries like Canada
control what they spend, it's not very complicated. They set budgetary limits
on how much they're going to pay for hospitals. They set limits on what
they're going to pay physicians, and they have a fee schedule similar to what
we use in Medicare but binding across all physicians. In Canada, they also
limit the diffusion of medical technologies. So while primary care, for
instance, is easily accessible in Canada, if you want to get an MRI, which is
readily available in the United States because we have MRIs all over the
place, they have far fewer MRIs in Canada, and there are some other high-tech
procedures that they do less of than we do, and that creates queues, or wait
lists.

GROSS: What about waits for surgery or medical procedures or even office
visits with specialists, is that a problem?

Mr. OBERLANDER: It really varies. In terms of primary care, there is not
much of a problem there, as far as I know, with waiting. And in fact, they
have a much greater proportion of primary care doctors than we do in the US,
so there are more doctors for you to see. For a lot of urgent surgeries,
there would not be a wait in Canada, but there are waits for things like hip
replacements. They are not as bad as some of the waits in the United Kingdom.
And we also always have to be careful in the US. One of the values, I think,
of the movie is that we have this stigma of socialized medicine, and Michael
Moore tries to go beyond that. And one of the arguments you hear is we can't
move to universal coverage because those countries ration, and the truth of
the matter is the United States rations in medical care, too. We ration
according to your insurance status. We don't like to think we ration and so
we pretend that we don't ration, but for the 45 million Americans who don't
have health insurance, they're really experiencing a form of rationing that is
much more severe than any Canadian ever would.

GROSS: Are there forms of rationing within a lot of HMOs too?

Mr. OBERLANDER: Absolutely. HMOs in the last three decades really have
focused on controlling costs. And the sort of supposition of the modern HMO,
which has a lot of merit to it, is that there's a lot of unnecessary medical
care in the United States, and a lot of services that are provided of very
little value because doctors get paid according to fees for each service that
they provide. So the more services they provide the more fees. HMOs were
really, in a way, created to fight against that and they absolutely do set
limits and they have their own form of rationing.

GROSS: Let's get back to Canada. You say that there are certain things you
might have to wait in line for, like an MRI. If you're rich, can you get to
the head of the line? Is there a way of getting special treatment?

Mr. OBERLANDER: In general, no. It's a very equitable system. Everybody is
in the same boat. You are all in the same system. In reality, a fairly heavy
percent of the Canadian population lives to the American border so you could
come across the border and get your MRI. And you hear stories of that, but
when we look at the evidence about that, what we find is a very small percent
of Canadians actually come over to the United States to get medical care. And
of course the reverse is true. We have Americans going to Canada to buy
cheaper prescription drugs, and also to Mexico.

GROSS: What do Canadians complain about within their own health care system?

Mr. OBERLANDER: The Canadian health care system, which is also known as
Medicare, is the most popular social institution in Canada. It is supported
by all political parties, so the conflict that surrounds it is really over
funding levels. And there have been battles between Ottawa and the provinces,
much like our battles over Medicaid, about who should pay for what.

I would say in terms of patients, there have been complaints in the last 15
years that some of the queues have gotten longer and some of them aren't
managed as well as they could be. But in terms of general support for the
foundation principles of the Canadian system, it's still very strong and a
very popular program.

GROSS: What are some of the advantages of health care not being a political
issue? It's such a political issue here?

Mr. OBERLANDER: Well, I wouldn't say it's not a political issue. I would
say it's a political issue in a different way, in the sense that you have
broad consensus that health care is a right and that health care should cover
everyone. Everyone should have health insurance. Once you agree on those
principles, there's plenty of room for disagreement on how you're going to
fund it and on how you're going to deal with things like wait lists and other
reforms to the system. In the United States, we have never gotten to that
point of recognizing that health care is a right. We recognize it for some
populations, such as the elderly, but we don't recognize it for everybody.

GROSS: Are there aspects of the Canadian health care system where health care
is free and available to everyone that you think could transfer to the United
States?

Mr. OBERLANDER: Well, in a sense we already have transferred some of the
lessons within our own Medicare program. And if you look at the American
Medicare program, it is a universal program for that population, the elderly,
folks on end stage renal dialysis, and the disabled. And the Medicare program
has very low administrative costs, just like the Canadian health care system,
and really does a lot of things well. So we have transferred some of those
lessons here. The question is, how do you transfer them to the population as
a whole? And I think Michael Moore would like to see a single-payer Canadian
style system for the entire country, and that's a strategy that reformers have
been pursuing for 35 years in the United States and it hasn't gone anywhere
and I wouldn't hold my breath.

GROSS: Why not?

Mr. OBERLANDER: The political barriers to it are very strong. I said before
that we spend $2 trillion a year on health care. All that money we spend on
health care is income to insurance companies and providers, the pharmaceutical
industry and so on. They literally profit from the status quo and they're
deeply invested in keeping the status quo. And as the Clintons found out in
the early 1990s, it's really hard to move the status quo in the United States.
And so the idea that we could displace private health insurance which, you
know, insures over 160 million Americans, I think really politically is just a
very tough fit for this country.

GROSS: How do the pharmaceutical industry and the insurance industry exert
their influence over Congress?

Mr. OBERLANDER: I think one of the more amusing and also poignant scenes in
the movie is where different members of Congress are walking into a room and
Michael Moore puts price tags over their heads. And the fact of the matter
is, the way we finance elections in this country allows the pharmaceutical
industry, the health insurance industry, and a whole lot of other health care
interests to fund campaigns, and they can put a lot of money in those
campaigns and give a lot of money to political parties. And once you've given
that money, the question is, `What are they buying for that money?' And I
think it's safe to assume that in many cases, they are buying a sense of
political obligation and a sense of members of Congress who take that money
that they're not going to rock the boat. They're not going to upset the
status quo. And I really do believe that that was at work during the Medicare
Drug Act, which in many ways was very favorable to the industry, and the
industry was working hand-in-glove with Congress on it.

GROSS: What about the AMA? Like what's their interest in the future of
health insurance in the United States and what's their preference?

Mr. OBERLANDER: The AMA is an interesting story because for most of the 20th
century organized medicine was the number one obstacle to national health
insurance. They were the most prominent interest group that was fighting
against it, and their argument was you would go to what they called socialized
medicine, which is really a term that doesn't mean anything but has a lot of
stigma with it, and you would threaten patients' quality of care and
physicians' autonomy and their income. And they organized and fought against
everything from prenatal care and medical care for children to the original
Medicare legislation in 1965 to national health insurance.

And what has happened to the AMA in the last few decades is that organized
medicine is no longer very organized, and the AMA only covers, I believe,
around 40 percent of physicians in terms of its membership. And a lot of
doctors are more active in their speciality society, be it the family
physicians or the American College of Surgeons and so forth. And the result
is the AMA really doesn't speak for all or even most of American physicians
anymore. If you look at what they're doing right now, they have recently
joined a coalition that's advocating for expanded coverage, but it's really a
sort of incremental agenda. And one gets the sense that they are much more
deeply involved in fights over medical malpractice and fights over what
Medicare is paying physicians than they are in advocating for the uninsured.
If they would advocate for the uninsured with the same intensity that they
advocate for medical malpractice reform, we might actually be able to break
the impasse.

GROSS: My guest is Jonathan Oberlander. He's an associate professor of
social medicine and health policy and administration at the University of
North Carolina-Chapel Hill.

We'll talk more after a break. This is FRESH AIR.

(Announcements)

GROSS: If you're just joining us, my guest is Jonathan Oberlander. He's an
associate professor of social medicine and health policy and administration at
the University of North Carolina in Chapel Hill. We're talking about the
American health insurance system and how it compares with other countries, and
we're using the Michael Moore movie "Sicko" as a kind of a jumping off point.

Well, you've expressed skepticism that a single-payer plan like the plan in
Canada would every really happen in the United States anytime in the near
future because of the politics of our system. You know, the insurance lobby,
the pharmaceutical lobby. Is there a system, from another country, that you
think would apply here and, you know, would be easier to, you know,
politically activate?

Mr. OBERLANDER: Well, no country copies another country's health care system
exactly, and every country has their own history of how their health care
system has developed, which really impacts what kind of reform is feasible. I
don't know if there are plans for a sequel, you know, a "Sicko 2" coming out
in a few years, but if Michael Moore was going to do "Sicko 2," I would send
him to Germany and I'd send him to Australia. And the reason I would send him
to those countries, is those countries do use private health insurance in
their universal coverage systems. And I think if we're really going to
consider how to get universal coverage in the United States, we probably are
going to continue with our mixed system that has a role for public insurance
and private insurance.

Now it's true that in a place like Germany, the kind of private insurance they
have is very different than ours. It's nonprofit. It's highly regulated.
They can't charge sick people more. And those are the kind of reforms that
President Clinton wanted back in 1993, and they're exactly the kind of reforms
that we would have to have if we were going to use that kind of system. But I
think those mixed models that use public insurance and private insurance are
much more feasible politically in the United States. They're not easy by any
stretch of the imagination, but I think they're a better fit.

GROSS: So in Germany, there's private insurance, but it's like nonprofit
insurance. Would you explain, like, what that type of insurance is like?

Mr. OBERLANDER: Sure. They have--and you know, it tells you something that
it's very hard for Americans to understand this because we really don't it
anymore, but in Germany they have this system that is based on what's called
"sickness funds." And these are nonprofit insurance companies that are heavily
regulated by the government and they're employer-based. So like the United
States, it is employment based insurance. But instead of having lots of
different for-profit insurance companies as we do that aren't well-regulated,
they have none-for-profit insurance companies that are heavily regulated and
that all play by one set of rules.

GROSS: But one of the problems we have in the United States is that if you're
unemployed or if you work part-time or if you're freelance, you don't get the
benefit of employer health benefits. So how do they deal with that in
Germany?

Mr. OBERLANDER: In Germany and in other countries that have employer-based
universal coverage, the government would buy you into the system. The fact in
the United States that when you lose your job, you lose your health insurance
and can become uninsured, that is uniquely American.

GROSS: Describe the Australian system.

Mr. OBERLANDER: The Australian system is a hybrid system and they have both
public and private insurance. And so for Australians who want to get it, they
are able to purchase private insurance and that can get them, for instance, a
different room in the hospital and so forth. And I think that's a really
interesting example for the United States, because, personally, while it might
be great and equitable to have everybody in the same system, if we make sure
that the government program is a good quality program, I'm not troubled at all
by the fact that some people would have access to private insurance. And
Australia has much more of a prominent role for private insurance than Canada
or then Great Britain.

GROSS: So with more money, you could get better care but everybody is assured
of getting adequate care?

Mr. OBERLANDER: Absolutely. And I think that's a model for the United
States that would work.

GROSS: In countries like England, France, and Canada that have--where
everybody's insured and everybody's in the same system, how much money do they
save on administrative costs? When you think of the amount of money Americans
are paying within their health insurance for administrative costs, it's pretty
high.

Mr. OBERLANDER: It's staggering. One study found that the United States
spends about 30 percent of all health care spending on administrative costs.
So 30 percent of $2 trillion. In Canada, it was about 17 percent. And one of
the reasons that it's so much cheaper in Canada is if you look at "Sicko" and
you see the amount of time that patients spend fighting with their insurance
companies on what they're going to cover, and the amount of time and effort
that insurance companies spend on figuring out how much they're going to
charge people, figuring out how sick they are, figuring out whether they're
going to insure them at all, none of that, none of that happens in countries
like Canada. So in other words, because we have a for-profit system that is
fragmented, it has very high marketing costs, very high costs for sales, and a
lot of costs associated with what's called medical underwriting, figuring out
how sick people are. And we really waste a lot of money on that function
instead of spending it on medical care.

GROSS: So if we had a single-payer system, we'd be saving a lot of money just
from eliminating a lot of the bureaucracy?

Mr. OBERLANDER: There's no question. And not even a single-payer system.
If we had a multi-payer system, like Germany, where you had regulated private
insurance, where everybody plays by the same rules, but insurance companies
have to accept somebody, regardless of how sick they are, we would save a lot
of money. And I think what's interesting in this regard is earlier this year
the McKenzie Institute, which is a consultant in health care--and this is not
Michael Moore. This is not moveon.org. This is a high-powered corporation.
They did a fascinating report looking at just this question, about why is
American medical care so much more expensive than other countries. And what
that report found is it's not because our quality of care is better. It's not
because we're getting better value for our money. It's because, in large
part, we have very high administrative costs due to medical underwriting and
profits, and because we pay our medical providers more.

GROSS: Jonathan Oberlander is an associate professor of social medicine and
health policy and administration at the University of North Carolina-Chapel
Hill. He's also the author of "The Political Life of Medicare."

He'll be back in the second half of the show.

I'm Terry Gross and this is FRESH AIR.

(Soundbite of music)

(Announcements)

GROSS: This is FRESH AIR. I'm Terry Gross.

Michael Moore's film "Sicko" raises a lot of questions about the American
system of health insurance and compare us to countries like Canada, France,
and England, where everyone is insured and health care is free. We're talking
about some of the issues raised in the film with Jonathan Oberlander, an
expert on health policy and politics.

He's an associate professor of social medicine and health policy and
administration at the University of North Carolina-Chapel Hill.

A lot of people are very critical of HMOs. "Sicko" is pretty critical of
HMOs. Did HMOs have a more idealistic philosophy when they started?

Mr. OBERLANDER: They really started out as a liberal idea in the 1930s and
1940s. And in conventional American medical care, you would get your
insurance and go to any doctor you wanted and any hospital you wanted, but it
really wasn't very organized and it really wasn't coordinated, and physicians
were paid on a fee for service basis. And the idea behind the early HMOs in
the 1930s and 1940s--they were called prepaid group practice plans--is that
they would integrate medical care in one organization that would provide your
insurance. In other words, they would finance your medical are, but they
would also arrange the delivery. So the classic HMO, like Kaiser Permanente,
they would own their own hospitals and they would have their own doctors. So
when you went to the doctor, you would see a Kaiser physician and just a
Kaiser physician. And the goal of these prepaid group practices in the 1930s
and '40s was really to emphasize prevention, to give more comprehensive
medical care, better integrated medical care, and have physicians on salary so
you would remove some of the inflationary incentives of fee for service.

GROSS: And would you say something went wrong along the way?

Mr. OBERLANDER: Well, what you see in "Sicko," and it really is accurate, in
the 1970s, HMOs were re-invented, or prepaid group practices were renamed
HMOs, and they were re-invented as a cost control mechanism. And since the
1970s, the HMO market has really taken off in the United States, particularly
since the late 1980s, and it's really changed. It used to be dominated by
nonprofit HMOs like Kaiser. After the 1970s, for-profit HMOs began
accelerating and they really dominate the market.

I think that a lot of abuses that are documented in the movie and a lot of
your listeners will be familiar with HMOs really came out of the for-profit
HMO movement in the 1980s and 1990s. Having said that, HMOs have really
flat-lined. We're really almost beyond managed care now in the United States,
and sometimes the movie left me with the impression that problems in the
health care system started and ended with HMOs, and I think that's just not
right.

GROSS: What do you mean when you say HMOs have flat-lined? I certainly know
of a lot of HMOs and a lot of people in HMOs.

Mr. OBERLANDER: They still have a good share of the market, but enrollment
in HMOs has declined over the last decade. And most Americans are now in a
much weaker form of managed care, which is called a PPO. And a PPO really
doesn't manage anything, and it doesn't coordinate anything and doesn't have
any of the emphasis on prevention or integration of care like a Kaiser
Permanente. It's just an organization that contracts with physicians and
hospitals to get a discounted rate, and that really is the form of managed
care that is prevalent right now.

GROSS: Are PPOs more expensive than HMOs?

Mr. OBERLANDER: On average, historically they have been a little more
expensive. And, you know, one of the questions that I think is worth asking,
we beat back managed care. Managed care spread in the United States in the
mid-1990s. We had a backlash against managed care led by physicians, led by
patients who were dissatisfied with all the barriers that managed care was
putting in their way. We really beat it back and got rid of a lot of the HMOs
and got rid of all of the tightly managed care.

Well, what is the consequence? Well, one of the consequences is we have
rapidly increasing medical costs again. And because we have rapidly
increasing medical costs, more employers are dropping health insurance. So
are some patients better off because we loosened managed care? Absolutely.
Have a lot of people lost health insurance because we beat back managed care?
That's probably true as well.

GROSS: Well, you know, the employer-based health insurance system seems to be
falling apart. It's too expensive for employers to deal with, so many
employers are trying to go to cheaper benefits, which the employees are
unhappy with, or they're cutting down their staff so that there's fewer people
to pay insurance for, or they're relying more on freelancers or part-timers.
Is there a movement of employers who are unhappy with what employer-based
health insurance means now and who are trying to find an alternative?

Mr. OBERLANDER: If there's one thing that surprised me about "Sicko" in
terms of not being there, it is really inattention to the employer
perspective. As you say, the employer-based system is unraveling. You know,
it wasn't long ago when 69 percent of American companies provided health
insurance. We're down around 60 percent right now.

And health care is a moral issue. There's no doubt about that. But I think
one of the lessons of the failure of health reform is that moral outrage only
gets you so far. And I would have liked to have seen the movie frame it as an
economic issue as well, because for big American corporations, for small
businesses, really for all of them, they're having a hard time paying this
bill. And as a result, we have seen some pretty extraordinary events in the
last year. We have Lee Scott, who is the CEO of Wal-Mart, get up on a stage
with Andy Stern, who is the head of the Service Employees Union, and together
they announced a coalition that was going to advocate for universal coverage.
Given Wal-Mart's record in health benefits, that's pretty extraordinary.
We've had Steve Burd out in California, who is the CEO of Safeway and who is a
conservative Republican, and he is forming his own coalition of employers to
advocate for universal coverage.

And if you think about this historically, it's really--there was a short film,
I think, in the 1960s or '70s called "Bambi Meets Godzilla," where Bambi is
sort of dancing around in the forest and you see this huge foot stomp on Bambi
and that's the end of the movie. And that's like the health reform debate,
and Bambi would be the labor unions and the liberals advocating for universal
coverage. Godzilla would be the AMA and the insurance industry and businesses
and conservatives. It's never been a very even fight. But if you were to
move business from the side of opposition to support for universal coverage,
what you would have, I think, is a political realignment in health reform.
And if we get health reform in this country and universal coverage, I think,
in a way, it's more likely to come from that direction.

GROSS: My guest is Jonathan Oberlander. He's an associate professor of
social medicine and health policy and administration at the University of
North Carolina-Chapel Hill.

We'll talk more after a break. This is FRESH AIR.

(Announcements)

GROSS: If you're just joining us, my guest is is Jonathan Oberlander. He's
an associate professor of social medicine and health policy and administration
at the University of North Carolina-Chapel Hill.

Now there's something--there's like a new movement afoot that's called
consumer-driven health care that's being proposed as an alternative. What is
that?

Mr. OBERLANDER: Well, I think it's a badly named movement because it's
certainly not being driven by consumers. Essentially what it is referring to
is the spreading of high-deductible insurance policies and the idea in
consumer-driven health insurance is people will take these policies that have
very high deductibles, could be two, three, $5,000, and you pair them with a
health savings account, which is a tax-preferred account similar in some ways
to the IRA, and that really is the future of American health care, at least at
the moment. It is the successor to managed care. In a lot of ways, I think
it's much worse than managed care.

GROSS: In what ways?

Mr. OBERLANDER: Managed care had a lot of flaws to it, but I think when it
was done right, they were trying to coordinate care, they were trying to
integrate care, at least the good HMOs. What consumer-driven health care is
doing, and these high deductibles, is really just shifting the cost of medical
care onto the backs of patients. And you notice that they've transformed the
language of patients to the language of consumers. And really folks who have
serious illnesses and who are chronically ill can be hurt in these systems,
because in conventional insurance healthy people subsidize the sick. We all
pay the same premium, and the person who uses a lot of medical care is
subsidized by somebody who never uses any medical care. When you raise that
deductible to three, four, $5,000 and you have that individual who is
chronically ill year after year, they're never going to be able to save up
enough money in their health savings account. That's going to go to zero
every year and they're going to pay that deductible year after year. So we're
really, in my view, on the verge of shifting costs to sicker patients and
getting away from some of the things we know work, and that is managing
chronic illness. And I think it's not an answer to say we're going to have a
consumer-driven system and it's the responsibility of individuals and that's
it. There are a lot of people that can't help when they get sick.

GROSS: So in that system, how do you create the money that's supposed to be
in your like health account, your health bank account?

Mr. OBERLANDER: Your health saving account can be funded by your employer,
and some employers are doing this. And they like it because for them it
seems, much as managed care did many years ago, that they're going to save
money, and they're going to be able to limit their health care contribution.
I'm not sure in the long run how much this is going to save costs and there
are a lot of employers that won't fully fund that health savings account. And
when you sort of look at this consumer-driven health care revolution, it's
already stalling. You know, it just got here and already it's having some
trouble. Satisfaction isn't that good with it. Enrollment has really slowed
down. And so I guess the question is, if we exhaust managed care and we try
that and that hasn't worked, and we exhaust consumer-driven health care, and
that doesn't work, then the question is, `What's next?' And I would like the
answer to be universal coverage. I'm not sure it's going to be.

GROSS: Who's behind the consumer-driven health care movement?

Mr. OBERLANDER: Conservatives tend to support consumer-driven health care,
and they believe, as do a fair number of health economists, that the reason
that health care costs are too high in the United States is people consume too
much medical care, and use too much medical care of too little value. In
other words, they believe we actually have too much health insurance, which is
a remarkable thing to say in a country where 45 million are uninsured. But
their belief is if you move to high deductible plans, people will think twice
before they go to the doctor for unnecessary medical care. So for instance,
when I get a sore throat, instead of bothering my family physician, maybe I'll
have a cup of tea at home, and that will save the system money. And so the
philosophy is, if you feel it in your wallet and in your own bank account,
you're less likely to overuse the system.

GROSS: What is President Bush proposing?

Mr. OBERLANDER: President Bush actually has an interesting proposal to
change the tax system. One of the sort of dirty little secrets of American
health policy is that the employer-sponsored system is heavily subsidized by
the federal government. When I get health insurance, in my case, from the
University of North Carolina, I don't pay any taxes on that. I don't pay any
income taxes on what they contribute to my health insurance. I don't pay any
payroll taxes, and neither does anybody else who gets employer-sponsored
health insurance. And the government foregoes about $200 billion a year in
tax subsidies through that. It's a very, very expensive subsidy. It's very
regressive because it's worth a lot more to people in the upper income
brackets than it is to people who don't pay a lot of taxes. A lot of
economists would tell you that it's inefficient because it encourages overly
generous insurance policies.

What President Bush has proposed is to get rid of that system and to
substitute a standard deduction for health insurance that anybody buying
health insurance could take, whether you buy it in the individual market or
you get it from your employer. And the standard deduction would be $15,000
for family insurance and I believe 7500 for an individual. And the goal is
both to make insurance more accessible and hope that some people now who can
afford to buy it but don't will now have a financial incentive to purchase
insurance on the individual market.

And another goal is actually to slow down health care spending. I actually
don't think the political changes of this are very good because while most
people don't understand that the system is subsidized, if you change that tax
subsidy and you start taking that tax subsidy away, I think people will learn
about this really fast. And while President Bush isn't up for re-election in
2008, 468 members of Congress are. And I'm not advising any of them, but if I
was, I don't think I would tell them that a very good way to run for
reelection is to say to your middle-class constituents, `I've got a great
solution for the health care crisis. I'm going to tax your private
insurance.'

GROSS: During Bill Clinton's presidency, Hillary headed up the effort for
health care reform, and that effort failed. And I wonder what lessons you
think other politicians and health care experts took away from that failure.

Mr. OBERLANDER: You know, I think the Clinton plan failed for a lot of
reasons, but I think centrally they were really guilty of the sin of ambition.
They tried to do a lot of things at once. They tried to achieve universal
coverage. They tried to have an employer-mandate where every employer would
have to offer health insurance. They tried to control costs and set limits on
how much we spend on medical care in the United States. And I think most
critically, they tried to change the delivery system and move it towards
managed care. And one of the central reasons that they failed, and one of the
challenges for all health reformers, is they alienated people who already had
health insurance, who might have said, `Well, this is great. You want to
cover the uninsured, but why are you changing my health insurance? I like my
doctor. I don't want to change my health insurance. I don't want to join an
HMO.'

I think if you look at the proposals that some of the candidates have put out
right now, one of the things you notice right away is they're really building
on the existing system we have. They're trying to leave people who have good
insurance alone, and in fact trying to make that insurance more secure, but
they don't want to try and change the delivery system.

I think the other lesson, which is really very interesting, is you don't see a
lot of cost control in the plans that are coming out right now, because one of
the things that killed the Clinton plan is they threatened the income of the
insurance industry, of medical care providers, of really, the whole health
care system. And so when you look at these candidates' plans, they'll talk a
lot about saving money through information technology and administrative
savings, and there's some truth in that, but they're really not talking about
hard cost controls because politically I think they just don't want to go
there.

GROSS: How does it feel for you as a health care policy expert to feel that
the system is really failing, and yet fixing it is going to be so improbable
because of all the political obstacles?

Mr. OBERLANDER: It feels really bad. It feels like "Groundhog Day."
Remember the movie where Bill Murray wakes up to the same day over and over
again? And I started studying health care policy myself 20 years ago, and
sometimes my students today ask me, `What's changed in the system?' And what I
tell them is, `Nothing, absolutely nothing has changed.' And really the
problems that we have now--high costs, not great quality of care, huge
uninsured population--those are the same problems that I learned about 20
years ago, except that all of them are worse. So it is dispiriting.

The one good thing that I can take away from this is, we are seeing some real
movement at the state level. And I think if you look at places like
Massachusetts, and if you look at states like California, and you see that you
have Republican governors and Democratic legislatures coming together to adopt
reforms, then maybe there is some hope for change.

GROSS: Take one of those states and tell us what you find optimistic about
the actual reforms.

Mr. OBERLANDER: Well, I think the case in Massachusetts is very interesting.
They tried health reform there before, in the late 1980s, and it didn't work
out. And they're back at it, and the reform that they have passed is a sort
of combination reform that builds on the existing system and expands Medicaid
and makes available subsidized private insurance through a purchasing pool,
and also mandates that people who can afford to buy health insurance have to
buy it. And what I think is interesting about that program politically is it
was supported by Governor Romney, although he's sort of running away from it
right now, but when he was governor of Massachusetts, he was behind it and the
Democratic legislature was behind it. So it's an interesting bipartisan
combination, and I think it's a pretty good package. Is it going to get them
the universal coverage? I don't think so, but they've already insured over
100,000 residents in Massachusetts who did not have health insurance. So
they're really, right now, leading the pack among American states. There are
a bunch of other states that are talking about doing things, but Massachusetts
is really out ahead of them at the moment.

GROSS: Well, Jonathan Oberlander, thank you so much for talking with us.

Mr. OBERLANDER: Thank you so much for having me.

GROSS: Jonathan Oberlander is an associate professor of social medicine and
health policy and administration at the University of North Carolina-Chapel
Hill.

Coming up, jazz critic Kevin Whitehead reviews a new box set, collecting
recordings from the 1930s featuring tenor saxophonist Chu Berry.

This is FRESH AIR.

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Review: Kevin Whitehead on new Chu Berry boxed set

TERRY GROSS, host:

Tenor saxophonist Leon Berry, who was nicknamed "Chu," died at age 33 in a
1941 accident, ending a nine-year run in recording studios that found him
backing singers like Billie Holiday and Mildred Bailey, jamming in informal
sessions, squeezing short solos into big band numbers by Fletcher Henderson or
Cab Calloway, and getting a few featured numbers all to himself. Jazz critic
Kevin Whitehead reviews a new Chu Berry box set that details his meteoric
career.

(Soundbite of music)

Ms. BESSIE SMITH: (Singing)
I had a nightmare last night
when I lay down
when I woke up this morning
my sweet man couldn't be found
I'm going down to the river
Into it I'm going to jump
Can't keep from worrying
Cause I'm down in the dump
Someone...

(End of soundbite)

Mr. KEVIN WHITEHEAD: Chu Berry in dialogue with blues queen Bessie Smith in
1933. It was her last recording session and one of his first. The 1920 scene
Smith had dominated was already starting to look like ancient history as the
swing era loomed. Jazz was evolving so quickly, young musicians needed to
master an already established language and keep abreast of new developments,
which placed more demands on soloists. Players learned by imitating the
masters, even as they strove to define their own sound. Berry wasn't shy
about challenging tenor sax champ Coleman Hawkins, his role model for
improvising busy lines that elegantly outline a tune's chords. They became
sort of friendly rivals. Hawkins provides prettier phrases, but Berry had his
own leathery tones, slinkier lines, and jumpier time.

(Soundbite of music)

Mr. WHITEHEAD: Chu Berry with Lionel Hampton, 1939. The tenor saxophonist
is subject of a new seven-CD box from the Web order house Mosaic Records:
"Classic Chu Berry: Columbia, and Victor Sessions." It gives you almost as
detailed as a survey of his recording career as one could ask for, lacking
only a few essentials. An outgoing, outspoken musician from West Virginia,
Berry sparked the big bands he played in, urging his colleagues to try harder
and aim higher. He gave band leader Fletcher Henderson one of his big hits
with "Christopher Columbus" built on a pat Berry riff.

(Soundbite of music)

Mr. WHITEHEAD: He had even greater impact after he joined the chronically
underrated singer Cab Calloway, encouraging Cab to feature the band more on
hipper arrangements. Calloway, for his part, was a sterling showman who made
field hollaring hip for hipsters. His song celebrated looking sharp and
living large, even if hardy partying might lead to a breach in social decorum.

(Soundbite of music)

Mr. CAB CALLOWAY: (Singing)
Late this morning after half past ten
Old Pops comes falling in
Lipstick on his cheek and a knot on his chin
No hat, no shoes but a belly full of gin
Uncle, Auntie, he's still got on his pontie
Oh Pops in bed with his britches on
Oh Pops in bed with his britches on

(End of soundbite)

Mr. WHITEHEAD: On records, Chu Berry is so often glimpsed in short eight- or
16-bar bursts, you get impatient to hear him hog the spotlight. In 1940,
Calloway showcased him on "A Ghost of a Chance," where Berry borrows a lick or
two and the general atmosphere from Coleman Hawkins' recent hit "Body and
Soul." That record had pointedly bested Berry's version from the year before.

(Soundbite of music)

Mr. WHITEHEAD: By 1941, Chu Berry had been picking up ideas from young
mavericks like trumpeter Dizzy Gillespie and jamming with them on the Harlem
after-hours sessions that gave rise to a new style, soon known as Bee Bop.
Berry wouldn't live to see it through, though. He was on the road with Cab
Calloway when fatally injured in a car crash in Ohio. But the dozens of
sessions he recorded staked his claim as one of the great soloists of the
1930s. By the way, shortly before Berry died, his perennial rival Coleman
Hawkins was asked to list his favorite tenor players. Chu Berry came in at
number two.

(Soundbite of music)

GROSS: Kevin Whitehead teaches English and American Studies at the University
of Kansas and he's a jazz columnist for eMusic.com. He reviewed "Classic Chu
Berry: Columbia and Victor Sessions" on the Mosaic label. I'm Terry Gross.

(Credits)
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