Why the Dutch Girl Cried

Half-way through the medical student seminar, the Dutch girl began to cry.

The seminar, a conversation among medical students and patients, was intended to teach aspects of chronic illness. A young patient advocate from the Netherlands was an invited guest. None of us in the room, including her, had anticipated her tears.

“I was startled,” she told me later. She had thought the American patients would describe personal courage, doctor-patient communication, and personal resource-finding. Instead, she heard an angry litany about roadblocks in our health care system. “I was very upset,” she said, “because ill people should not be spending their precious energy arguing with their health insurance companies, begging them for help. They need that energy to recover and feel as well as possible.” So this day’s lesson was not about chronic illness. It became instead a conversation about, to her, America’s incomprehensible approach to medical care.

She cried because she heard American patients protesting private insurers’ denial of diagnostic tests, of medications, and of rights to consult specific physicians. These, she thought, would have been trivial, uncontroversial, and easily-supported requests in her native land. She explained in a later e-mail: “I did not want to emphasize how happy I was, because I felt guilty as well. I also felt a little embarrassed. I didn't have to write a letter or make a phone call when I needed chemotherapy or a new experimental drug or a prosthetic hip. How lucky I am,” she continued, “that I was born in the Netherlands.” Hers is message Americans should be startled to hear.

I, a teacher, had been taught. I had presented to students what I considered to be common problems in chronic disease management—identifying resources, self-advocacy, maintaining optimism. I now saw that I had unquestioningly accepted the structure of our health care system. I had been oblivious to how crazy it looks to foreign eyes.

I asked her Dutch physician, who had worked for several years in the United States and is my friend, what features of American medicine he would like to import to his home? His answer: “Nothing. I feel that the Dutch health care system is very good… I do not miss many things.” I then thought about patients of mine who, travelling, had fallen ill in England, France, Germany, Italy, Korea, Hong Kong, and Japan. They had found unencumbered access to top flight care and no bankrupting hospital bills, the opposite of what ill foreigners experience here.

My Dutch colleague says, and his patient’s tears show, that the uniform (national) health care services of other lands work better than does our patchwork plan. Americans pay 62% more per capita for health care than do the Dutch. One of every 7 Americans, but not a single Dutch person, has no medical insurance at all. Dutch insurers do not waste resources on armies of functionaries hired to find reasons to deny. Dutch physicians’ offices are not peopled with administrative assistants whose job is to get requests approved or to contest refusals to pay.

In the United States, obtaining approvals from private insurers is an abstruse, argumentative, and unpredictable process—at least two cycles of application-refusal-appeal then a telephone conversation with an arbiter who may or may not be authorized to approve. In contrast, Medicare and Medicaid—our closest approximation to the European way—makes approvals for tests or medications straight-forward, reasonable, and predictable. Medicare offers fair rules, uniformly applied; private insurance does not.

The young Dutch woman saw, more easily than did I, the cruelty in our system. Patients should focus on getting well, she said. Doctors should spend their time with their patients, not arguing with insurers. I agree.

America can do better. The President’s Affordable Care Act (ObamaCare) is a start—a health care system that has uniform rules for all for those who qualify, perhaps for all at a future date. The Affordable Care Act promises to use our resources for direct patient care and not for private insurance bureaucracies. With it, perhaps, we will be able to offer care for every person, well or chronically ill, and not subject the ill and vulnerable to the vagaries of whether they can or cannot be insured.

We should do this now. We should not need a young Dutch woman’s tears to tell us what to do.

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