Yale School of Management professor Theodore Marmor, an internationally recognized authority on health care and social policy, has a lot to celebrate.

In what he describes as a "serendipitous convergence" of good fortune, he has in recent months received prestigious grants, awards and appointments recognizing his work in the world of health policy, politics and management -- foreign and domestic.

The most recent feather in Marmor's cap is a grant for $250,000 from the Robert Wood Johnson (RWJ) Foundation to collaborate on a book about "politics, health and health care." The grant extends a long-standing relationship between the foundation and Marmor, who has directed the RWJ postdoctoral program in health policy at Yale since 1993.

Marmor, who lectures frequently for a wide variety of groups, was the keynote speaker at the 10th anniversary of the Hannover School of Public Health last November. He has also been named as the 2001 Rock Carling Fellow of the Nuffield Trust in England, an honor rarely bestowed on an American. Dedicated to the study of public health issues, the Carling Fellowship consists of a public lecture and monograph by the holder and a related seminar. Marmor's lecture, to be given next November in London, will address "fads and fashions in health policy."

Marmor's 21 years on the Yale faculty have by no means curbed his academic wanderlust. Indeed, the "itinerary" of fellowships and visiting professorships on Marmor's curriculum vitae include many of the world's greatest institutions of higher learning. His far-flung stints over the past four years have included the Australian National University in 1999; All Souls College, Oxford, 1998; the Netherlands Institute of Advanced Study, 1997­98; and the Kennedy School of Government, 1996.

Marmor's "The Politics of Medicare," a groundbreaking study originally published in 1970, is also enjoying a resurgence of attention. This past summer, on the eve of the publication of its second edition, the study was the featured subject of a symposium at the annual meeting of the American Political Science Association, where it was hailed as "a classic" that had helped shape the field of political science.

Now Marmor is about to embark on a sabbatical at the London School of Economics (LSE) as the Centennial Visiting Professor in the department of social policy. According to the terms of the appointment, his semester at LSE will be followed by the delivery of a number of lectures through 2003.

Looking ahead, Marmor has co-written with Jonathan Oberlander an article titled "The Path to Universal Health Coverage," which will appear in "The Next Agenda: Blueprint for the New Progressive Movement," a collection of essays recommending goals for America's future and guidelines on how to achieve them.

Finally, as testimony to his influence in the medical field, Marmor was elected this fall as the first non-physician public member of the American Board of Ophthalmology.

Just back from Paris, where he delivered a lecture on Dec. 15 titled "Hype and Hyperbole in Medical Managerialism," and preparing to leave for his stint in London, Marmor paused to share his thoughts on medical care policy generally and to speculate about America's in particular. Edited excerpts from that conversation follow.

How does health care policy in one country affect another? Isn't health care policy something that individual nations develop themselves and implement themselves?

The answer to that question is complicated. First, it's true that health care policy is politically and socially and economically very important and salient in every country, and nobody goes around acting as if that's something which they let other people dominate. So, for instance, it's very controversial in the European Union about whether nations should have autonomy about their own health care policies. And that continues: even if there are influences that cross borders, there's very little domination across borders. Not only is it the case that there's pride of choice and decision making but also the particular configuration of ideas and institutions in the legacy of the past means that all countries have distinctive combinations at any one time that are not exactly like anything else.

Is the United States the only industrialized democratic country that does not have universal health coverage?

That's not quite true. That's the clichéd understanding. Many countries have widespread insurance but not universal health insurance of one plan for all people. So, for instance, in Holland 99% of the population is insured, but 60% are compulsorily insured. In Germany, 10% of the population are permitted to opt out of the national plan, and so you've got nothing like 100% in the German sickness fund. The cliché is that South Africa and the United States are the only two countries in the world without universal health insurance that have a claim to the description "industrial democracy." That's technically not true, but it is fair to say that the United States is among the countries in the Organization for Economic Cooperation and Development that has the largest proportion of uninsured people.

What percentage of people in the United States are uninsured?

About 16%. Something between 43 and 45 million people are uninsured at any one time, which understates the proportion of people who are uninsured over time. That figure should probably be increased to something like 20% to 25% over a two- or three-year period -- perhaps 20% experience a period of uninsurance. And the lack of insurance does not mean that they die in the streets, which is another misrepresentation. It means that they get care later; there's more anxiety and grief about the finances of care. But for a variety of reasons, both legal and social, we have safety net arrangements that stop this from producing what might be called absolutely scandalous circumstances. They're just regrettable circumstances. If people were dying in the streets, we'd do something about it.

You've talked about the problem of emergency rooms having traditionally served as a safety net. What's happening now?

The emergency rooms are crowded, and when there's a flu season, they're very crowded. They've become the object lesson in the dilemmas, tensions and inadequacies of American medical care.

What country's health policy system is the closest to the American system?

The closest to the American arrangements for medical care has been Canada, with Australia a close second.

The U.S. system is that close to Canada's?

Close in the sense that our physicians for most of the 20th century were organized more similarly than physicians and hospitals were organized in Europe. All three [America, Canada and Australia] are federal systems of government. All three were dominated by fee-for-service reimbursement through most of the 20th century. All three had important roles for private insurance and employment-related insurance, particularly with non-profit institutions of the Blue Cross/Blue Shield type. All three had medical associations that fought national health insurance like mad. And all three were technologically inventive and aging at similar rates in the post-war period. That's what distinguishes those three from Western Europe, which aged earlier, which had nationalized more of the hospital sector in most of the countries, which had built upon what in general is called a sickness fund experience and which is occupationally related, worker related, and is generally done through firms. Yes, America has changed a lot in the last 15 years because of the growth of so-called managed care. But if you're asking about the period from 1945 to 1990 to which countries America most easily compared, it would have been Canada and Australia.

It has nothing to do with our all being English-speaking, does it?

Yes, it does. The Anglophone medical community obviously shares access scientifically more easily, although English is now the common language of all of medicine. But much more importantly, the social, economic circumstances were similar and the political ideologies, while not identical, had more similarities, particularly Canada, Australia and the U.S. -- the spectrum, the range -- than, for example, we did with Scandinavia

How did Canada implement its policy of universal medical care?

In two steps: In the late 1950s for hospital insurance; in the late 1960s for medical insurance. We really took a very similar course. Private insurance expanded dramatically in Canada in the post-war period, so did it in the United States. They went down the incremental road of one medical service across the nation, we went down the road of population groups, as I've written. Likewise, in Australia they didn't go to universal health insurance until the 1980s. So those three societies looked at from the standpoint of Britain, France or Sweden were laggard, if you believe that the pace at which you move to national health insurance is a relevant evaluation.

You've said that there are differences in the health insurance even among European Union countries. In what sense is that so?

I think there are basically two dominant patterns in Europe. There's a pattern in Scandinavia and Great Britain of the direct use of state authority and state ownership, making citizens the beneficiary of the health care program in their capacity not as workers, not as elderly people, not as children, but as citizens. By contrast, in the continental countries -- France, Belgium, Germany, Holland, Austria ... my prediction would be in Central Europe as well, as they change from the Soviet model -- broad-scale health insurance care coverage is built up from both an occupationally- and geographically-based sickness fund. This comes out of the late 19th-century labor movement and out of the Bismarckian tradition. By this, I mean the use of state authority, as in Germany in the 1880s, to set up social insurance programs managed at the local and industry level to sop up discontent about the social welfare conditions.

The normal distinction is between what's called the Bismarckian tradition of social insurance and the Beveridge [after English economist William Henry Beveridge, 1879­1963, who set the ground rules for the post-war British welfare state of universal coverage, without categories of recipients] tradition of direct public programs for health services.

Can you explain, roughly, how the Canadian system works?

The best way to understand Canada's form of health insurance is to understand that it is 10 provincial versions of a national Blue Cross/Blue Shield plan of a kind that was dominant in America in the 1960s. That means that all hospital bills are taken care of and all physicians' bills for practical purposes are taken care of, without co-insurance and deductibles to speak of. It's what's called "service benefits": You go to the hospital; you get the service. It's not an indemnity plan. And it covers physicians' services and hospital services of a very broad kind. It doesn't uniformly cover drugs outside the hospital nor home care, nor any of those things. It's a Blue Cross/Blue Shield program of the 1960s, which is partially funded from federal funds, and the rest from provincial funds. So its financing is public, but its operation is in nonprofit community-based hospitals of exactly the kind we've had in the United States, and its physicians are dominantly physicians organized in small group practices or solo practices of the kind we had in the 1960s and part of the 1970s. There's been a divergence because of the way in which our so-called managed care has developed, but that's the way to understand it.

Is this what we should look to as our model? Is this what you would hope America would incrementally adopt?

It's what I have proposed that America pay attention to as a model. But increasingly I am struck with the problems created by advocates who talk about a "single-payer plan," or the Canadian-style plan as the only thing worth doing in the world.

I'm actually an advocate of Canada's virtues who is skeptical about simple transplantation models. The principles they've established of universal coverage of broad, comprehensive benefits in the hospital and doctors area, of public responsibility and accountability, of no substantial co-insurance with the doctors' bills ... All of those I think are good principles, but in fact, many of them are ones we already have in our own Medicare. ... I think we should learn from Canada, from Australia and other countries, without trying to be slavish about transplanting Canada. Although I might like to think it's desirable, it's not politically do-able, and therefore in that sense is not the single most desirable option. The cliché is "if what's optimal is not doable, it's not optimal."

-- By Dorie Baker

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