COLUMN ONE : Diagnosis: Healthier in Europe : By most standards, Western Europeans are in better medical shape than Americans. And costs are sharply lower. But bureaucracies and under-the-table payments mar the system.

For someone with a potentially fatal disease, Regine Delvaux is exceptionally healthy. A diabetic for 26 of her 37 years, Delvaux holds down a part-time office job in Brussels and, in the past four years, has been able to adopt two young children.

She owes her active life to the Belgian national health system, which, like those of other Western European governments, guarantees that virtually all Belgians are insured and pays the lion’s share of the costs. That means Delvaux receives virtually free care, including the regular insulin she needs to fend off kidney failure, blindness and the other scourges that diabetes can bring.

The contrast with the United States is striking. Europeans have better access to health care than Americans, an estimated 35 million of whom are uninsured. By most objective measures, they are healthier.

And what is most extraordinary, Europe actually spends less for health care--about one-third to one-half less in most countries--than the United States. The U.S. health bill, growing far faster than overall inflation, will reach something like $800 billion this year, or about 13.5% of the nation’s entire economic output.

No wonder President-elect Bill Clinton is looking at Europe as he seeks to redeem his campaign promise to overhaul the U.S. health care system. Clinton has promised to require employers to provide insurance to all workers, to guarantee public insurance for those who do not work and to set a national limit on overall health-care spending.

Most Western European countries already do all this.

Clinton and his health-care planners will not want to copy everything they find across the Atlantic. European-style health care is hardly trouble-free.

Inflexible bureaucracies sometimes interfere with the delivery of care. Some doctors, unwilling to settle for government-prescribed fee schedules, take part of their payments under the table. For a minor operation to correct nearsightedness, a Brussels clinic charges not only the official rate of about $300 but also another $900 in unreported cash.

Medical services are rationed, especially in countries that spend relatively little on health care. In Britain, which spends less than all but the poorest Western European nations, the elderly frequently wait two years for hip replacements and cataract operations.

Even in the Netherlands, which spends 30% more per person than Britain for health care, a recent survey found that one-third of all hospital admissions came only after excessive waits. At the same time, under pressure from health care providers and patients, the Dutch government pays for such dubious treatments as herbal medicine and psychic healing.

In a range of European countries, rising costs have triggered reform movements that have a distinctly American flavor. The Netherlands, for example, is edging toward competition between insurance companies in an effort to introduce incentives to control costs.

Yet for all the flaws, analysts on both sides of the Atlantic rank European health care miles ahead of America’s. “What can Europeans learn from Americans about the financing and organization of medical care?” asked Alain C. Enthoven, a health-care financing specialist at Stanford University. “The obvious answer is, ‘Not much.’ ”

The reasons that America spends more and gets less are legion: uncontrolled use of sophisticated medical technology, massive administrative costs, expensive malpractice insurance and higher-paid doctors, to name a few.

All this is rooted in the uniquely American pioneer experience and distrust of big government. The legacy is an every-man-for-himself approach to health care. Except for the elderly and the very poor who are enrolled in Medicare and Medicaid, those on the receiving end of the health care system get what they--or their employers--can pay for.

“In America, part of your population is accustomed to getting every available medical technology,” said Henk ten Have, a professor of medical ethics at Catholic University in Nijmegen, the Netherlands. “But another large part gets no care at all.”

Collective Care

Health care in Europe, by contrast, is grounded in collective responsibility. European governments either directly provide most health care, as in Britain, or require that everyone be insured, while paying for most of their citizens’ insurance, as in Germany.

Either way, European countries operate on the same principle that governs public education in the United States: All of society benefits from a healthy citizenry, and all of society should shoulder the costs.

It is an attitude that Abram de Swaan, a University of Amsterdam sociologist, traces back 150 years to cholera epidemics that broke out in urban slums throughout Europe and claimed the lives of the rich as well as the poor. Out of self-protection more than charity, Europe developed modern sewage systems. Now cholera is largely under control, but the principle of collective responsibility remains intact.

“The social welfare systems in West European countries promote the dignity and well-being of all persons and the welfare of society as a whole,” said Reinhard Priester of the Center for Biomedical Ethics at the University of Minnesota. “In contrast, the United States embraces individualism, sees provider autonomy as the preeminent value and neglects community-oriented values.”

In only two of the 24 industrial nations that make up the Organization for Economic Cooperation and Development does the government pay for less than half of the health care. Those two are the United States and Turkey.

In Western Europe, by contrast, all governments pick up at least two-thirds of health care costs. Each country has its own approach.

In Britain and Sweden, the government owns and operates most of the health care system, with the money coming largely from income tax revenue. Most other countries offer a mix of public insurance and compulsory, government-subsidized private insurance, with the government’s contribution coming from a Social Security-like tax on employers and workers.

The Netherlands relies relatively heavily on private insurance. But even there, the 70% of the population at the bottom of the income scale is covered mostly by public insurance; for the rest, a combination of public and private insurers pays most of the bills.

No matter what the system, patients may generally choose their doctors, and they can buy supplementary insurance to cover what their government-financed insurance does not. Most governments dictate what doctors may charge, and some play a role in determining what procedures are appropriate to diagnose and treat particular conditions.

Patient Satisfaction

To Americans, the European approach might seem heavily centralized, bureaucratic and rigid. But Europeans are happier with their approach than Americans are with theirs.

A 1990 study by the Harvard School of Public Health found that only 10% of Americans said their “health care system works pretty well.” That put the U.S. system squarely at the bottom of the 10 nations included in the survey.

Of the six European countries surveyed, satisfaction levels ranged from 47% in the Netherlands to 12% in Italy. Canadians, whose national health insurance system is much more European than American, were the most satisfied of all, with a 56% rating.

These ratings square with the few objective ways of measuring national health. Although America’s diverse population, with its many minority groups, makes comparisons with more homogeneous Europe somewhat uncertain, it is nevertheless true that the United States falls consistently below Western European nations in infant mortality rates and life expectancy.

Europe achieves these results even though it spends substantially less for health care than the United States--typically 7% to 9% of national economic output, compared with America’s 13.5%. Central to Europe’s approach is a technique that seems unthinkable in the United States: Governments set strict health-care budgets, and local health authorities must live within their allowances.

“The strict planning systems for hospital care in Switzerland and the Netherlands, the two European systems most similar to those of the United States, are the major reason why expenditures are constrained in these countries,” said Bengt Jonsson, a health specialist at the Stockholm School of Economics.

With strict health-care budgets, Europe has escaped America’s uncontrolled growth in the purchase of medical technology. Two nearby European hospitals may not both buy the same piece of sophisticated machinery unless they can show a clear need; instead, one gets the equipment, and the patients at both hospitals use it.

Dr. Niek Klazinga, an official with the Dutch National Organization for Quality Assurance in Hospitals, said a single hospital in Houston three years ago had 13 sophisticated and expensive magnetic resonance imaging machines, more than all of the Netherlands.

American hospitals, armed with the latest medical gadgetry, are compelled to use it to recoup the cost. “When a patient with a headache is told that he needs a brain scan to make sure he doesn’t have a tumor, his natural reaction is, ‘Where do I lie down?’ ” said Arthur L. Caplan, director of biomedical ethics at the University of Minnesota.

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In most of Europe, by contrast, the expensive brain scan may be used as a last resort--or not at all. In the Netherlands, every neighborhood has a general practitioner who serves as the gatekeeper to medical technology.

“General practitioners know that 70% of all headaches are emotional,” Klazinga said. Before they permit brain scans to check for tumors, he said, they test all other possible causes.

Joseph Newhouse, a professor of health policy at Harvard, estimates that “technological change, or what might loosely be called the march of science and the increased capabilities of medicine,” accounts for at least half the explosive growth of U.S. medical costs in the last half-century.

Robert Brook, senior health services researcher at the RAND Corp. in Santa Monica, said the use of costly technology often does not help and sometimes is downright dangerous to patients’ health.

“Perhaps one-third of the financial resources devoted to health care today are being spent on ineffective or unproductive care,” Brook and Kathleen Lohr of RAND’s Washington office wrote recently.

Footing the Bill

Technology aside, Europe is more willing to pay for preventive care than is the United States, where the uninsured generally benefit from no such care at all and even those with insurance sometimes find reimbursement unavailable.

Americans, and especially the poor, must typically get sicker than Europeans before they can get the care they need, said Jean-Pierre Poullier, a health policy analyst with the Paris-based Organization for Economic Cooperation and Development. That has the perverse effect, he said, of jacking up the cost of their treatment when they finally get it.

Diabetes provides a stark example. Dr. Ann Owen, an American who was born and trained as a physician in the United States but has specialized in treating diabetics in Belgium since 1983, said uninsured or underinsured diabetics in the United States often have no access to the insulin they need to control their blood sugar. Nor can they afford to care for the non-life-threatening complications of their disease.

“That means many people have to go into a coma before they can get treatment,” Owen said. “By then, they need intensive care at a hospital, and in a few days you’re up to $50,000.

“In Belgium,” she added, “insulin is considered so essential to life that it’s available for free.”

Delvaux, the long-term diabetic, is glad it is. Since 1989, when the Belgian government set up a special program for diabetics, Delvaux has also been reimbursed for most of the costs of her regular doctor visits and blood sugar tests. “I have hardly had to pay more than a couple of hundred francs (about $7) a month,” she said.

Thanks to her regular treatment, which includes a steady supply of insulin that is administered by a pump permanently implanted in an underarm, she has not been hospitalized for about 20 years.

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In Los Angeles, Felipe Perez shows what might have happened to Delvaux. Perez, 39, has a less serious form of diabetes. Although he does not require regular insulin, he would benefit from other forms of routine treatment.

But as one of America’s 35 million uninsured persons, he does not receive it. Two years ago, Perez lost his paid health insurance when he was laid off from his city job. Once last year he went to a community health clinic in Lincoln Heights and was prescribed medication for his diabetes. But he couldn’t afford to buy it.

Earlier this year, he landed a part-time job with Los Angeles County as a home health-care worker for the elderly, but he gets no health benefits himself.

As a consequence, he found himself at L.A. County-USC Medical Center for the better part of a week recently so that doctors could treat an infection in his underarm that, because of his diabetes, had grown to the size of a walnut. The cost, most of which will be absorbed by the hospital: about $5,500.

Doctors’ Pay

Medical salaries are another part of the cost-quality equation. General practitioners in the United States earned an average income of $77,900 in 1985 after covering their expenses but before paying taxes, according to the American Medical Assn.’s most recent data. That compares with $48,200 in Germany, $32,400 in the Netherlands, $24,700 in France and $19,700 in Belgium.

The United States has fewer doctors for its population than most European countries, with the notable exception of Britain, and its supply of registered nurses falls at about the European average.

Yet its health care system employs more people than Europe’s--especially those who sell health insurance and administer claims. “Behind every hospital bed in the United States is a clerk filling out forms,” said Poullier of the OECD.

Jack A. Meyer, an analyst with New Directions for Policy, a Washington research group, said administrative costs soak up 22% of U.S. health-care spending. The American urban landscape, said Caplan of the University of Minnesota, is dotted with insurance company towers (Prudential, John Hancock) and even an entire city (Hartford, Conn.).

“We have a huge administrative bureaucracy to keep the rich from having to share costs with the poor, the healthy from having to share costs with the sick and the able-bodied from having to share costs with the disabled,” Caplan said.

European nations avoid a substantial share of these administrative costs because they do not make such distinctions. At least in this respect, their decision to make health a collective rather than an individual responsibility actually saves money.

Times staff writer Somini Sengupta in Los Angeles contributed to this story.

Health Care: America vs. Europe

For all the flaws, analysts on both sides of the Atlantic rank European health care far ahead of what the U.S. offers.

Americans Spend More . . . (health expenditures per capita, 1990) United States: $2,566 France: $1,543 Germany: $1,487 Sweden: $1,479 Netherlands: $1,266 Italy: $1,234 Britain: $974 *

. . . but Are Less Satisfied . . . (share of persons who believe the health care system works pretty well and only minor changes are needed) United States: 10% Netherlands: 47% France: 41% Germany: 41% Sweden: 32% Britain: 27% Italy: 12% *

. . . and Achieve Poorer Results (infant mortality rates per 1,000 births, 1990) United States: 9.2% Italy: 8.5% Britain: 7.9% Germany: 7.5% France: 7.2% Netherlands: 6.9% Sweden: 5.9% Sources: Organization for Economic Cooperation and Development; Robert J. Blendon, Harvard School of Public Health

Who Pays the Freight?

Here is the share of health care spending paid by governments and by private individuals and insurers, 1989:

Governments Private France 75% 25% Germany 72 28 Britain 87 13 Italy 79 21 Netherlands 73 27 Sweden 90 10 United States 42 58

HOW DOCTORS ARE DOING

The average after-tax income of general practitioners in 1985, the latest year with available data: France: $24,700 Germany: $48,200 Britain: $27,900 Netherlands: $32,400 Sweden: $22,200 United States: $77,900 Reliable figures for salaries of Italian doctors were not available.

Sources: American Medical Assn., Organization for Economic Cooperation and Development