The List

The List: The World’s Worst Healthcare Reforms

This month, U.S. policymakers are working to overhaul their country’s healthcare system. In the past, they’ve looked to other countries’ models for guidance on how to make healthcare less expensive, more efficient, and more equitable. Here are four reforms they should avoid at all costs.



System: Free basic medical care provided by the government, with a byzantine and under-regulated employer-based private insurance market

Reform: Before it collapsed, the Soviet Union had an enormous socialized medical system, with millions of hospital beds and hundreds of thousands of healthcare workers. The transition from that system to a public-private model, between 1989 and 1993, went, in a word, horribly.

Ninety percent of Russians are technically covered. But, doctors and hospitals extract "donations" for free care. Anyone who can afford it pays out-of-pocket for private hospitals and doctors. In theory, consumers can pick their own insurance plan. In reality, their employers generally do it for them, bought-off by the insurers.

In 2006, Vladimir Putin's government approved a $3.2 billion health care reform plan that failed to improve the system. The reform contained a hodgepodge of policy priorities, such as paying doctors to perform primary care, but did not address any of the healthcare system's structural defects.

Even with the $3.2 billion infusion, Russia still allocates only 3.4 percent of government spending to healthcare, whereas the World Health Organization (WHO) recommends 5 percent.


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System: A state-subsidized, public-private health insurance model

Reform:  Starting in the late 1980s, China started to erode its centralized "cooperative medical system" and put a decentralized, partly privatized, market-oriented model in place. In theory, most Chinese were to pay income-scaled and government-subsidized sums into insurance pools.

But the reforms pushed costs onto local governments that were unwilling to pay for them. Government spending on healthcare fell. More than 100 million people lost their coverage.

Now, two-thirds of Chinese people have to pay directly for doctors and hospitals. If they cannot afford care, there are some free and low-cost clinics, though they are woefully substandard. Less than 1 percent of Chinese medical professionals have graduate degrees. China's system, which is burdensomely expensive for the poor, is one of the most income-sensitive in the world.

This year, the country announced a new overhaul. As with everything in China, it's big: Between 2009 and 2011, it plans to spend $124 billion to make sure that all have access to primary care.  The government plans to build 700,000 new clinics, for instance. Plus, President Hu Jintao has promised to revamp the health insurance system, ensuring that each Chinese person pays something he or she can afford for the guarantee of coverage.


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System: Socialized medicine, with universal coverage and government-owned hospitals

Reform: In 2003, "President for Life" Saparmurat Niyazov decided that poor, landlocked Turkmenistan's medical costs were too high and that its healthcare system urgently needed reform. The country had already suffered from a shortage of doctors, and the only qualified ones were in cities, Niyazov said on a public radio address.

So, in a frankly insane healthcare reform effort, he restricted the public's access to care by replacing up to 15,000 doctors and nurses with unqualified military conscripts. The next year, he ordered hospitals and clinics outside of the capital, Ashgabat, to close -- even though the vast proportion of Turkmenistan's population lives in rural areas. The BBC quoted him as saying, "Why do we need such hospitals? If people are ill, they can come to Ashgabat." He also implemented fees and created an "unofficial" ban on the diagnosis of certain communicable diseases, like hepatitis.

As a result, an epidemic of the bubonic plague reportedly broke out (Turkmenistan's highly secretive government does not allow in organizations like the WHO) and existing rashes of AIDS, hepatitis, and tuberculosis worsened. At the time of Niyazov's death from a cardiac infarction in 2006, Turkmenistan had one of the lowest life expectancies in Asia -- less than 60 years.

Only after Niyazov's death did the edicts end and hospitals reopen -- dentist-turned-President Kurbanguly Berdymukhamedov even performed an operation himself at an opening ceremony -- though fatalities from easily treatable conditions remain woefully high in this impoverished country.


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System: Employer-based private coverage, with an under-regulated private insurance market, and
government-subsidized public plans for the poor, elderly, and disabled

Reform: The United States has the rare distinction of being both one of the world's richest countries and having one of its least-functional health care systems.

Americans spend around one in every six dollars on healthcare. But, in aggregate, they're not getting much bang for their buck. People in the United States are as likely to die from diseases like lung cancer as citizens in all OECD countries - which, on average, spend less than half as much per capita. Some 47 million lack any health insurance coverage. An estimated 600,000 people file for bankruptcy every year because they cannot pay their medical expenses. Indeed, the United States is the only rich country without universal coverage.

The U.S. government has repeatedly tried to create a more coherent plan and to make sure more Americans are insured. Reformers have scored piecemeal victories -- such as the 1997 creation of the State Children's Health Insurance Plan, or Massachusetts' recent implementation of universal coverage.

But for the most part, the history of health reform in the United States has been a history of failure. The last attempt at comprehensive reform -- the 1993 bill derided as "HillaryCare," during the administration of Bill Clinton -- floundered in Congress. Since then, costs and premiums have doubled, a lower percentage of employers offer coverage, and millions more are uninsured.

Efforts at healthcare reform have tended to be derailed by partisan politics -- and last week, Senate Republican Jim DeMint promised to make the issue President Barack Obama's "Waterloo." But with Democrats in the White House and enjoying a Senate supermajority, healthcare reform looks more likely to pass now than at any other time in recent history.  Let's just hope it works this time.

The List

The List: The Middle East's Most Powerful Spooks

In a region known for cutthroat espionage, these five intelligence chiefs have leveraged their skills and connections to gain influence far above their pay grades.


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Position: Director of Egypt's General Intelligence Service

Career: The archetypical Arab intelligence chief, Omar Suleiman has risen from anonymous government apparatchik to serious candidate for the Egyptian presidency in less than a decade. Dubbed "one of the world's most powerful spy chiefs" by London's Daily Telegraph, Suleiman was born in 1935 in a poverty-stricken fundamentalist stronghold in southern Egypt. Choosing the military as his profession, he excelled academically, collecting degrees in Egypt and abroad and earning a transfer to military intelligence. His selection as director of Egypt's intelligence service in 1993 came just as the regime was reeling from extremist attacks against tourist sites and other critical infrastructure.

In 1995, he famously insisted that President Hosni Mubarak's armored Mercedes be flown to Ethiopia for a state visit; The car saved the Egyptian leader's life during an assassination attempt the next day. In response to the attack, Suleiman helped dismantle Mubarak's Islamist opponents, a campaign that earned him a reputation for ruthlessness. Following the September 11, 2001, terrorist attacks, Suleiman's experience with combating Islamist terrorists has made him a favorite of Western intelligence services hungry for insights into al Qaeda and affiliated organizations.

Influence: More than from any other single factor, Suleiman's influence stems from his unswerving loyalty to Mubarak. Of Suleiman's allegiance, a former senior Israeli intelligence officer told Haaretz, "His primary task, perhaps his only one, is to defend the regime and protect the life of the president." In a sign of presidential gratitude, Egypt's secret warrior has also recently served as its diplomatic face, traveling throughout the region as Mubarak's personal emissary. This charge includes working as a mediator during ongoing Israeli and Palestinian negotiations and as Cairo's interlocutor to dozens of Palestinian groups, including Hamas. Whether this unofficial promotion is a trial run for a Suleiman presidency remains to be seen.


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Position: Director of Israel's Mossad

Career: Meir Dagan's path to the leadership of Mossad was not a traditional one for an espionage chief who had spent most of his career in military operations, not intelligence. Born in the Soviet Union in 1945, Dagan served as a paratroop commander in the Six Day War, worked in special undercover units in the 1970s, and commanded an armored brigade in the 1982 Lebanon war. Highly decorated and wounded twice, Dagan benefited from his relationship with future Prime Minister Ariel Sharon. During Sharon's term in office, Dagan was steadily promoted through the national security ranks leading to his appointment as Mossad chief in 2002. Sharon reportedly informed his old friend that Israel required a spy service "with a knife between its teeth." Dagan, the veteran operator, seems to have obliged.

Influence: Dagan's sway was on full display in June when the Israeli cabinet met to consider extending his term to a near-record eight years. No vote was required as senior politicians including Prime Minister Benjamin Netanyahu raced to praise Dagan as "an excellent Mossad chief" who had done much to reform the service following a period of decay. Such unanimous acclaim is especially impressive at a time when Israel is relying heavily on its vaunted intelligence service to counter several threats, including that "existential" one from Iran. Dagan has clearly sought to bolster Mossad operations against Tehran with some apparent success; a parade of Israeli journalists has recently hinted at Mossad's clandestine campaign against the Iranian nuclear program.

Additionally, the assassination of Hezbollah security chief Imad Mugniyah -- widely credited to Mossad -- has only strengthened Dagan's hand. It was reportedly Dagan's intelligence and advice that coaxed Israeli political leaders to approve airstrikes against a possible Syrian nuclear facility in September 2007. Finally, Tel Aviv's reliance on Mossad-derived intelligence to guide its greater Iranian policy grants Dagan considerable influence over his country's foreign policy.


Position: Commander of the Quds Force, the external wing of the Iranian Revolutionary Guard Corps

Career: Referred to as "the tip of Iran's spear" by American journalist David Ignatius, Brig. Gen. Qassem Suleimani was an unknown until he assumed command of the Quds Force, the unit responsible for supporting Iran's regional allies and proxies. A decorated veteran of the Iran-Iraq War, Suleimani attracted the attention of President Ali Akbar Hashemi Rafsanjani, who appointed the young war hero to a command position within the Revolutionary Guard following the war. Since his promotion to Quds Force chief in 2000, Suleimani has been omnipresent, representing the interests of the Revolutionary Guards in Lebanon, Afghanistan, Iraq, and Central Asia.

U.S. commanders in Iraq have charged the Quds Force with passing an array of sophisticated weapons to Iraqi militia groups, leading to Suleimani's designation as a terrorist supporter by the U.S. State Department in 2007. In early 2008, he reportedly traveled to Basra, where he negotiated a cease-fire between militias and government forces, a testament to his influence within Iraq's Shiite power circles.

Influence: Suleimani's key role in overseeing Tehran's regional strategy and his relationship to the senior leadership make him a major player in shaping Iranian foreign policy. Former Western intelligence officials have suggested that Suleimani maintains a close connection to Supreme Leader Ayatollah Ali Khamenei, with former U.S. counterterrorism czar Richard Clarke stating that the Quds Force "reports directly to the Supreme Ayatollah." Former CIA official Robert Grenier has echoed that sentiment, referring to Suleimani as "an extremely important and influential guy."

Although little is known about his political views, Suleimani's exploits indicate he is aligned with Iranian leaders who seek to aggressively counter any U.S. presence in the region. With Khamenei relying heavily on the Islamic Republic's security organs during the current political crisis, the fortunes of well-connected and capable regime stalwarts such as Suleimani can be expected to rise.



Position: Former commander of Syria's military intelligence agency, current deputy chief of staff of the Syrian military

Career: Few paths to power have been as unlikely -- or as oddly romantic -- as Assef Shawkat's. Born in the coastal town of Tartus, Shawkat served in the Syrian military while pursuing a graduate degree in history, a subject for which he has a deep affinity. Shawkat moved easily within elite circles, socializing that paid off spectacularly when he captured the heart of Syrian President Hafez al-Assad's daughter, Bushra. His dogged pursuit of Bushra -- her father initially opposed the relationship -- earned him some measure of respect: "Anyone who could go into the home of Hafez Assad and take his daughter away without his permission has the power to do anything,'' a Syrian newscaster who had met Shawkat many times told the New York Times in 2005.

By the late 1990s, Shawkat had joined the inner sanctum, assuming command of military intelligence in February 2005 -- the same month former Lebanese Prime Minister Rafik al-Hariri was assassinated. The initial findings of a U.N. commission cast suspicion on Shawkat, leading many observers to suggest that President Bashar al-Assad would hand his brother-in-law over for questioning or possible trial. In January 2006, the U.S. Treasury Department added to the avalanche of condemnation by freezing Shawkat's assets and dubbing him "a key architect of Syria's domination of Lebanon.

Influence: By 2008, having successfully avoided the calls for his extradition, Shawkat appeared poised to continue the consolidation of his power base. However, his ascension may have been stalled by the death of Hezbollah security chief Imad Mugniyah in February 2008. Killed in the heart of Damascus, Mugniyah's death was viewed as an embarrassing breach of security or even an indication of Syrian involvement. Tellingly, Shawkat was barred from participating in the joint Hezbollah-Syrian-Iranian investigation into Mugniyah's death. Additionally, just this month, Shawkat was "promoted" to deputy chief of staff of the Syrian military, a transfer that may signal a deterioration of the Assad-Shawkat relationship. However, given Shawkat's marriage to Bushra and his long-standing ties to senior members of the security apparatus, it is way too early to count him out of the Syrian power game.


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Position: Director general of Saudi Arabia's General Intelligence Presidency (GIP)

Career: The youngest son of the Saudi kingdom's founder, Prince Muqrin bin Abdul-Aziz lived in relative anonymity for the first 60 years of his life. Born in 1945 and educated in the West, Prince Muqrin served in the Royal Saudi Air Force and as governor of several Saudi provinces, including al-Madinah, whose capital is the holy city of Medina. In 2005, he was tapped by his half brother King Abdullah to head the GIP, a daunting task given his lack of intelligence experience and the long shadow of his predecessors, among them legendary chief Prince Turki bin Faisal.

Influence: Despite his inexperience, Muqrin's star has risen quickly in the past three years as he has become a versatile point man for King Abdullah. Muqrin's responsibilities include managing Riyadh's critical Pakistan and Afghanistan portfolio. He has been a regular visitor to Islamabad, maintaining the kingdom's relationships with a wide array of Pakistani political leaders. As for Afghanistan, Muqrin was dispatched to Kabul in January to meet leading officials, including President Hamid Karzai.

The prince might have had an ulterior motive: News reports suggest that the trip was part of Muqrin's overall campaign to bring Taliban leaders into talks with Kabul, suggesting that Muqrin is continuing his predecessor's policy of maintaining contact with Taliban leaders. A month later, Muqrin was sent to Damascus to personally deliver overtures to the Assad regime as part of the larger Arab campaign to reengage Syria. Involvement in critical Saudi foreign-policy efforts and his relative youth have positioned Muqrin well for greater responsibilities in the near future.