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Today we begin examining bow your some European nations provide nearly universal healthcare to their citizens. Each country has a different approach, but all spend less per person than we do in the U.S., where 47 million Americans have no healthcare coverage. We start in Germany. It has the world's oldest healthcare system and one of its most successful. Virtually all Germans have ready access to doctors, cheap drugs, high-tech medicine, even dental care. And Germany spends half of what the U.S. does per person. How do they do it? One way is by putting doctors on a budget, as NPR's Richard Knox reports now from Germany.

RICHARD KNOX: This isn't your generic bland doctors office. It's all designer furniture in bright splashes of color.

Dr. CRISTOPH LIEBL: (Speaking German)

KNOX: Doctor Cristoph Liebl is a dark-haired guy with a runner's build. His first appointment this afternoon is with Hugo and Inga Fulletson(ph). Inga's 80. She says she has a problem with her ears.

Dr. LIEBL: The ringing is pretty obnoxious and they suffer a lot and quite often drives the people nuts. Problem is, there's nothing you can do about it, really.

KNOX: Libel examined Inga, discusses whether acupuncture might help, writes a prescription for her high blood pressure. The Fulletsons leave his office very satisfied.

Mr. HUGO FULLETSON: (Speaking German)

KNOX: Like most Germans, the Fulletsons are very happy with their medical care. They say they get everything they need, no complaints. Liebl says they didn't have to wait long when Hugo had to have a heart bypass and Inga needed a knee replaced.

Dr. LIEBL: The system is really good. As far as the medical treatment and stuff is concerned, in my opinion it's very good.

KNOX: But Liebl's at his wit's end with this great system.

Dr. LIEBL: I don't get paid at the moment. I haven't been paid for what I'm doing for the last two, three weeks.

KNOX: That's because it's the end of the quarter. Liebl, like most German GP's, has already used up his budget. Every quarter, doctors all over Germany are allocated a certain pot of money. Once that's used up, that's it.

Dr. LIEBL: I feel abused, exploited in a way. You know, because, I mean, the work we are doing is pretty demanding and I have a lot of responsibilities. And I think that should reflect in what I get paid.

KNOX: It's not that German doctors live in poverty. The average German primary care doctor makes around $123,000 a year before taxes. That's about one-third less than the American average. This is one way Germany keeps health costs down.

Dr. KARL LAUTERBACH: I think the biggest difference between the U.S. citizen and the Germans citizen is that everything is cheaper.

KNOX: That's Karl Lauterbach, a doctor himself, and a member of the Bundestag, the German parliament. When he says everything is cheaper here, he means hospital care, prescription drugs, MRI scans, heart bypass operations, and administrative costs are almost 50 percent lower. But the biggest reason German health costs are so much lower is that doctors here are paid less. Dr. Heinz-Harold Abholz says he earned a lot more 20 years ago.

Dr. HEINZ-HAROLD ABHOLZ (University of Dusseldorf): I get a third of the money I earned in the middle of the '80s.

KNOX: Abholz is an expert on general practice at the University of Dusseldorf. He understands why German doctors miss the good old days. But he says they still do okay.

Dr. ABHOLZ: German doctors are the best-earning professional group in Germany.

KNOX: More than lawyers, he says, more than architects or engineers.

And not all doctors are unhappy with the system.

Dr. ACHIM MORTSIEFER: 3:00 p.m.

KNOX: Dr. Achim Mortsiefer locks up his office in a residential neighborhood of Cologne. He's about to do something nearly unheard of in the United States, house calls. Almost all German general practitioners do them.

Dr. MORTSIEFER: We visit two patients that I visit every four weeks and just have a look at them.

KNOX: The patients he's visiting today depend on house calls. They're an elderly couple, Elspeth and Edwin Fedrowitz. They live in a small, crowded apartment on the fourth floor.

Mortsiefer says Elspeth's got a never-ending list of problems. He's been seeing her for back pain, chronic anxiety, exhaustion from looking after her husband. Mortsiefer says Edwin needs a lot of care; both his legs were amputated nine years ago because of blood vessel disease.

Ms. ELSPETH FEDROWITZ: (Through translator) We tried to save the leg, but the operations were not successful, so we - they had to amputate.

KNOX: There's no elevator. Edwin hasn't been out of the apartment for four years.

Mortsiefer's gone way beyond his role as a doctor to help them. He found Edwin and Elspeth a ground floor apartment that would have made life much easier, but they've lived in this apartment for 48 years and they refuse to move.

Mortsiefer checks Edwin's legs. He writes prescriptions for high blood pressure and gives Elspeth some pain medication.

Dr. MORTSIEFER: Auf wiedersehen.

Ms. FEDROWITZ: Auf wiedersehen.

KNOX: He's frustrated he can't do more for them.

(Soundbite of car door opening)

Dr. MORTSIEFER: Very difficult patients. They smoke. They still smoke. Both. And if I recommend some new treatment, they always say, no, we don't need that.

KNOX: Mortsiefer worries more about his patients than about his own income.

Dr. MORTSIEFER: If you want to earn money, you have to choose another profession.

KNOX: How much more did you get for these home visits?

Dr. MORTSIEFER: Nearly 20 euros, or something like that. Not very much.

KNOX: That's $31. A German plumber gets more.

And because this is the end of the quarter, did you get anything for those?

Dr. MORTSIEFER: I don't know. Difficult to say. No. Maybe nothing.

KNOX: But he doesn't dwell on that. Some doctors, he says, calculate how much is left in their quarterly budget every day.

Dr. MORTSIEFER: The problem is, if you think about money the whole day, you will be unhappy. So that's an old rule of life, isn't it?

KNOX: So we've heard two very different versions of how German doctors view their health care system, that it abuses doctors and that everything is okay. Who should we believe? To get a reality check, I pay a call on an old friend. I met Juergen in der Schmitten 17 years ago when he was a medical student. Now he's a 42-year-old general practitioner in Meerbusch, a suburb of Dusseldorf.

Dr. JUERGEN IN DER SCHMITTEN: This is Winnie the Pooh.

KNOX: Juergen's putting his 5-year-old son, Kilian, to bed.

Dr. IN DER SCHMITTEN: (German spoken)

KNOX: The in der Schmittens live in a modest, two-story row house. It cost around $400,000 two years ago. Juergen had to lay out another substantial sum to buy into a medical practice with two partners, so he has a lot of debt and no savings. He drives a second-hand, five-year-old Audi. He works long hours to bring in an income a little better than the average German GP. Over dinner I asked him how things have changed for doctors since we first met.

Dr. IN DER SCHMITTEN: The atmosphere, the feeling on the side of physicians and perhaps also patients, that things are getting worse. I think that's the most striking change, really.

KNOX: He says something we've heard from other Germans, even people who aren't very sympathetic to doctors. Germans are worried about the future of health care. Already Germany has a higher proportion of old people than America does.

Dr. IN DER SCHMITTEN: The doctors argue, well, if the society's aging, if the society wants to have more expensive medicine, then it'll have to pay for it. And we are not the ones who will work more and more and more and don't see an income - increase in income for that.

KNOX: He says Germany will have to spend more on health care in the coming years. But here's the thing: Germany can spend more, cover virtually everybody, and still not spend nearly as much as the United States.

Richard Knox, NPR News.

NORRIS: And if you want to compare medical costs, go to our Web site. You can find out how the average American medical bill stacks up against medical bills in Europe. That's at npr.org/health.

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