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MADELEINE BRAND, host:

This is Day to Day. I'm Madeleine Brand.

ALEX CHADWICK, host:

I'm Alex Chadwick. Cancer, heart disease, diabetes; chronic illnesses are expensive. And as more than 40 million people in this country know, they are all the more devastating if you do not have health insurance.

BRAND: But, compare that with the situation in the Netherlands. There, people are required by law to buy insurance, and insurance companies are required to sell coverage to everyone for the same price, no matter how sick they are.

CHADWICK: For our series on healthcare in Europe, NPR's Patti Neighmond examined how the U.S. and the Netherlands handle one chronic illness, diabetes.

PATTI NEIGHMOND: This story starts in the U.S. Steve Edelman lives in California. At age 15, he was diagnosed with Type I Diabetes.

Dr. STEVE EDELMAN: I didn't really realize that a lot of the things to maintain my care, like a yearly eye exam, yearly kidney test, yearly cholesterol test, things like that, were not being done. It took me 10 to 15 years to finally realize what I needed to do to avoid all these terrible complications of diabetes.

NEIGHMOND: Diabetics often lose feeling in their feet, which can mean broken bones and ulcers. Eye problems can lead to blindness. Patients can suffer seizures, and even die. No one ever talked with Edelman about these potential complications, or how to avoid them. As a result, he now suffers from eye and kidney disease. Because of his experience when he was younger, Edelman became a doctor and diabetes specialist. He works at the University of California, San Diego. Dr. Edelman says the fragmented care he experienced when he was younger can be blamed on the healthcare system as a whole. But, he says, it's made worse by health insurance companies.

Dr. EDELMAN: I've gone through hell and back with my insurance company, getting approval for this continuous glucose monitor, which is FDA approved. And I've also had problems getting an insulin pump, which has been around now for 15 years.

NEIGHMOND: Edelman has spent enormous amounts of time trying to get his insurance company to pay for the care he needs.

Dr. EDELMAN: And I say to myself, and I've said to my wife, I'm a doctor. I know how to get around the system. I scream and yell, I say the right keywords, and I have had a hard time getting some of the things I need. I couldn't imagine how it is for a layperson, who's not a physician, to have to deal with this system.

NEIGHMOND: Which is why Dr. Edelman created a website to help other diabetic patients. It's called "Taking Control of Your Diabetes."

Dr. EDELMAN: Patients living with a chronic disease, such as diabetes, need to know what they need to do. And that ranges from controlling their sugar levels to their blood pressure, to their cholesterol, to getting on an aspirin, things like that.

NEIGHMOND: In the Netherlands, there's no need for patients to be so proactive. Ten years ago, the government responded to a projected diabetes epidemic by training thousands of nurses to care for these patients. Take the case of 62-year-old Rene Thain. Thain lives in Maastricht, in the southern part of the country. Like Steve Edelman, he struggled with diabetes for years; but, unlike Edelman, Thain isn't completely on his own.

(Soundbite of conversation in Dutch)

NEIGHMOND: Every three months, Thain spends about 30 minutes with a nurse specifically trained in diabetes. Marcel Brusten (ph) says this half hour is particularly valuable for Thain.

Mr. MARCEL BRUSTEN: He doesn't always think the right way for his diabetes. He thinks he's doing well, but he ends up with low blood sugar levels, or too high blood sugar levels. But he can inject too much insulin, he can inject too little insulin, he can be bicycling too long or too - he uses too much energy. It's difficult. I think it's difficult for all the patients.

NEIGHMOND: Difficult, but these routine meetings four times a year help keep Thain relatively healthy.

(Soundbite of bicycle)

NEIGHMOND: He's an avid biker who enjoys treks through the hills in nearby Belgium. But recently, Thain did suffer a setback.

Mr. STEVE THAIN: (Through Translator) It all started when I was on vacation in 2004. While I was on holiday, I had to go see the doctor every day. My toe was getting bigger and redder.

NEIGHMOND: Once Thain got home, his general practitioner sent him to the Diabetes Center University Hospital in Maastricht. He was diagnosed with a rare problem that occurs in patients who no longer have feeling in their feet. The nerves don't function properly, the bones weaken and crumble, causing sores and infection, and can sometimes even lead to amputation. But when those symptoms began for Thain, he got comprehensive care. His diabetes specialist, Dr. Nicolaas Schaper.

Dr. NICOLAAS SCHAPER (Diabetes Specialist, Netherlands): He was immediately referred to our multidisciplinary outpatient clinic for diabetic foot patient problems. And there is a team of an orthopedic surgeon, an internist, a rehabilitation doctor, and a shoemaker, and a plaster technician, who immediately could start therapy with intensive treatment with plaster techniques.

NEIGHMOND: Thain wore a plaster cast for about four months. Today, his foot is pretty much back to normal, a success Schaper credits, not to luck, but to a system that's geared to kick into action when problems occur. Compare that to the U.S., where it's fair to say insurance companies try to avoid patients like Rene Thain, and patients like 43-year-old Neal McGill, who lives in Chicago. McGill is overwhelmed with medical bills.

Mr. NEAL MCGILL (Diabetes Patient): Oh, I have one from the hospital, which is 43,000. I have one that's 11,000. I have some that's 4,000, 5,000, 2,000. Five dollars and sixty seven cents.

NEIGHMOND: McGill's insurance covered only 1,500 dollars of the hospital costs. He's a part-time employee, so he had partial benefits. McGill works in a warehouse, lifting and moving heavy boxes. And, like Rene Thain, he doesn't have any feeling in the bottom of his feet.

Mr. MCGILL: I came home Saturday morning, and discovered that I had blood in my sock. And a bottle cap was inside my shoe.

NEIGHMOND: McGill's wound was treated, but it became infected anyway.

Mr. MCGILL: My blood was infected in my whole body, which caused my foot to swell, and there was pain and everything else.

NEIGHMOND: Doctors tried to avoid it, but McGill's toe had to be amputated. And, with it, a lot of natural padding on the bottom of his foot was also removed.

Dr. STEPHANIE WU (Rosalind Franklin University Hospital, Chicago): So, Mr. McGill, I'm about to go in and inject you. I'm going to use a little bigger needle than I normally use, because we're going to go in and...

NEIGHMOND: At Chicago's Rosalind Franklin University Hospital, McGill's doctor, Stephanie Wu, injects his foot with silicone, to help build up the padding and reduce the pressure on his foot. But McGill's still in pain. Surgery would help, but he can't afford it. A 675 dollar custom-made shoe could stabilize his foot, but he can't afford that, either. After McGill maxed out on his hospital bills, his insurer dropped his coverage. For now, he pays his doctor what he can, when he can. Dr. Wu.

Dr. WU: I do whatever I can. I go beg and plead for him. And it's very frustrating, because I feel like I spend more time writing letters to insurance companies than treating patients.

Dr. SCHAPER: I think that's a ridiculous system. And I think it's a very costly system.

NEIGHMOND: Dutch endocrinologist, Nicolaas Schaper.

Dr. SCHAPER: Your system, if I may say so as a foreigner, is extremely insufficient, and extremely overspending on a minority of patients, and under-spending on a majority of patients.

NEIGHMOND: The U.S. spends more than double what the Dutch spend on health care per person, but in the Netherlands, everyone has health insurance and access to medical care. The Dutch government even pays insurance companies a subsidy to make sure they cover high-cost patients like Rene Thain. Vinem Vendeven (ph) is a health economist.

Mr. VINEM VENDEVEN (Health Economist): It means that, for an 80-year-old person, an average insurer will receive tenfold payments that they receive for the young ones. And, within each age group, they receive a much higher payment for the chronic ill, the diabetic patients, the cancer patients, the AIDS patients.

NEIGHMOND: So, instead of running away from high-cost patients with chronic problems, Dutch insurance companies end up competing for their business. Patti Neighmond, NPR News.

CHADWICK: We've got more on how The Netherlands health care system compares to other European countries and to America, at npr.org/yourhealth.

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