MICHELE NORRIS, host:
American voters say health care is one of the top issues they want the next president to address, so this month we're reporting on European countries that have taken a different approach to health care, to get an idea of how other health systems work.
NPR's Patti Neighmond went to the Netherlands to survey health care there. And Patti joins us now.
Patti, tell me first how the system works in the Netherlands.
PATTI NEIGHMOND: Michele, all individuals are required by the law to buy insurance, and they do that either on their own, or if they're low-income they get some help from the government. Insurance companies are private, but they are also required by law to sell health benefit packages for the same price to everyone.
Now, in addition to people being required to buy insurance on their own, there's also a tax on salaries - employers contribute to that - and that helps pay for subsidies for very sick individuals and for the poor.
NORRIS: So how did this system develop, and what does it say about the country?
NEIGHMOND: Well, the system really developed from the Netherlands' sense of egalitarianism, solidarity and a certain practical nature. As far as egalitarian, everybody participates. Everybody shares in the pain, everybody pays - employers, employees, individuals and the government.
Solidarity - anyone who can't afford insurance or is very sick, they get some help. They get help from the government in buying their insurance. So there's a certain sense of helping one another. And realistically, the system spends liberally on treatments that are effective. Treatments that don't work, they don't spend so much on. They focus a lot on primary care and on disease prevention. And that is the focus of Holland's health care.
NORRIS: So Patti, let's take a listen to what you learned on your trip.
NEIGHMOND: In the Netherlands, most women try to have their babies at home. If complications arise, they end up in the hospital, but women delivering at home saves the Dutch health care system a lot of money. And for Dutch women, home feels like the right place to be. They view birth as natural, not medical, and there are a lot of services available to reinforce that.
In Amsterdam, for example, there's a center which combines a spa, a shopping center, a school for pregnant women. There's a daycare center here, classrooms for teaching about natural childbirth, a massage room, a cafe, and plans for a sauna and whirlpool.
Ms. BEATRIZ SMOLDER(ph) (Midwife): The street where we are now in is called Birth Street, and some people call it the Birth Canal. And because in this street you can do anything, what you need if you're pregnant or when you're a mother.
NEIGHMOND: Beatriz Smolder started this center 30 years ago. She's a midwife who is probably Holland's most vociferous proponent of natural, no pain medication childbirth. In fact, only eight percent of all Dutch women have epidurals during childbirth.
Ms. SMOLDER: I'm a pain seller. And...
(Soundbite of laughter)
NEIGHMOND: It's Smolder's belief that epidurals interfere with the process of birth and that pain, on the other hand, helps guide it.
Ms. SMOLDER: If you feel pain and you're pushing and it's painful, you stop for a while. And you can stretch, and you push again, and so the pain leads the woman the way how to push out the baby safely. If you're totally numb, like in many women in the States - she doesn't feel anything and the baby is pulled but the woman cannot say stop because she doesn't feel anything. So a lot of lacerations and damage is done because the woman is not in touch with her pelvic floor anymore.
NEIGHMOND: That's not necessarily what Dutch doctors think though. One obstetrician says he thinks a painful delivery actually interferes with mothers and newborns bonding. Whatever the case is regarding pain, one thing is clear: universal prenatal care and women giving birth at home have combined to produce an infant mortality rate that is about 25 percent lower than in the U.S.
(Soundbite of baby crying)
Ms. KIM OYE(ph): Are you hungry?
NEIGHMOND: Kim Oye just had her second baby without any pain medication.
Ms. OYE: Yeah, it's painful. I mean, after the first one, I was like, oh my God, we should get a medal. We should get paid for this. I mean, this is like - but, yeah, in the end, yeah. It gives you a sort of natural high.
NEIGHMOND: Paul Schnable is a sociologist at Utrecht University in the Hague. He says that childbirth at home is part of the Dutch philosophy to keep people out of hospitals and doctors offices unless they really need the treatment.
Professor PAUL SCHNABLE (Utrecht University): That's why you see that many deliveries here are still at home because people think, well, it's a natural thing to have a baby and not a disease or - this all fits in this picture that you should keep things as natural as possible. That's a strong feeling.
NEIGHMOND: And at the end of life the Netherlands has legalized euthanasia. It allows doctors to help patients die by giving them a lethal dose of medication.
Prof. SCHNABLE: You could say it's very much accepted by the general population that people can decide on their moment that they would like to die and that you could help them. But if you have a bad cancer which is aggressive and which is bringing a lot of pain or suffering, most people know, well, I'm not going to recover from this. This is going to be the end. More and more they decide themselves to have it stopped and to step out of life.
NEIGHMOND: And between birth and death, the Dutch medical system is quite practical as well - you might even say stoic. They tend to view people in the U.S. as weak and needy, popping a pill for everything, from mood to virility to memory. In the Netherlands, Schnable says, the notion that life can be challenging is embraced.
Prof. SCHNABLE: Life is not easy, and it certainly is not fun, and that you have to accept that life comes with problems. It helps you to grow. It helps you to become an adult, a person who can endure hardship or can endure problems and will grow by being challenged by them, and not immediately taking medicines or whatever.
NEIGHMOND: As a result, the Dutch spend less than half what the U.S. spends on medications per person, and even less than what Canada, France, Germany, Switzerland and Australia spend. And Schnabel says it's the primary care doctor who keeps patients away from unnecessary medication.
Dr. SCHNABEL: And his philosophy is that most of the pains, most of the afflictions you have will go away by itself. And if you really are suffering, I will give you some medication, but only for a short time and just as much as is needed - not much more, and certainly nothing extra. And that's a philosophy from the doctors, but it's also the philosophy in the population.
NEIGHMOND: But The Netherlands is not immune to the lure of expensive modern medical advances, and so things are changing. In the town of Maastricht in the southern part of The Netherlands, obstetrician Jan Nijhuis says today, more and more women want epidurals, and more want to have their babies in the hospital.
Dr. JAN NIJHUIS (Obstetrician): In Holland, many women get frustrated because they have so much pain and can't get an epidural. And they think they are being told they are losers, that they did not perform well. And it's very sad, in fact.
NEIGHMOND: And more epidurals mean more babies are born in the hospital, because when pain medication is used, the fetal heartbeat has be monitored. And also, for end-of-life care there is some pressure to change. Like in the US, The Netherlands faces an aging population increasingly exposed to advances in technology and medications. Those treatments can be life-extending, but they are also very expensive. Patti Neighmond, NPR News.
NORRIS: And at our Web site, you can get a broader view of how the Dutch health care system stacks up against other European countries and the US. That's at npr.org in the section called Your Health.