What Hillary could learn from Canada and Germany.

Josefa Hagel was resting comfortably in a bed at Schwabing Hospital in Munich. She had been there for nearly two weeks, but tomorrow she would go home.

The 92-year-old Hagel had been rushed to the hospital with the classic signs of a heart attack--shortness of breath and chest pains. But days of tests and monitoring revealed no serious problem. Hagel, a sprightly woman with gray hair and sparkling gray eyes, had spent her time at Schwabing, the oldest of Munich's municipal hospitals, in an austere, semi-private room with well-worn furnishings and no telephone or television.

Even so, as far as Hagel was concerned, Schwabing had served her well. The room was spotless. The medical staff had been attentive. "The doctors take the time to sit down and talk to you," she told an American visitor. And now she was well and going home. Her bill for the twoweek hospital stay would be $112--an $8-a-day insurance co-payment. The remainder of her charges--about $4,100--would be paid by Hagel's insurer, the Allgemeine Ortskrankenkasse, or AOK.

The AOK is the largest of the 1,200 non-profit, payroI1-financed "sickness funds" that comprehensively cover the health care of more than 90 percent of Germany's residents. The system was created in 1883 by Otto yon Bismarck, and the AOK was already 18 years old when Josefa Hagel was born. Through World War I, the Weimar Republic, the rise of Hitler, World War II, and the post-war economic boom, AOK was there to pay Hagel's bills. Through the birth of her children, three operations, and the death of her husband, AOK picked up the tab. "It always covered what was necessary," she said, surprised at a question about health insurance. "I've never had a problem. I've never thought about it."

Across the Atlantic, Joan Evans, a woman in a white, flowered nightgown, had been lying in Toronto's busiest emergency room for more than twelve hours after injuring her head in a fall. But since all of North York General's beds were filled, Evans had to bide her time until a room opened up.

She wasn't alone. All but two of the room's 19 curtained examining cubicles were filled. Four more patients lay in beds along the wall. And seven others, Joan Evans among them, were in a cluster of beds behind the nurses' station.

This happens a lot at North York, which is forced to strike a delicate balance nearly every day between patient demand and available resources. But Canadians are willing to put up with some inconveniences to pay for the comprehensive care they are guaranteed.

This was certainly true of patients in North York's emergency room this morning. Many were dozing. Some lay propped on pillows, reading magazines or books. One woman was knitting. An American reporter wandered from bed to bed, interviewing patients about the Canadian healthcare system. When the reporter came near Joan Evans, she blurted out: "We don't have socialized medicine. We have social responsibility."

Although she'd been waiting, Evans was here by choice. Under Canada's system, she could go to any hospital she chose. And many of the other hospitals probably had room, because on a given day, Toronto has 1,000 empty hospital beds. But Evans liked North York. She'd been here before, and this was where her doctor practiced.

Under Canada's tax-financed, single-payer system, Evans' red-and-white plastic card from the Ontario Health Insurance Plan entitled her to full medical treatment She knew she would get good care and that if she had to wait for a bed behind a more serious case, the decision would be made on medical, not economic, grounds.

Josefa Hagel and Joan Evans were deeply satisfied with their care. Surveys consistently find greater satisfaction among patients and doctors in Canada and Germany than in the United States. In those countries, health care is, as Princeton health economist Uwe Reinhardt says, "part of the cement of society."

This is not by chance. Both countries have consciously decided health care is a universal, public good. People who are poor receive the same high quality of care as people who are well off, and while the well off are able to buy amenities--a private room, television, a telephone-everyone is treated the same medically, treated well, and is certain that this equal treatment will be there.

"We see people having equitable access to affordable and appropriate health care regardless of geography, income, age, gender," said an Ontario Ministry of Health annual report. And, "In Germany, we operate under the social solidarity principle," explained Johann Fann, a top executive with the Bavarian AOK. "The rich pay for the poor, the young for the old, the well for the sick." Although both Canada and Germany are market-based economies, they have taken health care largely out of the marketplace. Unlike England, they do not have socialized medicine. The government controls overall spending, but hospitals and doctors operate independently of the government.

The Clinton administration says it wants the same goal, but it has proposed a radically different path for American medicine--a path that does not eschew the market but in fact embraces it. This is a risky exercise, for many of the problems that beset American medicine today-inferior care for the poor, spiraling costs, problems with insurance and bureaucracy--are products of market medicine. And remember that, compared to the U.S., Canada spends a third less per capita on health care and Germany spends 42 percent less. Yet both nations cover everyone for just about everything at high levels of quality.

Although President Clinton's 1,300-page Health Security Act promises to "ensure individual and family security through health care coverage for all Americans," as you plow through the bill, with its cost-sharing options and rules on marketing, profit incentives, and even advertising, Clinton-style health care sounds a lot less like a public good and a lot more like a market commodity. Indeed, under the Clinton plan, people who need medical care aren't "patients." They're "consumers."

This dependence on the marketplace is, of course, by design. Using the largely untested theory of managed competition, the administration hopes to make the United States the first country in the world to provide universal health care using market mechanisms. While this may be uniquely American--the market, after all, has served us well in so many other ways--it does create a kind of policy schizophrenia.

For the market is not built to promote equity. In the market, "money talks" and "you get what you pay for." Those who want more and can afford more, get more. The market's purpose is to generate profits and provide goods on demand. Applied to medicine, this, in part, is why Americans have more heart bypass surgeries, hysterectomies, and cataract operations than any people on the planet. It's the reason we have more high priced technology, such as magnetic resonance imaging machines and cardiac catheterization labs, than any other country. It's why, until the real possibility of genuine reform reared its head recently, some of the hottest stocks on Wall Street had been those of health related companies.

But in the market, those who can't afford more get less. Despite spending nearly $1 trillion annually on health care, 37 million Americans are uninsured and an equally large number are underinsured or fear losing what coverage they do have. So it's worth examining how Canada and Germany turn the ideal of equitable, universal care into a working, day-to-day reality for their people--the very thing Clinton says he wants to do.

Although these systems wrestle with the same economic and medical pressures faced by American medicine, their annual limits on spending help keep costs from growing uncontrollably. And because what money is spent is allocated through direct negotiations with hospitals and physicians' associations, the people closest to the systems have a strong voice in how they are run. To be sure, these overall caps also mean that Canadians sometimes must wait for nonlife-threatening procedures like hip replacements, German doctors' fees are cut if they bill too much, and the purchase of new technology is parsimonious and its use limited. You can see all of these things in the operating rooms, wards, and doctors' offices of Schwabing and North York General. You can see the difficult decisions and trade-offs Canada and Germany are willing to make in order to guarantee their citizens the best possible care regardless of their income.

The Doctor Will See You... Later

To Americans who detest even a short wait at the deli counter, queuing--waiting--for medical care is synonymous with rationing. And yet a policy of "no waiting"--in other words, what Americans with access to care generally have now--creates another economic dilemma. "If your queues are too long, you don't have enough resources. If you have no queues, you have an excess of resources," says C. David Naylor, a researcher at Sunnybrook Health Center in Toronto.

In the foreign systems, the responsibility for evaluating patients rests solely in the hands of doctors, who must decide who receives treatment immediately and who will wait. In Ontario, for instance, non-emergency waits for coronary bypasses can last up to three months. In the United States, nonemergency bypass surgery can usually be arranged in one day to two weeks. But there is no evidence that heart patients fare any better in America than they do in Canada.

A 1993 University of Sherbrooke, Quebec, study published in the New England Journal of Medicine found that American doctors were more apt to admit a patient with chest pains to the intensive care unit, more likely to prescribe drugs, and more likely to order X-ray angiography to look for clogged arteries. The study also found that U.S. heart attack victims were three times more likely than Canadians to be operated on.

Yet despite the less aggressive treatment, Canadian heart patients were no more likely to die or suffer a second heart attack than their U.S. counterparts. The only disadvantage was that the Canadians had a slightly greater chance of experiencing chest pains.

In fact, a 1987 Rand study found that 17 to 35 percent of American bypasses might be unnecessary. Still, the number of Americans receiving bypass surgery doubled during the 1980s to 265,000 in 1991. The explosion may have been spurred by the market as well as by medical need; heart bypasses are extremely lucrative. Indeed, fully one-quarter of all U.S. hospital revenues come from cardiac-related business. Of that, more than 80 percent comes from four procedures--cardiac catheterization, angioplasty, bypass surgery, and heart valve surgery, according to the Advisory Board Company, a Washington-based consulting firm. A financial officer at Philadelphia's Lankenau Hospital-one of the area's leaders in bypass surgery--describes the procedure as an economic "winner."

In Canada and Germany, budget caps and uniform insurance coverage remove any question of financial incentive for prescribing surgery. For example, Bernard S. Goldman, the chief of cardiovascular surgery at Canada's Sunnybrook Hospital, had a budget in 1992 to do 635 bypass operations. There was little doubt that he would find enough candidates. His only objective was to start with the most serious cases and work his way toward the least serious. Goldman sees no problem or crisis in this approach. "Hysteria is built into the U.S. system with patients being rushed into surgery," he says. And the numbers back him up.

German Engineering

It was only lunchtime, but Katherine Neubach, a family doctor in the Munich suburb of Neuaubing, had already seen 32 patients for ailments such as the flu, high blood pressure, and pancreatitis. But her day was far from over.

At noon, she drove her blue Volkswagen Rabbit to the apartment of a patient who was too sick to go to a nearby oncologist for a chemotherapy appointment. The patient, a middle-aged woman with bowel cancer, was bedridden with nausea and diarrhea. Hooking a coat hanger to a chandelier, Neubach hung plastic bags of saline solution to begin the intravenous treatment the oncologist had prescribed. Neubach made sure the patient was comfortable and told her she'd be back later that day. If needed, she'd give the woman a shot of morphine.

Such house calls are part and parcel of Neubach's job as a primary care physician. In Germany, the family doctor is always the first stop and the key player in health care. "The goal," Neubach explains, "is for someone to be responsible for the patient." As a gatekeeper to the entire German health care system, it is also her responsibility to use its resources wisely. Her own prosperity depends on it.

Each year a lump sum payment to cover all doctor services is negotiated between the nonprofit insurance companies, known as sickness funds, and the regional physicians associations, the Kassenarztliche Vereinigung, or KV. The money is forwarded to the KV, which distributes it to doctors based on a point system for different procedures and examinations. Because the KV is dealing with a fixed pot of money, if the demand for services exceeds what is budgeted, the payment per point is simply cut and each doctor makes less for each treatment.

This way, when doctors churn out patients and assign marginally relevant tests and procedures, they aren't milking insurance companies-they are bilking colleagues. That is why the KV aggressively polices its own members. "The KV monitors pharmaceutical use, hospital use, the number of cases," Neubach says, "and it can call an audit at any time." Still, because it's a professional society run solely by doctors, there's far less of the frustration American doctors feel when dealing with insurance companies or Medicare and Medicaid. Physicians do not have to worry about insurance company "pre-approval" or "utilization reviews" as they must in the United States.

To maximize her salary as much as the system allows, Neubach sees as many patients as she can, refers as few as possible to specialists, and provides additional services like house calls. (Neubach's income last year was about $136,000.) The sickness funds pay doctors a meager $5 for a routine office visit. That is why Neubach tends to dispatch minor complaints like sore throats and ear infections in five to 10 minutes. But her patients don't seem to mind the quick treatment. In pan that's because when they need Neubach to make a house call, she makes it. And in part it's because on average Germans see their doctors about 11 times a year --twice as often as Americans. That Germans pay nothing out of pocket for an office visit may also help to keep satisfaction levels high.

Any health care system ultimately comes down to the basic relationship between doctor and patient. So it is noteworthy that in Germany and Canada there is considerable freedom for both. For doctors, the trade-off for working under limited budgets is the power to manage what resources there are. Patients in both Germany and Canada have complete freedom to choose doctors and to change doctors as often as they like. So while Neubach, for example, decides what services her patients get and whether they see specialists, she must be sensitive to their wishes. If her patients are dissatisfied, they can simply go to another doctor.

In Canada, the family doctor plays a similar role. Canada's Royal College of Physicians and Surgeons has adopted a policy that 50 percent of all doctors should deliver primary care. (By comparison, only 30 percent of American doctors are primary care physicians, down from 87 percent in the thirties.) Canadian doctors' fees are also held in check. In Ontario, for example, doctors work from a fee schedule negotiated with the Ontario Health Insurance Plan. Doctors' incomes are capped (maximum annual income is $320,000), and the physicians' associations agree to pay the plan back if billings exceed the set targets. Last year billings actually went down.

Overall, the Canadian and German patients' freedom of choice promotes quality. North York General Hospital, for instance, knows that even while it is pinching pennies it can't afford to let its reputation slip because there are many other hospitals patients could choose. And because all patients are free to choose and are equally insured, there is no shunting poor patients into public clinics while luring well-heeled patients into private doctors' offices. All patients have access to the same medical care. The story is the same in Germany. "I suppose there is a big difference having a practice in Beverly Hills or the inner city," Neubach says. "Here it is all the same."

Room With a View

Majorie Chin of the North York General billing office was on the phone. "Good morning. I'm calling from the business office downstairs. Just a reminder to stop by just to pay a telephone or television bill. Thank you." She hung up, glanced at the discharge list, and called the next patient. This is what North York's billing office worries about--TVs, telephones, and room rates. With 473 beds, the Toronto hospital employs just 12 people to handle its billing. By comparison, Lankenau Hospital in suburban Philadelphia, with 475 beds, has a staff of 65 to deal with the payment of bills.

The simplicity of Majorie Chin's job reflects the administrative and financial simplicity of the Canadian health care system itself. Although it is a government-run system, it is surprisingly efficient. It provides a clearly defined public good uniformly by raising revenues through a mix of income, sales, and property taxes. As a result, people who make more pay more for the system.

It is also user friendly. Canadian patients simply present their plastic health cards on entering the hospital. At North York, the numbers on the red-and-white cards are quickly verified by computer and admissions take no more than seven minutes. Discharge is almost as quick, since the only bills are for telephones, televisions, and semi-private and private rooms. A private room costs $120 a day. About twothirds of Canadians have supplementary private insurance that picks up this tab.

In the last few years, Canadian health costs have risen (though at a far slower rate than U.S. costs) and taxpayers have been restive. This is what that means on the ground: Ontario actually cut most hospital budgets by two percent in 1992. But because each hospital's administrators and doctors decide how to spend its annual budget, each can adapt according to its needs. "We at least have the option of shifting resources," North York General president Murray MacKenzie says. So North York made some tough choices: It closed 30 general medical beds in order to maintain its neo natal intensive care unit.

With its 1,200 different Sickness funds, the German system would appear to be more like America's cumbersome, private insurancebased system. Yet Germany, like Canada, operates with administrative simplicity. (And Germany's insurers are not completely profit-driven in the way American companies are.) Despite the multiplicity of insurers, premiums are raised uniformly through payroll taxes, billing forms are similar if not identical, and payment procedures are standardized. The result is that both Germany and Canada spend less than half what the U.S. does on bureaucratic paperwork. American hospitals spend about 20 cents of every dollar on administration; Canada, nine cents; Germany, about eight cents.

In Germany, hospitals also must negotiate annual fees--calculated loosely as global budgets--with the sickness funds. Currently, about 12.5 percent of an individual's salary goes to health insurance, with that sum split between employee and employer. Premium increases are tightly controlled by the government. "All the funds want to pay as little as possible" to the hospitals, explains the AOK's Johann Fann. "The funds have negotiations in advance to set a sum they are willing to pay, so there is only one offer on the table. The results have to be approved by state authorities."

A German patient only has to tell the hospital the name of his sickness fund. Once that's verified, a billing sheet is added to the patient's folder. Bills are calculated by multiplying the number of days the patient spends by a daily rate designated by ailment. A single sheet with the diagnosis, treatment, outcome, and the number of days spent in the hospital is sent to the sickness fund when a patient is discharged, and payment comes in two to six weeks. Schwabing Hospital, with 1,372 beds, manages with just 18 people in its billing office. German patients are now liable for an $8-a-day co-payment for up to 14 days in the hospital. That is the only bill they will see, regardless of the number of services or doctors they use.

In crafting its plan for American health care, the Clinton administration has adopted goals similar to those in Canada and Germany. For example, the Clinton plan mandates a basic benefits package, but it reserves individuals the right to buy additional coverage. It also prohibits insurers from denying coverage because of a person's pre-existing medical condition. It seeks to ensure that no one is denied coverage based on age, race, or geography, and it pools the risk of all individuals in order to spread the financial burden. The proposed benefits package covers hospitalization, doctor's office visits, some preventive medicine, and pharmaceuticals. By offering identical benefits and creating standardized payment forms, the plan attempts to simplify the bureaucracy. And it tries to control costs by limiting insurance premium increases and slowing the growth of Medicare.

These are all admirable objectives. But whether they can be achieved under the complicated, market-based Clinton plan is questionable. The elements which control costs and assure everyone access to equal care in Canada and Germany are just not in the Clinton plan. Consider:

* Bureaucracy: In its effort to leave all the existing players in place (especially the insurers), the Clinton plan adds new layers of bureaucracy. First, it would create "health alliances,'' which would collect premiums from individuals and businesses and "certify" health plans that would in turn provide care. While the administration paints this as a simple and minor exercise, the alliances would be handling vast amounts of money as the principal conduit between consumers and health providers. The plan calls for the states to set up the alliances. But in many major metropolitan areas this would require extensive inter-alliance negotiations. Otherwise someone living in Arlington, Virginia, might not have access to the Johns Hopkins Medical Center 40 miles away in Baltimore.

On top of these new alliances would be a new National Health Board, which Health and Human Services Secretary Donna Shalala describes as a "minor" oversight body. But internal administration memos indicate that it would be a multi-billion-dollar agency with a large staff and "far-reaching authority." The board would set premium targets for each alliance to help control costs and collect information for consumer report cards on health plans and facilities. This sounds like a good idea. But Pennsylvania's experience in collecting performance data and then ranking hospitals on a single procedure-heart bypass surgery--has been extremely contentious, with hospitals repeatedly challenging the findings with reams of their own statistics.

So in the Clinton market there will be hospitals, doctors, insurance companies, health plans, health alliances, and the National Board. This means there will be more boxes on the flow chart than there are now. The Clinton approach in fact balkanizes American medicine, and it doesn't really make administration simpler or save much money. Observers such as Urban Institute economist Marilyn Moon estimate that at best the Clinton plan would save $10 to $15 billion in administrative costs--or 1.6 percent of the nation's total health care bill.

* Choice: The Clinton plan differs from Canada and Germany on doctor choice--something the administration is very touchy about. "One of the great lies that is currently afoot in the country is that the president's plan will limit choice," Hillary Rodham Clinton snapped in one speech late last year. "To the contrary, the president's plan enhances choice."

But that depends on how you define choice. Compared to Canada or Germany, where virtually all doctors and all hospitals are available to all people, the Clinton plan offers only limited choice. True, a German patient must be referred to a specialist by a primary care doctor. But if a patient is unhappy with one doctor, he can try another. No patient is captive to any single doctor or hospital. But in the Clinton plan, "managed competition" will be buttressed by "managed care." This approach, used by health maintenance organizations, limits an individual to a set "network" of doctors and hospitals. Because HMOs are paid an annual fixed fee per patient, they have a built-in economic incentive to limit the kinds of care they give in order to make sure that the cost of care does not exceed the HMO's overall receipts. This could mean, for example, fewer tests or fewer specialist referrals.

To some degree, this is similar to the imperatives Katherine Neubach faces or the efforts of Canadian surgeons to prioritize their patients. But the essential difference is that unlike German or Canadian patients who can switch doctors, under the Clinton plan people would be stuck for at least a year. The time most people want to see another doctor or go to another hospital is when they disagree with a diagnosis or treatment.

But guess who will be able to switch at any time under Clinton? The "managed" market will offer options and additional coverage so that those willing to pay more in premiums and deductibles will have more choices. In Canada and Germany, an individual can buy perks with extra insurance, but extra insurance does not buy better medical care.

Although the Clinton plan would subsidize the poor and the unemployed, it does not give them the option of choosing plans that cost more unless they pay the difference themselves. Stephanie Woolhandler of the Harvard Medical School, a Clinton critic who favors a Canadianstyle system, contends that the Clinton plan "is really ratifying a multi-tiered health-care system."

* Cost controls: The Clinton plan, unlike Canada and Germany, does not cap medical costs. But without curbing costs, every other goal--the comprehensive benefits, the universal coverage--is jeopardized. The economic hallmark of the Canadian and German approaches is setting budgets and then negotiating with private health care providers over how that money is to be spent. Both systems believe that hard choices have to be made in the public arena, and sometimes those choices are very hard. This past December, to stay within its global budget, North York General was forced to shift to a reduced emergency schedule for 12 days--deferring all elective procedures and furloughing most of its staff. The German system has begun to resort to additional co-payments for items such as pharmaceuticals in an effort to blunt demand. (Germans consume twice as many prescription drugs per person as Americans.)

But the Clinton plan envisions no global budgets and no direct negotiations, the features which control costs in the other systems. So how will it save money? How will the hard choices be made? The program's key line of defense against spiraling costs is limits on premiums set by the National Health Board. But under a market system there are two risks. First, there could be pressure from consumers or health care providers that push the premium caps higher and higher. The second risk is that the caps hold and providers are faced with the dilemma of balancing patient care against making money.

The tough decisions that will have to be made--limiting access to specialists, telling people they must wait for an MRI scan or not have one at all, closing some hospitals while beefing up others--will be made by companies whose main concern is not universal coverage or equal access, but rather profit. So the final question posed by the Clinton approach to health care is which will ultimately be served: the public good or the bottom line?

KIDS R' THEM

The World Health Organization says the well-being of a nation and the effectiveness of its health care system can be measured, in part, by the health of the babies it brings into the world. By that measure, Canada and Germany are far better off than the United States.

When the countries are ranked by the number of babies who survive their first year, Canada comes in ninth. Germany is 15th. The United States ranks 23rd.

Whether a baby is born healthy depends a lot on the quality of medical care the mother gets during pregnancy. In that regard, the United States again has a dismal record.

Nearly one in three American women do not get adequate prenatal care. Some pregnant women never see a doctor until they arrive at the hospital in labor. Because so many American women don't get good prenatal care, more sickly, premature, and low-birthweight babies are born in the United States than in any other industrialized nation. There are enormous social and economic costs.

These tiny babies are 40 times more likely to die in the first four weeks of life. And even if medical technology saves them--at a cost of more than $1,000 a day in an intensive-care unit nursery--they frequently face a lifetime of problems such as cerebral palsy, learning disabilities, and mental retardation.

Hospital bills for these underweight babies total at least $2 billion a year. The Institute of Medicine estimates that for every $1 society spends on prenatal care, it saves $3 in medical costs later on by detecting and managing problems that could lead to premature birth.

Checkups--which include such simple things as weighing the pregnant woman, taking her blood pressure, measuring her abdomen, and testing her urine--an make an enormous difference. They can pinpoint a baby's failure to grow, as well as pregnancyinduced diabetes or other conditions that could lead to premature birth. Good nutrition, vitamins and counseling on the dangers of drinking, smoking, and drug abuse can help prevent underweight babies, respiratory and developmental problems in babies, and fetal alcohol syndrome. Screening the mother for syphilis can prevent birth defects. Genetic testing can detect inherited diseases.

Despite overwhelming evidence that prenatal care makes a big difference, the United States has no public policy to ensure that all pregnant women will get it.

To the contrary, financial barriers often work against a woman's best intentions. This is especially so for the 555,000 women who give birth each year without insurance. These women account for about one in every seven births. Private physicians often won't take them as patients unless they pay hundreds of dollars up front.

A 1993 study in the Journal of the American Medical Association reported that women with no health coverage were 2 1/2 times more likely than privately insured women to postpone care until the end of pregnancy. They were six times more likely to get no medical care at all. Even women whose maternity costs are paid by Medicaid may have trouble finding a doctor, because obstetricians complain they don't get reimbursed enough to take those women as patients.

Such problems do not exist in Canada and Germany. Universal health coverage and standard reimbursement rates for doctors make it rare that a pregnant woman goes without regular checkups.

In Germany, "there is simply never a question of whether a pregnant woman has easy access to care she needs, and there is never a question of proof of payment for those services," said Dr. C. Arden Miller, a pediatrician and professor at the University of North Carolina, who has studied maternity care in 10 European countries.

His study of Germany found that 98 percent of pregnant women arrive at the hospital with their Mutterpass at the time of delivery. The 32-page booklet, designed by the physicians and insurance funds in 1985, becomes a record for all the exams and tests a woman gets, including at least 10 prenatal visits, two ultrasound scans and any necessary lab work.

In Canada, even immigrant women, often poor and coping with language difficulties, rarely miss prenatal care.

Dr. Dennis Xuereb, a North York obstetrician, said his waiting room was evidence of the single standard of care that exists for every woman--regardless of income or status.

"We have Somalian refugees. We have Sri Lankan refugees. We have Chinese refugees. We have lawyers, engineers, we have every cross-section you can imagine," Xuereb said. "Every single patient is treated the same way and has the fight to the same care."