What experts say about who has the world's best health-care system | Opinion

[0:00]I want to start with a simple question. Which country in the world has the best health care system? Yeah. So, I hate that question. Here's where you should ask me why I hate that question. I knew you were going to start with that question. I think it's a question that a lot of people ask, which country has the best health care system, and I don't think there's a correct answer to it. It depends on what it is that we value. I'll give you an answer but then I'll tell you why the answer might not be applicable. If you look at the World Health Rankings, the country that came out on top is France. I think in general starting from France and working Northern, you tend to get the best health care systems. But the reason why it's not entirely applicable is that what works in one country may not work in another country. So, a number of years ago, just a few years ago, I wrote a piece in The New York Times with my colleague Aaron Carroll. We actually did a tournament of health systems. It was like a bracket tournament, the way March Madness is a bracket tournament, or like a tennis tournament. And we had me and Aaron, Uvey Reinhardt, Ashish Shah, physician, now Dean of Brown, and Craig Garthwaite, an economist at Northwestern. And we each voted in each of the brackets, like in each of the pairings, for which system we liked better. And then like we ultimately got a winner. But one of the important takeaways from that whole process is that in no pairing did any country win five to zero. There were five of us, right? We were we were not unanimous in any decision. There was always at least someone who disagreed, and in many cases it was three to two. And we each had different reasons. You know, someone was very, uh, big on like the cost, equity, access, or the quality. And so to me, like, look, this is five people who who know health care pretty well, and and know these systems pretty well, and we couldn't even agree. So, there's just no clear winner, actually. But the one thing that stands out is that among all major developed nations, it's pretty clear that the United States comes in dead last. On the other hand, I think everyone, especially experts, should be skeptical that they know the answer. Because what works in one country or one setting doesn't necessarily work in another. So, you know, there are there are aspects of the Australian system I like. There are aspects of the English system I like, but I don't think that there's a system we could just bring over here and install, like a new fridge. So, maybe the better question is, what would the best system for the US look like? And what would that look like? So, good a good health care system, or a good, yeah, let's just call it a health care system. A good health care system has, I think, to me, several attributes. One is, How does it affect our health as a country? How long is it that people are living? What is the infant mortality rate? What is the rate of certain types of diseases, and how well are they doing in prevention? And the second question I'd want to know the answer to is, were the benefits of the treatment greater than the cost of the treatment? A bad health care system could have overspending on care that's of really questionable health benefit at the same time that it has underspending on health care that's of vital importance to people. So, when people say, do we spend too much on health care? We spend way too much on some things and way too little on others. So, a good system would fix both problems. And the third dimension for health care system is, how well does it reflect our values as a society? And by values, I mean, what are the rich willing to do for the poor? What are the healthy willing to do for the sick? The answer to that doesn't come from economics. It's just a, it's an answer that we all have within us. But that answer profoundly affects how you answer questions about what's good and bad about health care. And I would hope that going forward, as we think about the learnings from other countries, we can take a hard look at what it is that we have, and whether they align with our core principles that we otherwise hold so dear. So my goal is have a health system that does the most it can to improve our health, that protects people from financial ruin, and that conforms to our values as a society. So, yeah, that would be the right thing to do in principle. The the the next question should be like, can we get there from here? And I don't I just don't see it. What we've seen over time is that the costs of health care have gone up, but outcomes have also improved. So, if we take some measure, and the measure that I like to use is life expectancy at age 40. And then I look on the other axis at the cost of health care per person. And what you find is if you look back to 1976, All of these countries, the US, Germany, Canada, look similar in terms of what share of GDP goes to health care. And they are all living, people are living about 35 years after age 40. Okay. Fast forward 20 years, and the US is spending a lot more of its GDP on health care, and its life expectancy increases have not kept up with the life expectancy increases in other countries. So, the US becomes increasingly an outlier both in terms of outcomes, that is life expectancy, and in terms of spending. Now, you can put the two on the same graph, but that doesn't mean that they're related in any way. I think we're simplifying the other health care system to the point of getting it totally wrong. But a lot of it depends on who you're talking to, right? I think there's a view that some Americans have that another system's care is terrible. You know, there's very long waiting lines and waiting lists, that the latest medical technologies are routinely not available. I think for a lot of other Americans, there's this view that other countries have just figured it out, and what we should be doing in the United States is copying what they've already figured out. And I think both those views are not right at all. So, I think people mix up this term called Socialized Medicine with what I would call universal health care. One is the insurance part, that is who runs the insurance, and you can have socialized insurance where the government is running the insurance, or private insurance, or private companies, or both. And then second, there's the providers of medical care, who could be either government run employees or private employees. There are some methods that one could classify as being socialized medicine, meaning that the government is a single payer, the government operates all the health care, and people belong to a single government system. Uh, so Britain has socialized medicine because the hospitals are government institutions, and the physicians and nurses are government employees. And France has yet a different kind of a system, also not not government owned. And Switzerland, Netherlands, Germany, these are places that have universal health insurance, but they have active and important private health insurance companies that administer it. So, very different structures of these systems. The the thing that they share in common is that they're universal. So, I think, coming full circle, my great worry with health care reform in America is that it is collapsed to the level of kind of fighting and arguing about these slogans. And the slogans have nothing real behind them. These slogans have become so politically charged and tied to a particular candidates, or a particular viewpoint that has become completely partisan and will shut down constructive debate. And if you go back to what I was talking about, how do you evaluate a good health care system? You don't evaluate it by the share of government in the system. You evaluate it by whether patients want the care that they get, and whether the care that patients get is worth it. I think that other countries have great hospitals, cover a lot of medical treatments, have fantastic doctors. And at the same time, they have not figured out a bunch of things that we have not figured out. So, if you are the kind of person who's going without health insurance in the United States, I hate to say it, but I think they are better off in many other countries than here in the US. But for a lot of diseases, for a lot of people, regardless of income, this is probably the country where you would like to get your health care.