Which Country Has the World's Best Health Care?
Ezekiel J. Emanuel, chair of the Department of Medical Ethics and Health Policy, University of Pennsylvania, has produced a highly readable, scientifically grounded, and politically relevant analysis comparing health care in the United States and ten other high-income countries. Emanuel’s global perspective permits him to address seven challenges facing them all:
- Cost pressure mounting due to aging populations and new technologies.
- Rising drug prices.
- Inefficiency in delivery of health services and provision of unnecessary services.
- Coordination between hospitals and outpatient health care providers.
- Mismatch between health care delivery institutions and chronic care needs.
- Provision of mental health care.
- How to provide and pay for long-term care.
The US. system is an outlier in dealing with all seven challenges. US health care costs add up to 18% of GDP—much greater any other country. With just 4% of the planet’s people, Americans account for half the world’s spending on drugs.
In the 1940s and 1950s the US government encouraged employer-based health insurance. This was better than nothing, but it left out retired, self-employed, and unemployed Americans. The government introduced Medicare for seniors in 1957; Medicaid for some of the poor in 1964; and the Affordable Care Act in 2010—the first structure for universal coverage. However the Trump administration repealed the individual mandate for ACA, weakening its scope. The outcome of all this is a patchwork of complex insurance arrangements very difficult to navigate, with significant differences from one state to another.
Here are the numbers in 2020: Of 325 million Americans, most have private insurance—156 to 181 million employer-sponsored; 15 million individually purchased. Public insurance covers the next largest segment: Medicare, 55 million; Medicaid + CHIP (for children), 65 million; Veterans, 9 million; Indian Health Services, 2.2 million; Tricare, 9.4 million.
This leaves 28 million Americans uninsured. But even persons with “good” insurance may encounter serious problems: For her son to be treated for bleeding in the national intensive care unit, for one night, a mother was billed $50,000. Why: because the hospital had subcontracted the work to a third party that was “out of network!”
Here is a paradox: The US system is highly complex but also “lean”—with ever fewer physicians and nurses, fewer hospital admissions, and fewer other services than any other developed country, while having bloated costs. It underperforms in many ways and leaves millions uninsured or underinsured. Yet it is tremendously innovative—not just in new drugs and devices but also in efforts to improve how care is delivered and paid for. Government, private insurers, and venture capitalists are looking for ways to improve the system.
This book went to press just as Covid-19 struck. Dr. Emanuel says we should learn about what approaches work best from cross-country comparisons. He warns that we should prepare for more infectious disease outbreaks. By July 2020 it appears that the United States leads the world in infections and deaths from the virus. Taiwan was able to keep a lid, relatively speaking, on COVID-19, because medical data are centralized with passports and other key documents, making it easy to identify Taiwanese who had visited mainland China and to test and, if necessary, quarantine them. Dr. Emanuel says nothing about funding for public health, which has decreased in the United States, but stresses the need for government leadership in providing frequent and accurate information and implementing physical distancing, testing, and quarantine where needed
Dr. Emanuel is reluctant to say which health system is best, but the American one is surely one of the worst. He does not address life expectancy where the United States lagged more than 40 other countries—even before Covid-19. He does say that Germany, the Netherlands, Norway, and Taiwan are in the top tier of health systems. China has one of the worst systems—overly focused on hospitals, with a poorly develop ambulatory care, very low patient trust, and very thin attention to rural areas.
How to improve the US system? 1. Ensure universal coverage with auto-enrollment and larger subsidies. 2, Cover children at no additional cost to their families. 3. Simplify the system so patients and providers do not have to figure out what is covered and how. 4. Increase reimbursement for primary care doctors relative to specialists. 5. Adopt best care practices for patients with chronic and mental health conditions. 6. Regulate drug prices. None of these reforms would be easy to implement. Most of them require coordinated work by the federal government and private insurers.
Dr. Emanuel is focused on the costs of health care but does not address how life style shapes medical needs. More than half of Americans are overweight, leading to diabetes and other chronic diseases. There is no national information campaign about diet and exercise as there has been about smoking; no large-scale education about tai-chi and other gentle movement and mediation programs potentially beneficial for all ages; almost no serious research to distinguish useful forms of alternative medicine from crackpot schemes. The book’s index has no entry for diabetes or exercise. The entries for complementary approaches include many references to traditional Chinese medicine in China and Taiwan and a few sentences about payment for acupuncture in Norway and a few other countries.
Focused on what services are available and at what price, Emanuel does not discuss the spirit that should undergird medical care, as do Stephen Trzeciak and Anthony Mazzarelli in their 2019 book Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference.