I just finished reading the book, Which Country Has the World’s Best Health Care? by Ezekiel Emanuel. I won’t keep you in suspense about Emanuel’s answer to that question. He asserts that no country can be said to have the best health care overall. There are several dimensions (Emanuel identifies 22) on which one can assess a country’s health care system, each of which is important to patients, health care providers and/or taxpayers. Countries that do well on one dimension — say, universal coverage — may not do well on another, such as wait times for elective procedures.
But there are some countries that score well on multiple dimensions and don’t rank badly on any of them — the Netherlands, for one. And there are countries that rank near the bottom on several dimensions and score well on only a few. The United States is one of those. The US spends more money per capita on health care than any other country by far, and that doesn’t buy us better outcomes. Also, fewer than 92% of Americans are covered by health insurance while in most first-world countries that number is greater than 99%. And even though many Americans feel that physician choice is one of the strengths of our system, patients in the US are more limited in their choice of doctors than many other first-world countries due to the wide use of HMO-type insurance plans that make it expensive to see an out-of-network physician.
The United States is not the worst of the countries Emanuel studied, however. That dubious distinction belongs to China.
Emanuel’s book doesn’t examine every country in the world. He chose to focus on a handful of countries that could be meaningfully compared to the United States — relatively wealthy countries with broad access to health care but with different payment models and policy priorities. The ten countries he chose to study in addition to the US are Canada, the United Kingdom, Norway, France, Germany, Netherlands, Switzerland, Taiwan, and China. There is a chapter devoted to each country as well as four introductory and closing chapters.
The book is intended both for a lay audience and as a resource for healthcare experts and policymakers. It thus contains a mix of interesting and readable analysis along with detailed facts and figures. After the first couple of chapters I focused on the former and skipped the latter. (It wasn’t important to me that I know that Canada has 2.7 hospital beds per 1,000 inhabitants, or that the payroll tax rate in France is 0.75% for employees and 12.84% for employers.)
Each of the country-focused chapters starts with a History section that describes how that country arrived at the system it has today. (I was surprised to learn that most countries achieved close-to-universal coverage only recently.) There are subsequent sections on Coverage, Financing, Payment, Delivery of Health Care Services, Pharmaceutical Coverage and Price Controls, Human Resources (the numbers and types of physicians and nurses), and a final section called Challenges which summarizes what works well in that country and what doesn’t, and describes the changes that country will need to make in order to deal with trends in the health care landscape, such as aging populations and increasing costs.
To give the United States its due, Emanuel writes that our health care system is particularly innovative — not just in developing new drugs and devices, but also in how care is delivered and paid for. Emanuel suggests this may, in part, be cultural. Ours, he notes, is a society that values innovation and rewards entrepreneurs. Among other things, there have been successful experiments in the US with reducing prices.
For instance, Medicare introduced a competitive bidding process for durable medical equipment, such as home oxygen, walkers, and electric wheelchairs, that reduced prices. Similarly, some private payers have introduced reference pricing — paying a fixed fee for specific services such as colonoscopies and cataract surgeries, and having patients pay the difference if they choose to get their care at a higher-priced facility. Finally, others are focusing on “steering” patients to lower-cost but higher-quality providers, especially specialists and hospitals. This would save money while improving care quality. The challenge is whether these and other experiments can be successfully expanded across the country, and to other medical goods and services, and whether they can reduce total cost of care.
Emanuel’s purpose in writing this book was to help policy makers in every country, especially the United States, learn from what other countries are doing. Emanuel understands that no country can accomplish a wholesale replacement of their entire health care ecosystem — there are too many moving parts and too many influential stakeholders with a stake in the existing schema. But his book may suggest adjustments that any given country could make to address its more pressing issues.
This book isn’t for everybody. You may find it worthwhile if you’re a policy nerd like me, or if you just want to be better able to rebut the bombast of your right-wing relative who rails against socialized medicine and insists that the US has the best health care in the world. But without a doubt it is must reading for anyone who is in a position to influence healthcare policy.