Austin Frakt and Aaron Carroll recently approached me about a New York Times UpShot piece aiming to rank eight healthcare systems they had chosen: Australia, Canada, France, Germany, Singapore, Switzerland, the United Kingdom, and the United States. This forced me to think about a pretty fundamental question: what do we want from a healthcare system?
I would argue that most people want a healthcare system where they can get timely access to high quality, affordable care and one that also promotes innovation of new tests and treatments. But underlying these sentiments are a lot of important issues that need unpacking. First, what does it mean to be able to access care when you need it? A simple way to think about this is being able to see a doctor (or other healthcare professional) quickly and easily and in cases where there are follow-on tests, procedures, and treatments, you can get them without much delay. This brings up one important point: while experts often discount the importance of timeliness, regular people generally don’t: anyone who has waited weeks or months for a follow-up after an abnormal test result or to get a needed surgery knows that waiting times are not just an inconvenience. Delayed access can be stressful, agonizing and in some instances, downright harmful.
Beyond access, of course, we want care we can afford. Almost all of us need some sort of insurance that would pay for an unexpected, catastrophic healthcare expense (like spending a few weeks in an ICU). Most of us need some sort of financial coverage for other, slightly less expensive services such as an MRI or a knee replacement. And even still, some of us will struggle to pay for simpler things like doctors’ visits and need financial help there as well. There is broad consensus that we want a healthcare system where people aren’t denied the services they need because they can’t afford them.
While accessibility, timeliness, and affordability are key, there are other aspects of care that get less attention but are just as important: we want care that is safe and effective and produces the best outcomes possible. It’s great if you can have timely cardiac surgery and pay little or nothing out of pocket. But if you die unnecessarily from a preventable error, you didn’t get what you needed from the healthcare system.
Finally, we want a healthcare system that creates new knowledge so that we get better at caring for sick people. One of my earliest memories of medical school was caring for a young woman, an artist with two small children, who died of a complication of chronic myelogenous leukemia after a bone marrow transplant. Today, her disease could have been managed by a simple, daily pill that has turned CML into a chronic, yet manageable disease. A system that generates new therapies that save lives is critical and its importance is often overlooked when assessing health system performance.
Health System Organization
So what is the ideal way to organize a healthcare system to accomplish these goals? One school of thought believes that market-based systems are the solution because they rely on competition, customize care for individuals, keep prices down, and allow the highest quality providers to flourish. For others, the answer is a government-run, single-payer system where everyone has equal access, gets comparable quality, and patients don’t have to worry about costs because the government takes care of it. While either approach can be supported with selected data and facts, as I have looked at health systems from around the globe, one theme becomes obvious: systems organized very differently can achieve comparable levels of performance and no single approach consistently outperforms others.
So which countries have the best systems? As the UpShot piece outlines, we did a tournament-style competition where in each round, we had to pick winners and losers. At the end, we were also asked to rank the selected 8 countries based on our overall assessment. To do so, my approach was simple. Health systems should be judged not by how they are organized (i.e. markets or government) but what they produce. How well does it do what a healthcare system ought to do? So that’s the approach I took.
Evaluating Health Systems
That leads us to the next question: what metrics should we use? If you made it to the first day of a health policy 101 class, you learned about two metrics: per capita spending and life expectancy. If you made it to the second class, you learned that unfortunately, these are far too crude to tell you much about health system performance and do not help generate an actionable set of policy prescriptions. Health care spending is driven by many factors, including what is encompassed in spending calculations (research and development? medical education?) and prices (if one country pays its nurses half as much as another – does that mean the first is twice as efficient?). Life expectancy is even more complicated as it is driven in large part by behavior, lifestyle, and genetics of the underlying population. As Irene Papanicolas and I point out in our recent JAMA piece, drawing these boundaries when comparing healthcare systems is important.
So if we can’t just look at those metrics, what else should we examine? While one could evaluate literally hundreds of metrics, I prioritized 16 (see Table 1).
None of these are perfect but they seemed reasonable to me – a few on access, quality, cost and innovation. Ultimately, I was interested in assessing performance in areas that are clearly within the purview of the healthcare system – how many people are covered and covered for what? How quickly can you see someone when you’re sick? How good is the system at taking care of you when something terrible happens, like you have a stroke or a heart attack? Does the system generate lots of innovation so that everyone’s care gets better over the time? I tried not to overly weigh any one of these but tried to look at them holistically.
Based on these measures (for country data, see Table 2), my ranking of the selected health systems is as follows:
A few caveats. First, these are all very good healthcare systems – and we’re generally comparing systems that are far superior to much of the rest of the world. Second, there was rarely a clear winner in head to head competitions. Switzerland and Germany both have excellent systems and reasonable people could draw a different conclusion from the same data. I struggled among the U.S., France, Australia, and the U.K., all of which had clear strengths and clear challenges. Singapore lagged behind in large part because there is so little data about their performance and lack of data means it might be better than it looks, or it could be worse. I just don’t know.
The ranking of the U.S. above places like France and the UK may be surprising. Some people will point, rightly, to the fact that the U.S. has the highest spending in the world yet still has people who are uninsured. The healthcare spending problem of the U.S. is largely a political choice – we have extraordinarily high prices on everything from physician salaries to pharmaceuticals. While some of these high prices may spur innovation (i.e. pharmaceuticals), the cost of spending nearly 20% of our GDP on healthcare means less money for everything else. We could do better with different policy choices.
On the issue of universal coverage, things are a bit more complicated. While its narrowly true that the U.S. is the only country here without universal coverage, it’s too simplistic. First, 91% of Americans are now insured (thanks in part to the ACA). Some countries have universal coverage for their citizens but not necessarily for immigrants or other groups. Second, it is important to consider what is actually covered. While most Americans can get access to the latest treatments, in many countries, access to the most expensive therapies can be difficult or non-existent. I don’t know if we will get to 100% coverage but we are inching towards it and I hope that with the next set of policy reforms, we can get into the high 90’s. And that would be good.
Finally, if you take a big step back and look at the data, Americans do better than average in timely access, especially to specialty services and “elective” surgery (which is often not that elective). They tend to be among the leaders in acute care quality, when healthcare means the difference between life and death, although the quality of primary care could surely be better. And America is the innovation engine of the world, pumping out new drugs and treatments that benefit the whole world. All of that earns America a high rank in my book – behind Switzerland and Germany but ahead of others. You can disagree but overall, while the U.S. healthcare system has a lot of work ahead, we should not overlook its strengths – and they are sizeable.
So here’s the big picture: when it comes time to measure health system performance, it’s important to think about boundaries (what is the responsibility of the healthcare system and what isn’t). It’s also important to consider whether the system is delivering what people need: coverage of a broad range of services, especially those that are important for the sickest among us, timely access to affordable, high quality care, and innovation that ensures care gets better over time. For most people, whether the system is market-based or government-run matters a lot less than whether it’s meeting their needs. And that’s the way it should be.
Affordable, incentivizes both good health practice and charitable, not predatory, business practice, is well trained, & is firmly pro-life.
1. It should have low admin costs.
2. It should have patients and agents of patients–docs, NPs, etc.–in power structure.
3. It should have some competition betwwen providers on pricedures and other services like room rates.
4. It should have much simplified billing and everyone should be able to understand prices. Maybe public good for hospital services?
5. It should keep up with the underlying science of the craft.
6. It should be competitive in outcomes with the other good world systems.
7. It should be competitive in cost …ditto..
8. It should not have enormous numbers of stakeholders other than patients and doctors and nurses and techs.
9. It would be good if it got the technology imperative under control. Allow new technology and drugs to enter the system appropriately, not too soon and not too late.
10. It should have kind and humane cost-sharing…just enough to manage moral hazard, but not so high as to inhibit needed care.
11. It should not add its own high opportunity costs to the other thousands of things society wants to do.
12. It should cover some dentistry.
13. It should cover much mental health.
14. It should cover much rehab.
15. It should cover some LTC.
16. It should inhibit provider-induced demand.
17. It should figure out some way to bring astronomical drug prices under control but not inhibit innovation.
18. The utility function of health care should be to help patients and not to provide jobs or create investment opportunities.
19. Regulations and rules need to be moderated to healthy levels so that the sector is not stifled.
20. The purpose of health care should be to keep patients from being disabled, dying too soon, and going broke.
Many people will disagree, but I think I’m with with Ashish on ranking the U.S. healthcare system ahead of some of the other familiar names on this list.
The belief that the U.S. health system is some sort of failed state requiring massive intervention is a fundamental assumption for many people. The reality is more complicated.
We’re both a runaway success (for innovation and acute care) and an abject failure in other areas (access, cost). I’m curious what the NHS supporters among you make of his rating ..
What would your ideal healthcare system look like?
I’m not sure how pjnelson’s ‘managing a commons’ applies to our present health care system….but, maybe it should. [Personally, I would like to try, as an experiment, in one defined location, making acute med and surg a public good.]
At any rate, none of Elinor Ostrom’s principles for managing a common’s can be found in our system.
Thanks for this citation, however. I thought she was brilliant in this paper.
The geologists who are monitoring the tectonic plates in the California, Oregon and Washington states have reported that a major earthquake will occur of the magnitude of the last major event that occurred in 1720. This event apparently is 50% likely in the next 100 years. All studies of Disaster recovery indicate that recovery is related to the level of social capital in the communities involved and the anticipatory pre-event mitigation strategies that were put in place. Now, with 3 major hurricanes affecting the USA and its protectorates of Puerto Rico and the US Virgin Islands, the currently unfunded liabilities to our nation, just from Disaster Mitigation and Recovery Planning are likely beyond our wildest prognostications.
I might add that the difference in health spending for the other developed Nation’s cluster at 11-13% of their nation’s economies. Our nation’s health spending last year was 18%. For our nation, the difference between 13% and 18% for our national economy (GDP) was $1 Trillion in 2016. The chorus for a single payer change has begun to have a larger voice again. The analysis by Dr. Jha would not hold up under the likely onerous rationing triggered by a single-payer system. A decrease in the portion of our nation’s health spending would also be likely to occur as a funding source for the increased spending for Disaster management and our Nation’s security. As a final note, our Nation’s maternal mortality ratio continues to worsen and accounts for at least 500 citizens who die annually largely because they lived in the wrong nation during their pregnancy. It has worsened annually for at least 25 years.
As a counter point to Dr. Jha’s analysis, see the “Mirror, Mirror..” report on the Commonwealth Fund’s website. It was also published in a recent edition of the NEJM. I continue to argue for the use of the “Design Principles for Managing a Commons” as a basis to guide our nation’s healthcare reform. Identified and validated by Professor Elinor Ostrom, and her many colleagues, the successful preservation of a common-pool resource is possible. The best example of this in the United States is the preservation of the fresh water aquifer under Los Angeles, California from sea water contamination. She was a Nobel prize winner in 2009 for her world-wide research.