The Best Health Care System in the World
nytimes.com
nytimes.com
They conclude that Switzerland is the best system in the world.
But different judges seem to have different priorities and it's clear that at least some of them are judging not the best healthcare system in terms of just cost or quality of care, but on how feasibly the foreign system could be implemented in the United States.
In any case, it's a stupid metric. Unless there was a single healthcare system that had the best healthcare at the lowest cost, which I think is the combination that most people are looking for, there is clearly no objectively "best" system. Even determining things like quality care in the first place is difficult.
Still, it was interesting to read comparisons of the various countries' health systems. It's a worthwhile read.
Discussion of great ideas that could never be implemented would be largely academic when considering how the American system can be improved.
In the World Health Organization ranking (1), of all the countries compared in the article, the only one that appears between the first ten in any of the categories (except cost) is France and, in only one metric, Australia and the UK.
Not pointing that seems a strange omission.
1. https://en.wikipedia.org/wiki/World_Health_Organization_rank...
Canada: 1
Singapore: 1
Germany: 0
Switzerland: 3
France: 3
UK: 2
Australia: 1
The other larger* countries that feature in the top-ten of these categories - Japan, Sweden, Spain, Austria - all have universal healthcare. I'm not sure where you stand, but it seems that no matter how you slice it Americans are getting a raw deal with their healthcare.
* = those roughly the same population as the smallest country on the list - Switzerland - or more
Specifically, I don't know how I missed Switzerland there. Obviously, I should double check before posting.
I am fairly certain the designers of such systems did not consider "the ease, cost, or willingness of the USA to implement the same thing".
I really think that should be considered as a major feature as well. Not receiving hospital bills months after a procedure and you thought things were all taken care of.
The only thing you might get after the event is follow up appointments.
A very quick run down on how we pay for all this: All employees (its a little more complicated for the self employed) have tax deducted at source, called Pay As You Earn (PAYE). There are two components: Income Tax - banded according to income and National Insurance (NI) - also banded. The NI contribution is generally to cover the NHS and Social Security, State Pension etc. Class One NI rates: https://www.gov.uk/national-insurance/how-much-you-pay so 12% up to £45,000 gross salary and 2% above that. Most people in the UK do not need to worry about filling in a tax return.
I agree that not billing patients reduces paperwork, but that's a relatively small part of overall billing.
They still don't bill patients, they just furiously do pointless paperwork to swap tax money behind the scenes.
Prior to this, it was a more integrated system, where all staff just worked for one central entity - the NHS - and were just paid a salary. Medical supplies, drugs etc... were all centrally procured, as required.
Turns out that if you're buying drugs for 65 million people, you can get amazingly good deals from pharmaceutical companies and quickly build up incredible procurement expertise. This is all thrown away once you smash it up, though.
> "This seems to work well in Australia, but in the U.S. the public system most likely would be badly underfunded. Therefore, France would be superior."
Essentially: "This system can't be the best in the world because it wouldn't work in one of the most horribly broken in the world, sabotaged or otherwise."
The utter irony? France's system would be MORE expensive. But because they decide that Australia's (cheaper) system would be underfunded (and yet somehow France's would be fully funded?!?) it's worse:
"The French health system is relatively expensive at 11.8 percent of G.D.P., while Australia’s is at 9 percent."
I guess there is no perfect healthcare system, but in my limited experience I am not surprised the Swiss system ended victorious. Having to cater for only 8 million people surely helps them though.
As a final remark - I bumped into another British expat over here a few weeks ago and he was walking on crutches after a hip replacement operation. When I asked him how he thought it would have played out on the NHS, he said he'd still be waiting to see a consultant!
I agree that it feels cruel to tell people "You must pay this much money for that amount/quality of healthcare", but I don't see any other working system. Maybe if you keep the price affordably low and give additional subsidies to the poorest individuals. As long as people have to pay, even if it's within their means, they'll try to be intelligent with going to the doctor.
I'm also a bit surprised they didn't also look at the Japanese system. I've heard it's good and the life expectancy figures match. However, I admit I haven't researched it in any detail.
I wouldn't read too much into that remark. The NHS has been underfunded for decades. There was a time when the NHS was one of the most cost effective healthcare systems in the world, but it's been seriously undermined by both Labour and Tory governments over the past 25 years. There's no reason it can't be a well-run healthcare system again, but it will take time to undo the damage that's been done.
If it was underfunded - especially for decades - then some of those things would be big problems, right?
I imagine that, if it were funded with another 1-2% of GDP it would truly excel more like the French system.
why is having fewer people more advantageous? to take that to the logical extreme, does a healthcare system that only caters to ONE person make sense? will it be cheaper than a system that serves 50 million?
if there are more patients, the fixed and overhead costs per person should go down, and the variable, healthcare costs per person remains the same but in fact everyone will benefit from risk pooling.
This is wrong. It does not matter how much I earn. (Nassim Taleb is right, New York Times is no good.) Healthcare is pegged to income in Germany but definitely not in Switzerland. I pay 279 CHF (300 USD) per month and pay all bills up to 2500 CHF per year myself. If my health-related costs during the year exceeds 2500 CHF the insurance kicks in and starts paying. In this way, people don't go to the doctor for tiny things but quickly go to see one for serious stuff. All health-related costs are deductible from my income tax.
More about "health insurance" in Switzerland in my blog post that I wrote after moving to Zurich in 2014: https://medium.com/@iwaninzurich/eight-reasons-why-i-moved-t...
For example the way each system delivers primary care is quite different. In some systems, GP visits are free but very bureaucratic. You have to make an appointment a week in advance. Does not matter if your appendix is bursting. If you go to the ER they will send you to get a referral from an emergency GP clinic. In other countries GPs are just private clinics and it works just fine without any insurance.
I particularly do not like how employment is sometimes intertwined with health insurance. It is just a bureaucratic mess.
These systems seem to exist primarily in the minds of conservative Americans. In years of traveling and living abroad, I have yet to encounter anyone who lives under one.
I'm not saying that they don't exist. I'm just saying that they're most commonly encountered on Fox News.
The US may not require appointments, but US insurers will find themselves in the media on a regular basis for such gems as:
"car accident victim flown to hospital denied insurance coverage because the flight wasn't pre-authorized"
Waits for GP appointments can be longer, but they all have slots open first thing in the morning if you need to be seen same day for something urgent.
The US is by far the most bureaucratic system imo. So much time and money spent on billing, collections, insurance administration, etc.
I genuinely do not think there is a single country in the world that would send someone out of ER if they had an appendix bursting. Not sure how you could actually believe that was the case.
GP visits do generally require an appointment and you may need to wait for some days.
Prescriptions: Flat fee of less than £10 per prescription. There are many medical and means tested exemptions.
NHS Dental Care can be hard to find but is generally available with a three tier flat fee structure for a full treatment not per visit, again loads of exemptions. Eg ~£56 for an extraction or root canal.
Some anecdotes:
A few years ago I had a wisdom tooth problem that hit on the weekend which is out of hours for dentists. I rang 111 and was referred across county (40 min drive). The tooth was extracted within 20 mins of me arriving. I don't remember whether I even had to pay but if I did then it would have been £50. If I'd been on benefits - no charge.
A few weeks ago I fell in my garden and hurt some ribs. It bloody hurt. To be on the safe side I went to A&E. 20 mins later I was triaged to the front of the queue and X rayed etc. Three hours later (I was obviously non crit) I was seen by a doctor and then discharged.
About eight years ago (very long story short) my dad was flown by helicopter from Exeter RD&E Hospital after a couple of weeks of stay to the Royal Brompton in London because the best cardiac surgeon for what he needed was based there. After a couple of months of care, surgery and recovery, his ticker is still going. Cost of care? who knows? A lot in six figures. It cost me a fortune in bus fares visiting the old boy.
I have many more but that gives you some idea. We habitually whinge about the NHS (OK: everything) here in the UK about waiting times but when the shit hits the fan - it is always there to pick you up and stick you back together.
I am not a specialist in medical issues, but I lived in Japan for many years. The health care was great for me.
Doctors are relatively autonomous. They get paid by the government (single payer?) plus a relatively small co-pay depending on your insurance (mostly based on employer).
Contributions from individuals vary from about $100 a year (for low income) up to maybe 4-5% of income at salaries most Japanese make ($25k to $100k usd). Employers also contribute.
I never felt financially fleeced, unlike the US (with great insurance, no less). I almost never had to wait -- just once for a few days for a minor surgery. The costs for treatment and meds were reasonable. The quality of care seemed comparable to or better than the US (for a young person, at least).
My only complaint was that doctors had a minor (but known) racket. If you had something that required 7 days of meds, they would give you a 3-day prescription and have you come back for a 1-minute second visit to get the other 4 days of prescription. A doctor friend told me that this was allowed and somewhat exploited because doctors were paid per visit. My doctor friend also told me that this was a way to balance payments -- that is, they would take longer on the initial visit to get the right diagnosis, but then they needed you to come in for the minor visits to get paid correctly for the time. Minor inconvenience, imho.
I also have friends who made sure to have their medical stuff done before they left Japan -- child delivery, hip replacement, lots of dental, etc.
Any other Japan folks have positive or negative stories to share? What about other Asian countries?
I'd also like to know what protection each system provides against personal bankruptcy.
And which system allows life saving therapy for those .01 percenters for whom a cure is available but extremely expensive or inconvenient (e.g. hepatitis C vaccine or CAR-T therapy). At what percentiles are those lines drawn? How to the programs compare?
(For example, I have the sense that Canada disallows a larger fraction of expensive treatments and delays treatments longer than most other systems, especially near end of life.)
It's long out of print, but (ahem) I imagine you could download a copy that would run fine under DOSBox if you looked on the right Web sites. Hypothetically speaking, I mean.
For instance, say you choose to block grant Medicaid to states (a frequent proposal this year). Those block grants are a significant reduction compared to projected spending under current law.
But if states are individually deciding how to deal with reductions and what to do with the funds they do continue to receive, how do you assess the outcome of that policy decision?
And then how do you put that on a slider widget?
I've heard it suggested that one of the dysfunctions of the US system is to detect cancers that would never have caused the patient any harm, leading to stress and needless medical interventions and expense. This improves both your metrics without actually improving healthcare, possibly actively making it worse, even before accounting for cost.
But have a look at "most common cause of female death" here: https://visual.ons.gov.uk/causes-of-death-over-100-years/
Cancer is the most common cause of death in women from age 30 to 79, and also from age 5 to 14.
(Brain tumors in children, breast cancer from age 30 to 54, and lung cancer from 55 to 79).
Advances in cancer detection (including working out which are the cancers that need to be treated) and treatment are going to save lives.
Also which particular cause of death "wins" may be more about taxonomy decisions about what gets lumped together (e.g. for the very youngest "other misc." is the biggest grouping) and, as a result, I would guess that any deaths due to e.g. an unnecessary mastectomy of a potentially benign tumor leading to surgical complications would end up listed under the same cause of death as one left entirely untreated.
So advances will save lives only if they're truly advances, and not just throwing shiny technology at the problem without a full understanding of the benefits and costs.
They seemed to judge the systems in likelihood of being accepted in the USA and presumably the Euro style welfare would have a tough time being accepted if anyone tried a transplant.
"In ancient China doctors were paid when their patients were kept well, not when they were sick. Believing that it was the doctor’s job to prevent disease, Chinese doctors often paid the patient if the patient lost his health."