- 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 gonna start with that question.
I think it's a question that a lot of people ask --
which country has the best health care system?
- 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, 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 a tennis tournament.
And we had me and Aaron, Uwe Reinhardt, Ashish Jha --
a physician, now Dean of Brown --
and Craig Garthwaite -- an economist at Northwestern.
And we each voted in each of the brackets --
in each of the pairings --
for which system we liked better.
And we ultimately got a winner, but one of the important
take-aways from that whole process
is that in no pairing did any country win 5 to 0.
There were five of us, right?
We were not unanimous in any decision.
There was always at least someone who disagreed,
and in many cases, it was 3 to 2.
And we each had different reasons.
Someone was very big on the cost, equity, access,
or the quality.
Look, this is five people who know health care pretty well
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, 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, a good health care system or a good --
Yeah, let's just call it a health care system.
A good health care system has, 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 under-spending 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 a 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 an answer that we all have within us.
But that answer profoundly effects 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 next question should be, can we get there from here?
And 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 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,
in other systems, care is terrible.
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 the single payer.
The government operates all the health care,
and people belong to a single government system.
- 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 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 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 has collapsed to the level 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 candidate 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 the 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.