Ezekiel J. Emanuel - Which country has the best health care in the world?

Which country has the worlds best health care system?

I get this question at almost every speech I give. Most of the time the question comes from someone who wants to know which country the United States should model itself after to create the worlds best system here at home. But sometimes I wonder whether Im really being asked a question about medical tourismwhether the questioner wants to know which country they should go to if they need to get some medical service, such as dental care, a hip replacement, or cataract surgery.

This is the type of question I usually love.

I rank everything. I rank the 10 best meals Ive ever had (#1 Alinea in Chicago, #2 Tanja Grandits in Basel, and #3 OCD in Tel-Aviv). I rank chocolates (#1 Askinosie, #2 Dick Taylor of California, and #3 Fruition of New York). I rank Alpine cheeses (#1 is a tie between Alpha Tolman and Alp Blossom). I rank colleges. I rank academic departments of bioethics and health policy that compete with my own. I rank the meals I cook, the races I run, the bike rides I take, the speeches I give.

I should love ranking health systems. But I dont. When asked, I answer, That is a terrible question. You cannot just take the worlds best system, whether it is the Dutch or Swiss or Norwegian or Australian one, and plunk it down in the United States and think we will get better health care. Health care is path dependent. We have built up numerous institutions over decades that constrain and limit our ability to change the system. And each country prioritizes different values that color which policy options they adopt. Some of these systems, like Norway, provide free insurance with no co-pays for children and people who need a lot of health care. Others, like the United States, emphasize making patients have more skin in the game. Some emphasize hospital-based care, others want more care in the home. Some, anticipating the aging of the population, have proactively instituted mandatory long-term care insurance. Others prioritize more comprehensive, free care for children. Still others are more passive, waiting for a crisis to stimulate policy changes.

Consider where the US system is now. About half of all Americans get their coverage through employer-sponsored insurance, with employers paying most of the premium as a pre-tax fringe benefit. (I use paying ironically because the money really comes from reduced worker wages. Although economists believe and can prove that, no one else seems to accept the idea.) The majority of other Americans are covered by 2 government-financed programs: Medicare and Medicaid. Nearly 5,000 private community hospitals and hundreds of thousands of privately employed physicians deliver care. Insurers organize these hospitals and physicians into preferred networks and adjust co-payments to encourage patients to stay in network. We have built up extensive networks of private home health care agencies and home hospices, commercial dialysis centers, ambulatory surgical centers, and skilled nursing facilities. Myriad governmental bodiesfrom state insurance commissioners and physician and nurse licensure boards to the federal Food and Drug Administration (FDA) and the Federal Trade Commissionregulate various components of the system. Private organizations, such as the Joint Commission and boards of medical and surgical specialties, help ensure quality of care. All these institutionsthe way they are paid, how they deliver care, and what they regulateshape how the system operates and constrain what reforms can be instituted.

Other countries lack many of these core features. Norway doesnt have a fragmented insurance market with employer-sponsored insurance, a separate government program for the elderly, and another one with different benefits for low-income individuals. Switzerland has an individual mandate to buy insurancebut not a tax exclusion to help people pay for it. Germany has employer-sponsored insurance; it also has no tax exclusion, but employer and employee contributions go to a single agency that then pays the insurance companies a uniform premium. Similarly, Germany has almost no health care provider networks or financial incentives to stay in network. We cannot eliminate preexisting institutional structures to become like the Norwegian or Swiss or German systems overnightor even over decades. One of the reasons the Clinton health care reform proposal in the early 1990s failed was because it tried to change too much of that preexisting institutional structure in one go. Insurers, some of which were threatened with extinction, fought back. These organizations would do the same today if we tried to adopt foreign health care systems.