- 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.
