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 going to start with that question i think it's a question that a lot of people ask which country has the best healthcare system and 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 healthcare systems but the reason why it's not entirely applicable is that what works in one country may not work in another country so a number of years ago 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 uh march madness is a bracket tournament or like a tennis tournament and we had me and aaron over reinhardt a shisha physician now dean of brown and craig garthwaite an economist at northwestern and we each voted in each of the brackets like in each of the the pairings for which system we liked better and then like we ultimately got a winner but one of the important takeaways from that whole process is that in no pairing did any country win five to zero 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 three to two and we each had different reasons you know someone was very uh big on like the cost equity access or the quality and so to me like look this is five people who who know healthcare 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 you know there are 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 u. s look like and what would that look like so good a good health care system or a good yeah let's just call it a health care system a good health care system has i think 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 a really questionable health benefit at the same time that it has underspending 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 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 just a it's an answer that we all have within us but that answer profoundly affects 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 that that the next question should be like can we get there from here and i don't 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 u. s germany canada look similar in terms of what share of gdp goes to health care and they are all living people are living about 35 years after age 40.
okay fast forward 20 years and the u. s 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 healthcare 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 another system's care is terrible you know 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 a single-payer the government operates all the healthcare 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 not government owned in 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 kind 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 that 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 u.
