The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt. In this post we respond to readers’ questions about the bracket tournament on the best health system in the world.
TRANQUILLITY OF SPIRIT
I have both French and American passports. Americans should understand the tranquillity of spirit that truly universal health care brings to a population. People have worries … but not about losing everything because of an illness. — Bob Nelson, Calais, France
I’m British. For me the idea that “Can I afford to accept treatment?” is bizarre. And harsh. If you’ll forgive me for saying so, the U.S. system has a sense of selfishness to it. Your country seems to have lost your sense of “together.” Rather, it looks like “everyone for themselves.” — Arthur, Glasgow
Austin and Aaron respond: You are certainly not the only people to feel that way, but it seems many Americans value choice over security. This includes plentiful options for health insurance, including the “choice” to be uninsured. This freedom comes with at least three kinds of costs. First, it’s more than just a headache to choose a health plan. Studies show people — even experts — are terrible at doing so, routinely picking plans that aren’t the best for them. Second, the vast array of health plans with varying requirements and protocols impose administrative costs on physicians and hospitals. By one estimate, the administrative complexity of the U.S. health care system adds nearly $300 billion per year in avoidable costs. Third, strong results from the Oregon Medicaid study (a randomized trial of access to Medicaid coverage) include that the program significantly reduced the financial risk of poor health and improved mental health. It’s safe to say that the U.S. health care system may be many things, but tranquil isn’t one of them.
I have practiced medicine for nearly 40 years, mostly in a large academic health center. The frictional administrative costs of multiple insurers, each with its own forms, rules, payment, denials and appeals apparatus, highly paid C-suites, shareholders, etc., and the counterpart to this required by all providers in order to get paid — billers, coders, compliance folks, etc. — is a colossal waste and does nothing to enhance access or quality of care. — Concerned MD, Pennsylvania
I chose France, for many reasons, but primarily because their system is well organized and administered, which results in better and more efficient care for patients. Check out their “card of life,” which contains timely, accessible and secure health care/financial info and speeds payment to doctors and hospitals. Far less paper and insurance hassles and denials. — Scott, Port St. Lucie
Austin and Aaron respond:
In a comparison of the U.S. and Canadian health systems, scholars at Harvard concluded that the commercial health care market in the United States imposes inefficiently high administrative costs. One reason they’re not lower is that no single insurer can move the system toward efficiency — it’s a collective action problem. But some of the high cost imposed on doctors and hospitals may benefit insurers, since they lead to delayed payments and denial of claims.
Patients are caught in the middle when health care providers and insurers bicker over claims and care. That kind of tussle seems to be reduced when the provider is the insurer — as when a hospital system offers a health plan. This is more evidence that the organization of health systems and coverage can make a difference in consumers’ experience, just as the commenters suggest.
However, we should be careful not to think there are too many savings to be had by removing just any kind of administrative waste. A number of advocates have argued that by removing medical underwriting and individual rating, insurers would be much more efficient and save money. After the Affordable Care Act imposed guaranteed issue and community ratings, huge savings did not result. Further, one person’s waste is another person’s job. The trade-offs can’t be ignored.
THE SWEET SPOT IS REGULATED NONPROFITS?
Based on personal experience with the German health care system and my sister’s personal experience with the Swiss system: Both systems use competing nonprofit private companies (that is the key) that are heavily regulated. A highly regulated nonprofit company is an efficient compromise construction between a government single-payer system (not exposed to competition) and between a free market of competing, unregulated, for-profit health insurance companies. — Gerhard, NY
Austin and Aaron respond:
This may be entirely correct. Let’s remember that Switzerland won the battle, and most people in that country do have insurance from a regulated market of guaranteed-issue, community-rated nonprofit private insurance companies. Many components of the United States health care system are nonprofit, too, and there’s a robust literature on how nonprofit and for-profit entities fare relative to each other. For instance, there appears to be a relationship between the availability of nonprofit nursing homes in an area and levels of consumer welfare. A “review of systematic reviews” of profit versus nonprofit hospitals found that for certain outcomes nonprofit hospitals performed better. Overall quality and efficiency differences could not be determined, though. In general, however, it appears that for-profit entities focus on cost (pushing it lower) while nonprofits focus on quality (pushing it higher). There are always trade-offs, and we in the U.S. have generally favored the latter.
WHAT ABOUT THE DUTCH?
Weird how you picked the U.K. and Germany but not the Netherlands. According to the annual Euro Health Consumer Index (E.H.C.I.), the Netherlands systematically has the best health care in Europe — yes, better than Switzerland, year on year, and with the U.K. at 14th sandwiched between Portugal (13th) and the Czech Republic (15th). — Rdeman, London
Austin and Aaron respond: There are, of course, more countries than we had space to discuss. We tried to pick countries that varied across the spectrum from socialized to privatized. Though we welcome delving more deeply into some of these other countries, aspects of them are close to those of the ones we’ve already discussed. The Netherlands, like many other countries, has a health care system along what the Princeton professor Uwe Reinhardt calls the “Bismarckian model,” in which health insurance is mandated from one of a small number of tightly regulated nonprofits.
People also can buy voluntary insurance above that, which covers things not covered by statutory insurance. The country spends about 12 percent of gross domestic product on health care, and out-of-pocket payments are quite low. How it would have compared in this battle isn’t clear, but we think it would have done pretty well.
BEING INJURED ABROAD
We received many, many testimonials from American readers who received good treatment at reasonable prices (and no payment troubles) while living abroad or traveling. By contrast, one reader from Australia advised that all visitors to the United States “carry travel insurance,” and a Canadian expressed surprise (below) at what awaited him after he broke his neck on a visit to the U.S.
Five years ago I fell off a rock and broke my hip while vacationing in Ireland. An ambulance took me to the hospital. Needless to say, my biggest worry was how am I going to pay for this. I was distraught. I had no coverage in the USA. The staff at the hospital were very kind and assured me I would be O.K. They replaced my hip, and when it was time to leave, they asked if I could pay $600. No other bills arriving four months later, like in the USA. $600, one bill, Done! Jaw-dropping amazing. I am grateful to Ireland, thank you! — Golf Pork, Seattle
I live in British Columbia. Some years ago I broke my neck in a motor vehicle accident in Washington State. I received excellent treatment and had the comfort of knowing that my British Columbia government health insurance would cover all expenses, even out of country. I was, however, taken aback when the first person I met in the emergency ward had a clipboard and was asking me how I would pay for all this. I had never before faced this question. — David Paterson, Vancouver
Austin and Aaron respond: We hesitate to allow anecdotes to define a health care system. What matters is the overall experience. T.R. Reid wrote an amazing book on this subject in 2009, though, which was reviewed in The New York Times.
Another problem with anecdotes about overseas health care excellence is that they can always be countered by people who came to the United States because they couldn’t get good care in their country. We hear all the time about how people from Canada flock to the United States when wait times are too long. Those stories are almost always exceptions, not the rule, as a great paper in Health Affairs showed.
It’s interesting to note, though, that most of the stories in the comments are driven by the “shock” of Americans when they can receive high-quality, reasonably priced health care in other countries. We’ve been conditioned to believe that the only choices available are our system or utter chaos. This exercise was designed to show otherwise. There are lots of other choices available, many of them are good, and some that are probably better.