I got my start as a blogger. But more specifically, I got my start as a health policy blogger. My first piece of writing I remember people really caring about was a series called “The Health of Nations,” in which I checked out books from the college library, downloaded international reports, and profiled the world’s leading health systems. It was crude stuff, but it taught me a lot. The way we do health care isn’t the only way to do health care. It’s not the best way. Or the second best, or the third.
Ezekiel Emanuel is a bioethicist, oncologist, and co-director of the University of Pennsylvania’s Health Transformation Institute. He was a top health policy adviser in the Obama administration, he’s a senior fellow at the Center for American progress, he makes his own artisanal chocolate, and he’s got a new book — Which Country Has the World’s Best Healthcare? — where he goes into more detail than I ever did, or could, to profile other health systems and rank them against our own.
So this conversation on The Ezra Klein Show is about which country has the world’s best health system. But it’s also about how innovation in health care actually works, whether there’s any evidence that private insurers add actual value, whether health care is the best investment to make in improving health (spoiler: no), how do you improve a health system when half of the political system will fight like hell against those improvements, and much more.
Emanuel has also been doing a lot of work on coronavirus policy, so we spend some time there, discussing the question that’s tormenting me now: Are we simply giving up that fight? And is there even a politically viable option to giving up, given how much time the government has wasted and how exhausted the public is?
An edited excerpt from our conversation follows. The full conversation can be heard on The Ezra Klein Show.
Let’s do it. Which country has the best health care system?
I know this is an evasive answer, but the honest truth is it depends what your criteria are and what you actually care about. If you’re a health policy wonk, a lot of what you’ll care about is: Do you get universal coverage and how expensive is it? Do you have some mechanism to control the total expenditures in the country? By that criteria, we don’t do well but other countries do well.
A lot of people care about: Do I have choice of doctor and hospital unlimited choice? By that criteria, places like Germany or Switzerland or France are at the top. Other people don’t want to have co-pays at the point of care and no deductibles. There you see that Britain and Canada and, at least for public hospitals, Australia are good. Some people want low drug prices. For that, you’ve got Norway, Taiwan, Australia. Some people want no waiting times. Well, obviously, Canada, Norway, Britain are not on your list but Switzerland and Germany are very high on your list.
It really depends what the criteria or set of criteria are.
Because I read the book, I was ready for your evasive answer here. Which system would you want to buy into? Given your preferences, whatever they may be.
Probably the Netherlands, if you’re forcing me to choose. I think that they have a very good combination: you get to choose your private insurer, you get to choose your primary care doctor. And their primary care doctors are really gatekeepers to a higher level of care. They’re also innovative. So I think they’ve got a very good system. But there are lots of other alternatives I’d be more than happy with.
My sense of the Netherlands is it’s what would happen if you made Obamacare exchanges a nationwide system and subsidized them properly. Is that basically right?
Yeah, it’s either the exchanges or it’s Medicare Advantage made national. But yes, it’s making an exchange national and then providing high levels of subsidies for people to buy in. That’s why health policy wonks like me like it.
Which system would you want to be poor in?
I think Britain or Norway. If you’re poor, those are very good subsidized systems. You can also get away pretty well if you’re poor in Australia. I’d say a place that’s not so great is Switzerland, which has private insurance and the subsidies are good but not great.
What system would you want to be in 15 years from now?
I think one of the important points is long-term care. And 15 years from now, I will be 77 and worrying about long-term care.
The Germans and the Dutch are the two that we looked at that have dedicated financing for long-term care, and both are emphasizing aging in place (aging in your own home or your relatives’ home). Unlike every other country we looked at, they have secured the financing for long-term care.
I think most other countries, whether the United States or Britain or Australia, and especially China, are really muddling through. And the consequence is a very large burden on people who have relatives who are aging. If you really care about your children not having to care for you when you age, having this dedicated financing mechanism is more important.
I’ll be honest that I had an ulterior motive on that question. You write in the book that “in the next decade or two, the US will again become one of the best systems in the world” which was a sentence that genuinely surprised me.
If you made me take the bet, I would take a hard under on that. But make the case. Why should I believe that 15 years from now the US will be not the second to worst system that your team looked at behind China?
Because I think we have a lot of innovation happening in our system. We have a lot of innovation not focused on drugs and devices or new surgical procedures or new imaging tests — we have that, too. But I think we have a lot of innovation and experimentation going on with how to pay for care differently and how to deliver care differently. I think we have some very successful models on chronic care coordination and are beginning to sort out some important advances related to mental health care. The real challenge for the US is to get those things generalized and adapted.
Now, there are many things that can torpedo that progress. We have a lot of interests that would be challenged — hospitals being one of them. I would just note that a lot of hospitals are seeing decreases in occupancy and probably some of them need to close and shift to outpatient care. I think we’ve seen a lot of that happening because of Covid. And I think it will continue to happen.
If we wanted to increase life expectancy or some other indicator of healthy well-being over the next 10 years, should that be a conversation about our health insurance and health care system? Or should it be a conversation about something else?
Health care adds 10, 20, on a good day, 30 percent to health outcomes and longevity; other things — education, employment, housing, nutrition, exercise, not smoking, driving safely — add a lot more.
The highest return investment that the United States can make is in early childhood interventions, especially for children born into poverty, which is now 40 to 50 percent of the American birth cohort. So one of the immediate things I would do is make it a requirement for Medicaid. To get Medicaid, you have to provide early childhood interventions for at least two years to every child born on Medicaid. And once they’re born on Medicaid, they have to get that benefit for two years, whether they go off of Medicaid or not. Those early childhood interventions, as Jim Heckman at the University of Chicago has shown, returned $7 to $15 per kid. So that’s one intervention I would do.
I would also make child care veritably free. That experiment has been tried in Montreal. It actually pays for itself very quickly. That is a huge second investment I would make. A third investment I would make is to make pre-K universal, required, and free. So you can see all of my investments are investing in kids.