To put into context Democrats' growing calls for "Medicare for all," the New York Times' Aaron Carroll and Austin Frakt assembled a panel of five health policy experts to assess and rank the health care systems of eight nations: Australia, Britain, Canada, France, Germany, Singapore, Switzerland, and the United States.
Writing in the Times' "The Upshot," Frakt and Carroll point out that proponents of "Medicare for all" often say that it would bring the United States into alignment with how health care is delivered in "the rest of the world."
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But while it is true that many other countries offer universal coverage, Frakt and Carroll write that developed nations vary widely in how they approach the concept, with some leaning toward single-payer systems, others toward private insurers, and a few in between.
To help illuminate which approach is "best," the panel selected eight countries that represent a range of health care systems to square off in a bracket-style competition.
The expert panel included:
- Carroll, a health care researcher and professor of pediatrics at Indiana University School of Medicine;
- Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University's School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health;
- Craig Garthwaite, a health economist at Northwestern University's Kellogg School of Management;
- Uwe Reinhardt, a health economist at Princeton University's Woodrow Wilson School of Public and International Affairs; and
- Ashish Jha, a physician at the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute.
Breaking down the competition
In the first round of competition:
- Britain defeats Canada: The judges voted 4 to 1 in favor of Britain's single-payer system over Canada's single-payer system, citing factors such as the British system's greater efficiency, competition, and access to care;
- The United States beats Singapore: The judges voted 3 to 2 in favor of the United States' mix of government and private insurance over Singapore's mix, citing factors such as the Singapore system's reliance on mandated savings accounts, a lack of data on the system, and poorer outcomes for certain conditions—as well as the United States' greater innovation;
- France defeats Australia: The judges voted 4 to 1 in favor of France's universal coverage mandate and mix of public and private insurance over Australia's public and private mix of coverage, citing factors such as France's greater range of services covered, greater competition, and improved access to care; and
- Switzerland beats Germany: The judges voted 3 to 2 in favor of Switzerland's heavily regulated private system over Germany's mix of public and private offerings, citing factors such as Switzerland's greater competition, outcomes, and performance on quality measures.
In the second round of competition:
- Switzerland defeats Britain: The judges voted 3 to 2 in favor of Switzerland over Britain, with Switzerland's better access to care and patient outcomes beating out Britain's lower costs; and
- France beats the United States: The judges voted 3 to 2 in favor of France over the United States, with France's cost efficiency and greater equability beating out the United States' greater innovation and better quality of care.
And in the final round, Switzerland emerged triumphant, as the judges ruled in favor of its highly competitive market over France's "impressively comprehensive" system.
According to the judges, Switzerland not only successfully combines "conservative and progressive beliefs about health care systems in a workable model," but it also provides a feasible model for the United States, given its similarity to the Affordable Care Act—and it provides a "higher quality of care across a range of measures" and generates more innovation than does the French system.
According to the Times, the close vote underscores the "room for disagreement about the relative merits of health systems." Some judges favored a broad view of health care quality, focusing on factors such as innovation, while others adopted a narrower outlook, assessing factors such as how a country provides care for the most low-income citizens.
Ultimately, however, the experts concluded that there are "many ways to reach that goal [of universal coverage], and there will always be trade-offs." And the competition provides a good starting point for assessing those trade-offs, the Times concludes.
'What a health care system ought to do'
Writing on his blog, Jha delves deeper into how he defines an "ideal health care system," arguing that it's less about the organization of the system and more about overall outcomes. In other words, "How well does [a health care system] do what a health care system ought to do?"
He explains that while "it's important to think about boundaries (what is the responsibility of the health care system and what isn't)," it is also necessary "to consider whether the system is delivering what people need: coverage of a broad range of services, especially those that are important for the sickest among us, timely access to affordable, high quality care, and innovation that ensures care gets better over time."
In fact, "for most people, whether the system is market-based or government-run matters a lot less than whether it's meeting their needs," Jha concludes. "And that's the way it should be" (Carroll/Frakt, "The Upshot," New York Times, 9/18; Jha, An Ounce of Evidence, 9/18).
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