In June, The Washington Post released a video and article in which freelance journalist James Fox asked seven top-flight experts: “Which country in the world has the best healthcare system?” When I prepared to open the video, I lashed myself to the mast and awaited the gale. Some years ago, health economist John Goodman crafted what he calls Goodman’s Law, which states, “When people begin to think about healthcare, their IQ drops by 15 points.” Let me offer Graboyes’ Amendment to Goodman’s Law: “When the discussion turns to which country in the world has the best healthcare system, IQ drops an additional 10 points.”
Instead, I was pleasantly surprised. The video was well-produced. The conversation was down-to-earth, with no pyrotechnics or bluster. The seven experts comprised a philosophically balanced cohort. Their comments were measured, thoughtful and nonpolitical. Both interviewer and interviewees were earnest in their desire to remain upbeat and reasonable. Anyone interested in the American healthcare debate ought to take 9 minutes, 14 seconds to listen to seven knowledgeable experts grapple with a question that dominates healthcare conversations.
That said, I think the question itself is counterproductive, and the responses—including those here—generally miss one of the most important points of all. More on that later. Meanwhile, here’s a synopsis of the video.
I could feel my blood pressure drop when the first interviewee, Austin Frakt (Boston University), answered, “I hate that question. Here’s where you should ask me why I hate that question.” Sherry Glied (New York University) followed: “I knew you were going to start with that question.” Leana Wen (George Washington University) parried: “It depends on what it is that we value.” And John McDonough (Harvard University) concluded the opening round with: “I don’t think there’s a correct answer to it.”
My pressure rose a bit when David Cutler (Harvard University) said, “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 [northward], you tend to get the best healthcare systems.” Frakt brought my pressure back down by noting that a few years back, he and four other healthcare experts did their own rankings (in March Madness bracket style), and they weren’t unanimous on a single pairing. Subjectivity ruled. My blood pressure spiked again when McDonough said: “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.”
“The rankings” that Cutler refers to are from the World Health Organization’s infamous World Health Report (2000). That report ranked France 1 and the United States a nonsensical 37, between Costa Rica (36) and Slovenia (38) and Cuba (39). That report was chaotically executed and bathed in ideology—structured to guarantee a low score for the United States. It was later excoriated by academic observers and renounced by some of its key editors, and whatever merits it might have had in 2000, it’s 21 years old to boot. Yet its findings continue to spread across the internet like radioactive dust. McDonough is bright and highly accomplished, but I’d rate his U.S.-is-dead-last comment as the single least defensible observation in the video.
Getting past the rankings tropes, we hear a string of pithy comments. Cutler: “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.” Glied: “I don’t think that there’s a system we could just bring over here and install like a new fridge.”
Katherine Baicker (University of Chicago) tries to redirect the conversation: “Maybe the better question is, what would the best system for the U.S. look like?” Others offer qualities that might inform the answer. Wen says it’s: “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?”
Amitabh Chandra (Harvard University) gives a classic response from economics: “Were the benefits of the treatment greater than the cost of the treatment?” At the same time, he recognizes that the answers lie beyond economics: “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 affects how you answer questions about what’s good and bad about healthcare.”
The conversation then turns to various aspects of fairness, spending levels, “socialized medicine” and “universal coverage,” and waiting lines for care. The video closes with two sharply contrasting views of U.S. healthcare. Wen says: “I hate to say it, but I think [people] are better off in many other countries than here in the U.S.” She’s immediately followed by a contrasting view from Chandra: “For a lot of diseases, for a lot of people regardless of income, [the United States] is probably the country where you would like to get your healthcare.” Those two statements aren’t mutually exclusive, but they hint at sharply differing perceptions of American care.
The Question’s the Problem
The problem with asking which country has the best health system is that the question itself is corrosive. The best response would be to adopt Frakt’s answer—“I hate that question”—and repeat it over and over until the questioner stops asking. But if you do so, you won’t appear in the video and no one will ever interview you again. So, like these seven panelists, you express your caveats about the question and do your level best to say something sensible.
Journalists love the question for the same reason they prefer to write article after article on the latest election polls rather than on the substantive policy differences between candidates. Poll-and-rankings stories are easy to write and easy for readers to comprehend, and they tend to be popular. They generate angry, simplistic responses ideally suited for Twitter storms. The World Health Organization rankings offer Americans ample opportunity for oikophobia (“The rankings prove that American healthcare is the worst.”) and oikophilia (“The rankings are garbage, and American healthcare is the best.”) Bluster crowds out serious, nuanced discussion. It would be better to focus on the specific features—good and bad—of each country, but that requires more work on the part of journalists and generates a smaller volume of the fulminant hot takes that drive advertising revenues.
I once summarized the problems with country healthcare rankings. That article linked to two outstanding takedowns of the WHO rankings’ foibles (“WHO’s Fooling Who?” and “The Worst Study Ever?”) and to an article noting that some of the WHO report was met with disdain at its writing and renounced by some of its own editors.
Philip Musgrove, the editor-in-chief of the WHO report that accompanied the rankings, calls the figures that resulted from this step ‘so many made-up numbers,’ and the result a ‘nonsense ranking.’ Dr. Musgrove, an economist who is now deputy editor of the journal Health Affairs, says he was hired to edit the report’s text but didn’t fully understand the methodology until after the report was released. After he left the WHO, he wrote an article in 2003 for the medical journal Lancet criticizing the rankings as ‘meaningless.’
Among other things, the report implicitly assumed that health is entirely determined by healthcare when, in fact, healthcare is far outweighed by other causal factors, including individual behavior, genetics, environment and social circumstances. As I noted in my article, the report’s data were “often obsolete, spurious, essentially conjured up by the authors, or self-reported by propaganda-prone governments.” And the rankings measured its authors’ ideological views of fairness more than they did the quality of care. “Other things being equal, WHO’s indexes would favor an egalitarian country where 100 percent of the population receives awful care over a less egalitarian country where 80 percent receive good care and 20 percent receive terrific care.”
One especially pernicious effect of the rankings game is that it drives most conversation toward an America-versus-Western Europe cheerleading competition, leading us to ignore some of the remarkable developments occurring in other countries. In East Africa, Rwanda pioneered the use of unmanned aerial vehicles (drones) for rapid deployment of blood products and other medical supplies. In India, the Narayana Health System delivers cardiac bypass surgery for 1/50 the price we pay in the developed world—with success rates equivalent to those of the top-tier U.S. hospitals. Across Africa, out of necessity, mobile health apps are now more widely used than in developed countries.
Having participated in innumerable discussions of “Which country in the world has the best health care system?”, I always feel that the question forces the participants and conversation into a clockwork universe—to put things in literary terminology. This literary structure was well-described in a brilliant essay on the great television serial, “Breaking Bad.” The essayist Emily Todd VanDerWerff puts it this way:
The ‘clockwork universe’ is a storytelling world where every single character and element is meant to contribute to the overall forward thrust of the story and its attendant themes. The characters may have rich inner lives. They may seem to have free will. But the more the workings of the story are poked at and pulled apart, the more the characters are revealed to primarily be there to play specific roles within it.
Describing the ultimate master of the clockwork universe as device, VanDerWerff continues: “In Shakespeare’s best tragedies, the characters all seem dimly aware they’re trapped in a Shakespearean tragedy and don’t know how to get out.”
And, so it is with the “which country has the best health care system” universe. As already noted, when we answer it, we mostly fall into predictable self-caricature, with people often either falling into “America is the worst” or “America is the best” mode. I’ll freely reveal my biases: Whenever I’m dragged into this infernal discussion, I tend toward the latter—praising what is best about America’s system and bashing what is worst about the systems in Western Europe and Canada. But I readily admit ambivalence and unease with the conversation.
For me, the biggest problem with the rankings game is that it drives all conversation toward a monomaniacal focus on today. In each country, how many people have health insurance today? What is life expectancy today? What’s the rate of infant mortality today? What are the costs of care today? How fair is healthcare financing today? (Using the WHO report exacerbates this problem, as it is a poorly executed snapshot from nearly a generation ago.)
What this omits is tomorrow. What will healthcare look like tomorrow (or 20 years from now)? What will costs be tomorrow? How long will tomorrow’s population live, and what will the state of their health be? These things are determined not by the resources and processes in place today, but rather by the process of innovation—technological and institutional changes. And how we provide care and pay for it today strongly affects what sort of care we will be able to provide in the future. Innovation does not simply occur autonomously. In fairness, the WHO report acknowledged the importance of innovation and its relationship to a country’s system of healthcare financing and management in several places.
Publicly subsidized production of consumables, pharmaceuticals and medical equipment often leads to low quality, lack of innovation, outmoded technology, inefficient production modalities and distribution delays.
Where there is a call for innovation and flexibility to respond to specific needs, as in the development of new drugs and equipment, markets are better. But direct market interactions between patients and providers in the health sector have the major disadvantage of exposing individuals to the financial risks of illness unless the financial resources are adequately pooled.
I read these statements as recognizing a conflict between egalitarianism and innovation—a conflict that I would argue is quite real. But these observations elicit only passing mention by the WHO. The rankings reward egalitarianism greatly and innovation not at all.
Without a doubt, America falls short of many countries on measures of egalitarianism. (Though on closer inspection, intended equality exceeds actual quality in many of those countries.) But innovation is where America shines above all other countries, and that success may rest on those features that the WHO and others deem to be highly unattractive.
U.S. healthcare is characterized by high spending, gaps in coverage, large profits and potential profits for providers, inegalitarian financing mechanisms, unequal provision of care across socioeconomic groups, and a population that demands rapid care and abhors rationing. But arguably, it is this basket of characteristics that drives American companies to generate new drugs, new devices, new medical procedures and new institutional arrangements for providing care.
Innovations originating in the U.S. not only benefit America, they benefit the rest of the world, today as well as future generations. In the past year, three American companies—Pfizer, Moderna and Johnson & Johnson—rescued the world from the grip of COVID-19 via the rapid and near-miraculous development and distribution of pathbreaking vaccines. (I happily note that Pfizer partnered with the German firm, BioNTech.) Telemedicine, as well as the use of a multitude of mobile health apps, proliferated during the pandemic, with much innovation coming from America. Countless other lifesaving technologies—many originating in the U.S.—also are out there or in development.
To get an idea of the mind-bending technologies we’ll likely see in the near future, read Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, by Eric Topol (Scripps Research). (Topol also expounds upon why, even in America, innovation in healthcare runs more slowly than it could. (Topol and I discuss these issues in this podcast.)
I’m not dogmatic about these points. Others might argue that America’s lead in innovation is not as great as I assume. They might add that the egalitarian impulses of Western Europe and Canada don’t, in fact, impair the rate of innovation. I’m happy to listen to or participate in such debates. The trouble is that the WHO’s World Health Report, among other things, focused public discussion on the present and on egalitarianism and sidelined the conversation on what healthcare might look like for future generations. We owe it to our children and grandchildren—and ourselves—to do better.