The Best Health Care System in the World
“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats. This is often accompanied by calls to match the health care coverage of "the rest of the world." But this overlooks a crucial fact: The “rest of the world” is not all alike. The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.
Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament. We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.
So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts' selections will decide who advances). When we cite hard data, they come from the Commonwealth Fund’s International Country Comparison in 2017.
Canada vs. Britain: Single-Payer Showdown
Both have single-payer systems, but vary in the government’s role and in what is covered. In Canada, the government finances health insurance, and the private sector delivers a lot of the care. Insurance is run at the province level. Many Canadians have supplemental private insurance through their jobs to help pay for prescription drugs, dentists and optometry. The government ends up paying for about 70 percent of health care spending in all.
Britain has truly socialized medicine: The government not only finances care, but also provides it through the National Health Service. Coverage is broad, and most services are free to citizens, with the system financed by taxes, though there is a private system that runs alongside the public one. About 10 percent buy private insurance. Government spending accounts for more than 80 percent of all health care spending.
U.S. analogues are Medicare (more like Canada) and the Veterans Health Administration (more like Britain). Canada and Britain are pretty similar in terms of spending — both spend just over 10 percent of G.D.P. on health care. They also have reasonably similar results on quality, although neither ranks near the top in the usual international comparisons. In terms of access, though, Britain excels, with shorter wait times and fewer access barriers due to cost.
U.S. vs. Singapore: A Mix of Ideas
The United States has a mix of clashing ideas: private insurance through employment; single-payer Medicare mainly for those 65 and older; state-managed Medicaid for many low-income people; private insurance through exchanges set up by the Affordable Care Act; as well as about 28 million people without any insurance at all. Hospitals are private, except for those run by the Veterans Health Administration.
Singapore has a unique approach. Basic care in government-run hospital wards is cheap, sometimes free, with more deluxe care in private rooms available for those paying extra. Singapore’s workers contribute around 37 percent of their wages to mandated savings accounts that may be spent on health care, housing, insurance, investment or education, with part of that being an employer contribution. The government, which helps control costs, is involved in decisions about investing in new technology. It also uses bulk purchasing power to spend less on drugs, controls the number of medical students and physicians in the country, and helps decide how much they can earn.
Singapore’s system costs far less than America's (4.9 percent of G.D.P. versus 17.2 percent). Singapore doesn’t release the same data as most other advanced nations, although it’s widely thought that it provides pretty good care for a small amount of spending. Others counter that access and quality vary, with wide disparities between those at the top and bottom of the socioeconomic ladder.
France vs. Australia: Everyone Covered
The list of services covered in France is more extensive than in Australia -- perhaps more than in any other health care system. Australia has the advantage in expense. Australia provides free inpatient care in public hospitals, access to most medical services and prescription drugs. There is also voluntary private health insurance, giving access to private hospitals and to some services the public system does not cover.
The government pays for at least 85 percent of outpatient services, and for 75 percent of the medical fee schedule for private patients who use public hospitals. Patients must pay out of pocket for whatever isn’t covered. Most doctors are self-employed, work in groups and are paid fee-for-service. More than half of hospitals are public.
Everyone in France must buy health insurance, sold by a small number of nonprofit funds, which are largely financed through taxes. Public insurance covers between 70 percent and 80 percent of costs. Voluntary health insurance can cover the rest, leaving out-of-pocket payments relatively low. About 95 percent of the population has voluntary coverage, through jobs or with the help of means-tested vouchers. The Ministry of Health sets funds and budgets; it also regulates the number of hospital beds, what equipment is purchased and how many medical students are trained. The ministry sets prices for procedures and drugs.
The French health system is relatively expensive at 11.8 percent of G.D.P., while Australia’s is at 9 percent. Access and quality are excellent in both systems.
Switzerland vs. Germany: Neighborly Rivalry
Germany’s system and Switzerland’s have a lot in common. Germany has slightly better access, especially with respect to costs. Switzerland has higher levels of cost-sharing, but its outcomes are hard to beat — arguably the best in the world.
Like every country here except the U.S., Switzerland has a universal health care system, requiring all to buy insurance. The plans resemble those in the United States under the Affordable Care Act: offered by private insurance companies, community rated and guaranteed-issue, with prices varying by things like breadth of network, size of deductible and ease of seeing a specialist. Almost 30 percent of people get subsidies offsetting the cost of premiums, on a sliding scale pegged to income. Although these plans are offered on a nonprofit basis, insurers can also offer coverage on a for-profit basis, providing additional services and more choice in hospitals. For these voluntary plans, insurance companies may vary benefits and premiums; they also can deny coverage to people with chronic conditions. Most doctors work on a national fee-for-service scale, and patients have considerable choice of doctors, unless they've selected a managed-care plan.
A majority of Germans (86 percent) get their coverage primarily though the national public system, with others choosing voluntary private health insurance. Most premiums for the public system are based on income and paid for by employers and employees, with subsidies available but capped at earnings of about $65,000. Patients have a lot of choice among doctors and hospitals, and cost sharing is quite low. It's capped for low-income people, reduced for care of those with chronic illnesses, and nonexistent for services to children. There are no subsidies for private health insurance, but the government regulates premiums, which can be higher for people with pre-existing conditions. Private insurers charge premiums on an actuarial basiswhen they first enroll a customer, and subsequently raise premiums only as a function of age — not health status. Most physicians work in a fee-for-service setting based on negotiated rates, and there are limits on what they can be paid annually.
Both systems cost their countries about 11 percent of G.D.P.
Conclusion
Germany would have tied Switzerland had we averaged our rankings of the nations instead of using head-to-head matchups in a bracket system (Switzerland eliminated Germany in the first round). It’s an example of how close the voting was. Not one vote was unanimous among the judges, and all the semifinal and final votes were 3-2. Clearly, there is room for disagreement about the relative merits of health systems, and different experts would surely reach different conclusions.
Some judges took a global view, giving the edge to countries, like the United States, that promoted innovation that benefited the rest of the world. In other cases, how health systems treated the poorest of society was paramount. To nobody’s surprise, the United States could do better at balancing health care costs with access, quality and outcomes. But there are many ways to reach that goal, and there will always be trade-offs. Learning about them from other systems and debating them honestly would probably do us a lot of good.
We hope that readers will consider this to be merely the beginning of a discussion, not the end. We welcome your questions or comments. In fact, we look forward to writing articles in which we answer those questions and ask other experts with different views to weigh in.
Have you experienced a health system outside the United States? Tell us its best or worst feature. And what advice would you give Americans?
Aaron E. Carroll