“Discussions of [health care system] reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a “private” system, or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings. [..]
Universal coverage matters, not how we get there.
[..] We have spent the last several decades fighting about health insurance coverage. [..] The only thing we seem able to focus on concerns insurance — who provides it, and who gets it.
No other country I’ve visited has these debates the way we do. Insurance is really just about moving money around. It’s the least important part of the health care system.
Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care. [..]
If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services.
Public delivery systems are essential, but so are private options.
If you choose to get care in a public system, you often have to wait in line. Most often, the wait doesn’t lead to worse outcomes, and people accept it because it’s much cheaper than paying for private hospital care. Those who don’t want to wait, or feel they can’t, can pay more to jump the queue.
In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But “more” isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning.
[..] allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.
Strong social policies matter.
[..] I met with Adam Elshaug, a professor in health policy at the Melbourne School of Population and Global Health. When I asked about Australia’s rather impressive health outcomes, he said that while “Australia’s mortality that is amenable to, or influenced by, the health care system specifically is good, it’s not fundamentally better than that seen in peer O.E.C.D. countries, the U.S. excepted. Rather, Australia’s public health, social policy and living standards are more responsible for outcomes.”
Addressing these issues in the United States would require significant investment, to the tune of hundreds of billions or even trillions of dollars a year. That seems impossible until you remember that we spent more than $4.4 trillion on health care in 2022. We just don’t think of social policies like housing, food and education as health care.
Other countries, on the other hand, recognize that these issues are just as important, if not more so, than hospitals, drugs and doctors. Our narrow view too often defines health care as what you get when you’re sick, not what you might need to remain well.
When other countries choose to spend less on their health care systems (and it is a choice), they take the money they save and invest it in programs that benefit their citizens by improving social determinants of health. [..]
We are already doing what other countries can’t.
[..] When I asked experts in each of these countries what might improve the areas where they are deficient (for instance, the N.H.S. has been struggling quite a bit as of late), they all replied the same way: more money. Some of them lack the political will to allocate those funds. Others can’t make major investments without drawing from other priorities. [..]
We currently spend about 18 percent of G.D.P. on health care. That’s almost $12,000 per American. It’s about twice what other countries currently spend.
With that much money, any of these countries could likely solve the issues it faces. But spending substantially more on health care is something they feel they cannot do. We obviously don’t have that issue, but it’s intolerable that we get so little for what we spend.
We cannot seem to do what other countries think is easy, while we’ve happily decided to do what other countries think is impossible. [..]
We’ve already decided to spend the money; we just need to spend it better.”
Full article, AE Carroll, New York Times, 2023.6.13