
The Best Health Care System in the World - rafaelc
https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news&_r=0
======
chadash
___Spoiler alert_ __

They conclude that Switzerland is the best system in the world.

But different judges seem to have different priorities and it's clear that at
least some of them are judging not the best healthcare system in terms of just
cost or quality of care, but on how feasibly the foreign system could be
implemented in the United States.

In any case, it's a stupid metric. Unless there was a single healthcare system
that had the best healthcare at the lowest cost, which I think is the
combination that most people are looking for, there is clearly no objectively
"best" system. Even determining things like quality care in the first place is
difficult.

Still, it was interesting to read comparisons of the various countries' health
systems. It's a worthwhile read.

~~~
Y7ZCQtNo39
If you live the United States, it is not a stupid metric. We should be focused
on improving our system in ways that realistic and possible to achieve.

Discussion of great ideas that could never be implemented would be largely
academic when considering how the American system can be improved.

~~~
RobertoG
Fair enough, but, at least, they should speak about how those reference
countries are doing against the rest.

In the World Health Organization ranking (1), of all the countries compared in
the article, the only one that appears between the first ten in any of the
categories (except cost) is France and, in only one metric, Australia and the
UK.

Not pointing that seems a strange omission.

1\.
[https://en.wikipedia.org/wiki/World_Health_Organization_rank...](https://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems_in_2000)

~~~
smcl
That's not correct - are we looking at the same table? There are more of the
reference countries in the top 10 of the various categories (except cost).
Here's the number of times each appear in the top ten categories in the
Wikipedia article you posted:

Canada: 1

Singapore: 1

Germany: 0

Switzerland: 3

France: 3

UK: 2

Australia: 1

The other larger* countries that feature in the top-ten of these categories -
Japan, Sweden, Spain, Austria - all have universal healthcare. I'm not sure
where you stand, but it seems that no matter how you slice it Americans are
getting a raw deal with their healthcare.

* = those roughly the same population as the smallest country on the list - Switzerland - or more

~~~
RobertoG
You are right, I was wrong.

Specifically, I don't know how I missed Switzerland there. Obviously, I should
double check before posting.

------
planetjones
The Swiss health system is very good in terms of treatment, but the costs are
rising every year by 5-6%. It is also a two tier system - everyone must pay
for basic health insurance, but supplementary cover is extra and is subject to
acceptance. This means that you may not be able to get the latest cancer
drugs, latest technology or be treated by the senior doctors unless you have
the supplementary cover. I don't offer a better solution; but merely state the
facts.

I guess there is no perfect healthcare system, but in my limited experience I
am not surprised the Swiss system ended victorious. Having to cater for only 8
million people surely helps them though.

As a final remark - I bumped into another British expat over here a few weeks
ago and he was walking on crutches after a hip replacement operation. When I
asked him how he thought it would have played out on the NHS, he said he'd
still be waiting to see a consultant!

~~~
ZenoArrow
> "As a final remark - I bumped into another British expat over here a few
> weeks ago and he was walking on crutches after a hip replacement operation.
> When I asked him how he thought it would have played out on the NHS, he said
> he'd still be waiting to see a consultant!"

I wouldn't read too much into that remark. The NHS has been underfunded for
decades. There was a time when the NHS was one of the most cost effective
healthcare systems in the world, but it's been seriously undermined by both
Labour and Tory governments over the past 25 years. There's no reason it can't
be a well-run healthcare system again, but it will take time to undo the
damage that's been done.

~~~
caseysoftware
The health/economic experts in the article cite the British system for its
quality, efficiency, competitiveness, and access. If that's true, it's sounds
like it's funded "enough" for the current responsibilities.

If it was underfunded - especially for decades - then some of those things
would be big problems, right?

~~~
jaggederest
I think it's more of a credit to the British system that, even underfunded
relative to ideal the NHS produces still excellent outcomes.

I imagine that, if it were funded with another 1-2% of GDP it would truly
excel more like the French system.

------
mwj
Having grown up in Australia and lived my adult life in the UK and
Switzerland, it is hard to argue with the result. The level of care in CH is
outstanding, even at the basic level. The NHS is very good when it's good (eg.
IMO emergency care), but can be equally chaotic and disorganised at times
(often the "less important" community level care). Waiting times can be a
problem. I also had a great experience with the healthcare in Australia while
growing up, but I was lucky enough that my family could afford good private
insurance that could fill in the gaps. I can't speak for what it's like now
though, haven't lived there for over a decade. Overall probably a fair
article.

~~~
lukasm
Emergency care is good everywhere, because the establishment uses it. They
don't use the rest of the healthcare system, therefore there is a little
incentive to fix it.

------
s3nnyy
> "Switzerland has a universal health care system, requiring all to buy
> insurance. [...] Almost 30 percent of people get subsidies offsetting the
> cost of premiums, on a sliding scale pegged to income."

This is wrong. It does not matter how much I earn. (Nassim Taleb is right, New
York Times is no good.) Healthcare is pegged to income in Germany but
definitely not in Switzerland. I pay 279 CHF (300 USD) per month and pay all
bills up to 2500 CHF per year myself. If my health-related costs during the
year exceeds 2500 CHF the insurance kicks in and starts paying. In this way,
people don't go to the doctor for tiny things but quickly go to see one for
serious stuff. All health-related costs are deductible from my income tax.

More about "health insurance" in Switzerland in my blog post that I wrote
after moving to Zurich in 2014: [https://medium.com/@iwaninzurich/eight-
reasons-why-i-moved-t...](https://medium.com/@iwaninzurich/eight-reasons-why-
i-moved-to-switzerland-to-work-in-it-c7ac18af4f90)

~~~
refurb
So it's quite similar to ACA? Everyone buys insurance, with the poorest
subsidized. Plus, people are responsible for a deductible for the care
provided.

~~~
s3nnyy
I am not familiar with ACA. But I guess these kind of things are easier to
pull of in a small country like Switzerland.

------
lumberjack
You do not have to look at healthcare systems as a package. Each incorporate
good and bad ideas that can be studied separately. I think overall the article
was quite lacking in discerning the features of each healthcare system,
especially considering that each is its own market with different market
dynamics.

For example the way each system delivers primary care is quite different. In
some systems, GP visits are free but very bureaucratic. You have to make an
appointment a week in advance. Does not matter if your appendix is bursting.
If you go to the ER they will send you to get a referral from an emergency GP
clinic. In other countries GPs are just private clinics and it works just fine
without any insurance.

I particularly do not like how employment is sometimes intertwined with health
insurance. It is just a bureaucratic mess.

~~~
gerdesj
In the UK you have several options: If you are not sure and need some advice,
you can ring 111 - they may direct you to A&E. If it is an emergency you ring
999 (which coves all emergency services. You can present yourself to the
nearest A&E (Accident and Emergency) if you are able to get there on your own.

GP visits do generally require an appointment and you may need to wait for
some days.

Prescriptions: Flat fee of less than £10 per prescription. There are many
medical and means tested exemptions.

NHS Dental Care can be hard to find but is generally available with a three
tier flat fee structure for a full treatment not per visit, again loads of
exemptions. Eg ~£56 for an extraction or root canal.

Some anecdotes:

A few years ago I had a wisdom tooth problem that hit on the weekend which is
out of hours for dentists. I rang 111 and was referred across county (40 min
drive). The tooth was extracted within 20 mins of me arriving. I don't
remember whether I even had to pay but if I did then it would have been £50.
If I'd been on benefits - no charge.

A few weeks ago I fell in my garden and hurt some ribs. It bloody hurt. To be
on the safe side I went to A&E. 20 mins later I was triaged to the front of
the queue and X rayed etc. Three hours later (I was obviously non crit) I was
seen by a doctor and then discharged.

About eight years ago (very long story short) my dad was flown by helicopter
from Exeter RD&E Hospital after a couple of weeks of stay to the Royal
Brompton in London because the best cardiac surgeon for what he needed was
based there. After a couple of months of care, surgery and recovery, his
ticker is still going. Cost of care? who knows? A lot in six figures. It cost
me a fortune in bus fares visiting the old boy.

I have many more but that gives you some idea. We habitually whinge about the
NHS (OK: everything) here in the UK about waiting times but when the shit hits
the fan - it is always there to pick you up and stick you back together.

------
guyzero
It's nice to see a US newspaper acknowledging that other developed countries
exist.

------
EwanG
Looks at select parts of the HC systems around the world and allows you to
pick YOUR favorites. Would be interesting to anonymize the countries, submit
as a poll to leading pundits on both sides of the fence, and see where the end
result comes in.

------
csa
How is Japan not in the discussion?

I am not a specialist in medical issues, but I lived in Japan for many years.
The health care was great for me.

Doctors are relatively autonomous. They get paid by the government (single
payer?) plus a relatively small co-pay depending on your insurance (mostly
based on employer).

Contributions from individuals vary from about $100 a year (for low income) up
to maybe 4-5% of income at salaries most Japanese make ($25k to $100k usd).
Employers also contribute.

I never felt financially fleeced, unlike the US (with great insurance, no
less). I almost never had to wait -- just once for a few days for a minor
surgery. The costs for treatment and meds were reasonable. The quality of care
seemed comparable to or better than the US (for a young person, at least).

My only complaint was that doctors had a minor (but known) racket. If you had
something that required 7 days of meds, they would give you a 3-day
prescription and have you come back for a 1-minute second visit to get the
other 4 days of prescription. A doctor friend told me that this was allowed
and somewhat exploited because doctors were paid per visit. My doctor friend
also told me that this was a way to balance payments -- that is, they would
take longer on the initial visit to get the right diagnosis, but then they
needed you to come in for the minor visits to get paid correctly for the time.
Minor inconvenience, imho.

I also have friends who made sure to have their medical stuff done before they
left Japan -- child delivery, hip replacement, lots of dental, etc.

Any other Japan folks have positive or negative stories to share? What about
other Asian countries?

------
jdhn
I wish that there was a calculator out there that would allow you to build
your own healthcare system, so to speak. You could tweak attributes such as
funding mechanisms, etc. I imagine this hypothetical calculator could function
like this [0].

[0] [http://www.crfb.org/debtfixer/](http://www.crfb.org/debtfixer/)

~~~
randcraw
Yes, this is very much a multivariable optimization. For comparison of
healthcare systems, it'd help to choose a common set of N disease therapies
and services, then assess each for outcome and cost applied across perhaps
three economic tiers of the public: zero, middle, and upper incomes.

I'd also like to know what protection each system provides against personal
bankruptcy.

And which system allows life saving therapy for those .01 percenters for whom
a cure is available but extremely expensive or inconvenient (e.g. hepatitis C
vaccine or CAR-T therapy). At what percentiles are those lines drawn? How to
the programs compare?

(For example, I have the sense that Canada disallows a larger fraction of
expensive treatments and delays treatments longer than most other systems,
especially near end of life.)

------
merpnderp
Since cancer and cardiovascular disease are by far thelargest killers, early
detection coupled with survival rates would be the two most important factors
with cost the third. Narrow the problem down to something much more measurable
than most comparisons attempt.

~~~
ZeroGravitas
Aren't early detection and survival rates somewhat linked?

I've heard it suggested that one of the dysfunctions of the US system is to
detect cancers that would never have caused the patient any harm, leading to
stress and needless medical interventions and expense. This improves both your
metrics without actually improving healthcare, possibly actively making it
worse, even before accounting for cost.

~~~
DanBC
It's true that over-testing, over-diagnosis, and over-treatment all cause harm
(and sometimes death).

But have a look at "most common cause of female death" here:
[https://visual.ons.gov.uk/causes-of-death-
over-100-years/](https://visual.ons.gov.uk/causes-of-death-over-100-years/)

Cancer is the most common cause of death in women from age 30 to 79, and also
from age 5 to 14.

(Brain tumors in children, breast cancer from age 30 to 54, and lung cancer
from 55 to 79).

Advances in cancer detection (including working out which are the cancers that
need to be treated) and treatment are going to save lives.

~~~
ZeroGravitas
Those figures might be slightly misleading e.g. the most common cause of death
might only account for 7% of deaths at certain age ranges and the same time
and money invested into other causes may provide more bang for buck.

Also which particular cause of death "wins" may be more about taxonomy
decisions about what gets lumped together (e.g. for the very youngest "other
misc." is the biggest grouping) and, as a result, I would guess that any
deaths due to e.g. an unnecessary mastectomy of a potentially benign tumor
leading to surgical complications would end up listed under the same cause of
death as one left entirely untreated.

So advances will save lives only if they're truly advances, and not just
throwing shiny technology at the problem without a full understanding of the
benefits and costs.

------
ZeroGravitas
I'm sure I've read that "health" outcomes are to a surprising degree
influenced by general welfare policies. Every time they mentioned good or
better outcomes I wondered how much of that was down to the health care system
in that country and how much to everything else.

They seemed to judge the systems in likelihood of being accepted in the USA
and presumably the Euro style welfare would have a tough time being accepted
if anyone tried a transplant.

------
dinospaceship
Relevant frontline documentary from a few years ago:
[http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/c...](http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/models.html)

------
amriksohata
[https://www.theguardian.com/society/2017/jul/14/nhs-holds-
on...](https://www.theguardian.com/society/2017/jul/14/nhs-holds-on-to-top-
spot-in-healthcare-survey)

------
amai
The best health care system:

"In ancient China doctors were paid when their patients were kept well, not
when they were sick. Believing that it was the doctor’s job to prevent
disease, Chinese doctors often paid the patient if the patient lost his
health."

------
grzm
The full article title is "The Best Health Care System in the World: Which One
Would You Pick?"

