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July 1, 2020

Who has the world's best health care system? Here's what Ezekiel Emanuel thinks.

Daily Briefing

    In a recent interview with Vox's Ezra Klein, Ezekiel Emanuel—a bioethicist who served as a health policy adviser to former President Barack Obama, and current co-director of the University of Pennsylvania's Health Transformation Institute—talked about which country currently has the best health care system in the world, and why he believes the United States could top the list in the decades to come.

    Who has the world's best health care system? It depends.

    Emanuel told Klein that which country currently has the best health care system depends on "what your criteria are and what you actually care about." According to Emanuel:

    • If your priority is choice of doctor and hospital, countries such as France, Germany, and Switzerland rank high;

    • If you care more about not having copayments or deductibles, countries such Australia, Britain, and Canada rank high; and

    • If you're looking for low drug prices, countries like Australia, Norway, and Taiwan are at the top of the list.

    But Emanuel said that, "if he's being "forc[ed] to choose," his personal preference is the Netherlands' health system.

    "I think [the Netherlands has] a very good combination: you get to choose your private insurer, you get to choose your primary care doctor. And their primary care doctors are really gatekeepers to a higher level of care," Emanuel said. "They're also innovative."

    Klein said he views the Netherlands' health system as "what would happen if you made [the United States' Affordable Care Act] exchanges a nationwide system and subsidized them properly."

    Emanuel responded, "[I]t's either the exchanges or it's Medicare Advantage made national. But yes, it's making an exchange national and then providing high levels of subsidies for people to buy in. That's why health policy wonks like me like it."

    Why the US could become one of the world's best health care systems

    Klein noted that in Emanuel's new book—called "Which Country Has the World's Best Health Care?"—Emanuel writes that, "in the next decade or two, the [United States] will again become one of the best systems in the world."

    Emanuel said he's optimistic about the U.S. health care system because it features "a lot of innovation" around "how to pay for care differently and how to deliver care differently." For instance, he said, "I think we have some very successful models on chronic care coordination and are beginning to sort out some important advances related to mental health care."

    But the challenge, Emanuel said, "is to get those things generalized and adapted." In addition, Emanuel said "there are many things" that could derail the United States' progress.

    "I would just note that a lot of hospitals are seeing decreases in occupancy and probably some of them need to close and shift to outpatient care," he said. "I think we've seen a lot of that happening because of [Covid-19]. And I think it will continue to happen."

    How the US could improve life expectancy

    However, Emanuel told Klein that improving health care isn't necessarily the most important step to improving people's health and extending life expectancy.

    "Health care adds 10, 20, on a good day, 30% to health outcomes and longevity," while other interventions, such as education and nutrition programs, "add a lot more," Emanuel said.

    To improve life expectancy in the United States, Emanuel said he would focus on "early childhood interventions, especially for children born into poverty, which is now 40 to 50% of the American birth cohort." Emanuel said that research from Jim Heckman at the University of Chicago has found such interventions can return $7 to $15 per child (Klein, Vox, 6/23).

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