Torture the statistics until they confess. That seems to be the approach of many academics, journalists and policy wonks to the ideologically loaded question: which country’s healthcare system is best?
The rot started with the infamous World Health Organization rankings of 2000, which put France first and the UK 18th. But then again San Marino (population 30,000) was placed third, and I doubt it even has a major hospital.
Albania’s waiting times supposedly beat the NHS because “Albanians are a hardy lot, who only go to the doctor when carried there”
We have recently been treated to the latest such European effort, under the auspices of the Swedish presidency of the EU. The so called “Euro health consumer index” tries to rank the patient friendliness of national healthcare systems.
Tendentious? That would be putting it kindly. Entertaining? You bet. Here are just a few of their analytical bon mots: Germany’s healthcare productivity may be due to the fact that “it is well known that hindering a German from working is difficult”. The Dutch now have the highest per capita spending in Europe - except that they don’t because that award goes to “the three rich bastards” of Norway, Switzerland and Luxembourg.
Albania is included “at the request of the Albanian ministry of health, who in a very nice email wrote ‘we might well finish last but we want to be in there anyway’”. Fear not: Albania swept the floor with Romania, Latvia and Bulgaria. And Albania’s waiting times supposedly beat the NHS because “Albanians are a hardy lot, who only go to the doctor when carried there”.
Of course it used not to be like this. “Fog in the Channel, Continent cut off” was roughly the approach. And this convenient solipsism meant that for much of the post war period we in Britain were able to console ourselves that the NHS was “efficient” simply because it was “cheap”; that being “tax-funded” automatically meant it was “equitable”; and “universal” necessarily equated with “patient responsiveness”.
But now in an era of much greater transparency we are routinely challenged on that sort of complacency.
The problem is cross-national comparisons tend to have one of two ideological purposes: either to demonstrate that your own system is the best in the world, or to demonstrate the opposite - that the whole thing needs to be ditched and replaced. In other words, a battle between the self-deluding and the self-despising.
Those polar opposites have been on full display in the US health reform debate. So we have heard that the proposed reforms are part of a plot to introduce a “Nazi-style NHS”. Alternatively we have heard that US healthcare needs to be blown up and completely replaced.
Fortunately, US public opinion is more nuanced than the ideologues would suggest. When the respected Pew Center surveyed Americans earlier this year, just over a third said the US healthcare system was the best or above average, about a third said average, and just under a third said below average.
In any event, each country’s healthcare system is in important ways unique and highly local: a product of its distinctive history, its particular politics, its economic system, its geographical and cultural diversity, and its values.
So in health reform, you start from where you are, and you remember where you come from. For the US that means recognising that 85 per cent of the population has healthcare insurance and most say they are happy with it. It means recognising that (like half the G7 nations) many Americans - 160 million people - get coverage via their employer. And it means recognising that in a country as vast and diverse as the US, any attempt to impose a one size fits all straitjacket is unlikely to work. No other Western nation faces the challenge of organising healthcare for 300 million people. Try designing a single new healthcare system for Spain, Germany, Britain, France, Poland, and the Netherlands and you get a sense of challenge.
But compared with other countries, two facts about how the US organises healthcare stand out. First, the US is alone among the major industrialised countries in not requiring its citizens to have healthcare coverage. And second, the costs are higher. So a key test of President Obama’s proposed reforms will be whether he succeeds in tackling both items.
On the coverage question, Barack Obama fought the primary election against Hillary Clinton claiming she was wrong to argue that every American should be required to have healthcare coverage. In his recent joint address to Congress he (rightly in my view) changed his mind. That makes sense because in a purely voluntary system, people tend to defer signing up for health coverage until they need care, so that costs then go up for everyone, and some are forced to go without. (It is a bit like trying to take out fire insurance on your house when you see flames flickering in the basement.)
But enforcing a so called “individual mandate” requires action either to make healthcare more affordable for low and middle income families, or to add expensive and controversial new taxpayer funded subsidies.
On this issue, international comparisons of “the US versus the rest” are clear. American reformers should get more serious about cost containment, while taking the bull by the horns and mandating universal coverage.