One of the nice things about the debate over universal health insurance is that we're not talking about some bold new policy initiative that would go where no nation has gone before, but about an approach that has been adopted, in different ways, by most other industrialized countries. Thus, rather than having to rely on a priori arguments, we can use actual information about how our health care system stacks up to those of other countries. In what follows, I'll try to provide some basic data. I've tried to rely on well accepted and unbiased sources from either organizations like OECD or the peer-reviewed literature.
I've put some of the charts in clickable form, since testing revealed that they did not translate well when resized. Also, a lot of the links to studies require subscriptions.
Spending: Our heath care spending is way out of line with other countries'. Here's a chart:
As you can see, our closest competitor, Switzerland, spends around two thirds as much per capita on health care as we do, and about 80% as much as a percentage of GDP. We are, basically, out of line with the entire rest of the industrialized world as far as health care spending is concerned, and not in a good way. This is even more striking when you consider that most of the countries this chart compares us to have some sort of universal coverage, which one might expect to increase the amount of health care people use, and thus the amount spent on it.
Moreover, here's an interesting fact: the US government spends more per capita than many other industrialized countries, despite the fact that they cover all their citizens and we do not. And those countries include not just the UK, which is famous for cost control, but France, which is not. Here's a graph from the OECD (the
red crimson-esque parts are public expenditures):
Quality: So since we spend so much more, do we get much better health care? According to the OECD (pdf), our life expectancy is below the median for OECD countries, and our infant mortality rate was higher than their median. For a bit more nuance, here's a chart comparing quality of health care in some areas in five countries (US, Canada, Australia, New Zealand, and the UK:
As the people who wrote this study said, "No country scores consistently the best or worst overall. Each country has at least one area of care where it could learn from international experiences and one area where its experiences could teach others."
Access and Service: Here's a study comparing patient experiences in six countries: the US, UK, Australia, New Zealand, Canada, and Germany. (Subscription required.) A press release summarizing its findings includes this summary of the results:
- Patient safety: Among sicker adults, Americans had the highest rate of receiving wrong medications or doses in the prior two years. Among sicker adults who had a lab test in the past two years, adults in the U.S. were more likely than their counterparts in the other countries to have been given incorrect results or experienced delays in notification about abnormal results, with rates double those reported in Germany or the U.K. Rates of lab errors were also relatively high in Canada.
- Effectiveness: The indicators of effectiveness in the 2004 and 2005 surveys were grouped into four categories: prevention, chronic care, primary care, and hospital care and coordination. Compared with the other five countries, U.S. patients fared particularly well on receipt of preventive care and care for the chronically ill, although all countries had considerable room for improvement. Canada scored well on primary care, and Germany ranked first on hospital care and coordination. Across the indicators of effectiveness, the U.S. ranked first and New Zealand ranked last.
- Patient-centeredness: In 2004 and 2005, survey questions asked patients to rate the quality of their physician care in four areas: communication, choice and continuity, patient engagement, and responsiveness to patient preference. On measures of communication and patient engagement, New Zealand ranked highest. Germany was first on measures of choice and continuity, and Australia performed well on responsiveness to patient preference. Across the measures of patient-centeredness, Germany generally was highest, followed by New Zealand. The U.S. ranked last on nearly all aspects of patient-centeredness.
- Timeliness: Germany and the U.S. stand out among the six countries in terms of patients with health problems reporting the least difficulty waiting to see a specialist or have elective or non-emergency surgery. Yet Americans, along with Canadians, were more likely to say they waited six days or more for an appointment with a doctor or had trouble getting care on nights and weekends. Across all five measures of timeliness, Germany and New Zealand ranked first and second, respectively. The U.K. ranked fifth, and Canada ranked last.
- Efficiency: The 2005 survey included four questions on coordination of care that serve as indicators of health care system efficiency. Compared with their counterparts in other countries, sicker adults in the U.S. more often reported that they visited the emergency room for a condition that could have been treated by a regular doctor had one been available and that their medical records or test results failed to reach their doctor's office in time for appointments. About one of four U.S. sicker adults reported these concerns. U.S. sicker adults, along with their German counterparts, also were more likely to be sent for duplicate tests by different clinicians. On measures of efficiency, the U.S. ranked last among the six countries, with Germany and New Zealand ranking first and second, respectively.
- Equity: Nine measures from the two surveys gauged the extent to which patients' income affected their ability to access care. The U.S. scored last on seven of the nine measures of low-income patients not receiving needed care and had the greatest disparities in terms of access to care between those with below-average and above-average incomes. With low rankings on all measures, the U.S. ranked last among the six countries in terms of equity in the health care system. The U.K. ranked first, with no or negligible differences in terms of patients' access to care by income. The U.S. is the only country surveyed with large numbers of uninsured, and this contributed to its low rating for equity in the health care system. But even among above-average income respondents, the U.S. lagged considerably behind their counterparts in other countries.
Canadians Flocking South? The evidence says no:
"To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home. "
(You can get the pdf of the study for free from the site I linked. It's fun watching them try to separate the various reasons why Canadians might seek care here: are they traveling and just got sick? Do they happen to live closer to a US hospital than a Canadian one? Or did they come for the medical care? Etc.)
In general, if you want a good quick overview of some other countries' heath care systems, Ezra Klein's series is really good. Reams of useful information on US health care can be found at the invaluable Kaiser Family Foundation website. As I noted earlier, Uwe Reinhardt is one of the best health economists out there, and his primer for journalists (pdf) on Kerry and Bush's health care proposals is a really good (and short!) introduction to some of the issues; while this Washington Monthly article on the VA system is a good readable explanation of facts like these:
"Yet here's a curious fact that few conservatives or liberals know. Who do you think receives higher-quality health care. Medicare patients who are free to pick their own doctors and specialists? Or aging veterans stuck in those presumably filthy VA hospitals with their antiquated equipment, uncaring administrators, and incompetent staff? An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be “significantly better.”
Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care. It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals."
Enjoy! (ha ha)