I started as a blogger. More specifically, I started out as a health policy blogger. My first play I remember was a series entitled "The Health of the Nations" in which I checked out books from the university library, downloaded international reports, and introduced the world's leading health systems. It was rough stuff, but it taught me a lot. The way we take care of health care is not the only way to ensure health care. It is not the best way. Or the second best or the third.
Ezekiel Emanuel is a bioethicist, oncologist, and co-director of the Health Transformation Institute at the University of Pennsylvania. He was a leading health policy advisor to the Obama administration, he's a senior fellow at the Center for American Progress, he's making his own artisan chocolate, and he's got a new book – Which country has the best health care in the world? – where he can go into more detail than ever before or profile other health systems and compare them with our own.
This conversation on the Ezra Klein Show is about which country has the best healthcare system in the world. But it's also about how healthcare innovations actually work, whether there's evidence that private insurers add real value, whether healthcare is the best investment in health improvement (spoiler: no), how you use a healthcare system Half of the political system will fight like hell against these improvements and much more.
Emanuel has also worked a lot on corona virus policy, so we spend some time there and discuss the question that is tormenting me now: are we just giving up this fight? And is there any politically viable option to give up given how much time the government has wasted and how exhausted the public is?
An edited extract from our conversation follows. The complete conversation can be heard on The Ezra Klein Show.
Let's do that. Which country has the best healthcare system?
I know this is an evasive answer, but the honest truth is that it depends on what criteria you have and what really interests you. If you're a health policy winner, a lot of things are important to you: do you get universal coverage and how expensive is it? Do you have a mechanism to control total spending in the country? We don't do it well according to these criteria, but other countries do it well.
Many people take care of the following: Do I have an unlimited choice of doctors and hospitals? According to these criteria, places like Germany, Switzerland or France are at the top. Other people do not want co-pays at the point of care and no deductibles. There you can see that the UK and Canada and Australia, at least for public hospitals, are good. Some people want low drug prices. For that you have Norway, Taiwan, Australia. Some people don't want to wait. Of course Canada, Norway and the UK are not on your list, but Switzerland and Germany are at the top of your list.
It really depends on what criteria or criteria are set.
Having read the book, I was ready for your evasive answer here. Which system do you want to buy into? Given your preferences, whatever they may be.
Probably the Netherlands if you force me to vote. I think they have a very good combination: you can choose your private insurer, you can choose your family doctor. And their general practitioners are really goalkeepers for a higher level of care. They are also innovative. I think they have a very good system. But there are many other alternatives that I would be more than happy with.
In my opinion, what would happen if you made Obamacare a nationwide system and properly subsidized it. Is that fundamentally correct?
Yes, it is either the exchanges or Medicare Advantage that have been nationalized. But yes, it does an exchange nationally and then offers a high level of subsidies for the people to shop. That is why health policy like me.
In which system do you want to be poor?
I think Great Britain or Norway. If you are poor, these are very good subsidized schemes. You can also get away pretty well if you are poor in Australia. I would say a place that is not that great is Switzerland, which is privately insured and whose subsidies are good but not great.
Which system do you want to be in 15 years?
I think one of the most important things is long-term care. And in 15 years, I will be 77 and worry about long-term care.
The Germans and the Dutch are the two we looked at and have earmarked funding for long-term care, and both emphasize aging on the spot (aging in your own home or in your relatives' home). Unlike any other country we've looked at, they have secured long-term care funding.
I think most other countries, whether the United States or Great Britain or Australia and especially China, are really messed up. And the result is a very big burden for people with aging relatives. If you really care that your children don't have to take care of you in old age, this special funding mechanism is more important.
I am honest that I had an ulterior motive on this question. You write in the book that "the United States will become one of the best systems in the world again in the next decade or two," which really surprised me.
If you got me to take the bet, I'd be tough on it. But do the case. Why should I believe that in 15 years, the United States will not be the second worst system your team has seen behind China?
Because I think there are a lot of innovations in our system. We have a lot of innovations that don't focus on drugs and devices or new surgical procedures or new imaging tests – we have that too. But I think we have a lot of innovation and experiments with how to pay for care differently and how to deliver care differently. I think we have some very successful models for coordinating chronic care and are starting to clarify some important advances related to mental health care. The real challenge for the United States is to generalize and adapt these things.
Now there are many things that can torpedo this progress. We have many interests that would be questioned – hospitals are one of them. I just want to point out that occupancy is declining in many hospitals and some of them are likely to have to close and switch to outpatient care. I think we've seen a lot of it because of Covid. And I think it will continue to happen.
If we wanted to increase life expectancy or any other indicator of healthy wellbeing in the next 10 years, should this be a conversation about our health insurance and health system? Or should it be a conversation about something else?
Health care on a good day increases health outcomes and longevity by 10, 20 percent. other things – education, employment, housing, nutrition, exercise, no smoking, safe driving – contribute much more to this.
The highest-return investment the United States can make is early childhood interventions, especially for children born to poverty, who now make up 40 to 50 percent of the American birth cohort. One of the immediate things I would do is make it a requirement for Medicaid. To receive Medicaid, you must offer early childhood interventions to every child born on Medicaid for at least two years. And once they are born on Medicaid, they must receive this benefit for two years regardless of whether they leave Medicaid or not. These early childhood interventions, as Jim Heckman of the University of Chicago showed, raised $ 7 to $ 15 per child. So this is an intervention that I would do.
I would also demonstrably make childcare free of charge. This experiment was attempted in Montreal. It actually pays off very quickly. This is a huge second investment that I would make. A third investment I would make is to make Pre-K universal, necessary and free. So you can see that all of my investments are in children.
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