Public Policy

Building a better U.S. health care system

More community-level investments and partnerships needed


 

Since 2010, when Democrats passed the Affordable Care Act – also known as Obamacare – without a single Republican vote, the GOP has vowed to repeal and replace it. With the election of Donald Trump in November 2016, Republicans gained control of the presidency and Congress and hoped to put Obamacare on the chopping block.

Dr. Ashish Jha

Although the Affordable Care Act’s (ACA’s) individual mandate was eliminated in the Tax Cuts and Jobs Act passed in late 2017, Republican leaders have been unable to secure the votes they need for a full repeal of Obamacare and a complete reboot of the American health care system. That may be, in part, because in the search for a better American health care system, there is no single right answer. In few places is that more clear than when making comparisons of health care systems across the world.

“Comparisons are fun, and everyone loves rankings,” said Ashish Jha, MD, MPH, a physician with the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute in Cambridge, Mass. Last fall Shah published an analysis on his personal blog comparing health care in the United States with that in seven high-income nations.1 It was prompted by a similar side-by-side comparison he participated in with other experts for the New York Times.2 “The most important part is we get to ask questions about things we care about, like ‘What do other countries do when they’re better than us?’ We’re not going to adopt any country’s model wholesale, but we can learn from them,” he said.

For instance, just 7.4% of people in Switzerland (according to data from the Organisation for Economic Cooperation and Development) skip medical tests, treatments, or follow-ups because of costs, compared with 21.3% in the United States. Meanwhile, the United States leads in innovation, producing 57% of new drugs (according to the Milken Institute), which is more than Switzerland’s 13% and Germany’s 6%.1

Although many Americans tend to think that health care in other developed nations is entirely single payer or government run, systems across Europe and the rest of the globe vary immensely in how they approach health care. One thing common among high-income nations, however, is some form of universal health care. In Canada, for example, the government funds health insurance for care delivered in the private sector. In Australia, public hospitals provide free inpatient care. In France, the Ministry of Health sets prices, budgets, and funding levels.2

“There are really two main purposes” when it comes to international comparisons, said Eric Schneider, MD, senior vice president for policy and research for the Commonwealth Fund. “The first is to understand how other countries perform, and the second is what lessons can we learn from the way care is financed, organized, and delivered in other nations and how we might import some of those ideas to the U.S. and improve policies here.”

The Affordable Care Act, Dr. Jha said, was something of the ultimate test for applying lessons learned in other countries and those put forward over the past decades in the United States by policy experts and leaders in health care thinking.

“The Affordable Care Act includes several ideas that are prevalent in other countries, particularly around how to expand insurance coverage and how to subsidize the poor so they can have good insurance coverage, too,” said Dr. Schneider. “The notion of essential health benefits, the mandate for insurance, the notion of subsidies, in some ways, these were all borrowed from abroad.”

For instance, health care in The Netherlands – which, like the United States, also relies on private health insurers – ranked among the highest of other high-income countries in the world in The Commonwealth Fund’s 2017 international comparison, published in July 2017.3 The Dutch have standardized their health benefits, reducing administrative burden for providers and making copayments more predictable for patients.

Dr. Schneider believes that the United States should continue to build on the progress of the Affordable Care Act – particularly since more than 20 million Americans have gained insurance coverage since the passage of the law (91% of Americans are insured today).4 And the ACA has renewed focus in the United States on improving and strengthening primary care and changing the incentives around care delivery.

Some Democrats and Republicans in Congress have started working on bipartisan solutions to solve some of the problems inherent in the ACA – or those engineered by those who oppose it.

Dr. Joshua Lenchus

Dr. Joshua Lenchus

“I think we have an opportunity to move forward,” said Joshua Lenchus, DO, FACP, SFHM, chair of the Society of Hospital Medicine Public Policy Committee. “I think complete repeal of the ACA is unlikely to see success. Until someone comes up with something that maintains close to the number of people insured now but changes the direction we’re headed in, this is what we’re stuck with.”

That direction is, at least in part, a health care system with spending that continues to rank among the highest in the world.1,3 The United States spends more than 17% of its GDP on health care, compared with the 11.4% spent by Switzerland, which Jha ranked as having the best health care system among the high-income nations he evaluated.1Craig Garthwaite, a conservative health economist at Northwestern University’s Kellogg School of Management in Evanston, Ill., called the Swiss health care system a “better-functioning version of the Affordable Care Act” in the New York Times’ head-to-head debate.2

However, Dr. Lenchus noted that Switzerland’s system may not be scalable to a country the size of the United States. At 8.5 million people, Switzerland’s population is on par with that of New York City. The U.S. system must support more than 323 million people.

And international comparisons can be challenging for other reasons, as Dr. Jha wrote in a JAMA Viewpoint piece in August 2017 with coauthor Irene Papanicolas, PhD, of the London School of Economics, because they must account for the limitations of data, consider different values in national systems, and define the boundaries of the health system.5 For instance, Dr. Schneider said, some other high-income countries also invest more in housing, nutrition, and transportation than does the United States, which reduces the detrimental impact of social determinants of health, like poverty, poor nutrition, and homelessness.

Dr. Lenchus believes better health care in the United States hinges on more community-level investments and partnerships and on more focus on the social determinants of health. “To some degree, this country should be able to leverage the resources we have at a community level to improve the health of that community’s population,” he said. “Hospitalists are in a prime position to do that.”

Indeed, the Commonwealth Fund report concluded the United States excels on measures that involve the doctor-patient relationship – like end-of-life discussions and chronic disease management – and on preventive measures like screening mammography and adult influenza vaccination.

In a New England Journal of Medicine Perspective published in July 2017, Dr. Schneider and a coauthor outlined four strategies to improve health care in the United States, gleaned from comparisons abroad: ensure universal and adequate health insurance coverage, strengthen primary care, reduce administrative burden, and reduce income-related disparities.6

Regardless of how the United States goes about achieving a better health care system, Dr. Jha said we should stop the partisan rhetoric.

“Where I find a lot of consensus is we should have more competition and less monopoly,” he said. “Liberals and conservatives should be able to get together and say: We are really going to have competitive markets, and we should see the prices of health care services fall; we should see premiums come down, and it would make the coverage problem a lot easier to solve.”

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