I’ve spent my career studying how different health care systems work. People love to ask me which country has the best care — and are often disappointed when I don’t have an easy answer for them.
Every health care model involves people doing their best to balance competing priorities in the face of limited resources. In other words, every system involves tradeoffs.
In the U.S., even people who should know better often turn to reductive comparisons in debates over whether we should continue with our private, market-driven system or switch to fully government-funded coverage.
One article claimed that when looking at life expectancy and spending, “there is one key difference between the U.S. and other countries: a single-payer health care system.” Another advocacy group suggests that “single payer national health insurance would resolve virtually all of the major problems facing America’s health care system today.”
Arguments like these falsely reduce complex metrics to singular causes. They also ignore variation among countries with similar models. Switzerland, Germany, and Netherlands all have private insurance yet perform better than the U.S. on life expectancy and spending. Likewise, demonization of single-payer systems — in which patients supposedly languish without access to care or new drugs — ignores metrics in which single-payer countries outperform the U.S.
But instead of endlessly debating whether single-payer or private insurance is ideal, we should spend more time looking closely at the nearly 200 natural experiments running in countries around the world, each managing tradeoffs differently. Diving deeper into how patients fare in different settings can help the U.S. learn where we excel and what we can do better.
For example, many Americans are rightfully concerned about our high rates of infant and maternal mortality. But to understand why these rates are so high, we need to dig below topline numbers and examine care during pregnancy, childbirth, and beyond; diet and social factors; race and inequities; and more. Examining what other countries that fare better do differently can help us learn how we can improve our care in the U.S.
Many American mothers are at unusually high risk of premature labor, and these preterm babies have lower survival rates, even with the best care. Premature births may be influenced by factors such as stress and less generous insurance coverage for young women. Yet, comparative data suggests that the U.S. is one of the better places to give birth to a premature baby. So, tackling America’s high infant mortality rate may have more to do with preventing premature births than with care during childbirth.
American mothers are also twice as likely to die from pregnancy and childbirth as mothers in many other wealthy countries. But around half of these deaths occur after delivery. Here, the U.S. could learn from places like Australia, France, and Japan. Women in these countries enjoy continuous insurance coverage and are entitled to postpartum at-home visits that support their health and their children’s. Providers also use these visits to issue referrals for additional resources, like mental health treatment.
These are the kind of actionable comparisons that can yield real results for patients, without requiring us to overhaul our entire health care system. I lead the International Collaborative on Costs, Outcomes and Needs in Care, a research initiative that looks at data and policies to understand the care patients receive in different high-income countries when navigating medical issues like a hip fracture or multiple complex chronic conditions. For example, does the waiting period for a hip surgery or the drugs patients receive afterwards affect their likelihood of survival?
When we analyze the care millions of people receive across different health systems for the same conditions, we can isolate specific changes countries can make to keep people healthier within their existing systems. These granular comparisons have much more to teach us than simplified attempts to grade and rank entire health care systems.
In a recent example of how specific comparisons can spark innovation, the Biden administration launched a program that will allow Medicare to negotiate prices directly with manufacturers. This step follows the lead of European countries, who have long used government negotiation to lower drug prices.
We have much to learn from how other countries assess fair pricing. Australia, Canada, Germany, and others have bodies that evaluate whether a new drug provides enough value to justify extra costs. These assessments can then be used to negotiate prices; part of the reason these countries spend around a third less than Americans on new brand-name drugs. The process moves quickly enough to ensure access to novel treatments, covering new drugs within six months to a year.
This is the kind of zooming in we need to do when talking about American health care: from “health care is expensive” to “health care is expensive because of higher drug prices” to “drug prices could be lower if we instituted specific policies or processes.”
Idealizing or demonizing entire health care models diverts attention from understanding the experiences of patients and how we can give them better care. Instead of a crude competition of “Who’s the best?,” let’s use international comparisons as a springboard to make all of us better.
Irene Papanicolas is a professor of health services, policy, and practice at the Brown University School of Public Health who studies costs and quality of care in different health care systems.