Different countries have different ways of meeting the health needs of their residents. What do Americans see when we look at health care in other industrialized countries?
What can the differences between our health system and some of those abroad teach us about improving health care coverage, access, and affordability here in the U.S.?
This week, Shanoor Seervai talks to Eric Schneider, senior vice president for policy and research at the Commonwealth Fund, about the challenges facing the U.S. as it seeks to create one of the world's best health systems.
SHANOOR SEERVAI: Hi everyone! Welcome to The Dose. I’m Shanoor Seervai, and over the past few episodes, we’ve talked to doctors and health experts from around the world about how the health systems in their countries are different from what we have in the United States. If you haven’t already listened to these episodes, you can find them by visiting The Dose dot show, or by searching for The Dose in your favorite podcast app.
Today, we’re going to look at how all these different health systems are relevant to what we have here in the U.S. Of course, there are plenty of differences between, for example, France and us. But it’s worth thinking about lessons the U.S. could learn from other countries. Joining me is Eric Schneider, senior vice president for policy and research at the Commonwealth Fund. In 2017, Eric published an article in the New England Journal of Medicine about the challenges facing the U.S. as it seeks to become one of the world’s best heath systems.
Eric, I’m going to get started right away: Based on your research about health systems in other industrialized countries, what makes a health care system excellent?
ERIC SCHNEIDER: So, we’re often asked what makes a health care system excellent. From our perspective, health care systems are trying to achieve two things. One is to reduce morbidity and mortality and keep people healthy. The other is to do that at an affordable cost, to the people and to the system.
SHANOOR SEERVAI: Well, that doesn’t sound like an easy task. Where does a country even begin if it wants to achieve this?
ERIC SCHNEIDER: There are two key strategies to achieving those objectives. One is to deliver primary care in a timely way for urgent problems, for prevention, and for chronic conditions, like diabetes, heart disease. The second is to make sure that were using scientifically proven approaches to care, not too much care or too little care.
SHANOOR SEERVAI: Could you give me an example of how to deliver primary care in a timely way?
ERIC SCHNEIDER: So timely access to primary care is something that the Netherlands excels at, for example. In the Netherlands the general practices are located in the community, people have a general practitioner that they can visit at any time, nights and weekends. They have a general practitioner on call who can even come out to the home to make home visits to address urgent needs and to make sure that problems are treated when they’re small, before they become big problems.
SHANOOR SEERVAI: Yea, Marthe Haverkamp from the Netherlands, who was on the show recently, talked about how primary care is available essentially ‘round the clock in her home country. And she told me this story from when she lived in the U.S., about having to take her daughter to the emergency room for a small cut on her leg, because everything else, even in New York City, was closed. But to your other point — using scientifically proven approaches to care — can you elaborate on that?
ERIC SCHNEIDER: The use of scientifically proven care is something that the United Kingdom and the Netherlands have excelled at because they have guidelines that are used extensively that are agreed upon by doctors in those systems that represent the best available care for specific conditions. In a recent report from the Commonwealth Fund, we found that the U.S. was ranked 11th out of 11 countries that have high incomes and are comparable to the U.S. in many other ways.
SHANOOR SEERVAI: Wow, the U.S. showed up last on your rankings? Who came out on top?
ERIC SCHNEIDER: Three countries stood out as examples of the top three, essentially the best health care in the world — that’s the U.K., Australia, and the Netherlands. Those three countries have different approaches to financing and organizing care, but all of them achieve high performance relative to the other countries on the list.
SHANOOR SEERVAI: OK, so financing and organizing care aren’t our strong suits. Is there anything the U.S. gets right?
ERIC SCHNEIDER: The U.S. actually does very well on the care process measures in our report. What I mean by that is that the U.S. we know has some of the best hospitals in the world, some of the best specialists and providers in the world, people come here for training, for those who can afford that care. For those who can pay for that care, they can get the best in the U.S.
But for many Americans that ideal care is out of reach. Primarily because it’s unaffordable.
SHANOOR SEERVAI: What are the consequences of these huge disparities — that those who can pay get the best care, but for those who can’t afford it, the system basically says, “tough luck”?
ERIC SCHNEIDER: As a result, Americans have among the highest rates of preventable deaths and the highest infant mortality rate among the 11 countries we looked at.
So our research at the Commonwealth Fund points to three countries that are high performers, and as a primary care physician for many years, I’ve actually visited some of those countries and we’ve learned a great deal about how we can go from last among 11 to number 1, if we chose to do that.
SHANOOR SEERVAI: Tell me more: How could we get there?
ERIC SCHNEIDER: First, all of those countries achieve universal coverage for their people. Nobody has to worry about being uninsured. The second thing they do well is to deliver primary care in a timely, accessible way, even on nights and weekends. They have a strong orientation toward primary care.
SHANOOR SEERVAI: Okay, so make sure that everyone has health coverage and good primary care. But still, navigating the health system in the U.S. can be so confusing.
ERIC SCHNEIDER: The third thing they do well is reduce the barriers and complexity and red tape that we experience in the U.S. People don’t have to worry about surprise billing. In some countries they don’t even have copays or deductibles, their care can be coordinated more effectively. Reducing that administrative complexity takes away another barrier to effective care. The fourth thing other countries do well is they spend on important social services like housing and transportation. For people with low incomes, those people can get access to care more easily and they’re more healthy when they come to the health care system. So, when you combine those four principles that are used in these other countries, if the U.S. could emulate those, we could easily be number one in the world.
SHANOOR SEERVAI: You make it sound easy, but in reality, this is probably very complicated. Or does it have to be?
ERIC SCHNEIDER: Just to give you an example of how this could work: In a Dutch general practice, I was seeing patients with a colleague of mine there and a fellow came in with a problem. He’d been working under a car and he’d got something in his eye and needed to be seen. Now, he happened to be visiting that town, so he walked in to the nearest GP practice, which was where we were sitting, and didn’t have to worry about whether his insurance would cover the visit, was registered in the system, and was able to register there for an urgent appointment. And saw the general practitioner who removed this bit of metal and sent this fellow on his way.
SHANOOR SEERVAI: That was it? He just walked in and walked out? No bills and paper work?
ERIC SCHNEIDER: There was no bill. The bill was submitted by the GP at the end of the visit through the electronic system, which both recorded that the visit had occurred, billed the insurance company, and even sent a note to his general practitioner in the home city and this whole encounter took about 30 minutes.
SHANOOR SEERVAI: Now tell me how you think that would have played out in the U.S.
ERIC SCHNEIDER: In the U.S., that same encounter, first off, the person is wondering where he or she could be seen. There might be an urgent care center nearby, they could walk in there. There would be no other record available to the people in that urgent care center. This type of problem would actually have to be, in the U.S., referred to an ophthalmologist. Meaning an appointment with a specialist days or weeks later, or the patient might have to go to the emergency room, might wait for four to five hours in the emergency room for a problem of that sort. And then, really doesn’t know what the bill might be at that point, especially if they’re outside of their home city, if they’re in an out-of-network situation. The bill could run thousands of dollars.
SHANOOR SEERVAI: Something that a doctor in the Netherlands handled in 30 minutes could take days or weeks and thousands of dollars here?
ERIC SCHNEIDER: So that example illustrates the four principles I was talking about earlier. In a system with universal coverage the person with an acute problem doesn’t have to worry about if they’ve got insurance or not, or where that insurance allows them to go, they just go to the nearest general practitioner.
Strong primary care, that GP could deliver the service that patient needed right on the spot in a very timely way.
SHANOOR SEERVAI: Sounds like it makes things much easier for someone with a relatively simple problem. And I noticed that in your story, you never once talked about forms that needed to be filled out or other red tape.
ERIC SCHNEIDER: No administrative complexity, no complexity to that visit for the patient, they just swipe a card, are registered, are seen. There’s no real paper work to be done. And we never even asked or thought about whether this person had a high income or a low income, if they could pay for the care. They get the same treatment whether they’re rich or poor.
That example really illustrates how the U.S. system could be modified to serve the needs of people more effectively. Universal coverage, stronger primary care, reduced red tape and complexity, and treating people the same regardless of their income.
SHANOOR SEERVAI: And I wonder, you said this man was visiting the town where he received care — what’s it like for Americans when they are traveling abroad and have a medical emergency?
ERIC SCHNEIDER: Many Americans are often surprised when they’re travelling abroad and need care urgently to go to systems. In the U.K. people are often shocked there is no copayment, no bill, they even feel guilty that they’re not paying for the care. Given that the U.S. spends more than any other country on health care per person, you would think that the example I gave you earlier of a patient in the Netherlands would be a patient in the U.S. But we just don’t achieve the quality of care, the health outcomes, that other nations achieve, even though they’re spending per person about half as much as we spend.
SHANOOR SEERVAI: What’s the alternative, then? What kind of health care system do we need so that we’re not spending more than any other country, and still not providing the best care?
ERIC SCHNEIDER: So the goal is not a government-run health care system, because there are many ways to achieve universal coverage. Two of the top three performing countries I mentioned, Australia and the Netherlands, use a mix of public government funding and private funding through private insurance companies to achieve universal coverage and high-performing care.
SHANOOR SEERVAI: That’s important to remember — there are many different ways to get to universal coverage. One final question, Eric: How did the Affordable Care Act change things? There has been a lot of debate about our health care system this past year, but did the ACA take us any closer to the goal of universal coverage?
ERIC SCHNEIDER: The ACA in the United States has reduced the numbers of uninsured to historic levels and we could continue to build on that progress to achieve universal coverage. From our research it’s clear that the first and most fundamental step toward achieving a high-performing health care system is universal insurance coverage that can get people the access they need to the type of care they need without a lot of red tape.
SHANOOR SEERVAI: And if we’re open to learning from other countries, we could actually get more people the care they need.
ERIC SCHNEIDER: All of us have used health care from the time we were born and we will need health care in the future. It’s unavoidable. Given the stakes, it would be shame for us not to learn from the lessons that other countries can teach us about how to create a health care system that provides high-quality, affordable health care for everyone.
SHANOOR SEERVAI: Thanks so much for joining us, Eric.