Professor and bioethicist Ezekiel Emanuel offers a detailed overview of the health care processes in developed nations.
Professor Ezekiel Emanuel co-directs the Healthcare Transformation Institute at the University of Pennsylvania and serves the World Health Organization as a special adviser to the director-general. His reputation is that of a thoughtful bioethicist. Emanuel rescinds the promise of his book’s title early on, admitting that no country can legitimately claim to have the world’s best health care. The title is a wise marketing ploy, but Emanuel doesn’t attempt to rate national health care systems. Instead, he applies data analytics and specific examples to portray each country’s approach to medical care.
Readers will quickly grasp that the abundance of the German systems and the quality and value of the Netherlands’ approach put these systems above the pack. Meanwhile, Emanuel explains, China’s bare-bones approach, and the unevenness, for-profit shenanigans and expense of the US system, put them at the bottom.
Though the author concludes that no country has the best system for everyone, his clear-eyed assessment of broad categories reveals stellar practices, many worth emulating.
The United States
Emanuel reports that the world perceives US health care as top-notch, but only for those who can afford it. The United States spends by far the most on health care – $3.5 trillion in 2017, accounting for 18% of GDP.
The US health care system has substantial challenges. It is underperforming on almost every measure – coverage, quality and cost.Ezekiel Emanuel
The United States, according to the author, has about 850,000 practicing doctors – 2.6 per 1,000 people (the EU average is 3.6) and about 12.5 nurses per 1,000 people. Most developed nations have 10. The United States also has 2.4 hospital beds per 1,000 people; the EU has 5.1.
Summing up a broken system, Emanuel laments that, though America spends nearly twice the per-person average among Organisation for Economic Co-operative and Development (OECD) nations on health care, Americans do not receive good value.
Conservative Americans, Emanuel realizes, perceive Canada’s health care system as socialist and inefficient, with long wait times. Applying his consistent metrics, Emanuel describes how Canada spends 11.3% of GDP on health care. It has 2.7 hospital beds and 2.4 physicians per 1,000 people.
Britain’s National Health Service (NHS)
Emanuel found aspects of the NHS to admire; it has delivered generous, universal health care to the British for more than 70 years.
However, the author reveals, the UK spends 9.6% of GDP on health care; for every 1,000 people, the UK has 2.9 doctors and 2.6 hospital beds – all below the EU average. And, Emanuel cautions, at 7.9 nurses per 1,000 people, the UK falls short of the United States, Germany, France, Norway, Switzerland and the Netherlands.
Norway’s National Insurance Scheme (NIS)
The (NIS) covers health, pension, unemployment, disability and other needs. Emanuel points out the benefits of Norway’s oil-based economy: Norway spends nearly twice what the UK spends – yet only 10.4% of its GDP.
The Norwegian system…is…based on paying taxes. There is no access barrier, such as enrollment in an insurance plan or paying a premium.
The Norwegian system…is…based on paying taxes. There is no access barrier, such as enrollment in an insurance plan or paying a premium.Ezekiel Emanuel
But, he reveals, few incentives motivate physicians to save money or offer quality care.
In France, Emanuel discovered, a patient can choose any doctor and any hospital, and access specialists without referral. France spends 11.5% of GDP on health care. It boasts 6.3 hospital beds, 3.3 doctors, and 9.9 nurses per 1,000 of the population. Emanuel regrets that nurses face disrespect in a paternalistic system that caters to doctors.
Germany’s system covers everyone, with – and this may seem inconceivable to many Americans – what Emanuel characterizes as too many hospitals. Germany spends only 11.5% of GDP on health. Germans share 8.2 beds, 4.5 physicians, and 13 nurses per 1,000 people. However, Emanuel points out, Germany’s doctors and nurses earn less than those in the US.
Demonstrating his ability to move from macro to micro factors shaping health care, Emanuel shares that Dutch doctors intervene reluctantly and prefer to send patients home until their conditions worsen. The Dutch, Emanuel tells, spend about $84 billion per year on health care for a population of 17 million – almost $5,000 per person.
Emanuel finds signs of strain in Swiss health care, including high costs and crushing complexity. The Swiss spend 12.2% of GDP on health care. Per 1,000 population, the Swiss have 3.6 hospital beds, 4.2 doctors and nine nurses. The author expresses concern that their system could collapse due to mass rejection of high premiums.
Emanuel reveals that China spends 6.2% of GDP on health care – less than $1,000 per person in its population of 1.4 billion. Per 1,000 people, China fields 4.1 hospital beds, 2.4 doctors and 2.7 nurses. The system, Emanuel stresses, suffers from corruption and structural problems that affect delivery.
Who is this book for? Health care professionals and policy makers can find beacons of worthy care in nations whose systems offer hints for those seeking to change the medical approaches in their own countries. For any but the most wealthy Americans, Emanuel’s descriptions of the comparatively dreamy health care in other nations may fuel rueful head-shaking or plans to move abroad.
Investors can find opportunities in various nations’ shortcomings and strengths. For laypeople, Emanuel provides a fascinating overview and demonstrates conclusively that the profit motive and sound health care are mutually incompatible.
Numerous other insightful books analyze or offer solutions to the United States’ health care dilemma. Unsurprisingly, Emanuel wrote two of the most perceptive and useful, Reinventing American Health Care and Prescription for the Future. Elizabeth Rosenthal’s An American Sickness offers a compelling historical perspective on how US health reached its current deplorable state.