American health care has plenty of problems, and we can learn by observing other countries’ achievements. But unfortunately, one of the more popular modes of research is also one of the most uninformative (“counter-informative,” really). That mode is asking people in various countries, “How satisfied are you with your country’s health care system?” and pretending the responses are meaningful and comparable.
With some regularity, my friends and colleagues return from overseas to tell me, as one doctor did: “People I talked to over there seemed very happy with their system.” I asked whom he talked to and, unsurprisingly, they were well-to-do urbanites vacationing at the same pricey inns where he stayed. People in slums or on remote farms, I responded, might have been less enthusiastic.
But even with demographically representative samples, cross-country comparisons of subjective responses are hopelessly entwined with cultural idiosyncrasies. America was founded by discontented, cranky people who never accepted limits on their aspirations. Our tendency to whinge and smash ceilings is what made America the world’s engine of creativity. Quiescent folk who are content with their countries’ health care systems aren’t the likeliest candidates to redesign care or find the cure for cancer.
Years ago, I interviewed for a job in British Columbia. My wife and I wondered what Canadian health care would mean for us, so we did some digging. One specific and personally familiar datum stood out. Every eight or nine years, some radiologist sees suspicious spots on my wife’s latest mammogram and tells her to get a biopsy. After one sleepless night, she has the procedure. Thankfully, the results have always been fine, but if they weren’t, she’d be in surgery or other therapy within days. In British Columbia, we found, the average wait-time for the biopsy would be one month — not one night. After a bad result, the average wait-time for treatment would be 17 weeks. Yet Canadians, surveys always show, are happier with their system than we are with ours.
In November 1984, late at night, I found myself transporting a woman in labor to a hospital in Monrovia, Liberia — a desolate 50-kilometer ride away. The hospital was a dark, crowded, hellish-looking place. In contrast, my wife gave birth at a high-quality hospital adjacent to Columbia University. If you asked the Liberian mother, “How satisfied were you with your hospital?” she might well have answered, “Very satisfied.” If you asked my wife or me the same question, we, being cranky, pampered Americans, might have rattled off our nitpicky complaints. (They forgot to bring me a cot for after she delivered!!!) Comparing the Liberian mother’s answer with ours tells you about our life experiences and attitudes, but near-zero about the comparative quality of care.
To learn from other countries, downplay subjective, culturally slanted responses to overbroad, amorphous questions. Focus, instead, on smaller, concrete points.
The U.S. Food and Drug Administration’s monopoly on medical device approvals allows the agency to run developers through needless gauntlets; in the European Union, devices are approved by private, competitive, state-sanctioned entities (“notified bodies”). By all means, compare the costs, time lags, safety and efficacy of the two systems.
Observe unmanned aerial drones transporting blood and medicines in Rwanda, Tanzania and Vanuatu and ask whether such technologies might benefit Americans (say, in rural areas) and, if so, why we don’t use them.
Ask how India’s Narayana hospitals can perform cardiac bypasses for under $2,000 (versus $100,000 in America) and still get equal or better surgical results.
Ask why vaccination rates are lower in the United States than in loads of other countries, and ask whether it’s our health care system’s fault. (Spoiler: It’s more about well-educated, but credulous, Americans buying into junk science.) Look at Singapore’s health savings accounts and Switzerland’s competitive private health insurance markets. Ask why Kobe Bryant had to go to Germany for therapy on his broken knee.
While you’re at it, explore why five-year cancer survival rates are lower in other countries than in America.
There’s a whole world full of good ideas out there. But improving American care lies in discovering and implementing hundreds of small improvements — not in asking gooey, sweeping, pop-psych questions while hunting for an off-the-rack system to transplant here.