Aaron E. Carroll's Blog, page 123

Which Country Has the Best Health Care System? Readers Respond

The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt. In this post we respond to readers’ questions about the bracket tournament on the best health system in the world.

TRANQUILLITY OF SPIRIT

I have both French and American passports. Americans should understand the tranquillity of spirit that truly universal health care brings to a population. People have worries … but not about losing everything because of an illness. — Bob Nelson, Calais, France

I’m British. For me the idea that “Can I afford to accept treatment?” is bizarre. And harsh. If you’ll forgive me for saying so, the U.S. system has a sense of selfishness to it. Your country seems to have lost your sense of “together.” Rather, it looks like “everyone for themselves.” — Arthur, Glasgow

Austin and Aaron respond: You are certainly not the only people to feel that way, but it seems many Americans value choice over security. This includes plentiful options for health insurance, including the “choice” to be uninsured. This freedom comes with at least three kinds of costs. First, it’s more than just a headache to choose a health plan. Studies show people — even experts — are terrible at doing so, routinely picking plans that aren’t the best for them. Second, the vast array of health plans with varying requirements and protocols impose administrative costs on physicians and hospitals. By one estimate, the administrative complexity of the U.S. health care system adds nearly $300 billion per year in avoidable costs. Third, strong results from the Oregon Medicaid study (a randomized trial of access to Medicaid coverage) include that the program significantly reduced the financial risk of poor health and improved mental health. It’s safe to say that the U.S. health care system may be many things, but tranquil isn’t one of them.

DARN PAPERWORK

I have practiced medicine for nearly 40 years, mostly in a large academic health center. The frictional administrative costs of multiple insurers, each with its own forms, rules, payment, denials and appeals apparatus, highly paid C-suites, shareholders, etc., and the counterpart to this required by all providers in order to get paid — billers, coders, compliance folks, etc. — is a colossal waste and does nothing to enhance access or quality of care. — Concerned MD, Pennsylvania

I chose France, for many reasons, but primarily because their system is well organized and administered, which results in better and more efficient care for patients. Check out their “card of life,” which contains timely, accessible and secure health care/financial info and speeds payment to doctors and hospitals. Far less paper and insurance hassles and denials. — Scott, Port St. Lucie

Austin and Aaron respond:

In a comparison of the U.S. and Canadian health systems, scholars at Harvard concluded that the commercial health care market in the United States imposes inefficiently high administrative costs. One reason they’re not lower is that no single insurer can move the system toward efficiency — it’s a collective action problem. But some of the high cost imposed on doctors and hospitals may benefit insurers, since they lead to delayed payments and denial of claims.

Patients are caught in the middle when health care providers and insurers bicker over claims and care. That kind of tussle seems to be reduced when the provider is the insurer — as when a hospital system offers a health plan. This is more evidence that the organization of health systems and coverage can make a difference in consumers’ experience, just as the commenters suggest.

However, we should be careful not to think there are too many savings to be had by removing just any kind of administrative waste. A number of advocates have argued that by removing medical underwriting and individual rating, insurers would be much more efficient and save money. After the Affordable Care Act imposed guaranteed issue and community ratings, huge savings did not result. Further, one person’s waste is another person’s job. The trade-offs can’t be ignored.

THE SWEET SPOT IS REGULATED NONPROFITS?

Based on personal experience with the German health care system and my sister’s personal experience with the Swiss system: Both systems use competing nonprofit private companies (that is the key) that are heavily regulated. A highly regulated nonprofit company is an efficient compromise construction between a government single-payer system (not exposed to competition) and between a free market of competing, unregulated, for-profit health insurance companies. — Gerhard, NY

Austin and Aaron respond:

This may be entirely correct. Let’s remember that Switzerland won the battle, and most people in that country do have insurance from a regulated market of guaranteed-issue, community-rated nonprofit private insurance companies. Many components of the United States health care system are nonprofit, too, and there’s a robust literature on how nonprofit and for-profit entities fare relative to each other. For instance, there appears to be a relationship between the availability of nonprofit nursing homes in an area and levels of consumer welfare. A “review of systematic reviews” of profit versus nonprofit hospitals found that for certain outcomes nonprofit hospitals performed better. Overall quality and efficiency differences could not be determined, though. In general, however, it appears that for-profit entities focus on cost (pushing it lower) while nonprofits focus on quality (pushing it higher). There are always trade-offs, and we in the U.S. have generally favored the latter.

WHAT ABOUT THE DUTCH?

Weird how you picked the U.K. and Germany but not the Netherlands. According to the annual Euro Health Consumer Index (E.H.C.I.), the Netherlands systematically has the best health care in Europe — yes, better than Switzerland, year on year, and with the U.K. at 14th sandwiched between Portugal (13th) and the Czech Republic (15th). — Rdeman, London

Austin and Aaron respond: There are, of course, more countries than we had space to discuss. We tried to pick countries that varied across the spectrum from socialized to privatized. Though we welcome delving more deeply into some of these other countries, aspects of them are close to those of the ones we’ve already discussed. The Netherlands, like many other countries, has a health care system along what the Princeton professor Uwe Reinhardt calls the “Bismarckian model,” in which health insurance is mandated from one of a small number of tightly regulated nonprofits.

People also can buy voluntary insurance above that, which covers things not covered by statutory insurance. The country spends about 12 percent of gross domestic product on health care, and out-of-pocket payments are quite low. How it would have compared in this battle isn’t clear, but we think it would have done pretty well.

BEING INJURED ABROAD

We received many, many testimonials from American readers who received good treatment at reasonable prices (and no payment troubles) while living abroad or traveling. By contrast, one reader from Australia advised that all visitors to the United States “carry travel insurance,” and a Canadian expressed surprise (below) at what awaited him after he broke his neck on a visit to the U.S.

Five years ago I fell off a rock and broke my hip while vacationing in Ireland. An ambulance took me to the hospital. Needless to say, my biggest worry was how am I going to pay for this. I was distraught. I had no coverage in the USA. The staff at the hospital were very kind and assured me I would be O.K. They replaced my hip, and when it was time to leave, they asked if I could pay $600. No other bills arriving four months later, like in the USA. $600, one bill, Done! Jaw-dropping amazing. I am grateful to Ireland, thank you! — Golf Pork, Seattle

I live in British Columbia. Some years ago I broke my neck in a motor vehicle accident in Washington State. I received excellent treatment and had the comfort of knowing that my British Columbia government health insurance would cover all expenses, even out of country. I was, however, taken aback when the first person I met in the emergency ward had a clipboard and was asking me how I would pay for all this. I had never before faced this question. — David Paterson, Vancouver

Austin and Aaron respond: We hesitate to allow anecdotes to define a health care system. What matters is the overall experience. T.R. Reid wrote an amazing book on this subject in 2009, though, which was reviewed in The New York Times.

Another problem with anecdotes about overseas health care excellence is that they can always be countered by people who came to the United States because they couldn’t get good care in their country. We hear all the time about how people from Canada flock to the United States when wait times are too long. Those stories are almost always exceptions, not the rule, as a great paper in Health Affairs showed.

It’s interesting to note, though, that most of the stories in the comments are driven by the “shock” of Americans when they can receive high-quality, reasonably priced health care in other countries. We’ve been conditioned to believe that the only choices available are our system or utter chaos. This exercise was designed to show otherwise. There are lots of other choices available, many of them are good, and some that are probably better.

JAMA Forum: The High Costs of Unnecessary Care

In a recent study published in PLOS One, researchers surveyed physicians across the United States to ask about their perspectives on unnecessary medical care. These physicians reported that more than 20% of overall medical care was not needed. This included about a quarter of tests, more than a fifth of prescriptions, and more than a 10th of procedures.

Why? How? What’s it all mean? Go read my latest post over at the JAMA Forum!

@aaronecarroll

When a Drug Coupon Helps You but Hurts Others

The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It also appeared on page A16 of the September 26, 2017 print edition.

It’s completely rational for you to use coupons to lower the cost of your brand-name drug purchase.

But if the coupon is causing you to switch away from a generic drug with an overall lower cost, you may be playing a role in pushing up drug spending and premiums for others.

Let’s say that I needed the brand drug Effexor XR, used to treat depression and anxiety disorders. It would cost me at least $65 per month on my health insurance plan. It retails for about twice that amount, and the difference would be picked up by my insurer. But the generic version, Venlafaxine, would cost my insurer far less, and my co-payment would be only $10 per month.

My insurer and I would both save money if I purchased the generic. Wyeth, the maker of Effexor XR, would lose a sale.

But Pfizer is fighting back. It offers an Effexor XR coupon card I could use at the pharmacy that would reduce my cost to as low as $4 per month. At that price, I would prefer the brand-name product. Why pay $10 for a generic when for $4 I can get the brand-name drug?

But for the insurer, unless it is getting a discount or a rebate from the manufacturer, the cost is about $130 minus the co-payment.

The company is by no means alone in this tactic. Many other drug manufacturers also offer coupon cards online for their brand-name products that compete with generics.

Such coupons are not new. But from 2007 to 2010, brand-name drugs with coupons grew as a share of retail drug spending, to 54 percent from 26 percent. The figure may well be even higher today, according to Leemore Dafny, an economist at Harvard Business School.

Though such coupons assist patients, they do nothing for insurers, for whom generics are still a better deal. And that’s the problem. By encouraging patients to switch from generic to brand drugs, coupons effectively impose higher costs on insurers. That ends up increasing premiums, and not for any particularly good reason. Generic drugs are generally regarded as equivalent to their corresponding brand products and are 80 percent cheaper, on average.

This is precisely why plans impose much higher cost-sharing for brand-name drugs than their generic equivalent. Doing so can help keep premiums down without harming patients. Perhaps in response, Americans are using more generics. In 2006, 90 percent of prescriptions that were filled were for a generic equivalent to a brand-name drug, when such a generic was available. In 2012, that number had increased to 95 percent.

The circumvention of insurance plan designs by these coupons has long been suspected to contribute to drug spending and premium growth. A recent study examining data from 2007 through 2010 and published in The American Economic Journal: Economic Policy, puts some numbers to the phenomenon. Co-pay coupons increase use of brand drugs for which generics are available by 60 percent and spending by as much as 4.6 percent.

“Coupons raise spending in two ways,” said Ms. Dafny, an author of the study. “In addition to making more expensive brand drugs more attractive to consumers, it allows manufacturers to raise brand prices.”

For example, the $4 cost with the coupon holds the consumers’ prices fixed at a low level. That allows the manufacturer to raise the overall price without losing sales. This raises spending, too, but for the insurer.

In total, the coupons for drugs with generic competition are responsible for several billion dollars of additional drug spending per year, according to the study, which was also written by Christopher Ody with Northwestern’s Kellogg School of Management and Matthew Schmitt with the U.C.L.A. Anderson School of Management.

The coupons do so, by and large, without expanding the number of people using medications, just by switching which product they purchase — brand or generic. Drug manufacturers also offer coupons for drugs without generic competition, but they were not the focus of the study.

If drug coupons are problematic for insurers and drive up premiums, why don’t insurers reject them?

“They say they can’t ban them because they can’t tell when a coupon is being redeemed at the pharmacy counter,” Ms. Dafny said. But “public payers ban them, after all, and their enrollees pick up prescriptions at the same pharmacies.”

Medicare, for example, bans their use. But enforcement is incomplete, and by one estimate 6 percent of Medicare enrollees use coupons anyway. And Massachusetts has passed laws that ban co-pay coupons for brand drugs with generic equivalents.

The likelier explanation, Ms. Dafny says, is that denying consumers access to coupons would cause a backlash. In the short term, out-of pocket-prices would rise for the few: the consumers relying upon them. But in the long term, encouraging consumers to use generic drugs when available — which is what insurers are trying to do — would reduce drug spending and premiums for everyone.

@afrakt

Healthcare Triage: Marijuana, Intoxication, DWI, and Breathalyzers

How do breathalyzers work? And will there ever be a breathalyzer for marijuana? As pot has become legal in several states, law enforcement has sought a method to detect marijuana use in drivers. This is complicated, though. Breathalyzers for alcohol work on principles that don’t necessarily work for pot. And they’ve been extensively researched, which is difficult to do with federal controls on marijuana. There may never be a breathalyzer for pot, but one thing’s is for sure: eating your own feces won’t beat a breathalyzer.

@aaronecarroll

The amended version of Graham-Cassidy is a mess

The revised bill was leaked last night and will apparently be unveiled today. The reporting has suggested that it’s worse than before. Not only is Graham-Cassidy now full of bribes and giveaways to lure hesitant senators, but it also makes it much easier for states to avoid the application of the ACA’s insurance regulations.

That’s because states that want to get out from under the ACA no longer have to submit waivers that the Trump administration has to then approve. They just have to submit applications. Once they do, section 204 of the bill appears to allow the states to establish their own rules for their insurance markets.

Section 204 is really convoluted. Even for lawyers who do this kind of thing for a living, it’s difficult to parse. And on one critical point in particular—whether insurers will be allowed to charge sicker people more for their coverage—it appears to be internally inconsistent.

In general, section 204 says that the states are free to adopt new rules for any insurance plans supported by the Graham-Cassidy block grants. To the extent that the states’ new rules diverge from certain specified ACA rules—the “non-applicable provisions”—the new rules supersede the ACA’s rules.

Which ACA rules can be superseded? It’s a familiar list: the requirement to cover the essential health benefits, the cap on cost-sharing limitations, and the obligation to sell tiered plans (gold, silver, bronze). Insurers can exclude preventive services, including contraception, and states no longer have to treat insurers as part of a single risk pool.

Look carefully at section 204(b)(2), however. It says that the rules that can be superseded include subsections (ii) and (iii) of 42 U.S.C. 300gg(a)(1)(A), which governs community rating. If you chase down that cross-reference, you’ll see that (ii) and (iii) allow health insurers to vary their premiums based on age and rating areas.

But here’s the key: the basic obligation of 300gg(a)(1)(A)—the requirement that premiums can’t vary along anything but the specified conditions—isn’t listed as one of the provisions that states can supersede. No matter what rules the states adopt, then, insurers still can’t discriminate based on health status.

Or can they? If you keep reading, section 204(c) asks states to supply a “description” of the state’s new rules. In that description, the state must specify “[t]he criteria by which, and the degree to which, a health insurance issuer of such coverage may vary premium rates for such coverage, except that in no case may an issuer vary premium rates on the basis of sex or on the basis of genetic information.”

The suggestion is pretty clear: states can allow insurers to vary their premiums, including on the basis of health status, so long as insurers don’t discriminate on the basis of sex or genetics. Plus, it doesn’t make much sense to give the states the freedom to establish separate risk pools if insurers still had to charge the same rate to everyone, healthy or sick.

So what the hell does section 204 mean? Can states discriminate on the basis of health status or not? Who knows?

The craziest thing is that the sloppy drafting may be intentional. It reads to me like a deliberate effort to allow senators to read whatever they want to into the bill. Senator Cassidy and other moderates can claim it preserves the protections for preexisting conditions. Senator Cruz and other conservatives can claim it doesn’t.

Both have a point—but they can’t both be right. One of them is being sold a bill of goods.

My own tentative view is that the statute doesn’t allow insurers to vary their rates based on health status. Nothing in section 204(c) expands the carefully specified list of ACA provisions that can be superseded. There’s internal tension, to be sure, but absent something more, my working assumption is that insurance plans nationwide will remain subject to rules on community rating.

Even if that’s right, however, Graham-Cassidy would still allow insurers to discriminate against the sick. States could liberate insurers to sell plans with huge deductibles and missing benefits, which will discourage sick people from signing up. Since those plans would be in their own risk pools, they could keep their premiums low. Sick people would then be forced into comprehensive plans with sky-high premiums. (Thanks to Tim Jost for walking me through this.)

However you read Graham-Cassidy, then, it allows insurers to screw sick people. It’s just not clear exactly how they can screw them.

@nicholas_bagley

The only option left to the Senate is to make health care reform someone else’s problem

I wish I had more time to blog. I really do. But I’m consumed with grant submissions, mentoring researchers, and writing columns about health policy because it’s clear that someone’s got to do it.

That said, I’m taking ten minutes out of my day here to rant. Read it or don’t.

If it hasn’t become abundantly clear, the only thing left for Republican Senators to try is to kick the can down the road. Again. They’re going to try and pass a bill which gives less money overall to states, a lot less money to some states, and then tells them to “figure it out”. Later, they can claim that they gave the states all the tools they needed to fix the health care system, so now it’s THEIR fault things don’t work.

This is ridiculous.

There is no magic. There is no innovation. If there was a way to make the health care system broader, cheaper, and better, we would do it right now. We would have done it years ago. No matter what you may think of Democrats in 2009, they didn’t choose the ACA because they wanted to keep states from fixing the health care system. The ACA was the best they could get.

There are no governors, of red or blue states, who have a magic plan for health care innovation. There are no state legislators (who likely work part-time) who have a secret plan to unleash the power of federalism. The Republicans in Congress have had seven years, all the money in the world, the phone numbers of every conservative wonk in the country, the CBO, experts eager to offer their help… If they couldn’t figure this out, do they think that Montana will? Oklahoma? Indiana? In less than two years?

THERE IS NO WAY TO SPEND LESS, COVER MORE, AND MAKE IT BETTER.

Pretty much every health care organization is against this bill. The organization of Medicaid directors is against this bill. Most governors are against this bill. Nearly every wonk I can think of is against this bill.

There are legitimate ways to reform the health care system according to conservative principles. They all involve tradeoffs. The people defending this bill refuse to acknowledge that. Many are – at this point – seemingly just making stuff up and promising the moon. And – I’ll bet all the money in my pocket on this – when they can’t deliver, it’s going to be someone else’s fault.

Welcome to public service in 2017.

@aaronecarroll

Healthcare Triage News: Let’s Talk Cassidy-Graham

We had a whole other video planned for today but we have to talk about the Cassidy-Graham bill, which is getting closer to passing despite our predictions last week.

@aaronecarroll

Frakt’s rules of temporal tense in research articles

Very early in my research career (actually, as a grad student) I noticed that researchers were not consistent in their use of temporal tense (past, present, future) in journal articles and manuscripts. It was (and still is) all over the map. You’ll see stuff like this, even within the same paper:

“We ran OLS regressions and find …” [“ran” is past tense; “find” is present]
“We estimate a model with fixed effects.” [“estimate” is present]
“The coefficient is … which meant that.” [“is” is present; “meant” is past]

Yikes! Which of these is correct? This bothered me, and I wondered if there were rules about whether research was or is or results are or were. I think I asked around and got different opinions. Then I made up my own set of rules, which I’ve followed to this day, and attempt to get others to follow. They’re below. Do you agree with them? Comments open for one week.

All the things I (or my colleagues and I) did methodologically, I (we) did in the past, so I use past tense for methods and data collection. However, all the results are true for all time (so we think), so I like to report results in the present tense, with one exception.

Example: “We ran [past] an OLS and found [past] that people with bigger feet are [present] smarter than people with smaller feet, even controlling for age.”

The only exception is if I’m explicitly referencing a prior year. Example: “However, we found that in the 1990s, people with bigger feet were [past, because we’re explicitly referencing a past year] stupider than people with smaller feet.” It would read oddly to say that people in the 1990s with bigger feet “are” stupider …

That’s it. Not hard to follow. Even if you disagree, it has the advantage of consistency. At a minimum, authors should at least figure out what tense they want to use for methods and results and then do so consistently in a single paper. Read closely, and you’ll find that researchers don’t/didn’t/and may never pay attention to tense.

@afrakt

The Best Health Care System in the World: Which One Would You Pick?

The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and was jointly authored by Aaron Carroll and Austin Frakt. Click through to the original to cast your own votes in each health system face-off described below.

“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

This is often accompanied by calls to match the health care coverage of “the rest of the world.” But this overlooks a crucial fact: The “rest of the world” is not all alike.

The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.

Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament.

We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.

To select the winner of each matchup, we gathered a small judging panel, which includes us:

Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University School of Medicine
Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health

and three economists and physician experts in health care systems:

Craig Garthwaite , a health economist with Northwestern University’s Kellogg School of Management
Uwe Reinhardt , a health economist with Princeton University’s Woodrow Wilson School of Public and International Affairs
Ashish Jha , a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute

A summary of our worldviews on health care is at bottom.

So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts’ selections will decide who advances). When we cite hard data, they come from the Commonwealth Fund’s International Country Comparison in 2017.

But enough talk. Let’s play.

FIRST ROUND
Canada vs. Britain: Single-Payer Showdown

Both have single-payer systems, but vary in the government’s role and in what is covered.

In Canada, the government finances health insurance, and the private sector delivers care. Insurance, run at the province level, doesn’t cover drugs, dentists or optometry. Many Canadians have supplemental private insurance through their jobs to help pay for these. The government ends up paying for about 70 percent of health care spending in all.

Britain has truly socialized medicine: The government not only finances care, but also provides it through the National Health Service. Coverage is broad, and most services are free to citizens once they’ve paid taxes, though there is a private system that runs alongside the public one. About 10 percent buy private insurance. Government spending accounts for more than 80 percent of all health care spending.

U.S. analogues are Medicare (more like Canada) and the Veterans Health Administration (more like Britain).

Canada and Britain are pretty similar in terms of spending — both spend just over 10 percent of G.D.P. on health care. They also have reasonably similar results on quality, although neither ranks near the top in the usual international comparisons. In terms of access, though, Britain excels, with shorter wait times and fewer access barriers due to cost.

Our pick: Britain, 4-1

AARON: Britain. It’s efficient. Given the rather low spending, it provides great access with acceptable outcomes.

CRAIG: Britain. Patients in Britain have a greater ability to shop across providers (using additional private insurance). This, combined with reforms within the N.H.S., helped increase competition and quality.

AUSTIN: Britain. While the countries are close in spending and quality, Britain has much lower cost-based barriers to access.

ASHISH: Britain. Access problems can be profound in Canada — nearly one in five Canadians report waiting four months or more for elective surgery, which can be more than just an inconvenience.

UWE: Canada. The Canadian system is simpler for citizens to understand and highly equitable.

FIRST ROUND
U.S. vs. Singapore: A Mix of Ideas

The United States has a mix of clashing ideas: private insurance through employment; single-payer Medicare mainly for those 65 and older; state-managed Medicaid for many low-income people; private insurance through exchanges set up by the Affordable Care Act; as well as about 28 million people without any insurance at all. Hospitals are private, except for those run by the Veterans Health Administration.

Singapore has a unique approach. Basic care in government-run hospital wards is cheap, sometimes free, with more deluxe care in private rooms available for those paying extra. Singapore’s workers contribute 36 percent of their wages to mandated savings accounts that may be spent on health care, as well as on housing, insurance, investment or education. The government, which helps control costs, is involved in decisions about investing in new technology. It also uses bulk purchasing power to spend less on drugs, controls the number of medical students and physicians in the country, and helps decide how much they can earn.

Singapore’s system costs far less than America’s (4.9 percent of G.D.P. versus 17.2 percent). Singapore doesn’t release the same data as most other advanced nations, although it’s widely thought that it provides pretty good care for a small amount of spending. Others counter that access and quality vary, with wide disparities between those at the top and bottom of the socioeconomic ladder.

Our pick: United States, 4-1

AARON: United States. Singapore is intriguing, because it’s so different from other systems. But its huge mandatory savings requirement would be a nonstarter for many in the United States.

CRAIG: United States. Singapore, a scrappy underdog, has become a fan favorite of conservatives. But its reliance on health savings accounts is problematic: When people are spending more of their own money on health care, they tend to forgo both effective and ineffective care in equal measure.

AUSTIN: United States. It’s hard for me to overlook Singapore’s lack of openness with data.

ASHISH: United States. The lack of data in Singapore is a problem, and it had higher rates of unnecessary hospitalizations and far higher heart attack and stroke mortality rates than the United States. Plus, the U.S. has a highly dynamic and innovative health care system. It is the engine for new diagnostics and treatments from which Singapore and other nations benefit.

UWE: Singapore. It’s hard to defend the messy American health system, with its mixture of unbridled compassion and unbridled cruelty.

FIRST ROUND
France vs. Australia: Everyone Covered

The list of services covered in France is more extensive than in Australia — perhaps more than in any other health care system. Australia has the advantage in expense.

Australia provides free inpatient care in public hospitals, access to most medical services and prescription drugs. There is also voluntary private health insurance, giving access to private hospitals and to some services the public system does not cover.

The government pays for at least 85 percent of outpatient services, and for 75 percent of the medical fee schedule for private patients who use public hospitals. Patients must pay out of pocket for whatever isn’t covered. Most doctors are self-employed, work in groups and are paid fee-for-service. More than half of hospitals are public.

Everyone in France must buy health insurance, sold by a small number of nonprofit funds, which are largely financed through taxes. Public insurance covers between 70 percent and 80 percent of costs. Voluntary health insurance can cover the rest, leaving out-of-pocket payments relatively low. About 95 percent of the population has voluntary coverage, through jobs or with the help of means-tested vouchers. The Ministry of Health sets funds and budgets; it also regulates the number of hospital beds, what equipment is purchased and how many medical students are trained. The ministry sets prices for procedures and drugs.

The French health system is relatively expensive at 11.8 percent of G.D.P., while Australia’s is at 9 percent. Access and quality are excellent in both systems.

Our pick: France, 4-1

AARON: France. It provides almost everything you’d want, and it’s expensive only compared with countries other than the United States. (Compared with the U.S., it’s a bargain.)

CRAIG: France. It has seemingly done a better job of using markets to create competition across public and private hospitals — which provides incentives for quality provision and innovation.

AUSTIN: Australia. It was a close call. Australia achieves good outcomes (by some but not all measures better than France) with a lot less spending, making it a better value.

ASHISH: France. Both countries cover everyone, but people in France report somewhat fewer problems getting access to care, as well as shorter waiting times.

UWE: France. The Australian system is basically two-tiered: a public insurance-and-delivery system, and another based on private health insurance, each of which cover roughly half the population. This seems to work well in Australia, but in the U.S. the public system most likely would be badly underfunded. Therefore, France would be superior.

FIRST ROUND
Switzerland vs. Germany: Neighborly Rivalry

Germany’s system and Switzerland’s have a lot in common. Germany has slightly better access, especially with respect to costs. Switzerland has higher levels of cost-sharing, but its outcomes are hard to beat — arguably the best in the world.

Like every country here except the U.S., Switzerland has a universal health care system, requiring all to buy insurance. The plans resemble those in the United States under the Affordable Care Act: offered by private insurance companies, community rated and guaranteed-issue, with prices varying by things like breadth of network, size of deductible and ease of seeing a specialist. Almost 30 percent of people get subsidies offsetting the cost of premiums, on a sliding scale pegged to income. Although these plans are offered on a nonprofit basis, insurers can also offer coverage on a for-profit basis, providing additional services and more choice in hospitals. For these voluntary plans, insurance companies may vary benefits and premiums; they also can deny coverage to people with chronic conditions. Most doctors work on a national fee-for-service scale, and patients have considerable choice of doctors, unless they’ve selected a managed-care plan.

A majority of Germans (86 percent) get their coverage primarily though the national public system, with others choosing voluntary private health insurance. Most premiums for the public system are based on income and paid for by employers and employees, with subsidies available but capped at earnings of about $65,000. Patients have a lot of choice among doctors and hospitals, and cost sharing is quite low. It’s capped for low-income people, reduced for care of those with chronic illnesses, and nonexistent for services to children. There are no subsidies for private health insurance, but the government regulates premiums, which can be higher for people with pre-existing conditions. Private insurers charge premiums on an actuarial basiswhen they first enroll a customer, and subsequently raise premiums only as a function of age — not health status. Most physicians work in a fee-for-service setting based on negotiated rates, and there are limits on what they can be paid annually.

Both systems cost their countries about 11 percent of G.D.P.

Our pick: Switzerland, 3-2

AARON: Switzerland. It has superior outcomes. It’s worth noting that its system is very similar to the Obamacare exchanges.

CRAIG: Switzerland. The Swiss system looks a lot like a better-functioning version of the Affordable Care Act. There’s heavy, but quite regulated, competition among insurers and an individual mandate.

AUSTIN: Germany. Germany has a low level of cost-based access barriers — tied with Britain for the lowest among our competitors.

ASHISH: Switzerland. Switzerland outperformed Germany on a number of important quality measures, including fewer unnecessary hospitalizations and lower heart attack mortality rates.

UWE: Germany. The Swiss social insurance system — a late comer, enacted only in the 1990s, and financed by per-capita premiums — is less equitable than many other European systems, including Germany’s.

SEMIFINALS
Switzerland vs. Britain: Meaning of a Market

How does the cost-effectiveness of Britain’s “socialized medicine” stack up against the competitive but heavily regulated private system of Switzerland?

Our pick: Switzerland, 3-2

AARON: Switzerland. It has better quality, and perhaps access, but those come at a higher cost. I’m willing to make that trade-off.

CRAIG: Britain. Switzerland’s system — privately funded with private insurers — is often held up as a bastion of competition. But it is not necessarily more of a market than Britain; it just hides the heavy hand of government a bit more. In reality, the insurance and provider market is heavily regulated.

The U.K. system is almost entirely publicly funded, but it has done a lot to try to increase the competition between facilities, which has increased the quality of service.

AUSTIN: Britain. It systematically incorporates cost effectiveness into coverage decisions.

ASHISH: Switzerland. These are two countries with high-performing health systems, but Switzerland has better access and quality, albeit at somewhat higher costs.

UWE: Switzerland. Switzerland has better facilities and speed of access to care.

SEMIFINALS
France vs. U.S.: Access vs. Innovation

France has extensive coverage, with costs that are high relative to many other nations. The U.S. system, praised as dynamic and innovative, is even more expensive, falls short of universal coverage and can be bewilderingly complex. Which do our experts prefer?

Our pick: France, 3-2

AARON: France. France provides an amazing level of access and quality for the cost. The U.S. is considered the driver of health care innovation, which comes at a high price. But there are other ways to incentivize innovation in the private sector besides how we pay for and deliver care.

CRAIG: United States. The U.S. system is a bit of a mess in that it is quite expensive and doesn’t offer complete coverage to its populace. But the system really does have the strongest incentives for innovation on medical technology — which provides an amazing amount of welfare for citizens around the globe.

AUSTIN: France. It’s hard to justify the very high level of U.S. spending based on innovation alone, particularly without mechanisms to steer innovation toward technologies that are cost-effective.

ASHISH: United States. France has a far more equitable system, with few delays and reasonably good outcomes. However, the U.S. delivers a superior quality of care on the measures that matter most to patients, and the system is far more dynamic and innovative. It was close, but I picked the United States.

UWE: France. The U.S. is just too expensive for what it delivers, and includes too much financial insecurity to boot. At international health care conferences, arguing that a certain proposed policy would drive some country’s system closer to the U.S. model usually is the kiss of death.

FINAL
France vs. Switzerland: Top of the Mountain (Alps Edition)

France’s system is impressively comprehensive and in some respects simpler. Switzerland relies on a competitive yet much-regulated system of private insurers. Which has the edge and why?

Our pick: Switzerland, 3-2

AARON: Switzerland. This is a tough call. Switzerland does a good job of combining conservative and progressive beliefs about health care systems into a workable model providing top-notch access and quality at a reasonable cost. It doesn’t hurt that it does so through private (although heavily regulated) insurance.

CRAIG: France. Its system has more competition among providers than Switzerland’s does.

AUSTIN: Switzerland. The Swiss system is so close to the A.C.A.’s structure (which, to date, has survived all manner of political attacks) that something like it could work in the U.S.

ASHISH: Switzerland Both of these countries spend a lot on health care, outpacing the average among high-income countries, and both perform comparably on measures of access to care. However, in general, the Swiss health care system delivers a higher quality of care across a range of measures and invests more in innovation that fuels new knowledge and, ultimately, better treatments that we all benefit from.

UWE: France. It is cheaper, its financing is more equitable, and its system is simpler.

Conclusion

Germany would have tied Switzerland had we averaged our rankings of the nations instead of using head-to-head matchups in a bracket system (Switzerland eliminated Germany in the first round). It’s an example of how close the voting was. Not one vote was unanimous among the judges, and all the semifinal and final votes were 3-2. Clearly, there is room for disagreement about the relative merits of health systems, and different experts would surely reach different conclusions.

Some judges took a global view, giving the edge to countries, like the United States, that promoted innovation that benefited the rest of the world. In other cases, how health systems treated the poorest of society was paramount.

To nobody’s surprise, the United States could do better at balancing health care costs with access, quality and outcomes. But there are many ways to reach that goal, and there will always be trade-offs. Learning about them from other systems and debating them honestly would probably do us a lot of good.

We hope that readers will consider this to be merely the beginning of a discussion, not the end. We welcome your questions or comments. In fact, we look forward to writing articles in which we answer those questions and ask other experts with different views to weigh in.

Have you experienced a health system outside the United States? Tell us its best or worst feature. And what advice would you give Americans?

The panel:

Craig Garthwaite is a conservative economist who believes that well-regulated markets offer the best means of providing quality and innovation. He’s a lifelong Republican but has been broadly supportive of the market-based A.C.A.

Uwe Reinhardt, who has analyzed health care systems around the world for half a century, has been a longtime supporter of single-payer, although he has said he doesn’t believe the United States could manage that system well because it’s captured by special interests.

Ashish Jha and Aaron Carroll believe in universal coverage. Austin Frakt is less invested in universal coverage than universal access to affordable coverage. All three pay less attention to whether a system is more government-run or more market-based because they think either approach can succeed if devised well. Aaron and Austin blog at The Incidental Economist. For more information on health care systems, you can view Aaron’s Healthcare Triage playlist of videos. Ashish blogs at an Ounce of Evidence.

Healthcare Triage: Shrooms, LSD, and Legit Uses of Psychedelics in Treatments

With all the recent studies of medical marijuana and its benefits, some researchers have become interested in researching the use of psychedelics like psilocybin, LSD, and MDMA for treating mental illness. It’s hard to research though, because of the drugs’ legal status as Schedule I drugs. This makes them very hard for researchers to obtain, it makes it hard to get research approved, and it make it difficult to find funding for these studies. We’ve got the details.

This episode was adapted from a column I wrote for The Upshot. Links to sources and further reading can be found there.

@aaronecarroll