Which Country Has the Best Health Care in the World?

by Ezekiel J. Emanuel

A preeminent doctor and bioethicist gives an incisive tour of ten health care systems across the globe, in search of an answer to whose is best --- and how we can be more like them.

One thing we can all agree on: America does not have the world's best healthcare, at least not for all its citizens across 50 very different states. But which country does, and what can they teach us?

Author, physician, and bioethicist, Ezekiel Emanuel has examined the world's leading providers of healthcare.
Drawing from an analysis of ten countries --- Australia, Canada, China, France, Germany, Netherlands, Norway, Switzerland, Taiwan, and the UK --- the results are in. No health care system is perfect, whether the problem is too many hospital beds in Germany or treating chronic illness in France, and some problems are shared across many countries, from truly addressing mental healthcare to containing the rising costs of chronic care.
But the lessons from the best healthcare practices allow us to adapt some of the good found in other countries and avoid making the same mistakes as others. Healthcare remains uniquely important to all Americans, and uniquely fraught: here is the best evidence from around the world of what excellence looks like and how we can deliver it here.

Genres: Nonfiction, Health Care, Politics, Health, Medicine, Economics, Medical

256 pages, Hardcover

First published June 16, 2020

Reviews

[Geoff · Rating 3 out of 5]

A readable, in-depth examination of strengths and challenges of 11 different countries' health care funding and care delivery systems. The author wastes no time in walking back the buzzfeed nature of the title and, instead of coming up with a simple ranking, looks at where each system is doing well and poorly across the issues of controlling health care costs in general, the increasing costs of prescription drugs, inefficiencies in providing care, increasing coverage for the entire population, coordination of care for chronic illnesses, increasing mismatch between healthcare systems and the population needs (often in terms of too many or too few hospital beds), increasing mental health care needs, increasing long term care needs, and ability to innovate and try new solutions for providing, covering, and paying for health care.

After introducing the issues, the book goes deep on a historical and structural analysis of the health care systems of the USA, Canada, UK, Norway, France, Germany, the Netherlands, Switzerland, Australia, Taiwan, and China. He covers these in extensive (excessive) detail. To be honest, this part of the book really dragged for me, and it's the majority of the book. But policy wonks will be really interested. I did really like learning at a high level about each system. In the US, we often get a very stereotyped view of the systems in Canada and Europe when there are profound differences (such as the existence and amount of private insurance companies) between each country. And notably, every system has strengths and issues; there is no such thing as the universally perfect system. The historical circumstances that led to the creation of each system also make it really hard to say the features of one system should be lifted wholesale to another system.

In the final analysis, the US system compares pretty dismally compared to all of its peers except China. The one exception, is in the area of health coverage, health care, and health care funding innovation. The US is up the with the Netherlands and the UK in terms of willingness to experiment and pilot new solutions in each of these areas.

One the whole an interesting look at different health care systems that avoids a superficial ranking but didn't quite avoid overwhelming this reader with details.

[Pallav Sharda · Rating 3 out of 5]

Healthcare industry nerd's delight. I like the holistic perspective this book is bringing to a messy, complicated topic.

But the drawback is that it's quite boring and dry. Just plain facts, figures, history, statistics. Mind-numbing after a while to hear. I've been forced to skip ahead multiple times now.

Overall, it seems to be a good reference to have on the desk. But not an engaging, interesting read.

[Alexis · Rating 4 out of 5]

This is very interesting--at least if, like me, you're a healthcare dork. If you're not, this might be a bit dry--you probably don't really care about how the Swiss use a point system quite like the US' RVU, do you?

Rather than answering the question up front, Dr. Emanuel profiles 11 health systems, including the USA, to see how each country works and what it does well--and doesn't. Each chapter follows a similar structure, describing the system, its payment model, how care is delivered, how drugs are financed, and the challenges facing the system. Not-really-a-spoiler alert: No country is "best": each has strengths and weaknesses. For example, Canada's system is simple and accessible for hospital and medical care, but scores poorly because standard healthcare does not cover pharma and the provincial plans do not cover most outpatient non-MD providers, a particular issue for mental health. Switzerland provides an enviable level of choice, but at a high cost--a family of 4 in Geneva may pay CHF 1800 a month for insurance, with limited income based subsidies, and then has to pay cost sharing on top.

It turns out that the US does do a few things well--we're good at innovation in care delivery and payment methods. (We invented and exported the DRG system for payments. You're welcome.) What we are not good at is ensuring affordability and access, and despite people in the US thinking our system gives freedom of choice, in practice we score poorly due to our use of insurance networks. Also, sadly, mental health is an issue in many countries, not just the US.

There were some weaknesses in the book. For example, in the UK chapter, the vast majority of the discussion was on finance and structure, with very little devoted to care delivery. THis is a particular omission for the NHS as so much care is delivered via GP surgeries, and all that's mentioned is the existence of multiple providers in surgeries. If I hadn't lived in the UK for several years, I would never have known that specialist care in the UK is delivered in hospitals. There's also an embarrassing error in describing the National Insurance rates in which he says that higher-rate taxpayers pay 2% NI on *all* income, rather than on income above the NI threshold. While dental care was mentioned briefly in some chapters, it was not in all of them. I also would have liked to have seen some mention of obstetric care, which varies widely between countries. Dr. Emanuel likes to focus on "quality" care but doesn't always give definitions or metrics for determining quality, which would have made the point more effective. And as he himself admits, comparisons can sometimes be dicey because of differences in measures. Long term care can also be split between medical and social care systems, making it difficult to measure.

Nonetheless I think it's a worthy entry that should be more widely read. There's an unfortunate tendency in the USA to equate universal healthcare with single payer, which is not true, and there are many pieces under the hood that need to be coordinated. The countries in the book use a variety of systems (Emanuel places them in 5 categories--all of which exist in the US also!) None of them manage to provide care at no out of pocket cost in all categories, as Bernie Sanders proposed, though other than Switzerland, cost sharing for covered categories tends to be small. Only the Netherlands and Germany have dedicated funding for long term care. He concludes with some suggestions for improving the US system.

[Natalie aka Tannat · Rating 2 out of 5]

The author doesn't so much ask which country in the world has the best health care as which country should the United States try to emulate in order to become the country with the world’s best health care within the next ten to twenty years (author thinks this is doable). So in his final determination he mostly focuses on which countries the US system is closer to in style so that all the infrastructure doesn’t have to be thrown away. That said, his outlook is very, very American despite his suggestion that people from other countries might find the data in his book interesting. I mean, I did find some of it interesting but I got frustrated with the delivery and had to do some independent research to clarify what he was trying to say.

The good:
The goal of describing and comparing several different health care systems across the world was an interesting one, and I definitely learned something about what different kinds of systems are out there.

The bad:
I found more clearly written summaries of the health care systems he discussed online. He tried to compare the countries across specific metrics but I found that the individual chapters didn’t always mention the same things. The broad topics were the same, but sometimes he would make a comment about, say, ambulances in one chapter that wasn’t discussed throughout.

It felt like the different chapters were written, finalized, and then some were shuffled about since he started commenting and comparing to the German health care system in chapters before the actual German chapter, for example. There was no need to do this since he had a chapter at the end that actually compared all of the countries.

I started to question his expertise once he started sounding surprised that market forces weren’t making people spend their precious time researching and selecting the absolute best and most efficient health insurance package for them. One, that can be a lot of work and two, health care is notoriously one of the areas where people don’t shop around so market forces don’t work very well. Like I said above, his outlook was very American.

I think his discussion on the different systems was mostly accurate but he definitely oversimplified and ended up contradicting himself, at best. He talked a lot about public versus private aspects but was very sloppy about specifying whether the private aspects were for profit or not.

I still don’t really understand the American health care system.

So yeah, I don’t really recommend this book, although The Commonwealth Fund has a great section on its web site on international health care system profiles if you’re interested in learning more about the topic.

[Matthew Jordan · Rating 3 out of 5]

Comprehensive but boring. Good to have on your shelf if you forget how Norwegians pay for drugs. Bad to listen to as an audiobook (unless used as a sleep aid).

[Richard Thompson · Rating 4 out of 5]

Zeke is the least well-known of the high-achieving Emanuel brothers. I have done business with Ari who runs the William Morris Endeavor Agency and have admired Rahm's work as Obama's Chief of Staff and mayor of Chicago, but this is my first encounter with Zeke. They say that he is the smartest of the three. That's quite an accomplishment since his brothers are no dopes, but after reading this book, I believe it could be true. This is an intense well-researched book that explores the history and structure of health care systems in a number of countries. The bottom line is that they are all complex and they all have their strengths and weaknesses. The US is nowhere near the top, but our health care system isn't as completely horrible as it is often made out to be, and since innovation is one of its strong suits, we may be able to fix many of the problems and get back on par with other countries with systems that are fairer, simpler, cheaper and closer to providing universal coverage. If I had a choice, I'd pick Norway or Taiwan or maybe the Netherlands as having the system that I would most like to emulate, but it isn't as simple as that. Each country has its own unique political, social and cultural tendencies that present challenges and opportunities, so you can't just clone another country's system that works well for them, and it is almost impossible to make radical changes in any system overnight.

The avalanche of facts and figures in this book is mind-numbing. It's better as a reference manual for a policy wonk than as casual read, but I have a lot of respect for the reseach and analysis that went into the book so I came out of it feeling that Dr. Emanuel's reasoning and conclusions were sound. I'd be happy to see him put into a position in government where he could really make a differnce in addressing some of the glaring problems that the US health care system faces.

[Kailyn · Rating 3 out of 5]

(3.5/5) Straight facts. No cap.

Pretty boring read considering it’s read more like an academic rather than a story. But it’s about healthcare, so what do you expect? Still learned a lot though, especially about other countries’ healthcare systems.

[Alex Furst · Rating 3 out of 5]

Book #61 of 2024. "Which Country Has the World's Best Health Care?" By Ezekiel Emanuel. 3/5 rating.

This book looks at 11 health care systems around the world, focusing on:
1) history
2) coverage
3) financing
4) payment
5) delivery of care
6) prescription drug regulation
7) human resources
8) future challenges

Ezekiel makes the fascinating statement that a country's health care reflects its history and the values it finds most important when providing care.

The book starts with the vastly underperforming US system. We pay far more for worse care than the majority of European and other rich nations. The biggest positive is high innovation in technologies, as well as around how to set up different billing systems. This is the biggest hope for improving in the future. Ezekiel lays out other countries and their healthcare systems so that we can possibly take some of their more successful ideas and find ways to implement at least portions of them.

After looking at 11 individual countries, Ezekiel says that the tiers for top performers are:
1) Germany, Netherlands, Norway, and Taiwan
2) Switzerland, France, and Australia
3) UK and Canada
4) United States
5) China

Issues that countries are facing include:
- Cost
- Nursing and doctor shortages
- Long-term care
- Long waitlists
- Coordination of chronic conditions
- Mental health care
- Electronic medical records
- Drug prices

Ezekiel in the conclusion looks at 6 points for the US to realistically change:
1) ensuring universal coverage
2) better cost protection for children
3) mandating simplification of insurance
4) emphasizing primary care
5) more use of best practices around chronic care coordination and mental health
6) regulating drug prices

Overall, this book was interesting to look through a bunch of different health care systems to see where they thrive and where they are lacking. It just got to he long reading through all of the countries. The Conclusion and its overview of the how each country stacked up and where the US could realistically improve was a great 30 page read for any person who could actually make an impact on the US system.

Quotes:
"'That is a terrible question.' You cannot just take the world's 'best' system, whether it is the Dutch or Swiss or Norwegian or Australian one, and plunk it down in the United States and think we will get better health care. Health care is path dependent. We have built up numerous institutions over decades that constrain and limit our ability to change the system. And each country prioritizes different values that color which policy options they adopt."
"We cannot eliminate preexisting institutional structures to become like the Norwegian or Swiss or German systems overnight - or even over decades."
"Spending just under 18% of GDP on health care makes the United States a very expensive outlier."
"Again, the United States is an outlier - with just over 4% of the world's population, we account for about half of the world's drug spending."
"About 85% of all health care costs are for patients with chronic conditions."
"One consequence is that only about half of all adults with serious mental health needs actually receive services. Another consequence is that many patients with mental illnesses now end up in prison; in fact, 21% of prisoners in the United States have one or more mental health diagnoses."
"Studies have down that about 25% to 33% of patients with chronic illness or those admitted to a hospital for medical reasons or suicidal procedures have comorbid depression and anxiety. Having comorbid mental health conditions substantially increases health care costs, often by 60% to 70%."
"This amounts to over $1,400 per capita for prescription drugs, more than twice the per capita spending in most European countries. This high spending for drugs is a result of high drug prices, not high drug use by Americans."
"Approximately 90% of all prescriptions written in the United States are for generic drugs, but they account for only 26% of drug costs."
"There are approximately 850,000 active physicians for 325 million Americans, or 2.6 physicians per 1,000 people, which is below the international average."
"The government estimates that the United States will need 1 million more nurses by 2024."
"Nevertheless, one major reason for the nursing shortage is a dearth of nursing faculty."
"Surprisingly, the United States does not use more of the most expensive services than OECD countries do, such as hospitalizations or visits to a doctor, although it does use more expensive technologies, such as MRIs and expensive drugs. The big reason for the higher expenditures in the United States is the higher prices paid for health services."
"On average, drug prices in the United States are 56% higher than in European countries and constitute the single-largest cost category, explaining higher US health care costs compared to European countries. Indeed, bringing per capita US drug spending down to the per capita spending of the 2nd-most expensive country would save about $150 billion per year (or 5% of total health care expenditures)."
"The [Patented Medicines Prices Review Board] then compares the proposed factory price to (1) what other nations pay for the same drug and (2) what Canadian provinces pay for therapeutically similar drugs. By statute, the PMPRB compares the proposed price to that paid by a group of 7 nations, referred to as the PMPRB-7: France, Germany, Italy, Sweden, Switzerland, UK, and the United States [; Switzerland and the US were removed in 2020]. The PMPRB also compares the proposed price to what is being charged domestically for other medications in the same therapeutic class."
"For a generic medications, the pCPA [pan-Canadian Pharmaceutical Alliance] uses a tiered pricing framework based on the number of generic manufacturers on the market. If a new generic is the only one in the market, its price is set at 75% of the brand listing. Once a 2nd generic is introduced, the price of +both+ decreases to 50% of the brand price. Upon entry of a 3rd generic, the prices all decrease to either 25% for oral solid medications (pills) or 35% for nonoral medications (liquid oral, inhalers, etc.). Since its creation the pCPA has lowered generic drug prices by over 50%."
"In 2017, the UK spent about $260 billion USD (£197.4 billion), or 9.6% of the GDP, on health care. This translates to just under $4,000 USD (£2,989) per capita. Of the G7 countries, the UK has the 2nd-lowest percentage of GDP spent on health care, significantly less than the nearly 18% spent by the United States and the 12.2% spent by Switzerland."
"Wait times at [UK] emergency departments are also lagging; 84.4% of patients are seen, admitted, and treated or sent home within 4 hours of arrival, significantly below the NHS target of 95%."
"Consequently, in 2015, 90% of all drugs prescribed in England were dispensed for free."
"Norway has about 103,000 nurses. This is the 2nd-highest number of nurses per population: over 17 per 1,000 population and about 3.5 nurses per practicing physician....Nurses' salaries are comparatively high. According to Statistics Norway, full-time nurses earn on average about $67,000 USD annually (over 576,000 kr.). There is relatively high nurse job satisfaction, with few wanting to leave the profession or not recommending it."
"'Every country's health care system is driven by a core national value. For the United Kingdom, it's utility. For Germany, responsibility. For the United States, liberty. [And for France,] equality,' says Dr. Laurent Degos, vice president of the Pasteur Institute."
"At a rate of 6.3 annual consultations per person per year, the French visit physicians slightly less often than people on other developed countries but much more frequently than Americans."
"CEPS's strong central negotiating power has achieved remarkable control over drug pricing. The pharmaceutical retail price index for France is 61, nearly half that of the United States (100), Germany (95), and Switzerland (88). And this translates into real savings: whereas Germany consumes 6% fewer pills per capita, it spends nearly 40% per capita more due to higher prices. For instance, in the case of the statin Crestor, when it was branded, a one-month supply cost $86.40 USD in the United States, $40.50 USD in Germany, $25.80 USD in the UK, but only $19.80 USD in France."
"It is always important to ask the question: best for whom?"
"Ironically - and maybe surprisingly to many readers - the choice of physician is much more limited in the United States than in most other countries - not by the government, but by private insurers. (Medicare has excellent choice, but private insurers have constantly changing networks.) And there is no coherent mechanism for financing long-term care. Conversely, probably to the surprise of many readers too, the United States does excel in having many delivery organizations with best-in-class chronic care coordination."
"Waiting times seen to be less salient - but not necessarily less prevalent - in the countries where private financing predominates: the United States, Switzerland, and the Netherlands. This is not because there is hard evidence that waiting times are nonexistent or shorter; rather, it may be because there is no single entity, such as Britain's National Health Service or Australian Medicare, on which patients can focus their anger and complaints."
"About 4 million American children - or 5% - are uninsured. Outrageously, almost a third of these uninsured children live in just 2 states: Texas and Florida. In Texas alone 11% of children lack health insurance."
"The multitude of insurance products - usually dictated by employers - and complex insurance billing processes mean that US physician practices spend 4 times more on administration compared to their Canadian counterparts."
"More than 80 cents of every health care dollar in the United States goes toward patients with chronic illnesses: diabetes, asthma, hypertension, congestive heart failure, emphysema, cancer, and other conditions."
"With less than 4.5% of the world's population, the United States accounts for over 40% of all drug expenditures. It is the only country that grants drug companies monopolies through patents and marketing exclusivity and then allows them to freely set prices. All of the countries I studied explicitly regulate drug prices."

[Leonard · Rating 5 out of 5]

I didn't read everything in this informative title but noted that the issue of health care is complex, and every country is somewhat different than every other country when it comes to providing health care for its citizens. It's important to note that US citizens pay more per person for coverage and have a lower life expectancy, therefore getting less for our money than citizens in other countries.

[Pete · Rating 4 out of 5]

Which Country Has the World’s Best Health Care? (2020) by Ezekiel J. Emanuel is a serious comparison of a number of health care systems around the world. Emanuel is an oncologist and bioethicist.

The book has chapters on the health systems of the US, Canada, the UK, Norway, France, Germany, the Netherlands, Switzerland, Australia, Taiwan and China.

Each chapter describes how many people the system covers, what it covers, how it’s paid for, how drugs are paid for, how hospitals and physicians are paid for, how mental health care is handled, how many doctors and nurses there are per person, how long term care is paid for, if there is choice in the system and how much the system costs.

It’s really dry but it’s really good. It’s not an easy read unless your idea of a good read is a Vaclav Smil book. But, like a Smil book it is very much worth a read.

The book shows how path dependent health care is in each country. It’s surprising, for instance, to find that the Nazis overhauled the medical system in the Netherlands and that quite a lot of those changes remained. Emanuel also makes the point that universal health cover in most countries is actually fairly recent.

The book concludes with a chapter on how Emanuel evaluates the systems overall and which ones he thinks are the best.

Which Country Has the World’s Best Health Care is a really good book, but not a light and breezy read. It’s definitely a book well worth a read for anyone who is interested in health care.

[Amy Jo · Rating 3 out of 5]

OK, so diving into the funk and minutiae of health care systems is not normally my jam. I do not even know if I understand my health care situation; probably don't in all probability. However, the type of not easy and probably unanswerable type of question that the title poses interested me enough to pick it up.

After finishing this book, my non-expert opinion is that Emanuel does a good job of showing a layperson the pros and cons of and challenges facing some 11 developed countries. It is a lot more informative than stating it is not a simple question with a easy answer or it's path dependent or something that skirts the why of why people--especially those dissatisfied within the U.S. health care system--want to know this answer.

I tried to treat this read like a marathon taking my time rather than marathoning it. Trying to absorb all of the detail at least for a few weeks. Then I checked my due date; vaguely panicked and gestured. Then I actually marathoned the remaining 2/3 in 2 days. So, my memory might be even more shaky than usual.

Pros
-Although probably very broad strokes of explaining each system given the number of systems explained in one book, I overall feel a smidge more informed about what these other 10 countries have going for them. For example, I now know that universal coverage often does not always mean single-payer government. Knowledge is power and all that.

-Relates to my first pro, but I specifically wanted to point out how I now I know the areas that a good health care system needs to excel. I knew from being in a health system that wait times, affordable, and pharmacy costs are issues that should be actively controlled or addressed. However, the spelling out of the importance of simplicity of use and delivery of care makes sense, but I am not sure I would have caught on to its importance in itself to a good system.

-Pages 350-end are so nice and straightforward after all of the history and explanation of the different systems by themselves. Informational tables without charts that overwhelm you.

-Also, the last few pages with Emanuel's six recommendations on how to change the U.S. System based on what was learned by examining the other 10 systems. Change is hard to hope for when it requires some heavily opinionated powerful people to agree with something that could help millions of people they do not necessarily have to answer to literally.

-Not really a pro, but I wanted to point out how easy I am affected by subject matter that interest me when I whooped out loud when Taiwan was the outlier that covers dental. Like I am so glad no one has to buy supplemental insurance for dental. Although some things not being covered did not make sense to me, but I forgot already because it fascinated me that Traditional Chinese Medicine is mainstream enough in that culture.

-Learning that the struggle to transition to electronic health records-Emanuel is pro EHRs b/c data and care coordination is his thing-is still somehow ongoing for a lot of countries. Come on, Switzerland. Only your bank accounts need this much secrecy.

-Nurse practioners and nurses deserve all the flowers and respect. Really all medical staff though I feel like specialists already get proper amount of societal respect.

Cons
-SO MANY ACRONYMS! Acronyms, chart figures, and detailed insurance allowances and methods of financing was good NyQuil reading. It made it difficult to enjoy the read until I decided to marathon it. I know it comes with the territory of the subject matter, but it still would be a deterrent for me recommending this book to others.

-Relates to first point, but it is so dense of a read most of the time as someone who does not eat health care system information for breakfast. The amount of times my head would start nodding off in broad daylight due to the exact acronym commission having dominion over primary care while another acronym entity oversees outpatient care and payments might not overlap nor physician choice and then my head just turns off from the bureaucracy or the tediousness. I know it is important to know in order to know the system, but it was a personal struggle that demands extra attention.

-Why are there at least 3 different countries that use the term Medicare for a health care system? Someone should just play rock, paper, scissors in order to call dibs. It's a good term, but not that good. I personally like NHS if I have to pick a system name.


Took me too long to wade through the information overload, but glad I got to the last comparison pages that gave me what I craved. I will not be an expert about all these different health care systems, but I have a bit of a better primer about those systems and how systems that are good in different ways are good because of these measures they put in place. Maybe someday some people in the U.S. can push for changes that are similar to measures in the other examined countries and proven effective.


tl;dr: Yeah, there is no answer to the question; the question is the excuse for explaining 11 different health care systems. Also, if one is within the U.S. health care system, realizing the specific areas the country sucks at compared to other countries of comparable economic statuses is a bit funny in a "oh, oh we don't do something many other countries have done successfully because?" type of funny.
Oh, and if I was a random bored rich medically conscious person, I would visit Norway except for long term care then I would try Germany. Taiwan sounds interesting even if funding and overworked hospital staff seems troubling.

[Mike · Rating 4 out of 5]

An excellent comparative study of selected advanced countries/ economies in providing their residences with ‘universal medical care’. Netherlands, Germany and Norway, while needing some improvement, are close to be stellar examples of universal coverage.

China and US need major work to achieve universality and systemic efficiencies.


If you have an interest in this type of book, you will find it easy to read. Very well researched. Thoughtful. Insightful. It will depress you a little bit if you are a US reader.......

[Meir Brooks · Rating 2 out of 5]

This is, unfortunately, not a very good book.

I write "unfortunately" because I'm highly interested in health systems and a good comparative study of such systems would be invaluable. But even after reading the 411 pages of this book, cover-to-cover, I feel that my understanding of health systems and their challenges is not much improved.

The book is laser-focused on a specific list of details for each system, and it hardly diverges from it for more than a handful of pages. These details are the structure of the health system in each of 11 countries, encompassing history of how the system came into being coverage, financing of the system, how providers are paid, how consumers pay, human resources, pharmaceuticals, and challenges. The "History", "Coverage" and "Challenges" sections are reasonably interesting. There are also a number of sub-issues covered in each of these, such as long-term care and mental health. These are chock-full of acronyms and money amounts (always in local currency as well as USD) that may be useful as a reference but will flee your mind by the next page. It is worth saying that for anyone who is strongly interested in comparability on these dimensions, the book could be useful, but I'm sure similar information is available online. Moreover, given that healthcare systems are constantly changing, the book's information may soon be out of date.

But the much bigger problem is what the book never touches upon. First, there is essentially zero discussion of health systems generally-- why they are complicated, why the private market alone cannot provide good healthcare, and conversely why a totally centralized national system can be problematic. "Adverse selection" pops up briefly a couple times in the examples, "moral hazard" is never named and only indirectly described. So one gets a lot of details about these frighteningly complex systems without a good sense of the trade-offs and problems that require them to be complex.

Second, the choice of countries is odd. It makes a lot of sense to choose countries that represent a particular kind of system: US is of course the starting point (and a good cautionary tale), and then the UK can represent the fully socialized system, Switzerland as a mostly privatized one, Germany for its competing health funds, and perhaps the Netherlands and Taiwan as being exemplars on particular dimensions. But I don't see what Australia, Canada, France and Norway really add-- three of these could have easily been dropped without much loss.

The approach to the China case is, frankly, baffling. I am all in favor of having a developing country on the list-- in fact, I would have loved more on how poor countries handle healthcare with their much more limited funds and different demographic and health profiles. But China is treated on the same level as the other ten, even though it is about one-third as rich as the next poorest country (the UK), and of course its health system was built when it was much poorer. Incredibly, this fact seems to never be mentioned-- or if it is mentioned, then it is buried in some comment at the beginning, but never when China's performance is compared to the other countries on the list. In fact, the inclusion of China seems to be geared toward rejecting the idea that the US' system is the worst in the world, which is of course patently false (though it may be the worst or close to it *relative to its income level*, to the extent that such a term is meaningful), but it's odd to argue that by comparing its performance to a much poorer country. The fact that all the countries on the list are vibrant democracies while China is an authoritarian dictatorship is also not mentioned or at least not mentioned in any significant fashion, which is again a strange oversight.

Third, in its absolute focus on dollar amounts and coverage, the book ignores entirely something that most people would consider a rather important part of health systems: health outcomes. Again, it is perfectly legitimate not to focus on these, because arguably the health system is much more about how health shocks affect people's finances rather than how healthy it makes a population. But of course when people cannot afford healthcare, or need to wait for months or years before getting treatment, this will affect health, and it is strange that this aspect is simply not addressed in this 411-page book. Not for a single page, as far as I could tell (I think it was mentioned briefly when noting that Americans do not have better health despite spending much more). Similarly, the total lack of discussion of demographics and incomes means that there is no sense that one system may be better for a particular country than for another, not only due to history and politics but because of population characteristics.

Overall, this book can serve well as a detailed, comparative snapshot of the 11 countries mentioned on the specific axes mentioned, as of 2020, if all "baseline" characteristics of these countries are to be ignored. Moreover, for anyone who genuinely wants to read 400 pages to get an answer to the narrow question "Who has the world's best healthcare," where "best healthcare" is interpreted essentially as "most efficient and convenient healthcare," this can be good. Otherwise, I'm sure there are better books to read on the subject.

[Isaac · Rating 5 out of 5]

This book was a somewhat tough read, pages, and pages of pretty dry information and analysis but despite that I think it should be required reading for anyone who wants to have a serious opinion on the healthcare debate.

The book examines the healthcare systems in 11 countries (US, Canada, UK, France, Germany, Netherlands, Switzerland, Norway, Taiwan, China, Australia) and compares performance across some 22 dimensions like coverage, drug price costs, waiting times, comprehensiveness, simplicity, etc. It goes country by country, but the conclusion looks at the dimensions across the countries and sums up with some lessons the US could learn from the analysis.

I learned so much from this book just about how healthcare systems can be structured, all the different things that impact the various dimensions. Single payer is not the same as universal, insurance can be public or private independently from public or private “delivery systems”. Under what conditions should a doctor be paid a salary vs per procedures. To what extend should general practitioners serve as a gate keeper to specialists. How electronic are one’s health records, how accessible are they to different care providers? How do we finance long-term care, how do we deal with mental health issues? Are drug prices based on rates in other countries, or on a cost-benefit analysis or do we just let them charge whatever they want (and different prices for different markets)?

I also didn’t come away with a ton of strong opinions because it’s done so differently in so many countries and no one has it all figured out, especially long-term care which almost no one is willing to confront.

[Cynthia · Rating 3 out of 5]

I wrote a very long review that I am sad that got deleted.

For completion sake, I’ll write a short summary of said review

Very well researched, densely packed full of information, and rational enough to not give an umbrella answer.

Overall, there are leaders in terms of best health care system such as Taiwan, Norway, and Netherlands. There are clear losers too, such as US and China.

I liked the last chapter that compared countries responses to covid. Lots to learn!

[Vincent · Rating 5 out of 5]

This is a 5 star book if the following apply to you:
1) very very interested in healthcare policy
2) already have a very good understand of healthcare policy, mostly from a US centric focus.
3) have a very high tolerance for poor/rote/boring writing

If the above does not fit, then I'd say read the disclaimer, introduction, last 2 chapters, and coda. Or put another way, everything except the country analysis. That said, there's probably still some stuff in these sections that might not be super clear/intuitive for someone who isn't well versed with healthcare policy already. Emanuel does not do a great job of explaining the basics of healthcare/policy, but it's really hard to blame him for this, because that sort of good introduction would likely require another book in itself.

I really need to emphasize how boring and bad the writing is again. The sentence structure repeats itself very frequently. At times when stating statistics his writing is so muddled it becomes hard to decipher the detail. Part of me doesn't blame him, because this is a policy wonk comparative analysis book. By nature it's repetitive, but I still don't think that's a good excuse for how painfully boring and slow this was to read at times.

I think this book would have been IMMENSLEY improved if each detailed section (coverage/financing/payment/delivery of care/pharmacy regulation/human resources) began with a bullet point list or data chart summary. This way you'd have guiding points to refer to while reading his poorly composed sentences. The writing could be reserved for extra detail or nuance that isn't captured by the highlighted statistics. Or at the least have an index in the back that summarizes all the quantitative measures. Hell I'd take an excel spreadsheet I can download and look at while reading. I guarantee Emanuel made something like this for this book, so it'd be great if he could share it with us. Furthering this point, he did include a number of charts throughout the book, including great ones for Pharmacy Pricing regulations, by country financing summaries, and several in the last chapter summarizing his analysis. These were great and I would have loved to see more. It would have only aided the writing.

Now that I've got the majority of my complaints out of the way, I think both the methodology of his analysis and conclusions are spot on and terrific. His method for analysis and the sections of healthcare he focused on are almost identical to what I'd choose. He also correctly identified the challenges between comparing across countries, and was very honest about the shortcomings in his work. For the most part, he used smart/correct metrics to evaluate each section of healthcare. I did have some minor complaints, I wish he was more clear about dollar totals and rates. It seemed like everything was annualized, but I think using PMPM when discussing individual cost rates would have been better and more easily comparable across countries. Additionally, his lack of understanding of premium pricing, and more specifically family + rate basis pricing hurt his criticism there a bit, but it's hard to fault him considering that calculation is yet another US convoluted pricing mechanism that is unnecessarily difficult.

Anyway, ending with positives. The six lessons section is great, I more or less agree with all of it. If all six of these occurred, I think you would have one of the best health systems in the world. Although, I'd probably throw in a few more changes (mostly centered around employee sponsored insurance). I've got some other loose thoughts, but there's zero chance anyone has read this far in the review anyway so I'll end here.

[Robert · Rating 4 out of 5]

I didn't expect this book to be light reading but it was even wonkier than I thought it would be.

It's a systematic, plodding walk through the healthcare systems of 11 different countries, trying to comprehensively compare them and identify what is good and bad about each.

I confess I only listened in detail to the chapters on the US, Canada and the UK and then skipped to the summary and conclusions.

Fortunately Emanuel is rather repetitive (it seems he makes every point at least 10 times), so I don't think I missed as much as I might have.

The main points I gleaned:

(1) The healthcare thing is a lot more complicated than it is currently debated it in the US, where we just like to talk about single payer (Medicare for All) or not, as a binary option, but in reality there are wide variety of systems that can deliver good healthcare with many different policy options for each.

(2) The US is unlikely to ever completely eliminate insurance companies

Because we already have private insurance playing such a big role in our healthcare system it's unlikely that we can completely eliminate it, as much as many liberals would like to see it. The insurance companies are too big, too entrenched, too politically powerful, plus a transition to single payer would involve tax increases which are never popular.

(3) But just like we suspected, the United States has one of the WORST healthcare systems among industrialized countries.

It's by far the most complicated, the most expensive and covers the fewest people while delivering some of the worst health outcomes. The only bright spot is that it's quite innovative as hospitals, doctors and politicians are forced to constantly experiment to deal with its shortcomings. Emanuel is optimistic that all this innovation will lead to major improvements.

For the record Emanuel think the top tier health systems are Netherlands, Germany, Norway and Taiwan; followed by Switzerland, France and Australia in the second group; with the US and China as the worst.

At the end Emanuel has some (seemingly) simple and easy suggestions for improving the US healthcare which look quite promising, but I am not really qualified to assess them.

So overall I felt a bit more optimistic. There are a lot of options out there and we in the US can't get any worse!

[Bryan · Rating 4 out of 5]

A very good overview of some of the major health systems among the developed nations of the world including Canada, Norway, UK, Germany, France, Australia, Taiwan, China, the Netherlands, and, of course, the US. Not surprisingly, the US ranks worst in this group, except for China. That is not to say that the US doesn't have some things it does well. The US system is the most innovative in a variety of ways, and we do a bit better than many at coordinating care for chronically ill patients, but by most measures we are near the bottom. The US system is the most expensive (and still is outperformed by the others in many measures), leaves a large number uninsured and is the most complicated to navigate of all the systems.

We could do better, and the author outlines some specific ways we could improve. We could also learn from other countries to see what has worked and what has not. Americans have often been poor at doing this, to our detriment. One thing that may disappoint some readers is that the author does not identify which health system is the best overall, but he does do an excellent job at showing why those that are near the top, such as the UK and the Netherlands, are considered so good. Even the better systems also have challenges they have not conquered, and he points these out as well.

[Kyle · Rating 4 out of 5]

Ezekiel Emanuel dives deep into a question he gets asked over and over as a health policy expert: "which country has the best healthcare." It seems everyone is agreement about the United States not having the best, but which one does?

Ezekiel dives deep into the healthcare systems of 11 different countries, including the US, getting into the weeds of the history of it, delivery care system, financing, pharmacy, and challenges faced by each country. This background, although having the tendency to be a little wonkish, provides the reader with a great understanding of the different healthcare systems in place around the word. It also helps the readers understand the nuances and the "path dependency" of different systems.

While it is no surprise, the book doesn't actually name a country, however, it does outline certain criteria for evaluating a healthcare system and ranks those. Additionally, the book concludes with recommendation for improvement of the US system.

Overall a great read for those truly looking to understand health policy proposals, what a "Medicare for All" looks like, or just looking to understand the complexities of healthcare systems across the world.

[JournalsTLY]

If in a hurry and yet still want know which country has the world's best health care - read chapter 12. And then chapter 13 will let you know where the healthcare system in USA needs to improve in.

Reader can then zoom in to the details of the nations that want know about . I found the historical narrative for each country useful - about how the healthcare system evolved and how it is caught in local politics.

Many good details. Many facts. One unsaid trend is the brain drain of healthcare staff from less developed nations to developed nations; and the high cost / relative lack of staff in rural places of all nations. Good reference work indeed.

Interesting that Singapore was mentioned at the start of the book as a nation with good and relatively low cost (in GDP teems) healthcare but was not featured as a country study.

And a tad unfair that corruption was featured quite highly as a factor in China's system even though I suspect financial foul play and manipulation (legally or otherwise) is present in other nations too?

[Michael Platt · Rating 5 out of 5]

Highly recommend this book. Spoiler, there isn't a single answer to the question of which country has the world's best health care. But it IS clear that it is NOT the U.S. The strength of the book is the detail it goes into it describing the health care systems of each country. Very enlightening. The author is careful to explain two important ideas. 1) Saying a country has a better health care system does not mean that country's doctors and nurses are "better", only that the "system" and (generally) outcomes are better. It's also important to dispel the notion that health "coverage" and health "care" are entirely separate things, as many opponents of health care reform are wont to point out. To the average patient, without "coverage" they receive no "care". That a country excels in coverage will generally also mean the excel in care and outcomes. In any case, LOTS of good and valuable information here - especially in regard to lessons we in the U.S. might learn from other developed countries.

[Lin · Rating 4 out of 5]

Really enjoyed this book. A great read, and a subject in which we should all be much better informed. Having lived in three of the countries included in this book, and with friends that live in another two -- it was very truthful, and insightful to see how each of the countries measured up against each other in each of the categories the author created for this book.

I really wish that our policymakers could realize that, with all this information available, it's not difficult to see what works and what doesn't, and to apply the best of the best to our own scenario here in the U.S. We can only hope for that day when our politicians understand that healthcare is also a basic right for citizens. This country has so much to offer in the field of healthcare, except its universal availability, which compares more closely to the dark ages. Healthcare has become a luxury almost unaffordable but to those fortunate enough to have company health benefits. How progressive is that?

[Jonathan · Rating 4 out of 5]

How do the United States, Canada, United Kingdom, Norway, France, Germany, Netherlands, Switzerland, Australia, Taiwan, and China's healthcare systems compare? You've come to the back right place.

Emanuel takes a system level perspective necessary for anyone in health care policy or system improvement. When comparing health care systems, there is no one best because the values and measured outcomes are too many. In this book, the history and challenges outlined for each country were my favourite, and the figures to describe financing, payment, and pharmaceutical regulations were terrific.

Head to the last couple chapters for the major takeaways. Included is an historical analysis and comparison between; coverage, financing, payment, delivery, pharmaceutical regulation, and workforce.

[James · Rating 3 out of 5]

If you’re a professional who follows healthcare (such as a journalist), this is an essential book. If you’re not, it’s a bore. I’d like to give it 5 stars because it’s an important subject and the research is so well done, but it’s as dry as the Gobi at noon in mid July.

The research is comprehensive, well conducted, and systematically presented in a simple, straightforward manner.

If you’re not reading this as a professional and you don’t need all the detail, just read Chapter 12, which nicely summarizes the data and the conclusions. Chapter 12 is worth the price of the book.

I wish Japan’s healthcare system had been included in the study. It’s not perfect, but my guess is it would be highly rated on most of the dimensions used in the evaluations

[Sanjay Banerjee · Rating 5 out of 5]

The author profiles the Healthcare systems of 11 countries of the World using a unique comparative structure - history of evolution of the system, coverage, financing, payment, delivery of healthcare services, Pharmaceutical coverage and price controls, Human Resources, challenges in the healthcare system - to know which systems perform well and why and which face endemic problems. I would recommend this book highly not only to healthcare professionals, patients and policymakers but also anyone interested to get a concise view of different forms of healthcare systems prevalent in the developed world and to make sense of the same.

[Nathaniel · Rating 2 out of 5]

I think someone for whom data is enough, this book is great. Emanuel is really diligent and consistent about about a wide range of metrics. Sadly, his ability to contextualize healthcare policy decisions or provide any sort of hypothesis as to why certain barriers exist is really poor (perhaps because of the genre?), which is why I’ve rated it so low.

I found this interminably dull. I often said (aloud!), ‘That’s nice, but why or, even better, what do you think about that, Zeke?’ His conclusions are more interesting(ish), but read as flat or obvious if you’ve been paying attention to any of the data he’s presenting.

Also, I’d like to be a Dutch citizen now. ✌️

[Joel · Rating 5 out of 5]

Encyclopedic and consistent review of what can be learned from ohter countries health care systems organized around several key dimensions. No country has the best but many have better and can be used as models or templates for key changes to our "patchwork system." Views from provider/hospital, patient, government, and payers. Many of the best were the Netherlands, Norway, Germany, UK, and Taiwan. Also looked at China (the worst with the U.S. just ahead), Switzerland, France, Australia, and Canada. Great final chapter on lessons learned and then a very bried Coda on what was learned from countries dealing with Covid-19.

[Stephanie · Rating 4 out of 5]

4.5 stars. Not a 5 because it was so information heavy, one sentence after the other was purely just content I wanted to memorize for myself but physically couldn’t fit it all in my brain lol

But extremely well written and fascinating to anyone who holds a special interest in the US healthcare system like me. Bottom line is, no singular country has the world’s best healthcare but we can all learn from each other and improve.

US still sucks though. He didn’t say that because I’m sure he’s a nice, scholarly academic but I still think with the facts given, we’re a long way from a GREAT health system. Shoutout to Taiwan hehe my little country got a huge cameo in this book!!!

[David Langhals · Rating 5 out of 5]

You can't answer the question without having someone first explain the main differences between the systems that are common considered the best. On top of that there are societal values and differences that make it hard to compare. Once you've dove into each of the 11 countries systems listed; it becomes easier to understand how and why they got to where they are and which areas need to be amended and changed to make healthcare systems more efficient, better accessible, and more helpful to the patients and doctors that rely on them.

[Shann Yu · Rating 4 out of 5]

Tough topic to write (and read) about, but author did a good job of covering a selection of countries’ healthcare systems. For better or worse, I thought this book frequently read like an encyclopedia, and it is easy to lose sight of the message. I suggest reading this with TR Reid’s The Healing of America. Whereas the latter book takes a largely patient-centric view and covers each country at a high level, this one gets below the hood and explains from an organizational view why things are as they are.