Most industrialized nations have long supported the idea that access to healthcare is a fundamental right, and have built centrally planned systems to accomplish that goal. The result has been universal coverage that delivers excellent-quality outcomes at lower costs than the United States.
In some countries, such as England and Canada, the government controls both financing and certain aspects of healthcare delivery, while in others, including Australia, Sweden and Germany, the system is publicly funded, but with the majority of the medical care privately delivered.
In sharp contrast, the United States provides healthcare coverage through a variety of channels–some public (Medicare and state-based Medicaid programs), some commercial (employer-sponsored health insurance) and more (individual, brokers and exchanges). Almost all of the care in the U.S., other than the Veterans Administration and some county-sponsored clinics, is delivered privately.
Policy experts argue that these other global healthcare systems have advantages over the United States. In particular, they tout the personal financial protection and the superior clinical outcomes they achieve.
Most independent, published reports on global health outcomes put the United States in the lower half of industrialized nations, and at the bottom on measures like life expectancy and childhood mortality. And our results are getting worse. A recent study noted that among Whites, life expectancy is declining, not improving.
You might think, based on the success of others, that the U.S. would identify the best parts of each, and embrace these global models. We could debate whether the results would be as positive in practice as in theory, but the objective information is not the issue. Our country won’t decide to follow their lead. And the reason is simply our culture.
Behind The Scenes In Canada, England and Australia
During my training years at Stanford, I had the opportunity to spend six months in Calgary, Canada, working in its university hospital, and have returned many times since then. In addition, for over a decade, we at Kaiser Permanente have collaborated with the British National Health System to help them improve both their outpatient and their hospital care. And most recently, I traveled to Australia, and had the opportunity to discuss its healthcare system with a variety of individuals.
Although all three countries have a federally financed healthcare system, they vary in design. In some cases, decisions are made through the federal government, in others at the provincial or county level. And although some countries, such as Australia, encourage private insurance to supplement the public system, others, such as Quebec Province, have outlawed it.
But overall, how health care is financed, delivered and experienced is more similar than different. Citizens in all three countries report satisfaction levels with their national health systems of between 85% and 90%. Support for their healthcare system, respect for their physicians and confidence in the quality of care provided is extremely high in each. And these outstanding outcomes are achieved at a cost relative to their GDP, which is dramatically less than in the U.S.
The Patient Experience
On the plus side, universal coverage relieves stress on families and facilitates the work of physicians and hospitals. When patients go to a doctor in the community or are admitted to a public hospital, their bills are paid by the government, with minimal out-of-pocket expense to themselves. The stress of worrying about how they will pay for the care they receive is eliminated and the risk of personal bankruptcy virtually nonexistent.
The drawback, however, is delays in access, particularly for routine procedures. Urgent, more acute problems are generally attended to in relatively short order. But expected waits for routine procedures in public hospitals vary from four to six months, depending on the particular intervention–far longer than what commercially insured Americans experience today.
Why so? These publicly funded systems tend to be political in nature. And when it comes to taxing people to pay the cost, elected officials are reluctant. For that reason, the funds available to provide the access for routine but expensive diagnostic and surgical procedures are insufficient, less than most patients desire and physicians recommend. As a result, in many of these countries, individuals who can afford to do so buy private insurance and move to the front of the line.
While publicly insured individuals sometimes can wait up to a year for a total joint replacement those with private insurance can be scheduled in a couple of months. And even for urgent, but not emergent care, those with public insurance can be delayed in getting what they need, while those privately covered are treated instead.
The delays in obtaining care are no secret. Everyone I spoke with who had public coverage knew they existed. What surprised me was people’s reaction. Nearly all of the people I talked with accepted the waits as a reasonable trade for the economic security they provided, and few were outraged or even resentful that others could jump the queue. Overall, most of the citizens were grateful for the healthcare they obtained.
Part of the reason is cultural. In British culture, sacrifice for the greater good is held dear as a value and a virtue. The metaphor of the stiff upper lip–as evidenced in London during the German bombings of World War II–attests to a certain forbearance and resilience, even in the face of adversity. And the idea that some are entitled to go ahead of others is intrinsic to a culture that bestows and respects titles, be they earl, lord or king.
What Would Americans Say?
How would average Americans react to the same delays and inconvenience? Most Americans would be up in arms if they had to wait months for an appointment to see an orthopedic surgeon and a year to have a total joint surgery performed. They would be outraged if others cut in line ahead of them. I predict across the U.S. there would be legal challenges, legislative prohibitions and intervention by regulatory agencies. Americans would not accept the limitations of these other healthcare systems.
Of course the U.S. rations healthcare, too, but less visibly than other countries do. Patients covered by Medicaid, particularly in states where government payments are significantly below the cost of providing the services, often have difficulty finding specialists and diagnostic facilities willing to provide services to them. And even though the middle class in the U.S. can more quickly obtain advanced diagnostic testing, specialty care and routine surgical procedures, high deductibles, often $5,000 or more, increasingly are creating a different type of access challenge. Although many Americans complain about the U.S. healthcare system in general, nearly all report being satisfied with their doctors and the care they provide.
The Swedish Formula
A few years ago, I had the opportunity to spend a week visiting the main hospital in the city of Jonkoping. The difference between how medicine is practiced there and in the U.S. was huge. The physicians and hospital administrators viewed healthcare as a public service, and felt privileged to be able to provide it for the benefit of all. Collaboration, not competition, was the focus of their day-to-day practices. Even how they paid their physicians reflected this emphasis on equality and even-handedness, with the salary difference between primary care physicians and surgical specialists being relatively small, particularly when compared to the U.S.
None of this should be surprising. Sweden is a homogeneous country, with most of its citizens sharing a common history and ethnicity. When you perceive others as family, the greater good trumps personal freedom, including in your approach to healthcare. And you are appalled when someone is hurt or suffers. As a consequence, Sweden is the only country I know of where the legal limit for blood alcohol while driving is zero.
How Well Does It Work?
Healthcare in Sweden is efficient and effective, remarkably so. The quality outcomes achieved rank among the highest in the world, and the costs of doing so are much lower than in the U.S. In this hospital, their passion and key to success is standardization. Individual doctor choices are limited. Hospital-wide efforts bring together physicians and nurses to define, down to the smallest detail, how patients will be treated. New doctors are expected to follow these standardized clinical protocols, and changes in clinical practice require common agreement. Deviating from these care pathways is culturally unacceptable.
The advantages of their approach to healthcare delivery are numerous. Nurses never need to adjust to the specific approach used by each doctor. Operating rooms don’t have to stock dozens of different instrument sets and total joint implants to meet the preferences of each individual surgeon. And the same excellent level of care is provided regardless of the day of the week or the doctor on call.
And when a public health risk is identified, doctors and nurses on hospital staff respond rapidly. The entire healthcare team is committed to implementing effective protection for everyone in the hospital, whether patient, visitor or staff, as a core value, even when it impinges on their own autonomy and freedom. Within and across practices and specialties, team spirit prevails.
The result is high quality delivered at low cost, with consistently favorable clinical outcomes.
What Would Americans Say?
In spite of the outstanding results they achieve, physicians and patients in the U.S. would resist and reject this expectation for consistency and conformity. The Swedish approach simply clashes with our culture, which values rugged individualism. American doctors and patients perceive variation and freedom in practice as virtuous, even when the data contradict that view. In the end, culture proves overwhelmingly powerful.
Healthcare As Cultural Imperative
It would be almost impossible to get Italians to act like Germans or vice-versa. How we are raised and the values we are taught shape how we see the world. Culture comes from history and is handed down from generation to generation. Wars are fought over such differences.
The U.S., for example, values personal freedom above the common good. Our nation was born in revolution, refusing to be told how to act and what to do. Our constitution was founded on the concept of equality, averse to relegating anyone to being a second-class citizen. We believe in individualism, and tell ourselves stories about how anyone can become President.
Doctors expect the right to practice medicine as they decide. Patients are impatient, and will scream if others are allowed to cut in line ahead of them.
How health systems are organized and care is delivered reflect a nation’s values. And ours is no exception. It’s precisely because our nation embraces individual independence over the collective good that the integration of healthcare, with the requisite collaboration and cooperation among American doctors, proves so difficult. It helps explain why we cling to a deeply flawed payment system that reimburses individuals for doing more, and are slow to move to one that would reward value over volume. Although we are slowly moving to approaches that pay more to organizations and physicians who achieve superior quality outcomes, focus on prevention and maximize patient safety, it is happening in spite of, not because of, our medical culture.
Is Culture Destiny?
Culture can change. And ours must. We believe, and presidential candidates often tell us, that our care is the best in the world no matter how often the Institute of Medicine shows us graphs about how much better clinical outcomes are in places like Sweden than here.
Now, make no mistake: These other healthcare systems are far from perfect, and most face plenty of challenges, including escalating costs and rancorous political debate. But compared with the U.S., they offer higher-quality, universal coverage at lower costs.
Even within the U.S., there are geographies doing a much better job than others, according to the Medicare database and the Dartmouth Atlas. And within geographies there are physicians and hospitals achieving better outcomes based on the data from the National Committee for Quality Assurance and the Leapfrog Group. But to help everyone match the performance of the best will require greater collaboration, conformity and consistency. And each of these characteristics runs head-on into our culture, which values highly individual freedom and independence. And that’s why, no matter how much better these other healthcare systems might be, the U.S. won’t be embracing them soon.
Cultural change is possible, but cultural shifts seldom happen by themselves. They require leadership. That leadership can come from above. Governments can legislate new laws and regulations, insurance companies can adjust guidelines and fees, and hospital administrators can send e-mails and implement new policies. But most of these efforts fail to have the positive impact the people who designed them expected.
This is why physician leadership is so crucial, and going forward will determine whether our healthcare system achieves its potential. Physicians will resist changes imposed by health plan executives and hospital administrators, and nearly all pay-for-performance incentives fail to achieve their desired results. Physicians will change their practices and implement improvements to benefit patients, but only when the efforts are led by colleagues they know, respect and trust.
This is our culture in the United States. As Malcolm Gladwell described in his book The Tipping Point, the colonists followed Paul Revere because they knew and trusted him, not because of his title or position. The United States will never be Australia, England, Canada or Sweden. As long as our culture prevents us from embracing the approaches others use, we will have to accept the limitations that result.
But nothing should stop our country from achieving outcomes just as good as theirs.
Dr. Robert Pearl is the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD.