When President Donald Trump fell ill with COVID-19, there was absolutely no contemplation of moving America’s head of state to another country to receive healthcare services. This might be surprising, considering the oft-quoted World Health Organization ranking of our healthcare system at 37th globally. Wouldn’t we want our president to be treated in the country with the very best healthcare?
The problem, of course, is that international comparisons in healthcare often mislead. This was true before the pandemic, but it has also been true in the midst of it.
First, these international comparisons often fail to consider how the U.S. population is different – more diverse and much bigger – than many of the world’s countries, particularly European countries, whose size is often similar to that of U.S. states. Indeed, there are more Californians than there are Canadians and slightly more North Carolinians than there are Swedes.
Secondly, and more critically, the focus on the prevalence of various diseases or longevity (which is influenced by a host of cultural and lifestyle factors) in international comparisons is misplaced. A better metric is survival rates, or specifically how patients fare when they are sick. After all, doctors cannot enforce healthier lifestyles, but they can help heal us from sickness.
And in America, they do a fine job of this.
Before COVID-19’s travel restrictions, it was very common for elite foreigners to travel to the U.S. for medical care. One McKinsey and Company study estimated that 60,000 to 85,000 foreign patients made this trip each year, and the Fraser Institute, a Canadian think tank, counted more than 50,000 Canadians crossing the border in search of care in 2014. This came about despite WHO’s ranking of Canada ahead of us, at 30th.
America’s medical system was, in some ways, better prepared for a pandemic than other nations. While we have a relatively low physician-to-population ratio, and fewer total hospital beds per capita than other comparable countries, the U.S. is home to more ICU beds per capita than any other nation, according to an analysis of 2012 data. Perhaps this is because we are used to treating a relatively unhealthy and overweight population, a population at higher risk for a COVID-19. Ironically, our healthcare system enables many people to live longer and better lives in spite of their comorbidities, chronic conditions, and poor lifestyle choices. From the outside, our lack of health might reflect poorly on our healthcare system, but it is exactly because of the high quality of care available in the U.S. that so many Americans can afford to live in the unhealthy way that they do.
Similarly, the U.S. uses a great deal more neonatal ICU care than other industrialized countries. But you would not know it from our infant mortality rate, which is relatively high for two reasons: First, Americans carry high-risk pregnancies (e.g., to mothers who are teenage, obese, or of advanced maternal age) at a higher rate than other countries. And secondly, the U.S. counts more babies as live births who, due to prematurity or low birth weight, have little chance of survival. Ironically, our infant mortality rate suffers, because we make a greater effort to save every life. If you are about to deliver a baby, you would be fortunate to deliver in the U.S., where the baby will receive this high level of care.
Despite our risk factors for COVID-19, despite the greater degree to which the coronavirus has spread in the U.S., and despite criticisms and conflict over our government’s response, the U.S. health system has done a phenomenal job at what it is supposed to do: keep patients alive. The U.S. has one of the world’s best COVID-19 survival rates, meaning if you are diagnosed with it, you would have a greater chance of survival here than in many other countries, including many of those that the WHO and others rank as having healthcare systems superior to our own.
According to the latest CDC numbers, the U.S. survival rate for COVID-19 is 0.98. That means that if you are diagnosed with COVID, you have a 98% chance of not dying from the virus. Conversely, you face a mortality rate of nearly 2% (2.2).
By contrast, the United Kingdom, another wealthy country, has a lower survival rate of 96%. The Johns Hopkins Coronavirus Resource Center tracks the mortality rate (the inverse of the survival rate) for each country, and finds that the U.S. also performs better than Mexico (where the COVID-19 mortality rate is currently 10%), Italy (4%), the UK (4%), Belgium (3%), Sweden (3%), Canada (4%), China (5%), Spain (3%), and many other countries.
Now, COVID-19 survival rates, even more so than survival rates for other illnesses, are plagued by confounding variables. A country could, as many suggest the U.S. has done, reach a rosier rate by simply testing more people, identifying more cases (many of which are mild or even asymptomatic), and counting those among the denominator.
Indeed, the U.S. has experienced a higher caseload and greater spread of the virus than most other countries. The number of cases and the spread of the virus are reflections of many factors, including government policy, culture, and individual choices and behaviors. The medical system – our hospitals, doctors, and nurses – have little control over this, just as they have little control over how many Americans drive recklessly or are obese.
While the spread of the virus (and testing response) has an effect on the mortality numbers, it is not the full story.
Another important part of the story is access to healthcare services. Fortunately, so far American doctors have not seen the worst of their COVID-19 concerns come true: They have not been in the unenviable position of triaging COVID-19 patients and rationing access to beds, ventilators, or hospital care. Even in the midst of New York City’s peak, we were not sending elderly patients home to die, as some Italian hospitals were forced to do.
This explicit form of rationing is particularly shocking to many Americans, but it is not uncommon in countries with socialized medicine. Even more common is an implicit form of rationing where patients must simply wait longer for appointments, treatments or surgeries, due to the failure of the health system to match supply with demand.
Because Americans have some of the world’s shortest wait times, we have better access to preventive care and care for serious diseases. This is why America has the world’s best cancer survival rates, best longevity after age 80, and better heart attack survival rates than the average of comparable countries.
With COVID-19 survival rates, time – critical time which allowed for medical knowledge to advance – is also a factor: America’s COVID-19 survival rate, like survival rates around the world, has improved greatly since the beginning of the pandemic, when health providers knew little about the disease.
For decades, American medical innovators ultimately have served patients throughout the world, as advancements in treatments, techniques, pharmaceuticals, and devices are exported overseas. More patients are alive today in all parts of the world thanks to the way America incentivizes and rewards medical innovation.
However, there is one area where international healthcare rankings do get criticism of the U.S. right: Americans do not have equal access to high quality care. And the private payment pipeline that most Americans use, often involving insurance companies and employers, is overly complex and inefficient. The quality of care Americans receive can vary greatly based on their type of insurance and available resources. Of course, the vast majority of Americans will never stay in a suite like the one President Trump visited at Walter Reed.
This said, people outside (and even inside) the United States often misunderstand two things: First is the degree to which our government finances healthcare. Approximately one-third of Americans are in a government insurance plan. Health reformers should take note it is not privately insured patients, but Medicare and Medicaid patients (and uninsured patients) who face the greatest challenges accessing healthcare, because these programs reimburse health providers at below-market rates.
Second, virtually all American hospitals are legally obligated to treat patients in need of emergency care regardless of their ability to pay. This may not be “universal healthcare” by the typical definition, but it is a type of universal care.
Progressive political advocates, who are quick to seize on any ranking of the U.S. that depicts our system as inferior to that of countries with socialized medicine, often paint a picture of Americans dying in our streets for lack of healthcare. This is not accurate, nor are the rankings that suggest that American healthcare stinks.
Of course, we can do better, and reforms should focus on how we pay for healthcare. But as we work to reform America’s convoluted healthcare payment system, we should take care not to damage what is best about American healthcare – namely, the best quality of healthcare available in the world. Instead, we should seek to expand access to healthcare for the sake of all Americans and, ultimately, all people around the world.
