International Health Care Systems

US Ranks Last

According to a Commonwealth Fund report examining the health care system of 11 countries, Americans receive the worst health care.  The report summarizes the findings as follows:

The United States health care system is the most expensive in the world, but comparative analyses consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in prior editions of Mirror, Mirror. The United Kingdom ranks first, followed closely by Switzerland.


The authors summarized the results in tabular form as well.

Why does the US fair so poorly? Cost and access to care are two clear areas where the US falls behind. The US spends over $8,500 per person on health care; the next closes countries are Switzerland and Norway, both of which spend $5,600 per person. Another reason is that a large share of Americans are uninsured and those who are insured often have high out-of-pocket costs. The US also did poorly on aggregate measures of health. The U.S. ranked last or second to last in infant mortality, mortality amendable to health care, and life expectancy at age 60.

But what about disease-specific measures of health care? Is the US good at treating complex diseases? The answer is likely yes, but those types of metrics are not included in the study. Instead, the study looks at broad categories of effective care, safe care, coordinated care, and patient centered care.

Effective care includes measures such as “Doctor or other clinical staff talked about exercise or physical activity,” “Doctor or other clinical staff talked with patient about a healthy diet and healthy eating” and “Physicians reporting it is easy to print out a list of patients who are due or overdue for tests or preventive care.” These are certainly important dimensions of care, but patients with cancer need more advanced treatment than just preventive care or reminders to exercise or watch one’s diet. Similarly, management of chronic diseases includes such broad measures as “Patients with hypertension who have had cholesterol checked in past year” and “Primary care practices that routinely provide written instructions to patients with chronic diseases.” Again, these are important measures of quality but likely far from the most important for most patients. Nevertheless, the US did fairly well on this dimension, ranking #3/11.

Safe Care. The US ranked #7/11 on these measures which included “Patient believed a medical mistake was made,” patient given the wrong medication, and hospital reporting of hospital-based infections.

Coordinated Care. The US ranked #6/11 on these measures which included whether the patient had a regular doctor, efficiency of specialist referrals, communicating information after a hospital stay to post-acute care providers.

Patient-centered care. The US ranked #4/11 on this dimension. The US was best in the world at giving clear instructions about symptoms to watch for, and physicians encouraging patients to ask questions, but did poorly in terms of continuity of care (i.e., having the same doctor for more than 5 years). However, the US is a fairly mobile (about 15% of the country moves each year) and thus it should not be surprising that few patients have the same doctor for 5 years.

Overall, on most health care quality measures, the US performs about average. Where the US falls short is that the system is expensive, many patients are uninsured, and those who are insured often have high out-of-pocket payments. Although the US healthcare system clearly has areas where it can improve, the headline that the US has the “worst” healthcare system in the developed world is highly misleading.


1 Comment

  1. These results are disappointing, but not completely surprising. Most countries have government-managed healthcare, so the cost is managed by a central agency while in the US the cost is born by the individual and their insurance company. Government payments through medicare and medicaid costs should be on par with the other countries, but I am not sure that it does. Our complex market-based healthcare system should have the best outcomes, if it is the most expensive. Most of the medical “breakthroughs” in medicine seem to come from the United States, which you would be more “expensive,” but I do not think that element would be measured in this study.

    We should expect that the cost burden of the uninsured would be declining if the ACA “captures” more of the uninsured population, but I am not sure when we will start realizing those expected benefits.

    I am afraid that I may have offered little to further this discussion!

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