United States in a class by itself for bad health care system: report

© The Commonwealth Fund

The United States health care system is in a class by itself for massive spending on poor patient health and outcomes, compared with other developed nations, said leaders of The Commonwealth Fund.

“Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System” is the 20th anniversary version of the analysis that compares the nation’s health care system with those of other wealthy countries. The results: generally bad across 70 performance measures of access to care, care process, administrative efficiency, equity and health outcomes.

Among the 10 nations, the United States ranked 10th overall and has become “the only clear outlier … where health system performance is dramatically lower,” the report said.

“The U.S. continues to be in a class by itself in the underperformance of its health care sector,” the report said. “While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.”

The nine other comparison countries were Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland and the United Kingdom. The report was the first version to account for effects of the COVID-19 pandemic because all data was from 2021 or later.

Commonwealth Fund leaders held an online discussion about the findings. Analysts were Fund President Joseph Betancourt, MD; immediate past President David Blumenthal, MD; Reginald D. Williams II, vice president for international health policy and practice innovations; and Bethanne Fox, vice president of outreach and strategy.

Here are some of the results across the five domains.

Access to care

Rank: 10 of 10

“Access to care focuses on the affordability and availability of health services at the population level,” the report said.

“In the U.S., lack of affordability is a pervasive problem,” the report added. Despite Medicaid expansion through the Affordable Care Act, an estimated 26 million people remain uninsured. Those with insurance may have high deductibles that leave them effectively underinsured, possibly making them unable to visit physicians when medical issues arise, or skip tests, treatments, follow-up visits and medications.

Care process

Rank: 2 of 10

The lone bright spot for the United States is care process, which includes prevention, safety, coordination, patient engagement and sensitivity to patient preferences. Successes range from mammograms to flu vaccinations to patient safety measures that reduce adverse events such as heart attacks, heart failure, pneumonia and major surgeries.

The study called this rank “particularly interesting,” with a possible explanation arising from value-based care efforts by public and private payers in recent years.

“While criticisms of these efforts are common in the U.S., the strategy may have succeeded in increasing systemwide conformance to guidelines for preventive services in particular,” the report said. “Despite comparatively high performance on care process, health outcomes in the U.S. are the worst of the 10 countries in this analysis, showing that care process may not be the primary driver of health outcomes.”

Administrative efficiency

Rank: 9 of 10

Only Switzerland is worse in administrative efficiency. The United States has a complex system of public and private payers across thousands of health plans, meaning physicians and other clinicians spend enormous amounts of time and effort billing insurers, the report said. Patients in the United States and Switzerland must deal with medical bill issues, and in both countries are more likely to seek treatment in emergency departments instead of primary care offices.

Equity

Rank: 9 of 10

Patients report income-related differences in access and treatment, with instances of unfair treatment or feelings that health concerns are ignored due to racial and ethnic backgrounds. High performers, such as Australia, Germany and the United Kingdom, limit cost sharing for patients, ensuring that ability to pay does not stop patients from obtaining needed health services.

Health outcomes

Rank: 10 of 10

Outcome measures included life expectancy at birth, excess deaths due to the COVID-19 pandemic, and deaths with preventable and treatable causes. Australia, New Zealand and Switzerland used various policies to manage the pandemic. The United States has an ongoing substance use crisis and ongoing gun violence that contribute to deaths in numbers much higher than in other countries.

Amassing the data

Results are based on a three-year rotating survey of adults aged 18 years and older, adults aged 65 years and old, and primary care physicians. The 2024 data were compiled from surveys in 2021, 2022 and 2023, supplemented with data from the World Health Organization, the Organisation for Economic Co-operation and Development, Our World in Data, and other resources.

Norway, the top performer in the 2021 edition of the “Mirror, Mirror” study, exited the Commonwealth Fund’s international surveys, and was not included in this year’s report.