A study published on Sep. 19 by the non-profit, New York City-based Commonwealth Fund, has examined the healthcare systems of ten advanced nations and found the U.S. healthcare system to demonstrate dramatic “underperformance” along several key dimensions: care access, administrative efficiency, equity, and health outcomes, though the study gives our healthcare system a second-place ranking for “care process.”
The authors of the report—David Blumenthal, Evan D. Gumas, Arnav Shah, Munira Z. Gunja, and Reginald D. Williams II—in their report, “Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System: Comparing Performance in 10 Nations,” state that, “While each country’s health system is unique — evolving over decades, sometimes centuries, in tandem with shifts in political culture, history, and resources — comparisons can offer rich insights to inform policy thinking. Perhaps above all, they can demonstrate the profound impact of national policy choices on a country’s health and well-being.” This is the eighth report of its kind; the Commonwealth Fund’s first comparison report was published in 2004. This report compares the health systems of Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. The authors note that Norway was the top-ranked health system in the most recent previous report, published in 2021, but that Norway exited the study process after that report.
In terms of care access, the report’s authors note that “The Netherlands, the United Kingdom, and Germany perform best on access overall, and both the Netherlands and Germany rank at or near the top on the two components of affordability and availability. The U.K.’s health system is the top one for affordability.” And, they note, “The Netherlands, U.K., and Germany excel on measures of affordability because each country has low cost-related barriers to care, as reported by patients, and minimal out-of-pocket health care expenses. In these countries, universal coverage ensures that copayments for health services, if any, are small, guaranteeing both access and affordability.” They particularly praise the Dutch system, where “visits to primary care, maternity care, and child health care providers are fully covered; other health care services are covered once patients pay their annual deductible. In the U.K., the National Health Service (NHS) provides free public health care, including hospital, physician, and mental health care.”
And, in comparison, the report’s authors note that, “In the U.S., lack of affordability is a pervasive problem. With a fragmented insurance system, a near majority of Americans receive their health coverage through their employer. While the ACA’s Medicaid expansions and subsidized private coverage have helped fill the gap, 26 million Americans are still uninsured, leaving them fully exposed to the cost drivers in the system. Cost has also fueled growth of private plan deductibles, leaving about a quarter of the working-age population underinsured. In other words, extensive cost-sharing requirements render many patients unable to visit a doctor when medical issues arise, causing them to skip medical tests, treatments, or follow-up visits, and avoid filling prescriptions or skip doses of their medications.” Indeed, they note that, “In terms of care availability, U.S. patients are more likely than their peers in most other countries to report they don’t have a regular doctor or place of care and face limited options for getting treatment after regular office hours. Shortages of primary care services add to these availability problems.”
The researchers have similarly harsh statements to make in terms of issues around administrative efficiency, equity, and health outcomes in the U.S. healthcare system.
The one area in which the U.S. healthcare system shines, the authors say, is around what they call “care process.” As they explain it, “Care process looks at whether the care that is delivered includes features and attributes that most experts around the world consider to be essential to high-quality care. The elements of this domain are prevention, safety, coordination, patient engagement, and sensitivity to patient preferences. Most notably, the U.S. is among the top performers on care process, ranking second. New Zealand is first, with Canada and the Netherlands close behind. Sweden performs comparatively poorly.”
Further, they write, “Strong U.S. performance in the care process domain is the result of the successful provision of preventive services, such as mammograms and flu vaccinations, and an emphasis on patient safety. With respect to preventive care, the U.S. record might reflect the vigorous pay-for-performance policies implemented by Medicare and other payers to reward the delivery of these services.”
In the end, the report’s authors conclude that “The U.S. continues to be in a class by itself in the underperformance of its health care sector. 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.”
