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Outrage of the Month: U.S. Health Care System Continues to Rank Dead Last Among High-Income Countries

Health Letter, September 2021

By Michael Carome, M.D.


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Despite spending far more on health care than any other nation, the U.S. continues to have the worst health care system compared with those of 10 other similar high-income countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom). That was the disturbing but unsurprising finding of the Commonwealth Fund’s August 2021 report, Mirror, Mirror 2021 – Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries.

For each of the countries ranked in the Commonwealth Fund report, the researchers analyzed 71 indicators across five key domains of health-care–system performance as of 2020: access to care, care process, administrative efficiency, equity and health care outcomes. The U.S. ranked dead last on all these domains except one — care process, in which it ranked second — resulting in an overall ranking of last (see Table below).

Overall Ranking of Health-Care–System Performance in 11 High-Income Nations

Country Ranking
Norway 1
Netherlands 2
Australia 3
United Kingdom 4
Germany 5
New Zealand 6
Sweden 7
France 8
Switzerland 9
Canada 10
United States 11

The U.S. similarly ranked last overall among these same peer countries in the Commonwealth Fund’s 2017 and 2014 health-care-system–ranking reports.

Remarkably, the U.S. spends more on health care as a proportion of gross domestic product (GDP) — 16.8% in 2019 — than each of the other 10 countries ranked in the Commonwealth Fund report. Norway, the country with the highest-ranked health care system, spent only 10.5% of its GDP in 2019 on health care, and no other country spent more than 11.7%.

The Commonwealth Fund report considers access to health care to be good when people can obtain affordable care in a timely manner. The U.S. ranked last on affordability of health care and ninth on timeliness, which resulted in an overall last-place ranking for access to health care. Compared with people living in the Netherlands, U.K., Norway and Germany, people in the U.S. are much more likely to report that their health insurance denied payment for a claim and are more likely to report difficulty paying medical bills.

Given its poor performance on measures of affordability and timeliness of health care, the U.S. predictably ranked last overall in the Commonwealth Fund’s analysis of health care outcomes. For this health-care–system domain, the researchers examined 10 health care outcomes that are most likely to be responsive to health care. Stunningly, on nine of these outcomes, the U.S. performed worse than any other country – in many cases far worse.

For example, the U.S. had the highest infant mortality rate (5.7 deaths per 1,000 live births) and the lowest life expectancy at age 60 (23.1 years). The U.S. rate for maternal mortality (17.4 per 100,000 live births) is twice that of France, the country with the next-highest rate (7.6 deaths per 100,000 live births). And the rate of preventable mortality in the U.S. (177 deaths per 100,000) is more than twofold higher than the best-performing country, Switzerland (83 deaths per 100,000).

The Commonwealth Fund report identified four features that distinguish the best-performing countries from the U.S.:

  • Provision of universal health care coverage and removal of cost barriers
  • Investment in primary care systems to ensure that high-value services are equitably available in all communities to all people
  • Reduction of administrative burdens that divert time, efforts and spending from health-improvement efforts
  • Investment in social services, especially for children and working-age adults

The chronic poor performance of the U.S. health care system is inexcusable. Implementation of an expanded and improved Medicare-for-All system is the only path forward for eliminating the chronic substantial gaps in measures of health care access, quality and outcomes between the U.S. and other high-income countries. Until the U.S. takes such action, countless people will continue to suffer and die unnecessarily in this country.