The U.S. health system ranks last among 10 nations on key health equity, access to care and outcome measures, despite the fact it spends by far the most on healthcare, according to a study by the Commonwealth Fund.
In four of five categories, the U.S. is either the lowest or second-lowest ranked in the Commonwealth Fund's analysis when compared to the health systems of 10 wealthy countries. The organization compared the health systems of 10 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the U.K. and the U.S. The analysis evaluated health systems based on access to care, administrative efficiency, equity and health outcomes.
Based on these factors, Australia, the Netherlands and the U.K. rank the highest, according to the analysis.
"Despite their overall rankings, all the countries have strengths and weaknesses, ranking high on some dimensions and lower on others," the Commonwealth Fund report authors wrote.
No country is at the top or bottom on all areas of performance. "Even the top-ranked country—Australia—does less well, for example, on measures of access to care and care process," the authors wrote.
"Nevertheless, in the aggregate, the nine nations we examined are more alike than different with respect to their higher and lower performance in various domains. But there is one glaring exception—the U.S.," the report authors wrote. "Especially concerning is the U.S. record on health outcomes, particularly in relation to how much the U.S. spends on health care. The ability to keep people healthy is a critical indicator of a nation’ capacity to achieve equitable growth."
"In fulfilling this fundamental obligation, the U.S. continues to fail," the report concluded.
Higher spending, lower life expectancy
While healthcare spending is not a measure of performance, the report said, it does provide important context, not least when compared with health outcomes.
As recently as 1980, U.S. spending on healthcare was on a par with other rich nations such as Germany and Sweden. Since then, the U.S. has far outpaced its healthcare spending compared with other nations, spending more than 16% of its gross domestic product on healthcare in 2022, for example, with that figure expected to exceed 20% of GDP by 2035.
Other nations are calculated to have spent between 8% and 12% of their GDP on healthcare in 2023. In addition, the two top ranked nations—Australia and The Netherlands—also spend the least on healthcare.
Such data contrast with the reality of Americans having the shortest lives and the most avoidable deaths. The U.S. ranks last in four out of five health outcome measures.
Life expectancy is more than four years below the 10-country average, and the U.S has the highest rates of preventable and treatable deaths for all ages. In addition, it has the highest number of excess pandemic-related deaths of people aged under 75.
An ongoing substance abuse crisis and the prevalence of gun violence also contribute to such poor outcomes, the study said.
Some bright spots, but U.S. healthcare need to do a whole lot better
Where the U.S. does do relatively well is in the category of what the report calls "care process," namely preventive care, safety, coordination, patient engagement and sensitivity to patient preferences. Here, it ranks second, behind only New Zealand.
A concerted focus on patient safety in the past 20 years or so has resulted in significant reductions in adverse events happening during U.S. hospital stays, the report said. Also, strong preventive performance may partly be a result of a larger focus on so-called value-based care.
But, overall, the U.S. is largely failing the population in its healthcare provision and the status quo of spending increasing amounts of money and getting increasingly poor outcomes is unsustainable, said Joseph R. Betancourt, M.D., Commonwealth Fund president.
“Too many Americans are living shorter, sicker lives because of this failure,” he said. “We need to build a health system that is affordable and that works for everyone. It’s past time that we step up to this challenge.”
To start doing so, the U.S. must invest in improved primary care provision. The system must improve its “nightmarish” administrative inefficiency and address the ongoing consolidation among healthcare systems, which is driving up patient costs, the report said.
On a policy level, far more also needs to be done to reduce gun violence and mitigate the substance abuse crisis as well as address historic and ongoing effects of racism on the care provision for minority populations.
“Reversing the dismal track record of the U.S. health system would require multiple, demanding interventions by government at all levels and by the private sector,” the report authors said.