US ranks last on key health care measures compared with other high-income nations, despite spending the most, report says

By Jacqueline Howard, CNN

(CNN) — The US spends more on health care than any other high-income country, but a new report suggests that “Americans are sicker, die younger and struggle to afford essential health care.”

Compared with nine other high-income nations, the United States ranked last overall this year, with a lower life expectancy and higher rates of death and disease despite spending the most on health care, according to the report, released Thursday by the independent research group The Commonwealth Fund.

The three top-performing countries in the report were Australia, the Netherlands and the United Kingdom.

“This report reveals that our health system is continuing to lag far behind other nations when it comes to meeting our citizens’ basic health care needs. The US spends more on health care than any other country, and Americans are sicker, die younger and struggle to afford essential health care. We spend the most and get the least for our investment,” Dr. Joseph Betancourt, president of The Commonwealth Fund, said in a news briefing.

“As a primary care doctor, I see the human toll of these shortcomings in our system on a daily basis. I have patients who need medications they can’t afford. I spend time going back and forth with insurance companies who have denied care I know my patients need, and I see older patients who arrive sicker than they should because they’ve spent the majority of their lives uninsured,” Betancourt added.

“This report underscores the many lessons we could learn from others on how to strengthen our health care delivery and outcomes,” he said. “It provides a blueprint for health leaders and policymakers on how the US can achieve more equitable, affordable care for all Americans.”

Countries with highest health care rankings

Researchers at The Commonwealth Fund compared and analyzed the performance of health systems across 10 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom and the United States.

The researchers took a close look at how the health systems performed on 70 measures across five key domains in those countries: access to care, the health care process, administrative efficiency, equity and health outcomes. The assessments were based on data from the World Health Organization, the Organisation for Economic Cooperation and Development, Our World in Data and international surveys that the Commonwealth Fund conducts.

The countries with the highest overall rankings across the five key areas were:

1. Australia
2. The Netherlands
3. The United Kingdom
4. New Zealand
5. France

The countries that had the lowest overall rankings across the five key areas were:

6. Sweden
7. Canada
8. Switzerland
9. Germany
10. The United States

When the researchers analyzed each country by each key domain, the United States ranked last on access to care, indicating that Americans face the most barriers to accessing and affording health care. The nation also ranked last in health outcomes, including acute illnesses, chronic diseases and death.

The researchers noted that people in the United States live the shortest lives and face the most avoidable deaths among the 10 countries, and the US had the highest rates of excess deaths related to the Covid-19 pandemic for people younger than 75, according to the report.

The United States ranked ninth in equity, indicating that disparities persist in how people with various incomes and from different backgrounds may access and experience health care. The country also ranked ninth in administrative efficiency, indicating that doctors and patients in the US are more likely to report problems related to insurance approvals and billing.

“Administrative requirements can cost time and money for patients and doctors,” Reginald Williams II, vice president of international health policy and practice innovations at The Commonwealth Fund, said in the briefing.

“Many countries have simplified their health insurance and payment systems, usually through legislation, regulation and standardization. For example, other countries apply standardized payments to all physicians for services, and do that on a regional basis, so that doctors know what they’ll be paid, and patients know what portion they’ll be responsible for,” he said. “They make it much simpler.”

The one domain for which the United States ranked high was the care process, which suggests that the health care it delivers includes aspects or attributes that are considered essential for high-quality care.

The researchers noted that “all countries have something to learn from one another.” Yet there were relatively small differences in the overall performance among all of the countries except the United States, which was “the only clear outlier.”

The other nine countries may have different health care systems, but they all had universal coverage, the researchers wrote, which ensures that any copayments for health services are small, improving both access and affordability.

“A lot of the lagging performance of the United States’ health care system has to do with access to care and equity of care, both of which are heavily influenced by the availability and quality of insurance,” Dr. David Blumenthal, former president of The Commonwealth Fund, said in the briefing.

“The United States lags both in having 20-plus million Americans still uninsured – 7% to 8% of the population – though an historic low, still very high by international standards,” he said. “It also lacks in terms of the ability of lower-income people to get access to basic services.”

Additionally, the researchers found that health care spending was similar in the other countries but not in the US, which spends far more on health care than its peers yet has the worst overall performance.

The two countries with the highest overall rankings, Australia and the Netherlands, had the lowest health care spending

To improve the state of its health care, the US can expand insurance coverage, shrink disparities in care, and reduce the administrative burden and complexities of insurance plans, the researchers wrote.

It’s also important for the United States to “invest in interventions outside of health care to address the social drivers of health: poverty, homelessness, hunger, discrimination, gun violence, substance use,” Williams said.

The report also called for a more robust primary care system in the United States.

For instance, “primary care physicians in the Netherlands are required to have coverage after hours. As a person in the Netherlands, you always can get access to your primary care physician or a covering physician, 24/7, and that, of course, is not true in the United States,” Blumenthal said.

“Americans are most likely to report difficulties getting after-hours care, resulting in their having to use emergency rooms for after-hours care,” he said. “That’s a very simple intervention that would reduce the cost of care, reduce the access problems and reduce the administrative complexity of care.”

‘The American electorate makes the choices’

The upcoming US presidential election could play a significant role in the future of the nation’s health care system, Blumenthal said.

“The American electorate makes choices about which direction to move in, and that is very much an issue in this election,” he said. “If we are continuing to lay the foundation for improvement of our health care system, elections that result in expansions of insurance coverage, based on the existing programs, would take us in the direction that makes us closer in performance to other international comparisons.”

The rankings in the new report parallel those in a paper that The Commonwealth Fund released last year that found the US had the highest rates of deaths from avoidable or treatable causes and the highest maternal and infant death rates yet still spends more on health care than any other high-income country.

“We’re not getting the best value for our health care dollar,” Dr. Georges Benjamin, executive director of the American Public Health Association, who was not involved in either report, said last year.

To help fix the holes in the US health care system, Benjamin said, there are three steps the nation can take.

“We’re still the only nation that does not have universal health care or access for all of our citizens,” Benjamin said.

Second, “we don’t do as much primary care prevention as the other nations, and we still have a public health system, which is fractured,” he said. “The third thing is, we under-invest compared to other industrialized nations in societal things. They spend their money on providing upfront support for their citizens. We spend our money on sick care.”

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