While the United States continues to suffer from poor health outcomes and low equity despite record health spending, top performers such as Australia and the Netherlands offer valuable lessons on health care access, affordability, and efficiency.
Report: Mirror Mirror 2024: The U.S. Healthcare System is Broken – Comparing the Performance of 10 Countries
A recent report by the Commonwealth Fund compared the performance of health systems in 10 countries.
“Mirror, Mirror 2024” is the Commonwealth Fund’s eighth report comparing the performance of health systems in selected countries. Its purpose is to highlight lessons learned from these countries’ experiences and how they can help improve the U.S. health system. While health systems differ from country to country, comparisons provide insights into policy thinking and shed light on the impact of national policy choices on national health and well-being. This edition also introduces new indicators on telehealth utilization and discrimination in health care, broadening the analysis.
Research and Results
The study compared health systems in Australia, Canada, France, Germany, New Zealand, Sweden, Switzerland, the Netherlands, the UK and the US. Overall, 70 unique measures were assessed across five areas: process of care, access to care, equity, health outcomes and administrative efficiency. The study used a combination of survey data collected from patients and primary care physicians from 2021-2023, as well as standardised data from international organisations such as the WHO and OECD. The study used data from a survey conducted by the Commonwealth Fund among primary care physicians, older adults and the general population from 2021-23.
Australia, the Netherlands, and the UK were the top three countries, while the United States was last. Of note, each country had low and high performance areas. Australia had challenges in access to healthcare despite its high overall ranking, while the United States excelled in the area of healthcare processes, despite its lowest ranking. Healthcare expenditure was not a performance indicator, with the exception of the United States, which spent 16.5% of its gross domestic product (GDP) on healthcare in 2023, more than any other country. However, Australia and the Netherlands had the lowest healthcare expenditure as a percentage of GDP. This gap has been widening since the 1980s, and now U.S. spending significantly exceeds that of other countries.
Other countries’ health expenditures were clustered. The access to health domain focused on the availability and affordability of health services at the population level. The Netherlands, the UK and Germany performed best in terms of access to health. These countries also performed well in the affordability index as they had minimal out-of-pocket health expenditure and low cost-related barriers to healthcare. Notably, Australia performed poorly in this domain.
The care process domain assessed whether care included attributes and characteristics essential to high-quality care. New Zealand ranked first in care process, followed by the United States, the Netherlands, and Canada. Sweden performed the poorest. The United States’ strong performance in this domain was due to its focus on providing preventive services such as mammograms and flu shots, and on patient safety.
Administrative efficiency focuses on the time patients spend dealing with medical billing and insurance issues, resolving medical billing disputes and paperwork, the need for healthcare providers to report data to government agencies, etc. The UK and Australia perform well in administrative efficiency, while the US and Switzerland rank last.
Equity reflects differences in access to health care and experiences of care between people with below-average and above-average incomes. In addition to the traditional income-based analysis, this edition of the report also adds an equity perspective that explores rural-non-rural disparities and gender-based equity. Australia and Germany were top performers in this area, with the smallest gaps between residents with below-average incomes and those with above-average incomes. In contrast, New Zealand and the United States ranked last.
Health outcomes are those outcomes most likely to respond to interventions. The study also considered the impact of the COVID-19 pandemic. Outcome measures were life expectancy at birth, deaths from treatable and preventable causes, and excess deaths due to the pandemic. Australia, Switzerland, and New Zealand were the top three countries for health outcomes, while the United States was last.
The impressive performance of the top three countries is in part due to their successful management of COVID-19. Australia’s strict lockdown and New Zealand’s early border closure contributed to the positive results, while the United States suffered high treatable and preventable deaths due to its drug use crisis and continuing gun violence. The UK suffered from COVID-19 related outcomes but experienced a slight decrease in treatable deaths.
What the US needs to improve
The United States’ significantly higher performance in the process of care is due in large part to the aggressive efforts of public and private payers in recent years to value-based care and pay-for-performance initiatives. Despite its performance in this area, the United States has the poorest health outcomes, suggesting that the process of care may not drive health outcomes. In addition, financial barriers to care are substantial in the United States.
Despite the successful implementation of the Affordable Care Act, 26 million Americans remain uninsured. All other countries in this study have universal health insurance. Their health care delivery systems also suffer from several deficiencies, including administrative inefficiencies and underinvestment in primary care. To improve health equity, the United States needs to expand insurance coverage to the uninsured and reduce financial barriers to accessing health care.
A more functional health care delivery system requires at least two reforms. First, we need to build a stronger primary care system by investing more in training primary care providers and increasing compensation for primary care clinicians. Second, the United States needs to address the unrestrained consolidation of health care resources that is driving up prices and making insurance unaffordable.
Therefore, the proliferation of entities that trade primary care practices like a commodity must be scrutinized for their long-term impacts on quality and cost of care. Further scrutiny must be given to administrative inefficiencies resulting from the complexity of insurance plans and billing practices that burden patients and providers. Insurance plan complexity and variation must be minimized to reduce administrative burden. Additionally, the United States needs interventions that address the historical and ongoing impacts of gun violence, drug use, and racism on the health and care of Black, Indigenous, and Hispanic people.
Conclusion
The variation in health system performance among the 10 countries featured in Mirror Mirror 2024 suggests ample opportunities for cross-border learning. The United States remains an underperformer in health care. The other nine countries vary in the performance and details of their health care systems but have found the means to meet their populations’ most basic health needs, such as universal health coverage. The report highlights the importance of addressing not only health services but also social policies aimed at reducing poverty, drug abuse, and gun violence as key drivers of better health outcomes.
