This is an election year, but a new report suggests it’s long past time for journalists and voters to hold politicians accountable for the poor quality of America’s health care system.
That’s because, among the 10 highest-income countries, the United States spends more on health care than any other country, yet has the worst health outcomes for the money it spends, and Americans are dying four years sooner than their counterparts in other countries, according to a Commonwealth Fund report.
Additionally, the report released on Thursday, September 19, found that the United States had the highest number of deaths per capita from COVID-19 among people under the age of 75 in 2022, and the highest rate of preventable and treatable deaths among all age groups.
“One of the things that is clear from this study, the first of its kind since the pandemic began, is that the United States has had a low national record in COVID-19 deaths,” said lead author David Blumenthal, M.D., former president of the Commonwealth Fund. Of the 10 countries, the U.S. had the highest COVID-19 death rate per capita, Blumenthal noted, adding, “This is a novel finding.”
“There are two things that play into the COVID deaths. One is that the health care system in general was flawed and had difficulty dealing with the stress that COVID put on the health care system,” Blumenthal said in a later interview.
The second factor, he added, is the excess number of deaths due to COVID. “It’s not just the number of deaths directly due to COVID, it’s the excess deaths due to COVID, and this is a test of the resilience of our failed health care system,” he explained. The excess deaths stemmed from inequities in the system and financial barriers to care for patients, he said. Patients had struggled to seek care before and after COVID, but those factors were more difficult to overcome during the pandemic, he added.
Blumenthal said another reason for the rising death toll is the federal government’s response to the pandemic: “For a long time, the US government tried to minimize the pandemic, and then demonized public health as a means to reduce the political impact of the pandemic,” he said.
Other causes of death in the United States
The other leading causes of death in the United States are drug abuse and gun violence. Last year, the United States saw more than 100,000 overdose deaths and about 43,000 firearm deaths — far higher than the other high-income countries cited in the study: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland and the United Kingdom.
As the report’s title suggests, the U.S. health care system is failing across five measures that compare U.S. health care with nine other countries. So far, the U.S. ranks last by far in overall health care system performance, with Australia, the Netherlands, and the United Kingdom coming in as the top three countries, the researchers found.
A story worth reporting
Blumenthal said journalists should write about the soaring cost of health care. “I’m going to dig into and re-emphasize some of the research that’s been done in the past about disparities in health care costs in different parts of the United States,” he explained. “I’m going to point out areas that have very high health care costs and shed light on why they’re so high. And why are doctors and other health care providers charging so much? Do they really need that much to provide the right services?”
Commonwealth Fund President Joseph R. Betancourt, MD, MPH, agreed, saying, “We have an opportunity to tell the story of how high health care costs lead to increased out-of-pocket expenses for individuals, affecting their ability to seek and receive the care they need.”
Betancourt added: “These are real human stories about the lack of access to care due to its high cost, leading to premature disability and earlier death than in other countries. There is a clear causal relationship between the costs in our health care system and the health capabilities of our people. Sharing these stories broadly is an opportunity.”
Reflecting the patient experience
The purpose of the “Mirror, Mirror” report is to compare the performance of the U.S. health care system with that of other countries and identify key lessons to improve affordability, access, equity and outcomes, Betancourt said. Since the foundation published the first edition of the “Mirror, Mirror” report in 2004, its goal has been to reflect the lived experiences of Americans and commit to improving the U.S. health care system. Since the first edition, follow-up studies have been conducted in 2006, 2007, 2010, 2014, 2017, 2021 and this year.
In the report, researchers analyzed 70 indicators of health system performance across five areas:
Access to health care Health outcomes Administrative efficiency Equity Health care process
The United States ranked lowest in access to care and health outcomes, and second from the bottom in administrative efficiency and equity. The United States ranked second in health care processes, one of the report’s bright spots. Indicators include care coordination, patient safety and engagement, attention to patient preferences, and attention to disease prevention, including mammograms and vaccinations, the report said. The United States ranked second behind New Zealand in this indicator. “With regard to preventive care, the U.S. record may reflect aggressive pay-for-performance policies implemented by Medicare and other payers to reward the provision of these services,” the researchers added.
The 10 countries studied have more similarities than differences when comparing their performance across the five areas, with the United States being a poor and notable exception, the researchers wrote.
Another way to look at overall performance is to consider how much they spend on health care. “The top two countries in the overall ranking, Australia and the Netherlands, also spend the lowest percentage of their GDP on health care,” the report states. “Other countries are tightly packed, but the United States has by far the worst overall performance, despite spending a much larger share of its GDP on health care.”
The report notes that the U.S.’s record on health outcomes is especially poor given how much it spends on health care. “The ability to keep its population healthy is a key indicator of a nation’s ability to achieve equitable growth. The United States continues to fail in meeting this basic obligation,” the researchers write.
High costs limit access
“No other country in the world requires more patients and families to pay out of pocket for basic health care costs than the United States,” Betancourt said when the report was released on Wednesday, Sept. 18. “Even insured people across the United States are struggling with rising health care costs that are far higher than those in other countries.”
The Netherlands, the United Kingdom and Germany have universal health insurance systems that guarantee access and affordability, and that out-of-pocket costs are at least small, the researchers noted. For example, the report adds:
In the Netherlands, primary care, obstetric care and childcare are covered in full. All other services are covered after patients pay an annual copayment. In England, the National Health Service provides free public healthcare, including hospital, doctor and mental health care. In Germany, copayments are limited to 1% of gross income for chronically ill patients and 2% for other patients. All other care is covered in full, the report shows. Health outcomes
For outcome questions, researchers assessed life expectancy at birth and how countries dealt with preventable and treatable conditions, such as avoidable deaths and excess deaths due to the pandemic. Australia, Switzerland and New Zealand ranked highest. The United States ranked last in part because its life expectancy is more than four years lower than the 10-country average. The United States also had the highest preventable and treatable deaths during the pandemic and the highest excess deaths among people aged 75 and over of all age groups.
Health Equity
The equity score reflects how income affects access to care and patients’ experiences of health care. Australia and Germany rank highest. The United States and New Zealand rank lowest because low income affects access to care and a patient’s racial or ethnic background can lead to inequitable treatment, the report found. In the United States, racism harms the health of people in Indigenous communities and Black Americans, and an inadequate social safety net leads to increased hunger, homelessness and poverty, the researchers wrote.
Administrative Efficiency
Of the 10 countries, the US health system is characterised by the report’s findings of a complex mix of public and private health insurance, each with different cost-sharing rules and coverage limits. Both Switzerland and the US performed poorly on this criterion. Many US patients are forced to pay to receive treatment; many are billed after the fact. In both Switzerland and the US, many patients seek treatment in expensive emergency departments when they could be treated in cheaper settings. US insurers frequently reject doctors’ requests, forcing them to go through time-consuming appeals, also contributing to inefficiencies, the report added.
Care Process
One bright spot for the U.S. health care system is the process of care indicator. Elements of this domain are care coordination, patient safety and engagement, attention to patient preferences, and attention to disease prevention, including mammograms and vaccinations, the report said. The U.S. ranked second in this indicator, behind New Zealand. “With regard to preventive care, the U.S. record may reflect aggressive pay-for-performance policies implemented by Medicare and other payers to reward the provision of these services,” the researchers added.
RESOURCES International Health System Profiles, Country Profiles, Health System Characteristics, Commonwealth Fund. “Unexpected Medical Bills and Health Insurance Denials in the United States,” Commonwealth Fund, August 1, 2024. “High Health Care Costs in the United States: Where Are They Going?”, Commonwealth Fund, October 4, 2023. “Nearly 43,000 People Will Die from Gun Violence in 2023: How to Tell the Truth,” AHCJ, February 14, 2024. “U.S. Drug Overdose Deaths Still Higher Than Other Countries – How Harm Reduction Programs Can Help,” Commonwealth Fund, June 22, 2023.
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