The US Ranks Last in Health Care System Performance

Research shows policy reforms may be needed to close the performance gap

Posted Jul 09, 2018

This post is coauthored with my colleague Professor Alexander Pacek, Texas A&M University

The link between health and happiness is one of the best-documented in the study of well being. Simply put, one's health overview—meaning access to care, affordability, and quality of outcomes—has a dramatic affect on one's level of happiness. Specific health problems like heart disease, diabetes, and cancer clearly lower the well-being of individuals. At the national level, countries with higher levels of infant mortality and lower life expectancy are less happy than those where infant mortality is low, and life expectancy high (or increasing). One could extend the examples, but the pattern is clear: at both the individual and aggregate level, health promotes happiness.

USGovernment/WikimediaCommons
Source: USGovernment/WikimediaCommons

But the connections are more complex than these simplistic summary would suggest. Other determinants of unhappiness—including poor working conditions, unemployment, poverty—are themselves strongly associated with poor health outcomes, especially in the absence of universal access to (quality) care. More generally, financial insecurity (especially fear of unemployment or underemployment) contribute to chronic stress and anxiety, among other psychological problems, that in turn are detrimental to physical well-being. All of these conditions are clearly determined in part by our economic and social policies, which we can—if we wish—change so as to maximize our health and happiness. It is in this context that an important new study of cross-national health patterns by the non-partisan Commonwealth Fund warrants attention.

This comprehensive and detailed study examined five aspects of healthcare systems, considering both observable outcomes and the institutional structure providing care. “Care Process” integrates 24 measures on the overall quality of patient interactions with the health care system (such use of preventive measures like mammography screening). “Access” utilizes six measures of affordability and nine measures of timeliness. “Administrative Efficiency” uses seven measures of the difficulty of the process by which patients navigate the health care system (including such measures as doctor evaluations of care be affected by administrators denying access to treatment). “Equity” uses 11 measures to ascertain the extent of different experiences by income groups. Most importantly, "Health Care Outcomes" assesses the bottom line of how well the system treats people using nine measures (such as the breast cancer and heart attack survival rates, as well as overall health measures).

The United States does not receive high marks. Overall, despite a level of spending that dwarfs the other countries in the study, the U.S. comes in dead last in three of the five, and arguably the most important three, of the five domains: health outcomes, equity, and access. We are tied for last on administrative efficiency and about average on care process. The U.S. is also last in their summary indicator aggregating all five dimensions.

The bottom line, and the paper's most basic conclusion, is that "the performance of the U.S. health care system ranks last compared to other high-income countries."

The study also finds that the "U.S. has the highest rate of mortality amenable to health care." More people die unnecessarily in the U.S. due to inadequate care, or the pure absence of care, than any in any of country in the study. The issue is not merely problems in the American life style, Americans die more than Europeans because of poor quality health care or lack of access to care. It is that simple.

It is also worth noting that despite this low level of performance, the health care spending in the U.S. is (about 16.6 percent of GDP in 2014) is far higher than other industrial democracies (OECD average is around 11 percent for the same time period). We thus spend more, but do worse, than nearly every other comparable country.

What about the countries that did best? What did their health and social policies look like? The study identified three countries as the top performers, standing out from the rest: the U.K., Australia, and the Netherlands. On one level, these countries have have different health care systems. The U.K.’s National Health Service is by far the most government controlled/funded of the three, being the exemplar of a centralized system of "socialized medicine." Australia is similar, but relies more on a combination of public and private involvement; it is roughly equivalent to the U.S. Medicare program with universal access. The Netherlands relies on private providers regulated by government in a system similar to the logic of Obamacare. As the study concludes, it seems there are different paths toward the end of good healthcare.

However, as the study again notes, these three countries all succeed in what the U.S. so conspicuously lacks: universal access. As the study notes, the U.S. is the only high-income country lacking universal health insurance coverage." This is thus the key toward making progress: achieving universal coverage. (A summary of scholarly research documenting the role of universal healthcare and health and happiness outcomes can be found here).

There is reason for hope on this front. The Affordable Care Act (Obamacare) is at least a down payment on the goal of universal coverage, and, as noted, is similar to one of the three models for a good healthcare system. It may thus be most useful to close by quoting the study's own conclusions:

"The U.S. has taken an important step to expand coverage through the Affordable Care Act. As a 2017 Commonwealth Fund report showed, the ACA has catalyzed widespread and historic gains in access to care across the U.S. More than 20 million Americans gained insurance coverage. Additional actions could extend insurance coverage to those who lack it. Furthermore, Americans with coverage often face far higher deductibles and out-of-pocket costs than citizens of other countries, whose systems offer more financial protection. Incomplete and fragmented insurance coverage may account for the relatively poor performance of the U.S. on health care outcomes, affordability, administrative efficiency, and equity."