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August 17, 2021

US Health Care System Ranks Distant Last Among 11 High-Income Nations—Report

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum
JAMA Health Forum. 2021;2(8):e213053. doi:10.1001/jamahealthforum.2021.3053

Despite spending the highest proportion of its gross domestic product on health care compared with 10 other high-income nations, the United States ranks last overall in providing equitably accessible, affordable, high-quality health care, according to a report from the Commonwealth Fund.

The US health care system “delivers too little of the care that’s most needed—and often delivers it too late—especially for people with complex chronic illness, mental health problems, or substance use disorders, many of whom have faced a lifetime of inequitable access to care,” the report notes.

The report compares the health care systems of Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

In their analysis, the authors examined 71 performance measures across 5 domains—access to care, care process, administrative efficiency, equity, and health care outcomes. To measure and compare patient and physician experiences across the 11 nations, they used information from Commonwealth Fund international surveys in each country as well as administrative data from the Organisation for Economic Co-operation and Development and the World Health Organization.

The United States has been ranked last overall in each of the 7 editions of the report published since 2004.

No country leads in every area. Norway, the Netherlands, and Australia are the top-performing countries in the overall ranking, followed by the UK, Germany, and New Zealand. The performance of the US health care system “falls well below the average of the other countries and far below the two countries ranked directly above it, Switzerland and Canada,” the authors wrote.

The United States also ranks last overall in access to care, which includes measures of affordability and timeliness—rated much lower than the next-lowest country, Switzerland—and also trails the other 10 countries in administrative efficiency, equity, and health outcomes.

US residents at all income levels are less able to afford health care compared with people in other high-income countries. Among lower-income adults, 50% in the United States report cost-related difficulties in accessing health care in 2020 vs just 12% in the UK. The disparity in affordability between the United States and other wealthy countries also holds for higher-income adults, with 27% of US higher-income adults reporting financial barriers to care compared with only 6% of higher-income adults in Norway, France, and Sweden.

“Compared to residents of the US, residents of the Netherlands, the UK, Norway, and Germany are much less likely to report that their insurance denied payment of a claim or paid less than expected. Residents of these countries are also less likely to report difficulty in paying medical bills,” the report says.

Among the countries included in the report, only the United States lacks universal health insurance coverage.

The United States also ranks lowest on the equity domain, having the largest income-related disparities, and ranks last for health care outcomes.

“US disparities are especially large when looking at financial barriers to accessing medical and dental care, medical bill burdens, difficulty obtaining after-hours care, and use of web portals to facilitate patient engagement,” the report says.

In addition, the United States ranks last overall compared with the other 10 high-income countries in the domain of health care outcomes. It has the highest infant mortality rate (5.7 deaths per 1000 live births), the lowest life expectancy at age 60 (23.1 years), the highest rate of preventable mortality (177 deaths per 100 000 people, more than twice that of the best-performing country, Switzerland), and the highest maternal mortality rate (17.4 deaths per 100 000 live births).

All 11 countries reduced their rate of avoidable mortality over 10 years. However, the United States, which had the highest level in 2007, reduced it by the least amount (a 5% reduction in deaths per 100 000). In contrast, Switzerland cut its rate of avoidable mortality by 25% (by 2017), and Norway lowered its rate by 24% (by 2016).

Norway, Australia, New Zealand, and the UK are the top performers in administrative efficiency, which is how well health systems reduce paperwork and other bureaucratic tasks that patients and clinicians often face during care, whereas the United States again ranks last.

Some 63% of US primary care physicians report that time spent helping patients get needed medications or treatment because of insurance coverage restrictions is a major problem, compared with just 6% in Norway. Nearly as many US primary care physicians (58%) characterize time spent on administrative issues related to insurance or claims as a major problem, vs 11% in Norway.

However, the United States performs well on “care process,” which includes 4 categories (preventive care, safe care, coordinated care, and engagement with patients), ranking second behind New Zealand. On average, for example, along with the UK and Sweden, the United States demonstrates higher performance on preventive care, which includes higher rates of mammography screening and influenza vaccination for older adults, and a higher proportion of patients who talked with a clinician about nutrition, smoking, and alcohol use.

Top-performing countries rely on certain measures to attain better and more equitable health outcomes, the report says. These include offering universal coverage and removing cost barriers, investing in primary care and extending it to every local community to reduce the risk of discrimination and unequal treatment, and reducing administrative burdens that cost patients and clinicians time and effort.

The top-performing countries, the report explains, also invest in programs that target factors beyond health care and that boost equitable access to education, child care, community safety, housing, nutrition, transportation, and worker benefits that result in a healthier population and fewer avoidable demands on health care.

“Lessons from the top-performers can inform the United States and other countries seeking to improve their health care systems,” the authors note.

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Article Information

Published: August 17, 2021. doi:10.1001/jamahealthforum.2021.3053

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

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