Report: U.S. spends the most on health but outcomes are among the worst

In this election year, a new report shows it's well beyond time for journalists and voters to hold politicians accountable for the poor quality of America's health care system.

Here's why: Among 10 high-income nations, the United States spends the most on health care and, for that money, gets the worst health outcomes. Also, Americans die four years earlier than their counterparts in those other countries, according to the report from the Commonwealth Fund.

What's more, America had the most deaths per capita due to COVID-19 among people under age 75, and the highest rates of preventable and treatable deaths for all ages in 2022, according to the report, published Thursday, Sept. 19.

In a follow-up interview, Blumenthal said, "On COVID deaths, two things were at work. One is the failings of our health care system generally, which made it hard to deal with the stresses that COVID placed on it."

The second factor was the number of excess deaths from COVID, he added. "It's not just deaths due to COVID directly, but excess deaths due to COVID, which is a test of the resiliency of our health care system that we failed," he explained. Excess deaths stemmed from inequities in the system and patients' financial barriers to care, he said. Before and after COVID, patients have had trouble seeking care, but those factors were more challenging to overcome during the pandemic, he added.

Another reason for more deaths was the federal response to the pandemic, Blumenthal noted. "The national government in the United States tried to minimize the pandemic for long stretches of time and then demonized public health as a way to reduce the political impact of the pandemic," he said.

Other causes of U.S. deaths

Other leading causes of U.S. deaths are substance misuse and gun violence. Last year, the United States reported more than 100,000 overdose deaths and roughly 43,000 gun-related fatalities, much higher numbers than those of 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 system is failing when using the five measures to compare U.S. health against that of the other nine nations. By far, the United States ranked lowest in overall health system performance, while Australia, the Netherlands and the United Kingdom were the top three countries, the researchers found.

Stories to report

Blumenthal said journalists should write about high health care prices. "I would drill down and re-emphasize some of the work that has been reported in the past on the differential prices across different areas of the United States," he explained. "I'd point out the very high price areas and figure out why it costs so much. Also, why do physicians and other providers charge so much? Do they need that amount of money to deliver adequate services?"

Commonwealth Fund President Joseph R. Betancourt, M.D., M.P.H, agreed, saying, "There's an opportunity to tell stories about how high prices that lead to high out-of-pocket costs for individuals impact their ability to seek and get the care they need."

Then, Betancourt added:"These are real human stories, and the result of not getting care because of the high price is leading to premature disability and early deaths compared to other countries. There's a clear causal link between that expense in our health care system and people's ability to be healthy. Sharing that story broadly is an opportunity."

Reflecting patients' experience

The goal of the "Mirror, Mirror" report is to compare the performance of the U.S. health system to that of other countries and to identify key lessons to improve affordability, access, equity and outcomes, Betancourt said. Since the fund produced the first edition of the "Mirror, Mirror" report in 2004, the goal has been to reflect Americans' lived experience and to make a commitment to improve the American health care system. Since the first report, follow-up studies were done in 2006, 2007, 2010, 2014, 2017, 2021, and this year.

For this report, researchers analyzed 70 measures of health system performance in five areas:

1. Access to care
2. Health outcomes
3. Administrative efficiency
4. Equity
5. Care processes

The United States was lowest in access to care and health outcomes, next to last in administrative efficiency and equity. America was second in care processes, one of the bright spots in the report. That metric encompasses care coordination, patient safety and engagement, sensitivity to patients' preferences and attention to illness prevention, including mammograms and vaccinations, the report said. America was second on this measure behind New Zealand. "With respect to preventive care, the U.S. record might reflect the vigorous pay-for-performance policies implemented by Medicare and other payers to reward the delivery of these services," the researchers added.

While the 10 countries measured are more alike than different when performance is compared against the five domains, the United States is a poor and glaring exception, the researchers wrote.

Another way to view overall performance is to consider how much we spend on health care. "The two countries with the highest overall rankings, Australia and the Netherlands, also have the lowest health care spending as a share of gross domestic product (GDP)," the report states. "The other countries are clustered closely together - except for the U.S., which spends far more of its GDP on health care yet has by far the worst overall performance."

The U.S. record on health outcomes is especially poor given how much we spend on care, the report noted. "The ability to keep people healthy is a critical indicator of a nation's capacity to achieve equitable growth. In fulfilling this fundamental obligation, the U.S. continues to fail," the researchers wrote.

High costs limit access

"No other country in the world expects patients and families to pay as much out of pocket for essential health care as they do in the United States," Betancourt said when presenting the report last Wednesday, Sept. 18. "Even insured Americans across the United States are struggling with soaring health care costs far more than people in other countries."

The Netherlands, the United Kingdom and Germany have universal coverage guaranteeing access and affordability and ensuring that copayments are at least small, the researchers noted. The report added, for example:

• In the Netherlands, primary care, maternity care and child care are fully covered; other services are covered after patients pay an annual deductible.
• England's National Health Service provides free public health care, including hospital, physician and mental health care.
• In Germany, copayments are capped at 1% of gross income for the chronically ill and at 2% for all other patients. All other care is covered in full, the report showed.

Health outcomes

On the issue of outcomes, the researchers assessed life expectancy at birth and how each country managed preventable and treatable conditions, such as avoidable deaths and excess deaths due to the pandemic. Australia, Switzerland and New Zealand ranked the highest. The United States was last in part because life expectancy is more than four years below the 10-country average. The U.S. also has the highest rates of preventable and treatable deaths for all ages and for excess deaths among those over age 75 during the pandemic.

Health equity

The equity score reflects how income influences access to and patients' experience with health care. Australia and Germany rank highest. The United States and New Zealand rank last because low income affects access to care, and patients' racial or ethnic backgrounds can lead to unfair treatment, the report showed. In America, racial discrimination has harmed the health of those in Indigenous communities and Black Americans, while an inadequate social safety net leads to increased hunger, homelessness and poverty, the researchers wrote.

Administrative efficiency

Among the 10 nations, the U.S. health care system has what the report cited as the uniquely complex mix of public and private health plans, each with different cost-sharing rules and coverage limits. Switzerland and the United States both performed poorly on this measure. Many U.S. patients are forced to pay to get care. Many people get medical bills after the fact. In both Switzerland and America, many patients seek treatment in costly emergency departments when they could get care in less-expensive settings. Another inefficiency stems from U.S. insurers' frequent denials of physicians' requests, forcing them to make time-consuming appeals, the report added.

Care processes

For the U.S. health system, the care process measure is one of the bright spots. Elements of this domain are care coordination, patient safety and engagement, sensitivity to patients' preferences and attention to illness prevention, including mammograms and vaccinations, the report said. America was second on this measure behind New Zealand. "With respect to preventive care, the U.S. record might reflect the vigorous pay-for-performance policies implemented by Medicare and other payers to reward the delivery of these services," the researchers added.

Resources

• International Health Care System Profiles, country profiles and health system features, Commonwealth Fund.
• "Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S.," Commonwealth Fund, August 1, 2024.
• "High U.S. Health Care Spending: Where Is It All Going?," Commonwealth Fund, Oct. 4, 2023.
• "Nearly 43,000 People Died from Gun Violence in 2023: How to Tell the Story," AHCJ, Feb. 14, 2024.
• "U.S. Overdose Deaths Remain Higher Than in Other Countries - How Harm-Reduction Programs Could Help," Commonwealth Fund, June 22, 2023.