Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update

June 23, 2010

Authors: Karen Davis, Ph.D., Cathy Schoen, M.S., and Kristof Stremikis, M.P.P.
Contact: Karen Davis, President, The Commonwealth Fund, kd@cmwf.org


international health system comparisons Open this interactive Web feature to compare health system performance across countries.


Key Findings

  • Quality: The indicators of quality were grouped into four categories: effective care, safe care, coordinated care, and patient-centered care. Compared with the other six countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. However, its low scores on chronic care management and safe, coordinated care pull its overall quality score down. Other countries are further along than the U.S. in using information technology and managing chronic conditions. Information systems in countries like Australia, New Zealand, and the U.K. enhance the ability of physicians to identify and monitor patients with chronic conditions.
  • Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans with health problems were the most likely to say they had access issues related to cost, but if insured, patients in the U.S. have rapid access to specialized health care services. In other countries, like the U.K. and Canada, patients have little to no financial burden, but experience wait times for such specialized services. There is a frequent misperception that such tradeoffs are inevitable; but patients in the Netherlands and Germany have quick access to specialty services and face little out-of-pocket costs. Canada, Australia, and the U.S. rank lowest on overall accessibility of appointments with primary care physicians.
  • Efficiency: On indicators of efficiency, the U.S. ranks last among the seven countries, with the U.K. and Australia ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of the use of information technology, rehospitalization, and duplicative medical testing. Sicker survey respondents in Germany and the Netherlands are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available.
  • Equity: The U.S. ranks a clear last on nearly all measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick, not getting a recommended test, treatment, or follow-up care, not filling a prescription, or not seeing a dentist when needed because of costs. On each of these indicators, nearly half of lower-income adults in the U.S. said they went without needed care because of costs in the past year.
  • Long, healthy, and productive lives: The U.S. ranks last overall with poor scores on all three indicators of long, healthy, and productive lives. The U.S. and U.K. had much higher death rates in 2003 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Canada and Australia. Overall, Australia ranks highest on healthy lives, scoring in the top three on all of the indicators.

Featured Comment:

Ellen Shaffer, of Center for Policy Analysis (June 25, 2010):

Some suggest that the main reason we are outspending the world on health care is that we have more poor people, not because of our health care system, and that high health care spending is concentrated in areas with a higher percent of African Americans. This would have to mean that we are spending more money taking care of our poor who are sick. To the extent that this is true, it is only possibly the case because we take care of poor people in the worst possible way - not through universal access to timely primary care, but through crisis medicine when even U.S. standards generally would not tolerate outright denials of care. We should aim to reduce poverty. Race should no longer be associated with poverty. Relatively lower income should no longer determine the degree of power and control over life circumstances that are in turn associated with longevity and good health (nor for that matter should gender, sexuality, religion, or most demographic factors and lifestyle choices; age of course is the exception.). We should not only continue to document these pernicious trends, we should turn our scholarship and advocacy to redressing them. Furthermore, our health care system can contribute to social equity, and presently does poorly. An unspoken argument is that poverty and race account not only for our higher health care spending but also for our worse health outcomes, so it will not help to look to reforms of the health care delivery system for solutions. But rates of medical errors or C-sections (or misuse of neonatal intensive care units) are higher in the U.S. than they should be, that they are not disproportionately prevalent in "poverty ghettos," and that they contribute to unjustifiable costs and poor outcomes. Reforming the health care delivery system should not be an excuse for failing to remedy social inequalities. Pointing to inequalities cannot divert attention from the inefficiencies and remediable deficiencies in our delivery system. The new health reform law and ongoing HHS initiatives make reasonable efforts to acknowledge and address access, inequalities, and delivery system reforms. They won't be as successful as they could be in a single payer system like Medicare and the VA, but even a single payer system in the U.S. would have to implement the kind of delivery and organizational reforms that are now before us.