A candid look at the evidence shows that the American health care system performs less well than those of other countries on many important dimensions. The United States is the only major industrialized nation that fails to provide health coverage for all, yet spending on health care totaled $4,631 per capita in 2000, 69 percent more than in Germany, 83 percent more than in Canada, and 134 percent more than the average in industrialized nations. Enrollment in private managed care slowed spending in the mid-1990s, but other countries did as well or better in the same period using other cost-containment strategies. Between 1990 and 2000, inflation-adjusted health spending in the United States increased by 3.2 percent a year, compared with an average of 3.1 percent among industrialized nations.

The United States has emphasized private markets and consumer cost-consciousness as strategies for containing costs, yet our total costs are higher and growing as rapidly.⁽²⁾ At 56 percent, private spending as a share of total health care expenditures is far higher in the United States than in other industrialized nations, which average 26 percent. Our per capita out-of-pocket health care spending was $707 in 2000, more than twice the industrialized nation average of $328.

A common perception is that other countries control costs by rationing care that patients need. The truth is that Americans receive fewer days of hospital care than residents of other industrialized nations and make about the same number of visits to physicians. We are, however, more likely to undergo specialized procedures, such as coronary angioplasty. In short, health care spending in the United States is higher because we pay higher prices for the same services, have substantially higher administrative costs, and have higher rates of complex procedures.

There is some evidence that greater use of specialized services and leading-edge medications contributes to better outcomes for patients. The United States has fewer deaths from heart attacks, for example, than the average industrialized nation: about 60 each year per 100,000 population, compared with 75 in the United Kingdom and 65 in Australia. Yet our broader record for providing high-quality care is hardly reassuring. According to The Commonwealth Fund 2002 International Health Policy Survey of Sicker Adults, people in poor health are more likely to report medical errors in the United States than in four other English-speaking countries.⁽³⁾ The difference reflects, in part, the greater complexity of care in the United States. Since Americans are more likely to see three or more physicians a year and more likely to be taking three or more medications, they have more opportunities to encounter medical or medication mistakes and more chances for lack of coordination to cause problems. They are also more likely to receive duplicate tests and less likely to have their medical records available when they go for care.

The most striking way in which the United States falls short, however, is in access to needed services. Each year since 1998, the Fund's international survey has found that the United States ranks last among five English-speaking countries on measures of equity and first for access problems due to costs. Americans are much more likely than their counterparts in other countries to say they did not visit a physician, fill a prescription, or get a recommended test, treatment, or follow-up care because of costs. Disparities between people in above-average and below-average income groups were greatest in the United States, and the uninsured were much more likely to report problems in obtaining needed care.⁽⁴⁾