From Last to First — Could the U.S. Health Care System Become the Best in the World?



    New @NEJM commentary outlines U.S. health system problems: access, underinvestment in primary care, bureaucracy
    The U.S. could improve health system performance by ensuring universal coverage and strengthening social supports


Americans often describe the U.S. health care system as the best in the world. But according to a report from the Commonwealth Fund, the U.S. health care system ranks last among 11 high-income countries. The country leads the world in health care spending, but its residents are sicker and more likely to die of preventable conditions than those in other wealthy countries.

In a New England Journal of Medicine “Perspective,” the Commonwealth Fund’s Eric C. Schneider, M.D., and David Squires consider what makes a health care system successful, how health care in the United States falls short, and what steps the country could take to become the top health care system in the world.

What the Study Found

The United States offers some of the most advanced specialty health services in the world. For Americans with access, care is patient-centered, and outcomes for some major diseases are as good as or better than in other countries. Despite these strengths, health care outcomes are worse than 10 other high-income countries and many Americans lack affordable, high-quality health care.

Four challenges characterize the U.S. health care system: high costs, difficulty accessing primary care, confusing and inefficient administration, and disparities in care because of income, education level, race, or ethnicity. Countries that outperform the U.S. address these issues through universal health insurance, stronger primary care systems, payment approaches that minimize billing conflicts, and greater investment in social supports that lead to better health.

Laws enacted between 2010 and 2015, including the Affordable Care Act, have placed the United States on a path to improvement. More Americans now have health insurance, and innovations by Medicaid and Medicare are laying the groundwork for stronger primary care.


The U.S. health care system could make progress toward becoming the best in the world by removing financial and other barriers to timely care, making strong primary care widely available, and reducing inequities. Instead of reversing the accomplishments of recent years, health reforms should aim to ensure adequate health insurance for all, offer ready access to primary care, modernize payment approaches, and support the social services that can improve health.

Publication Details

Publication Date: July 17, 2017
Authors: Eric C. Schneider, M.D., David Squires
Contact: Mary Mahon, Vice President, Public Information, The Commonwealth Fund
E. C. Schneider and D. Squires, “From Last to First — Could the U.S. Health Care System Become the Best in the World,” New England Journal of Medicine, published online July 14, 2017.
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