Skip to main content

Advanced Search

Advanced Search

Current Filters

Filter your query

Publication Types



Fund Reports


Mirror, Mirror on the Wall: Looking at the Quality of American Health Care through the Patient's Lens

See the full series of "Mirror, Mirror" publications, with updated data years. 

Health care leaders in the United States often claim that the American health system is the best in the world. Based on both per-capita spending and the percentage of national income spent on health care, our nation is certainly far and away the leader. But are Americans really getting what they pay for?

A report from The Commonwealth Fund that examines how well the health system works from the perspective of patients confirms what several other recent studies have shown that the U.S. performs worse than its peer nations on several dimensions of quality. According to Mirror, Mirror on the Wall: Looking at the Quality of American Health Care Through the Patient's Lens, four other industrialized nations Australia, Canada, New Zealand, and the United Kingdom scored better than the U.S. on safety, efficiency, effectiveness, and equity, while the U.S. ranked second-to-last on measures of "patient-centered" care. The U.S. did, however, have the shortest waits for hospitalization and elective surgery, and placed second (to New Zealand) on prompt access to primary care physicians and specialists.

"While the U.S. spends the most on health care of any country, we're not getting commensurate value from the view of patients," said Fund president Karen Davis, the report's lead author. "We have the most highly skilled health professionals and most advanced medical technology, yet our system doesn't ensure that patients fully benefit from this wealth of resources."

The Fund analysis, which was based on patients' responses to the 2001 International Health Policy Survey and the 2002 International Health Policy Survey of Sicker Adults, used criteria for evaluating quality developed by the Institute of Medicine. For each of the quality dimensions below, an overall score was assigned to each country based on scores on several measures.

Patient Safety: U.S. Ranked Last

  • Highest reports of medication errors (receiving the wrong medication or dose over the past two years).
  • Most likely to say a medical mistake was made in their treatment.

Patient-Centered Care: U.S. Ranked Second-to-Last

  • Ranked last (tied with the U.K.) on physicians spending enough time with patients.Last on physicians listening carefully to patients' health concerns.

Timeliness: U.S. Ranked Third

  • Best on hospital admission waiting times.
  • Next to last on waiting five days or more for physician appointment when last needed medical attention.

Efficiency: U.S. Ranked Last

  • Last on being sent for duplicate tests by different health care professionals.
  • Worst on not having medical records or test results reach doctor's office in time for appointment

Effectiveness: U.S. Tied for Last

  • Last in patients not getting a recommended test, treatment, or follow-up due to cost.
  • Last in patients not filling a prescription due to cost.

Equity: U.S. Ranked Last for Lower-Income Patients

  • Worst on patients having problems paying medical bills.
  • Worst on patients being unable to get care where they live.


Publication Details



Mirror, Mirror on the Wall: Looking at the Quality of American Health Care through the Patient's Lens, Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Anne-Marie J. Audet, M.D., M.Sc., S.M., Michelle M. Doty, Ph.D., M.P.H., and Katie Tenney, The Commonwealth Fund, January 2004