Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally
By Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen
The Commonwealth Fund, June 2014
The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland.
The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes.
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 10 countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. While there has been some improvement in recent years, lower scores on safe and coordinated care pull the overall U.S. quality score down.
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 were the most likely to say they had access problems related to cost.
Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively.
Equity: The U.S. ranks a clear last on 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; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.
From the Discussion
It is difficult to disentangle the effects of health insurance coverage from the quality of care experiences reported by U.S. patients. Comprehensiveness of insurance and stability of coverage are likely to play a role in patients’ access to care and interactions with physicians. We found that insured Americans and higher-income Americans were more likely than their counterparts in other countries to report problems such as not getting recommended tests, treatments, or prescription drugs. This is undoubtedly a reflection of the lack of comprehensive health insurance coverage and the high out-of-pocket costs for care in the U.S., even among the insured and those with above-average incomes. Fragmented coverage and insurance instability undermine efforts in the U.S. to improve care coordination, including the sharing of information among providers. Patients in other countries, in addition, are more likely to have a regular physician and long-time continuity with the same physician.
These results indicate a consistent relationship between how a country performs in terms of equity and how patients rate other dimensions of performance: the lower the performance score for equity, the lower the performance on other measures. This suggests that, when a country fails to meet the needs of the most vulnerable, it also fails to meet needs for the average citizen. Rather than regarding performance on equity as a separate and lesser concern, the U.S. should devote far greater attention to building a health system that works well for all Americans.
http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
Comment:
By Don McCanne, MD
In this 2014 update of The Commonwealth Fund study on the performance of the U.S. health care system compared to other nations, the United States once again comes in last, in spite of having the most expensive system of all nations.
This year the authors express hope that implementation of the Affordable Care Act (ACA) will improve our performance, though so far the changes in the first three years of ACA have not been enough to lift us from the bottom. There is reason to believe that it is too weak of a program to ever have enough impact.
An interesting finding in this report is that the United Kingdom came in first in most categories studied, placing it in solid first place overall. Their National Health Service is government owned and operated – socialized medicine – and is one of the least expensive systems of all, spending only 40 percent per capita of what we spend in the United States. The next time someone claims that we are headed towards socialized medicine, we can respond, “Don’t we wish.”
However we do have to be careful about drawing sweeping conclusions from this study. Canada, which has a single payer system, scored next to the bottom, just above the United States. They scored lower in access, especially in timeliness of care, and in efficiency and safety. Although they have single payer government insurance systems in each province, the health care delivery system remains largely private. Since the deficiencies are primarily those of private delivery systems, it would suggest that the Canadian government should play a much greater role in improving resource allocation.
One of the more important deficiencies of a single payer system is that when conservative governments are in control – as they now are in Canada – the politicians attempt to reduce the role of government. Currently in Great Britain, conservatives are attempting to move more towards privatization, but so far their solidarity has prevented a massive shift in that direction, though they have introduced some worrisome policies.
Nevertheless, politics will always play a role in any system. That makes it even more imperative to put in place a system that is much less vulnerable to political whim – a universal national system in which the people take pride.