International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

To read full report go to Mirror, Mirror 2017, Commonwealth Fund

This report compares health care system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

METHODS: Seventy-two indicators were selected in five domains: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes. Data sources included Commonwealth Fund international surveys of patients and physicians and selected measures from OECD, WHO, and the European Observatory on Health Systems and Policies. We calculated performance scores for each domain, as well as an overall score for each country.

KEY FINDINGS: The U.S. ranked last on performance overall, and ranked last or near last on the Access, Administrative Efficiency, Equity, and Health Care Outcomes domains. The top-ranked countries overall were the U.K., Australia, and the Netherlands. Based on a broad range of indicators, the U.S. health system is an outlier, spending far more but falling short of the performance achieved by other high-income countries. The results suggest the U.S. health care system should look at other countries’ approaches if it wants to achieve an affordable high performing health care system that serves all Americans.

“The United States ranks last in health care system performance among the 11 countries included in this study (Exhibit 2).” – Commonwealth Fund 2017 –

Mortality: Health Care Outcomes

The Health Care Outcomes domain includes nine measures of the health of populations. Taken together, they are intended to reflect outcomes that are attributable to the performance of the countries’ health care delivery systems. The measures fall into three categories:

• population health outcomes (i.e., those that reflect the chronic disease and mortality of populations, regardless of whether they have received health care),
• mortality amenable to health care (i.e., deaths under age 75 from specific causes that are considered preventable in the presence of timely and effective health care), and
• disease-specific health outcomes measures (i.e., mortality rates following stroke or heart attack and the duration of survival after a cancer diagnosis).

Population Health Outcomes

In the population health outcomes category, two measures compare countries on the mortality of populations defined by age (infant mortality and life expectancy after age 60) and one measure focuses on the proportion of surveyed nonelderly adults who report at least two of five common chronic conditions.

Mortality Amenable To Health Care

For each country, mortality amenable to health care includes both the current rate of deaths amenable to care and the 10-year trend.

Disease Specific Health Outcomes

In the disease specific health outcomes category, two measures focus on 30-day in-hospital mortality following myocardial infarction and stroke, and two measures examine five-year relative survival for breast cancer and colon cancer.

Top 3 Health Systems: Achieving In Diverse Ways

The three countries with the best overall health system performance scores have strikingly different health care systems. All three provide universal coverage and access, but do so in different ways, suggesting that high performance can be achieved through a variety of payment and organizational approaches. Experts generally group universal coverage systems into three categories: Beveridge systems, single-payer systems, and multipayer systems. These three systems are represented among our highest performers.

The U.K.’s National Health Service (OA Rank 1st; Outcomes 10th)

The Beveridge model takes its name from the creator of Britain’s modern welfare state, William Beveridge. In the NHS, initiated by Aneurin Bevan in 1948, health services are paid for through general tax revenue, as opposed to insurance premiums. Furthermore, the government plays a significant role in organizing and operating the delivery of health care. For example, most hospitals are publicly owned, and the specialists who work in them are often government employees. This is not true of all providers. Most general practitioner practices are privately owned. Health care in the U.K. and other Beveridge countries is centrally directed and has more direct management accountability to the government than in other health systems.

Australia’s Single-Payer Insurance Program (OA Rank 2nd; Outcomes 1st)

In Australia, everyone is covered under the public insurance plan, Medicare. Much like the NHS, Australia’s Medicare is funded through tax revenue. Medicare is distinguished, though, by lesser public involvement in care delivery. Many Australian hospitals are private, and roughly half the population purchases private health insurance to access care outside the public system. To put into an American context, Australia’s Medicare resembles Medicare in the U.S.

The Netherlands’ Competing Private Insurers (OA Rank 3rd; Outcomes 6th)

Unlike Australia and the U.K., the Dutch health system relies on private insurers to fund health services for its population. Dutch insurers are mainly financed through community-rated premiums and payroll taxes, which are pooled and then distributed to insurers based on the risk profile of their enrollees. All plans include a standard basic benefit package; subsidies are available for people with low incomes; adults are required to enroll in a plan or must pay a fine. Dutch health care providers are predominantly private. This multipayer system—partly inspired by the managed competition model—shares many similarities with the insurance marketplaces created under the Affordable Care Act.