Health system performance in the U.S. is dramatically lower than that of nine other countries in a new assessment from the Commonwealth Fund.
In Commonwealth Fund's "Mirror, Mirror 2024" report, the foundation analyzed 70 health system performance measures in five areas — access to care, care process, administrative efficiency, equity and health outcomes — for Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom and the United States.
In its eighth report comparing countries' health systems, the Commonwealth Fund finds that no single country ranks at the top or bottom across all performance areas. However, the report notes: "Nevertheless, in the aggregate, the nine nations we examined are more alike than different in terms of their higher and lower performance across various domains. But there is one glaring exception — the U.S."
Americans have the shortest life expectancy and the highest rates of avoidable deaths among the 10 countries, placing the U.S. last for health outcomes. Notably, this year's report accounts for the impact of COVID-19 on health system performance, using data collected since the pandemic began and excluding data from before 2020.
Here are six key takeaways from the foundation's latest global report, which can be accessed in full here:
1. The U.S. ranked last overall, dropping to 10th place for access to care and health outcomes, and ninth for equity and administrative efficiency. The only area where the U.S. performed well was care process, where it ranked second.
2. Care process evaluates health system prevention, safety, coordination, patient engagement and sensitivity to patient preferences. It does not evaluate quality of care for acute care conditions, especially in hospitals. The U.S. ranks second in this area, driven by its chronic care management, preventive services like mammograms and flu vaccinations, as well as a focus on patient safety, which has led to reductions in adverse events during hospital stays.
The Commonwealth Fund describes this high performance as "particularly interesting" for the U.S., suggesting that value-based care reimbursement models may contribute to these results, although they do not translate into improved health outcomes for the country.
3. In terms of access to care, the U.S. ranks lower than the other nine countries, scoring last in affordability and low for availability. U.S. patients are more likely than their peers in most other countries to report they don't have a regular physician or place of care and face limited options for getting treatment after regular office hours.
Shortages in primary care services exacerbate these availability issues, occurring against a backdrop of fragmented insurance coverage, with 26 million Americans uninsured and cost-sharing requirements that prevent patients from seeking medical attention when needed. By contrast, the Netherlands, the United Kingdom, and Germany perform best on access overall.
4. Australia and the United Kingdom virtually tied for the best performance on administrative efficiency, while Switzerland and the U.S. performed worst on most of these measures. The complex system of public and private payers in the U.S. works against this category, with the country receiving the worst score for providers spending time on paperwork or disputes related to medical bills.
5. New Zealand and the U.S. rank last in equity, which assesses disparities in access to care and patient experiences between individuals with below-average and above-average incomes. The U.S. struggled with particularly low scores related to patients forgoing care due to financial reasons and difficulties accessing after-hours medical services. A high percentage of patients in both countries reported feeling unfairly treated or having their health concerns dismissed during healthcare encounters.
6. The U.S.'s bottom ranking for health outcomes is driven by poor performance in four of five outcome measures. Life expectancy is more than four years under the 10-country average, and the U.S. leads in preventable and treatable deaths across all ages, as well as excess deaths from the pandemic for those under 75.
High rates of substance use and gun violence significantly worsen outcomes, with over 100,000 overdose deaths and 43,000 gun-related deaths in 2023 — figures far higher than in other high-income countries. "To create a health system that truly safeguards the well-being of Americans, the U.S. will need interventions besides those directly related to healthcare services," the report notes.