American flag with stethoscope

In the same week that efforts to repeal and replace Obamacare with something even worse, collapsed yet again. The Commonwealth Fund released its 2017 Report, Mirror Mirror 2017, that compares how 11 different health systems in high-income countries around the world perform on various metrics. Those countries included in the report are Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., and the U.S. The U.S. came in dead last.

The report used a variety of data sources to compile the results including Commonwealth Fund International Surveys of the physicians and the public as well as other reputable standardized data sources, such as the Organization for Economic Cooperation and Development, the European Observatory on Health Systems and Policies, and the World Health Organization. The analysis was based on 72 indicators of performance in five domains important to patients, providers, and policymakers. The domains are:

  • Care Process
  • Access
  • Administrative Efficiency
  • Equity
  • Health Care Outcomes


The U.S. ranking

The U.S. ranked 11th out of 11 in three of these domains: Access, Equity, and Health Care Outcomes thus earning an overall ranking at the bottom of the list. If you have been tracking the vitriolic debates about health insurance reform in recent months, the rankings in the first two domains should not be surprising. When you fail to provide universal coverage or even expand Medicaid in certain recalcitrant red states, you end up having vast differences in people’s ability to access and pay for care. When you fail to invest in prevention, particularly with respect to obesity and type 2 diabetes, you end up with a swath of the southeastern United States that is dubbed the “stroke belt,” the “heart attack belt”, or the “diabetes” belt.

In fact, it is well known that the people in the U.S. have inequitable access to care and unequal health outcomes depending on where they live. For example, a recent study in JAMA documented that there are huge differences in cardiovascular and stroke mortality that can be tracked to the county level, with very high mortality rates being found along the Mississippi River Valley to eastern Kentucky. We also know that health outcomes in the U.S. vary not only by geography but also by race and socioeconomic status, although the three factors are, of course, inextricably linked.

In term of access, it is noteworthy that the U.S. has the poorest performance of all of the countries in the affordability subdomain, “scoring much lower than even the second-to-last country, Switzerland.” Way to go U.S.A, we have poor access, grossly inequitable care, and bottom of the barrel health care outcomes, we are the least affordable. Can you get any worse?

The U.S. also ranked next to last in Administrative Efficiency compared to the other 10 countries in the study. Our complex system with multiple payers and multiple plans make it almost impossible for doctors and patients to understand ahead of time what will be paid for and what will not. Doctors complain about how much time they spend on billing and collection and patients often have to resort to a complicated appeal process to get the coverage they deserve (or not).

International Health System Rankings 2017 Commonwealth
Exhibit 2 from

Because the rankings appear to suggest that Canada and France are down at the bottom with the U.S., I think it is helpful to see how the countries compare by performance score, not just ranking—note that Canada’s score is closer to the eleven-county average than to the U.S. score even though Canada ranked as 3rd from the bottom:

Commonwealth Mirror Mirror 2017 performance scores (697 x 498)

The measure that the U.S. did the best on was Care Process, ranking 5th out of 11. The report notes that “the U.S. tends to excel on measures that involve the doctor-patient relationship and preventive measures, like mammography screening and flu shots, performing less well on measures of care coordination. You can learn more details about this Care Process domain by clicking here.


Cost of care

The one area the U.S. did excel in was the percent of GDP we spend on healthcare. As the chart below illustrates, none of the other countries come even close to spending what we do; and year by year, the gap is getting worse.

Commonwealth Mirror Mirror healthcare spending (688 x 543)

It is important to note that although the Affordable Care Act, also known as Obamacare, was signed into law in 2010, implementation was rolled out over several years with individual exchanges only going live in 2014. So much of what you see reflected in this chart is pre-Obamacare. Click here to see a timeline of the ACA rollout.


What can we learn from the top performers?

Unfortunately, American politicians have been loathed to learn from other countries. We use terms like socialist to label the systems of the U.K. and Canada, knowing that this conjures up images of Soviet-era communism—something that makes politicians and free-marketeers shudder in disgust. That being said, the report does go on to point out some interesting lessons for the United States. The first is noteworthy as the Senate seems to be contemplating repealing Obamacare without any replacement. All of the other high-income countries in the study have some form of universal coverage. Even with the coverage gains that we achieved with the implementation of Obamacare, including the expansion of Medicaid, we still left millions without health insurance coverage.

The next point that is of great interest is that the three top performing health systems, the U.K’s National Health Service (NHS), Australia’s Single-Payer Insurance Program, and Netherland’s competing private insurers, all have different ways of achieving universal coverage. In the U.K., the government plays a significant role in organizing and delivering care. But in the Netherlands, coverage is provided by competing private insurers sharing some similarity to the ACA insurance marketplaces. Australia’s single-payer system is similar to our Medicare and, in fact, is called Medicare. All of the programs are funded by tax revenue, although in the case of the Netherlands financing, is via community-rated premiums and payroll taxes.


My take on the state of the U.S. healthcare system

The U.S. has the most expensive, inequitable healthcare system with the poorest health outcomes of 11 high-income countries—all of which provide universal coverage for populations. The Affordable Care Act was starting to make a dent in some of these issues but is now in danger of being ripped away from people who depend on it with no serious plan for how to replace it. Healthcare is not a luxury item that only rich people should have. When people get sick and cannot get care, they are often unable to work and they may have to rely on public programs to provide even the most minimal of support to survive. It is just plain short-sighted to continue to allow people in this country to go without healthcare unless we have decided that people who can’t afford healthcare or health insurance should just get sick and die without care. But, we aren’t there…yet. Instead, we look the other way while people fall ill and can’t access healthcare until they are so sick that they need expensive emergency room visits or hospitalizations. When this happens, we all pay the price. It is just plain bad business for the country and it is also inhumane.

President Trump, Leader McConnell, Speaker Ryan, and Secretary Price, I have to wonder what’s going on in your heads to make choices that not only do not make American great again, but take us on a path that looks a lot like that taken in underdeveloped countries around the world.


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