Researchers compared the health-care systems of 11 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.
The research relies on 71 performance measures, based on surveys conducted in each country and administrative data from the Organization for Economic Cooperation and Development and the World Health Organization. The measures analyzed fell under five themes: access to care, the care process, administrative efficiency, equity and health-care outcomes.
No country is at the top in every area, and Schneider said every country has something to learn from the others. But Norway, the Netherlands and Australia were the top-performing countries overall.
The high performers stand apart from the United States in providing universal coverage and removing cost barriers, investing in primary care systems to reduce inequities, minimizing administrative burdens, and investing in social services among children and working-age adults, the Commonwealth Fund found.
The latter is particularly important for easing the burdens on health systems created by older populations, according to Schneider. “These sort of basic supports throughout younger age groups reduce, we think, the chronic disease burden that’s higher in the U.S.,” he said.
The Netherlands, for example, has a well-organized system of locally placed primary care doctors and nurses who provide care on a 24/7 basis, Schneider said, which helps prevent minor problems from turning into major ones.
The United States was rated last overall, researchers found, ranking “well below” the average of the other countries overall and “far below” Switzerland and Canada, the two countries ranked above it. In particular, the United States fell at the end of the pack on access to care, administrative efficiency, equity and health-care outcomes.
J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies, noted that the higher-ranking countries are more homogenous and less populated than the United States, and that they benefit from a stronger societal consensus around “the place that health occupies in the social compact.”
Morrison called the findings “a pretty stark indictment of the United States.”
The United States has consistently ranked last in the seven comparative reports the Commonwealth Fund has published since 2004, especially on what Schneider described as the related areas of health access and outcomes.
However, on care process — which measures things like preventive care and engagement with patients — the United States performed well in the latest iteration, coming in second place behind New Zealand. The United States has high rates of mammography screening and flu vaccination, for example, and a greater percentage of adults talk with their doctors about topics such as nutrition, smoking and alcohol abuse.
The data was collected before the pandemic or in its early months, so it does not reflect how the coronavirus has affected health systems. But it sheds light on the state of high-income countries’ health systems heading into the pandemic.
“One could predict, based on the inequities and the relatively weaker primary care, that we would be in a position to struggle in fighting the pandemic,” Schneider said of the United States.
The United States has the highest coronavirus death rate of the surveyed countries, after the United Kingdom.
For those who can afford it, the United States is known internationally for high-quality care. And its resources and capabilities in research and development of treatments made the United States a key player in the development of coronavirus vaccines.
Coronavirus vaccines are widely available and free for all Americans. But otherwise, many Americans don’t see the benefits of the health system. During the second half of 2019, shortly before the coronavirus reached the United States, 35.7 million people of all ages — or 11 percent of the U.S. population — lacked health insurance, according to data from the Centers for Disease Control and Prevention. And many insured Americans don’t have adequate coverage, Schneider said.
Spending on health care as a share of GDP had grown in all of the countries the Commonwealth Fund surveyed, even before the pandemic. But the increase in the United States has “greatly exceeded” those of other nations. The United States spent 16.8 percent of its GDP on health care in 2019; the next highest country on the list was Switzerland, at 11.3 percent of GDP. The lowest was New Zealand, which spent roughly 9 percent of its GDP on health care in 2019.
Meanwhile, health care in the United States is the least affordable.
Unlike other countries surveyed, the United States does not have universal health coverage. U.S. doctors are the most likely to face difficulty in getting medication or treatment for patients because of restrictions on insurance coverage, the report found.
“We have almost two health-care systems in America: one for people with means and insurance, and another one that falls short for people who are uninsured or don’t have adequate insurance coverage,” Schneider said.
To examine equity in health care, the study focused on income-related disparities. Australia, Germany and Switzerland have the most equitable systems, the research found, while the United States “consistently demonstrated the largest disparities between income groups” across indicators, apart from those related to preventive services and the safety of care.
Those inequities contribute to poor health outcomes among marginalized or lower-income groups, Schneider said. The United States ranked last on health-care outcomes among surveyed countries, with the highest infant mortality rate and lowest life expectancy at age 60. The U.S. rate of preventable mortality is more than double that of Switzerland, the highest-performing country in that category.
Health-care disparities fueled underlying conditions in populations with less access to care in the United States, making these populations more vulnerable to covid-19, the disease caused by the coronavirus. Americans are sicker on average than the populations of other high-income countries, according to the report.
Meanwhile, countries such as the United Kingdom — which has universal, and free, primary care coverage — were better able to tap into primary care networks during their coronavirus vaccination rollouts, Schneider said.
He said the findings demonstrate that the United States should invest more in primary care. The report also emphasizes the need to expand and strengthen insurance coverage, and to focus on “smarter spending.”
“It’s a wake-up call,” Morrison said.
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