New Health Rankings: Of 11 Nations, U.S. Is Dead Last

From The Commonwealth Fund.

According to a recent publication from the Commonwealth Fund, based on a broadly inclusive set of performance metrics, the U.S. health care system performance ranks last among 11 high-income countries.

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 2010, 2007, 2006, and 2014.

“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.”

The United States spends far more on health care than other high-income countries, with spending levels that rose continuously over the past three decades. Yet the U.S. population has poorer health than other countries. Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. In addition, as the baby boom population ages, more people in the U.S.—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on health care systems to respond.

Timely and accessible health care could mitigate many of these challenges, but the U.S. health care system falls short, failing to deliver indicated services reliably to all who could benefit. In particular, poor access to primary care has contributed to inadequate prevention and management of chronic diseases, delayed diagnoses, incomplete adherence to treatments, wasteful overuse of drugs and technologies, and coordination and safety problems.

This report uses recent data to compare health care system performance in the U.S. with that of 10 other high-income countries and considers the different approaches to health care organization and delivery that can contribute to top performance. We based our analysis on 72 indicators that measure performance in five domains important to policymakers, providers, patients, and the public: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes.

Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).

The United States ranks last in health care system performance among the 11 countries included in this study. The U.S. ranks last in Access, Equity, and Health Care Outcomes, and next to last in Administrative Efficiency, as reported by patients and providers. Only in Care Process does the U.S. perform better, ranking fifth among the 11 countries.


The United States ranks in the middle on Care Process (5th), with stronger performance on the subdomains of prevention, safety, and engagement. The U.S. performs slightly below the 11-country average in the coordination subdomain.

The U.S. tends to excel on measures that involve the doctor–patient relationship, performing relatively better on wellness counseling related to healthy behaviors, shared decision-making with primary care and specialist providers, chronic disease management, and end-of-life discussions.

The U.S. also performs above the 11-country average on preventive measures like mammography screening and older adult influenza immunization rates. However, the U.S. performs poorly on several coordination measures, including information flows between primary care providers and specialist and social service providers. The U.S. also lags other countries on avoidable hospital admissions.


Overall, the United States ranks last on Access. The U.S. has the poorest performance of all countries on the affordability subdomain, scoring much lower than even the second-to-last country, Switzerland. The U.S. ranks ninth on the subdomain of timeliness.


The United States ranks 10th on Administrative Efficiency. Compared to the other countries, more U.S. doctors reported problems related to coverage restrictions. Larger percentages of U.S. patients also reported Administrative Efficiency problems compared to those in other countries (except France).


The United Kingdom, the Netherlands, and Sweden rank highest on measures related to the equity of health systems with respect to access and care process.

In contrast, the United States, France, and Canada have larger disparities between lower and higher-income adults. These were especially large on measures related to financial barriers, such as skipping needed doctor visits or dental care, forgoing treatments or tests, and not filling prescriptions because of the cost.


The United States ranks last overall in Health Care Outcomes. However, the pattern of performance across different outcomes measures reveals nuances. Compared to the other countries, the U.S. performs relatively poorly on population health outcomes such as infant mortality and life expectancy at age 60. The U.S. has the highest rate of mortality amenable to health care and has experienced the smallest reduction in that measure during the past decade (Exhibit 4). In contrast, the U.S. appears to perform relatively well on 30-day in-hospital mortality after heart attack or stroke. The U.S. also performs as well as several top performers on breast cancer five-year relative survival rate and close to the 11-country average on colorectal cancer five-year relative survival rate.

Causes of Poor Performance

The country’s performance shortcomings cross several domains of care including Access, Administrative Efficiency, Equity, and Health Care Outcomes. Only within the domain of Care Process is U.S. performance close to the 11-country average. These results are troubling because the U.S. has the highest per capita health expenditures of any country and devotes a larger percentage of its GDP to health care than any other country.

The U.S. health care system is unique in several respects. Most striking: it is the only high-income country lacking universal health insurance coverage. The U.S. has taken an important step to expand coverage through the Affordable Care Act. As a 2017 Commonwealth Fund report showed, the ACA has catalyzed widespread and historic gains in access to care across the U.S. More than 20 million Americans gained insurance coverage. Additional actions could extend insurance coverage to those who lack it. Furthermore, Americans with coverage often face far higher deductibles and out-of-pocket costs than citizens of other countries, whose systems offer more financial protection. Incomplete and fragmented insurance coverage may account for the relatively poor performance of the U.S. on health care outcomes, affordability, administrative efficiency, and equity.

Several new U.S. federal initiatives—notably the Affordable Care Act—have promoted actions to improve U.S. health care system performance. In addition to extending insurance coverage to millions of Americans, recent legislation includes initiatives to spur innovation in health care delivery by changing payment incentives for providers. But health systems can be slow to change. Additional legislative and policy reforms may be needed to close the performance gap between the U.S. and other countries.

The U.S. could learn important lessons from other high-income countries. For example, the U.S. performs poorly in administrative efficiency mainly because of doctors and patients reporting wasting time on billing and insurance claims. Other countries that rely on private health insurers, like the Netherlands, minimize some of these problems by standardizing basic benefit packages, which can both reduce administrative burden for providers and ensure that patients face predictable copayments.

The U.K. stands out as a top performer in most categories except for health care outcomes, where it ranks with the U.S. near the bottom. In contrast to the U.S., over the past decade the U.K. saw a larger decline in mortality amenable to health care (i.e., a greater improvement in the measure) than the other countries studied. (The U.S. has had the smallest decline, or lowest level of improvement.) In the early 2000s, the U.K. made a major investment in its National Health Service, reforming primary care and cancer care in addition to increasing health care spending from 6.2 percent of GDP in 2000 to 9.9 percent of GDP in 2014. The reforms and increased spending may have contributed to the rapid decline in mortality amenable to health care in the U.K.

There is a striking contrast between the U.S’s poor performance on infant mortality, life expectancy, and amenable mortality and its relatively better performance on in-hospital mortality after heart attack or stroke. Researchers have noted that the only modest decline in the rate of amenable mortality in the U.S. may be attributable to better management, once diagnosed, of hypertension and cerebrovascular disease that lead to cardiovascular mortality. These findings highlight the combined impact of a lack of universal insurance coverage and barriers to accessing primary care, and suggest that the U.S. could make gains by investing more in preventing chronic disease. The high level of inequity in the U.S. health care system intensifies the problem. For the first time in decades, midlife mortality for less-educated Americans is rapidly increasing.

In conclusion, the performance of the U.S. health care system ranks last compared to other high-income countries. Despite spending nearly twice as much as several other countries, the country’s performance is lackluster. This report points to several areas that the U.S. could improve, building on recent health reforms, to achieve better performance. The success of U.S. initiatives to reduce readmissions and hospital-acquired conditions suggest the country’s health care can be improved. To gain more than incremental improvement, however, the U.S. may need to pursue different approaches to organizing and financing the delivery system. These could include strengthening primary care, supporting organizations that excel at care coordination and moving away from fee-for-service payment to other types of purchasing that create incentives to better coordinate care. These steps should ensure early diagnosis and treatment, improve the affordability of care, and ultimately improve the health of all Americans.

January 12, 2018. 

Editor: Although the publication date of this article may not be current, the information is still valid.


U.S. health system is still lagging behind other countries

By Rabah Kamal and Cynthia Cox,  Kaiser Family Foundation.

The Peterson-Kaiser Health System Tracker is launching a new Health System Dashboard that will track U.S. health system performance over time across four domains: health spending, quality of care, access and affordability, and health and wellbeing. The dashboard examines trends in the U.S. health system, compares the U.S. to a group of other large and wealthy countries (“comparable counties”), and also highlights differences and disparities across demographic groups. Data in this dashboard come from a variety of sources, analyzed by Kaiser Family Foundation experts, and the tool will be updated continuously as new information becomes available.

In this post we take a step back to look at the bigger picture of what these data tell us about how well the health system is working. We find signs that the U.S. health system is improving in its ability to promote health and provide high-quality care, with some recent improvement in the accessibility of that care and a slowing of spending growth. However, the U.S. health system is not always keeping pace with similar countries, with gaps in health outcomes widening in a number of areas.

Below is a sample of findings across 10 key indicators of health system performance, with more details on each of these indicators in the dashboard (which tracks more than 50 indicators over time).

  1. Life expectancy at birth has improved over the past decades, rising by more than 5 years since 1980. However, comparable countries have an average life expectancy of 82 years – 3 years longer than the U.S. life expectancy of 79 years – and the gap is growing.
  2. Disease burden, a measure that accounts for both longevity and quality of life, has improved significantly over the past quarter century, dropping 16% between 1990 to 2015, with particular improvement seen for circulatory diseases. Disease burden rates are 25% higher in the U.S. than comparable countries on average, and the gap has widened slightly.
  3. The rate of hospital-acquired conditions (such as adverse drug events or surgical infections) has improved, declining an estimated 21 percent from 2010 to 2015. This suggests that patient safety may have improved.
  4. Thirty-day mortality following hospital admission improved in recent years for heart attack and stroke (decreasing 8% and 4%, respectively) but worsened for heart failure (increasing 6%) from 2009 – 2015. While not all deaths are preventable, lower rates of death shortly following a hospital stay may suggest care has improved. Relative to comparable countries, 30-day mortality is lower in the U.S. following hospital admissions for heart attack and stroke.
  5. The rate of potentially preventable hospital admissions has improved, decreasing 23% from 2005 to 2013. Relative to comparable countries, admission rates are higher in the U.S. than in comparable countries for several diseases that could possibly be prevented, like congestive heart failure (68% higher), asthma (194%), and diabetes (38%) – though admission rates for hypertension are lower (by 24%) in the U.S relative to the average of comparable countries.
  6. Due to recent gains in health coverage as a result of the Affordable Care Act, the uninsured rate among the nonelderly dropped from 18% in 2010 to 10% in 2016. Even with 91% of the total U.S. population now insured, coverage lags behind comparable countries, all of which provide essentially universal coverage.
  7. Fewer adults are reporting problems paying medical bills. From 2011 to 2016, there was a 10% drop in the percent of adults reporting being worried about their ability to pay medical bills.
  8. The share of Americans delaying or foregoing needed care due to costs improved, dropping from 13% in 2009 to 9% in 2015. The rates of delayed or forgone medical care for people in worse health reached an all-time low (18%) in 2015.
  9. Health spendingper person has grown steadily from $355 per capita in 1970 to $9,990 in 2015. More recently, from 2010 to 2015, per capita spending grew an average of 3.6% per year. Over the past five years, health spending in the U.S. has even grown more slowly than in comparable countries. On average, other wealthy countries spend about half as much per person on health than the U.S.
  10. Health spending continues to grow faster than the economy, but the difference has moderated in recent years. U.S. healthcare spending accounted for 17.8% of GDP in 2015 – much more than comparable countries, where health spending averages 10.8% of GDP.

Although there is general improvement across many indicators, there are often disparities across racial or ethnic groups, genders, and income levels. Where possible, the dashboard data are broken out across demographic groups to highlight these disparities.

May 19, 2017


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