US ranks last among 7 countries on health system performance

June 23, 2010

Despite having the most expensive health care system, the United States ranks last overall compared to six other industrialized countries—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—on measures of health system performance in five areas: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives, according to a new Commonwealth Fund report. While there is room for improvement in every country, the U.S. stands out for not getting good value for its health care dollars, ranking last despite spending $7,290 per capita on health care in 2007 compared to the $3,837 spent per capita in the Netherlands, which ranked first overall.

Provisions in the Affordable Care Act that could extend to 32 million uninsured Americans have the potential to promote improvements to the United States' standing when it comes to access to care and equity, according to Mirror Mirror On The Wall: How the Performance of the U.S. Compares Internationally 2010 Update, by Commonwealth Fund researchers Karen Davis, Cathy Schoen, and Kristof Stremikis. The United States' low marks in the quality and efficiency dimensions demonstrate the need to quickly implement provisions in the new law and stimulus legislation that focus on realigning incentives to reward higher quality and greater value, investment in preventive care, and expanding the use of .

"It is disappointing, but not surprising that, despite our significant investment in health care, the U.S. continues to lag behind other countries," said Commonwealth Fund President and lead author Karen Davis. "With enactment of the Affordable Care Act, however, we have entered a new era in American health care. We will begin strengthening primary care and investing in health information technology and quality improvement, ensuring that all Americans can obtain access to high quality, efficient health care."

Earlier editions of the report, produced in 2004, 2006, and 2007, showed similar results. This year's version incorporates data from patient and physician surveys conducted in seven countries in 2007, 2008, and 2009.

Key findings include:

On measures of quality the United States ranked 6th out of 7 countries. On two of four measures of quality—effective care and patient-centered care—the U.S. ranks in the middle (4th out of 7 countries). However, the U.S. ranks last when it comes to providing safe care, and next to last on coordinated care. U.S. patients with chronic conditions are the most likely to report being given the wrong medication or the wrong dose of their medication, and experiencing delays in being notified about an abnormal test result.

On measures of efficiency, the U.S ranked last due to low marks when it comes to spending on administrative costs, use of information technology, re-hospitalization, and duplicative medical testing. Nineteen percent of U.S. adults with chronic conditions reported they visited an emergency department for a condition that could have been treated by a regular doctor, had one been available, more than three times the rate of patients in Germany or the Netherlands (6%).

On measures of access to care, people in the U.S. have the hardest time affording the health care they need—with the U.S. ranking last on every measure of cost-related access problems. For example, 54 percent of adults with chronic conditions reported problems getting a recommended test, treatment or follow-up care because of cost. In the Netherlands, which ranked first on this measure, only 7 percent of adults with chronic conditions reported this problem.

On measures of healthy lives, the U.S. does poorly, ranking last when it comes to infant mortality and deaths before age 75 that were potentially preventable with timely access to effective health care, and second to last on healthy life expectancy at age 60.

On measures of equity, the U.S. ranks last. Among adults with chronic conditions almost half (45%) with below average incomes in the U.S. reported they went without needed care in the past year because of costs, compared with just 4 percent in the Netherlands. Lower-income U.S. adults with chronic conditions were significantly more likely than those in the six other countries surveyed to report not going to the doctor when they're sick, not filling a prescription, or not getting recommended follow-up care because of costs.


Data are drawn from the Commonwealth Fund 2007 International Health Policy Survey, conducted by telephone in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States; the 2008 International Health Policy Survey of Sicker Adults, conducted in the same seven countries plus France; the Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians, conducted in the same eight countries plus Italy, Norway, and Sweden; the Organization for Economic Cooperation and Development Health Data 2009; and World Health Organization mortality and population statistics for 2002-03. The 2007 Commonwealth Fund survey focuses on the primary care experiences of nationally representative samples of adults ages 18 and older in the seven countries. The 2008 survey targets a representative sample of "sicker adults," defined as those who rated their health status as fair or poor, had a serious illness in the past two years, had been hospitalized for something other than a normal delivery, or had undergone major surgery in the past two years. The 2009 survey looks at the experiences of primary care physicians.

Explore further: US ranks last among other industrialized nations on preventable deaths

Related Stories

Recommended for you

How the finch changes its tune

August 3, 2015

Like top musicians, songbirds train from a young age to weed out errors and trim variability from their songs, ultimately becoming consistent and reliable performers. But as with human musicians, even the best are not machines. ...

Cow embryos reveal new type of chromosome chimera

May 27, 2016

I've often wondered what happens between the time an egg is fertilized and the time the ball of cells that it becomes nestles into the uterine lining. It's a period that we know very little about, a black box of developmental ...

Shaving time to test antidotes for nerve agents

February 29, 2016

Imagine you wanted to know how much energy it took to bike up a mountain, but couldn't finish the ride to the peak yourself. So, to get the total energy required, you and a team of friends strap energy meters to your bikes ...


Adjust slider to filter visible comments by rank

Display comments: newest first

not rated yet Jun 23, 2010
Welcome to rampant capitalism where no one cares about the sick except when it comes to taking their cash.
2.3 / 5 (4) Jun 23, 2010
Welcome to rampant capitalism where no one cares about the sick except when it comes to taking their cash.

It's hardly capitalism when the government is spending about 50% of every health care dollar. David Goldhill, CEO and author of "American Health Care Killed My Father" and a Democrat, wrote that seniors on Medicare now pay more out of pocket for their health care than they did before Medicare existed. That's how much government has messed up the free market in health care. If more people knew this, there would be more support to get government out of health care. You can read his article in the Atlantic, or see
not rated yet Jun 23, 2010
According to wikipedia the spending on health care in 2009 was 19% of the federal budget (not 50%)

(As an aside: Spending on military matters was 23%)
5 / 5 (2) Jun 23, 2010
The US spends about twice as much per capita on healthcare (or slightly but not significantly less if you adjust for higher GDP/capita in the US) as those "socialist" developed nations and yet consistently ranks below average in quality metrics.

There's a place for government run operations and there's a place for free enterprise. Categorically stating that only one approach is right in all cases is stupid. The evidence from all over the world is overwhelming for the healthcare to be fully government run. Evidence trumps ideology.

And if you have evidence that somewhere in the world a private healthcare system is putting the government-run one to shame, please present it. Not hand waving stories about the inefficient government and the liberal media, but actual case studies of successful sustainable private healthcare implementations somewhere in the world. I would love to change my mind since I am a dirty capitalist pig at heart :D
1 / 5 (1) Jun 23, 2010
Antialias is correct. According to it we should restrict defense spending in favor of more medical spending.
Oh, that pesky constitution that requires a defense against all enemies foreign and domestic.
Thank you for giving the source of the data. We would like to know the methods used to tease the data out.
One last sleve-tugging question. If American health care is so rotten then why do rich people from all over the world come here for treatment?
5 / 5 (3) Jun 23, 2010
The reason the rich people from all over the world come here is because the the high-end of healthcare in the US is very good. That says absolutely nothing about the healthcare for an average citizen. When the middle class people from all over the world come to the US for healthcare I will be much more impressed :)
not rated yet Jun 25, 2010
The high cost comes from the unrestrained ability of the public to sue doctors for millions, the doctor's main failing is that they are human and make occasional errors like everybody else. Thus doctors are paid twice as much as doctors in the other countries mentioned but take home less after their liability insurance is paid. Payouts are typically ten times what they are in Australia and malicious or trivial cases are summarily thrown out in Oz.

The other cost comes from the public's reluctance to see a doctor for minor ailments, thus more minor ailments end up as (expensive) major disease than in other countries.

Although Australian health costs only half that of the USA, every citizen is covered for life for doctor, hospital and specialist care (gov. pays 85%) and prescription medications are subsidised 100% above the first $25 or $5.50 for the disadvantaged (to a max of $500 per year, afterwhich they are subsidised 100%). Dental is not currently covered and the poor.

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.