Once again, the US trails rich countries in health care -- except in cost! Why do we tolerate it?

Sometimes the news is good, sometimes it is bad (too much of the latter!!). Sometimes it is surprising, and sometimes it is not. Often it is more of the same, and sometimes this is surprising because we had thought or hoped that it had changed, preferably for the better, and sometimes it is not surprising because we knew it had not.

A good example of this is international health rankings, in which the US consistently and continually ranks at the bottom of the wealthy nations and has a health status that is in the middle of what are known as “middle income countries”. These are called middle-income because they are better off than the really poor countries, but compared to the US and similar countries, they are poor.  In 2000, the World Health Organization (WHO) published a ranking of health system performance in their member nations, based on 1997 data, in which the US ranked #37 in the world, between Costa Rica and Slovenia, on overall performance. When many were aghast that the US could be like Slovenia, the prime minister of that nation took offense and pointed out that his country had been making significant advances. In the area of Disability Adjusted Life Expectancy (DALE) the US in fact ranked #72! I had reproduced these tables in  US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017, and do so again now.

Of course, 1997 is a long time ago. Maybe, since then, we, like Slovenia, have gotten better. Except we haven’t. This is the sadly non-surprising part of the news.

While the WHO has not redone that 2000 survey, in 2017 Bloomberg published its Global Health Index, and, as I said then,

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

For an ongoing comparison, the Commonwealth Fund publishes a report every few years called “Mirror, Mirror on the Wall” comparing US health outcomes and cost to other high-income countries. I have cited it, in its various editions, on many occasions (Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost, June 26, 2010, ACA: Where are we? And where should we go?, July 27, 2014, US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017, Our health system: Not equitable, not effective, and not even efficient. Bad business!, March 24, 2022), and address it in detail in my 2015 book “Health, Medicine and Justice: Designing a fair and equitable health system” (Copernicus). The relative performance and ranking of the other countries varies a bit over the years, but the position of the US at the bottom of the heap, #1 only (and consistently) in cost, and worst in performance, is unchanging. The most recent report, “Mirror, Mirror 2024: A portrait of a failing US health system” has just come out, and the title provides the answer: not good. Not better. Failing. And, probably, failing worse. The study’s conclusion, in the Summary, is:

The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.

Here is the table of rankings:

And, if you prefer a visual portrayal about how much worse the US health system is performing:

But we do lead in spending:

And, logically, trail the pack by a lot in value for dollar spent:

This is the non-surprising non-news. But, while not surprising, it should be very concerning. It’s not getting better, and there is little reason to think that it will, if past performance is a predictor of future performance. And we’re talking more than two decades of consistent past performance. It is not a question of what the fact are, of what is true, no longer if it ever was. The US health system performs terribly as a health (or even medical care) system. Costs are enormously high, outcomes are consistently poor, and we dramatically underperform every other country that has in any way comparable resources (and many, many with far fewer resources). It is incredibly inequitable. See, for example, some of the countries grouped around the US in the 2017 Bloomberg rankings, such as Qatar, Brunei, and Bahrain – countries with money and inequitable distribution. So, the question is why are we not doing anything about it?

The answer simply requires a little re-framing of the data presented above. I, and likely you, see the incredible cost/performance ratio as a negative, something to be addressed and fixed. But all that money that is being spent is going somewhere, and certainly a large amount of it is not going to provide high-quality healthcare. It is going to profits for insurance companies and pharmaceutical companies and the Wall St. investors that own them, and for enormous salaries for the C-suite executives who run them, as well as those in the ostensibly non-profit sector (see Why many nonprofit (wink, wink) hospitals are rolling in money by Elisabeth Rosenthal (Washington Post, July 29, 2024). For them the current system is working very well, thank you, they are getting very rich. Your problem, and mine, is that we think that this system should be about providing high-quality and cost-effective care for the American people, at which it is obviously failing. But if we understand it as a cash-cow for these corporations, as a method for transferring money from the rest of the economy to them, it is working great. And, because it is working so well and they are making so much money and spending a great deal of it contributing to politicians, it is unlikely to change.

Unless YOU make it change.  There is, and has been for decades, a loud and effective rant from the corporations and individuals profiting from your health care dollars and their employees (or shall we say “beneficiaries of their largess”) in the legislative, think tank, and punditry arenas, that the Democratic party, and particularly its progressive wing, are radical socialists who are anti-American. This has been very successful. See above, we have kept to the unique American way of doing things. The one that takes money from you in premiums, co-pays, and deductibles and provides you with poor outcomes. That every other wealthy capitalist country has found a way of delivering higher quality for less money is the evidence that it is possible and will not destroy the country. But it will destroy the conveyor belt that takes your money and puts it into their pockets, and this is a terrifying thought, so that they will do anything to prevent it.

Their tactics include both painting mainstream Democrats who merely want to tinker around the edges of the system as flaming radicals, and funding organizations such as the Heritage Foundation to come up with truly radical proposals like Project 2025 (pdf of the health section here) that would institutionalize the worst, most anti-human practices going on today. The strategy is that if they can get half the country to support politicians who support those policies (whether those voters actually support those policies or not), it moves the center of the discussion to the “right” and means compromise will be much less threatening to them. But much more threatening to you.

People want good healthcare for themselves, for their families, and for their friends. They don’t want to pay ever-more for health insurance only to have the insurers deny their care, often as a matter of routine, when they need it. They deserve, as do the people of other countries, a health system that is intrinsically structured to provide the best possible health care for our people and not to make money for Wall St., big corporations, insurance companies and health systems. We know it can be done as it has been done everywhere else.

Make it the thing you vote for and let your representatives know it; you want health care, as the old saying goes, for people and not for profit!

Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost

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On December 5, 2008, I commented on the data from the 2008 Commonwealth Fund report comparing health status in a number of countries (Not Getting What We Pay For). The US fared very poorly on that study. The Commonwealth Fund has just released its 2010 study “Mirror, Mirror on the Wall” (Commonwealth Fund executive summary, Commonwealth Fund full report) and the news is no better. In comparing 7 industrialized countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), the US is #1 in health expenditures per capita at $7,290, 87% higher than second-place Canada, over twice that of the average of the other 6 ($3354) and nearly 2.5 times as much as the UK. [“Expenditures shown in $US PPP (purchasing power parity)”.].

Distressingly, but unsurprisingly to those who pay any attention to the area, including having read this blog or having seen the 2006 or 2008 Commonwealth Fund reports, this expenditure does not lead to good performance on the study’s measures of Quality Care (comprised of Effective Care, Safe Care, Coordinated Care, and Patient-Centered Care), Access (comprised of Cost-related Problems and Timeliness of Care), Efficiency, and Equity, nor on the all-important health outcome “Long, Healthy, Productive Lives”. In fact, the US ranks last -- # 7 – on that outcome indicator. And while there is not one country that leads in all the categories – Australia, for example, ranks #3 overall, but is #1 in “Long, Healthy, Productive Lives”, and is tied with the US for last in “Access”; the UK, while #6 on “Long, Healthy, Productive Lives”, is #2 overall (behind the Netherlands) despite spending the 2nd lowest amount (to New Zealand’s lowest) per capita, and ranks #1 or #2 on 6 of 10 criteria, and #7 on only Patient-centered care.

The US ranks very poorly, as it did in 2008, on Efficiency, which is interesting. We can more easily understand low rankings in Access and Equity, given our completely inequitable system of funding and access, but poor Efficiency scores reflect our poor communication, with tests often being repeated because information is not carried forward, patients being readmitted, and a variety of other characteristics. There are 8 subcategories comprising Efficiency, and the US ranks #6 on 4 and #7 on 4 (and for the whole category).

Of course, this kind of report doesn’t seem to affect policy makers too much. We already knew this, and the health reform process was in part an attempt to address it, but the current bill, PPACA, certainly doesn’t do enough. Some of the additional funding that is targeted to public health will make a difference, but it is clear from the debate in Congress that there are many who simply do not support improving the health of the American people if doing so will require cuts to the profits of the big healthcare industries who contribute large sums to them.

Some critics of the Commonwealth Fund report, such as Dr. Richard Cooper of the University of Pennsylvania, have stated that the problem in the US is not that that we have a health system which is overbuilt on the high-tech, high-cost specialty end rather than on primary care, but rather that we have more poor people; he provides evidence that, on a large regional basis, areas of the country with more poor people (e.g., the Southeast) have worse health status than those with fewer poor people (e.g., the upper Midwest). There can be no doubt that poor health status is tied to low socioeconomic status, and that the large number of poor in the US is in significant part responsible for the poor health system performance identified by the Commonwealth report and others. However, as I and many others have pointed out in the past (Public Health and Changing People's Minds, May 15,2010; Poverty, Primary Care and the Cost of Medical Care, Feb 18, 2010; Health is more than Medical Care, Jan 27, 2010), health is not simply a result of the health care, or medical care, system. The other countries measured in the Commonwealth Fund report do not have a lower percentage of poor people by chance or luck; they are, to greater or lesser extents, social democracies with policies that ensure that their people have housing, food, and education. There are poor people in those countries, but their most basic needs are ensured and this goes a very long way to decreasing their health risk. Public health, medical professionals and others in those countries are well aware – expert in – the social and socioeconomic needs of the poor in their societies, but the situation of those people, is significantly improved, to a much greater degree than in the US by a much more extensive safety net.

Poverty is bad for your health, and programs that help ameliorate the impact of poverty improve the health of populations. In addition, the presence of adequate health care services, especially primary care services, further enhances outcomes. It is not an either/or choice. Shi and colleagues demonstrated that the increased infant mortality and low birthweight rates in poor communities are virtually eliminated by a higher primary care presence.[1]

The data provided by the Commonwealth Fund should be embarrassing to every policy maker, every person of influence, and every citizen of the US. It is incontrovertible data that demonstrates yet once again that the issue is not that we aren’t spending enough money, but is the way that the money is spent: We spend it in ways that make our health status poor and our health corporations wealthy. There should be no tension between increasing primary care, increasing public health and prevention, and providing the core needs of people for food, housing, education, and work. They are all components of a society that is not only basically decent, but which is concerned about its future, the health of its people, and its workforce. What we clearly do not need, however, is to continue to spend money in the way that we are on high-tech subspecialty care that benefits few patients and often not for very long. Indeed we need to spend much less, and use the money where it will have a positive impact.

Maybe by 2012 the Commonwealth Fund will show the US making some progress. I hope so, but it is going to take some serious structural changes.

[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380.