NEW YORK - Your level of income defines the health care you receive far more in the United States than in other wealthy nations, according to the Commonwealth Fund’s new 11-country report. The study, the only to include survey data to measure and compare patient and physician experiences across wealthy nations, ranks the U.S. last overall, and on providing equally accessible and high-quality health care, regardless of a person’s income. For example, in the United Kingdom, 7 percent of people with lower incomes and 4 percent with higher incomes reported that costs prevented them from getting needed health care—a three percentage point gap between those with higher and lower incomes. In the U.S., 44 percent of lower income and 26 percent of higher income people reported financial barriers to care. Remarkably, a high-income person in the U.S. was more likely to report financial barriers than a low-income person in the U.K.

“What this report tells us is that despite the substantial gains in coverage and access to care due to the Affordable Care Act, our health care system is still not working as well as it could for Americans, and it works especially poorly for those with middle or lower incomes,” said Commonwealth Fund President David Blumenthal, M.D. “The health care policies currently being contemplated in Congress would certainly exacerbate these challenges as millions would lose access to health insurance and affordable health care.”

In the report, Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, the authors note that although the U.S. has made significant progress, our health system substantially lags other countries—especially when it comes to access to care, primary care, affordability, and equity. Among the 11 high-income countries surveyed, the U.S. is the only one without universal health insurance coverage. The U.S. offers its citizens the least financial protection among these wealthy countries.

Paying More for Less

Despite having the most expensive health care, the United States ranks last overall among the 11 countries on measures of health system equity, access, administrative efficiency, care delivery, and health care outcomes. While there is room for improvement in every country, the U.S. has the highest costs and lowest overall performance of the nations in the study, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The U.S. spent $9,364 per person on health care in 2016, compared to $4,094 in the U.K., which ranked first on performance overall.

Since 2004, the U.S. has ranked last in every one of six similar reports. This year, the study added new measures and refined the scoring giving each country an overall score as well as a score on five distinct areas of performance. The new approach highlights how the 11 countries cluster at different levels of performance: the U.K., Australia, and the Netherlands were the top performers, while New Zealand, Norway, Switzerland, Sweden, and Germany were in the middle of the pack. Canada and France were near the bottom, though both still performed better than the U.S.

In a New England Journal of Medicine Perspective to be published at 9:00 am on July 14th, lead author and Commonwealth Fund senior vice president for policy and research Eric Schneider, M.D. reflects on lessons from top performing countries and actions the U.S. could take to move from last to first among wealthy countries. They include:

• Expand health insurance coverage. The highest-performing countries have universal coverage that allows people to get the health care they need at little or no cost.
• Invest more in primary care. Spending up front to make primary care accessible, available on nights and weekends, and affordable keeps people healthier and reduces costs in the long run.
• Cut down on paperwork. The U.S. leads the world when it comes to time spent dealing with the requirements of our cumbersome health insurance system. Reducing the administrative burden would give countless hours back to patients, caregivers, and physicians while also making the system easier for people to navigate.
• Invest more in social services to reduce disparities. Factors beyond traditional health care, such as housing, education, nutrition, and transportation, have a substantial effect on people’s health. Investing in services that provide support in these areas can make our population healthier as a whole and reduce health care costs.

“Far too many people in the U.S. can’t afford the care they need, and far too many are uninsured, especially compared to other wealthy nations,” said Schneider. “If we are going to be the best, we have to do better for patients. We are not the U.K., Australia, or the Netherlands and we don’t have to be. Each of those countries follows a different path to top performance. A country that spends as much as we do could be the best in the world. We can adapt what works in other countries and build on our own strengths to achieve a health care system that provides affordable, high-quality health care for everyone.”

Additional report findings related to the U.S. include:

Access to Care: Other studies show that access to care and ability to afford care have improved markedly in the U.S. following the Affordable Care Act. Nevertheless, compared to other countries, Americans of all incomes have the hardest time affording the health care they need. The U.S. ranks last on most measures of financial barriers to care, with one-third (33%) of adults reporting they did not take a prescription drug, visit a doctor when sick, or receive recommended care in the past year because of the expense. This is four times the rates for patients in Germany (7%), the U.K. (7%), Sweden (8%), and the Netherlands (8%).

Health Care Outcomes: The U.S. ranks last overall on health care outcomes. Compared to other countries, the U.S. comes in last on infant mortality, life expectancy at age 60, and deaths that were potentially preventable with timely access to effective health care. However, there are some bright spots: the U.S. performs relatively well on certain clinical outcomes, such as lower in-hospital mortality rates for a heart attack or stroke, and is a top performer in breast cancer survival.

Care Process: The U.S. ranks in the middle for care process, which is a combination of four separate measures: delivery of preventive services, safety of care, coordinated care, and patient engagement. On three of the four measures, the U.S. ranks near the top, coming in third on safety and fourth on prevention and engagement. The U.S. tends to excel on measures that involve the doctor–patient relationship, wellness counseling, and preventive care, such as mammograms and adult flu shot rates.

Administrative Efficiency: The U.S ranks near the bottom on this measure because of the amount of time providers and patients must spend dealing with administrative issues, duplicative medical testing, and insurance disputes. More than half (54%) of U.S. doctors reported problems trying to get their patients needed treatment because of insurance coverage restrictions. In Norway and Sweden, which rank first on this measure, only 6 percent of doctors reported this problem.