Despite High Spend, US Ranks Lowest on Access to Care, Health Equity

The United States ranked last in The Commonwealth Fund’s reported measurements of health equity, access to care, administrative efficiency, and healthcare outcomes compared to ten other wealthy nations. 

This year’s edition of The Commonwealth Fund’s annual “Mirror, Mirror” report assessed 11 similarly wealthy countries and compared 71 performance measures of healthcare systems across five domains. The US ranked last in all except care process, where it ranked second.

The US achieved poor results in all but one category, despite the fact that it still spends more of its gross domestic product (GDP) on healthcare than any other nation.

Norway, the Netherlands, and Australia were the top-performing countries overall, followed by the UK, Germany, New Zealand, Sweden, France, Switzerland, Canada, and the US.

Lack of access to care continues to plague the US healthcare system. The access to care domain was measured through the lens of affordability and timeliness. Measures of affordability included patient reports of avoiding medical care because of cost, having exorbitant out-of-pocket expenses, struggling to pay medical bills, and facing insurance issues.

The US lagged far behind the next-lowest performer, Switzerland, in terms of affordability. Patients from top-performing countries were far less likely to report struggling with medical bills or getting insurance claims denied.

In the timeliness domain, researchers measured how quickly patients can obtain medical information, urgent care, physician appointments, and mental health services. The US ranked ninth overall for timeliness.

Health equity was evaluated based on income-related disparities. Australia, Germany, and Switzerland ranked highest, meaning that they had fewer income-related disparities and financial barriers to care.

Meanwhile, the US had the lowest health equity rankings, an area that has been in the spotlight recently since COVID-19 exposed stark care disparities.

“U.S. disparities are especially large when looking at financial barriers to accessing medical and dental care, medical bill burdens, difficulty obtaining after-hours care, and use of web portals to facilitate patient engagement,” the report stated.

“Compared to the other countries, the United States and Canada had larger income-related inequities in patient-reported experiences.”

The healthcare outcomes domain was split into three subdomains: population health outcomes, mortality amenable to healthcare, and condition-specific health outcomes. Norway had the lowest infant mortality rate, while Australia had the highest life expectancy after age 60.

By comparison, the US had the highest infant mortality rate and lowest life expectancy after age 60. US preventable mortality rates were more than double those of Switzerland, the highest performing country.

US doctors struggled the most with administrative efficiency, likely due to insurance restrictions and obstacles to getting patient medication. US adults also reported spending more time on paperwork relating to medical bills. Both US and Canadian adults frequented the emergency department at higher rates than other nations, which is known to be a less efficient care option.

The US only performed favorably in the care process domain. Researchers attributed the success to satisfactory preventive care and patient engagement.

“Among people with chronic illness, U.S. adults are among the most likely to discuss goals, priorities, and treatment options with their provider, though less likely to receive as much support from health professionals as they felt was needed,” the report explained.

The results revealed troubling trends in the US healthcare system that have exacerbated inequality and put the country behind its peers.

The Commonwealth Fund made the following four observations that separate top-performing countries from the United States:

• They provide for universal coverage and remove cost barriers
• They invest in primary care systems to ensure that high-value services are equitably available in all communities to all people
• They reduce administrative burdens that divert time, efforts, and spending from health improvement efforts
• They invest in social services, especially for children and working-age adults

If the US uses its abundant resources and applies similar strategies to its own healthcare system, the healthcare sector could be equitable and accessible for everyone, The Commonwealth Fund concluded.