The United States has the worst-performing health system among all high-income countries. Even the best-performing U.S. states lag international comparators like France, Germany, the United Kingdom, and Australia. To move the United States from laggard to leader will require significant — but doable — changes in its healthcare system, including closing remaining gaps in insurance coverage, limiting debilitating out-of-pocket-expenditures, and reviving its failing primary care capabilities.
These are the conclusions of a comprehensive study from the Commonwealth Fund that compared the U.S. healthcare system to nine other nations: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom. Based on 70 performance measures across five domains — access to care, health outcomes, administrative efficiency, care process, and equity — the United States came in last overall and last or next to last in four of these five broad areas of performance. This is despite the fact that America spends far more per capita than other high-income countries.
But is comparison at the national level unfair? After all, the United States is more populous than these comparators and bigger geographically than all but Australia and Canada. (While Brazil, India, China, and Russia may seem more comparable in size and population to the United States, their wealth, measured in GDP per capita, comes nowhere near the United States.)
To address this issue, we also sought to compare healthcare outcomes in individual American states to the nine other countries in the Commonwealth Fund analysis. Comparable data on U.S. states and the nine comparator nations are limited but do exist for two key measures: life expectancy at birth and avoidable mortality, which is defined by the Organization for Economic Cooperation and Development (OECD) as deaths that could have been avoided through effective public health interventions or timely, high-quality medical care. Avoidable mortality captures deaths from many chronic conditions like heart disease, cerebrovascular disease, kidney failure, diabetes, and hypertension.
In 2021 (the most recent comparable data), life expectancies in the five U.S. states that performed best on this measure ranged from 79.9 years in Hawaii to 79 in New York. The shortest life expectancy among the nine high-income countries in the Commonwealth Fund analysis was 80.4 in the United Kingdom. In other words, no individual U.S. state matched the life expectancy of similarly sized, high-income political entities around the world.
With respect to avoidable mortality, the picture is only slightly better. Eight of the nine nations in the Commonwealth Fund study performed better than any U.S. state. Germany’s avoidable mortality was slightly worse than that of Hawaii, Massachusetts, New Jersey, and Connecticut but still better than 46 of the 50 U.S. states.
Why can’t even the best U.S. states outperform most high-income countries that spend far less per capita on health services? One answer is that the best-performing U.S. states suffer from the same problems as the U.S. as a whole, just less so. The problems start with insurance coverage. Health insurance is a well-documented determinant of health status because it provides access to care that prevents avoidable deaths. All high-income countries other than the United States cover all their residents. The best-performing American states in terms of life expectancy have uninsured rates of 3% to 6% compared to about 8% for the country as a whole. But 3% to 6% is not universal coverage.
Another problem is quality of coverage. In the United States, high coinsurance and deductibles deter many insured Americans from getting needed care and result in high out-of-pocket spending. High-performing U.S. states tend to have lower out-of-pocket spending than the U.S. average of 7.3% of income, but these numbers can still be as high as 3.4% of median state income in Minnesota ($3,195 in 2022), one of the high-performing U.S. states. In contrast, most other high-income countries place tighter limits on out-of-pocket spending. The Netherlands caps it at 385 euros ($417) a year. Germany caps out-of-pocket spending at 2% of family income and 1% for individuals with chronic illness. In the United Kingdom, care is free at the point of service.
A third problem is a lack of primary care in the United States. One proxy for access to primary care is whether respondents in surveys say they have a regular source of care. Eighty-seven percent of Americans say they do, compared to 90% or more in most other high-income countries. In high-performing U.S. states, the proportion is better than the U.S. average though still well below rates in comparator countries.
Of course, there is more at work than just healthcare services in dragging down U.S. healthcare performance. Poverty, homelessness, food insecurity, gun violence, and socioeconomic inequality in the United States all make it harder for the U.S. healthcare system to compete with other high-income countries.
Nevertheless, improving some critical aspects of the U.S. healthcare system is necessary, if not sufficient, to boost America’s healthcare performance. Continuing to reduce the number of uninsured and increasing the generosity of coverage could help, as would increasing the supply of primary care clinicians by raising their compensation and reducing their administrative burdens. Eliminating patient copayments for primary care would also encourage better management of the chronic illnesses that result in avoidable mortality.
Given its collective wealth, technologic sophistication, and spending, the United States should lead, not lag, the world in its healthcare performance. Its health system holds it back.