Mirror, Mirror 2021: Reflecting Poorly

Abstract

• Issue: No two countries are alike when it comes to organizing and delivering health care for their people, creating an opportunity to learn about alternative approaches.
• Goal: To compare the performance of health care systems of 11 high-income countries.
• Methods: Analysis of 71 performance measures across five domains — access to care, care process, administrative efficiency, equity, and health care outcomes — drawn from Commonwealth Fund international surveys conducted in each country and administrative data from the Organisation for Economic Co-operation and Development and the World Health Organization.
• Key Findings: The top-performing countries overall are Norway, the Netherlands, and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.
• Conclusion: Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.

Introduction

No two nations are alike when it comes to health care. Over time, each country has settled on a unique mix of policies, service delivery systems, and financing models that work within its resource constraints. Even among high-income nations that have the option to spend more on health care, approaches often vary substantially. These choices affect health system performance in terms of access to care, patients’ experiences with health care, and people’s health outcomes. In this report, we compare the health systems of 11 high-income countries as a means to generate insights about the policies and practices that are associated with superior performance.

With the COVID-19 pandemic imposing an unprecedented stress test on the health care and public health systems of all nations, such a comparison is especially germane. Success in controlling and preventing infection and disease has varied greatly. The same is true of countries’ ability to address the challenges that the pandemic has presented to the workforce, operations, and financial stability of the organizations delivering care. And while the comparisons we draw are based on data collected prior to the pandemic or during the earliest months of the crisis, the prepandemic strengths and weaknesses of each country’s preexisting arrangements for health care and public health have undoubtedly been shaping its experience throughout the crisis.

For our assessment of health care system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States, we used indicators available across five domains:

• Access to care
• Care process
• Administrative efficiency
• Equity
• Health care outcomes.

For more information on these performance domains and their component measures, see How We Measured Performance. Most of the data were drawn from surveys examining how members of the public and primary care physicians experience health care in their respective countries. These Commonwealth Fund surveys were conducted by SSRS in collaboration with partner organizations in the 10 other countries. Additional data were drawn from the Organisation for Economic Co-operation and Development (OECD) and the World Health Organization (WHO).

How the 11 Countries Rank on Performance

The top-performing countries overall are Norway, the Netherlands, and Australia (Exhibit 1).

The next three countries in the ranking — the U.K., Germany, and New Zealand — perform very similarly to one another (Exhibit 2). The U.S. ranks #11 — last. Exhibit 2 shows the extent to which the U.S. is an outlier: its performance falls well below the average of the other countries and far below the two countries ranked directly above it, Switzerland and Canada. In fact, the U.S. is such an outlier that we have calculated the average performance based on the other 10 countries, excluding the U.S. (see How We Measured Performance). The U.S. is last on all domains of performance except care process, on which it ranks #2.

Exhibit 3 shows that while spending as a share of gross domestic product (GDP) has increased in all countries, spending growth in the U.S. — by far the worst performer overall — has greatly exceeded growth in the other 10 nations. In 1980, high-income countries spent between 5 percent and 8 percent of GDP on health care. But as U.S. spending accelerated over the decades, the U.S. was spending a substantially larger share of its GDP on health care by 2019 than every other high-income country.

Exhibit 4 starkly shows just how much the U.S. is an outlier from the other nations when its performance as a health care system is compared to its spending as a share of GDP.

Access to Care: Universal, Affordable Coverage Is Paramount

Access to care includes measures of health care’s affordability and timeliness. The Netherlands performs best on this performance domain among the 11 countries, ranking at or near the top in both subdomains. Norway and Germany also performed well on access to care (Exhibit 1), but all three are outranked on affordability by the U.K. (Exhibit 5).

Overall, the U.S. is #11 — last — on access to care (Exhibit 1). The U.S. has the poorest performance on the affordability subdomain, scoring much lower than even the next-lowest country, Switzerland (Exhibit 5). Compared to residents of the U.S., residents of the Netherlands, the U.K., Norway, and Germany are much less likely to report that their insurance denied payment of a claim or paid less than expected. Residents of these countries are also less likely to report difficulty in paying medical bills (Appendix 4).

People in the countries performing the best on the timeliness subdomain are more likely to be able to get same-day care and after-hours care. The U.S. ranked #9 on timeliness.

Care Process: The U.S. Compares Favorably on Preventive Care, Safe Care, and Engagement and Patient Preferences

Care process includes measures of preventive care, safe care, coordinated care, and engagement and patient preferences. The U.S. ranks #2 on this performance domain (Exhibit 1). Along with the U.K. and Sweden, the U.S. achieves higher performance on the preventive care subdomain, which includes rates of mammography screening and influenza vaccination as well as the percentage of adults who talked with their provider about nutrition, smoking, and alcohol use. New Zealand and the U.S. perform best on the safe care subdomain, with higher reported use of computerized alerts and routine review of medications. Still, in all countries, more than 10 percent of adults report experiencing medical or medication mistakes in their care.

New Zealand, Switzerland, and the Netherlands perform best among countries on the coordinated care subdomain. Switzerland, New Zealand, Australia, Norway, and France perform well on measures related to communication between primary care doctors and specialists. No country stood out at achieving good communication between the primary care and hospital, emergency department, and home-based care provider or coordination with local social services providers.

The U.S. and Germany achieve the highest performance on the engagement and patient preferences subdomain, although U.S. adults have the lowest rates of continuity with the same doctor. 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.

Use of web-based portals for communicating medical concerns and refilling medications is highest among adults in Norway and the U.S. In the year prior to the COVID-19 pandemic, primary care clinicians in Sweden and Australia were the most likely to report using video consultations.

Administrative Efficiency: Many Countries Simplify Insurance Coverage, Billing, and Payment

Administrative efficiency refers to how well health systems reduce documentation (paperwork) and other bureaucratic tasks that patients and clinicians frequently face during care. The top performers on the administrative efficiency domain are Norway, Australia, New Zealand, and the U.K. (Exhibit 1). The U.S. ranks last.

U.S. doctors are the most likely to have trouble getting their patients medication or treatment because of restrictions on insurance coverage. Compared to most of the other countries, larger percentages of adults in the U.S. say they spend a lot of time on paperwork related to medical bills. For nonemergency care, U.S. and Canadian adults are also more likely to visit the emergency department — a less efficient option than seeing a regular doctor.

Equity: Income-Related Disparities Are Largest in the U.S., Canada, New Zealand, and Norway

Our analysis of equity focuses on income-related disparities, based on standardized data across the 11 countries, in the access to care, care process, and administrative efficiency performance domains. Similar standardized data are not available for measuring equity in performance with respect to different racial and ethnic groups (see How We Measured Performance for more detail).

Australia, Germany, and Switzerland rank highest on the equity domain, meaning these countries had the smallest income-related disparities in performance based on the included measures (Exhibit 6).

Within these countries, experiences reported by people in lower- and higher-income groups on 11 indicators in the affordability, timeliness, preventive care, safe care, and engagement and patient preferences subdomains are less divergent than they are within other countries (Appendix 7).

In contrast, the U.S. consistently demonstrated the largest disparities between income groups, except for those measures related to preventive services and safety of care. 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. Compared to the other countries, the United States and Canada had larger income-related inequities in patient reported experiences.

Exhibit 7 illustrates the importance of comparing country performance on equity: relatively good performance on a health care measure overall may mask pronounced gaps in the experiences of lower-income versus higher-income groups. It also illustrates the challenge that arises in assessing equity without also considering performance overall: income-related differences on a measure may be small, but a nation’s performance may be comparatively poor for both higher- and lower-income groups.

In Exhibit 7, income-related performance disparities in Switzerland and Australia are as small as those in Germany and the U.K. But the cost-related access problems for higher-income residents of Switzerland and Australia resemble the levels seen among lower-income residents of the Netherlands and Canada. Adults with higher incomes in the U.S., Switzerland, and Australia are as likely as, or more likely than, adults with lower incomes in five countries to report cost-related access problems.

Health Care Outcomes: Many Countries Achieve Better Outcomes Despite Lower Spending

Health care outcomes reported here refer to those health outcomes that are most likely to be responsive to health care. On this domain, Australia, Norway, and Switzerland rank at the top of our 11-nation group (Exhibit 1). Norway has the lowest infant mortality rate (two deaths per 1,000 live births), while Australia has the highest life expectancy after age 60 (25.6 years of additional life expectancy for those who survive to age 60).

The U.S. ranks last overall on the health care outcomes domain (Exhibit 1). On nine of the 10 component measures, U.S. performance is lowest among the countries (Appendix 8), including having the highest infant mortality rate (5.7 deaths per 1,000 live births) and lowest life expectancy at age 60 (23.1 years). The U.S. ranks last on the mortality measures included in this report, with the exception of 30-day in-hospital mortality following stroke. The U.S. rate of preventable mortality (177 deaths per 100,000 population) is more than double the best-performing country, Switzerland (83 deaths per 100,000).

The U.S. has exceptionally poor performance on two other health care outcome measures. Maternal mortality is one: the U.S. rate of 17.4 deaths per 100,000 live births is twice that of France, the country with the next-highest rate (7.6 deaths per 100,000 live births).

The second is the 10-year trend in avoidable mortality. As depicted in Exhibit 8, all countries reduced their rate of avoidable mortality over 10 years, but the U.S., with the highest level in 2007, reduced it by the least amount — 5 percent reduction in deaths per 100,000 population by 2017 — compared to 25 percent in Switzerland (by 2017) and 24 percent in Norway (by 2016).

Discussion

Some high-income nations get more for their health dollars than the U.S. does. As nations strive for better health care and better health for their residents, several basic lessons emerge from our findings.

Achieving better health outcomes will require policy changes within and beyond health care.

The striking contrast in performance between the U.S. and other high-income countries on avoidable mortality measures points to several intervention or policy targets. How have top-performing countries reduced avoidable mortality? A comparison of the features of top-performing countries and poorer-performing countries suggests that top-performing countries rely on four features to attain better and more equitable health outcomes:

1. They provide for universal coverage and remove cost barriers so people can get care when they need it and in a manner that works for them.
2. They invest in primary care systems to ensure that high-value services are equitably available locally in all communities to all people, reducing the risk of discrimination and unequal treatment.
3. They reduce the administrative burdens on patients and clinicians that cost them time and effort and can discourage access to care, especially for marginalized groups.
4. They invest in social services that increase equitable access to nutrition, education, child care, community safety, housing, transportation, and worker benefits that lead to a healthier population and fewer avoidable demands on health care.

Prioritizing maternal health is critical for reducing maternal mortality. Top-performing countries have had success in preventing maternal deaths through the removal of cost sharing for maternal care. They invest in primary care models that ensure continuity of care from conception through the postpartum period, including midwife-led models. They offer social support benefits, including parental leave.

Several additional causes of avoidable mortality are linked to mental health. Higher rates of suicide in the U.S. — rates that have increased every year since 2000 — could be addressed by expanding the capacity of primary care to diagnose comorbid mental health conditions and provide early intervention and treatment as well as promote social connectedness and suicide prevention. Compared to other countries, the U.S. has a comparatively smaller workforce dedicated to meeting mental health needs. Countries like the Netherlands, Sweden, and Australia more frequently include mental health providers on primary care teams.

Improving access to care requires expanding and strengthening insurance coverage.

The U.S. remains the only high-income country lacking universal health insurance coverage. With nearly 30 million people still uninsured and some 40 million with health plans that leave them potentially underinsured, out-of-pocket health care costs continue to mar U.S. health care performance.

Top-performing countries achieve near-universal coverage and much higher levels of protection against medical costs in the form of annual out-of-pocket caps on covered benefits and full coverage for highly beneficial preventive services, primary care, and effective treatments for chronic conditions. Germany abolished copayments for physician visits in 2013, while several countries have fixed annual out-of-pocket maximums for health expenditures (ranging from about USD 300 per year in Norway to USD 2,645 in Switzerland).

Australia addresses income-related equity through a mix of annual spending caps that are lower for low-income individuals as well as incentives for people to seek primary care. In 2019, 86 percent of Australians faced no out-of-pocket costs for primary care visits.

Improving access to care requires strengthening primary care and extending it to every local community.

Access to care, however, requires more than insurance coverage. Convenient and timely primary care is also vital. Top-ranking countries like the Netherlands and Norway ensure timely availability to care by phone on nights and weekends (with in-person follow-up at home as needed). In the Netherlands, cooperative “GP posts” are staffed by general practitioners (primary care physicians), who are obligated to provide at least 50 hours of after-hours care (between 5:00 pm and 8:00 am) annually in order to maintain their professional licensure. In Norway, the Patients’ Rights Act specifies a right to receive care within specific timeframes and with maximum wait times applying to covered services, including general practitioner visits, hospital care, mental health care, and substance use treatment.

In top-performing countries, workforce policy is geared to ensuring access within communities, especially those that have been historically marginalized. Norway, with the highest number of doctors per person among the 11 countries in our study, has a much larger supply of physicians relative to its population than the U.S. has. Outside the U.S., a larger proportion of clinicians are devoted to primary care and are geographically distributed to match population needs. For example, Norwegian local municipalities, which are responsible for the supply of GPs, may apply to the national government for extra funding to ensure they have an adequate number of physicians.

Reducing administrative burden can free up resources to devote to improving health.

Administrative requirements cost both time and money for patients, clinicians, and managers while also diverting resources away from efforts to improve care. Our results are consistent with other studies showing that administrative costs are more substantial in the U.S. than in other high-income countries. Many countries have simplified their health insurance and payment systems, usually through legislation, regulation, and standardization. For example, top-ranked Norway determines patient copayments for physician fees on a regional basis, applying the standardized copayments to all physicians practicing in the public sector within a specialty within a geographic area.

In countries where private insurance companies compete for customers, such as the Netherlands, standards including a mandatory minimum basic benefit package, community rating to keep premiums lower for sicker individuals, and cost-sharing caps to simplify choice for beneficiaries. These features create an incentive for insurers to compete on service and quality rather than on avoidance of people with higher health risks, similar to the marketplace insurance plans introduced by the Affordable Care Act. Germany and Canada negotiate provider payments administratively, as the U.S. Medicare and Medicaid programs do. As other countries have demonstrated, collective negotiation and standardized payment for services, at either the national or regional level, can greatly simplify transactions, reducing errors and appeals, and making time and attention available to improve care.

Smarter spending — not more spending — is required to achieve better health system performance.

The U.S. continues to outspend other nations on health care, devoting nearly twice as much of its GDP as the average OECD country. U.S. health spending reached nearly 17 percent of GDP in 2019, far above the 10 other countries compared in this report. Moreover, high U.S. out-of-pocket health spending per person, the second-highest in the OECD, makes it difficult for many Americans to access needed care.

The U.S. has managed to keep pace with or exceed other countries on several measures of care process included in the report, such as influenza vaccination rates for older adults, lower rates of postoperative sepsis after abdominal surgery, and more use of patient-facing health information technology for provider communications and prescription filling. But the U.S. still lags other nations on measures of health care outcomes, access to care, equity, and administrative efficiency. What explains the apparent disconnect?

First, many process measures focus on the care available to people who actually have access to care. For example, a measure of care quality for hospitalized patients focuses on those who had access to hospital care in the first place and ignores those who died before reaching a hospital. It is possible to deliver high-quality care to the population that has access to care and the means to pay for it, while delivering poor-quality care to the smaller share of the population that lacks those means. The result may be an average level of performance overall, but a health system that nevertheless inadequately serves the sickest and most vulnerable.

Second, administrative barriers may disproportionately deter poorer and marginalized individuals from receiving health services. Low-income people who work long hours or those with limited health literacy or support from family, friends, or neighbors may have difficulty navigating complex insurance eligibility rules, a maze of application procedures, or getting online access. In fact, this is why the U.S. is the only country among those compared here that employs health navigators to help direct patients through both insurance and the wider health care system.

Third, the relationship between health care outcomes and care process is inevitably complex, especially if the population is less healthy because of economic and social policies that produce inequities or fail to mitigate their consequences. The U.S. population is sicker on average than the populations of other high-income countries, with a high prevalence of chronic conditions like obesity, diabetes, heart disease, and respiratory ailments. This disease burden, coupled with insufficient access to care, partially explains the shorter and declining life expectancy in the U.S. compared to other countries. Even excellent care process, health information technology, and patient engagement may be no match for insufficient access, administrative deterrents, and inadequate chronic disease management. The high U.S. death toll during the COVID-19 pandemic illustrates the difficulty of achieving good health care outcomes if the population is sicker and access to preventive and primary care is limited, particularly because of affordability barriers.

It appears, then, that the U.S. health system delivers too little of the care that’s most needed — and often delivers it too late — especially for people with complex chronic illness, mental health problems, or substance use disorders, many of whom have faced a lifetime of inequitable access to care.

Conclusion

International comparisons allow the public, policymakers, and health care leaders to see alternative approaches to delivering health care, ones that might be borrowed to build better health systems that yield better health outcomes. Lessons from the three top performers we highlight in this report — Norway, the Netherlands, and Australia — can inform the United States and other countries seeking to improve.

As the COVID-19 pandemic has amply shown, no nation has the perfect health system. Health care is a work in progress; the science continues to advance, creating new opportunities and challenges. But by learning from what’s worked and what hasn’t elsewhere in the world, all countries have the opportunity to try out new policies and practices that may move them closer to the ideal of a health system that achieves optimal health for all its people at a price the nation can afford.