50 Americans Show Their Worst Experiences With The U.S. Healthcare System

The Commonwealth Fund is a private, nonprofit foundation based in the United States that focuses on health care research and policy. Since 2004, it has been releasing reports comparing the performance of health systems in high-income countries.

In the latest edition, the fund's experts analyzed ten: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States.

They examined five key domains of health system performance: access to care, care process, administrative efficiency, equity, and health outcomes. The United States came in last.

"The United States is not just an outlier on health system performance; it’s an outlier on health care spending as well," the report said.

In 1980, U.S. expenditures (8.2% of GDP) were at the high end of the distribution among the 10 nations studied, but comparable to outlays in Germany (8.1%) and Sweden (7.7%).

Back then, most countries included in this analysis spent between 4 percent and 8 percent of GDP, and had increased spending to between 8 percent and 12 percent by recent years.

The U.S., however, has far outpaced them, spending more than 16 percent of its GDP on health care in 2022. The Commonwealth Fund predicts that figure to exceed 20 percent by 2035.

The Netherlands, the United Kingdom, and Germany performed best on access overall, and both the Netherlands and Germany ranked at or near the top on affordability and availability as well. The U.K.'s health system was the top one for affordability.

The Netherlands, the U.K., and Germany excel on measures of affordability because each country has low cost-related barriers to care and minimal out-of-pocket health care expenses. In these countries, universal coverage ensures that copayments for health services, if any, are small, guaranteeing both access and affordability.

In the Netherlands, visits to primary care, maternity care, and child health care providers are fully covered; other health care services are covered once patients pay their annual deductible. In the U.K., the National Health Service (NHS) provides free public health care, including hospital, physician, and mental health care.

In the U.S., lack of affordability is a pervasive problem. "With a fragmented insurance system, a near majority of Americans receive their health coverage through their employer," the report said.

"While the ACA's Medicaid expansions and subsidized private coverage have helped fill the gap, 26 million Americans are still uninsured, leaving them fully exposed to the cost drivers in the system. Cost has also fueled growth of private plan deductibles, leaving about a quarter of the working-age population underinsured."

In other words, due to extensive cost-sharing requirements, many patients are unable to visit a doctor when medical issues arise, causing them to skip medical tests, treatments, or follow-up visits, and avoid filling prescriptions or skip doses of their medications.

In terms of care availability, American patients are more likely than their peers in most other countries to report they don't have a regular doctor or place of care and face limited options for getting treatment after regular office hours. Shortages of primary care services add to these problems as well.

Most notably, the U.S. ranked second on care process. New Zealand was first, with Canada and the Netherlands close behind.

Strong U.S. performance in this category was the result of the successful provision of preventive services, such as mammograms and flu vaccinations, and an emphasis on patient safety.

With respect to preventive care, the U.S. record might reflect the vigorous pay-for-performance policies implemented by Medicare and other payers to reward the delivery of these services.

In administrative efficiency — which focuses on doctors dealing with insurance or medical claims issues; requirements for providers to report clinical or quality data to governmental agencies; and patients' time spent resolving medical bill disputes and completing paperwork — the U.S. came in ninth, slightly ahead Switzerland.

In the uniquely complex U.S. system of public and private payers — featuring thousands of health plans, each with its own cost-sharing requirements and coverage limitations — physicians and other health care providers spend enormous amounts of time and effort billing insurers.

Under the equity domain — which reflected how people with below-average and above-average incomes differ in their access to health care and their care experience — the top belonged to Switzerland, the U.K., and the Netherlands.

Many of the countries have limits on cost sharing (or in the case of the U.K., no cost sharing at all) to ensure that the ability to pay does not constitute a significant barrier to obtaining needed health services. In Germany, which ranked fourth in this domain, out-of-pocket expenses are capped, with the cost of coverage being income-based. And because health coverage is mandatory, nearly everyone has access to a regular doctor.

The U.S. was once again last.

Finally, health outcomes. Here, the U.S. ranked last on four out of five of the criteria. Life expectancy is more than four years below the 10-country average, and the U.S. has the highest rates of preventable and treatable deaths for all ages. The ongoing substance use crisis and the prevalence of gun violence in the U.S. contribute significantly to its poor outcomes, with more than 100,000 overdose deaths and 43,000 gun-related deaths in 2023 — numbers that are much higher than in other high-income countries.

Despite its record on care process, the U.S. continues to trail other countries in almost every other respect.

"Despite spending a lot on health care, the United States is not meeting one of the principal obligations of a nation: to protect the health and welfare of its residents," The Commonwealth Fund concluded in its report. "Most of the countries we compared are providing this protection, even though each can learn a good deal from its peers. The U.S., in failing this ultimate test of a successful nation, remains an outlier."

The fund believes reversing the U.S. health system would require demanding interventions at all levels by both government and the private sector.

The country must expand and strengthen insurance coverage to reduce financial barriers and make care more equitable, while simplifying and standardizing insurance to cut administrative waste and costs. Building a stronger, better-compensated primary care workforce, using technology effectively, and curbing market consolidation would make care more functional and affordable.

The U.S. also needs greater public health investment and authority to handle not just possible future pandemics but also chronic disease.

Finally, true improvement also demands actions besides those directly related to health care services. These include efforts to reduce gun violence and substance use, to remedy the historical and ongoing effects of racism, and to institute policies that protect against poverty, homelessness, and hunger.