US healthcare system ranks last in equity, access

Photo: Dean Mitchell/Getty Images

Despite spending more on healthcare than any other nation, the U.S. is the lowest or second-lowest-ranking country when it comes to measures such as access, equity and outcomes, according to a new Commonwealth Fund analysis.

And the U.S. ranked last overall among 10 countries when factoring in all of those metrics. The top-performing countries this year are Australia, the Netherlands and the United Kingdom.

The poor showing by the U.S. stands in stark contrast to how much it spends on healthcare. In 1980, U.S. expenditures were at the high end of the distribution among the 10 nations studied, but comparable to outlays in Sweden and Germany – 8.2% of GDP. Since then, however, the U.S. has far outpaced other nations, spending more than 16% of its GDP on healthcare in 2022. And that figure is predicted to exceed 20% by 2035.

In 1980, the other countries included in the annual analysis spent between 4% and 8% of GDP, and had increased spending to between 8% and 12% by 2023.

The two countries with the highest overall rankings, Australia and the Netherlands, also have the lowest healthcare spending as a share of GDP, data showed.

WHAT'S THE IMPACT?

When focusing on access, the Netherlands, the U.K. and Germany perform best on access overall, and both the Netherlands and Germany rank at or near the top in affordability and availability.

In the U.S., lack of affordability is a pervasive problem, authors said. With a fragmented insurance system, a near majority of Americans receive their health coverage through their employer. And while the Affordable Care Act's Medicaid expansions and subsidized private coverage have helped fill the gap, 26 million Americans are still uninsured, which analysts said leaves them fully exposed to the cost drivers in the system.

Cost, they said, has also fueled the growth of private plan deductibles, leaving about a quarter of the working-age population underinsured. In other words, extensive cost-sharing requirements render many patients 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.

Availability-wise, U.S. patients are more likely not to 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 availability problems, Commonwealth Fund found.

The U.S., along with Switzerland, also performed poorly in administrative efficiency. Many patients in the U.S. are forced to deal with medical bill issues, and, in both countries, patients are more likely to seek treatment in emergency departments for conditions that are treatable in outpatient settings, like a primary care physician's office.

Adding to that is a complex, sometimes labyrinthine network of public and private payers, with thousands of health plans, each with their own cost-sharing requirements and coverage limitations. Because of that, authors said, physicians and other healthcare providers spend enormous amounts of time and effort billing insurers, and denials of service by insurance companies are common, which requires burdensome appeals by providers and patients.

The U.S. also ranks last on four of five health outcome measures. 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, as well as excess deaths related to the COVID-19 pandemic for people under age 75. The analysis attributes this in part to an ongoing substance abuse crisis and the prevalence of gun violence.

THE LARGER TREND

While the data may be sobering, the U.S. did rank highly in one area: care process. Prevention, safety, coordination, patient engagement and sensitivity to patient preferences are all components of care process, and the U.S. performed well – the result, authors said, of the successful provision of preventive services, such as mammograms and flu vaccinations, and an emphasis on patient safety.

A concerted focus in the U.S. on patient safety since the beginning of the century has yielded significant reductions in adverse events during hospital stays for heart attack, heart failure, pneumonia and major surgeries between 2010 and 2019, data showed.

The report offered several recommendations for the U.S. To improve equity, authors recommended reducing financial barriers to access to care by extending coverage to the remaining uninsured. To reduce administrative burden, minimizing the variation and complexity of insurance plans will be critical, they said, as will reducing the cost of care.

Other recommendations include expanding investment in public health and reforming the healthcare delivery system.

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.