Cost, Quality, Access: U.S. Finishes Last

The United States finished last on the Commonwealth Fund’s international ranking of industrialized health systems for the fifth consecutive time over the past 10 years, but in 2011, spent $8,508 per person, which is thousands more than the $3,406, which the top-ranked United Kingdom spent per person. Other countries included in the 2014 update of “Mirror Mirror On The Wall: How The Performance of the U.S. Health Care System Compares Internationally,” are Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, and Switzerland. The study’s authors noted that processes put in place by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) should help boost America in the rankings by focusing on health information technology and improving the process of care to achieve better safety and quality.

The Commonwealth Fund expanded its research from the seven countries initially included in 2010 to 11 countries in 2014. It incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care. Information from the Commonwealth Fund’s health care outcomes from its most recent (2011) national health system scorecard, in addition to information from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD), is referenced in the study.

Universal Coverage

The United States differs from other industrialized countries mainly because it lacks universal health coverage. The Commonwealth Fund noted that “Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes,” but commented that “the Affordable Care Act is increasing the number of Americans with coverage and improving access to care, though the data in this report are from years prior to the full implementation of the law.”

Other reasons the U.S. ranks behind most countries on many measures of health outcomes, quality, and efficiency is that physicians in the U.S. face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles. Many other countries have modern health information systems, but in the U.S., physicians and hospitals are slowly attempting to catch up.


The Commonwealth Fund analysts grouped four categories within quality: effective care, safe care, coordinated care, and patient-centered care. Compared with the other 10 countries, the U.S. does best on provision and receipt of preventive and patient-centered care. Low scores on safe and coordinated care lower the overall U.S. quality score, but as the U.S. continues to focus on improved health information technology, the ability of U.S. physicians to identify, monitor, and coordinate care for their patients should improve.


Americans report that problems with cost keep them from obtaining health care, a problem that would not exist if there were universal coverage. According to the surveys, patients in the U.S. may have quick access to specialized health care services; however, that same group of patients is less likely to report quick access to primary care. Authors of the study pointed out that, in other countries such as Canada, although patients have little to no financial burden, they often experience significant wait times for such specialized services. The authors noted that there is a frequent misperception that there is a trade-off between universal coverage and timely access to specialized services. Countries such as the Netherlands, the U.K., and Germany, however, are able to provide universal coverage with low out-of-pocket costs while maintaining quick access to specialty services.

Equity and Efficiency

Over one-third of adults from the U.S. participating in the study said they went without needed care because of costs in the past year. The numbers didn’t lie, as the U.S. ranks last on measures of equity in health care. The Commonwealth Fund study authors noted “Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs.” This resulted in patients being sicker by the time they actually received care as evidenced by the U.S. placing last in efficiency measures as well.

The U.S. also ranks last overall with poor scores on each of the three indicators of healthy lives: mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. On the flip side, the U.S. ranks higher on preventive care and is strong on waiting times for specialist care than many other countries. With the ACA’s focus on quality and outcomes and expanding coverage, the dead last finish may be on the road to change.