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.