U.S. Health Care Remains an Outlier Among High-Income Nations

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The United States continues to lead the world in health care spending but has worse health outcomes for certain conditions than most of 13 high-income countries, according to a new assessment by the Commonwealth Fund, which tracks health performance in developed nations.

Based on data collected between January 2020 and December 2021, the United States ranked lowest among peer nations in life expectancy at birth and highest in maternal and infant mortality, obesity, and deaths from assault. On the positive side, the United States ranked higher than most of the comparison countries in influenza vaccination and was among the highest in screenings for breast and colorectal cancers, for which early detection can improve outcomes.

The Commonwealth Fund report relied on data averages from the Organization for Economic Cooperation and Development (OECD), a consortium of 38 high-income countries, and other international sources to compare U.S. health system performance with health care in Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom.

The United States was highest in health care spending, with 17.8% of U.S. gross domestic product (GDP) going to health care costs compared to the OECD average of 9.6% GDP. Despite these extraordinary expenditures, the United States is the only high-income country that doesn't ensure health care access for all via a publicly funded national system.

Life expectancy at birth in the United States was measured at 77 years, three years lower than the OECD average. When U.S. life expectancy was broken down by race, American Indians or Alaska Natives fared worse at 71.8 years as did non-Hispanic Black Americans at 74.8 years. However, Hispanic Americans were found to have a longer life expectancy (81.9 years) than White Americans (78.8 years), and Asian Americans, at 85.6 years, topped overall life expectancy in the highest-ranking country, Japan (84.7 years).

The U.S. infant mortality rate was calculated at 5.4 per 1,000 live births, compared with the OECD country average of 4.1. Norway and Japan had the lowest rates by far at 1.6 and 1.8, respectively. Differences in maternal mortality rates between the United States and other countries were even more stark. The U.S. rate (2020 data) is 23.8 per 100,000 live births. New Zealand (2018 data) had the second highest rate, at 13.6, while in the Netherlands the rate was only 1.2 (2020 data). Inadequate prenatal care; high cesarean section rates; and prevalent chronic conditions, including diabetes, heart disease, and obesity, are thought to be contributors to the high rate of U.S. maternal mortality. The United States had by far the highest obesity rate at 42.8% (2019 data), although data from four of the lowest-ranking countries are self-reported, which tends to be an underestimate, according to the report's authors.

Rates of suicide are highest in South Korea and Japan, followed by the United States. Deaths in the United States from assault, which includes gun violence deaths, are 7.4 per 100,000, compared to the OECD average of 2.7.

The researchers acknowledged the influence of the COVID-19 pandemic, particularly on data related to delay of needed care as well as lags in data reporting among the comparison countries. Although they aimed to base the analysis on data from 2020 and 2021, some categories included data from as far back as 2010 because it was the most recent available from a particular country. Also noted were methodological differences in how individual countries measure such events as maternal and infant deaths. “Therefore, some of our cross-country analyses should be interpreted with caution, as data for 2020 and beyond were not available for all countries or for every measure,” the researchers cautioned.—Betsy Todd, MPH, RN

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