There are reports I enjoy and reports I don’t like, well basically loathe. In the latter category are international comparisons of our health system, which generally follow a common theme of showing how poorly designed and run it is and what lousy outcomes we get for our excessive spending. The latest of the genre is from the Commonwealth Fund and compares 13 developed countries–the US, Australia, Canada, Denmark, France, Germancy, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, and the UK, based on 2013 data. (Commonwealth Report) So lets start with the list of countries–see how similar they are to the US in size, diversity of population, economically, culturally and in other ways? That couldn’t possibly have anything to do with differences in health use or outcomes could it?
The US spent 17% of its GDP on health care in 2013, the next highest country is France at 11.6%. In almost all countries, including the US, rates of health spending growth have declined in recent years, along with the rate of general economic growth, and in fact the US’ per capita rate of growth is middle of the pack. Interestingly, per person average out-of-pocket spending is not highest in America. Ours is $1074 and Switzerland’s is $1630; but most other countries are far below this level. The report bears out what we repeatedly have observed, our higher spending is largely due to unit prices and to greater use of expensive technology. The United States has a lower than average number of physicians per capita and a low average annual physician visit rate–4 per year versus the developed country median of 6.5 and Japan at 12.9. We also have fewer acute hospital beds and middle of the pack hospital use. Think all that fully paid insurance in some countries might encourage unnecessary use?
Where we get hurt is our use of and what we pay for items like drugs and imaging. We and New Zealand are the highest per capita users of medications and prices in the US are much higher than elsewhere. Only Japan has a greater supply of imaging machines than the US and we use ours quite a bit more than most nations. We also may use other expensive medical equipment and devices more frequently, and pay more for them, than do other countries. In part, however, this is a reflection of a country more dedicated to free market economics, and in part to a population that values health and is willing to spend more on it. Those choices may rile academics but then they generally aren’t that big on freedom anyway.
In terms of health outcomes, some measures that are used should be adjusted for demographic and other factors. Our life expectancy may be lower than some countries, but we have more murders and more deaths by accident. Adjusted, I suspect it is at least as good as most developed nations. We supposedly have higher rates of chronic conditions, but this may be partly due to much better capture of diagnoses by US clinicians and payers, who are incented to find every little thing wrong with a patient. We actually have about the lowest rate of smoking, although the highest of obesity. Our cancer statistics are better than any other country; think that might be related to the high spending on drugs, imaging and other technology? So while there clearly are health system issues in this country, these reports paint a bleaker picture than actually exists and tend to conflate issues of delivering health care to those who need it with broader public health and social issues, like should we do more to stop people from being overweight?