By Eric C. Schneider, Dana O. Sarnak, David Squires,
Arnav Shah, and Michelle M. Doty
First, who funded this report?
About the Commonwealth Fund:
The Commonwealth Fund—among the first private foundations started by a woman philanthropist, Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good.
The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.
The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.
For me, this is a highlight:
The three countries with the best overall health system performance scores have strikingly different health care systems. All three provide universal coverage and access, but do so in different ways, suggesting that high performance can be achieved through a variety of payment and organizational approaches.
Two longer extracts, from near the beginning and the end.
The United States Health System Falls Short
The United States spends far more on health care than other high-income countries, with spending levels that rose continuously over the past three decades (Exhibit 1). Yet the U.S. population has poorer health than other countries. 1 Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. 2 In addition, as the baby boom population ages, more people in the U.S.—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on health care systems to respond.
Timely and accessible health care could mitigate many of these challenges, but the U.S. health care system falls short, failing to deliver indicated services reliably to all who could benefit. 3 In particular, poor access to primary care has contributed to inadequate prevention and management of chronic diseases, delayed diagnoses, incomplete adherence to treatments, wasteful overuse of drugs and technologies, and coordination and safety problems.
This report uses recent data to compare health care system performance in the U.S. with that of 10 other high-income countries and considers the different approaches to health care organization and delivery that can contribute to top performance. We based our analysis on 72 indicators that measure performance in five domains important to policymakers, providers, patients, and the public: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes.
Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).
Lessons for the United States
Comparing countries’ health care system performance using standardized performance data can offer benchmarks and other useful insights about how to improve care. Among the 11 countries we studied, the U.S. was ranked last in overall health system performance, while spending the most per capita on health care. The insurance, payment, and delivery system of the ACA have improved some aspects of health care system performance, but the U.S. still greatly lags countries with universal health insurance coverage. The top performing countries—the U.K., Australia, and the Netherlands—could offer important lessons to the U.S. and other countries.
THE HEALTH SYSTEMS ACHIEVING TOP MARKS DO SO IN DIVERSE WAYS
The three countries with the best overall health system performance scores have strikingly different health care systems. All three provide universal coverage and access, but do so in different ways, suggesting that high performance can be achieved through a variety of payment and organizational approaches.
Experts generally group universal coverage systems into three categories: Beveridge systems, single-payer systems, and multipayer systems. These three systems are represented among our highest performers.
THE U.K.’S NATIONAL HEALTH SERVICE
The Beveridge model takes its name after the creator of Britain’s National Health Service, William Beveridge. In the NHS, health services are paid for through general tax revenue, as opposed to insurance premiums. Furthermore, the government plays a significant role in organizing and operating the delivery of health care. For example, most hospitals are publicly owned, and the specialists who work in them are often government employees. This is not true of all providers. Most general practitioner practices are privately owned. Health care in the U.K. and other Beveridge countries is centrally directed and has more direct management accountability to the government than in other health systems.
AUSTRALIA’S SINGLE-PAYER INSURANCE PROGRAM
In Australia, everyone is covered under the public insurance plan, Medicare. Much like the NHS, Australia’s Medicare is funded through tax revenue. Medicare is distinguished, though, by lesser public involvement in care delivery. Many Australian hospitals are private, and roughly half the population purchases private health insurance to access care outside the public system. To put into an American context, Australia’s Medicare resembles Medicare in the U.S.
NETHERLAND’S COMPETING PRIVATE INSURERS
Unlike Australia and the U.K., the Dutch health system relies on private insurers to fund health services for its population. Dutch insurers are mainly financed through community-rated premiums and payroll taxes, which are pooled and then distributed to insurers based on the risk profile of their enrollees. All plans include a standard basic benefit package; subsidies are available for people with low incomes; adults are required to enroll in a plan or must pay a fine. Dutch health care providers are predominantly private. This multipayer system—partly inspired by the managed competition model—shares many similarities with the insurance marketplaces created under the Affordable Care Act. 10