According to a new performance analysis conducted by the Commonwealth Fund, the US health care system consistently underperforms, despite being the most expensive in the world. In comparison with 10 other nations, the US ranks last, as it has done in previous years’ studies.

The Commonwealth Fund is a private foundation with a mission statement of promoting 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.”

To do this, it supports independent research on health care issues and provides grants to faciliate improvements to health care practice and policy.

The Commonwealth Fund has previously conducted the “Mirror, Mirror” performance analysis in 2010, 2007, 2006 and 2004. In all editions of the study, the US has reported the worst health outcomes for patients, and is close to last on access, efficiency and equity of health care.

In 2014, the number of countries whose health care systems were analyzed in the study was expanded to 11, with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the UK also featuring.

Data for the report are drawn from three separate surveys conducted by the Commonwealth Fund across 2011-2013.

A total of 18,667 patients in 2011 and 20,045 in 2013 were surveyed across the 11 featured nations for their views on their country’s health care system. In another survey, 9,776 physicians across the 11 countries were surveyed on their experiences of providing care to patients.

The report’s summary breaks its findings down into five main factors: quality, access, efficiency, equity and healthy lives.


In terms of quality, the study reports that although there has been some improvement in recent years, low scores on safe and coordinated care have held the US ranking down in 2014. The Fund recommends that the US should continue to adopt health information technologies that improve the ability of doctors to identify best treatment for patients, particularly for those with chronic conditions.


“Not surprisingly – given the absence of universal coverage – people in the US go without needed health care because of cost more often than people do in the other countries,” state the authors on the issue of access to health care.

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“Not surprisingly – given the absence of universal coverage – people in the US go without needed health care because of cost more often than people do in the other countries,” claim the authors.

In the study, Americans were the most likely to report problems in accessing health care services due to cost. The report found that patients in the US have rapid access to specialized health care services, but that access to primary care suffers in comparison with other countries.

Although the study found that Canadian patients have “little to no” financial burden but experience lengthy waiting times for services, the authors say there is a “frequent misperception that trade-offs between universal coverage and timely access to specialized services are inevitable.”

The report describes how the Netherlands, UK and Germany provide universal coverage with quick access to specialty services in combination with low out-of-pocket costs.


The US ranked last for efficiency in the survey, with the UK ranking first. In particular, the study highlights performance issues with measures of national health expenditures and administrative costs, measures of “administrative hassles,” avoidable emergency room use and duplicative medical testing.


The report found the US to be by far the worst nation studied in terms of equity. One third or more of Americans who have a below-average income reported going without needed medical care in the past year because of costs. These Americans were less likely to see doctors when sick, fill a prescription or get a recommended test, treatment or follow-up care due to costs.

Healthy lives

Across the study’s three indicators of healthy lives – mortality amenable to medical care, infant mortality and healthy life expectancy at age 60 – the US ranked last overall. France, Sweden and Switzerland ranked highest within the healthy lives category.

The report measured performance using national mortality data and the self-reported perceptions and experiences of patients and doctors. The authors acknowledge that their methodology has some limitations. Of their rankings, the authors write:

They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients’ and physicians’ assessments might be affected by their experiences and expectations, which could differ by country and culture.”

However, the authors conclude from their findings that insurance needs to be expanded to cover the uninsured and that all Americans should have access to health care services. They say that the Affordable Care Act is a positive step toward this, in that low-moderate income families can now claim for financial assistance in obtaining coverage.

They recommend that the US should follow the lead of other countries in improving the safety and quality of care by incorporating public reporting of quality data and adopting payment systems that reward high-quality care.

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The study found that Canadian patients have “little to no” financial burden but experience lengthy waiting times for services.

“Based on these patient and physician reports,” the authors write, “and with the enactment of health reform, the United States should be able to make significant strides in improving the delivery, coordination, and equity of the health care system in coming years.”

Overall, the study ranked the national health care systems as follows:

  1. United Kingdom
  2. Switzerland
  3. Sweden
  4. Australia
  5. Germany and Netherlands (tied)
  6. New Zealand and Norway (tied)
  7. France
  8. Canada
  9. United States

Although the UK “continues to demonstrate strong performance,” and ranked first overall, in September 2013 the British broadcaster Channel 4 reported on previously unpublished data that the UK’s National Health Service (NHS) hospitals in England underperform in comparison to US hospitals.

The unpublished report comparing health care performance in the UK, US and five unnamed countries – authored by statistician Prof. Sir Brian Jarman, who also leaked the data to Channel 4 News – found the following:

  • In 2004, England had the highest hospital death rate of the seven countries examined.
  • The “hospital standardized mortality ratios” (HSMR) – an index Prof. Jarman developed himself – were 58% higher in English NHS hospitals compared with US hospitals, who had the best ranking on this index.
  • In 2012, a patient in an average NHS hospital in England was 45% more likely to die than if they’d been admitted to a US hospital.
  • Elderly people were found to be five times more likely to die of pneumonia in a hospital in England than if they were admitted to a hospital in the US.

However, despite the US spending more than twice as much per person on health care as in the UK, Prof. Jarman reminded that the US still has lower life expectancy and higher infant mortality rates.

Also, he points out that his statistics only apply to Americans who have access to health care in hospitals, so this means lower income groups who have a disincentive to go to a hospital because they would not be able to pay their health care bills were not taken into account. Prof. Jarman suggests it is possible, therefore, that health outcomes among these groups could be equivalent in the UK and US.

However, Prof. Jarman’s HSMR methodology had been described as flawed by data scientists and clinicians writing in the BMJ, and his findings were not peer-reviewed.