Broken Mirror on the Wall: On the Commonwealth Fund’s Increasingly Frustrating Comparison of International Health Systems

The Commonwealth Fund has released another edition of its Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. Following tradition, it concludes that the American health “system” is the worst of eleven developed countries. This time, it prompted the editorialists at the New York Times to conclude:

 electronic-medical-recordBritain and Switzerland were top scorers in a study examining the quality and efficiency of health care systems in 11 advanced nations by a leading American research organization. As usual, the United States finished last overall and last on several important measures of cost and health outcomes, despite having the most costly system in the world.

The poor results for the United States reflect the high cost of its medical care and the absence of universal health insurance, a situation being addressed by the Affordable Care Act.

Other advanced nations are far ahead in the game because they have long had universal health coverage and promoted strong ties between patients and doctors.

However, the report itself concludes that “the U.K. continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes” (emphasis mine). So, the British health system works well, except for that one small problem: It does not help people get better.

Nevertheless, the British system tops all four sub-categories within the category labelled “quality”: Effective, safe, coordinated, and patient-centered. If you spend any time in American health-policy circles, you know that these slogans feature prominently in titles of conferences and keynote speeches by high officials in the Department of Health & Human Services — even though they do not lead to systemic improvements.

We sympathize with the Commonwealth Fund’s criticism of U.S. health care as overly bureaucratic and suffering from administrivia. We haven’t met anyone who would disagree with that. Where we differ is on the idea that transferring some of that administrative load towards government efforts to “coordinate” care is going to improve things.

What is really frustrating is the authors’ conclusion (essentially unchanged for many years): “The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage”.

This is a meaningless term. The top two performers, Britain and Switzerland, have vastly different systems. Britain has a single-payer government monopoly, supplemented by private medical and hospital insurance for a small share of the population. Switzerland has mandatory private health insurance, described for an American audience by Professor Regina Herzlinger in her 2007 book. In 2007, Swiss voters rejected single-payer health care by a huge margin.

Who joins the U.S. at the bottom of the list? Canada! Canada has the most government-dominated single-payer system: There are no competing private insurers that offer access to privately paid physicians or hospitals, like in Britain.

Furthermore, an American senior is likely in the most centrally controlled single-payer system in the world: Medicare. Traditional Medicare’s fees are set by federally appointed panels, and spending is fully federally funded. That is more centrally controlled than Canada’s, where each province runs a system for its residents of all ages; and doctors and hospitals negotiate fees with provincial, not federal bureaucrats; and most of the funding is provincial. It’s a long way from consumer-driven, but at least it’s a level of government marginally closer to the people.

Americans can learn a lot from international health systems, but simply declaring that everywhere else is better because of “universal health care” confuses rather than clarifies the issues. For a more effective analysis of international health systems, please see a 2009 NCPA study.

Comments (18)

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  1. Devon Herrick says:

    Our health care system is in dire need of reform. Indeed, it would be hard to purposely design a health care system that had worse fiscal incentives. That said, international health care system comparisons suffer from biases that are built into the metrics. For instance, why is “coverage” a criteria? What exactly is coverage? Shouldn’t the valid metric be based on access to care? But, then again, what metric should access to care” be based on? Moreover, should whatever metric access is derived from, should access to primary care, specialty care, inpatient care or pharmaceutical care be weighted more heavily?

    You get the picture; there is no universally agreed on definition of what is important. The Commonwealth Fund dislikes the U.S. health care system because it isn’t a centrally-planned system of socialized medicine (actually, it’s about half socialized (care for seniors and poor people) and quasi-socialized for those with employer coverage.

    As Obama health advisor, David Cutler, said in his book Your Money or Your Life, we pay a lot for our health care and we get a lot for the money spent.

  2. Buster says:

    “The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage”.

    Why is that a problem? Some countries with universal coverage have poorly-functioning health care systems, while other countries that lack universal coverage have efficient health care system. Come to think of it, some countries with universal coverage have poorly-functioning public health care systems but highly efficient private health care systems.

  3. Studebaker says:

    Mirror, Mirror on the wall, how many ways can Commonwealth think of to bash the U.S. health care systems while making it seem like an unbiased, meticulously thought out report?

  4. Steve says:

    What a surprise that the NYT would pounce on a report that shows the US in the worst possible light and the apparent utopia of socialism. Michael Moore attempted to do this also with his so-called documentary, Sicko. In it, he claimed that Cuba had a model healthcare system.

    Like Devon noted, achieving consistency in definitions and metrics across countries is tremendously challenging, even under the assumption that governments are not cooking the books in their favor.

    Cuba supposedly has a lower infant mortality rate than the US. Give me a break!

    • Perry says:

      The problem with the mortality rate for infants is how it’s calculated. That being said, we attempt to save many infants here that would die in other countries.

      • Steve says:

        Exactly right Perry. For example, children who die within a few hours of being born in Cuba are sometimes not counted as having ever been born, and this obviously distorts the mortality rates.

        Also, it would be interesting to see the rates with abortion included.

  5. Freedom Lover says:

    “So, the British health system works well, except for that one small problem: It does not help people get better.”

    But isn’t that the whole point? How could a report have such a misleading emphasis? The US health system is definitely imperfect…but that’s precisely because we have strayed so far from free-market principles that lead to lower prices and more efficiency.

    There are so many examples of foreigners living under systems of “universal coverage” getting sick and getting great medical care- in the US! Could it be because they know they will ultimately get much better outcomes here, even though government and insurance has largely distorted the marketplace?

  6. Big Truck Joe says:

    We have the best healthcare in the world as exhibited by the wealthiest people on earth coming to US hospitals to get treatment. We have the most expensive healthcare in the world due to the high price we put on the value of life – whether a neonate baby or a octogenarian with Alzheimer’s – who would be dead in the socialist Utopias mentioned but we fight an expensive battle to save life…all life. We have the least effective healthcare in the world as 45 million uninsured people have the freedom to not get treated and remain uninsured and obese until they crash, medically speaking, and are rushed to the ER because they’ve never taken preventive care before. Am I missing anything???

    • Linda Gorman says:

      Would you please tell us the source for your conclusion that the uninsured do not get treatment?

      And that primary care has anything to do with obesity or that obesity has anything to do with being uninsured?

    • Val says:

      I would likewise be interested in your conclusion that the uninsured don’t get care.

  7. Bob Hertz says:

    The British and Canadian health care systems (and the VA systems in America)
    leave virtually no patients in debt.

    That is important, but it is not the whole story.

    These systems also leave persons untreated and in pain on waiting lists.

    If anyone cares to know, these are the only two metrics that concern me, and I have written extensively about both measures in The Health Care Crusade.

    Based on not too much reading, it appears to me that Germany and France have the best balance of no debt with modern care.

  8. John R. Graham says:

    Here are a few more interesting responses to the Commonwealth Fund Survey:

    Betsy McCaughey –

    Greg Scandlen –

  9. Val says:

    This is obviously written from a leftist view. We know Commonwealth and WHO hate that the U.S. doesn’t (yet) have a centrally-planned system. Americans have the highest spendable income after medical care of any country in the world, and we lead the world in technology and medical innovation. Further,

    Americans have better survival rates than Europeans for common cancers.[1] Breast cancer mortality is 52 percent higher in Germany than in the United States, and 88 percent higher in the United Kingdom. Prostate cancer mortality is 604 percent higher in the U.K. and 457 percent higher in Norway. The mortality rate for colorectal cancer among British men and women is about 40 percent higher.

    Americans have lower cancer mortality rates than Canadians.[2] Breast cancer mortality is 9 percent higher, prostate cancer is 184 percent higher and colon cancer mortality among men is about 10 percent higher than in the United States.

    [1] Concord Working Group, “Cancer survival in five continents: a worldwide population-based study,.S. abe at responsible for theountries, in s chnologies, ” Lancet Oncology, Vol. 9, No. 8, August 2008, pages 730 – 756; Arduino Verdecchia et al., “Recent Cancer Survival in Europe: A 2000-02 Period Analysis of EUROCARE-4 Data,” Lancet Oncology, Vol. 8, No. 9, September 2007, pages 784 – 796.

    [2] U.S. Cancer Statistics, National Program of Cancer Registries, U.S. Centers for Disease Control; Canadian Cancer Society/National Cancer Institute of Canada; also see June O’Neill and Dave M. O’Neill, “Health Status, Health Care and Inequality: Canada vs. the U.S.,” National Bureau of Economic Research, Working Paper No. 13429, September 2007. Available

  10. Big Truck Joe says:

    The uninsured get treatment if they “want” treatment. And as per the Campaign to End Obesity states:
    -Obesity is linked to more than 60 chronic diseases.
    -According to the American Cancer Society, 572,000 Americans die of cancer each year, about one-third of these cancer deaths are linked to excess body weight, poor nutrition and/or physical inactivity.
    -Over 75 percent of hypertension cases are directly linked to obesity.
    -Approximately two-thirds of U.S. adults with type 2 diabetes are overweight or have obesity…
    So, odds are that those who are uninsured and have episodes requiring ER Admission as my postulation states are going to have weight related issues otherwise they would simply be uninsured and healthy thereby not requiring hospital attention. Not cause and effect as you try to determine but simple correlation.

  11. Bob Hertz says:

    Note to John:

    I agree that medical bankruptcy data is unreliable. My point was that a lot of Americans owe a lot of money, long before bankruptcy.

    The short Fraser Report that I read from 2009 is pretty fuzzy itself. It talks about the total number of bankruptcies and kind of works backwards toward some generalizations about health care. It is not one of their better efforts.

    I do not see how it is possible that a Canadian would owe money for doctor visits or hospital stays. Drugs and long term care may be another matter.

    • John R. Graham says:

      Mostly drugs and long-term care, but also hospital care and physician care because a Canadian cannot buy insurance to cover catastrophic illness. He might nevertheless want to plan for the chance of coming to U.S. for treatment (either because of waiting times in Canada or lack of technology).

  12. Floccina says:

    In the USA you only better off with health insurance because most people have health insurance.