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Like many other health policy commentators, I often write about what is broken in the U.S. health system and discuss strategies for healing it – all from a decidedly inward-looking perspective. Recently, a pair of articles exploring how our health system fares on a global stage piqued my interest.

It stands to reason that wealthier countries will spend more on health per person than lower-income countries. The first article ("" by Emma Wager and colleagues) reveals that, in terms of health care expenditures, the U.S. continues to be an exceptionally big spender among its peer nations. In 2022, health expenditures per person in the U.S. were $12,555 – about twice as much as other high-income nations spent.

This analysis compared the U.S. with similar Organization for Economic Co-operation and Development countries (those with above median national incomes and above median income per person as measured by Gross Domestic Product [GDP] and median GDP per capita in at least one of the last 10 years). It also revealed that the difference between health spending as a share of the economy in the U.S. and comparable countries has widened considerably over the past decades.

One might expect the highest-spending country to have the world's healthiest population. But a recent Commonwealth Fund Report by David Blumenthal and colleagues ("") reveals that this couldn't be further from reality.

The report compares the performance of health systems in 10 countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United States) on five key domains of health system performance: access to care, care process, administrative efficiency, equity, and health outcomes. The report takes into account the impact of COVID-19 on health system performance, and also looks at system performance differences based on gender, rural vs. non-rural location, and physician-reported patient experience of discrimination.

The three top performing countries are Australia, Netherlands, and the United Kingdom; the U.S. ranks a very disappointing last overall. All 10 countries show strengths and weaknesses, and no country is at the top or bottom on every dimension. The authors note that even the overall top-ranked country (Australia) performs less well on "access to care" and "care process" domains – and the U.S. (lowest-ranked overall) ranks second in the "care process" domain.

In the aggregate, most of the ranked nations are more similar than different with regard to higher and lower performance in various domains. The one exception is the U.S. This is cause for concern, particularly in light of the U.S.'s poor performance on the health outcomes dimension. The health outcomes assessed are those that are most likely to respond to healthcare interventions: life expectancy at birth, excess deaths due to the pandemic, and avoidable deaths (those with preventable and treatable causes). Of the 10 countries, the U.S. ranked last on 4 of the 5 health outcome measures:

• Life expectancy in the U.S. is more than 4 years below the 10-country average
• The U.S. has the highest rate of death from both preventable causes and treatable conditions, as well as the highest rate of excess pandemic-related deaths in persons under the age of 75

The quality of health care insurance coverage in the U.S. is inferior to the other countries. Nearly 25% of Americans who have health insurance are underinsured. Plans with high deductibles and high copayments compromise health outcomes and reduce effectiveness in assuring access to care. Although the Affordable Care Act has dramatically reduced uninsured rates, 26 million Americans (7%-to-8% of the population) continue to lack coverage.

Care process is the one area in which the U.S. has a high ranking. The authors suggest that pay-for-performance and value-based care efforts undertaken by public and private payers may be playing a role. These strategies have increased adherence to clinical guidelines for preventive services.

What use can we make of this information? Policymakers might consider opportunities for cross-nation learning as they look for ways to improve the health system. For instance, dialogue with Australia could provide valuable insights into improving health system equity, administrative efficiency, and health outcomes. The Netherlands might have valuable information to share re: addressing access issues.

The "mirror" reveals other deficits for which policymakers and leaders could take action:

• The longstanding lack of investment in primary care can be addressed by improving compensation for frontline clinicians who play pivotal roles in managing chronic illness and reducing often unnecessary emergency, specialty, and hospital care
• A reduction in the huge volume of unregulated health insurance products with widely variable benefits can help reduce administrative inefficiency

The takeaway is obvious. The U.S. is an outlier on both healthcare spending and health system performance. Two of the highest-ranked countries on health system performance (Australia and the Netherlands) also had the lowest healthcare spending as a percentage of GDP. We can do better!

In a little more than a month, we'll enter a new year with a new administration in Washington. There couldn't be a better time for our leaders and policymakers to focus on understanding and making a commitment to resolve the complex issues that have kept our health system from being the world's best!

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