The who and how of improving the U.S. health care system

From Last to First — Could the U.S. Health Care System Become the Best in the World?

By Eric C. Schneider, M.D., and David Squires, M.A.
The New England Journal of Medicine, July 14, 2017

Many Americans believe that the United States has the best health care system in the world, but surprisingly little evidence supports that belief. On the contrary, since 2004, reports from the Commonwealth Fund have consistently rated the performance of the U.S. health care system last among high-income countries, despite the fact that we spend far more on health care than these other countries.

Timely access for people at risk for poor health may be impeded by three features of health care systems: the cost of care and its affordability for individuals, the administrative burden (or hassle) that people confront as they obtain and receive care, and disparities or inequities in the delivery of care based on income, educational attainment, race or ethnic background, or other nonclinical personal characteristics.

The first challenge the U.S. health care system must confront is lack of access to health care. The high-income countries that are top-ranked according to the most recent Fund report (the United Kingdom, Australia, and the Netherlands) offer universal insurance coverage with minimal out-of-pocket costs for preventive and primary care. Affordable and comprehensive insurance coverage is fundamental. If people are uninsured, some delay seeking care, some of those end up with serious health problems, and some of them die.

The second challenge is the relative underinvestment in primary care in the United States as compared with other countries. Other countries make primary care widely, and more uniformly, available. In contrast to the United States, a higher percentage of these countries’ professional workforce is dedicated to primary care than to specialty care, and they enable delivery of a wider range of services at first contact, even at night and on weekends.

The third challenge is the administrative inefficiency of the U.S. health care system. Both patients and professionals in the United States are baffled by the complexity of obtaining care and paying for it. Clinicians and their staff spend countless hours completing documentation to prove that insurance coverage is active, that benefits and services are covered, that services were delivered, and that payment or reimbursement occurred. Coping with the byzantine layers of administration results in high levels of burnout for doctors and other professionals, which can reduce the quality of care. The complexity also affects patients, who receive confusing benefit descriptions, limited information about doctors and hospitals, unintelligible and often unexpected (or “surprise”) bills for services, and unpredictable copayments at labs and pharmacies. It is possible to reduce these barriers to adherence and follow-up by reducing complexity for patients and clinicians: if we changed our reimbursement systems to use global payments, fee schedules, formularies, and defined benefits, it would make benefits and costs more predictable for patients and revenue more predictable for clinicians.

The fourth challenge is the pervasiveness in the United States of disparities in the delivery of care. People with low incomes, low educational attainment, and other social and economic challenges face greater health risks and worse health in all countries, but especially in the United States, which has a less robust social safety net than other high-income countries. Other countries achieve better population health by spending relatively more on social services than on medical care. Along with making insurance coverage available to the poor and ensuring that primary care has a strong presence, dedicating resources through social spending to stable housing, educational opportunities, nutrition, and transportation may reduce the demand for emergency, hospital, and long-term care services.

The United States could achieve the best-performing health care system in the world by undertaking coordinated efforts that address each of these challenges. Ensuring universal and adequate health insurance coverage, strengthening primary care, reducing administrative burden, and reducing income-related disparities by strengthening behavioral health and social service supports could go a long way toward improving the health of the U.S. population.


Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

By Eric C. Schneider, Dana O. Sarnak, David Squires, Arnav Shah, and Michelle M. Doty
The Commonwealth Fund, July 2017

The United States ranks last in health care system performance among the 11 countries included in this study. The U.S. ranks last in Access, Equity, and Health Care Outcomes, and next to last in Administrative Efficiency, as reported by patients and providers. Only in Care Process does the U.S. perform better, ranking fifth among the 11 countries.



By Don McCanne, M.D.

This NEJM Perspective article is based on the 2017 update of The Commonwealth Fund’s ranking of health care systems in eleven wealthy nations. Once again, the United states ranks last in overall performance, ranking at or near the bottom on access, administrative efficiency, equity, and health care outcomes.

Note particularly the four challenges described in the NEJM commentary: 1) Impaired access, 2) Underinvestment in primary care, 3) Pervasive administrative inefficiency, and 4) Disparities in the delivery of care. These are challenges for which a well designed single payer system would be ideally suited to address, but it must be part of a comprehensive public program addressing other factors contributing to our poor performance, especially in the need for social services.

Canada has a single payer system yet they rank ninth of the eleven systems. This is not a criticism of single payer financing itself, but rather it is a call to be certain that we elect public stewards who design and administer the single payer system with continuing oversight and appropriate intervention in not just the financing of the health care system but also in ensuring appropriate, comprehensive social services.

The authors of “Mirror, Mirror 2017” say that high performance can be achieved with any of three systems: national health service (United Kingdom), single payer (Australia, which requires supplemental insurance), and competing private insurers (Netherlands).

Well, the Netherlands, with its competing private insurers, ranks low in administrative efficiency. Australia requires a combination of public and private insurance and ranks low in equity, wherein varying ability to afford the private plans likely contributes to the inequity. The United Kingdom ranks first overall, but it is unlikely that Americans would support the transfer of our private health care delivery system to the government anytime soon.

So a well designed single payer system seems most appropriate for the United States, and the four challenges described make it clear that the need is urgent.


Speaking of a well designed single payer system, nobody has contributed more to our understanding of single payer and its role in achieving health care justice for all than have the co-founders of Physicians for a National Health Program - Steffie Woolhandler and David Himmelstein. Thus it is with great pride that we present the following announcement from Hunter College:

“Hunter College is proud to announce that David Himmelstein and Stephanie Woolhandler – esteemed teachers, brilliant scholars and front-line leaders in the field of public health – have been named Distinguished Professors by The City University of New York.

“’Nationally and around the world, Professors Himmelstein and Woolhandler are known and admired not only for their knowledge, research and expertise, but also for their forceful activism for quality health care,’ said Hunter President Jennifer J. Raab. ‘No one is more deserving of the designation ‘distinguished professor’ than these longtime collaborators.’”

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