US Healthcare during COVID- Lowest Performance, Highest Cost
The best of times for "the system", the worst of times for patients
Mirror, Mirror 2024: A Portrait of the Failing US Health System
Comparing Performance in 10 Nations
Commonwealth Fund Reports
SEPTEMBER 19, 2024
<RWM> Virtually all who read our essays and books, or listen to my many podcasts, are aware of the profound failures, medical mismanagement, notable ethical breaches, and deep corruption that characterize the medical system and public health response to the COVIDcrisis. We are also aware that the various branches of the US medical system, pharmaceutical-industrial complex and the US Government/HHS system has deployed a wide range of propaganda, censorship, and PsyWar tools and technologies to both block citizens and medical care providers from communicating about these failures and from proposing alternative solutions.
As an update on a long-standing, independent, survey-based assessment of the US healthcare system and its performance, the UK-based Commonwealth Fund has now published the results of its latest analysis of US Healthcare system performance, spanning 2021, 2022, and 2023, the key COVIDcrisis years. The title of the report is not hyperbole. Clearly, the US Healthcare system is failing to provide value for money, and is failing the citizens of the United States. Based on this analysis, combined with the preceding analyses, it is fair to conclude that the “Affordable Healthcare Act” (ACA), otherwise known as “Obamacare,” has been an abject failure. This federal interference in the US healthcare market has failed to achieve any of the intended objectives. It is well past time to reconsider the “Obamacare” approach to US Healthcare, and yet this is another topic that has been so thoroughly propagandized that almost no mention of the issues has been forthcoming during the ongoing Presidential election cycle campaigning.
So, let’s take a look at the issues that the Commonwealth Fund has just documented in this report, while recognizing a general UK bias towards socialized health care. The following is a selected subset of the report with some commentary. Those interested in additional details should take the time to dive into the full report, which is linked above and here.
Abstract
Goal: Compare health system performance in 10 countries, including the United States, to glean insights for U.S. improvement.
Methods: Analysis of 70 health system performance measures in five areas: access to care, care process, administrative efficiency, equity, and health outcomes.
Key Findings: The top three countries are Australia, the Netherlands, and the United Kingdom, although differences in overall performance between most countries are relatively small. The only clear outlier is the U.S., where health system performance is dramatically lower.
Conclusion: The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.
Healthcare Outcomes
<RWM> I think this is the most important of all the findings. Generally speaking, US Citizens are glad to pay more for longer, healthier lives. But in fact, we are paying the most of the ranked countries for the worst overall outcomes. This is the “money” graph. Paradoxically, it is the last of the summary graphics included in the report; perhaps the authors saved this for last because it provides the most compelling inditement. This graph essentially integrates outcomes from the entire US medical-industrial, pharmaceutical-industrial and federal public health service complex.
Health outcomes reported here refer to those outcomes that are most likely to be responsive to health care interventions. In this edition, we considered the impact of the pandemic by comparing performance on many measures before and after the start of the COVID-19 pandemic. We also examined specific COVID-related outcome measures. Outcome measures included: life expectancy at birth, excess deaths due to the pandemic, and deaths with preventable and treatable causes, which make up avoidable deaths. Across these measures, Australia, Switzerland, and New Zealand performed the highest among the 10 countries. The United States ranked last (Exhibit 9).
The U.S. ranks last on four of five health outcome measures. Life expectancy is more than four years below the 10-country average, and the U.S. has the highest rates of preventable and treatable deaths for all ages as well as excess deaths related to the pandemic for people under age 75. The ongoing substance use crisis and the prevalence of gun violence in the U.S. contribute significantly to its poor outcomes, with more than 100,000 overdose deaths and 43,000 gun-related deaths in 2023 — numbers that are much higher than in other high-income countries.25 The U.K. also struggled with COVID-19 outcomes but saw a slight decrease in treatable mortality. The Netherlands, while performing well in other domains, did not stand out for health outcomes compared to other countries.
Overall Healthcare System Performance
The United States ranks last overall. The three top-performing countries in 2024 are Australia, the Netherlands, and the United Kingdom.
Health Care Spending, and Price/Performance
<RWM> In terms of “Obamacare” and federal intervention in the healthcare marketplace, these findings clearly document the failure of this approach. Skyrocketing costs coupled with poor performance. Just as the Federal State has no Constitutionally-defined role or responsibilities for regulating the economy, it also has no Constitutionally-defined role or responsibilities for managing healthcare. In fact, under the US Constitutional system, the management of healthcare is the responsibility of the states, not the federal government. The logic of social engineering, socialism, and vague naive notions of “fairness” is what has lead us into this situation. What are we going to do to get relief from this truly unfair burden that the Federal State has imposed on its citizens?
While health care spending is not a measure of performance in the Mirror, Mirror 2024 rankings, it provides important context for our analysis. The United States is not just an outlier on health system performance; it’s an outlier on health care spending as well. In 1980, U.S. expenditures were at the high end of the distribution among the 10 nations studied, but comparable to outlays in Sweden and Germany (8.2% of GDP). Since then, however, the U.S. has far outpaced other nations, spending more than 16 percent of its GDP on health care in 2022 (Exhibit 3). That figure is predicted to exceed 20 percent by 2035.2 In 1980, the other countries included in this analysis spent between 4 percent and 8 percent of GDP, and had increased spending to between 8 percent and 12 percent by 2023.
The two countries with the highest overall rankings, Australia and the Netherlands, also have the lowest health care spending as a share of GDP (Exhibit 4). The other countries are clustered closely together — except for the U.S., which spends far more of its GDP on health care yet has by far the worst overall performance.
Access to Care
<RWM> With all of this expense and the programmatic “Obamacare” intention to increase healthcare access for all, what is the measured outcome for healthcare access? Once again, an abject failure. We are paying far more for far less accessibility.
Access to care focuses on the affordability and availability of health services at the population level. The Netherlands, the United Kingdom, and Germany perform best on access overall, and both the Netherlands and Germany rank at or near the top on the two components of affordability and availability (Exhibit 5). The U.K.’s health system is the top one for affordability.
The Netherlands, U.K., and Germany excel on measures of affordability because each country has low cost-related barriers to care, as reported by patients, and minimal out-of-pocket health care expenses. In these countries, universal coverage ensures that copayments for health services, if any, are small, guaranteeing both access and affordability.
In the Netherlands, visits to primary care, maternity care, and child health care providers are fully covered; other health care services are covered once patients pay their annual deductible.3 In the U.K., the National Health Service (NHS) provides free public health care, including hospital, physician, and mental health care.4
In Germany, copayments are capped at a fixed percentage of income — 2 percent of gross income for all patients, and 1 percent for chronically ill patients — above which all care is fully covered.5 In the U.S., the 2024 out-of-pocket limit for marketplace plans under the Affordable Care Act (ACA) cannot be more than $9,450 for single plans and $18,900 for family plans. Our 2023 international survey found that 41 percent of Americans spent $1,000 or more on health care out of pocket in the past year.
Both the Netherlands and Germany have also taken steps to ensure health services are available after regular office hours. In the Netherlands, general practitioners (GPs) must provide 50 hours of after-hours care annually, for which they’re compensated separately (as they also are for house calls).6 The Netherlands also has a system of local and regional GP posts that provide after-hours care and limit the need for emergency room visits. Most GPs are also part of networks that provide care during evenings or weekends. In Germany, physicians are required to offer after-hours care, with regulations varying from region to region.7
Australia, the top performer overall in this report, faired quite poorly when it came to access to care. Roughly half of Australian patients who do not choose to purchase voluntary health insurance may have to wait longer to receive services.8 Affordability is also a noted problem, although new billing incentives have led to improvement in recent years.9
In the U.S., lack of affordability is a pervasive problem. With a fragmented insurance system, a near majority of Americans receive their health coverage through their employer.10 While the ACA’s Medicaid expansions and subsidized private coverage have helped fill the gap, 26 million Americans are still uninsured, leaving them fully exposed to the cost drivers in the system. Cost has also fueled growth of private plan deductibles, leaving about a quarter of the working-age population underinsured. In other words, extensive cost-sharing requirements render many patients unable to visit a doctor when medical issues arise, causing them to skip medical tests, treatments, or follow-up visits, and avoid filling prescriptions or skip doses of their medications.
In terms of care availability, U.S. patients are more likely than their peers in most other countries to report they don’t have a regular doctor or place of care and face limited options for getting treatment after regular office hours. Shortages of primary care services add to these availability problems.
Administrative efficiency
<RWM> The data provided above clearly demonstrate the failure of “Obamacare” to meet its primary objectives of price/performance, affordability and access. But what about the experiences of medical providers under the Federal “Obamacare” system? U.S. physicians and patients are most likely to face hurdles related to insurance rules, billing disputes, and reporting requirements. The situation is maddening, burdensome, and is leading to an exodus of medical care providers who are retiring or opting out when possible.
Administrative efficiency focuses on measures of the challenges doctors have in dealing with insurance or medical claims issues; requirements for providers to report clinical or quality data to governmental agencies; and patients’ time spent resolving medical bill disputes and completing paperwork. Australia and the United Kingdom are virtually tied for the best performance on these measures (Exhibit 7). Switzerland and the U.S. come in last.
Australia and the U.K. excel in administrative efficiency by minimizing payment and billing burdens. In Australia, electronic claims processing ensures instantaneous payments from public and private payers. In the U.K., because services are free to patients at the point of care, physicians do not bill patients or the government directly for each service. Instead, they are compensated directly by the National Health Service based on monthly data gleaned from patients’ electronic health records.
Switzerland and the U.S. performed poorly on most of our administrative efficiency measures. Many patients in the U.S. are forced to deal with medical bill issues, and, in both countries, patients are comparatively more likely to seek treatment in emergency departments for conditions that are treatable in outpatient settings, like a primary care physician’s office.15
In the uniquely complex U.S. system of public and private payers — featuring thousands of health plans, each with its own cost-sharing requirements and coverage limitations — physicians and other health care providers spend enormous amounts of time and effort billing insurers. Denials of services by insurance companies are also common, necessitating burdensome appeals by providers and patients.16 The fragmentation of health care delivery across Switzerland’s many cantons and municipalities may also be hindering efficiency for providers and patients alike.17
Equity
<RWM> Price, availability, and “Equity” was how Obamacare was sold to us by the Administrative State. So how are things doing on the all-important (from a Socialist/Social engineering point of view) parameter of “Equity”?
Our Equity domain reflects how people with below-average and above-average incomes differ in their access to health care and their care experience. Australia and Germany rank highest for equity, meaning they are the countries with the smallest differences in health care access and care experiences between below-average and above-average income residents (Exhibit 8). New Zealand and the U.S. rank last on equity, having the highest income-related differences in reported cost-related access issues and instances of unfair treatment or feelings that health concerns were not taken seriously by health care professionals because of their racial or ethnic background.
High performers on equity, including Australia, Germany, and the United Kingdom, have limits on cost sharing (or in the case of the U.K., no cost sharing at all) to ensure that the ability to pay does not constitute a significant barrier to obtaining needed health services. In Germany, out-of-pocket expenses are capped, with the cost of coverage being income-based. And because health coverage is mandatory, nearly everyone has access to a regular doctor.
Australia offers free care in all public hospitals, and the nation’s universal Medicare system provides all Australians with coverage for all or part of the cost of GP and specialist consultations and diagnostic tests, with additional subsidies available for private hospital care.18 The country’s Pharmaceutical Benefits Scheme, meanwhile, regulates and subsidizes medication costs to keep them affordable.19
When we expanded the definition of equity to encompass geography and gender, country rankings changed notably. Switzerland shifted to first, Canada moved up to fifth, and Germany and Australia fell to fourth and sixth, respectively. Australia and New Zealand’s poor performance for rural versus nonrural respondents contributed to their lower rankings.20 Switzerland moved to first place as a result of its minimal disparities between rural and nonrural areas and between males and females. Switzerland’s small size, along with the nation’s extensive transit options and, as of 2015, increased funding for women’s health, led to improved performance, including fewer childbirth injuries and a higher rate of postpartum checkups.21
<RWM> In sum, this report clearly documents the abject and ongoing failure of the “Affordable Care Act”, otherwise commonly known as “Obamacare” to deliver on the promises and propaganda that have been used to sell this plan to US Citizens. How much longer are we going to tolerate this? How many more examples do we need to prove that the wisdom of that simple statement of Ronald Reagan:
"The nine most terrifying words in the English language are: I'm from the Government, and I'm here to help. "
It is long past time to re-think the role of the Administrative State and its Socialist bias. Each time it tries to sell us a new plan for advancing social equity, the outcome measures demonstrate that it makes things worse. A return to committing to the original structure and mandate of the State as defined in the founding documents of the US Constitution and Bill of Rights will require re-thinking and re-imagining the proper role of the State, which should be strictly limited. New Deal Socialism is a failure. Including the latest abomination called “Obamacare”. Stick a fork in it. It’s dead. We just need to have the courage to recognize this truth, and begin rebuilding based on foundational principles. It won’t be easy, but nothing worth doing ever is.