The 2022 Commonwealth Report - A Deeper Look (Part One)

What does the report actually tell us about US healthcare?

The latest Commonwealth Fund Report entitled “US Health Care from a Global Perspective” was released on January 31st. In case you haven’t heard, the US has the most expensive healthcare and the worst outcomes. No surprise here: the tag line is “Accelerated Spending, Worsening Outcomes.” Per usual, the report (released annually) is bouncing its way through the echo chamber and stoking angst. I’m not here to refute the idea that American healthcare is too expensive, too inaccessible, too opaque, and of variable quality. It’s an unwinnable argument. But, though I probably shouldn’t, I take the idea that the quality of care in the US is poor compared to other wealthy countries personally. It’s hard not to when you’re on the frontlines delivering care and when you actually give a damn about the quality of your work (as I believe many of my fellow frontline healthcare workers do). I have also developed a distaste for agenda-pushing, manipulative “reports” that come to a conclusion then manipulate their findings to fit that conclusion. These same reports are frequently (mis)used by those with ulterior motives — motives that have nothing to do with fixing healthcare and everything to do with getting a slice of the pie.

Nothing against the Commonwealth Fund. Their annual report has become yearly fuel for the “American healthcare is terrible” crowd and those curious about the idea of a single payer system. Again, this article is not meant to be a Pollyanna defense of what is clearly a system in need of (a lot of) improvement. The goal here, rather, is to spur some critical thought and help us move past the constant re-hashing of the same arguments (flawed or otherwise) that stoke outrage but don’t advance the conversation. Reports such as this one have their place, but too often the results are used to reach conclusions that the data and methodology simply don’t support. Rather than accepting the lead (“Accelerating Spending, Worsening Outcomes”) at face value, it’s important to parse the report to determine what it actually tells us. It’s a long report (and I’ve been somewhat busy with my day job of late), so I’m breaking it down in two parts. With that, let’s dig into Part One.

To set the stage, the Commonwealth Fund describes their report as a “cross-national comparison of health care systems to assess U.S. health spending, outcomes, status, and service relative to Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom.” In addition, the report compares the US system to 38 high-income OECD countries for which data is available. The main goal of the report is to measure the US against the 12 aforementioned countries with a focus on outcomes and quality.

From the start, it’s worth wondering if the whole premise here is a bit flawed. The US has by far the largest population (330 million) of the countries included. Japan is a distant second at 126 million, one third the size of the US. All of the other countries have populations under 100 million including Australia (25 million), the Netherlands (17 million), Sweden (10 million), Switzerland (8.6 million), and New Zealand (4.8 million). For reference, 12 US states have populations of 8.5 million or greater, and two states (California and Texas) have populations larger than Australia.

Not only does the US have the largest population, but it’s also one of the most ethnically diverse on the list. Countries such as Japan, Sweden, the Netherlands, the United Kingdom, Norway, France, and Germany have highly homogenous populations. To be fair, the map above is old (2013) and ethnic/cultural diversity can be difficult to measure accurately. The point here is that comparing a country with a large, diverse population to countries with smaller, more homogenous populations may not be an apples-to-apples comparison. A scientific study is only going to lead to valid conclusions if confounding variables are controlled for and population demographics are appropriately matched. Similarly, the differences here raise serious concerns about the generalizability of health outcomes from one country to the next. A reasonable counterpoint is that any wealthy country should be able to deliver high-quality, cost-effective care to its citizens. A larger population means more resources and, as diverse as we are, Americans generally agree that access to healthcare is a basic human right. Income disparity and social determinants of health are a significant contributor to our healthcare struggles.

Finally, it’s worth noting that some of the countries on the list are experiencing their own struggles. Depending on what you read, Britain’s revered NHS has been in crisis mode for years and was recently described as a “war zone.” Australia has had its own issues with healthcare costs. Just like in the US, Australian patients are skipping care and not filling medication prescriptions due to costs. This comprehensive breakdown of the Canadian system highlights challenges of access and suggests that Canadians are less confident in their system than Americans.

The US spends a higher percentage of its GDP on healthcare than any other country, 17.8%, with the next closest being Germany at 12.8%. The OECD average is almost half that number (9.6%). There’s no way to spin or sugar-coat this, so I won’t. We spend too much on healthcare. The complex reasons behind this are beyond the scope of my intent here — any may be beyond the scope of general comprehension.

Another one that’s not a good look for us. The US is the only country on the list that does not guarantee health insurance coverage. As of 2021, 12 states continued to refuse Medicaid expansion and 8.6% of the population was uninsured. So, not only is our healthcare too expensive, but it also leaves too many patients without coverage. No one would rationally debate that the US system has cost and access problems, but what about quality and outcomes?

Our lower life expectancy (a full 3 years below OECD average) is a frequently quoted statistic when criticizing outcomes of the US system. Despite all the money we spend, we die earlier — ostensibly due to the poor quality of care delivered. But is life expectancy an accurate surrogate for healthcare outcomes? Is a lower life expectancy the result of poor quality? Is our lower life expectancy reflective of the shortcomings of American medicine or something else? The answer depends in no small part on why Americans die younger than their counterparts from other countries. More on this later.

Avoidable deaths are defined here as those that can are preventable (through public health measures and maintaining a healthy lifestyle) and treatable after onset (through timely and effective interventions. Again, the US scored poorly on this metric though it’s worth noting that the number jumped significantly from 2019 to 2020 (likely due to COVID-related deaths). Even ignoring this large jump, the US has had an avoidable death rate much higher than comparators since the beginning of the millennium. The list of conditions the OECD considers preventable and treatable is extensive and includes injuries, alcohol-related deaths, and drug-related deaths. With such a broad range of conditions, little context, and lack of granularity, it’s hard to determine how much of this difference is due to poor care quality or factors that represent a mix of societal issues, public health issues, and care delivery issues. Can a higher avoidable death rate be appropriately attributed to bad care alone?

Part Two will hopefully answer these questions. Additional data in the report suggests that our performance is considerably influenced by some factors that are beyond the control of healthcare providers.