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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 May 26; 334(7603): 1078.
PMCID: PMC1877962

US comes last in international comparison of health systems

Three times in a row the US health system has come last in the US Commonwealth Fund's survey of health systems in six industrialised nations.

The United Kingdom was ranked first overall, scoring highest on quality, efficiency, and equity. In terms of “healthy lives”—measured by numbers of preventable deaths and life expectancy—Australia ranked highest.

The US and the UK had poor scores on indicators of healthy lives, the report said. Both countries had high mortality (in 1998) from treatable conditions. Mortality was 25% to 50% higher in the US and the UK than in Canada and Australia.

The US ranked last on the five dimensions of a high performance health system: quality, access, patients' safety, efficiency, equity, and healthy lives. The analysis drew results data from three international surveys of patients and primary care doctors.

The US performed best of all the countries in preventive care, “an area that has been monitored closely for over a decade by managed care plans,” the fund said.

The non-profit Commonwealth Fund, which works for improvements in health care, found that the US system did not achieve better health for its citizens than systems in the UK, Australia, Canada, Germany, and New Zealand—even though $6102 (£3100; €4540) is spent on health care for each citizen in the US, more than twice the median spend of $2571 in other countries in the Organization for Economic Cooperation and Development. The fund's comparisons in 2004 and 2006 showed similar results.

Unlike the other five industrialised countries in the comparison, the US does not have universal health insurance coverage. About 47 million US citizens, or about 16% of the population, do not have health insurance. While other countries provide citizens with a “medical home,” a long term tie to a general practitioner or family doctor, US citizens with insurance must often move from one doctor to another if they change jobs or if their company changes health insurance provider.

Karen Davis, president of the Commonwealth Fund, said that the US's “failure to insure health insurance for all and encourage stable, long term ties between physicians and patients shows in our poor performance on measures of quality, access, efficiency, equity, and health outcomes.”

“In light of the significant resources we devote to health care in this country,” Dr Davis added, “we should expect the best, highest performing health system.”

Without access to a family doctor many Americans did not seek care that could have been provided by a family doctor, or they went directly to an emergency department, the report says.

Americans with below average incomes were much less likely than similar people in other countries to visit a doctor when they were ill, the survey said. Because of costs, they were less likely to get a recommended test, treatment, or follow-up care, to fill a prescription, or to see a dentist.

The US is also way behind other countries in adopting information technology and national policies that promote quality improvement. Such sharing of information could lead to better management of chronic conditions and better coordination of care. The survey says that the US spent only $0.43 per person on health information technology in 2005, whereas in the UK the figure was $192 per person.

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Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care is available at

Articles from The BMJ are provided here courtesy of BMJ Publishing Group