US Healthcare System Data Microeconomics Discussion

Description

The Challenges of Healthcare in the USHow to best tackle healthcare has been a big theme of political debates for many years now. In this exercise you will look at data on how the US health care system compares to other rich countries’ systems and then consider which model could work best for us.Begin by opening this link: Mirror, Mirror 2021: https://lbcc.instructure.com/courses/81416/files/8498569?wrap=1Based on the information in the link answer the following questions:Exhibit 1 and 2. How does US healthcare performance compare to other high-income countries? In which area does it score well?Exhibit 3. How much did the US spend on health care as a percentage of GDP as of 2019 and how does this compare to other rich countries?From pages 7-9. summarize how the US does in each of the five categoriesNext, read this article: The Best Health Care System in the World: Which One Would You Pick?https://lbcc.instructure.com/courses/81416/files/8498564?wrap=1Based on this article, answer the following question:4. Which country seems to have a health care system that you would like to see in the US? Give reasons why you think it is best. You can also click on “Discuss your ideas in the comments” at the bottom of the article to see ideas posted by NYT readers. Some are very thoughtful.MIRROR, MIRROR 2021
Reflecting Poorly: Health Care in the U.S.
Compared to Other High-Income Countries
Eric C. Schneider
Arnav Shah
Michelle M. Doty
Roosa Tikkanen
Katharine Fields
Reginald D. Williams II
AUGUST 2021
AUGUST 2021
MIRROR, MIRROR 2021
Reflecting Poorly: Health Care in the U.S.
Compared to Other High-Income Countries
AUTHORS
ABSTRACT
Eric C. Schneider
Issue: No two countries are alike when it comes to organizing and
Arnav Shah
Michelle M. Doty
Roosa Tikkanen
Katharine Fields
Reginald D. Williams II
delivering health care for their people, creating an opportunity to learn
about alternative approaches.
Goal: To compare the performance of health care systems of 11 highincome countries.
Methods: Analysis of 71 performance measures across five domains —
TOPLINES
The United States trails far
behind other high-income
countries on measures of health
care affordability, administrative
efficiency, equity, and outcomes.
Lessons from the topperformers can inform the
United States and other
countries seeking to improve
their health care systems.
access to care, care process, administrative efficiency, equity, and health
care outcomes — drawn from Commonwealth Fund international
surveys conducted in each country and administrative data from the
Organisation for Economic Co-operation and Development and the
World Health Organization.
Key Findings: The top-performing countries overall are Norway, the
Netherlands, and Australia. The United States ranks last overall, despite
spending far more of its gross domestic product on health care. The U.S.
ranks last on access to care, administrative efficiency, equity, and health
care outcomes, but second on measures of care process.
Conclusion: Four features distinguish top-performing countries from
the United States: 1) they provide for universal coverage and remove cost
barriers; 2) they invest in primary care systems to ensure that high-value
services are equitably available in all communities to all people; 3) they
reduce administrative burdens that divert time, efforts, and spending
from health improvement efforts; and 4) they invest in social services,
especially for children and working-age adults.
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
INTRODUCTION
3
For our assessment of health care system performance
No two nations are alike when it comes to health
care. Over time, each country has settled on a
unique mix of policies, service delivery systems,
and financing models that work within its
resource constraints. Even among high-income
nations that have the option to spend more on
health care, approaches often vary substantially.
These choices affect health system performance
in terms of access to care, patients’ experiences
with health care, and people’s health outcomes.
In this report, we compare the health systems of
11 high-income countries as a means to generate
insights about the policies and practices that are
associated with superior performance.
With the COVID-19 pandemic imposing an unprecedented
stress test on the health care and public health systems of all
nations, such a comparison is especially germane. Success in
controlling and preventing infection and disease has varied
greatly. The same is true of countries’ ability to address the
challenges that the pandemic has presented to the workforce,
operations, and financial stability of the organizations
delivering care. And while the comparisons we draw are
based on data collected prior to the pandemic or during
the earliest months of the crisis, the prepandemic strengths
and weaknesses of each country’s preexisting arrangements
for health care and public health have undoubtedly been
shaping its experience throughout the crisis.
in Australia, Canada, France, Germany, the Netherlands,
New Zealand, Norway, Sweden, Switzerland, the United
Kingdom, and the United States, we used indicators
available across five domains:

Access to care

Care process

Administrative efficiency

Equity

Health care outcomes.
For more information on these performance domains
and their component measures, see How We Measured
Performance. Most of the data were drawn from surveys
examining how members of the public and primary care
physicians experience health care in their respective
countries. These Commonwealth Fund surveys were
conducted by SSRS in collaboration with partner
organizations in the 10 other countries. Additional
data were drawn from the Organisation for Economic
Co-operation and Development (OECD) and the World
Health Organization (WHO).
HOW THE 11 COUNTRIES RANK ON
PERFORMANCE
The top-performing countries overall are Norway, the
Netherlands, and Australia (Exhibit 1).
Exhibit 1. Health Care System Performance Rankings
AUS
CAN
FRA
GER
NETH
NZ
OVERALL RANKING
3
10
8
5
2
6
5
2
Care Process
6
4
10
9
3
1
Administrative Efficiency
2
7
6
9
8
Equity
1
10
7
2
Health Care Outcomes
1
10
6
7
Access to Care
8
9
7
3
SWIZ
UK
US
6
9
10
4
11
8
11
7
5
2
3
1
5
10
4
11
5
9
8
6
3
4
11
4
8
2
5
3
9
11
1
NOR SWE
1
7
4
11
Data: Commonwealth Fund analysis.
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
Change in Rankings Since the 2017
Edition of Mirror, Mirror
Readers familiar with the previous edition of this
report (2017) will notice that some of the country
ranks have changed. These changes should be
interpreted with caution. While most of the 71
measures included in the new edition are identical
to those used in 2017, 10 measures were modified
because survey items, response categories, or
available data changed. We replaced 17 of the
2017 measures with 16 new measures to reflect
newly available data as well as to better represent
previously defined performance domains and
subdomains. An expert advisory panel reviewed
the proposed changes. See Appendix 2 for more
detail on the changes by domain.
Readers should interpret changes in ranks in the
context of the statistical variation in countries’
performance scores (as visualized in Exhibit 2,
for example). We calculated performance
differences as the standard deviation from “average
performance” — a measure of the degree of
difference between countries given the range of
variation in this set of countries.
Depending on the domain, some countries have
quantitatively similar performance scores, meaning
that very small differences can produce changes
in rankings. The U.K.’s drop in rank from #1 to #4 is
associated with that country’s lower performance
on several domains (such as access to care and
equity) compared to 2017.
For more on the differences between the 2017 and
2021 editions of this report, please see How We
Conducted This Study.
commonwealthfund.org
4
The next three countries in the ranking — the U.K.,
Germany, and New Zealand — perform very similarly
to one another (Exhibit 2). The U.S. ranks #11 — last.
Exhibit 2 shows the extent to which the U.S. is an outlier:
its performance falls well below the average of the
other countries and far below the two countries ranked
directly above it, Switzerland and Canada. In fact, the
U.S. is such an outlier that we have calculated the average
performance based on the other 10 countries, excluding
the U.S. (see How We Measured Performance). The U.S. is
last on all domains of performance except care process, on
which it ranks #2.
Exhibit 3 shows that while spending as a share of gross
domestic product (GDP) has increased in all countries,
spending growth in the U.S. — by far the worst performer
overall — has greatly exceeded growth in the other 10
nations. In 1980, high-income countries spent between
5 percent and 8 percent of GDP on health care. But as
U.S. spending accelerated over the decades, the U.S. was
spending a substantially larger share of its GDP on health
care by 2019 than every other high-income country.
Exhibit 4 starkly shows just how much the U.S. is an outlier
from the other nations when its performance as a health
care system is compared to its spending as a share of GDP.
Access to Care
Universal, Affordable Coverage Is Paramount
Access to care includes measures of health care’s affordability
and timeliness. The Netherlands performs best on this
performance domain among the 11 countries, ranking at or
near the top in both subdomains. Norway and Germany also
performed well on access to care (Exhibit 1), but all three are
outranked on affordability by the U.K. (Exhibit 5).
Overall, the U.S. is #11 — last — on access to care (Exhibit 1).
The U.S. has the poorest performance on the affordability
subdomain, scoring much lower than even the next-lowest
country, Switzerland (Exhibit 5). Compared to residents
of the U.S., residents of the Netherlands, the U.K., Norway,
and Germany are much less likely to report that their
insurance denied payment of a claim or paid less than
expected. Residents of these countries are also less likely to
report difficulty in paying medical bills (Appendix 4).
People in the countries performing the best on the timeliness
subdomain are more likely to be able to get same-day care
and after-hours care. The U.S. ranked #9 on timeliness.
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
5
EXHIBIT 2
Comparative
Health Care System Performance Scores
Exhibit 2. Comparative Health Care System Performance Scores
Higher
performing
NOR
NETH
Top-3 average
AUS
UK
GER
NZ
10-country average
SWE
FRA
SWIZ
CAN
US
Lower
performing
Note: To normalize performance scores across countries, each score is the calculated standard deviation from a 10-country average that
excludes the US. See How We Conducted This Study for more detail.
Data: Commonwealth Fund analysis.
EXHIBIT
3
Note:
To normalize
performance scores across countries, each score is the calculated standard deviation from a 10-country average that excludes the US. See How We Conducted This Study for
more detail.
Data: Commonwealth Fund analysis.
Health
asas
a Percentage
GDP,
1980–2019
Exhibit
3. Care
HealthSpending
Care Spending
a Percentage ofof
GDP,
1980–2019
Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
Percent (%) of GDP
(Commonwealth Fund, Aug. 2021).
18
16
2019* data:
14
US (16.8%)
12
SWIZ (11.3%)
10
FRA (11.1%)
GER (11.7%)
SWE (10.9%)
8
CAN (10.8%)
NOR (10.5%)
6
UK (10.2%)
NETH (10.2%)
4
AUS (9.4%)
2
0
NZ (9.1%)
1980
1985
1990
1995
2000
2005
2010
2015
Notes: Current expenditures on health. Based on System of Health Accounts methodology, with some differences between country
methodologies. GDP refers to gross domestic product.
* 2019 data are provisional or estimated for Australia, Canada, and New Zealand.
Notes: Current expenditures on health. Based on System of Health Accounts methodology, with some differences between country methodologies. GDP refers to gross domestic product.
Data:
OECD Health Data, July 2021.
* 2019 data are provisional or estimated for Australia, Canada, and New Zealand.
Data: OECD Health Data, July 2021.
commonwealthfund.org
Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
(Commonwealth Fund, Aug. 2021).
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Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
6
EXHIBIT 4
Health Care System Performance Compared to Spending
Exhibit 4. Health Care System Performance Compared to Spending
0.40
Higher
health
system
performance
0.20
AUS
0.00
NZ
NETH
-0.20
NOR
GER
UK
SWE
FRA
-0.40
10-country average
SWIZ
CAN
-0.60
-0.80
Lower
health
system
performance
-1.00
-1.20
-1.40
US
0%
2%
4%
Lower health care
spending
6%
8%
10%
12%
14%
16%
18%
Higher health care
spending
Health care spending as a % of GDP
Notes: Health care spending as a percent of GDP. Performance scores are based on standard deviation calculated from the 10-country average
that excludes the US. See How We Conducted This Study for more detail.
Note: Health
care spending
as a from
percent
of GDP.for
Performance
based on in
standard
deviation calculated from the 10-country average that excludes the US. See How We Conducted This
Data:
Spending
data are
OECD
the yearscores
2019are
(updated
July 2021).
Study for more detail.
Data: Spending data are from OECD for the year 2019 (updated in July 2021).
EXHIBIT 5
Health Care System Performance Scores: Affordability
Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
(Commonwealth
Aug. 2021). Care System Performance Scores: Affordability
Exhibit
5.Fund,
Health
Higher
performing
UK
NETH
Top-3 average
NOR
GER
SWE
FRA
10-country average
NZ
CAN
AUS
SWIZ
US
Lower
performing
Note: To normalize performance scores across countries, each score is the calculated standard deviation from a 10-country average that
excludes the US. See How We Conducted This Study for more detail.
Data: Commonwealth Fund analysis.
commonwealthfund.org
Report August 2021
Note: To normalize performance scores across countries, each score is the calculated standard deviation from a 10-country average that excludes the US. See How We Conducted This Stud
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
7
Care Process
face during care. The top performers on the administrative
efficiency domain are Norway, Australia, New Zealand,
and the U.K. (Exhibit 1). The U.S. ranks last.
Care process includes measures of preventive care, safe care,
coordinated care, and engagement and patient preferences.
The U.S. ranks #2 on this performance domain (Exhibit 1).
Along with the U.K. and Sweden, the U.S. achieves higher
performance on the preventive care subdomain, which
includes rates of mammography screening and influenza
vaccination as well as the percentage of adults who
talked with their provider about nutrition, smoking, and
alcohol use. New Zealand and the U.S. perform best on
the safe care subdomain, with higher reported use of
computerized alerts and routine review of medications.
Still, in all countries, more than 10 percent of adults report
experiencing medical or medication mistakes in their care.
U.S. doctors are the most likely to have trouble getting their
patients medication or treatment because of restrictions
on insurance coverage. Compared to most of the other
countries, larger percentages of adults in the U.S. say they
spend a lot of time on paperwork related to medical bills.
For nonemergency care, U.S. and Canadian adults are also
more likely to visit the emergency department — a less
efficient option than seeing a regular doctor.
The U.S. Compares Favorably on Preventive Care,
Safe Care, and Engagement and Patient Preferences
New Zealand, Switzerland, and the Netherlands perform
best among countries on the coordinated care subdomain.
Switzerland, New Zealand, Australia, Norway, and France
perform well on measures related to communication
between primary care doctors and specialists. No country
stood out at achieving good communication between the
primary care and hospital, emergency department, and
home-based care provider or coordination with local social
services providers.
The U.S. and Germany achieve the highest performance
on the engagement and patient preferences subdomain,
although U.S. adults have the lowest rates of continuity
with the same doctor. Among people with chronic illness,
U.S. adults are among the most likely to discuss goals,
priorities, and treatment options with their provider,
though less likely to receive as much support from health
professionals as they felt was needed.
Use of web-based portals for communicating medical
concerns and refilling medications is highest among adults
in Norway and the U.S. In the year prior to the COVID-19
pandemic, primary care clinicians in Sweden and Australia
were the most likely to report using video consultations.
Administrative Efficiency
Many Countries Simplify Insurance Coverage,
Billing, and Payment
Administrative efficiency refers to how well health
systems reduce documentation (paperwork) and other
bureaucratic tasks that patients and clinicians frequently
commonwealthfund.org
Equity
Income-Related Disparities Are Largest in the U.S.,
Canada, New Zealand, and Norway
Our analysis of equity focuses on income-related disparities,
based on standardized data across the 11 countries, in the
access to care, care process, and administrative efficiency
performance domains. Similar standardized data are not
available for measuring equity in performance with respect
to different racial and ethnic groups (see How We Measured
Performance for more detail).
Australia, Germany, and Switzerland rank highest on the
equity domain, meaning these countries had the smallest
income-related disparities in performance based on the
included measures (Exhibit 6).
Within these countries, experiences reported by people
in lower- and higher-income groups on 11 indicators in
the affordability, timeliness, preventive care, safe care, and
engagement and patient preferences subdomains are less
divergent than they are within other countries (Appendix 7).
In contrast, the U.S. consistently demonstrated the largest
disparities between income groups, except for those
measures related to preventive services and safety of care.
U.S. disparities are especially large when looking at financial
barriers to accessing medical and dental care, medical bill
burdens, difficulty obtaining after-hours care, and use of
web portals to facilitate patient engagement. Compared to
the other countries, the United States and Canada had larger
income-related inequities in patient-reported experiences.
Exhibit 7 illustrates the importance of comparing country
performance on equity: relatively good performance on
a health care measure overall may mask pronounced
gaps in the experiences of lower-income versus higherincome groups. It also illustrates the challenge that arises
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Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
8
EXHIBIT 6
Health
Care System Performance Scores: Equity
Exhibit 6. Health Care System Performance Scores: Equity
Higher
performing
AUS
GER
Top-3 average
SWIZ
UK
NETH
10-country average
SWE
FRA
NOR
NZ
CAN
US
Lower
performing
Note: To normalize performance scores across countries, each score is the calculated standard deviation from a 10-country average that
excludes the US. See How We Conducted This Study for more detail.
Data: Commonwealth Fund analysis.
EXHIBIT 7
Cost-Related Access Problems Affect Low Income Populations,
Exhibit 7. Cost-Related Access Problems Affect Low-Income Populations,
Especially
in U.S.
the U.S.
Especially
in the
Note: To normalize performance scores across countries, each score is the calculated standard deviation from a 10-country average that excludes the US. See How We Conducted This Study
more detail.
Data: Commonwealth Fund analysis.
Percent who reported any cost-related access problem to medical care in past year, 2020
Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
(Commonwealth
Fund, Aug. 2021).
Lower income
Higher income
50
19
12
7
UK
14
14
6
6
NOR
FRA
20
21
24
19
GER
6
SWE
9
NETH
21
11
7
CAN
27
27
15
9
26
AUS
SWIZ
NZ
US
Definition of cost-related access problem: Skipped needed doctor visits, tests, treatments, follow-up, or prescription medicines because of cost
in the past year.
Definition
of cost-related
access problem:
Skipped
needed doctor
visits, tests,
treatments,
or prescription medicines because of cost in the past year.
Data:
2020
Commonwealth
Fund
International
Health
Policy
Surveyfollow-up,
of Adults.
Data: 2020 Commonwealth Fund International Health Policy Survey.
Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
commonwealthfund.org
(Commonwealth Fund, Aug. 2021).
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Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
9
in assessing equity without also considering performance
overall: income-related differences on a measure may be
small, but a nation’s performance may be comparatively
poor for both higher- and lower-income groups.
The U.S. ranks last overall on the health care outcomes
In Exhibit 7, income-related performance disparities
in Switzerland and Australia are as small as those in
Germany and the U.K. But the cost-related access problems
for higher-income residents of Switzerland and Australia
resemble the levels seen among lower-income residents of
the Netherlands and Canada. Adults with higher incomes
in the U.S., Switzerland, and Australia are as likely as,
or more likely than, adults with lower incomes in five
countries to report cost-related access problems.
mortality rate (5.7 deaths per 1,000 live births) and lowest
domain (Exhibit 1). On nine of the 10 component
measures, U.S. performance is lowest among the countries
(Appendix 8), including having the highest infant
life expectancy at age 60 (23.1 years). The U.S. ranks last
on the mortality measures included in this report, with
the exception of 30-day in-hospital mortality following
stroke. The U.S. rate of preventable mortality (177 deaths
per 100,000 population) is more than double the bestperforming country, Switzerland (83 deaths per 100,000).
The U.S. has exceptionally poor performance on two other
health care outcome measures. Maternal mortality is one:
Health Care Outcomes
the U.S. rate of 17.4 deaths per 100,000 live births is twice
Many Countries Achieve Better Outcomes Despite
Lower Spending
Health care outcomes reported here refer to those health
outcomes that are most likely to be responsive to health
care. On this domain, Australia, Norway, and Switzerland
rank at the top of our 11-nation group (Exhibit 1). Norway
has the lowest infant mortality rate (two deaths per 1,000
live births), while Australia has the highest life expectancy
after
age8 60 (25.6 years of additional life expectancy for
EXHIBIT
those who survive to age 60).
that of France, the country with the next-highest rate (7.6
deaths per 100,000 live births).
The second is the 10-year trend in avoidable mortality. As
depicted in Exhibit 8, all countries reduced their rate of
avoidable mortality over 10 years, but the U.S., with the
highest level in 2007, reduced it by the least amount —
5 percent reduction in deaths per 100,000 population by
2017 — compared to 25 percent in Switzerland (by 2017)
and 24 percent in Norway (by 2016).
Avoidable Deaths and Ten-Year Reduction
in Avoidable Mortality
Across8.Countries
Exhibit
Avoidable Deaths and Ten-Year Reduction in Avoidable Mortality Across Countries
Deaths per 100,000 population
280
240
2009 (or most recent year)
-5%
2019 (or most recent year)
200
160
120
-23%
-18%
-25%
-21%
-24%
-19%
-17%
-19%
-13%
-19%
80
40
0
SWIZ†
AUS*
SWE*
NETH*
NOR‡
FRA‡
NZ‡
CAN†
GER
UK‡
US†
Notes: Health status: avoidable mortality. Data years are: 2009 and 2019 (Germany); * 2008 and 2018 (Australia, the Netherlands, Sweden);
† 2007 and 2017 (Canada, Switzerland, US); and ‡ 2006 and 2016 (France, New Zealand, Norway, UK).
Data:
Commonwealth
analysis
of are:
data
from
Health
Statistics,
2021.
Notes: Health
status: avoidableFund
mortality.
Data years
2009
and OECD
2019 (Germany);
* 2008
and 2018 July
(Australia,
the Netherlands, Sweden); † 2007 and 2017 (Canada, Switzerland, US); and ‡ 2006
and 2016 (France, New Zealand, Norway, UK).
Data: Commonwealth Fund analysis of data from OECD Health Statistics, July 2021.
commonwealthfund.org
Source: Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
DISCUSSION
Some high-income nations get more for their health dollars than the U.S. does.
As nations strive for better health care and better health for their residents,
several basic lessons emerge from our findings.
Achieving better health outcomes will require policy changes
within and beyond health care.
The striking contrast in performance between the U.S. and other high-income
countries on avoidable mortality measures points to several intervention
or policy targets. How have top-performing countries reduced avoidable
mortality? A comparison of the features of top-performing countries and
poorer-performing countries suggests that top-performing countries rely on
four features to attain better and more equitable health outcomes:
1.
They provide for universal coverage and remove cost barriers so people can
get care when they need it and in a manner that works for them.
2.
They invest in primary care systems to ensure that high-value services are
equitably available locally in all communities to all people, reducing the
risk of discrimination and unequal treatment.
3.
They reduce the administrative burdens on patients and clinicians that
cost them time and effort and can discourage access to care, especially for
marginalized groups.
4.
They invest in social services that increase equitable access to nutrition,
education, child care, community safety, housing, transportation, and
worker benefits that lead to a healthier population and fewer avoidable
demands on health care.
10
Health Care Outcomes
vs. Health Outcomes
Health outcomes are
influenced by a wide variety
of social and economic
factors, many of them outside
the control of health care
systems. Policies and public
investments in education,
employment, nutrition,
housing, transportation, and
environmental safety shape
the health of the population.
Our report focuses on health
care outcome metrics —
those outcomes that can be
improved by the delivery of
health care services.
Compared to other OECD
countries, the U.S. spends
relatively less on social
programs such as early
childhood education, parental
leave, and income supports
for single parents. The
U.S. also spends less on
supports for workers, such as
unemployment protections
and labor market incentives.
Labor market policies in
particular have been linked to
so-called deaths of despair,
including suicides and
overdose deaths.
U.S. health outcomes could
therefore be improved
through actions targeting
factors beyond health care.
Accountable Communities
for Health offer one promising
approach to improving health
outcomes as well as equity.
commonwealthfund.org
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Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
11
Prioritizing maternal health is critical for reducing maternal mortality.
Top-performing countries have had success in preventing maternal deaths
through the removal of cost sharing for maternal care. They invest in primary
care models that ensure continuity of care from conception through the
postpartum period, including midwife-led models. They offer social support
benefits, including parental leave.
Several additional causes of avoidable mortality are linked to mental health.
Higher rates of suicide in the U.S. — rates that have increased every year
since 2000 — could be addressed by expanding the capacity of primary
care to diagnose comorbid mental health conditions and provide early
intervention and treatment as well as promote social connectedness and
suicide prevention. Compared to other countries, the U.S. has a comparatively
smaller workforce dedicated to meeting mental health needs. Countries like
the Netherlands, Sweden, and Australia more frequently include mental
health providers on primary care teams.
Improving access to care requires expanding
and strengthening insurance coverage.
The U.S. remains the only high-income country lacking
universal health insurance coverage. With nearly 30
million people still uninsured and some 40 million with
health plans that leave them potentially underinsured,
out-of-pocket health care costs continue to mar U.S. health
care performance.
Top-performing countries achieve near-universal coverage
and much higher levels of protection against medical
costs in the form of annual out-of-pocket caps on covered
benefits and full coverage for highly beneficial preventive
services, primary care, and effective treatments for
chronic conditions. Germany abolished copayments for
physician visits in 2013, while several countries have fixed
annual out-of-pocket maximums for health expenditures
(ranging from about USD 300 per year in Norway to USD
2,645 in Switzerland).
Australia addresses income-related equity through a mix
of annual spending caps that are lower for low-income
individuals as well as incentives for people to seek
primary care. In 2019, 86 percent of Australians faced no
out-of-pocket costs for primary care visits.
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Improving access to care requires strengthening primary care
and extending it to every local community.
Access to care, however, requires more than insurance
coverage. Convenient and timely primary care is also vital.
Top-ranking countries like the Netherlands and Norway
ensure timely availability to care by phone on nights and
weekends (with in-person follow-up at home as needed).
In the Netherlands, cooperative “GP posts” are staffed
by general practitioners (primary care physicians), who
are obligated to provide at least 50 hours of after-hours
care (between 5:00 pm and 8:00 am) annually in order
to maintain their professional licensure. In Norway,
the Patients’ Rights Act specifies a right to receive care
within specific timeframes and with maximum wait
times applying to covered services, including general
practitioner visits, hospital care, mental health care, and
substance use treatment.
In top-performing countries, workforce policy is geared
to ensuring access within communities, especially
those that have been historically marginalized. Norway, with the highest
number of doctors per person among the 11 countries in our study, has a
much larger supply of physicians relative to its population than the U.S. has.
Outside the U.S., a larger proportion of clinicians are devoted to primary care
and are geographically distributed to match population needs. For example,
Norwegian local municipalities, which are responsible for the supply of GPs,
may apply to the national government for extra funding to ensure they have an
adequate number of physicians.
Reducing administrative burden can free
up resources to devote to improving health.
Administrative requirements cost both time and
money for patients, clinicians, and managers
while also diverting resources away from efforts to
improve care. Our results are consistent with other
studies showing that administrative costs are more
substantial in the U.S. than in other high-income
countries. Many countries have simplified their
health insurance and payment systems, usually
through legislation, regulation, and standardization.
For example, top-ranked Norway determines
patient copayments for physician fees on a regional
basis, applying the standardized copayments to all
physicians practicing in the public sector within a
specialty within a geographic area.
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In countries where private insurance companies compete for customers, such
as the Netherlands, standards including a mandatory minimum basic benefit
package, community rating to keep premiums lower for sicker individuals,
and cost-sharing caps to simplify choice for beneficiaries. These features
create an incentive for insurers to compete on service and quality rather than
on avoidance of people with higher health risks, similar to the marketplace
insurance plans introduced by the Affordable Care Act. Germany and Canada
negotiate provider payments administratively, as the U.S. Medicare and
Medicaid programs do. As other countries have demonstrated, collective
negotiation and standardized payment for services, at either the national or
regional level, can greatly simplify transactions, reducing errors and appeals,
and making time and attention available to improve care.
Smarter spending — not more spending — is required to achieve
better health system performance.
The U.S. continues to outspend other nations on health
care, devoting nearly twice as much of its GDP as the
average OECD country. U.S. health spending reached
nearly 17 percent of GDP in 2019, far above the 10 other
countries compared in this report. Moreover, high U.S.
out-of-pocket health spending per person, the secondhighest in the OECD, makes it difficult for many Americans
to access needed care.
The U.S. has managed to keep pace with or exceed other
countries on several measures of care process included
in the report, such as influenza vaccination rates for
older adults, lower rates of postoperative sepsis after
abdominal surgery, and more use of patient-facing health
information technology for provider communications and
prescription filling. But the U.S. still lags other nations on
measures of health care outcomes, access to care, equity,
and administrative efficiency. What explains the apparent
disconnect?
First, many process measures focus on the care available to people who
actually have access to care. For example, a measure of care quality for
hospitalized patients focuses on those who had access to hospital care in the
first place and ignores those who died before reaching a hospital. It is possible
to deliver high-quality care to the population that has access to care and the
means to pay for it, while delivering poor-quality care to the smaller share
of the population that lacks those means. The result may be an average level
of performance overall, but a health system that nevertheless inadequately
serves the sickest and most vulnerable.
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Second, administrative barriers may disproportionately deter poorer and
marginalized individuals from receiving health services. Low-income people
who work long hours or those with limited health literacy or support from
family, friends, or neighbors may have difficulty navigating complex insurance
eligibility rules, a maze of application procedures, or getting online access. In
fact, this is why the U.S. is the only country among those compared here that
employs health navigators to help direct patients through both insurance and
the wider health care system.
Third, the relationship between health care outcomes and care process is
inevitably complex, especially if the population is less healthy because of
economic and social policies that produce inequities or fail to mitigate their
consequences. The U.S. population is sicker on average than the populations
of other high-income countries, with a high prevalence of chronic conditions
like obesity, diabetes, heart disease, and respiratory ailments. This disease
burden, coupled with insufficient access to care, partially explains the shorter
and declining life expectancy in the U.S. compared to other countries. Even
excellent care process, health information technology, and patient engagement
may be no match for insufficient access, administrative deterrents, and
inadequate chronic disease management. The high U.S. death toll during the
COVID-19 pandemic illustrates the difficulty of achieving good health care
outcomes if the population is sicker and access to preventive and primary care
is limited, particularly because of affordability barriers.
14
Additional Resources
Although the U.S. health
system has many unique
features, there are lessons
to be learned from countries
that succeed in ensuring
access to affordable,
quality care. That’s why the
Commonwealth Fund studies
health systems around the
world, seeks out policy and
practice innovations, and
compares health system
performance among the
U.S. and other high-income
nations. For more information
go to: https://www.
commonwealthfund.org/
international.
It appears, then, that the U.S. health system delivers too little of the care that’s
most needed — and often delivers it too late — especially for people with
complex chronic illness, mental health problems, or substance use disorders,
many of whom have faced a lifetime of inequitable access to care.
CONCLUSION
International comparisons allow the public, policymakers, and health care
leaders to see alternative approaches to delivering health care, ones that might
be borrowed to build better health systems that yield better health outcomes.
Lessons from the three top performers we highlight in this report — Norway,
the Netherlands, and Australia — can inform the United States and other
countries seeking to improve.
As the COVID-19 pandemic has amply shown, no nation has the perfect
health system. Health care is a work in progress; the science continues to
advance, creating new opportunities and challenges. But by learning from
what’s worked and what hasn’t elsewhere in the world, all countries have the
opportunity to try out new policies and practices that may move them closer
to the ideal of a health system that achieves optimal health for all its people at a
price the nation can afford.
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HOW WE MEASURED PERFORMANCE
Access to Care. The access to care domain encompasses
two subdomains: affordability and timeliness. The five
measures of affordability include patient reports of
avoiding medical care or dental care because of cost,
having high out-of-pocket expenses, facing insurance
shortfalls, or having problems paying medical bills. One
2017 measure was dropped (not available from a recent
survey).
The timeliness subdomain includes six measures (one
reported by primary care clinicians) summarizing
how quickly patients can obtain information, make
appointments, and obtain urgent care after hours. The
2021 report includes a new measure of the percentage
of respondents who received counseling or treatment
for mental health issues if they wanted or needed it. The
wording of two survey-based measures was modified since
2017. Five 2017 measures were not included. Two were not
available from a recent survey. Three other measures of wait
times were excluded because they were asked early in the
2020 COVID-19 pandemic and results were thought to be
unreliable.
Care Process. The care process domain encompasses
four subdomains relevant to health care for the general
population: preventive care, safe care, coordinated care,
and engagement and patient preferences.
The preventive care subdomain includes three survey
items related to counseling by health professionals
on healthy behaviors, three OECD measures of
mammography screening and influenza and measles
vaccination (new for the 2021 rankings), and three
OECD measures of rates (age- and sex-standardized) of
avoidable hospital admissions for three prevalent chronic
conditions: diabetes, asthma, and congestive heart failure.
The wording or timeframe differed slightly for three
measures. One 2017 measure was not available from a
recent survey.
The safe care subdomain includes three survey items:
two indicators of safe care based on patient reports
of experiencing medical, medication, or laboratory
mistakes, and failure to receive effective prescription
medication management, as well as one measure
indicating whether primary care doctors receive an
electronic alert or prompt to provide patients with test
results. One measure’s wording was modified since 2017.
Two OECD measures related to adverse events occurring
after hospital procedures are new in the 2021 report.
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The coordinated care subdomain uses seven measures to
summarize timely sharing of information among primary
care clinicians, specialists, emergency departments, and
hospitals. It includes five physician-reported measures of
effective communication among primary care clinicians
and home care, social service providers, and emergency
departments. Wording of four measures was modified
slightly since 2017.
The engagement and patient preferences subdomain
consists of 13 measures that evaluate the delivery of patientcentered care, which includes effective and respectful
clinician–patient communication and care planning that
reflects the patient’s goals and preferences. New measures
in the 2021 report include the percentage of chronically ill
patients who felt they got the support they needed from
health professionals to manage their health problems,
and three measures related to how patients and health
care professionals use health information technology (IT)
or video consultations. One 2017 measure was excluded
because it was not available from a recent survey.
Administrative Efficiency. The administrative efficiency
domain includes five measures. Four assess patients’ and
primary care clinicians’ reports of time and effort spent
dealing with paperwork or administrative issues, as well
as disputes related to documentation requirements of
insurance plans and government agencies. One patientreported measure evaluates barriers to care because
of limited availability of the regular doctor. Two 2017
measures were excluded because they were not included
in all of the countries surveyed.
Equity. The equity domain compares performance for
higher- and lower-income individuals within each country,
using 11 selected survey measures from the care process
and access to care domains. The analysis stratifies the
surveyed populations based on reported income (aboveaverage vs. below-average, relative to the country’s median
income) and calculates a percentage-point difference in
performance between the two groups. A larger percentagepoint difference represents lower equity between income
groups in that country. A negative percentage-point
difference indicates better performance among those with
below-average income. Two new 2021 measures are related
to patient use of health IT and one measure of patientreported levels of medical or medication mistakes. Two
2017 measures related to wait times were dropped and one
measure was unavailable from a recent survey (see access to
care, above).
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Health Care Outcomes. The health care outcomes domain
includes 10 measures of the health of populations
selected to focus on outcomes that can be modified by
health care (in contrast to public health measures such as
life expectancy at birth, which may be affected more by
social and economic conditions). The measures fall into
three categories:

Population health outcomes reflect the chronic disease
and mortality burden of selected populations.
We include two measures comparing countries
on mortality defined by age (infant mortality, life
expectancy at age 60) and one measure on the
proportion of nonelderly adults who report having
multiple common chronic conditions (arthritis,
asthma or chronic lung disease, diabetes, heart
disease, high blood pressure).

Mortality amenable to health care reflects deaths
under age 75 from specific causes that are considered
preventable in the presence of timely and effective
health care. In the 2021 edition of Mirror, Mirror we
dropped two previous measures replacing them
with new standardized and publicly available
OECD measures of mortality that consist of deaths
considered preventable through effective primary
prevention and other public health measures
(“preventable mortality”) and of deaths that were
considered treatable through more effective
and timely health care interventions (“treatable
mortality”).1 OECD combines these two measures to
report “avoidable mortality” — for which we report
the 10-year trend as an additional new measure.

Condition-specific health outcomes measures include
measures on 30-day in-hospital mortality following
myocardial infarction and stroke, as well as two new
measures in this section: maternal mortality and
deaths from suicide. We dropped two OECD measures
related to five-year cancer survival rates (breast and
colon), because recent data were not available.
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HOW WE CONDUCTED THIS STUDY
The 2021 edition of Mirror, Mirror was constructed using
the same methodological framework developed for the
2017 report in consultation with an expert advisory panel.2
Another expert advisory panel was convened to review the
data, measures, and methods used in the 2021 edition.3
Using data available from Commonwealth Fund
international surveys of the public and physicians and
other sources of standardized data on quality and health
care outcomes, and with the guidance of the independent
expert advisory panel, we carefully selected 71 measures
relevant to health care system performance, organizing
them into five performance domains: access to care,
care process, administrative efficiency, equity, and health
care outcomes. The criteria for selecting measures and
grouping within domains included: importance of the
measure, standardization of the measure and data across
the countries, salience to policymakers, and relevance
to performance-improvement efforts. We examined
correlations among indicators within each domain,
removing a few highly correlated measures. Mirror, Mirror
is unique in its inclusion of survey measures designed to
reflect the perspectives of patients and professionals —
the people who experience health care in each country
during the course of a year. Nearly three-quarters of the
measures come from surveys designed to elicit the public’s
experience of its health system.
Changes Since 2017
The majority of measures included in this report are the
same as in the 2017 edition of Mirror, Mirror (Appendix 2).
Seventeen measures were dropped if a survey question was
no longer included in the Commonwealth Fund International
Health Policy Survey or if we had reason to believe the
response to the measure might be less valid because of
effects of the COVID-19 pandemic, such as questions in
the timeliness subdomain related to wait times, which
were being fielded during the spring of 2020. Ten measures
were considered “modified” in the 2021 report because the
wording of a survey item was altered since the 2017 version.
We worked to include new measures to fill previously
identified gaps in performance measurement across the
11 countries and considered a wide array of potential new
measures related to topics such as quality of behavioral
and mental health care, hospital care, pediatric care,
and safety. We considered the data availability of new
measures, how recently they had been updated, and how
they correlated with other measures in each domain.
In the end we included 16 new measures across the five
domains (see How We Measured Performance for details).
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Data
Data for this report were derived from several sources.
Survey data are drawn from Commonwealth Fund
International Health Policy Surveys fielded during
2017, 2019, and 2020. Since 1998, in collaboration with
international partners, the Commonwealth Fund has
supported these surveys of the public’s and primary
care physicians’ experiences of their health care systems.
Each year, in collaboration with researchers in the
11 countries, a common questionnaire is developed,
translated, adapted, and pretested. The 2020 survey was
of the general population; the 2017 survey surveyed adults
age 65 and older. The 2020 and 2017 surveys examined
patients’ views of the health care system, quality of care,
care coordination, medical errors, patient–physician
communication, wait times, and access problems. The
2019 survey was administered to primary care physicians
and examined their experiences providing care to
patients, use of information technology, and use of teams
to provide care.
The Commonwealth Fund International Health Policy
Surveys (2017, 2019, and 2020) include nationally
representative samples drawn at random from the
populations surveyed. The 2017 and 2020 surveys’
sampling frames were generated using probability-based
overlapping landline and mobile phone sampling designs
and in some countries, listed or nationwide population
registries; the 2019 survey was drawn from government
or private company lists of practicing primary care
doctors in each country, except in France, where they
were selected from a nationally representative panel of
primary care physicians. Appendix 9 presents the number
of respondents and response rates for each survey, and
further details of the survey methods are described
elsewhere.4,5,6
In addition to the survey items, standardized data were
drawn from recent reports of the Organisation for
Economic Co-operation and Development (OECD) and the
World Health Organization (WHO). Our study included
data from the OECD on screening, immunization,
preventable hospital admissions, population health,
and disease-specific outcomes. WHO data were used to
measure health care outcomes.
Analysis
The method for calculating performance scores and rankings
is similar to that used in the 2017 report, except that we
modified the calculation of relative performance because the
U.S. was a distinct and substantial outlier (see below).
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Measure performance scores: For each measure, we
converted each country’s result (e.g., the percentage
of survey respondents giving a certain response or a
mortality rate) to a measure-specific, “normalized”
performance score. This score was calculated as the
difference between the country result and the 10-country
mean, divided by the standard deviation of the results for
each measure (see Appendix 3). Normalizing the results
based on the standard deviation accounts for differences
between measures in the range of variation among
country-specific results. A positive performance score
indicates the country performs above the group average;
a negative score indicates the country performs below the
group average. Performance scores in the equity domain
were based on the difference between higher-income and
lower-income groups, with a wider difference interpreted
as a measure of lower equity between the two income
strata in each country.
The normalized scoring approach assumes that results are
normally distributed. In 2021, we noted that the U.S. was
such a substantial outlier that it was negatively skewing
the mean performance, violating the assumption. In 2017,
we had included all 11 countries to calculate the mean
and standard deviation of each measure. After conducting
an outlier analysis (see below), we chose to adjust the
calculation of average performance by excluding the
U.S., using the other 10 countries as the sample group for
calculating the mean performance score and standard
deviation. This modification changes a country’s
performance scores relative to the mean but does not
affect the ranking of countries relative to one another.
Domain performance scores and ranking: For each country,
we calculated the mean of the measure performance
scores in that domain. Then we ranked each country from
1 to 11 based on the mean domain performance score,
with 1 representing the highest performance score and 11
representing the lowest performance score.
Overall performance scores and ranking: For each country,
we calculated the mean of the five domain-specific
performance scores. Then, we ranked each country from
1 to 11 based on this summary mean score, again with 1
representing the highest overall performance score and 11
representing the lowest overall performance score.
Outlier analysis: We applied Tukey’s boxplot method
of detecting statistical outliers and identified several
domains or subdomains (affordability, preventive care,
equity, and health care outcomes) in which the U.S. was a
statistical outlier. The test identified isolated instances of
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other countries as statistical outliers on specific measures,
but the pattern for other countries was inconsistent and
the outlier differences were smaller than in the U.S.
Sensitivity Analysis. We checked the sensitivity of the
results to different methods of excluding the U.S. as
an outlier (see above). We removed the U.S. from the
performance score calculation of each domain in which it
was a statistical outlier on at least one indicator (otherwise
keeping the U.S. in calculation of other domains where it
was not an outlier (see Appendix 3). In another sensitivity
analysis, we excluded the U.S. and other countries from
the domains in which they were outliers, but the results
were essentially similar.
We tested the stability of the ranking method by running
two tests based on Monte Carlo simulation to observe
how changes in the measure set or changes in the results
on some measures would affect the overall rankings. For
the first test, we removed three measure results from
the analysis at random and then calculated the overall
rankings on the remaining 68 measure results, repeating
this procedure for 1,000 combinations selected at random.
For the second test, we reassigned at random the survey
measure results derived from the Commonwealth Fund
International Health Policy surveys across a range of
plus or minus 3 percentage points — approximately
the 95 percent confidence interval for most measures —
recalculating the overall rankings based on the adjusted
data and repeating this procedure 1,000 times.
The sensitivity tests showed that the overall performance
scores for each country varied but that the ranks clustered
within several groups similar to that shown in Exhibit
2. Among the simulations, Norway, the Netherlands,
and Australia were nearly always ranked among the
three top countries; the U.S. was always ranked at the
bottom, while Canada, France, and Switzerland were
nearly always ranked between eighth and tenth. The
other four countries varied in order between the fourth
and seventh ranks. These results suggest that the selected
ranking method was only slightly sensitive to the choice of
indicators.
Four OECD indicators from the health care outcomes
domain (30-day in-hospital mortality rate following
acute myocardial infarction, 30-day in-hospital mortality
rate following ischemic stroke, maternal mortality, and
deaths from suicides) are included in the OECD measures
of treatable and preventable mortality. To evaluate the
potential impact of double-counting these four measures,
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we examined the correlations between each of the
four measures and the two composite measures and
recalculated the performance scores after removing these
four measures. The correlations were modest or low. We
found little difference in the overall performance scores
for the 11 countries after removing the four potentially
duplicative OECD indicators.
Limitations
This report has limitations. Some are particular to our
analysis, while some are inherent in any effort to assess
overall health system performance. No international
comparative report can encapsulate every aspect of a
complex health care system. As described above, our
sensitivity analyses suggests that country rankings in
the middle of the distribution (but not the extremes)
are somewhat sensitive to small changes in the data or
indicators included in the analysis.
Second, despite improvements in recent years,
standardized cross-national data on health system
performance are limited. The Commonwealth Fund
surveys offer unique and detailed data on the experiences
of patients and primary care physicians but do not capture
important dimensions that might be obtained from
medical records or administrative data. Furthermore,
patients’ and physicians’ assessments might be affected
by their expectations, which could differ by country and
culture. Augmenting the survey data with standardized
data from other international sources adds to our ability
to evaluate population health and disease-specific
outcomes. Some topics, such as hospital care and mental
health care, are not well covered by currently available
international data.
Third, we base our assessment of overall health system
performance on five domains — access to care, care
process, administrative efficiency, equity, and health care
outcomes — which we weight equally in calculating each
countries’ overall performance score. Other elements
of system performance, such as innovative potential or
public health preparedness, are important. We continue
to seek feasible standardized indicators to measure other
domains.
Fourth, in defining the five domains, we recognize that
some measures could plausibly fit within several domains.
To inform action, country performance should be
examined at the level of individual measures in addition
to the domains we have constructed.
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NOTES
ABOUT THE AUTHORS
1.
Organisation for Economic Co-operation and
Development (OECD), Avoidable Mortality: OECD/
Eurostat Lists of Preventable and Treatable Causes of
Death (November 2019 version).
2.
Eric C. Schneider et al., Mirror, Mirror 2017:
International Comparison Reflects Flaws and
Opportunities for Better U.S. Health Care
(Commonwealth Fund, July 2017).
3.
Members of the 2021 advisory panel include: Marc
Elliott, M.A., Ph.D., Distinguished Chair in Statistics
and Senior Principal Researcher, RAND Corporation;
Eric C. Schneider, M.D., M.Sc., is senior vice president
for policy and research at the Commonwealth Fund.
A member of the Fund’s executive management team,
Dr. Schneider provides strategic guidance to the
organization’s research on topics in policy, health services
delivery, and public health as well as scientific review
of initiatives, grants, projects, and publications. Prior to
joining the Fund, Dr. Schneider was principal researcher
at the RAND Corporation and he held the RAND
Distinguished Chair in Health Care Quality. From 1997,
he was a faculty member of the Harvard Medical School
and Harvard School of Public Health, where he taught
health policy and quality improvement in health care and
practiced primary care internal medicine at the Phyllis Jen
Center for Primary Care at Brigham and Women’s Hospital
in Boston. Dr. Schneider has held several leadership roles
including editor-in-chief of the International Journal
for Quality in Health Care, cochair of the Committee for
Performance Measurement of the National Committee
for Quality Assurance, member of the editorial board
of the National Quality Measures and Guidelines
Clearinghouses, as a member of the scientific advisory
board of the Institute for Healthcare Improvement, as
chair of the Performance Measurement Committee of the
American College of Physicians, and as a methodologist
on the executive committee of the Physician Consortium
for Performance Improvement of the American Medical
Association. Dr. Schneider holds an M.Sc. from the
University of California, Berkeley, and an M.D. from the
University of California, San Francisco. He is an elected
fellow of the American College of Physicians.
Niek Klazinga, M.D., Ph.D., Head of the Health Care
Quality Indicators (HCQI) Project, Organisation for
Economic Co-operation and Development Health
Division; Jennifer Nuzzo, Dr.P.H., Senior Scholar,
Johns Hopkins Center for Health Security; Irene
Papanicolas, Ph.D., Associate Professor of Health
Economics, Department of Health Policy, London
School of Economics and Political Science.
4.
Michelle M. Doty et al., “Income-Related Inequalities
in Affordability and Access to Primary Care in Eleven
High-Income Countries: 2020 Commonwealth Fund
International Health Policy Survey,” Health Affairs 40,
no. 1 (Jan. 1, 2021): 113–20.
5.
Michelle M. Doty et al., “Primary Care Physicians’ Role
in Coordinating Medical and Health-Related Social
Needs in Eleven Countries: Results from a 2019 Survey
of Primary Care Physicians in Eleven High-Income
Countries About Their Ability to Coordinate Patients’
Medical Care and with Social Service Providers,”
Health Affairs 39, no. 1 (Jan. 1, 2020): 115–23.
6.
Robin Osborn et al., “Older Americans Were Sicker
and Faced More Financial Barriers to Health Care
Than Counterparts in Other Countries,” Health Affairs
36, no. 12 (Dec. 1, 2017): 2123–32.
commonwealthfund.org
Arnav Shah, M.P.P., is a senior research associate for the
Commonwealth Fund’s policy and research department.
In this role, Mr. Shah provides support to a department
charged with adding value to the Fund’s work in all of
its core areas. Prior to joining the Fund, Mr. Shah was
a research assistant in the Health Policy Center of the
Urban Institute. From 2011 to 2012 he was a health policy
intern for the Center on Budget and Policy Priorities,
where he researched and wrote on the Affordable Care
Act, Medicare, Medicaid, and CHIP. During graduate
school he worked for the Center for Healthcare Research
and Transformation and the University of Michigan’s
Center for Value-Based Insurance Design. Mr. Shah holds
a master’s degree in public policy from the University of
Michigan’s Gerald R. Ford School of Public Policy.
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Michelle McEvoy Doty, Ph.D., is vice president of survey
research and evaluation for the Commonwealth Fund. She
has authored numerous publications on cross-national
comparisons of health system performance, access to
quality health care among vulnerable populations, and
the extent to which lack of health insurance contributes to
inequities in quality of care. Dr. Doty holds an M.P.H. and
a Ph.D. in public health from the University of California,
Los Angeles.
Roosa Tikkanen, M.P.H., M.Res., is a former senior research
associate for the Commonwealth Fund’s International
Health Policy and Practice Innovations program, where she
tracked health care policy developments in industrialized
countries; provided research support to and coauthored the
Fund’s annual international health policy surveys; provided
support for the International Issue Brief and Case Study
series; authored selected issue briefs and an annual OECD
data brief; coedited and coordinated the international
health policy newsletter; and prepared presentations for
the vice president. Before joining the Fund, she was a policy
analyst at the Center for Health Law and Economics at
Commonwealth Medicine based at UMass Medical School
in Boston. Ms. Tikkanen holds a B.Sc. in neuroscience and
an M.Res. in integrative biology from the University of
Manchester in England, and an M.P.H. from the Harvard
T.H. Chan School of Public Health. She is currently enrolled
in a four-year Ph.D. program in political science at the
Norwegian University of Science and Technology.
Katharine Fields, M.P.A., joined the Commonwealth Fund
in 2019 as program assistant in the International Health
Policy and Practice Innovations program. In this role, Ms.
Fields provides daily administrative support to the vice
president of the program, in addition to managing the
program’s grants, budgets, and assisting with the program’s
annual meetings. Prior to joining the Fund, she worked in
fundraising for a New York area art museum as well as for
a nonprofit theater organization. Ms. Fields holds a Master
of Public Administration degree from Baruch College and
earned her B.A. cum laude in historic preservation from the
University of Mary Washington.
commonwealthfund.org
20
Reginald D. Williams II is vice president of the
International Health Policy and Practice Innovations
program at the Commonwealth Fund. In this role, he is
responsible for fostering international dialogue, exchange,
and education that enables U.S. policymakers and health
care leaders to learn from cross-national experiences. Mr.
Williams is responsible for the organization’s international
benchmarking activities, its international research and
policy analysis, and the educational exchanges it conducts
with key international partners. Critical to all activities
is the cultivation of a robust international network of
senior policymakers and health care leaders, including the
Commonwealth Fund’s Harkness Fellowships in Health
Care Policy and Practice. Prior to joining the Fund, Mr.
Williams was at Avalere Health, a consulting firm dedicated
to improving health care, where he served as managing
director focusing on health care delivery innovation and
digital health. Prior to joining Avalere, he was a member of
the health policy team at the National Academy of Social
Insurance. He serves on the board of directors of Mental
Health America, a nonprofit dedicated to helping people
live mentally healthier lives. Mr. Williams earned an A.B. in
Biomedical Ethics from Brown University.
Editorial support was provided by Christopher Hollander.
ACKNOWLEDGMENTS
The authors would like to thank the members of the
2021 advisory panel (Marc Elliott, Niek Klazinga, Jennifer
Nuzzo, and Irene Papanicolas); our Commonwealth Fund
colleagues including David Blumenthal, Melinda Abrams,
Chris Hollander, Jen Wilson, Paul Frame, David Radley,
Jesse Baumgartner, and Gaby Aboulafia; and Rie Fujisawa
from OECD for their insights and assistance in producing
this report.
For more information about this report,
please contact:
Eric C. Schneider, M.D.
Senior Vice President for Policy and Research
The Commonwealth Fund
es@cmwf.org
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21
APPENDIX 1. Eleven-Nation Summary Scores on Health System Performance, 2021
AUS
CAN
FRA
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
OVERALL PERFORMANCE SCORE
0.22
-0.41
-0.16
0.03
0.23
0.02
0.28
-0.06
-0.20
0.07
-1.20
Access to Care
-0.59
-0.63
-0.30
0.62
1.06
-0.02
0.64
-0.27
-0.73
0.26
-1.36
Affordability
-1.06
-0.32
-0.10
0.45
0.81
-0.31
0.66
0.34
-1.32
0.92
-2.09
Timeliness
-0.12
-0.94
-0.51
0.79
1.32
0.26
0.63
-0.88
-0.15
-0.40
-0.64
Care Process
-0.02
0.11
-0.27
-0.18
0.20
0.56
-0.17
-0.28
-0.04
0.07
0.35
Preventive Care
0.15
0.31
-0.39
-0.64
-0.02
0.21
-0.15
0.42
-0.33
0.42
0.39
Safe Care
-0.25
0.16
-0.26
-0.27
0.22
1.03
-0.50
-0.32
-0.07
0.21
0.42
Coordinated Care
-0.20
-0.13
-0.27
-0.29
0.36
0.68
0.19
-0.59
0.38
-0.11
0.13
Engagement and
Patient Preferences
0.25
0.11
-0.15
0.49
0.23
0.31
-0.23
-0.63
-0.14
-0.25
0.47
Administrative Efficiency
0.51
-0.20
0.08
-0.69
-0.42
0.50
0.85
0.21
-1.10
0.25
-1.54
Equity
0.74
-0.77
-0.32
0.59
-0.01
-0.49
-0.37
-0.13
0.54
0.23
-1.69
Health Care Outcomes
0.45
-0.58
0.02
-0.19
0.29
-0.46
0.45
0.15
0.32
-0.46
-1.76
Note: The US is excluded from the performance score calculation of the other 10 countries. See How We Conducted This Study for more detail.
APPENDIX 2. Number of Measures per Domain: 2017 vs. 2021 Mirror Mirror Reports
Total number
of measures
in 2017
Added
in 2021
Modified
in 2021
Dropped
in 2021
Total number
of measures
in 2021
Access to Care
16
1
2
6
11
Affordability
6
0
0
1
5
Timeliness
10
1
2
5
6
Care Process
29
7
8
2
34
Preventive Care
9
1
3
1
9
Safe Care
3
2
1
0
5
Coordinated Care
7
0
4
0
7
Engagement and
Patient Preferences
10
4
0
1
13
Administrative Efficiency
7
0
0
2
5
Equity
11
3
0
3
11
Health Care Outcomes
9
5
0
4
10
Total
72
16
10
17
71
Domain
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APPENDIX 3. Calculation of Mean Performance Scores: Adjusting for Outliers
Overall performance score
excluding US from calculation
of every domain mean scorea
Overall score
if US is includedb
Overall score if US is excluded
only from domains in which
it is a statistical outlier on
one or more measuresc
AUS
0.22
0.24
0.24
CAN
-0.41
-0.22
-0.36
FRA
-0.16
-0.02
-0.11
GER
0.03
0.17
0.08
NETH
0.23
0.35
0.27
NZ
0.02
0.14
0.03
NOR
0.28
0.33
0.29
SWE
-0.06
0.06
-0.05
SWIZ
-0.20
-0.10
-0.14
UK
0.07
0.19
0.08
US
-1.20
-1.12
-1.20
Notes: In Mirror, Mirror 2021, the US performance score is calculated using mean and standard deviation derived from the 10 non-US countries.
Under this scenario, the US was excluded from calculation of all domain mean scores because it was a statistical outlier on some measures
within the affordability, preventive care, equity, and health care outcomes domains/subdomains. We also tested an approach that excluded the
US only from those domains in which the US was a statistical outlier (scores in the rightmost column). a Approach used in this report; b Approach
used in the 2017 report; c Domain-specific exclusion approach (not used in this report).
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APPENDIX 4. Access to Care
Raw data
Indicator
Source
Performance score (excluding US)
AUS
CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
AUS
1 Had any cost-related access problem 2020 CMWF
to medical care in the past year
Survey
21
14
11
11
9
18
8
11
2 Skipped dental care or check up
because of cost in the past year
2020 CMWF
Survey
32
27
19
19
10
37
21
3 Insurance denied payment for
medical care or did not pay as much
as expected
2020 CMWF
Survey
17
17
15
13
9
4
4 Had serious problems paying or was
unable to pay medical bills
2020 CMWF
Survey
9
7
10
4
5
5 Out-of-pocket expenses for medical
bills more than USD 1,000 in the past
year, USD equivalent
2020 CMWF
Survey
28
17
10
16
11
CAN
FRA
GER NETH
NZ
NOR SWE
SWIZ
UK
23
10
38
-1.43 -0.15 0.48 0.58
0.79
-0.77 1.01
22
26
21
36
-1.10 -0.50 0.66 0.57
1.76
-1.81 0.27
2
4
17
3
34
-1.17
0.17
0.98 1.24 0.88
8
6
8
9
4
22
-0.99 -0.04 -1.47 1.40
0.76 -0.35 0.35 -0.23 -0.92
12
12

55
7
44
-0.63
0.54
US
0.52
-1.81
0.77 -2.50
0.17
-0.40 0.37 -1.43
Affordability
Subdomain score for Affordability
-1.03 -0.76 -0.43
0.11
0.60
0.15
0.41 0.45

-1.04
1.18
-2.34
1.48 -2.77
-2.43 0.80 -1.39
-1.06 -0.32 -0.10 0.45
0.81 -0.31 0.66 0.34 -1.32 0.92 -2.09
Timeliness
6 Have a regular doctor or place
of care
2020 CMWF
Survey
93
90
95
96
99
96
100
87
93
97
89
-0.39 -1.16
0.33
1.12
0.40 1.32 -1.95 -0.39 0.53
7 Regular doctor always or often
answers the same day when
contacted with question
2020 CMWF
Survey
61
65
63
83
82
67
77
72
78
65
70
-1.26 -0.77 -1.03 1.45
1.27
-0.51 0.73
8 Saw a doctor or nurse on the same
or next day, last time they needed
medical care
2020 CMWF
Survey
65
38
53
75
66
61
47
33
53
52
49
0.84 -1.25 -0.08 1.58
0.93
0.48 -0.57 -1.66 -0.07 -0.20 -0.38
9 Somewhat or very difficult to obtain
after-hours care
2020 CMWF
Survey
43
57
54
51
26
42
31
54
49
59
51
0.30 -0.95 -0.68 -0.41
1.84
0.39 1.47 -0.65 -0.20
-1.11 -0.34
10 Primary care practice has
arrangement for patients to see
doctor or nurse after hours without
going to ED
2019 CMWF
Survey
69
48
75
96
90
92
91
77
56
84
45
-0.54 -1.84 -0.18
1.14
0.75
0.89 0.81 -0.06 -1.36
0.39 -1.65
11 In past 12 months, received
counseling or treatment for mental
health, among respondents who
wanted/needed to talk with health
professional about mental health
2020 CMWF
Survey
44
44
32
46
56
41
41
34
44
33
40
0.30 0.34 -1.25 0.68
2.00
-0.12 0.00 -1.07
-1.22 -0.15
0.18
0.12
0.79
0.33
-1.18
-0.79 -0.17
Subdomain score for Timeliness
-0.12 -0.94 -0.51 0.79
1.32
0.26 0.63 -0.88 -0.15 -0.40 -0.64
Domain score for Access to Care
-0.59 -0.63 -0.30 0.62
1.06
-0.02 0.64 -0.27 -0.73
0.26
Notes: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are
included when calculating its score. — No data for Sweden.
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-1.36
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APPENDIX 5A. Care Process — Preventive Care
Raw data
Indicator
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
AUS
CAN
FRA
GER
NETH
NZ
NOR SWE SWIZ
UK
US
2020 CMWF
Survey
30
26
16
23
11
22
15
18
17
21
46
1.80
1.11
-0.63 0.46
-1.66
0.34 -0.82 -0.31 -0.48
0.18
2.49
13 Talked with provider about health risks
2020 CMWF
of smoking and ways to quit in the
Survey
past year, among smokers
55
49
57
30
35
62
23
28
35
46
62
0.95 0.50
1.10
-0.85 -0.49
1.50
-1.39 -1.07 -0.52 0.27
1.29
14 During the past 12 months, talked
with doctor or other health care
2020 CMWF
professional about your alcohol use,
Survey
among respondents who drink heavily
13
11
8
7
6
17
5
13
9
17
20
0.52
-0.50 -0.85 -1.07
1.43
-1.36 0.51 -0.36
1.52
1.73
15 Women ages 50–69 with
mammography screening in the past
two years
OECD
55
62
49
50
76
72
72
90
49
75
77
-0.73 -0.20 -1.13
-1.04
0.79
0.46
0.47
1.79
-1.12
0.72
0.76
16 Children (age 1 and under) with
measles vaccination in past year
OECD
95
90
90
97
93
92
96
97
96
92
92
0.44 -1.39 -1.39
1.17
-0.29 -0.66 0.80
1.17
0.80 -0.66 -0.62
17 Older adults (age 65+) with influenza
vaccination in the past year
OECD

60
52
39
61
62
38
53

72
71

18 Avoidable hospital admissions for
diabetes, age-sex standardized rates
per 100,000
OECD
153
96
151
206
59
148
70
76
107
81
19 Avoidable hospital admissions for
asthma, age-sex standardized rates
per 100,000
OECD
63
14
30
32
37
65
21
16
25
20 Avoidable hospital admissions for
congestive heart failure, age-sex
standardized rates per 100,000
OECD
214
168 266 394
153
216
166
12 Talked with provider about healthy
diet, exercise and physical activity in
the past year
Subdomain Score for Preventive Care
Source
Performance score (excluding US)
0.16
0.46 -0.23 -1.35
0.56
0.62
-1.40 -0.16

1.50
1.15
226
-0.81 0.39 -0.76 -1.92
1.17
-0.70 0.93 0.82
0.16
0.71
-1.80
75
37
-1.16
1.10
0.28
0.04
-1.26
0.75 0.97 0.58
-1.68
0.03
227 403 108
412
0.18
0.65 -0.35 -1.65
0.80
0.15
0.66 0.05 -1.74
1.25
-1.52
0.15
0.31
-0.39 -0.64 -0.02
0.21
-0.15 0.42 -0.33
0.42
0.39
0.37
Notes: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are
included when calculating its score. — No data for Australia or Switzerland.
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Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
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APPENDIX 5B. Care Process — Safe Care
Raw data
Indicator
Performance score (excluding US)
Source
AUS
CAN
FRA
GER
NETH
NZ
NOR SWE
2020 CMWF
Survey
13
10
10
12
10
10
15
22 Primary care physician receives alert
2019 CMWF
or prompt to provide patients with test
Survey
results using computerized system
69
40
23
18
16
47
23 Health care professional did not
review medications in past year,
among those taking two or more
prescription medications
2020 CMWF
Survey
25
24
57
31
41
24 Postoperative sepsis after abdominal
surgery, rate per 100k hospital
discharges
OECD
3996
1473

2526
25 Postoperative pulmonary embolism in
hip and knee replacement discharges,
rate per 100k hospital discharges
OECD
523
525
267
347
21 Experienced a medical or medication
mistake in the past two years
Subdomain Score for Safe Care
SWIZ
UK
US
AUS CAN FRA GER NETH NZ
12
12
11
13
-0.96 0.77 0.83 -0.24 1.25 0.72 -2.05 -0.56 -0.11 0.37 -0.57
41
28
33
56
69
1.88
24
48
49
30
24
16
0.82 0.87 -1.77 0.37 -0.48 0.90 -0.99 -1.10 0.43 0.94 1.34
1507
421
1551
764
2036
3773 1045
-1.62 0.43
211
152
357
405
402
347
-1.40 -1.42 0.72 0.05 1.18
1.67 -0.03 -0.42 -0.40 0.06 -0.93
-0.25 0.16 -0.26 -0.27 0.22
1.03 -0.50 -0.32 -0.07 0.21
478
NOR SWE SWIZ
UK
0.17 -0.82 -1.13 -1.24 0.58 0.21 -0.54 -0.22 1.11

-0.42 0.40 1.29 0.37
US
1.53
1.01 -0.03 -1.43 0.72
0.42
Notes: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are included
when calculating its score. — No data for France.
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APPENDIX 5C. Care Process — Coordinated Care
Raw data
Indicator
Source
Performance score (excluding US)
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
AUS
CAN
FRA
GER NETH
NZ
NOR SWE SWIZ
UK
US
26 Primary care doctor usually or often
receives a report with the results of
the visit within 1 week after patient
sees specialist
2019 CMWF
Survey
43
50
66
47
61
52
72
45
73
26
65
-0.69 -0.22 0.87 -0.46 0.52 -0.12 1.27 -0.61 1.32 -1.87 0.71
27 Primary care doctor usually or often
receives information about changes
to a patient’s medication or care plan
after patient sees specialist
2019 CMWF
Survey
94
87
96
73
88
97
92
76
90
96
82
0.64 -0.23 0.85 -1.90 -0.06 0.98 0.36 -1.56
28 Specialist lacked medical history or
regular doctor not informed about
specialist care in the past two years
2020 CMWF
Survey
24
28
34
27
28
19
30
25
25
35
29
0.67 -0.16 -1.35 0.18 -0.15 1.82 -0.46 0.44 0.62 -1.60 -0.37
29 Experienced gaps in hospital
discharge planning in the past two
years
2020 CMWF
Survey
38
36
47
51
31
28
64
50
39
40
24
0.37 0.56 -0.41 -0.84 1.08
1.40 -1.98 -0.70 0.33
30 Primary care physician is usually
notified when patient is seen in ED
2019 CMWF
Survey
40
48
24
40
84
85
55
14
46
66
48
-0.44 -0.09 -1.14 -0.45 1.44
1.51
31 Primary care physician usually
communicates with home-based
nursing care providers about patients’
needs and services to be provided
2019 CMWF
Survey
14
24
36
29
27
18
43
46
32
30
33
-1.56 -0.60 0.61 -0.09 -0.32 -1.17
32 Practice frequently coordinates care
with social services or community
providers
2019 CMWF
Survey
38
42
21
74
47
52
57
12
51
65
40
-0.42 -0.19 -1.33 1.50 0.05 0.31 0.58 -1.80 0.29
1.01 -0.30
-0.20 -0.13 -0.27 -0.29 0.36 0.68
-0.11
Subdomain score for Coordinated Care
0.11
0.81 -0.79
0.19
1.43
0.22 -1.55 -0.19 0.70 -0.09
1.32
1.61
0.22 -0.01 0.29
0.19 -0.59 0.38
0.13
Note: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are
included when calculating its score.
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27
APPENDIX 5D. Care Process — Engagement and Patient Preferences
Raw data
Indicator
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
AUS CAN FRA GER NETH NZ
2020 CMWF
Survey
87
83
81
89
87
79
77
52
82
72
86
0.71 0.39 0.21 0.96 0.76 0.00 -0.16 -2.50 0.29 -0.67 0.57
34 Regular doctor always or often spent enough time
2020 CMWF
with them and explained things in a way they could
Survey
understand
84
78
76
84
85
82
75
63
82
68
80
0.86 0.00 -0.19 0.87 0.97 0.57 -0.40 -1.97 0.62 -1.33 0.29
33 Regular doctor always or often knew important
information about their medical history
Source
Performance score (excluding US)
NOR SWE SWIZ UK
US
35 With same doctor for five years or more
2020 CMWF
Survey
49
57
61
71
71
51
57
46
61
64
43
-1.14 -0.28 0.28 1.39 1.48 -0.92 -0.16 -1.47 0.24 0.56 -1.51
36 Doctors always treated the patient with courtesy
and respect during their hospital stay
2020 CMWF
Survey
75
74
87
72
83
85
72
74
69
73
71
-0.19 -0.40 1.73 -0.67 1.09
37 Nurses always treated the patient with courtesy
and respect during their hospital stay
2020 CMWF
Survey
73
71
85
70
79
84
79
76
74
71
69
-0.51 -0.92 1.63 -1.21 0.47 1.47 0.46 0.03 -0.45 -0.98 -1.16
38 Chronically ill patients discussed with health
professional their main goals and priorities in
caring for their condition in the past year
2020 CMWF
Survey
63
61
44
73
58
59
46
55
59
59
73
0.66 0.42 -1.65 1.90 -0.01 0.14 -1.38 -0.34 0.15
39 Chronically ill patients discussed with health
professional their treatment options, including
side effects in the past year
2020 CMWF
Survey
56
59
42
61
51
52
38
41
54
55
67
0.66 1.02 -1.13 1.28 0.04 0.16 -1.62 -1.26 0.34 0.50 1.64
40 Chronically ill patients who feel they definitely have
2020 CMWF
had as much support from health professionals as
Survey
needed to help manage health problems
68
61
66
66
66
68
58
48
62
61
55
0.93 -0.28 0.58 0.60 0.59 0.94 -0.72 -2.35 -0.01 -0.27 -1.05
41 Had a written plan describing treatment they want
at the end of life, among adults age 65 and older
2017 CMWF
Survey
33
43
13
62
16
18
4
5
36
15
53
0.47 1.00 -0.62 2.03 -0.46 -0.35 -1.11 -1.04 0.60 -0.52 1.33
42 Had a written plan naming someone to make
treatment decisions for them if they cannot do so,
among adults age 65 and older
2017 CMWF
Survey
49
63
18
68
18
33
7
7
37
32
64
0.74 1.37 -0.69 1.60 -0.69 -0.01 -1.23 -1.22 0.17 -0.05 1.27
43 In past two years, used a secure website, patient
portal, or mobile app to communicate/email
with regular practice about medical question or
concern
2020 CMWF
Survey
9
7
5
6
9
20
32
24
7
12
37
-0.46 -0.63 -0.90 -0.74 -0.45 0.80 2.07 1.18 -0.70 -0.16 1.92
44 In past two years, used a secure website, patient
portal, or mobile app to request Rx refills from
regular practice
2020 CMWF
Survey
6
7
5
7
16
19
40
28
4
22
34
-0.81 -0.68 -0.89 -0.69 0.07 0.29 2.05 1.03 -0.96 0.60 1.32
45 PCP or other health care professionals in practice
frequently or occasionally use video consultations
2019 CMWF
Survey
25
16
10
4
4
9
12
33
4
9
20
1.27 0.37 -0.31 -0.89 -0.88 -0.35 -0.04 2.12 -0.89 -0.40 0.74
1.31 -0.70 -0.35 -1.23 -0.59 -0.77
0.11
1.56
Subdomain score for Engagement and Patient Preferences
0.25
0.11 -0.15 0.49 0.23 0.31 -0.23 -0.63 -0.14 -0.25 0.47
Domain score for Care Process
-0.02 0.11 -0.27 -0.18 0.20 0.56 -0.17 -0.28 -0.04 0.07 0.38
Note: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are included
when calculating its score.
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
28
APPENDIX 6. Administrative Efficiency
Raw data
Indicator
AUS CAN FRA GER NETH
NZ
46 Primary care doctors report time spent on
2019 CMWF
administrative issues related to insurance
Survey
or claims is a major problem
27
25
43
52
44
31
11
81
47 Primary care doctors report time spent
getting patients needed medications
or treatment because of coverage
restrictions is a major problem
2019 CMWF
Survey
12
33
16
45
35
13
7
48 Primary care doctors report time spend
on administrative issues related to
reporting clinical or quality data to
government or other agencies is a major
problem
2019 CMWF
Survey
15
14
19
44
37
25
49 Patients who visited ED for a condition
that could have been treated by a regular 2020 CMWF
doctor, had he/she been available, in past
Survey
2 years
30
39
25
28
31
50 Spent a lot of time on paperwork or
disputes related to medical bills
5
6
12
6
5
Domain score for Administrative Efficiency
Source
Performance score (excluding US)
2020 CMWF
Survey
NOR SWE SWIZ
UK
US
AUS CAN FRA GER NETH NZ
NOR SWE SWIZ
61
34
58
0.69 0.79 -0.11 -0.56 -0.15 0.52 1.49 -1.98 -1.01 0.34 -0.77
12
22
24
63
0.78 -0.88 0.48 -1.87 -1.08 0.69 1.25 0.81 0.01 -0.18 -2.21
22
15
42
24
36
0.94 1.00 0.61 -1.61 -1.01 0.07 0.35 0.95 -1.44 0.14 -0.86
26
28
28
36
31
39
0.00 -1.95 1.28 0.47 -0.27 0.95 0.52 0.56 -1.33 -0.23 -1.58
5
4
3
12
2
19
0.16 0.02 -1.83 0.12 0.42 0.26 0.63 0.72 -1.72 1.21 -2.28
0.51 -0.20 0.08 -0.69 -0.42 0.50 0.85 0.21
UK
US
-1.10 0.25 -1.54
Note: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are
included when calculating its score.
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
29
APPENDIX 7. Equity
Indicator
Source
Raw data
Raw data
Below-average income
Above-average income
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
ACCESS TO CARE — Affordability
51 Had any cost-related access problem to
medical care in the past year
2020 CMWF
Survey
24
21
14
15
20
27
14
19
26
12
50
19
7
6
9
9
11
6
6
21
7
27
52 Skipped dental care or check up because of
cost in the past year
2020 CMWF
Survey
35
40
26
23
19
45
28
29
34
27
51
30
16
11
17
8
33
16
17
18
18
21
53 Had serious problems paying or was unable to
pay medical bills
2020 CMWF
Survey
10
13
16
9
12
14
11
16
14
7
36
5
2
3
2
3
4
2
2
3
3
9
54 Somewhat or very difficult to obtain after-hours
care
2020 CMWF
Survey
48
64
57
55
35
53
43
54
49
62
58
42
55
50
51
24
41
26
53
48
59
44
55 Have a regular doctor or place of care
2020 CMWF
Survey
94
89
96
96
98
96
100
87
95
97
85
94
94
95
94
99
97
100
86
92
99
92
56 Talked with provider about healthy diet, exercise 2020 CMWF
and physical activity in the past year
Survey
34
26
16
26
15
26
15
19
20
25
46
27
30
19
20
9
20
16
17
15
17
47
16
14
12
14
17
10
24
17
12
16
17
10
9
9
13
7
9
8
11
10
11
9
ACCESS TO CARE — Timeliness
CARE PROCESS — Preventive Care
CARE PROCESS — Safe Care
57 Experienced a medical or medication mistake in 2020 CMWF
the past two years
Survey
CARE PROCESS — Engagement and Patient Preferences
58 Regular doctor always or often spent enough
time with them and explained things in a way
they could understand
2020 CMWF
Survey
86
75
73
84
81
71
72
61
82
65
74
87
80
83
84
88
89
79
64
85
72
85
59 Regular doctor always or often knew important
information about their medical history
2020 CMWF
Survey
84
81
80
87
84
71
83
59
81
68
81
89
86
85
89
90
85
78
48
82
75
90
60 In past two years, used a secure website,
patient portal, or mobile app to communicate/
email with regular practice about medical
question or concern
2020 CMWF
Survey
10
6
3
5
9
21
32
19
6
10
30
9
9
8
9
9
22
33
26
7
12
48
61 In past two years, used a secure website,
patient portal, or mobile app to request request
prescription refills from regular practice
2020 CMWF
Survey
6
7
4
7
16
18
39
24
4
21
29
6
8
5
8
15
21
43
28
3
26
42
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
30
APPENDIX 7. Equity (continued)
Percentage-point difference between
above-average and below-average income*
Indicator
Source
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
Performance score (excluding US)
UK
US
AUS
CAN
FRA GER NETH
NZ
NOR
SWE SWIZ
UK
US
-1.26 0.33 0.64 -0.48 -1.66 0.25 -0.84 0.86 1.08
-2.18
ACCESS TO CARE — Affordability
51 Had any cost-related access problem to
medical care in the past year
2020 CMWF
Survey
5
14
8
7
11
16
8
13
6
5
23
1.10
52 Skipped dental care or check up because of
cost in the past year
2020 CMWF
Survey
5
25
15
6
10
12
12
12
16
8
29
1.32 -2.22 -0.49 1.06 0.30 0.03 -0.04 0.06 -0.67 0.65 -2.12
53 Had serious problems paying or was unable to
pay medical bills
2020 CMWF
Survey
6
11
13
7
9
9
9
14
10
4
27
1.14
-0.61 -1.16 0.70
54 Somewhat or very difficult to obtain after-hours
care
2020 CMWF
Survey
6
9
7
3
11
12
18
0
1
3
15
0.17
-0.31 0.09 0.68 -0.80 -0.95 -1.92
55 Have a regular doctor or place of care
2020 CMWF
Survey
-1
5
-1
-2
1
1
0
-1
-3
2
7
0.27
-2.17 0.60 0.94 -0.30 -0.55 0.04 0.52
56 Talked with provider about healthy diet, exercise 2020 CMWF
and physical activity in the past year
Survey
-7
3
2
-6
-5
-6
1
-2
-5
-7
1
1.03
-1.62 -1.39 0.61
6
5
3
1
10
1
16
6
2
5
8
-0.09 0.04 0.52 1.01 -0.96 1.02 -2.26 -0.15 0.78 0.10 -0.48
0.12 -0.08 0.03 -1.52 -0.37 1.74 -2.64
ACCESS TO CARE — Timeliness
1.19
1.11
0.74 -1.22
1.35 -0.71 -2.03
CARE PROCESS — Preventive Care
0.53
0.57 -1.02 -0.26 0.53 1.03 -0.84
CARE PROCESS — Safe Care
57 Experienced a medical or medication mistake in 2020 CMWF
the past two years
Survey
CARE PROCESS — Engagement and Patient Preferences
58 Regular doctor always or often spent enough
time with them and explained things in a way
they could understand
2020 CMWF
Survey
1
5
11
0
8
18
7
3
3
7
11
1.03
59 Regular doctor always or often knew important
information about their medical history
2020 CMWF
Survey
4
5
5
3
5
14
-4
-11
0
7
8
-0.23 -0.30 -0.35 0.02 -0.36 -1.68 1.06
2.05 0.38 -0.59 -0.76
60 In past two years, used a secure website,
patient portal, or mobile app to communicate/
email with regular practice about medical
question or concern
2020 CMWF
Survey
-1
3
5
3
0
1
1
6
1
2
18
1.24 -0.40 -1.27 -0.61 0.99
0.62
-1.83 0.43 0.23 -2.76
61 In past two years, used a secure website,
patient portal, or mobile app to request request
prescription refills from regular practice
2020 CMWF
Survey
-1
1
0
1
-1
3
3
4
0
5
13
1.13
0.28 0.50 0.24
-0.57 -0.77 -1.27 0.93 -1.62 -2.59
0.74
-0.77 -0.32 0.59 -0.01 -0.49 -0.37 -0.13 0.54 0.23
Domain score for Equity
0.13 -0.86 1.20 -0.31 -2.20 -0.09 0.68 0.57 -0.15 -0.92
1.15
0.61
-1.69
* A higher percentage-point difference means larger inequity between people with below-average income and those with above-average income. A negative performance score means worse performance among those with belowaverage income.
Note: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are included when
calculating its score.
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
31
APPENDIX 8. Health Care Outcomes
Raw data
Indicator
Performance score (excluding US)
Source
AUS CAN FRA GER NETH
NZ
NOR SWE SWIZ
UK
US
AUS
CAN
OECD
3.3
4.4
3.8
3.2
3.6
4.7
2
2.1
63 Adults age 18 to 64 with at least two 2020 CMWF
common chronic conditions
Survey
11
16
6
10
7
11
13
7
64 Life expectancy at age 60 in years
WHO
25.6 25.2 25.3 24.4
24.1
65 Treatable mortality, deaths per 100k
OECD
46
56
48
62
66 Preventable mortality, deaths per
100k
OECD
93
116
105
67 10-year trend in avoidable mortality,
deaths per 100k
OECD
-31
-34
68 30 day in-hospital mortality
rate following acute myocardial
infarction, deaths per 100 patients
OECD
3.2
69 30 day in-hospital mortality rate
following ischemic stroke, deaths
per 100 patients
OECD
70 Maternal mortality, deaths per
100,000 live births
71 Deaths from suicides, deaths per
100,000 population
FRA
GER NETH
NZ
NOR
SWE SWIZ
UK
US
3.3
3.7
5.7
0.13
-1.15 -0.45 0.24 -0.22 -1.50 1.64
8
10
21
-0.46 -1.96
1.35
24.8 24.7 24.5 25.4 24.1 23.1
1.47
0.96 -0.74 -1.34 0.03 -0.28 -0.57
49
62
47
49
39
69
88
0.73 -0.36 0.51
113
96
106
98
91
83
119
177
0.76
-36
-27
-35
-51
-46
-37
-41
-45
-14
-0.99 -0.58 -0.31 -1.53 -0.45 1.72
6.4
7.2
8.3
4
7.7
6.4
6.8
8.9
8.1
9.3
1.91
5.4
9.2
7.1
6.2
5.7
11.7
7.8
9.8
8.2
12
4.1
1.24 -0.38 0.52 0.90
OECD
3.9
7.5
7.6
3.2
5.3
6.6
0.0
5.2
6.8
6.5
17.4
0.58 -0.95 -0.99 0.87 -0.02 -0.57 2.23 0.03 -0.65 -0.53 -2.57
OECD
12.3
11.0
12.3
9.2
10.0
12.0
11.6
12.2
11.3
7.3
14.5
-0.84 -0.05 -0.84 1.05
0.56 -0.66 -0.42 -0.78 -0.23 2.21
0.45 -0.58 0.02
0.29 -0.46 0.45
Population Health
62 Infant mortality, deaths per 1,000
live births
0.61
0.16
1.52
0.13 -0.34 -1.94
0.90 -0.24 -1.07 0.88 0.55
-0.11 -2.29
1.12
-1.25 -2.11
0.62 0.40
1.49
-1.77 -2.33
-1.19 -0.25 -0.93 0.51 -0.34 0.34 0.93
1.61
-1.44 -2.70
Mortality Amenable to Health Care
-1.01
0.40
-1.01
1.04 -0.18 0.37
0.91
-2.18
Condition-Specific Health Outcomes
Domain score for Health Care Outcomes
0.16 -0.27 -0.87
-0.19
1.47 -0.54 0.16 -0.05 -1.20 -0.76 -1.24
1.11
-1.44 0.22 -0.63 0.05 -1.57
0.15
1.49
-1.72
0.32 -0.46 -1.76
Note: “Performance score” is based on the distance from the 11-country average, measured in standard deviations. The US is excluded from the performance score calculation of the other 10 countries. US results are
included when calculating its score.
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
32
APPENDIX 9. Sample Sizes of Commonwealth Fund International Health Policy Surveys
SAMPLE SIZES
AUS
CAN
FRA
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
2017 Commonwealth Fund International Health Policy Survey of Older Adults
2,500 4,549
750
751
750
500
750
7,000 3,238
753
1,392
2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
500
2,569 1,287
809
788
503
661
2,411
1,001
1,576
2020 Commonwealth Fund International Health Policy Survey of Adults
2,201 5,089 3,028 1,004
753
1,003
607
2,513 2,284 1,991 2,488
Adults ages 18–64
1,438 3,615 2,240
706
506
737
397
1,597
1,746
1,370
1,912
Adults with a regular doctor or place of care
2,073 4,698 2,880
973
748
961
607
2,227
2,117
1,951
2,215
Adults who saw or needed to see specialist in the past two years
1,350 2,820 2,061
772
390
456
338
1,255 1,279
974
1,498
Adults with a regular doctor or place of care and who saw or needed to see specialist in the past two years
1,311
2,683 1,991
752
389
454
338
1,152
1,212
962
1,402
Adults who wanted/needed to talk with health professional about mental health
662
1,452
591
183
158
234
129
653
470
552
987
Adults who were hospitalized in past two years
467
726
546
269
110
168
120
436
433
352
410
Adults with at least one of the following chronic conditions: asthma or chronic lung disease; diabetes; heart
disease, including heart attack; hypertension or high blood pressure
929
1,980
959
403
300
332
225
898
627
758
1,043
Adults who take two or more prescription medications regularly
901
2,179
971
396
300
321
251
1,109
785
825
1,251
Adults who smoke/use tobacco every day or some days
289
971
763
271
157
123
153
514
565
414
460
Adults who have had 4–5 alcoholic drinks on one occasion monthly, weekly, daily, or almost daily in the past year
638
1,267 1,042
286
280
335
177
535
677
737
515
Adults with below-average income
822
1,632
1,165
347
140
222
163
639
1,061
587
1,100
Adults with above-average income
741
2,066 1,096
407
420
488
323
1,235
670
803
903
Adults with below-average income with a regular doctor or place of care
777
1,481
1,116
337
138
213
163
576
1,002
575
943
Adults with above-average income with a regular doctor or place of care
694
1,952 1,030
386
417
474
323
1,076
610
796
833
2017 Commonwealth Fund International Health Policy Survey of Older Adults
25%
23%
24%
19%
52%
26%
15%
29%
45%
22%
19%
2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
15%
39%
20%
15%
49%
16%
34%
42%
43%
27%
21%
2020 Commonwealth Fund International Health Policy Survey of Adults
18%
17%
23%
24%
25%
14%
19%
30%
49%
14%
14%
1,095
Equity
RESPONSE RATES
Note: This appendix shows the sample size in each country for each survey, as well as the sample sizes for any indicators with restricted bases. Data for the indicators used in the Equity domain come from the 2020
Commonwealth Fund International Health Policy Survey of Adults and are stratified between respondents who reported having below-average and above-average income.
commonwealthfund.org
Report August 2021
Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries
33
APPENDIX 10. Measure Descriptions and Source Notes
Note on measures from Commonwealth Fund International
Health Policy Surveys: Base includes full sample of survey
unless indicated otherwise.
Note on linked vs. unlinked OECD measures: A number of
OECD indicators can be calculated using either unlinked
or linked data. Unlinked data refers to hospital data used
for indicator calculation that come from a single hospital
admission. These data are not linked to other hospital
admissions or death outside the hospital using a unique
patient identifier. Linked data refers to hospital data used
for indicator calculation that are linked to other hospital
admissions or death outside the hospital using a unique
patient identifier. When both versions were available for a
country, we included the linked data. Unlinked data was
included for countries where linked data was not available.
For more detail see: OECD Health Care Quality and Outcomes
(HCQO) 2018–19 Data Collection: Guidelines for Filling in the
Data Collection Questionnaires and Using SAS Programs.
5.
Timeliness
6.
Percent of adults who had a regular doctor or place of
care. Source: 2020 Commonwealth Fund International
Health Policy Survey of Adults.
7.
Percent of adults whose regular doctor or place of
care “always” or “often” answered the same day when
contacted with a question. Base: Has a regular doctor
or place of care. Source: 2020 Commonwealth…
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