U.S. Healthcare from a Global Perspective in 2022

healthcare-industry-reports-in-the-united-states

U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes

A doctor and nurses treat a patient in Germany, by a door with a sign reading “Exit” and an arrow.

A doctor and nurses treat a patient on November 18, 2021, at University Hospital in Leipzig, Germany. Germany spends less on health care per person than the U.S., yet life expectancy at birth is nearly four years higher. Photo: Jens Schlueter/Getty Images

The U.S. spends nearly 18% of its GDP on healthcare, yet Americans die younger and are less healthy than citizens of other high-income countries.
The U.S. not only has the lowest life expectancy among high-income countries, but it also has the highest rates of preventable deaths.

Munira Z. Gunja, Evan D. Gumas, Reginald D. Williams II

Introduction

In the previous edition of U.S. Health Care from a Global Perspective, we reported that the U.S. had the worst overall health outcomes among high-income countries.¹ Americans die at younger ages and from avoidable causes compared with residents of peer nations. Between January 2020 and December 2021, life expectancy declined in the U.S. and in other countries.² Since the pandemic remains an ongoing threat to global health and well-being, we updated our international comparison of health systems using 2019 data. We compared U.S. health spending, outcomes, status, and health care utilization with Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom. In addition, we compared the performance of the U.S. health system with the average of 38 high-income countries using currently available OECD data. For our analysis, data were taken from the Organisation for Economic Co-operation and Development (OECD) and other international sources (see details in theBu Çalışmayı Nasıl Yürüttük“How We Conducted This Study” section). We used the most recent data available for each metric we examined. This means that results for certain countries may reflect the peak period of the COVID-19 pandemic; during this period, mental health conditions increased, essential health services were disrupted, and patients may not have received care at the same level.³

Key Findings

Health spending, both per capita and as a share of GDP, is much higher in the U.S. than in other high-income countries. However, the U.S. is the only country without universal health coverage.
The U.S. has the lowest life expectancy at birth, the highest death rates for preventable or treatable conditions, some of the highest maternal and infant death rates, and some of the highest suicide rates.
The U.S. has the highest rate of people living with multiple chronic conditions and an obesity rate nearly twice the OECD average.
Americans see doctors less often than people in most other countries and have among the lowest rates of practicing physicians and hospital beds per 1,000 people.
While the U.S. has among the highest rates of breast and colon cancer screening and influenza vaccination, its COVID-19 vaccination rate lags behind many countries.

Findings

Health Care Spending and Coverage

In all countries, health spending has risen faster than economic growth since the 1980s.⁴ This increase has been driven by medical technologies, rising prices in the health sector, and greater demand for services.⁵ When the COVID-19 pandemic began in 2020, health spending rose rapidly in nearly all countries, as governments tried to contain the spread of the disease through COVID testing, vaccine development, relief funds, and other measures.⁶ Since then, spending growth has slowed, but it still remains higher than in previous years.⁷ In 2021, the U.S. devoted 17.8% of its gross domestic product (GDP) to health spending, nearly twice the average of OECD countries.

Health spending per person in the U.S. is nearly twice that of Germany, the closest country, and four times that of South Korea. In the U.S., this includes spending on public programs such as Medicaid, the Children’s Health Insurance Program (CHIP), Medicare, and military plans, as well as spending through employer-sponsored health insurance or other private insurance.

All countries in this analysis, except the U.S., provide government or public health insurance to all residents. In addition to public insurance, some countries also offer the option to purchase private insurance. In France, nearly the entire population has both private and public insurance. In 2021, 8.6% of the U.S. population was uninsured.⁸ The U.S. is the only high-income country with a significant uninsured population.

Health Outcomes

Despite high U.S. health spending, Americans experience worse health outcomes than their peers around the world. For example, life expectancy at birth in the U.S. was 77 years in 2020 — three years below the OECD average. Temporary data show that life expectancy in the U.S. declined further in 2021.⁹ Life expectancy in the U.S. also masks racial and ethnic inequalities.¹⁰ In 2019, the life expectancy of non-Hispanic Black Americans (74.8 years) and non-Hispanic American Indian or Alaska Native people (71.8 years) was four and seven years lower, respectively, than that of non-Hispanic White people (78.8 years). Hispanic Americans’ life expectancy (81.9 years) is higher than that of White Americans and is similar to life expectancy in the Netherlands, New Zealand, and Canada. As a group, Asian Americans’ life expectancy (85.6 years) is higher than that of people in Japan.

Avoidable mortality refers to preventable deaths and deaths that could be treated. Preventable deaths can be avoided through effective public health measures and primary prevention methods such as nutrition, diet, and exercise. Treatable deaths can essentially be prevented through timely and effective health interventions, regular checkups, screenings, and treatment.¹¹ Since 2015, avoidable deaths have increased in the U.S. and reached the highest rate among all countries in our analysis in 2020.

In 2020, the infant mortality rate in the U.S. was the highest among all countries in our analysis, at 5.4 deaths per 1,000 live births. In Norway, by comparison, there were 1.6 deaths per 1,000 live births. Women in the U.S. have long had the highest maternal mortality rate due to pregnancy and childbirth complications. In 2020, there were nearly 24 maternal deaths per 100,000 live births in the U.S., a rate more than three times higher than in most other high-income countries we studied. High cesarean section rates, inadequate prenatal care, obesity, diabetes, and socioeconomic inequalities that contribute to chronic conditions such as heart disease may help explain the high infant and maternal mortality rates in the U.S.¹²

Rising suicide rates increased dramatically during the COVID-19 pandemic and may indicate a heavy burden of mental illness.¹³ While the U.S. has the third-highest suicide rate, the United Kingdom has the lowest rate — nearly half the U.S. rate.

Obesity is a major risk factor for chronic conditions such as diabetes, hypertension, other cardiovascular diseases, and cancer. Factors contributing to obesity include unhealthy food environments, less-regulated food and agriculture sectors, lower socioeconomic status, and higher levels of behavioral health problems.¹⁴ The U.S. has the highest obesity rate among countries with available data, nearly twice the OECD average.

In 2020, three out of every 10 adults surveyed in the U.S. reported having been diagnosed at some point in their lives with two or more chronic illnesses, such as asthma, cancer, depression, diabetes, heart disease, or hypertension. In other countries, only slightly more than one-quarter of adults reported the same, and the U.S. rate is nearly twice that of France.

Since the start of the COVID-19 pandemic, the number of people who died from coronavirus in the U.S. has been higher than in other high-income countries. Between January 22, 2020, and January 18, 2023, there were more than 3,000 deaths per million cases in the U.S.

Sağlık Hizmeti Kullanımı

Although health care spending is the highest in the world in the U.S., Americans generally visit doctors less often than residents of most other high-income countries. With four visits per person per year, Americans see doctors less often than the OECD average. Less frequent doctor visits may partly reflect the relatively low supply of doctors in the U.S.; the number of practicing physicians in the U.S. is below the OECD average.

In the U.S., the average hospital stay for all inpatient care is 4.8 days, well below the OECD average. The U.S. has 2.8 hospital beds per 1,000 people, compared with the OECD average of 4.3.

Older Americans are more likely to receive the flu vaccine, and the rate is similar to that of several other high-income countries and close to the OECD average. However, the U.S. has one of the lowest COVID-19 vaccination rates among high-income countries. As of January 2023, 69% of the population was fully vaccinated, compared with 86% in South Korea; these figures are updated regularly.

During the COVID-19 pandemic, people in the U.S. faced difficulties accessing health care. About 14 million people in the U.S. were uninsured during the first full year of the pandemic. Before the pandemic, the number of uninsured people was about 9 million, suggesting that around 5 million people became uninsured during the first year of the pandemic. This allows cross-country comparisons to better understand existing challenges in access to health insurance.

ACKNOWLEDGMENTS

The authors thank Chris Hollander, David Blumenthal, Melinda Abrams, Jen Wilson, Paul Frame, Bethanne Fox, Celli Hortsman, Lauren Haynes, and Relebohile Masitha of the Commonwealth Fund for their helpful comments on earlier versions of the report and for editorial support.

HOW WE CONDUCTED THIS STUDY

Data Sources and Methods

Organization for Economic Co-operation and Development

This analysis used 2022 health statistics data compiled by the OECD, which tracks and reports health system measures across 38 high-income countries. The data were released in December 2022. Although data collected by the OECD reflect the highest standards for international comparison, one limitation is that differences in countries’ methods of collecting health data may be obscured. Full details on how indicators are defined and country-level definitional differences can be obtained from the OECD.²⁴

2020 Commonwealth Fund International Health Policy Survey

For the 2020 Commonwealth Fund International Health Policy Survey, nationally representative samples of adults age 18 and older were collected from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Surveys in each country were conducted using random-digit dialing based on both landline and mobile telephone sampling designs or, where possible, through address-based sampling frames. In Norway, Sweden, and Switzerland, participants were drawn from national population registries. In the U.S., an address-based sampling frame was also used to provide a representative sample. Participants in Sweden, Switzerland, and the U.S. were able to complete the survey by landline, mobile phone, or online. The Commonwealth Fund supported international surveys regularly and, in some countries, supported larger sample sizes to enable equity analysis. Final sample sizes ranged from 607 to 4,530 respondents. The survey research firm SSRS was commissioned to conduct the survey between February and May 2020 in collaboration with country contractors. The field period varied from four to 15 weeks across countries. Response rates ranged from 14% to 49%. Data were weighted by country to account for sampling design and differences in selection probabilities.

Our World in Data

This analysis used data from Our World in Data, which compiles data from many countries and regions around the world. Data on COVID-19 deaths and COVID-19 vaccination rates were current as of January 2023. One limitation of both datasets is that they report only confirmed deaths and reported vaccination rates; Our World in Data notes that these may underestimate actual totals. Full details about how indicators are defined and country-level data collection differences are available from Our World in Data.²⁵

Limitations of Our Analysis

The effects of the COVID-19 pandemic, job loss, and delayed or forgone necessary care likely worsened health outcomes.²⁶ Therefore, some country-level analyses should be interpreted cautiously, because data for 2020 and afterward are not available for every country or every metric. As businesses and health facilities reopened and returned to pre-COVID operating levels, the global health burdens experienced during the pandemic may continue. Another limitation of our study is that the data were not broken down by race and ethnicity. Studies have shown that Black and Latino Americans have significant health disparities within the U.S.²⁷ To compare only countries is not enough; to understand health outcomes among vulnerable and historically marginalized populations worldwide, data collection efforts broken down by race and ethnicity are needed.

Notes

Roosa Tikkanen and Melinda K. Abrams, U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? (Commonwealth Fund, January 2020).
Bridget M. Kuehn, "COVID-19 Shortened Life Expectancy in a Dozen Countries,,” JAMA 327, no. 3 (January 18, 2022): 209.
World Health Organization, "COVID-19, 90 Countries Continue to Experience Disruptions to Essential Health Services, "press release, April 23, 2021.
Luca Lorenzoni et al., Health Spending Projections to 2030: New Results Based on a Revised OECD MethodologyOECD Health Working Papers, no. 110 (Organisation for Economic Co-operation and Development, December 14, 2022).
Robert E. Moffit, ““Health Insurance Coverage and U.S. Health Care: A Review,” NBER Working Paper no. 27904 (National Bureau of Economic Research, October 2020).
Melinda K. Abrams, “Global Health Inequalities and COVID-19: What Have We Learned and What Should We Do?” Commonwealth Fund, June 2022.
“Early Estimate of Job Losses,” U.S. Centers for Disease Control and Prevention, October 2022.
Melinda K. Abrams et al., U.S. Health Care from a Global Perspective, 2022: Better Data, First Steps Back (Commonwealth Fund, January 2023).
In general, the OECD recommends re-fielding the International Health Policy Survey (IHP) dataset with expanded samples throughout the year and including U.S. samples. Health systems in high-income countries should be evaluated comparatively. Consideration should be given to quality, response rates, and cross-country differences in collected data. International Health Policy Survey (IPS): 2022 Summary Report (Organization for Economic Co-operation and Development, October 2022).
OECD, Health Expenditure, last accessed: July 2023.
OECD, Health Expenditure, last accessed: July 2023.