We have a crappy healthcare system

Take a gander at that chart. See that diamond well to the right on the horizontal axis (money spent) and well below the big cluster of diamonds on the vertical access (life expectancy)? That's us, placed on a map with the rest of the developed world in what probably is the most depressing graph in American health care. We spend a ton of money on health care, and we're obviously not doing it right.

We have the crappiest healthcare system in the developed world, to be precise. That's not just a disgruntled, single-payer supporting blogger talking. That's the Commonwealth Fund talking. Who are they? A private foundation that's been conducting healthcare policy research for generations. For the past decade, they've released reports detailing how the U.S. healthcare system measures up against other countries' systems. The results for 2014 are in, and are grim.

The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity.

Worth noting here, before we carry on, this isn't about the Affordable Care Act in large part. It's about the massive, incoherent, excessively complicated and expensive system that the ACA can maybe put a dent in. While the new law is most definitely helping people, it's not enough to address most of the larger issues at work making our system so irrational.

Let's start at the beginning, with the overall rankings. Spoiler alert: We're last.

In 2011 dollars, we spent $8,508 per capita, the next highest spender was Norway at $5,669. With all that money spent per person, we still rank dead last in access, efficiency, equity and healthy lives. We rise up to No. 3 in effective care and No. 4 in patient-centered care, but lead in absolutely nothing.

With that depressing overview established, head below the fold to find out how else we don't measure up.

It's worth reiterating here, in graphic form, just how much more we as a nation spend on health care than anyone else, because it's pretty remarkable:

While all that money is being poured into the system, we have the most unaffordable system.

[P]eople in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost. Patients in the U.S. have rapid access to specialized health care services; however, they are less likely to report rapid access to primary care than people in leading countries in the study.

Related to the access deficiency noted by Commonwealth, we have an equity problem.

The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.

Sarah Kliff at Vox has a graph to show the difference in the number of people reporting that they skipped getting medical care because of the cost involved:

Then there's efficiency, where we're a clear last:

On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing. Sicker survey respondents in the U.K. and France are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available.

Administrative costs are so high because we have so many payers—hospitals and doctors have multiple insurance companies to deal with, most of which are not paying the same rate for the same procedures. There's a tremendous amount of paperwork not just for doctors and hospitals, but for patients as well.

What all of this adds up to relates to the graph that opened this discussion: For all we're spending in the U.S. in the healthcare system, we're not healthy.

The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. The U.S. and U.K. had much higher death rates in 2007 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Australia and Sweden. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

We rank last on infant mortality—meaning we have the most of it—on preventable deaths, and on life expectancy. The reasons for this are still sort of mysterious, because the lower life expectancies and relatively poor health outcomes are a feature across demographic groups in the U.S.:

We rank poorly if you look at survival until age 50, looking just at deaths among younger adults. And we rank poorly if you look at survival after age 50. We rank poorly if you restrict the analysis to non-Hispanic whites (who, statistically, tend to be in the best health overall). Even if you only look at well-off Americans who aren't obese and don't smoke, they generally experience poorer health compared to their counterparts in other countries.

We've got very good health care for those who can afford it and have access to it, and in fact, we rank third in providing effective care. That includes high marks for proactive doctors who remind patients about their regular preventive care, and America doctors lead in talking to patients about exercise and living healthy lifestyles. But we're still dying younger—even those who have this great health care.

The Commonwealth Fund does see some hope for the U.S. now that Obamacare is implemented:

Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. Under the Affordable Care Act, low- to moderate-income families are now eligible for financial assistance in obtaining coverage. Meanwhile, the U.S. has significantly accelerated the adoption of health information technology following the enactment of the American Recovery and Reinvestment Act, and is beginning to close the gap with other countries that have led on adoption of health information technology. Significant incentives now encourage U.S. providers to utilize integrated medical records and information systems that are accessible to providers and patients. Those efforts will likely help clinicians deliver more effective and efficient care.

The key common denominator that all the nations leading the U.S. have is universal coverage. Even were all the states to implement the Medicaid expansion under the law—which would help significantly—we're still going to have millions of people without insurance, some non-citizens but the majority of them "white, low-income, working-age adults, many of them employed." In other words, the population that consistently falls through holes in the safety net.

If there is a key takeaway from the Commonwealth Fund report, it is this:

The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes.

For a nation that is spending nearly $3,000 per person more than its nearest competitor, that has some of the finest physicians and facilities in the world, we could be doing a hell of a lot better and we should be looking to the rest of the industrialized world about how to do that. It doesn't necessarily have to be a socialized, single-payer system. The Swiss have achieved high marks and high satisfaction with an Obamacare-like system. But it is going to require more government intervention, namely in what the Swiss are doing very effectively—regulating drug prices and fees for medical tests. The insurance companies aren't the only greedy bastards jacking up the cost of health care in the U.S. and those interests have to be taken on if this system is going to be fixed.

And it still needs to be fixed. We do have a good start in Obamacare. It has significantly reduced the number of uninsured. It is starting to separate insurance from employment. It has helped control costs in Medicare to a surprising degree. And, maybe most significantly for further reform, it's shown all the stakeholders that healthcare reform can be accomplished in this country. But we're far from finished.