What are the characteristics of the US healthcare system and how does it differ from those of other nations?

The coronavirus pandemic has resulted in millions of cases across the globe. The United States has one of the highest death rates due to COVID-19 across the world, and its mortality rates will likely increase. Due to different approaches to containing the virus across countries – as well as the quality and accessibility of health care – we may see diverging rates of mortality, disease burden, and other measures of health outcomes between the U.S. and comparable countries. This chart collection provides a baseline of how the U.S. already compared to similarly large and wealthy countries prior to the onset of the coronavirus pandemic.

The following charts and a related brief explore a number of different metrics used to look at health outcomes, quality of care, and access to services. While inconsistent and imperfect metrics make it difficult to firmly assess system-wide health quality in the U.S., a review of the available data prior to the onset of the pandemic suggests that in most of these measures, the U.S. continued to lag behind comparably wealthy and sizable countries. As rates of all-cause mortality, maternal mortality, and years of life lost have stagnated or increased over time, the gap has widened between the U.S. health system and those of its peers.

We examine long-term outcomes, treatment outcomes, hospital-related care and patient safety in the U.S. and 11 other countries identified as similarly wealthy based on GDP and GDP per capita. The data from most of the charts come from the Organization for Economic Co-operation and Development (OECD), which has compiled health quality statistics and data from several countries around the world. It is important to note that the healthcare systems, populations, and public health responses in these countries can vary considerably, and that these factors play a role in population health outcomes.

Life expectancy dropped sharply in 2020 within the U.S. and most comparable countries

As discussed in more detail in a separate brief, life expectancy at birth was similar in the U.S. and comparable countries in 1980 (74.5 and 73.7 years, respectively), but the gap has grown substantially in the following decades. Driven by the COVID-19 pandemic, life expectancy dropped in 2020 to 77.3 years in the U.S. and 82.1 in comparable countries on average. Prior to the pandemic, life expectancy was increasing in comparable countries, while the U.S. had experienced slower growth with declines in recent years.  

Of note, the above life expectancy data are period life expectancy estimates based on excess mortality observed in 2020. The period life expectancy at birth represents the mortality experience of a hypothetical cohort if current conditions persisted into the future and not the mortality experience of a birth cohort. Though the U.S. continues to have one of the highest excess mortality rates due to COVID-19 in 2021, excess mortality rates are lower in 2021 than in 2020. CDC has noted that 2021 life expectancy may increase slightly from 2020 but will likely stay below pre-pandemic rates.

Before the pandemic, the gap between the U.S. and comparable countries in mortality rates had already grown

One method for measuring quality is to look at all-cause mortality rates (number of deaths per 100,000 people, adjusted for age differences across countries). The mortality rate had been falling in the U.S. and in comparable countries, but had plateaued prior to the pandemic. Meanwhile, the mortality rate in comparable countries continued to trend downward, on average. From 1980 to 2017 (the latest year with internationally comparable data), the overall mortality rate for all causes of death in the U.S. fell about 29%, compared to a 43% decline in comparable countries.

In a separate analysis, we examined how the COVID-19 pandemic may have widened the gap in mortality rates between the U.S. and peer countries. We find that the U.S. and U.K. had the highest rates of excess deaths on a per capita basis for most of 2020, suggesting that the pandemic could increase the existing mortality rate gap between the U.S. and its peers.

Premature death rates in the U.S. continue to be higher than in comparable countries

An alternative to overall mortality rates is “years of life lost”, a marker of premature deaths. Years of life lost is measured by adding the collective years lost by those in a population who died before the longest possible life expectancy (e.g. 70). For example, a person who dies at age 45 would have 25 years of life lost. As a measure, it provides more weights to deaths at younger ages. The U.S. and comparable OECD countries have made progress in reducing years of life lost over the last 27 years (down 24% and 42%, respectively), although the gap between the U.S. and comparable countries increased over time, standing at 12,724 vs. 8,258 years of life lost in 2019.

In a separate brief, we reviewed excess death rates by age groups to examine how the pandemic has affected premature death in the U.S. and peer countries. With a much higher rate of death among people under age 75, the U.S. had the highest increase in premature deaths due the pandemic in 2020. The per capita premature excess death rate in the U.S. was over twice as high as the next closest peer country, the U.K. The higher rate of new premature deaths in the U.S. compared to peer countries was driven in part by racial disparities within the U.S. The premature excess death rates for American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian and Other Pacific Islander people in the U.S. were 3 times higher than the rates among White or other Asian people.

Disease burden is higher in the U.S. than in comparable countries

Disease burden, which accounts for both premature death and years living with disability, is often measured using disability adjusted life years (DALYs). Though DALYs have declined in the U.S. and comparable countries since 2000, the U.S. continues to have higher age-adjusted rates than those of peer countries. In 2017, the DALYs rate was 37% higher in the U.S. than for comparable countries, on average.

The U.S. ranks last in a measure of health care access and quality, indicating higher rates of amenable mortality than peer countries

Mortality amenable to healthcare is a measure of the rates of death considered preventable by timely and effective care. While the healthcare system might not be expected to prevent death in all instances, differences in amendable mortality indicate how effectively healthcare is delivered. The Healthcare Access and Quality (HAQ) Index is scaled from 0 (worst) to 100 (best) and is based on amenable mortality. The HAQ index uses age-standardized, risk-standardized mortality rates for 32 causes of death that timely and effective health care could potentially prevent. Lower scores indicate high mortality rates for causes amenable to health care, while higher scores indicate lower mortality rates, possibly reflecting better quality and access to care. The U.S. ranks last among comparable countries on the HAQ index with a score of 88.7, compared to an average of 93.7 for comparable countries in 2016. 

Maternal mortality rates in the U.S. have risen over time and are much higher than in peer countries

While wealth and economic prosperity are highly correlated with lower maternal mortality rates, the U.S. is an outlier with the highest rate of pregnancy-related deaths (20.1 deaths per 100,000 live births in 2019) when compared to similar countries (5.3 deaths per 100,000 live births).

Within the U.S., there are significant racial disparities in maternal mortality rates. Black women are more than three times as likely to die from pregnancy-related causes as White women – a disparity that persists across socioeconomic class.

30-day mortality for heart attacks and strokes is lower in the U.S. than in comparable countries

Mortality within 30 days of being admitted to a hospital is not entirely preventable, but high quality of care can reduce the mortality rate for certain diagnoses. The 30-day mortality rates after hospital admissions for heart attacks (acute myocardial infarction) and hemorrhagic stroke (caused by bleeding) are similar in the U.S. and comparable countries. The 30-day mortality rates for ischemic strokes (caused by blood clots) was 4.1 deaths per 100 patients in the U.S. in 2018, compared to an average of 6.4 deaths per 100 patients in similar countries.

Hospital admissions for diabetes and congestive heart failure were more frequent in the U.S. than in comparable countries

Hospital admissions for certain chronic diseases like circulatory conditions, chronic obstructive pulmonary diseases (COPD), asthma, and diabetes, can arise for a variety of reasons, but preventative services – or lack thereof – play a large role. Hospital admission rates in the U.S. are higher than in comparable countries for congestive heart failure and complications due to diabetes. Hospital admissions for these chronic conditions could be minimized with adequate primary care.

More cesarean sections are performed in the U.S. than in comparable countries

Cesarean sections are the most commonly performed surgical procedures in the U.S. and have become a key indicator of quality of care in maternal health. Cesarean sections can be lifesaving; however, when they are not medically indicated, they can pose unnecessary risks for both the mother and newborn, including an increased chance of blood clots, infections, and other complications that require further surgery.

The U.S. has consistently had higher cesarean section rates than its peers, on average, though rates have decreased slightly in recent years. In 2019, the rate of cesarean sections per 1,000 live births with inpatient admissions was 317 in the U.S. and 256 in comparable countries.

Obstetric trauma during vaginal delivery is more common in the U.S. than in most comparable countries, especially when instruments are involved

Obstetric trauma is more likely to occur in deliveries where instruments are utilized (i.e. forceps). The rate of obstetric trauma during deliveries with an instrument in the U.S. was 11.4 per 100 vaginal deliveries in 2018, higher than most comparable countries with available data. The rate of obstetric trauma during deliveries without an instrument in the U.S. was 1.8 per 100 vaginal deliveries in 2018, slightly lower than most other comparable countries with available data.

Post-operative complications – such as pulmonary embolism or deep vein thrombosis – are more common in the U.S. than most peer countries

Rates of post-operative complications are an important measure of hospital-based safety. Pulmonary embolisms and deep vein thrombosis are common complications after major surgeries, such as hip or knee replacement. The prevalence of post-operative clots for these procedures is higher in the U.S. than in the U.K., Sweden, Belgium, and the Netherlands, but lower than in Australia (among comparable countries with available data for the latest available year).

Post-operative sepsis is less common in the U.S. than in some peer countries

Sepsis is a spectrum of disease afflicting patients with infections, that can range from organ failure and shock to death in severe cases. Rates of post-operative infections and sepsis is an important marker of quality in patients undergoing surgery because this is a major source of morbidity and mortality and can sometimes be prevented. Prevention is multifactorial and can be affected by operative techniques and training, hygiene and safety protocols and antibiotic utilization amongst other things. The rate of post-operative sepsis following abdominal surgery is just above 1% in the U.S., lower than in most other countries that report data.

The U.S. has higher rates of reported medication and treatment errors than most comparable countries

Patients in the U.S. are more likely than those in comparable countries to report experiencing a medication or medical error at some point during their care, according to a survey by the Commonwealth Fund. In this case, medication errors include being given the wrong medication or dose, and treatment errors indicate that people thought a medical mistake had been made in their treatment or care. In 2020, 12.6% of patients in the U.S. experienced a medical error compared to 11.4% of patients in similar countries.

The Peterson Center on Healthcare and KFF are partnering to monitor how well the U.S. healthcare system is performing in terms of quality and cost.

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