’Tis the season for reflection on the progress of the U.S. health system as open enrollment season comes to a close for health insurance markets. With the Affordable Care Act, the U.S. made efforts to meet their peers in other industrialized nations to close its uninsured gap. The United States has made progress on that metric with 16.4 million out of an estimated 50 million uninsured gaining coverage through the Marketplace and Medicaid expansions. But will this change finally put the United States at the top of the health system rankings?
U.S. policymakers seek to rank as the nation’s health system as best in world. Unfortunately, rankings from the World Health Organization and Organization for Economic Cooperation and Development show the United States as quite a laggard. The WHO rankings that got the most attention placed the United States at 37th of 191 behind all other industrialized countries and Cuba in a comparison akin to football (U.S. and otherwise) league tables.
As health economists we were convinced that the United States might do better if we took into consideration different variables like access to the physicians. The result in a just published study shows that the United States is not necessarily at the bottom of the league table, but it is not at the top either. Just like the residents of U.S. fictional small town Lake Woebegone, Americans are just above average — some of the time.
More disturbing than not finding a top place for the United States was the highly sensitive scoring process. And actually the conceit of a single country-specific metric of health system performance is the futility of the process itself. We show that single country rankings are fraught with challenges around data availability, transparency and comparability across countries.
For example, although individual health behaviors are important predictors of health utilization and spending, measures such as obesity are not regularly or consistently collected across countries. Even when the data are available, we found that rankings at such 30,000-foot levels are highly sensitive to the statistical approach and set of variables used in a model.
Our work suggests that singular rankings are not well correlated with resource and utilization measures such as physicians per capita, which suggests that factors beyond the control of the health system are at play. One would think that more physicians would lead to better system performance.
The training and payment of physicians is one of the costliest attributes of any industrialized nation. Instead, we see countries with higher rank (Sweden) and lower rank (Hungary) have nearly identical per capita physicians.
In this era of big data, analysts have amassed data from a wide range of sources such that could someday provide new signal for a league table metric and truly provide country-to-country comparisons. For example, a metric could be created from an anonymous population’s aerobic activity based on cell phone traveled distance and type of transportation (e.g., car, transport or walking).
Unfortunately, our current health system inputs are stuck in the 20th century. More work is needed to make these connections across countries to improve our comparisons. Improvement in health insurance coverage is a start, but much more needs to be done to identify areas of inefficiency in our health system.
Citizens of the 21st century need to have a more comprehensive set of real-time metrics that are relevant to evolving health systems across the globe. One single ranking number is not going to tell us whether we are improving or not. The United States and other nations around the globe spend trillions a year on healthcare with well over half of the of expenditures based on tax receipts of citizens. Worse much of the expenditure is deficit financed in the United States and other countries.
Industrialized nations around the world owe it to our children’s children to develop appropriate metrics to gauge the effectiveness of health systems expenditures. Until then, our current international health system league tables are statistically unworthy of global discussion.