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Outcomes vs peers

Does the US buy better health with the highest spending in the world, or is it paying the most for the worst result?

The US ranks last overall and last on health outcomes among 10 high-income countries, and its avoidable-death rate improved the least over the prior decade. Care Process is its only strong domain.

Question

The problem

The U.S. hospital and care delivery landscape spends more than peer systems without reliably producing better population outcomes. The strategic issue is conversion efficiency: high spending does not translate into access, affordability, prevention, or avoidable-mortality performance at the level expected from the investment.

The recommendation

Make access and affordability core quality levers rather than separate policy domains. The recommended strategy is to treat cost-related skipped care as an outcome failure, prioritize reforms that convert spending into timely care, and benchmark U.S. performance against peers on both spending and results.

The paradox

The US spends the most in the world and ranks dead last overall.

$15,474
US health spending per person, ranked 10th of 10 on overall system performance
18.0 percent of GDP in 2024. In the peer-comparison year the US spent 16.5 percent of GDP, still the highest of the 10 countries.

Health spending vs overall system rank

Each dot is one country. The horizontal axis is health spending as a share of GDP. The vertical axis runs from rank 1 (best) at the top to rank 10 at the bottom, so the US sits alone at the bottom right: the far outlier on spending at 16.5 percent, and last overall.

Read it this way The other nine countries cluster between about 9.8 and 11.9 percent of GDP with no clear relationship between spending and rank, while the US sits far outside that range at 16.5 percent and still ranks last. That gap supports the conclusion that spending more has not bought the US a better system, though the chart alone cannot say which specific dollars are misspent. Use this chart to connect spending, access, and outcomes, and to test whether the recommendation is addressing the conversion failure rather than adding spending without accountability.

1 2 3 4 5 6 7 8 9 10 0.05.010.015.020.0 Australia Netherlands United Kingdom New Zealand France Sweden Canada Switzerland Germany United States HEALTH SPENDING (PERCENT OF GDP) OVERALL RANK (1 = BEST)
⊞ data table⬇ CSV
CountryHealth spending (percent of GDP)Overall rank
Australia9.81
Netherlands10.12
United Kingdom10.93
New Zealand11.34
France11.95
Sweden10.96
Canada11.27
Switzerland11.78
Germany11.89
United States16.510

Commonwealth Fund, Mirror Mirror 2024 Exhibits · 2024 · source

Where it breaks

The US is not bad at everything. It is 2nd on bedside Care Process but last on Access, Equity, Admin, and Outcomes, and the Access failure is cost.

Where the US ranks, domain by domain

Bar length is the US rank of 10, so a shorter bar is better. Care Process is the lone bright spot at 2nd. The reference line marks the midpoint of the field.

Read it this way Four of the five domains reach all the way to 9th or 10th place, past the midpoint reference line, while only Care Process falls far short of it at 2nd. That pattern shows the US shortfall is concentrated in outcomes, access, administration, and equity, not in the bedside clinical technique that Care Process measures. Use this chart to connect spending, access, and outcomes, and to test whether the recommendation is addressing the conversion failure rather than adding spending without accountability.

Caveat Equity is ranked 9th of 9 because Sweden was not scored on Equity. All other domains are of 10.

0 3 5 8 10 Health Outcomes 10 Access to Care 10 Administrative Efficiency 9 Equity 9 Care Process 2 Midpoint of the field
⊞ data table⬇ CSV
DomainUS rankField size
Care Process2of 10
Administrative Efficiency9of 10
Equity9of 9
Access to Care10of 10
Health Outcomes10of 10

Commonwealth Fund, Mirror Mirror 2024 Exhibits · 2024 · source

United States vs the top-ranked system, by domain

Rank across 10 countries, 1 is best. Australia ranks first overall. The US trails it in every domain except Care Process.

Read it this way In every domain pair except Care Process, the US bar sits well behind Australia's, most starkly on Health Outcomes and Overall at 10th versus 1st. Care Process is the one reversal, where the US ranks 2nd against Australia's 5th, isolating clinical delivery as the part of the system that is not dragging the US down. Use this chart to connect spending, access, and outcomes, and to test whether the recommendation is addressing the conversion failure rather than adding spending without accountability.

0 3 5 8 10 10 9 Access to Care 2 5 Care Process 9 2 Administrative Efficiency 9 1 Equity 10 1 Health Outcomes 10 1 Overall Midpoint of 10 countries United States Australia
⊞ data table⬇ CSV
DomainUnited States rankAustralia rank
Access to Care109
Care Process25
Administrative Efficiency92
Equity91
Health Outcomes101
Overall101

Commonwealth Fund, Mirror Mirror 2024 Exhibits · 2024 · source

Skipping care over cost: US vs peers, by income

Share reporting any cost-related access problem in the past year, split by lower and higher income. The US is highest in both groups, and even higher-income US adults exceed every peer.

Read it this way US lower-income adults report cost-related access problems at 50 percent, nearly double the next-highest country, New Zealand at 27 percent. Notice that higher-income US adults, at 27 percent, report problems at a rate matching or exceeding most other countries' lower-income adults, which shows this is not simply a poverty problem confined to the low-income group. Use this chart to connect spending, access, and outcomes, and to test whether the recommendation is addressing the conversion failure rather than adding spending without accountability.

Caveat From the 11-country 2021 edition, which included Norway. Lower and higher income are below and above the national median income. Cost-related access problem means skipped a needed visit, test, treatment, follow-up, or prescription because of cost.

0% 13% 25% 38% 50% 50% 27% United States 27% 11% New Zealand 26% 21% Switzerland 24% 19% Australia 21% 7% Canada 20% 9% Netherlands 19% 6% Sweden 15% 9% Germany 14% 6% France 14% 6% Norway 12% 7% United Kingdom Lower income Higher income
⊞ data table⬇ CSV
CountryLower income (percent)Higher income (percent)
United States5027
New Zealand2711
Switzerland2621
Australia2419
Canada217
Netherlands209
Sweden196
Germany159
France146
Norway146
United Kingdom127

Commonwealth Fund, 2020 International Health Policy Survey (Mirror Mirror 2021 Exhibit 7) · 2020 · source

The toll and the trend

What last place costs in lives, and whether it is improving. It is not.

76.4 years
US life expectancy, the shortest of the 10 countries
3.9 years below the OECD average of about 80.3 years.
5.4
US infant deaths per 1,000 live births, highest of the 10 countries
More than three times Norway's rate of 1.6 per 1,000.
17.9
US maternal deaths per 100,000 live births, 2024
44.8 for Black non-Hispanic women vs 14.2 for White non-Hispanic women. About triple the rate of most peer nations.

Ten-year decline in avoidable deaths

Percent decline in avoidable deaths per 100,000 over about a decade. A longer bar is a larger improvement. The US improved the least.

Read it this way Every country's avoidable-death rate fell over the decade, but the US bar is by far the shortest at a 5 percent decline against 13 to 25 percent for every peer. This chart shows the pace of improvement only, not the current absolute avoidable-death rate, so it shows the US falling further behind rather than how many additional lives that gap costs. Use this chart to connect spending, access, and outcomes, and to test whether the recommendation is addressing the conversion failure rather than adding spending without accountability.

Caveat Data windows differ slightly by country (roughly 2006 to 2019). From the 11-country 2021 edition, which included Norway.

0% 6% 13% 19% 25% Switzerland 25% Norway 24% New Zealand 23% Sweden 21% France 19% Netherlands 19% United Kingdom 19% Australia 18% Canada 17% Germany 13% United States 5%
⊞ data table⬇ CSV
CountryTen-year decline in avoidable deaths (percent)
Switzerland25
Norway24
New Zealand23
Sweden21
France19
Netherlands19
United Kingdom19
Australia18
Canada17
Germany13
United States5

Commonwealth Fund, Mirror Mirror 2021 Exhibits · 2021 · source

US domain standing barely moved, 2021 to 2024

Each line is one domain. The vertical axis is US rank divided by the number of countries, so a lower value is a better standing and the two editions are comparable. Care Process stays near the top, while Access, Equity, and Health Outcomes stay pinned at last place.

Read it this way The lines for Access, Equity, and Health Outcomes sit flat at the normalized maximum of 1.0, the top of the chart, in both editions, showing the US was already last in 2021 and made no measurable progress by 2024. Because rank is normalized to account for the field shrinking from 11 to 10 countries, small movements between editions should not be over-read. The flatness of those top-of-chart lines is the reliable signal here. Use this chart to connect spending, access, and outcomes, and to test whether the recommendation is addressing the conversion failure rather than adding spending without accountability.

Caveat Rank is normalized by field size because the 2021 edition compared 11 countries including Norway and the 2024 edition compared 10. Equity is normalized by 9 in 2024 because Sweden was not scored. Access, Equity, and Health Outcomes overlap at last place in both editions. Ordinal ranks are the finest granularity the exhibits publish.

0.0 0.3 0.5 0.8 1.0 2021 edition2024 edition Access to CareEquityHealth OutcomesAdministrative EfficiencyCare Process REPORT EDITION NORMALIZED RANK (LOWER IS BETTER)
⊞ data table⬇ CSV
Domain2021 rank (of 11)2024 rank (of 10)2021 normalized2024 normalized
Care Process220.180.2
Administrative Efficiency11910.9
Access to Care111011
Equity11 of 119 of 911
Health Outcomes111011

Commonwealth Fund, Mirror Mirror 2021 and 2024 Exhibits · 2024 · source

Geography

The same question, state by state and then county by county. Pick a state in the filter above to drill into its counties.

Diabetes prevalence

County · modeled prevalence (95% CI)

Each tile is a state. Pick a state in the Scope control above to drill into its counties.

AK 9.3% ME 10.0% WA 9.1% ID 9.6% MT 9.2% ND 9.4% MN 9.4% WI 10.5% MI 11.0% NY 10.7% VT 7.9% NH 8.5% OR 10.4% NV 11.3% WY 10.1% SD 11.0% IA 10.5% IL 10.9% IN 12.2% OH 12.3% PA NJ 10.2% MA 9.2% CA 11.2% UT 8.7% CO 8.3% NE 10.1% MO 11.3% KY WV 14.4% VA 11.7% MD 11.7% CT 9.4% RI 10.4% AZ 10.6% NM 12.3% KS 10.8% AR 12.4% TN 12.8% NC 11.3% SC 12.8% DC 8.2% DE 11.9% OK 12.2% LA 14.3% MS 14.5% AL 13.8% GA 12.7% TX 12.5% FL 12.3% HI 11.3% better than benchmark worse

CDC PLACES (model-based small-area estimates) · 2024 · source

Obesity

County · modeled prevalence (95% CI)

Each tile is a state. Pick a state in the Scope control above to drill into its counties.

AK 35.5% ME 32.8% WA 30.7% ID 32.3% MT 31.6% ND 37.0% MN 33.6% WI 37.8% MI 36.3% NY 28.9% VT 28.8% NH 31.8% OR 33.7% NV 31.3% WY 33.9% SD 36.2% IA 38.0% IL 34.1% IN 38.5% OH 37.2% PA NJ 28.9% MA 27.8% CA 28.0% UT 31.3% CO 26.2% NE 37.9% MO 36.7% KY WV 40.7% VA 34.5% MD 35.0% CT 30.6% RI 31.9% AZ 31.5% NM 34.4% KS 36.8% AR 39.4% TN 37.6% NC 35.1% SC 35.9% DC 24.9% DE 35.5% OK 39.1% LA 40.1% MS 40.5% AL 39.5% GA 35.3% TX 35.7% FL 32.1% HI 25.9% better than benchmark worse

CDC PLACES (model-based small-area estimates) · 2024 · source

Why this matters

The domain-by-domain breakdown shows the shortfall is concentrated, not uniform: Access to Care and Health Outcomes each rank 10th of 10 in both the 2021 and 2024 editions, and Equity ranks 9th of 9, while Care Process ranks 2nd of 10 in both editions. Because the gap sits in access and outcomes rather than clinical skill, more spending on care delivery alone has not closed it: US avoidable-death rates improved only 5 percent over the prior decade, versus 13 to 25 percent among every peer country.

Recommended actions

  • Concentrate policy attention on Access to Care and Health Outcomes, the two domains stuck at last place across two report cycles, rather than on Care Process, where the US already ranks 2nd of 10.
  • Prioritize interventions that reduce cost-driven care-skipping among lower-income adults, the single largest gap versus peer countries at 50 percent.
  • Monitor the maternal-mortality racial gap, 44.8 versus 14.2 deaths per 100,000, as its own equity KPI, since the national average of 17.9 masks that disparity.
  • Track the avoidable-mortality decline rate against peer countries annually. The US's 5 percent decade-long improvement, against 13 to 25 percent elsewhere, is the clearest sign the trend itself is falling behind, not just the current level.
  • Treat proposals to spend more on clinical care with skepticism unless they specifically target access or outcomes, since the US already spends the most of any peer and still under-performs.

The recommendation

Therefore, make access and affordability core quality levers rather than separate policy domains. The recommended strategy is to treat cost-related skipped care as an outcome failure, prioritize reforms that convert spending into timely care, and benchmark U.S. performance against peers on both spending and results.

Demographic slice none. country-level comparison, not sliceable by US demographic group.

Sources