The document compares key aspects of the U.S. health system to other OECD countries, specifically around access, costs, and quality of care. It finds that while access to care is generally good for those with insurance, the U.S. has a high uninsured rate compared to other countries. It also finds that U.S. health spending is much higher than other countries as a percentage of GDP without clear improvements in outcomes. This is partly due to higher administrative costs and physician salaries in the U.S. system compared to single-payer systems with more regulation and standardization.
4. Main U.S. access challenge is coverage:
As in Mexico and Turkey, a significant share of US popula?on is
uninsured
Unlike Turkey and Mexico, Total public coverage Primary private health coverage
U.S. rate of uninsured has Mexico
Turkey
50.4
67.2
not improved over last 15 United States
Poland
27.3
97.3
59.2
years. Slovak Republic
Netherlands
97.6
62.1 35.8
Austria 98.0
Belgium 99.0
Being uninsured in the
Spain 99.5
Luxembourg 99.7
Germany 89.6 10.2
United States is associated France
United Kingdom
99.9
100
with ge_ng less care, being Switzerland
Sweden
100
100
less healthy and increased Portugal
Norway
100
100
mortality (U.S. InsBtute of New Zealand
Korea
100
100
Medicine) Japan 100
Italy 100
Ireland 100
Iceland 100
Hungary 100
Greece 100
Finland 100
Denmark 100
Czech Republic 100
Canada 100
Australia 100
0 20 40 60 80 100
Source: OECD Health at a Glance, 2007
5. Why do coverage shoraalls persist?
• Coverage is voluntary
– not automaBc and no mandate to purchase coverage
(except in Mass.)
• Problems with availability of insurance
– declining share of employers offer health benefits
– individual market limits coverage for pre‐exisBng
condiBons and insurers can reject applicants based on
health risks
• Problems with affordability of insurance
– risk raBng, adverse selecBon in voluntary risk pools
6. Some lessons from OECD experience
• Regulate insurance market to set the playing
ground for compeBBon on basis of value in a
mulB‐payer system – Dutch and Swiss examples
– Risk adjustment
• Make coverage compulsory (or automaBc) –
Swiss example
• Subsidize coverage for those who cannot afford it
– Dutch and French examples
7. 0
1 000
2 000
3 000
4 000
5 000
6 000
7 000
United States
Norway 4 763
Switzerland 4 417
Luxembourg 4 162
(2006)1
Canada 3 895
Netherlands 3 837
Austria 3 763
France 3 601
Belgium 3 595
Germany 3 588
Source: OECD Health Data, 2009.
Denmark 3 512
Ireland 3 424
Sweden 3 323
Iceland 3 319
Australia (2006/07) 3 137
United Kingdom 2 992
OECD 2 984
Finland 2 840
Greece 2 727
Private expenditure on health
Italy 2 686
Spain 2 671
Per capita spending, 2007
Japan (2006) 2 581
New Zealand2 2 510
Portugal (2006) 2 150
exceeds other countries’
Korea 1 688
Czech Republic 1 626
Slovak Republic 1 555
Hungary 1 388
Poland 1 035
Public expenditure on health
Mexico 823
Cost outlier: U.S. Health spending greatly
Turkey (2005) 618
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9. • Health expenditure is high share
United States 19.8
Current health United Kingdom1 14.9
consumpBon
of final U.S. household
Turkey (2005) 16.9
expenditure represents a Switzerland1
Sweden
14.9
14.8
relaBvely high share in Spain
Slovak Republic
14.3
U.S. final household
15.0
Portugal (2006)
12.6
Poland
consumpBon, 2007
14.7
OECD
Norway 13.9
New Zealand2 11.9
Netherlands3 12.4
Mexico 13.3
Luxembourg 13.2
(2006)4 15.4
Korea 12.9
Japan (2006) 11.8
Italy
12.4
Ireland
12.0
Iceland1
10.4
Hungary
Greece 11.9
Germany 11.8
France 11.6
Finland 12.8
Denmark 11.0
Czech Republic 16.8
Canada 10.5
Belgium3 11.2
Austria
8.6
Australia
8.1
(2006/07)
7.1
Source: OECD Health Data, 2009
0 5 10 15 20
10. What problems are associated with
high U.S. health costs?
• Insurance is increasingly unaffordable
– Especially for those who must buy on the individual market, where as
likle as half of the premium intake goes to pay medical claims
– Wage increases for employed are dampened by rising insurance cost
• Problems in affordability of health care for the uninsured and
underinsured
– 62% of bankruptcies in 2007 related to health care costs
• Opportunity cost
• QuesBon of future sustainability
12. Richer countries spend more on health, although U.S.
costs exceed those of countries with comparable
income
Health expenditure and GDP per capita, 2007
8 000
USA
7 000
6 000
5 000
CHE NOR
DNK BEL CAN LUX
4 000 AUT NLD
DEU
FRA
ISL SWE IRL
3 000 GBR AUS
GRC ESP
FIN
NZL ITA
JPN
PRT
2 000
SVK KOR
HUN CZE
1 000MEX POL
TUR
0
10 000 15 000 20 000 25 000 30 000 35 000 40 000 45 000 50 000 55 000 60 000
Source: OECD Health Data, 2009.
13. RelaBvely high administraBve costs in (1) a mulB‐payer system that is (2)
characterized by minimal standardizaBon compared to elsewhere (benefits,
payment levels, payment methods)
Share of total health expenditures allocated to administraBve expenses, 2004
%
12
10.7
10.2
10
8 7.5 7.6
6.2
6
4.8
4.3 4.4
4.1
4 3.5 3.5 3.7
2.7 2.8
2.3 2.4
1.7 1.8 1.9
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OECD Health Data October 2006 AdministraBve costs and profits account for half of
premium for policies purchased in the individual market.
14. U.S. physicians earn more than counterparts in most countries
Physician remunera?on, ra?o to GDP per capita
Specialists General practitioners (GPs)
Salaried Australia (2004)
5.3 2.1 Salaried
Self-employed Austria (2003)
5.6 3.4 Self-employed
Belgium (2004) 1
7.8 2.3
Canada (2004)
4.9 3.3
1.6 Czech Republic
2.3 1.8
2.8
Denmark
2.5 Finland 1.9
France (2004)
4.5 2.8
2.7
Germany (2004)
3.7
2.3
Greece 2
2.4
1.7
Hungary 1.7
2.9
Iceland 3.0
4.6
Ireland 3
4.0
2.8
Luxembourg (2003) 3 1.6
4.2 2.0
2.4
Mexico 2.1
4.0
Netherlands
8.4 3.5
3.7
New Zealand
4.0
1.6
Norway
3.3
Portugal
2.5
Sweden (2002) 2.2
Switzerland (2003)
3.7 3.2
4.8
United Kingdom (2004)
3.8
4.8
United States (2001) 3.8
6.5 4.4
10 8 6 4 2 0 0 2 4 6 8 10
Ratio to GDP per capita Ratio to GDP per capita
15. Other factors explaining high cost of
U.S. health care
• More intensive service mix
– Higher share of docs are specialists and U.S. uses
more specialist‐intensive care, including elecBve
surgery, even though physician consultaBon and
hospital discharge rates are relaBvely low
• Physician incenBves to provide excess care to
the insured
– FFS, defensive medicine to avert malpracBce
judgments, ownership of scanners
16. Some lessons from U.S. experience
• Greater reliance on salary and capitaBon payments
helps with cost control, but may come at cost in terms
of producBvity
• AcBvity‐based payments appear to encourage
efficiency (more service for money), but may not have
a posiBve impact on overall health‐system efficiency
(less health improvement for money)
• Price controls, budgets and all‐payer rate se_ng can
help control rate of growth, but may be an impact on
Bmely availability of medicines and services
17. Quality of care
• U.S. quality of care good in some areas (e.g.,
cancer care), below average in others (e.g.,
renal care, asthma care); no parBcular area in
which quality of care is excepBonal, relaBve to
other countries (Docteur and Berenson, 2009)
• Some evidence that medical errors may be
relaBvely more common in the United States
18. 90.5
United States
88.6
88.3
Iceland
87.1
Canada
Breast cancer 5‐year
85.6
86.1
Sweden
83.8
survival rates, 1997 – Japan
Finland
86.1
86.0
2002 and 2002 –
82.0
85.2
Netherlands
80.0
2007 or nearest France
Denmark
82.6
82.4
available year
76.2
82.1
New Zealand
77.0
81.9
Norway
80.5
81.1
OECD (14)
77.9
United Kingdom
76.2
Ireland
72.2
75.5
Korea
76.9
75.4
Czech Republic
70.8
61.6
Poland 2002-2007 1997-2002
0 20 40 60 80 100
Age-standardised rates (%)
Source: OECD Health at a Glance 2009
19. Mammography, percentage of women aged 50 - 69 screened, 2005
*Norw ay1 98.0
*Netherlands 81.9
**Canada 70.4
*United Kingdom 69.5
*New Zealand2 63.0
**United States1 60.8
*Australia1 55.6
23-country average3 54.7
0 25 50 75 100
Percentage
Notes:
* stands for program data whereas ** stands for survey data.
1.2003 2.2002
3. Includes Japan, Poland, the Slovak Republic, Mexico, the Czech Republic, Switzerland, Korea, Hungary,
Australia, Belgium, Italy, Portugal, the United States, Iceland, New Zealand, the United Kingdom, Canada,
France, Ireland, the Netherlands, Sweden, Finland and Norway.
Source: OECD Health Data 2007
20. Breast cancer mortality, female, 1995
to 2005
Age-standardised rates per 100 000 females
1995 2000 2005
40
30
20
29.5
28.4
27.0
25.8
25.1
24.9
24.2
23.9
23.1
22.4
22.4
21.5
21.3
21.1
20.8
20.7
20.5
20.3
20.0
19.9
19.5
19.5
19.3
19.3
19.2
10
16.7
11.0
10.4
5.8
0
Source: OECD Health at a Glance 2009
21. Amenable mortality
• As of 2002‐2003, the US has the highest rate of
mortality due to preventable and treatable condiBons
(amenable mortality) among 19 countries studied
(Nolte and McKee, Health Affairs, 2008)
• This represents a decline in U.S. performance since
1997‐1998, when the U.S. was 15th among 19
countries studied. All countries experienced a decline
in rate of mortality amenable to health care, but U.S.
achieved a relaBvely small decline.
22. US health status below OECD average by some measures
Life expectancy and infant mortality, 2006
USA to OECD avg.
Life expectancy at birth (yrs):
Total population 80.7 < 81.8
Females 75.4 < 76.1
Males 78.1 < 78.9
Life expectancy at age 65 (yrs):
Females 20.3 > 20.2
Males 17.4 > 16.8
Infant mortality rate (per 1000 live
births) 6.7 > 5.1
Source: OECD Health Data 2009.
23. Life expectancy, Total population at birth, Years
Life expectancy at birth: 1995 Total 2006 Total Increase
population at population at 1995-2006
US improvement since Countries
birth Years birth Years
1995 falls well short of Australia
Austria
77.9
76.6
81.1
79.9
3.2
3.3
Belgium 77.0 79.5 2.5
avg improvement and Canada
Czech Republic
78.1
73.3
80.7
76.7
2.6
3.4
even improvement Denmark
Finland
75.3
76.6
78.4
79.5
3.1
2.9
among those with France
Germany
77.9
76.6
80.7
79.8
2.8
3.2
greatest longevity
Greece 77.7 79.6 1.9
Hungary 69.9 73.2 3.3
Iceland 78.0 81.2 3.2
Ireland 75.6 79.7 4.1
Italy 78.4 81.2 2.8
Japan 79.6 82.4 2.8
Korea 73.5 79.1 5.6
Luxembourg 76.8 79.4 2.6
Mexico 72.5 74.8 2.3
Netherlands 77.5 79.8 2.3
New Zealand 76.8 80.1 3.3
Norway 77.9 80.6 2.7
Poland 72.0 75.3 3.3
Portugal 75.4 78.9 3.5
Slovak Republic 72.4 74.3 1.9
Spain 78.1 81.1 3.0
Sweden 78.8 80.8 2.0
Switzerland 78.7 81.7 3.0
Turkey 67.9 71.6 3.7
United Kingdom 76.7 79.1 2.4
United States 75.7 78.1 2.4
OECD Average 76.0 78.9 3.0
OECD Health Data 2009 - Version: June 09
24. Factors explaining U.S. performance in
terms of health and quality
• IncenBves for overuse faced by health care providers (FFS payment,
malpracBce encouraged defensive medicine)
• Lack of incenBves for prevenBon (insurers, providers): limited use of P4P,
frequent change of coverage over lifeBme
• The uninsured (example: adult asthma admission rates)
• Limited use of health ICT applicaBons (e.g., EHR) that could promote
evidence‐based care and help to avert errors
• Lack of integraBon/coordinaBon in the delivery system
• Health status shoraalls also explained by factors not directly in health
system purview: violence, teen birth rate, segments of populaBon who are
at a great disadvantage in terms of income, educaBon
25. Some lessons from OECD experience
• SBll at an early stage of research into what structural
characterisBcs and policies contribute to top
performance in quality of care
• Quality measurement and benchmarking is essenBal
• Improved health data and informaBon systems needed
both to track and to improve quality of care
– Unique paBent idenBfiers allowing for data linkage
26. Conclusions
• Every reason to believe that U.S. gets poor value
for money, relaBve to other developed countries
• This is the case irrespecBve of whether increased
spending over Bme has yielded benefits valued
more than they cost
• Lessons from internaBonal experience may be
useful to build upon strengths and address
weaknesses, although naBonal context (i.e.,
insBtuBonal factors) and values very important
27. For more informaBon
• “OECD Health Systems: Lessons from the
Reform Experience,” by E. Docteur and H.
Oxley, OECD Economics Department Working
Paper, 2003.
• “The U.S. Health System: Assessment and
ProspecBve DirecBons for Reform,” by E.
Docteur, H. Suppanz and J. Woo, OECD
Economics Department Working Paper, 2002.
• OECD Health at a Glance, 2009 (forthcoming).
