Mirror, mirror on the wall, why does the USA have the worst health of all?
Through the noise of American leaders attacking Europe, one pure signal can be heard. On average, Europeans live five years longer than USA citizens. And they pay much more for their health care, endure more risk, and suffer worse rates of disease. All to fail on the fundamental measure of the good life, how long you live.
Why are the USA’s health outcomes the worst in the high-income world, and, given the wealth of this superpower, the worst in the world?
It is time for America to look in the mirror, and ask why does the USA have the worst health system in the world? Why are its health outcomes and health care so bad?
Next week I am inviting all my paid subscribers to a special live call. I would love to hear your thoughts about this changing world.
The Commonwealth Fund asks this question in its annual review of health system performance in ten high-income countries, Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System. The ten countries are: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, Britain, and the USA.
The USA performed the worst, by a long way.
This rating is based on analysis of five domains of health system performance: access to care, care process, administrative efficiency, equity, and health outcomes. You can read the details in the Mirror, Mirror report, and it is backed up by the World Health Organisation (WHO) 2013 country report on the USA health system, and WHO’s data portal on health system statistics.
The USA spent the most on health by far. One-sixth of the USA’s economy goes to this failing system.
And when these two measures are combined in a grid, the mirror is held up to an astonishing, outlying failure.
In case you missed it, the dot in the far bottom right is the USA. The USA is not an exceptional nation because it stands taller and sees farther, as Madeleine Albright once said. It is exceptional because it spends more on health, and dies more, as Emmanuel Todd wrote in La Défaite de l’Occident.
Exceptionally among most countries in the world over the last twenty years, US life expectancy has flatlined or declined in some years (excluding the COVID years that affected life expectancy in all countries). Life expectancy is the result of many factors. In the USA, guns, suicide, substance abuse (‘deaths of despair’), poor social security systems, high rates of obesity and other chronic disease risk factors, the legacies of racial segregation, ethnic prejudice and dismal incarceration rates all contribute to shorter lives and earlier deaths. So too does its failing health system and chaotic governments.
Unlike some issues that I comment on, I have deep professional experience in health policy. I have known in detail about the USA’s health policy failure for decades. I examined in detail the sad story of the spread of opioid deaths in America nearly twenty years ago. One of my final jobs in the bureaucracy was to prepare a report on health outcome and performance measures for the state. Sick America might have shocked high-profile historian Niall Ferguson when he wrote We’re All Soviets Now, but the poor health of ‘Late Soviet America’ did not shock me.
Nor was I fooled by Niall Ferguson’s explanation of the mismatch between expenditure and outcomes:
“But, like the Soviet system as a whole, the U.S. healthcare system has evolved so that a whole bunch of vested interests can extract rents. The bloated, dysfunctional bureaucracy, brilliantly parodied by South Park in a recent episode—is great for the nomenklatura, lousy for the proles.
Meanwhile, as in the late Soviet Union, the hillbillies—actually the working class and a goodly slice of the middle class, too—drink and drug themselves to death even as the political and cultural elite double down on a bizarre ideology that no one really believes in.”
Niall Ferguson, We’re All Soviets Now
Niall offers ideological slop—crude economics, bureaucratic scapegoats and the ‘woke mind virus’— as a distraction from this deep American tragedy. He then went on to make the case to redirect American social and health care spending to a ‘generational’ increase in America’s gargantuan defence spending.
The Commonwealth Fund’s Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System was more direct about America’s democratic failure to deliver decent health care to its citizens.
Despite spending a lot on health care, the United States is not meeting one of the principal obligations of a nation: to protect the health and welfare of its residents. Most of the countries we compared are providing this protection, even though each can learn a good deal from its peers. The U.S., in failing this ultimate test of a successful nation, remains an outlier.
Commonwealth Fund, Mirror, Mirror 2024
The starkest failure is worth stressing. The USA is the only high-income country in the world without universal health care coverage. Most high-income countries have had those systems for more than half a century. Many middle- and low-income countries have those systems today. But the USA does not.
Its peers as failed health policy states are countries like Yemen and Afghanistan. But the USA cannot excuse its failure on the grounds of invasion, bombardment, and sabotage by an external power. It only has itself to blame.
Yet the USA seems incapable of fixing this basic problem of twentieth-century government. I am curious about what my American readers think about this issue. How well understood in America is America’s failure of this ultimate test of a successful nation?
There are many dimensions to the tragedy of American healthcare. There is a patchwork of private insurance, employer-based plans, and public programs like Medicare and Medicaid. Millions are uninsured or underinsured, creating barriers to care that are both financial and bureaucratic. The Affordable Care Act (‘Obamacare’) improved the situation but still left about one in ten uninsured and one in four underinsured. The patchwork causes administrative inefficiency. The complex system is good for insurers and providers, but bad for patients, bad for actual care. Inequality is rampant in access and outcomes based on income, race, and geography. The system of pharmaceutical drug regulation is appalling, contributing to unaffordable prices and the oxycontin scandals of the last decade. Yet for years the USA has sought to undermine Australia’s pharmaceutical benefits scheme through coercive trade diplomacy. Thankfully, Australian Governments from both sides of politics have refused this poison pill of American free enterprise.
Every attempt to fix the problem seems only to make things worse. I will not try to retrace the history of the failures. They go back a long, long way. But somehow the self-perception persists that America offers the ‘best health care in the world’. For the elite at a luxury price, yes. But a five-year gap in life expectancy with the despised Europeans does not lie.
Robert F. Kennedy Jr.’s slogan to “Make America Healthy Again” resonated in the 2024 election. But it concealed a lie—when was American health ever great? —and is destined to fail. His agenda fights old wars. Kennedy is scarred by the COVID years and too much litigation against Big Pharma. He is not dealing with the fundamentals. Musk’s AI-generated spending review (Department of Government Efficiency) will prune some waste but send the libertarian dogs on all the wrong targets.
Health policy is hard. Implementing effective health care is harder still. Trust me, I spent 16 years of my life doing it. It tests the most capable of governments and the most effective of political leaders. The USA government and the Trump administration are not up to the job.
There is a difficult history question behind this all-American failure. Why has the ‘greatest democracy on earth’ failed the ultimate test of a successful nation?
On Wednesday, my deep dive for paid subscribers will explore that question with the benefit of Emmanuel Todd and a recent history of health care in America.
Coming up next week: Barack Obama
This post is part of my series on America. My full schedule with links to past posts for the World History Tour of World Powers is here as a pdf for you.
Thanks
❤️🙏
Jeff
P.S. The social media image of RFK Jr was generated by Elon Musk’s Grok AI.
And if you can catch up on my content from the week with these highlights:
My interview with
on the Burning Archive YouTube channel on how to shape peace after the Ukraine War and the unipolar world.My interview with the wonderful American journalist,
on her Substack and YouTube channel.And on my new World Literature Archive YouTube channel, my reading of the classic Russian epic poem (c. 1200), The Lay of Igor’s Campaign, with an uncanny connection to the war in Ukraine.
1) You don't even mention the two most important factors in public health: diet & exercise.
The diet of the avg Yank is atrocious & most do not engage in any physical activity.
80% of the country is overweight, obese or morbidly obese.
The most xpensive health care in the world is irrelevant in the face of these.
2) "The Affordable Care Act (‘Obamacare’) improved the situation but still left about one in ten uninsured and one in four underinsured".
Obamacare was nothing more than a sop to the health insurance industry, compelling hapless Yanks to purchase useless 'plans' with high deductibles & scores of hidden fees. What does 'insured' even mean when policy holders still cannot afford treatment?
I agree with the “We’re all Soviets now “ theme included in Jeff’s article.
Although a diametrically opposed ideology to that of the Soviet Union, the US is determined to pursue its ideologies as grimly as the USSR ever did.
I say” ideologies” because the US has a hybrid of inconsistent if not plain contradictory ideologies. Here are a few
1. Free markets and private enterprise
2. Person liberty
3. Freedom to carry guns
4. The death penalty
5. Significant opposition to abortion on demand
6. Opposition to socialised health care ( or socialised anything)
Is it any wonder that in trying to reconcile all of these strong elements of US political culture, there isn’t much room for a successful system of health care?
Some time ago, as president of the Australian Medical Association (please don’t hold that against me) I attended a meeting of the World Medical Association. At that meeting there was a laudable motion on the agenda to support the notion that doctors should not participate in torture of prisoners nor in executions. The motion never came to be debated let alone voted upon. The US delegation exerted its considerable influence to ensure the motion was dropped form the agenda, lest it be forced to defend the county’s use of doctors supervising waterboarding and other methods of post 9/11 torture, or the use of doctors to administer lethal injections in executions in some US states.
The point I am making is that other countries have made a determined effort to build healthcare systems to do the best they could to look after the health of their citizens.
The US has consistently designed a health care system based around non health related ideological holy grails and sacred cows. The results speak for themselves.