New publication details strengths and weaknesses of the U.S. health insurance system

Reviewed by Emily Henderson, B.Sc.May 12 2021

A landmark work that details the strengths and weaknesses of the U.S. health insurance system, including how it lags behind those of other wealthy countries in measures that include mortality from both preventable and treatable causes, has been published.

The first edition of "Health Insurance Systems: An International Comparison," authored by Dr. Thomas Rice, UCLA Fielding School of Public Health distinguished professor of health policy and management and published by Academic Press, an imprint of Elsevier, Inc., is now available. The work is an in-depth comparison of costs and outcomes in 10 different countries, and makes clear the problems the United States faces in delivering healthcare, Rice said.

The United States performed poorly overall in both equity and efficiency, compared with other wealthy nations, and at the same time, has a health insurance system that is substantially more costly than those in the other countries. Moreover, the evidence is convincing that this appears to be causal; that is, it is the unique features of U.S. health insurance that are responsible for our country's poorer performance in health equity and efficiency."

Dr. Thomas Rice, Distinguished Professor of Health Policy and Management, UCLA Fielding School of Public Health

The work reviews the insurance systems in Australia, Canada, France, Germany, Japan, the Netherlands, Sweden, Switzerland, the United Kingdom, and the United States. Rice categorizes the 10 countries into four distinct health systems, and makes country-to-country comparisons by system characteristics, equity, and efficiency. The book offers in-depth information previously available only in scattered locations - if at all - to researchers, policymakers, and the public, experts said.

Dr. Gregory P. Marchildon, a scholar at the University of Toronto, was most struck by how the United States and Canada, as the only two countries selected from the Americas, compared to the six European countries, Australia, and Japan.

"Both have truncated public health insurance systems relative to these other countries – in the United States, 10% of Americans are uninsured while in Canada, the benefit package is more limited," said Marchildon, who was not involved with Rice's work. "As a consequence, both countries perform quite poorly on a number of access and efficiency indicators, even if the United States is in its own unfortunate league on an `overall value for money' assessment."

As examples of how the United States health insurance system falls short, Rice points out the following:

• Compared with the nine other countries, the United States devotes almost 60% more of GDP to health, and health care spending per capita is double;
• In the United States, mortality from preventable causes per 100,000 population was 175; the same measure in Japan was 87 per 100,000;
• Mortality from treatable causes per 100,000 population, a different measure, was 88 in the U.S.; the same measure in Canada was 59 per 100,000'
• These cost differentials are not because Americans use more services; rather, they result from higher prices – as an example, the cost of a dose of herceptin, used to treat early-stage breast cancer, was $48 in Germany, while in the U.S., the cost was $211; a dose of immunoglobulin, an antibody commonly provided intravenously, ran $27 in the United Kingdom and $97 in the U.S.
• In terms of medical procedures, the cost of a normal delivery of a baby, without any complications, came in at $3,638 in the Netherlands, while in the U.S., delivering a baby cost $11,167; a colonoscopy in Switzerland totaled $582, while in the U.S., the same procedure came in at $2,874.
• In addition, access is poor: nearly one-tenth of the population lacks coverage and even more are underinsured, resulting in one-third of Americans saying that they experienced cost-related barriers to obtaining medical care in 2020-21-;twice as high as any of the other nine countries;
• In turn, in the United States, many health care outcomes are poor. For example, mortality amenable to health care, a measure of deaths that should be prevented by timely medical care, is higher in the United States than in the other countries and is more than double that of Switzerland

In addition, the impact of the COVID-19 pandemic on populations across the United States make it clear that the healthcare insurance system is not delivering for all Americans, despite its costs, Rice said. As of August 2020, on a per-capita basis, compared with whites, Blacks had COVID-19 hospitalization rates that were almost five times as great, and death rates that were more than double.

These facts suggest, quite clearly, that Americans are getting low value for their health care spending, Rice said, and suggesting there are four basic lessons the United States can learn from other nations:

• The systems are built on a bedrock of equitable access to care
• The countries have a single, publicly mandated system to promote fairness and efficiency
• Governments are actively involved in planning for the supply of health care resources and constraining prices
• Cost-effectiveness analyses and pricing tools are used to determine benefits and prices, particularly for pharmaceuticals

"The US health care system is beset with enormous problems. Spending is far higher than in all other countries even after adjusting for national wealth, but most indicators of access to care and many related to health care outcomes are poor," Rice said. "While the causes of these access and outcome disparities are numerous and complex, the health insurance system is at least partly at fault – and as a nation, the United States has to address these problems."