How Does the Quality of U.S. Health Care Compare
Internationally?
Timely Analysis of Immediate Health Policy Issues
August 2009
Elizabeth Docteur and Robert A. Berenson
Introduction
There is a perception among many
Americans that despite coverage,
cost and other problems in the
health care system, the quality of
health care in the United States is
better than it is anywhere else in
the world and might be threatened
by health reform. In fact, 55
percent of Americans surveyed last
year said U.S. patients receive
better quality of care than do those
in other nations, even though only
45percent said they thought the
United States had the world’s best
health care system.1 And while
Americans overwhelmingly
support government action to
increase coverage and reduce the
costs of health care, a recent poll
found that 63 percent worry that
the quality of their own care would
get worse if the government
ensured health care for all.2
Another poll found that as many as
81percent of Americans have such
concerns.3
Participants in the current reform
debate refer to the relative quality
of U.S. health care as providing
support for their views, and
perceptions of health-care quality
— what it is and where it can be
found — are often at the heart of
disagreements over what form of
health reform the country should
adopt. But hard facts to support
claims are often missing, and it is
clear that quality of care experts,
policy makers, health care
providers and the general public all
have different ideas as to which
aspects of health care signify its
quality and which ones are most
important.
This brief brings together available
evidence on how quality of care in
the United States compares to that
of other countries and comments
on the implications of the evidence
for the health reform debate. By
exploring how the quality of our
care compares internationally, we
can address the underlying
attitudes and concerns that people
have about health reform. For
example, if claims that the United
States has the best quality of care
in the world — overall or in
particular respects — were well
supported by the evidence, it
would caution us against adopting
forms of health reform that
threaten those attributes of our
health system responsible for this
standing. But if quality of care is
not remarkable — or may be even
lagging — there should be less
reluctance to change. In addition, a
more explicit need for health
reform to address quality
improvement would appear
warranted.
What constitutes high-
quality health care?
A number of definitions of health
care quality have been put forward
over the years. The U.S. Institute
of Medicine’s definition, which
has grounded expert work in the
United States and elsewhere,
describes quality as “the degree to
which health services for
individuals and populations
increase the likelihood of desired
health outcomes and are consistent
with current professional
knowledge.”4 A similar definition
is used by the U.S. Agency for
Healthcare Research and Quality:
“Quality health care means doing
the right thing at the right time in
the right way for the right person
and having the best results
possible.”5 Both definitions refer to
characteristics of health care that
are increasingly referred to as
“technical” or “clinical" quality or
“effectiveness.”6
In the context of efforts to assess
health system performance, the
term “quality” is often used to
encompass a range of desirable or
positive attributes of health care
and the overall performance of
health-care systems. A review of
eight country-specific and
internationally developed
frameworks for evaluating health
systems found a great deal of
commonality in how performance
has been conceptualized.7 In
addition to effectiveness, the
researchers identified 14 other
dimensions of the performance of
health care systems: acceptability,
accessibility, appropriateness, care
environment and amenities,
competence or capability,
continuity, expenditure or cost,
efficiency, equity, governance,
patient-centeredness (-focus) or
responsiveness, safety,
sustainability, and timeliness.
 

Timely Analysis of Immediate Health Policy Issues 2
Many of these performance
dimensions might reasonably be
considered to be attributes of high-
quality care (e.g., appropriateness,
competence, timeliness). Those in
a second group (e.g., cost,
governance, sustainability) are
readily observed as separate
performance concerns. Reasonable
people might have different views
on whether others (e.g.,
accessibility, acceptability,
responsiveness) are dimensions of
quality or closely related concepts,
and indeed these are treated in
different ways in the frameworks
reviewed. Accessibility is
particularly difficult to disentangle
from considerations of health care
quality in that it is a prerequisite to
receipt of quality health care.
Availability of providers and
services, coverage, benefits and
affordability all come into play as
potential explanations for different
user experiences with the health
care system and the outcomes
attained. Finally, (technical)
efficiency is a function of the
quality and quantity of services
produced at a given cost.
Efficiency, or value for money, is a
performance consideration of great
interest to public authorities and
purchasers, although only modest
headway in measuring efficiency
in health care has been made to
date, reflecting limitations in the
capacity to measure the quality of
health care.
It is evident from the U.S. reform
debates that popular conceptions of
what constitutes good quality
health care encompass a range of
dimensions. Although obviously
high quality implies superior
health outcomes, other attributes
considered indicative of quality
appear to underlie popular
expressions of U.S. health care
superiority, including a belief that
Americans with good insurance
coverage uniquely benefit from
prompt availability and
accessibility of cutting-edge
medical procedures, medicines,
and devices, as well as highly
educated and well-trained health
care professionals, who know and
consistently do what is best for
their patients. On the other hand,
those who assert that we have
inferior quality of care point to our
relatively poor population health
status,8 and factors such as barriers
to access for those without
adequate insurance coverage or
limited health plan provider
networks and insufficient
coordination among providers in
the fragmented health care delivery
system.
All of these aspects of quality and
broader health system performance
are important and legitimate
considerations; therefore, we cast a
relatively wide net in this brief.
Specifically, we focus on
effectiveness (or “technical” or
“clinical” quality) and consider
additional dimensions of quality or
health system performance that are
most closely related:
appropriateness, safety,
accessibility, acceptability, and
responsiveness.
What is the evidence on
how quality of care in
the United States
compares to other
countries?
To make an informed assessment
about the quality of care in one
health system versus another, it is
important to look at a wide range
of indicators. Because health care
involves a complex array of
activities, and because there are
many holes in our knowledge of
the relative quality in many areas,
it is impossible to use a single
measure as a meaningful proxy.
Measures that reflect multiple
dimensions of quality have a
certain appeal as performance
indicators for policy-makers,
although more specific or narrow
measures have the advantage of
being more actionable for
administrators and clinicians. And
even with a broad set of
comparative measures, people may
differ on which measures are most
important, for example, those
focusing on the level of typical or
average care for common
conditions versus the care
available for unusual, life-
threatening conditions.
The evidentiary basis for cross-
country comparisons of quality
could be strengthened by
additional studies and
improvements in methods and
data. Nonetheless, a number of
comparative studies on the quality
of care have been published.
Below we review some of the key
findings from recent research that
provide insight on how the quality
of care in the United States
compares to the quality of care
in other nations. We explore
quality as assessed by measures
based upon population health
status, measures of processes
and outcomes of care for particular
conditions, measures of patient
safety, and indicators based
on patients’ experience with
health services. In each area,
we put forward the evidence
we could find on how the
attribute in question stacks up
(or fails to do so).



 

Timely Analysis of Immediate Health Policy Issues 3
How strong is the evidence base for comparing health care quality across countries?
There is modest research literature comparing the quality of care in the United States with the quality of care furnished
elsewhere. Most studies of technical quality or effectiveness draw on data compiled from disease registries, medical
records or administrative data. Such studies generally focus on a particular condition, such as coronary heart disease
or specific forms of cancer, and they differ in the extent to which they endeavor to account for factors outside the
control of the health care provider and system that could affect the results.
Efforts to identify a set of indicators for use in making international comparisons across a range of conditions as part
of regular monitoring activities include an ongoing Organisation for Economic Co-operation and Development
(OECD) initiative, which builds on initial work by the Commonwealth Fund and a coalition of Nordic countries. To
date, the OECD has formulated, tested and validated a relatively small number of quality measures for use in
international comparisons, with other measures in development.55 Initial results have been published showing cross-
country differences based on data obtained from national sources, but with caveats as to factors making comparisons
indicative, rather than absolute. Limitations include differences in data sources used in measurement, different
reporting periods, and limited ability to adjust for age and other factors (not reflecting quality of care differences) that
can explain apparent cross-national differences.
Beyond this, surveys of citizens, patients and health care providers in five or more countries have been produced
annually since 1998 by the Commonwealth Fund.56 These provide information on how health care is perceived as well
as how the experience of health care differs internationally in relation to public expectations. Surveys can explore
aspects of health care and quality dimensions for which other forms of data do not exist in comparable form. Their
limitations include cross-country differences in the interpretation of questions and concepts, which could affect how
countries’ health systems fare relative to one another, as well as standard survey research problems like recall bias.
An important issue in health care quality measurement, as in other types of research that attempt to ascertain causality,
is that it is very difficult to adjust for factors outside the health care system which contribute to particular health
outcomes, such as socioeconomic status, lifestyle, and disease incidence or prevalence. Similarly, quality of care
measures could be affected by differential access to care across a population, reflecting coverage gaps in the United
States as well as shortfalls in supply or financial barriers presented by cost-sharing requirements here and in other
countries. Thus, the quality of care obtained by those with unfettered access might differ considerably from that of
those who face obstacles to getting needed care.
Are cross-country
differences in life
expectancy and
mortality indicative of
differences in health
care quality?
While U.S. life expectancy is at or
below the average in comparison
with that of other developed
countries, findings from research
that has adjusted mortality to
account for deaths not related to
health care (so-called amenable
mortality) show the United States
to be among the worst performers.
The United States is not among top
performers in terms of life
expectancy, an indicator
influenced by factors outside the
health system in addition to health
care. We rank among the lower
third of developed countries in life
expectancy at birth. Life
expectancy at age 65 may be a
better indicator of U.S. health care
performance because all older
Americans have reasonably good
insurance coverage through
Medicare. U.S. life expectancy for
both men and women at age 65 is
above the Organisation for
Economic Co-operation and
Development (OECD) average, but
below what the top countries have
achieved, particularly for women.9
Among 19 countries included in a
recent study of amenable
mortality,10 the United States had
the highest rate of deaths from
conditions that could have been
prevented or treated successfully.
The extent to which differences
across countries in the prevalence
of particular conditions may
explain the poor U.S. showing in
 

Timely Analysis of Immediate Health Policy Issues 4
What do life expectancy and mortality data tell us about the quality and effectiveness of
health care?
Health status measures based on mortality and life expectancy data have been used to assess the overall effectiveness
of the health system, reflecting the quality and accessibility of services, as well as environmental factors. Examples of
such measures include crude mortality rates for defined populations; disability-adjusted life years (DALY), an
indicator developed by the World Health Organization to assess the burden of disease; health-adjusted life expectancy
(HALE), which can be used to assess whether increases in longevity are accompanied by compression of morbidity;
and potential years of life lost (PYLL), a summary measures of premature mortality that assigns greater weight to
deaths that are further away from a defined benchmark (such as age 70).
Although very interesting as indicators of health status, all fall short as measures of health care quality because they
tend to be significantly influenced by factors other than health care. For example, of the 30 OECD countries, only
Hungary does worse than the United States in female premature mortality, as measured by PYLL, and only three
countries exceed the U.S. rate of male premature mortality. However, accidents, suicides and homicides play a large
role in explaining this finding, as the U.S. homicide rate is more than five times the OECD average.57
More sophisticated mortality measures set aside those deaths that cannot be attributed to the effectiveness of health
care. So-called amenable mortality is an indicator that aims to cast light on the relative effectiveness of health systems
by calculating the rate of deaths prior to a certain age which are considered by experts to be avoidable through
appropriate health care. As with other measures of mortality, amenable mortality is affected by differences in the
prevalence of particular conditions across populations being compared. Thus, two health care systems could have
identical rates of failing to provide adequate care for a condition that should not be fatal; however, if one of the two
countries has a higher rate of prevalence of the condition among its population, its amenable mortality rate will also
be higher. Nevertheless, amenable mortality does a better job than crude mortality data in assessing the effectiveness
of health care delivery in improving health.
the recent study is unknown,
although studies in which it was
possible to adjust for such
differences found that the greatest
part of regional differences in
mortality for certain conditions
were explained by differences in
disease prevalence.11 A recent
study comparing the United States
and 10 European countries found
that the United States had a much
higher prevalence of nine of 10
conditions, including cancer, heart
disease, and stroke, in its
population over age 50.12
However, it is unlikely that relative
differences across countries in the
prevalence of disease changed
during the five years that had
passed since an earlier study13 by
the same authors using the same
methodology, in which the U.S.
health system ranked somewhat
better (16 of 19) among its peers in
minimizing amenable mortality. In
the years between the two studies,
there was an average reduction in
amenable mortality for men of 17
percent across all countries
included in the study, compared
with only a 4 percent reduction in
the rate of amenable mortality for
men in the United States.
Studies of processes
and outcomes of care for
particular conditions
reveal differences in
health-care quality
Measures specifically designed to
assess technical/clinical quality of
care focus on health services and
health outcomes, such as five-year
survival rates for individuals with
particular conditions. Such
measures are less sensitive to
differences across countries in
disease prevalence.
Below we review available
evidence on U.S. quality of care in
a variety of clinical areas, in
comparison with other countries.
The overall evidence is mixed,
indicating that the United States
has neither the best nor the worst
quality of health care for particular
conditions among developed
countries. In certain cases where
U.S. quality appears low relative to
that of other countries — in the
areas of prevention and care for
chronic conditions, for example —
access barriers experienced by the
uninsured and the underinsured
may contribute to the results seen.
 

Timely Analysis of Immediate Health Policy Issues 5
Measuring the technical quality or effectiveness of health care:
A brief primer
The science of health care quality measurement has been developed over
the course of several decades. Quality measures include those to assess
health care processes (what was done), outcomes (what was achieved) and
structural measures that evaluate the capacity to do what needs to be done.
Process measures can be further categorized as measures of overuse (when
patients get services that are inappropriate for their medical condition,
subjecting them to unwarranted risk and/or expense), underuse (when
patients do not receive care that is indicated based on their medical
condition) and misuse (when a service is provided in a technically
incorrect manner), although the bulk of the measures used regularly for
comparison relate to underuse of services considered medically necessary
in defined circumstances.
Quality can be assessed objectively (against standards defined by evidence
or professional agreement) or subjectively (against patients’ expectations
or experiences, or reviewer judgment, for examples). Assessment draws
upon empirical data, such as administrative and medical records or patient
registries and the perceptions of those involved in health care (surveys,
testimonials). Quality is evaluated for populations and sub-groups within
the population, as there is a particular interest in evaluating whether and
how differences in health care contribute to observed disparities in health
status.
Quality of preventive care
The evidence on how the United
States compares to other developed
countries in terms of the quality of
its preventive care is quite mixed.
In a report that summarized survey
research comparing quality of care
in five countries, Davis et al.14
concluded that the United States
had relatively high-quality
preventive care. 85 percent of
American women reported having
had a Pap smear within the last
two years and 84 percent of
American women age 50 to 64
reported having received a
mammogram within the last two
years, the highest shares among the
countries included in the survey.
Perhaps reflecting differences in
data sources, the OECD15 found
that the United States had above-
average mammography rates (61
percent U.S. versus 55 percent
OECD), although was far below
the best performers (82-98 percent
in four countries). However, the
United States had the highest
cervical cancer screening rate (83
percent) among 22 countries
reporting data to OECD.
Among 30 OECD countries, the
United States had above-average
rates of flu vaccination for senior
citizens (65 percent U.S. versus 55
percent OECD average and 80
percent in top-performing
Australia). However, childhood
vaccination rates were below the
OECD average.16 The U.S.
pertussis vaccination rate stood at
86 percent in 2005; only Austria
and Canada reported lower rates.
Even with a 92 percent childhood
measles vaccination, the United
States came in below average in a
field where one-third of OECD
countries have rates above 95
percent.
Quality of care for chronic
conditions
Findings on the quality of U.S.
care for several chronic conditions
also provide a mixed picture.
Among 30 OECD countries, the
United States ranked below
average in adult asthma care. Adult
hospital admission rates for
asthma, an indicator of inadequate
care for the condition, were second
highest among 17 countries
reporting (12 per 10,000 U.S.
versus 5.8 OECD average) and
U.S. asthma mortality, double the
OECD average rate, was fifth
highest among 25 countries
reporting.17
A handful of studies undertaken in
the 1990s18 have compared
outcomes for U.S. and Canadian
patients with end-stage renal
disease and found that Canadians
have longer survival times while in
hemodialysis or peritoneal dialysis
programs, and after receipt of
kidney transplant, even when
extensive adjustment for
comorbidity is done.
A survey of patients in six
countries19 found that more than
half of U.S. diabetics had received
four recommended services, a rate
comparable to the UK and
Germany, and higher than the rate
seen in Australia, Canada and New
Zealand. The same survey found
that 85 percent of U.S.
hypertension patients reported
having received two recommended
tests, a rate identical to Canada and
exceeded only by Germany (91
percent).
 

Timely Analysis of Immediate Health Policy Issues 6
Quality of care for certain
acute conditions
Studies of diverse conditions
ranging from heart disease, hip
fracture and vision impairment
also are mixed in terms of their
findings as to how U.S. quality
compares to that of other countries.
• Yusuf et al.20 studied patients
undergoing invasive cardiac
procedures in six countries and
found that higher rates of
invasive and revascularization
procedures in United States
and Brazil were associated
with lower rates of refractory
angina or readmission for
unstable angina, no apparent
reduction in cardiovascular
death or myocardial infarction,
but higher rates of stroke. Tu
et al.21 found that short-term,
but not long-term, cardiac
outcomes were better in the
United States than Ontario.
• Ho et al.22 found that inpatient
hip fracture mortality was
higher in Canada (Manitoba
and Quebec) than in the United
States (California and
Massachusetts). Canadians had
longer waits for surgery,
although this was found not to
explain the difference in
mortality observed.
• Norregaard et al.23 found
similar postoperative visual
acuity for cataract patients
across four countries studied,
including the United States,
despite considerable
differences in the organization
of care and patterns of clinical
practice. The United States had
fewer adverse intra-operative
events than the other three
sites studied but, along with
Manitoba, had higher rates of
early postoperative events. The
United States and Manitoba
used a more advanced surgical
method for cataract removal as
compared with Barcelona or
Denmark.24
Quality of cancer care
While interpreting the available
evidence is challenging in the light
of different screening protocols
across countries, it does suggest
that the United States as one of
several world leaders in providing
high-quality cancer care.
A study by Gatta and colleagues,25
looked at five-year cancer survival
rates for the United States and 17
European countries. The United
States had the highest survival
rates for cancer of the colon,
rectum, lung, breast, and prostate.
U.S. survival rates were also
among the highest for melanoma
(fourth), uterine (second) and
ovarian (fifth) cancer, cervical
cancer (sixth), Hodgkins disease
(third) and non-Hodgkins
lymphoma (fourth). The United
States was ninth in survival of
stomach cancer. Although average
survival differences between the
United States and Europe as a
whole were in some cases large,
the difference between the United
States and the other countries with
relatively high five-year survival
rates were generally small
(approximately 3 to 4 percent for
many cancers) and (due to small
sample sizes) usually not
statistically significant. The study
also looked at cross-country
differences by population group,
finding that survival rates for
colon, breast and uterine cancer
were similar in the United States
and Europe for patients under 45
years, but were much better in the
United States for patients age 65 or
older at diagnosis. In the case of
stomach cancer, the U.S. survival
rate for patients under age 45 was
below those of many European
nations, but similar among the
older patients. Other studies (e.g.,
Coleman, et al. 2008)26 have also
found that U.S. survival rates for
certain cancers, particularly
prostate cancer, are among the
best. Among 30 OECD countries,
the United States had one of the
best five-year survival rates for
patients with breast or colorectal
cancer.27
There is an important link between
survival rates and screening rates
for many cancers (e.g., melanoma,
prostate cancer, breast cancer,
colorectal cancer). Many cancers
are more amenable to treatment
when caught early. But it is also
true that in countries with higher
screening, more cancers will be
diagnosed early, and survival rates
in those countries will be higher
simply because there are more
patients in the denominator with
less advanced disease. Thus, Gatta
et al.28 found that those countries
with the highest breast cancer
incidence rate (share of population
newly diagnosed with the disease
in a given year) also had the
highest survival rates.
Differing national commitments to
screening becomes an issue,
particularly, in the case of prostate
cancer, where U.S. incidence rates
are double those of Europe
because aggressive screening
uncovers cancers at a very early
stage. The implications for quality
are complicated, in that cancer
detection has instigated more
treatments with serious risk of
quality of life deterioration for a
condition that is very slow to
 

Timely Analysis of Immediate Health Policy Issues 7
develop. In 2008, the U.S.
Preventive Services Task Force
updated its screening advice,
recommending that known risks of
screening outweigh potential
benefits for older men, and that
informed patient preferences
should serve as a determinant of
appropriate care in younger men.
Other countries, such as Denmark,
had recommended against
widespread use of the test as early
as 1990 (cited in Coleman et al.
2008).29
Differences across countries in
access to diagnostic and treatment
services explain most of the
observed differences in cancer
survival rates.30 Better survival
rates are associated with higher
national income levels, higher
levels of expenditure on health,
and higher investment in health
technology, as proxied by
indicators such as the rate of CT
scanners per person. The
relationship between cancer
survival and level of expenditure
on diagnosis and treatment has yet
to be fully explored, due to data
limitations, although some cross-
country differences in expenditure
have been documented. Using an
approach to assess relative
spending across nations with
different income levels, OECD
found that the United States spent
between 41 and 62 percent of its
per capita GDP on the first six
months of breast cancer treatment
following diagnosis for each
patient, while Canada and France
spent about one-third of their
respective per capita GDPs for
treatment during the initial phase.31

U.S.-Canada
comparisons more often
find Canadian quality is
better
A significant share of the academic
research studies comparing the
outcomes and effectiveness of
health care across countries
consists of U.S./Canada
comparisons, perhaps reflecting
policy interest, data availability or
other factors. Although studies
findings go in both directions, the
bulk of the research finds higher
quality of care in Canada.
A review of the evidence on
quality differences between the
United States and Canada found
that each of the two countries
performed better in different
studies. Guyatt et al.32 identified 38
studies comparing populations of
patients in Canada and the United
States. Studies addressed diverse
problems, including cancer,
coronary artery disease, chronic
illnesses and surgical procedures.
Of 10 studies that included
extensive statistical adjustment and
enrolled broad populations, five
favored Canada, two favored the
United States, and three showed
equivalent or mixed results.
Overuse of health
services not linked with
service volume
Although there have been
relatively few studies comparing
the rates of overuse of health
services, the limited available
evidence suggests that higher rates
of certain surgeries and procedures
in the United States put more
Americans at risk, in comparison
with their counterparts, even if it is
the case that the share of
procedures that are inappropriate
does not vary across countries with
different service rates.
The degree of variation in the
share of populations receiving
particular services is greater than
what would be expected based on
population health status
differences, raising a question as to
whether there is underuse of the
procedure in countries with
relatively low rates or overuse in
the countries with relatively high
rates. For example, OECD
countries’ rates of caesarean
sections per 100 live births range
from 13.6 to 37.9, with U.S. rates
among the highest in the OECD.
Although determining the extent to
which the procedure is overused
requires investigation of patient
characteristics, including age and
comorbidities, the World Health
Organization has stated that rates
above 15 percent offer no benefits
in terms of population health.33
The United States also has the
highest rates of coronary
revascularization procedures, with
more than double the rates of other
countries with similar mortality
rates from heart disease.34
However, relying on assessment of
performance against evidence-
based criteria, McGlynn et al.35
found comparable rates of
inappropriate use of coronary
angiography and CABG, when
comparing New York State and
Canada, despite different rates of
use of service in the areas studied.
Findings from studies by Bernstein
et al.36 and Gandjour et al.37 also
suggest that rates of inappropriate
services are not dependent on the
frequency of the procedure.
Despite performing relatively few
cardiovascular procedures, in
comparison with the United States,
the rates of inappropriate surgeries
 

Timely Analysis of Immediate Health Policy Issues 8
in the UK and Germany were
comparable.
Higher rates of surgery may have
both positive and negative impact
of health outcomes. On the one
hand, when performed on
appropriate candidates, surgery
will tend to have positive benefits
in terms of life expectancy and
morbidity associated with the
underlying condition. On the other,
greater per capita rates of heart
surgery may contribute to the
higher rates of mortality due to
surgical and medical errors in the
United States.
Patient safety problems
appear more prevalent in
the United States
Few studies have compared patient
safety at an international level, as
data and indicators for use within
countries are still in development.
Notwithstanding such limitations,
available evidence suggests that
patients may be at greater risk of
safety problems in the United
States than they are elsewhere.
Data are available for cross-
national comparisons on mortality
due to surgical and medical
errors.38 These data show that the
United States has relatively high
rates, in comparison with other
OECD countries, but the rates may
be problematic as quality
indicators due to differences in
reporting accuracy across countries
and the relative infrequency of this
outcome.
Surveys provide another source of
information on relative safety. A
six-country survey of patients with
a high incidence of chronic illness
and recent intensive use of the
health care system found that
patients in the United States were
more likely than patients in other
countries to report mistakes or
adverse events and gaps in expert-
recommended safe medication
management practices.39 A survey
of chronically ill or intensively ill
patients in eight countries40 found
that the United States had the
highest reported rates of problems
such as being given the wrong
medication or dosage,
experiencing a medical error,
receiving incorrect test results, or
facing delays in hearing about
abnormal test results. Patient
reports of these types of problems
were lowest in the Netherlands (17
percent), France (18 percent), and
Germany (19 percent) and highest
in the United States (34 percent).
Physician and patient
perceptions of health
care quality suggest
strengths and
weaknesses of U.S. care
As with most of the indicators
described above, physician and
patient reports suggest some areas
of strength, but as a general matter
do not distinguish American health
care as providing especially high
quality compared to the health care
provided in other countries.
A survey of physicians in five
countries41 found that U.S.
physicians were more likely than
physicians in other countries to
report that interventions in patient
care geared towards cost control
were threatening the quality of
care they could provide to their
patients. U.S. physicians were less
likely to report that community
resources were inadequate, but
more likely to say that limitations
on the medicines they could
prescribe posed a problem.
Compared with doctors in
Australia, Canada, New Zealand
and the United Kingdom,
American doctors were less likely
to agree that their health care
system works well and more likely
to consider that the system needs
complete rebuilding. A 2003
survey of hospital executives
yielded a similar finding; half of
American hospital executives said
they were not satisfied with the
performance of their country’s
health care system, compared with
between 4 and 12 percent of
hospital executives in four other
countries.42
Davis43 reviewed findings from
multi-country surveys conducted
in 2004 and 2005 that examined
patients’ satisfaction and
experience with their health care.
Patients assigned the U.S. health
system mixed marks in terms of
whether their health care providers
communicated needed
information. U.S. patients were
less satisfied than patients in other
countries with the quality of
communication relating to doctor’s
office visits, but more satisfied
than other patients with the quality
of communication relating to
hospitalization. On the other hand,
U.S. patients were less satisfied
than patients in other countries
with how much their physicians
engaged them in making health
care decisions. In terms of
satisfaction with the level of
choice of doctor, Americans were
less satisfied than patients from
New Zealand and more satisfied
that Canadian patients. Finally, in
terms of timeliness, American and
German patients reported
relatively short waiting times for
seeing a specialist or obtaining
elective surgery. But Americans
were less likely to say they could
get medical attention when needed
 

Timely Analysis of Immediate Health Policy Issues 9
and could readily obtain care on
nights and weekends. Considering
timeliness measures as a whole,
German patients were more
satisfied than American patients,
and British and Canadian patients
were least satisfied.
Is the average quality of
care in the United States
negatively affected by
access barriers faced by
the uninsured?
When comparing the quality of
care in the United States to that of
other countries it is impossible to
ignore one stark difference — the
fact that close to one-fifth of the
U.S. population under age 65 is
uninsured. The United States is
one of only three countries in the
OECD, together with Mexico and
Turkey, which has a sizeable share
of its population lacking coverage.
It stands to reason that some of the
gap between United States and
other countries in average quality
may well be related, in at least
some part, to the insurance
coverage problem in this country.
Most of today’s measures capture
problems of “underuse,” or the
share of a population that receives
the screening or treatment
indicated, based on agreed medical
practice standards. For many such
measures, quality and access are
intrinsically linked.
There is, in fact, some suggestive
evidence of a quality-coverage
relationship. In their updated study
of amenable mortality, Nolte and
McKee44 suggest that an increase
in the share of Americans
uninsured between the two study
periods may be responsible for the
failure of the United States to
improve its performance apace
with other countries studied,
resulting in the United States
dropping from 16th to 19th place
over five years. Furthermore, the
findings showing that the United
States does better than Europe in
cancer survival for the over-65
population suggests a possible role
for insurance status as an
explanatory factor, especially since
working age and retirees have the
same coverage in most European
countries.
In addition, there is evidence to
suggest that access barriers are an
issue affecting U.S. performance,
in particular. As compared with the
residents of other countries, many
more Americans — and
chronically ill Americans — say
they skip medicines or medical
appointments due to cost.45 46 Such
behavior, which may reflect
problems of underinsurance as
well as uninsurance, may result in
impaired health outcomes. By
contrast, the types of access
problems reported in other
countries — mainly longer waits
for elective surgeries — are likely
to affect perceptions of service
quality and reduced quality of life
during the waiting period without
impact on clinical outcomes.47
Based on a comprehensive review
of the relevant research literature,
the Institute of Medicine48
concluded that the uninsured have
worse health and higher mortality
than the insured population in the
United States. Population based
studies have shown that uninsured
Americans have shorter survival
times for conditions such as cancer
of the breast, colorectum and
prostate than those with
insurance.49 A review of the
research literature over the past 25
years by Hadley50 found that the
uninsured receive fewer preventive
and diagnostic services, tend to be
more severely ill when diagnosed,
and receive less therapeutic care.
He concluded that insurance
coverage could reduce mortality by
an estimated 4 to 25 percent,
depending on the condition.
But all of this does not necessarily
mean that the uninsured have
worse quality of care, as measured
by provision of evidence-based,
recommended processes of care
that are likely to improve patient
outcomes. In fact, a study by Asch
et al.51 found that health insurance
status was largely unrelated to the
quality of care as measured by
adherence to professionally
recommended standards of care,
among those with at least one
contact with the health care system
within a two-year period. This
somewhat surprising finding
suggests that the access barriers
experienced by the uninsured may
not result in differential treatment
once an uninsured person succeeds
in engaging with the health care
delivery system.
Summary and
conclusions
Taken collectively, the findings
from international studies of health
care quality do not in and of
themselves provide a definitive
answer to the question of how the
United States compares in terms of
the quality of its health care. While
the evidence base is incomplete
and suffers from other limitations,
it does not provide support for the
oft-repeated claim that the “U.S.
health care is the best in the
world.” In fact, there is no hard
evidence that identifies particular
areas in which U.S. health care
quality is truly exceptional.
 

Timely Analysis of Immediate Health Policy Issues 10
Instead, the picture that emerges
from the information available on
technical quality and related
aspects of health system
performance is a mixed bag, with
the United States doing relatively
well in some areas — such as
cancer care — and less well in
others — such as mortality from
conditions amenable to prevention
and treatment. Many Americans
would be surprised by the findings
from studies showing that U.S.
health care is not clearly superior
to that received by Canadians, and
that in some respects Canadian
care has been shown to be of
higher quality.
To be sure, there are limitations to
the current evidence base. In
particular, there is no data or
evidence by which to answer the
question of whether the United
States is a place where one finds
health care that exceeds the quality
of the best care available
elsewhere in the world — in other
words, whether the “best U.S.
health care is the best in the
world.” Although it is often held
that the U.S. strength lies in state-
of-the-art, technically oriented
care, especially focused on
“rescue” care, rather than care for
more routine acute and chronic
conditions, studies typically do not
compare the “best” care offered in
different countries. Further, there
remain other aspects of health care
for which we have no quality
measures or inadequate data for
comparisons.
Existing studies also fail to tell us
much at all about the reasons for
the apparent differences in quality
observed across countries,
although numerous hypotheses
have been put forward (e.g.,
differences in the use of health
information technology,
differences in the coordination of
care and the fragmentation of
health care delivery, variations in
reliance of incentives for providers
and consumers to provide and
select care based on consideration
of quality). We do know, however,
from a five-country survey of
primary care physicians52 that U.S.
physicians’ practices are more
limited in information capacity,
provide less patient access outside
of traditional work hours, and are
among the least likely to work in
teams or to receive financial
rewards for quality, all factors that
could bear on the quality of
primary care furnished.
Taken together, these studies do
provide a strong basis for
determining whether proposed
health reform initiatives might
threaten or, alternatively,
strengthen the current level of U.S.
quality. While evidence is not
conclusive, it is clear that the
argument that reform of the U.S.
health system stands to endanger
“the best health care quality in the
world” lacks foundation. Like
other countries, the United States
has been found to have both
strengths and weaknesses in terms
of the quality of care available, and
the quality of care the population
receives. The main ways in which
the United States differs from
other developed countries are in
the very high costs of its health
care and the share of its population
that is uninsured.
In the light of the fact that the
United States spends twice as
much per person on health care as
its peers, those who question the
value for money obtained in U.S.
health expenditures are on a firm
footing. The evidence suggests that
other developed countries achieve
comparable quality of care while
devoting at most two-thirds the
share of their national income.
Faced with the evidence, one
might well ask why it is that
assertions of the superiority of
U.S. health care are so common.
Technical definitions and popular
conceptions of quality include
many different dimensions and
there may not be agreement about
which dimensions are most
important. For example, people
who make the claims that the
United States has the “best quality
of care” in the world may be
prioritizing a degree of access to
medical technology and innovation
which they believe to be unique to
the United States. Perhaps media
attention paid to outcomes for a
select few (e.g., multiple organ
transplant recipients, high-risk
delivery of multiple births) has
cast into shadow the average
outcomes of the majority of
Americans with more routine, yet
serious, conditions and other
health care needs.
But a less-than-fully informed
public comes at a cost in that
assertions of excellence divert
attention from the need to inspire
and foster systematic quality
improvement activities.
Furthermore, there seems to be a
routine genuflection to the
widespread belief of U.S. quality
excellence, even among experts. In
an environment where even
insured Americans receive only
about half of the services that
experts consider necessary, there is
a strong argument for placing
quality firmly on the health reform
agenda.53 In short, health reform
can be seen as an opportunity to
systematically improve quality of