Health Care Spending in the United States and Other High-Income Countries.
Level 3 - non-randomized controlled study
Cross-national observational comparative analysis using aggregated international health system data.
PubMed 29536101 · doi:10.1001/jama.2018.1150
What was done
A cross-national comparative analysis was conducted comparing health care spending, structural capacity, utilization, and performance metrics in the United States against 10 other high-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark). Data were drawn primarily from the Organisation for Economic Co-operation and Development (OECD) and supplemental country-specific sources for the years 2013 to 2016.
What was found
In 2016, the US spent 17.8% of GDP on health care compared to 9.6% (Australia) to 12.4% (Switzerland) in peer nations. US health insurance coverage was 90% (vs 99%-100% in others), with 55.3% having private insurance. US life expectancy was lowest at 78.8 years (other countries range: 80.7-83.9 years; 11-country mean: 81.7 years), and infant mortality was highest at 5.8 deaths per 1000 live births (mean: 3.6 per 1000). Adult overweight/obesity was highest in the US at 70.1% (other countries: 23.8%-63.4%; mean: 55.6%), while daily smoking was second lowest at 11.4% (mean: 16.6%). Physician supply (2.6 per 1000; 43% primary care), nursing supply (11.1 per 1000), and hospital beds (2.8 per 1000) were similar to peer nations. Discharge rates (per 100,000: acute myocardial infarction 192, pneumonia 365, COPD 230) and procedure rates (per 100,000: hip replacement 204, knee replacement 226, CABG 79) were largely comparable, though US advanced imaging utilization was higher (MRI: 118 per 1000; CT: 245 per 1000). Major cost differences were administrative costs (8% of spending in the US vs 1%-3% elsewhere), pharmaceutical spending per capita ($1443 in the US vs $466-$939), and generalist physician salaries ($218,173 in the US vs $86,607-$154,126).
Why it matters
This study demonstrates that higher US health spending is not driven by higher utilization of inpatient or surgical care, but primarily by higher prices for labor, pharmaceuticals, and administrative overhead.
Limits
The study relies on aggregate, country-level observational data from international databases, which precludes patient-level adjustments and causal inferences. Reporting definitions and data completeness can vary across countries, and only 11 high-income nations were analyzed.