Health Care Spending in the United Statesand Other High-Income CountriesIrene Papanicolas, PhD; Liana R. Woskie, MSc; Ashish K. Jha, MD, MPH

IMPORTANCE Health care spending in the United States is a major concern and is higher thanin other high-income countries, but there is little evidence that efforts to reform US healthcare delivery have had a meaningful influence on controlling health care spending and costs.

OBJECTIVE To compare potential drivers of spending, such as structural capacity andutilization, in the United States with those of 10 of the highest-income countries (UnitedKingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland,and Denmark) to gain insight into what the United States can learn from these nations.

EVIDENCE Analysis of data primarily from 2013-2016 from key international organizationsincluding the Organisation for Economic Co-operation and Development (OECD), comparingunderlying differences in structural features, types of health care and social spending, andperformance between the United States and 10 high-income countries. When data were notavailable for a given country or more accurate country-level estimates were available fromsources other than the OECD, country-specific data sources were used.

FINDINGS In 2016, the US spent 17.8% of its gross domestic product on health care, andspending in the other countries ranged from 9.6% (Australia) to 12.4% (Switzerland). Theproportion of the population with health insurance was 90% in the US, lower than the othercountries (range, 99%-100%), and the US had the highest proportion of private healthinsurance (55.3%). For some determinants of health such as smoking, the US ranked secondlowest of the countries (11.4% of the US population �15 years smokes daily; mean of all 11countries, 16.6%), but the US had the highest percentage of adults who were overweight orobese at 70.1% (range for other countries, 23.8%-63.4%; mean of all 11 countries, 55.6%).Life expectancy in the US was the lowest of the 11 countries at 78.8 years (range for othercountries, 80.7-83.9 years; mean of all 11 countries, 81.7 years), and infant mortality was thehighest (5.8 deaths per 1000 live births in the US; 3.6 per 1000 for all 11 countries). The USdid not differ substantially from the other countries in physician workforce (2.6 physicians per1000; 43% primary care physicians), or nursing workforce (11.1 nurses per 1000). The US hadcomparable numbers of hospital beds (2.8 per 1000) but higher utilization of magneticresonance imaging (118 per 1000) and computed tomography (245 per 1000) vs othercountries. The US had similar rates of utilization (US discharges per 100 000 were 192 foracute myocardial infarction, 365 for pneumonia, 230 for chronic obstructive pulmonarydisease; procedures per 100 000 were 204 for hip replacement, 226 for knee replacement,and 79 for coronary artery bypass graft surgery). Administrative costs of care (activitiesrelating to planning, regulating, and managing health systems and services) accounted for 8%in the US vs a range of 1% to 3% in the other countries. For pharmaceutical costs, spendingper capita was $1443 in the US vs a range of $466 to $939 in other countries. Salaries ofphysicians and nurses were higher in the US; for example, generalist physicians salaries were$218 173 in the US compared with a range of $86 607 to $154 126 in the other countries.

CONCLUSIONS AND RELEVANCE The United States spent approximately twice as much asother high-income countries on medical care, yet utilization rates in the United States werelargely similar to those in other nations. Prices of labor and goods, including pharmaceuticals,and administrative costs appeared to be the major drivers of the difference in overall costbetween the United States and other high-income countries. As patients, physicians, policymakers, and legislators actively debate the future of the US health system, data such as theseare needed to inform policy decisions.

JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150

Viewpoint page 977 andEditorials pages 983, 986,988, and 990

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Author Affiliations: Department ofHealth Policy and Management,Harvard T. H. Chan School of PublicHealth, Boston, Massachusetts(Papanicolas, Woskie, Jha); HarvardGlobal Health Institute, Cambridge,Massachusetts (Papanicolas, Woskie,Jha); Department of Health Policy,London School of Economics andPolitical Science, London, England(Papanicolas, Woskie).

Corresponding Author: IrenePapanicolas, PhD, Department ofHealth Policy, London School ofEconomics and Political Science,Houghton Street, London WC2A2AE, England (i.n.papanicolas@lse.ac.uk).

Clinical Review & Education

JAMA | Special Communication

1024 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

T he United States spends more per capita on health carethan any other nation, substantially outpacing even othervery high-income countries.1,2 However, despite its

higher spending, the United States performs poorly in areas suchas health care coverage and health outcomes.3-5 Higher spendingwithout commensurate improved health outcomes at the popula-tion level has been a strong impetus for health care reform in theUnited States.6

Although it is well known that the United States spendsmore on health care than other countries, less is known aboutwhat explains these differences. The consensus has been thatthe US fee-for-service system is a primary factor,7 leading to

fragmentation, overuse, andan underinvestment in socialdeterminants of health,8-10

dr iv ing high uti l izat ion ofhealth care services and pooroutcomes. Older studies havefound that the United Statesmay underinve st in socia lservices,11 although other datasuggest that higher pricesin the United States, especiallyfor pharmaceuticals, may bea contributor to spending dif-ferences.12,13 One study sug-

gested that increasing rates of outpatient spending and remu-neration of clinicians is a major contributor to the cost differencebetween the United States and other countries.14 Given thatother high-income countries are able to spend less and achievebetter health outcomes, a more nuanced, data-driven under-standing of all aspects of health care cost are needed to assist inreform of the US health care system.

The Organisation for Economic Co-operation and Develop-ment (OECD) and the Commonwealth Fund have recently col-lected and made available increasingly comparable data on inputsand performance of the health care systems across high-incomecountries. Using these and related data, we compared perfor-mance of the United States with 10 other high-income countries onkey metrics that underpin health care spending. By examininggranular data, we sought to understand why US health care costsare so much higher and where policy makers might target theirefforts to encourage a more efficient system.

MethodsSelection of Comparison CountriesTen high-income countries were selected for comparison. Thesecountries were chosen because they were among the highest-income countries in the world, had relatively high health carespending, and had populations with similar demographic character-istics that have similar burdens of illness.3,15 Based on these criteria,the United Kingdom (consisting of England, Scotland, Wales, andNorthern Ireland), Canada, Germany, Australia, Japan, Sweden,France, Denmark, the Netherlands, and Switzerland were chosenfor comparison. These 10 selected countries represent differentgeographic areas and diverse health system structures.

Conceptual Framework and Indicator SelectionTo better understand the higher US health care costs relative toother high-income countries, a range of outcomes were explored.We first analyzed comparative data on general health systemspending, including spending by function. Next, comparativeinputs, including labor costs and structural capacity (which,aside from contributing to direct costs, may also influence mainte-nance costs or influence the price to use equipment) were ex-amined. Because many of the leading explanations relating tohigher health care costs involve the transformation of health caredollars to health care outcomes,16 we extended the analysis toexamine a range of intermediate outputs—namely, access, utiliza-tion (inpatient, outpatient, major procedures), pharmaceuticalspending and utilization, patient experience, and quality of care—aswell as valued health system outcomes, such as population health.To provide a broader context of overall factors that can contributeto differences in health care spending, we also examined socialspending, as well as demographic differences, risk factors, andprevalence of disease. In line with previous international compari-sons, the health care system included all groups whose primaryintent is to improve health.5,17

This approach resulted in the presentation of a total of 98 indi-cators across 7 domains: (1) general spending; (2) populationhealth; (3) structural capacity; (4) utilization; (5) pharmaceuticals;(6) access and quality; and (7) equity. In each domain, measureswere selected that were available across the majority of the coun-tries in the analysis. We were unable to find comparable pricingdata for most areas, such as for diagnostic procedures and treat-ments, except for workforce remuneration and pharmaceuticals.In the area of quality, the focus was on indicators that capturedquality of prevention, primary care, and inpatient care across theareas of appropriateness, effectiveness, experience, and safety. Inthe area of access to care, variations related to financial costs aswell as waiting times were explored. In addition, reflecting equity,variations related to service availability, quality of care, and costwere assessed.

Data SourcesData were extracted from a range of databases compiled by inter-national organizations, with the majority coming from the OECD.

JAMA.COM +

Animated Summary VideoHealth Care Spending in theUnited States and OtherHigh-Income Countries

Key PointsQuestion Why is health care spending in the United States somuch greater than in other high-income countries?

Findings In 2016, the United States spent nearly twice as much as10 high-income countries on medical care and performed less wellon many population health outcomes. Contrary to someexplanations for high spending, social spending and health careutilization in the United States did not differ substantially fromother high-income nations. Prices of labor and goods, includingpharmaceuticals and devices, and administrative costs appearedto be the main drivers of the differences in spending.

Meaning Efforts targeting utilization alone are unlikely to reducethe growth in health care spending in the United States; a moreconcerted effort to reduce prices and administrative costsis likely needed.

Health Care Spending in the United States and Other High-Income Countries Special Communication Clinical Review & Education

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© 2018 American Medical Association. All rights reserved.

Data on structural equipment, workforce, utilization, pharmaceuti-cal spending, access, and quality were accessed from OECD.statand the OECD 2015 Health Care at a Glance report. Additionaldata on health spending, health system, and country characteris-tics were obtained from the World Bank International Bank forReconstruction and Development–International DevelopmentAssociation database and the 2016 OECD Health Systems Charac-teristics Survey.

Data on retail pharmaceutical spending per capita wereobtained from the OECD for all countries. Data on total pharmaceu-tical spending per capita were obtained from IntercontinentalMarketing Services or the International Federation of Pharmaceuti-cal Manufacturers and Associations. Pharmaceutical data oncountry-level output of new chemical entities was taken fromDaemmrich.18 Population perceptions of the health system andselect access measures were obtained from the 2016 Common-wealth Fund Survey of Consumers.15

All data on per capita spending, gross domestic product (GDP),and remuneration were translated into US dollar equivalents, withexchange rates based on purchasing power parities of national cur-rencies. Remuneration data were then converted to 2017 dollarsusing the US Consumer Price Index in line with Laugesen andGlied.19 Data on health spending are presented by function of careas a percentage of the country’s total spending on health consis-tent with System of Health Accounts categorization, with adapta-tions for outpatient spending to address issues of comparabilitywith the United States’ National Health Expenditure Accounts(eTable 2 in Supplement 1). When OECD data were not availablefor a given country or more accurate country-level estimates wereavailable, country-specific data sources were used. The focus wason indicators from 2013 onward with an occasional exception. Forexample, for the United States, data for the horizontal index, neo-natal mortality by low birth weight, and antibiotic prescribing werefrom 2009, 2004, and 2004, respectively.

Figure 1. Spending

General

Overall population (in millions)

Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11

Denmark6

CHE8

Sweden10

NLD17

Australia24

Canada36

France64

UK66

Germany83

Japan127

US323

69

Mean

Population ≥65 y, % US14.5

Australia14.7

Canada15.7

NLD17.3

UK17.3

CHE17.5

Denmark18.1

France18.2

Sweden19.9

Germany21.4

Japan25.1

18.2

GDP per capita, US $(in thousands)

Japan37.50

UK38.50

France41.00

Canada42.40

Germany42.90

Australia45.10

NLD46.30

Sweden51.60

US52.10

Denmark53.40

CHE54.00

45.90

Land area (× 1000 sq km) CHE42

NLD42

Denmark43

UK244

Germany357

Japan378

Sweden450

France549

Australia7741

US9834

Canada9985

2697

Poverty rate, % below povertyline of 60%

Denmark12

NLD15

France15

Germany16

CHE17

Sweden17

UK18

Australia20

Canada21

Japan22

US24

18

Total spending on health, % of total national GDP

Australia9.6

UK9.7

Canada10.3

NLD10.5

Denmark10.8

Japan10.9

France11

Germany11.3

Sweden11.9

CHE12.4

US17.8

11.5

Health spending

Public spending on health,% of total national GDP

Australia6.3

Canada7.4

UK7.6

CHE7.7

US8.3

Japan8.6

France8.7

Germany8.7

Denmark9.2

NLD9.5

Sweden10

8.4

Inpatient care Canada17

US19

Sweden21

UK24

Japan27

Germany27

Denmark28

CHE28

France30

Australia31

NLD32

26

Outpatient care NLD22

France23

Germany23

Japan27

UK30

Sweden31

CHE33

Denmark34

Canada36

Australia39

US42

31

Mean spending on healthper capita, US $

UK3377

France3661

Japan3727

Australia4357

Canada4641

Germany5182

NLD5202

Denmark6463

CHE6787

Sweden6808

US9403

5419

Long-term care Australia2

US5

France11

Canada14

Germany16

UK18

Japan19

CHE19

Denmark24

NLD26

Sweden26

16

Medical goods Denmark10

NLD12

Sweden12

CHE13

US14

UK15

Australia17

Japan20

Canada20

France20

Germany20

16

Governance andadministration

Japan1

France1

Denmark2

Sweden2

UK2

Australia3

Canada3

CHE4

NLD4

Germany5

US8

3

Home-based care DenmarkNA

CHENA

Australia0

Canada0

NLD0

Sweden0

Germany1

Japan3

UK3

US3

France4

2

Preventive care Australia2

CHE2

France2

Japan3

Denmark3

Sweden3

Germany3

US3

NLD4

UK5

Canada6

3

Other Denmark0

NLD0

Japan1

CHE1

UK3

Canada4

Sweden5

Germany5

Australia6

US6

France9

4

Health expenditure by function of care as a % of total national health expenditure

Population with health carecoverage, %

Australia100

Japan100

Canada100

Denmark100

CHE100

NLD99.9

France99.9

Sweden100

Germany99.8

UK100

US90

99

GDP indicates gross domestic product; NA, not applicable. CHE indicates Switzerland; NLD, the Netherlands. See eTable 1 in Supplement 2 for data ordered by country.

Clinical Review & Education Special Communication Health Care Spending in the United States and Other High-Income Countries

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Supplement 1 includes tables that provide a breakdown ofsources and methods for the data reported herein. In these tables,we note issues of comparability and timeliness for each indicator,such as workforce. In figures describing data for each of the 7 do-mains, a simple mean of the data for each indicator across all 11 coun-tries is presented in the final column. Throughout the Results sec-tion in the text, all comparative findings are presented descriptively.

ResultsDemographic Characteristics and Health Care SpendingIn 2016, the US population was significantly larger than allcomparison countries at 323 million (Figure 1 and eTable 1 inSupplement 2). Japan had the next largest population with 127 mil-lion. The US system also covered the second largest geographicalarea (9 834 000 sq km), following Canada (9 985 000 sq km). Theother countries other than Australia had much smaller land mass.In 2016, the United States spent 17.8% of its GDP on health care(range of the other countries, 9.6%-12.4%; mean of all 11 countries,11.5%) (Figure 1 and Figure 2) and had almost double the healthspending per capita (mean, $9403) compared with the other coun-tries (range, $3377-$6808; mean of all 11 countries, $5419).Although the United States spent more, the percentage of thepopulation with health insurance in the United States was 90%,lower than in all of the other countries (range, 99%-100%).

All systems had relatively similar levels of public spending as apercentage of GDP (defined as spending from government and/orsocial or compulsory insurance funds), with the United States spend-ing at about the mean level (8.3%) of all the countries, although, un-like the other countries, this spending covered only about 37% ofthe population. By expenditure as a function of care, the UnitedStates spent only 19% of its health spending on inpatient care, whichexcludes same-day hospital care. This proportion was less than thatof all other countries, with Australia (31%) and the Netherlands (32%)spending the most (Figure 1). The United States spent a greater pro-portion than the other countries on outpatient care (44% com-pared with a mean of 31%) and governance and administration, whichincludes activities relating to planning, regulating, and managinghealth systems and services (8% compared with a mean of 3%).

Across the 11 countries, the United States had the lowest per-centage of the population older than 65 years (14.5% compared witha mean of 18.2%) and also had the highest rate of poverty, with 24%of the population living below the poverty line, followed by Japan(22%) and Canada (21%). The United States ranked below the meanbut was not an outlier with regard to total social spending (spend-ing on old age, incapacity, labor market, education, family, and hous-ing [Figure 3]) at 16.7% of GDP (compared with a mean of 19.4% ofGDP in all 11 countries). This reflected public social spending, whichwas, at 11.3% of GDP, below the mean of all 11 countries (15.3% ofGDP). The United States ranked fourth with regard to private socialspending at 5.4% of GDP (compared with a mean of 4.1%) and wassimilar to the United Kingdom (5.6%) and ranked behindthe Netherlands (7.1%) and Switzerland (6.0%), reflecting mostlyprivate pension payments.20

Insurance System CharacteristicsThe structural characteristics of the health care system are de-tailed in the Table. Three countries, the United Kingdom, Sweden,and Denmark, have national health care systems, whereasCanada and Australia have regionally administered universal insur-ance programs. Germany, France, the Netherlands, and Switzerlandhave statutory/mandatory health insurance systems. Only theUnited States has a voluntary, private employer-based andindividual-based system. All of the countries except the UnitedStates have an automatic or compulsory enrollment process.Private insurance as the primary form of insurance is highest in theUnited States at 55.3%, followed by Germany at 10.8%. The major-ity of the countries do not have private insurance as the primaryform of insurance.

Population HealthAmong important determinants of health, the United States had thehighest percentage of overweight or obese adults (70.1% com-pared with a mean of 55.6%) but had relatively low smoking rates(11.4% of the population compared with a mean of 16.6%) (Figure 4and eTable 2 in Supplement 2). The drinking rate (8.8 L per capita)and unemployment rate (4.4%) in the United States are bothclose to the mean values of all 11 countries at 9.1 L per capita and5.4%, respectively.

Figure 2. Health Spending as a Percentage of Gross Domestic Product

20

8

10

12

14

16

18

6

4

2

0

Spen

ding

on

Hea

lth

as a

% o

f GDP

UnitedStates

UnitedKingdom

CanadaGermany AustraliaJapanSweden France TheNetherlands

Switzerland Denmark

Total health spending Government health spending Private health spendingMean Mean Mean

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© 2018 American Medical Association. All rights reserved.

The United States consistently had the poorest populationhealth outcomes (Figure 4). The United States had the lowest lifeexpectancy (78.8 years compared with a mean of 81.7 years) andthe lowest health-adjusted life expectancy (69.1 years comparedwith a mean of 72.0 years). The variability of life expectancy acrossthe United States (ranging from 81.3 years in Hawaii to 75 years inMississippi) (eTable 3 in Supplement 1) was similar to that of the lifeexpectancy across all countries in the study.

The United States had the highest infant mortality (5.8 deathsper 1000 live births compared with a mean of 3.6), neonatal mor-tality (4.0 deaths per 1000 live births compared with a mean of 2.6),and maternal mortality (26.4 deaths per 100 000 live births com-pared with a mean of 8.4) (Figure 4). The United States also had thesecond highest percentage of infants with low birth weight (8.1%compared with a mean of 6.6%). Japan had the highest low birthweight (9.5%). When adjusting neonatal mortality to exclude deathsof infants born weighing less than 1000 g, the United States rankedfifth relative to the other countries, with 1.61 deaths per 1000 livebirths, compared with a mean of 1.70 for all 11 countries.

Workforce and Structural CapacityThe physician workforce in the United States was lower than themean of all 11 countries at 2.6 per 1000 population compared with3.3 per 1000 population (Figure 5 and eTable 3 in Supplement 2).The proportion of US physicians who were primary care physicians(43%) was the same as the mean of all 11 countries. Using a func-tionality-based approach to identifying primary care physicians,US general internists provided a significant amount of primary care,whereas internists in Canada almost exclusively provided acutehospital-based care (Figure 6). Compared with countries withcomparable data, mean remuneration of generalists, special-

ists, and nurses was higher in the United States. When adjustingfor purchasing power parity, the mean US remuneration for gener-alists was $218 173, nearly double the mean remuneration in all 11countries, which ranged from $86 607 in Sweden to $154 126 inGermany. The remuneration for specialists was higher in the UnitedStates at $316 000 compared with other countries, ranging from$98 452 in Sweden to $202 291 in Australia). The remuneration ofnurses was also higher in the United States ($74 160) than in othercountries, where it ranged from $42 492 in France to $65 082 in theNetherlands. The remuneration of health care professionals as a ra-tio to the mean national wage was highest in the United States forspecialists (5.3 compared with a mean of 3.7), generalists (3.6 com-pared with a mean of 2.7), and nurses (1.23 compared witha mean of 1.1).

There was notable variation between countries in the supply ofmedical equipment, such as magnetic resonance imaging (MRI) units,computed tomography (CT) machines, and mammography ma-chines. Japan had the highest number of MRI units and CT scannersper population (approximately 52 and 107 per 1 million population, re-spectively), and the United States had the second highest for MRI(38 per 1 million population) and third highest for CT (41 per 1 millionpopulation). The lowest per capita rate for both MRI units and CT scan-ners was in the United Kingdom, with 7.2 MRI units and 9.5 CT scan-ners per 1 million population. The United States had fewer hospitalbeds per 1000 population (2.8) than Japan (13.2) and Germany (8.2)and fewer long-term beds per 1000 population older than 65 years(38.8) compared with the mean of the study countries (54.2).

UtilizationThe United States’ utilization of health care services was similarto the other countries (Figure 7 and eTable 4 in Supplement 2),

Figure 3. Social Spending as a Percentage of Gross Domestic Product

30

20

25

15

10

5

0

Soci

al S

pend

ing

as a

% o

f GDP

UnitedStates

UnitedKingdom

Germany Sweden France TheNetherlands

Switzerland Denmark Canada Japan Australia

Total social spendingMean

Public social spendingMean

Private social spendingMean

Social spending is the provision by public (and private) institutions of benefits toand financial contributions targeted at households and individuals to providesupport during circumstances that adversely affect their welfare, provided thatthe provision of the benefits and financial contributions constitutes neither adirect payment for a particular good or service nor an individual contract ortransfer. Such benefits can be cash transfers or can be direct (in-kind) provisionof goods and services. Main spending areas include old age, health, family,incapacity, labor market, and housing (Organisation for Economic Co-operationand Development). Private social spending is functionally the same as publicsocial spending but provided through a private mechanism. Social benefits

delivered through the private sector (not transfers between individuals) involvean element of compulsion and/or interpersonal redistribution; for example,through pooling of contributions and risk sharing. This may include old-agepensions and support services for older adults, survivor benefits, disability andsickness cash benefits, family support, unemployment benefits, housingsupport (eg, rent subsidies), and other social policy areas excluding healthspending. Pensions constitute an important part of private social spending inthe United States and can be mandatory or voluntary. Independent,out-of-pocket spending on social services is not included.

Clinical Review & Education Special Communication Health Care Spending in the United States and Other High-Income Countries

1028 JAMA March 13, 2018 Volume 319, Number 10 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

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except for imaging. The United States performed the second high-est number of MRI scans and the highest number of CT scans (118MRIs per 1000 population compared with a mean in all 11 countriesof 82 per 1000 population; 245 CTs per 1000 population com-pared with a mean of 151 per 1000 population).

Annual hospital discharges in the United States, at 125 per 1000population, were just below the middle of the distribution (rangingfrom 84 per 1000 in Canada to 255 per 1000 in Germany, with amean of 150 per 1000 in all 11 countries) (Figure 8). Discharges forcommon conditions in the United States such as acute myocardialinfarction (192 per 100 000 population compared with a mean of190 per 100 000 population), pneumonia (365 per 100 000 popu-lation compared with a mean of 352 per 100 000 population), andchronic obstructive pulmonary disease (230 per 100 000 popula-tion compared with a mean of 206 per 100 000 population) weresimilar to the means of all 11 countries. For discharges for mental andbehavioral conditions, the United States was below the mean of all11 countries (679 per 100 000 population compared with a meanof 736 per 100 000 population) (Figure 7). Consultation levels in theUnited States were below the mean at 4 visits per person per yearcompared with a mean of 6.6 (Figure 8).

The United States had somewhat higher levels of some com-mon surgical procedures, such as revascularization procedures (forcoronary artery bypass procedures, 79 per 100 000 population com-pared with a mean of 54 per 100 000 population), knee replace-ments (226 per 100 000 population compared with a mean of 163

per 100 000 population), cesarean deliveries (33 per 100 live birthscompared with a mean of 25 per 100 live births), coronary angio-plasties (248 per 100 000 population compared with a mean of 217per 100 000 population), and cataract surgeries (1110 per 100 000population compared with a mean of 971 per 100 000 popula-tion). For a few procedures, the United States had comparable orlower rates vs the other 10 countries, such as for hip replacements(204 per 100 000 population compared with a mean in all 11 coun-tries of 207 per 100 000 population).

Length of stay had less variation across countries with the ex-ception of Japan, which had a mean all-cause length of stay of 16.9days, far longer than in the other countries (Figure 8). The UnitedStates had relatively fewer days in the hospital compared with themean for 3 different length-of-stay measures (all-cause hospitaliza-tion, normal neonatal delivery hospitalization, and acute myocar-dial infarction hospitalization) (Figure 7).

The United States had high levels of administrative burden; thiswas notable in particular for administrative spending, for which theUnited States was an outlier (8% of GDP spent on administration andgovernance compared with a mean of 3% of GDP) (eTable 1 inSupplement 1). Physicians in the United States also reported hav-ing a higher level of administrative burden than the mean of all 11countries in 3 areas; however, this burden was high in all insurance-based systems. Fifty-four percent of surveyed physicians in theUnited States identified time spent on administrative issues re-lated to insurance or claims as a major problem, 33% reported that

Figure 4. Population Health

Smoking, % of populationaged ≥15 y who smoke daily

1 2 3 4 5 6 7 8 9 10 11

Sweden11.2

US11.4

Australia12.4

Canada14

UK16.1

Denmark17

Japan18.2

NLD19

CHE20.4

Germany20.9

France22.4

16.6

Mean

Alcohol consumption, L percapita in population aged ≥15 y

Japan7.2

Sweden7.2

NLD8

Canada8.1

US8.8

Denmark9.4

CHE9.5

UK9.5

Australia9.7

Germany11

France11.9

9.1

Obese or overweight, % ofpopulation aged ≥15 y

Japan23.8

France49

Germany60

Canada60.3

UK62.9

Australia63.4

US70.1

CHE41a

Denmark47.4a

NLD47.4a

Sweden48.3a

55.6

Rank (highest to lowest)Determinants of health

Life expectancy in totalpopulation at birth, mean, y

US78.8

Germany80.7

Denmark80.8

UK81

NLD81.6

Canada81.7

Sweden82.3

France82.4

Australia82.5

CHE83

Japan83.9

81.7

Health-adjusted lifeexpectancy, mean, y

US69.1

Denmark71.2

Germany71.3

UK71.4

Australia71.9

Sweden72

NLD72.2

Canada72.3

France72.6

CHE73.1

Japan74.9

72

Life expectancy for womenaged ≥40 y, mean, y

US42.6

Denmark43.4

UK43.7

NLD43.9

Germany43.9

Canada44.8

Sweden44.8

Australia45.4

CHE45.8

France46.4

Japan47.7

44.8

Life expectancy for menaged ≥40 y, mean, y

US38.7

Germany39.4

Denmark39.8

UK40.5

France40.6

NLD40.8

Canada41.1

Sweden41.5

Australia41.7

Japan41.8

CHE42

40.7

Life expectancy

Infant mortality, deaths per1000 live births

Japan2.1

NLD2.5

Sweden2.5

Australia3.2

Germany3.3

Denmark3.7

France3.8

CHE3.9

UK3.9

Canada5.1

US5.8

3.6

Neonatal mortality, deaths per1000 live births

Japan0.9

Sweden1.7

Australia2.3

Germany2.3

NLD2.5

France2.6

UK2.7

Denmark3

CHE3.1

Canada3.2

US4

2.6

Maternal mortality, deaths per100 000 live births

Denmark4.2

Sweden4.4

Australia5.5

CHE5.8

Japan6.4

NLD6.7

Canada7.3

France7.8

Germany9

UK9.2

US26.4

8.4

Neonatal mortality, deaths per1000 live births excluding <1000 g

AustraliaNA

JapanNA

CHENA

FranceNA

Germany1.49

Sweden1.56

US1.61

Canada1.63

UK1.77

NLD1.96

Denmark2.09

1.7

Low birth weight, % of totallive births

CHENA

Sweden4.4

Denmark5

France6.2

Canada6.3

Australia6.4

NLD6.5

Germany6.6

UK6.9

US8.1

Japan9.5

6.6

Maternal and infant health

NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands. See eTable 2 in Supplement 2 for data ordered by country.a Patient self-reported data.

Clinical Review & Education Special Communication Health Care Spending in the United States and Other High-Income Countries

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“time spent on administrative issues related to reporting clinical orquality data to government or other agencies is a major problem,”and 16% reported having spent “a lot of time on paperwork or dis-putes related to medical bills.”

PharmaceuticalsAmong the 11 countries, the United States had the highest pharma-ceutical spending per capita at $1443, with Switzerland following at$939 and a mean of $749 for all 11 countries (Figure 9 and eTable 5in Supplement 2). Retail spending per capita was also highest in theUnited States at $1026, representing about 71% of the total, whichwas consistent with the group mean at 72% (Figure 9). For 4 phar-maceuticals (Crestor, Lantus, Advair, and Humira) used for com-mon conditions, the United States had higher prices than all other

countries; for 3 of these, the US price was more than double thenext highest price. With respect to a measure of innovation, theUnited States and Switzerland had the highest number of newchemical entities at 111 and 26, respectively. The United Statesaccounted for 57% of total global production of new chemical enti-ties. No estimates were available for Canada, Australia, Sweden,the Netherlands, and Denmark. The United States also had highgeneric penetration at 84% of the total pharmaceutical market,which was comparable with markets in the United Kingdom andGermany. Australia and the Netherlands had low generic penetra-tion at 30% and 17%, respectively. Despite having the highest rateof generic penetration, the amount that the United States spenton generic products as a percentage of total pharmaceutical spend-ing was similar to other countries, suggesting that brand-name

Figure 5. Workforce and Structural Capacity

Magnetic resonanceimaging units

DenmarkNA

CHENA

SwedenNA

UK7.2

Canada8.9

France12.6

NLD12.9

Australia14.7

Germany30.5

US38.1

Japan51.7

22

Computed tomographyunits

SwedenNA

UK9.5

Canada12.7

NLD13.3

France16.6

Germany35.3

CHE36.1

Denmark37.1

US41

Australia56.1

Japan107.2

36.5

Mammography machineunits

NLDNA

SwedenNA

GermanyNA

France7.5

Denmark14.2

Canada17.3

UK21

Australia23

CHE28.3

Japan33

US43.3

23.5

Overall physicians per1000 population

Rank (highest to lowest)Practicing workforce

1 2 3 4 5 6 7 8 9 10 11

UK2.1

Japan2.4

Canada2.6

US2.6

France3.1

Australia3.5

NLD3.5

Denmark3.6

Germany4.1

Sweden4.2

CHE4.3

3.3

Mean

Primary care physicians,% of total

Denmark22

Sweden33

Japan43

US43

Australia45

Germany45

UK45

NLD47

Canada48

CHE48

France54

43

Specialists, % of total France46

Canada52

CHE52

NLD53

Australia55

Germany55

UK55

Japan57

US57

Sweden67

Denmark78

57

Nurses per 1000 population UK8.2

France9.4

Canada9.5

Japan10.5

US11.1

Sweden11.2

Australia11.5

NLD12.1

Germany13

Denmark16.3

CHE17.4

11.8

Generalist physicians DenmarkNA

CHENA

Sweden86 607

Australia108 564

NLD109 586

France111 769

Japan124 558a

UK134 671

Canada146 286

Germany154 126

US218 173

133 723

Specialist physicians CHENA

Sweden98 452

JapanaDenmark140 505

France153 180

UK171 987

Germany181 243

Canada188 260

NLD191 995

Australia202 291

US316 000

182 657

Nurses SwedenNA

CHENA

France42 492

Japan44 712

UK49 894

Germany53 668

Canada55 349

Denmark58 891

Australia64 357

NLD65 082

US74 160

51 795

Ratio of generalistremuneration to mean wage

JapanNA

DenmarkNA

CHENA

Sweden2

Australia2.1

NLD2.1

France2.6

Canada3.0

UK3.1

Germany3.3

US3.6

2.7

Ratio of specialistsremuneration to mean wage

JapanNA

CHENA

Sweden2.3

Denmark2.6

UK3.4

NLD3.6

France3.6

Australia3.8

Canada3.9

Germany3.9

US5.3

3.7

Non–health-specific annualwage, meanb

Japan39 113

Sweden42 816

UK42 835

France42 992

Germany46 389

Canada48 403

Australia52 063

Denmark52 580

NLD52 833

CHE60 124

US60 154

49 118

Ratio of nurse remunerationto mean wage

CHENA

SwedenNA

France0.99

Denmark1.12

Japan1.14

Canada1.14

Germany1.16

UK1.16

NLD1.23

US1.23

Australia1.24

1.1

Hospital beds per 1000population

Sweden2.5

Canada2.7

Denmark2.7

UK2.7

US2.8

NLD3.3

Australia3.8

CHE4.6

France6.1

Germany8.2

Japan13.2

4.8

Long-term beds per 1000population aged ≥65 y

Japan35.1

US38.8

Denmark48.9

UK49.5

Germany53.1

Canada53.7

Australia54

France59

NLD65.5

CHE67.6

Sweden70.6

54.2

Equipment per 1 million population

Workforce remuneration, US $

Beds

NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.See eTable 3 in Supplement 2 for data ordered by country. Generalist physiciansare defined as any practicing physician registered in his or her country asa generalist physician or a specialist in the field of family medicine, pediatrics,geriatrics, or internal medicine and excludes students, interns, andnonpracticing physicians. Remuneration numbers may be an underestimate insome countries (eg, Canada) because they do not account for practice expenses

for self-employed physicians. Japan is excluded from remuneration means withthe exception of nursing. Definitions of specialist and generalist physiciansin regard to remuneration were taken from the Organisation for EconomicCo-operation and Development.a The number for Japan, 124 558, is a combined total of generalists and specialists.b In 2016 constant prices at 2016 US dollar purchasing power parities.

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pharmaceuticals were largely responsible for high overall spending.These countries have notably different ways in how they financepharmaceuticals; there is considerable variation in both the sharecovered by private insurance and the percentage covered by pri-vate out-of-pocket spending. The United States had high levels ofprivate spending (36% compared with a mean of 8%), althoughsimilar to Canada (30%), and was below the mean for out-of-pocket spending at 30% (compared with a mean of 36%). Withregard to antibiotic prescriptions, which are often considered ameasure of inappropriate treatment, the United States was abovethe mean, with a defined daily dose (average maintenance doseper day for a drug used for its main indication in adults) of 24 com-pared with a mean of 20.2.

Access and QualityRelative to comparison countries, US performance varied on qual-ity and access measures (Figure 10 and eTable 6 in Supplement 2).Of the other countries examined, the United States was the only onein which a sizeable minority (approximately 10%) of individualslacked coverage for basic health care services (Figure 1). For the 3access measures (ability to get same- or next-day care when sick,2-month wait time to see a specialist, and adequate time spent withregular physician) the United States generally performed better thanthe other countries. In the United States, 51% were able to get same-or next-day care compared with a mean of 57% in all 11 countries. Inthe United States, 6% had a wait time of 2 months or more to see aspecialist compared with mean of 13% in all 11 countries. Waitingtimes to see a specialist were longer for national health serviceand single-payer systems (ie, percentage with wait times longerthan 2 months: Canada, 39%; United Kingdom, 19%; Sweden, 19%)compared with insurance-based systems (Netherlands, 7%;Switzerland, 9%; Germany, 3%; France, 4%), with a mean of 13%.The United States ranked near the mean for patients reporting hav-

ing spent adequate time with their regular physician (81% com-pared with a mean of 83% in all 11 countries).

The United States had relatively high screening rates for breastcancer (81% compared with a mean of 67% in all 11 countries) butlower rates of measles immunization (92% compared with a meanof 94%) (Figure 10). The United States had considerably lower ratesof all 4 clinical outcome measures than the other countries. Thirty-day mortality for ischemic stroke was 4.2 per 100 patients in theUnited States compared with a mean of 7.9 per 100 patients in all 11countries. For obstetric trauma without instrument, the United Stateshad 1.5 cases per 100 deliveries, whereas the mean was 2.3 per 100deliveries in all 11 countries. The United States had high avoidablehospitalizations for diabetes and asthma relative to comparisoncountries (191.0 per 100 000 population compared with a mean of125.6 per 100 000 population for diabetes, and 89.7 per 100 000population compared with a mean of 42.4 per 100 000 popula-tion for asthma). When accounting for disease prevalence, the rateof US hospitalizations for diabetes was similar to that of other coun-tries, although hospitalizations for asthma were highest in the UnitedStates, closely followed by the United Kingdom. Relative to the othercountries, the US public reported the lowest satisfaction with theirhealth system, with only 19% reporting that the system works well.

US Disaggregated DataWhen access and quality measures were disaggregated by payer,the United States performed slightly worse for those covered byMedicaid, but performance was uneven across insurance groups(eTable 4 in Supplement 1). Nine percent of both privately insuredindividuals and those insured by Medicaid reported a 2-month waittime to see a specialist; this was lower than rates for Medicarepatients (11%) but higher than for uninsured individuals (8%). Onselected prevention measures, such as measles immunization, pri-vately insured individuals had the highest rate of coverage at 95%,

Figure 6. Practicing Physicians by Primary Care Specialization

100

80

60

40

20

0

Phys

icia

ns, %

Specialist

Obstetrics andgynecology

Geriatrics

Pediatrics

Internal medicine

Family medicine

Generalist, notfurther specified

AustraliaJapanCanadaDenmarkSwitzerlandNetherlandsFranceSwedenGermanyUnitedKingdom

UnitedStates

The total number of physicians, or 100%, differs for each country. Data are 2017or closest available year. A functionality-based definition to identify primarycare was used to identify physicians as those who provide a set of activitieswhose functions define the boundaries of primary care. This included chronic,preventive, and acute care in both inpatient and outpatient settings irrespectiveof disease: disease prevention, early detection and diagnosis, treatment andmanagement, care coordination and integration, and health maintenance,counseling, and/or patient education. The clinicians were often a patient’s first

point of contact for the health system with some degree of longitudinalresponsibility for the patient. This definition was used to reach out to countryexperts and identify who is considered a primary care clinician in eachrespective country. National workforce data or Eurostat data, where available,was then categorized according to expert responses. Physicians specializing inobstetrics and gynecology are categorized as specialists for all countries buthave their own category in this figure.

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whereas for breast screening, Medicare beneficiaries had the high-est rates (82%). Conversely, Medicare beneficiaries had the highestrates of mortality for both ischemic stroke and acute myocardialinfarction. There was also variability in avoidable admissions:patients with Medicaid insurance had the highest number ofasthma-related admissions and Medicare beneficiaries had thehighest number of admissions for diabetes. When disaggregatedby income or race, life expectancy was significantly differentamong US groups, with nonwhite and poorer populations havingshorter life expectancies (eTables 3 and 4 in Supplement 1).

EquityThe United States had the highest horizontal inequity, indicatingthe most inequitable access to physicians when adjusted for need. TheUnited States had an 11% rate of out-of-pocket spending as a percent-age of total national health spending (compared with a mean of13% in all 11 countries) and a 2.6% rate as a percentage of house-hold consumption (compared with a mean of 2.4%) (Figure 11 andeTable 7 in Supplement 2). However, the United States had a higherproportion of unmet need in the population, with 22.3% of the popu-

lation reporting that they missed a consultation because of cost com-pared with the mean of 9.4% for all 11 study countries. Given that thesystem has free access at the point of entry, the United Kingdom re-ported one of the lowest levels of barriers to accessing health ser-vices, but the level was higher than in both Germany and Sweden.

DiscussionIn this study based on data primarily from 2013-2016, the UnitedStates spent approximately twice as much as other high-incomecountries on medical care and fared worse on common populationhealth outcomes such as life expectancy and infant mortality. How-ever, the main findings of this comparison were that, contrary tosome explanations for high spending, US social spending and healthcare utilization were relatively similar to other high-income na-tions. Although utilization of some surgical procedures (such as coro-nary angioplasty, total knee replacement, and cesarean delivery) washigher in the United States, this utilization did not appear to ex-plain a large part of the higher spending in the United States.

Figure 7. Utilization

Discharges per 100 000 population

Acute myocardial infarction

Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11

Japan89

France124

UK160

Denmark174

NLD175

US192

Canada193

Australia196

CHE223

Sweden273

Germany287

190

Mean

Mental and behavioral NLD119

UK269

Japan319

France368

Canada629

US679

Australia856

Denmark892

Sweden1068

CHE1182

Germany1719

736

Pneumonia Canada187

NLD224

CHE269

France271

Australia338

US365

Japan378

Germany380

Sweden432

UK459

Denmark567

352

Chronic obstructivepulmonary disease

Japan45

France138

CHE142

NLD161

Sweden186

US230

Denmark234

Canada241

UK251

Australia286

Germany352

206

Magnetic resonance imaging SwedenNA

Australia41

NLD52

UK53

Canada56

CHE70

Denmark82

France105

Japan112

US118

Germany131

82

Examinations per 1000 population

Computed tomography SwedenNA

UK79

NLD81

CHE100

Australia120

Germany144

Canada153

Denmark162

France197

Japan231

US245

151

Total hip replacementper 100 000 population

Japan90

Canada136

Australia171

UK183

US204

NLD216

Sweden234

France236

Denmark237

Germany283

CHE292

207

Total knee replacementper 100 000 population

JapanNA

NLD118

Sweden124

UK141

France145

Canada166

Denmark168

CHE176

Australia180

Germany190

US226

163

Hysterectomy per 100 000women

JapanNA

UK161

NLD167

France182

Sweden186

Denmark197

Canada232

Australia262

US266

CHE291

Germany301

225

Cesarean delivery per100 live births

NLD16

Sweden17

Japan18

Denmark21

France21

UK23

Canada26

Germany31

Australia32

CHE33

US33

25

Cataract surgery per 100 000population

JapanNA

CHE438

UK736

NLD1005

Germany1027

Sweden1029

Denmark1037

Australia1060

Canada1060

US1110

France1207

971

Coronary artery bypass graftsurgery

JapanNA

CHENA

UK26

France29

Sweden31

Australia54

Canada58

Germany64

NLD69

Denmark73

US79

54

Coronary angioplasty CHENA

UK128

Canada157

Australia172

Denmark190

Japan193

Sweden205

France237

NLD248

US248

France393

217

Surgical procedures

Normal delivery UK1.5

Canada1.6

NLD1.9

US2

Sweden2.3

Australia2.7

Denmark2.7

Germany2.9

CHE3.6

France4.1

Japan5.7

2.8

Length of stay per capita, mean, d

Cardiovascular procedures per 100 000 population

Acute myocardial infarction JapanNA

Denmark3.9

Sweden4.7

Australia5.4

US5.4

Canada5.5

NLD5.6

France6

UK7.1

CHE7.3

Germany10.3

6.1

NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands. See eTable 4 in Supplement 2 for data ordered by country.

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The data also suggest that some of the more common explana-tions about higher health care spending in the United States,such as underinvestment in social programs, the low primarycare/specialist mix, the fee-for-service system encouraging highvolumes of care, or defensive medicine leading to overutilization,did not appear to be major drivers of the substantially higher UShealth care spending compared with other high-income countries.Instead, the data suggest that the main driving factors werelikely related to prices, including prices of physician and hospitalservices, pharmaceuticals, and diagnostic tests, which likely alsoaffected access to care. In addition, administrative costs appearedmuch higher in the United States. These findings indicate thatefforts targeting utilization alone are unlikely to reduce the gap inspending between the United States and other high-income coun-tries, and a more concerted effort to reduce prices and administra-tive costs is likely needed.

Several findings in this report may be surprising to policy mak-ers. There is broad consensus among US policy makers that theUnited States spends too much on health services and too little onsocial services. This analysis showed that US social spending ap-pears to be similar to that in other high-income OECD countries. This

finding calls into question the belief that higher health care spend-ing is due to a lack of investment in social determinants. In particu-lar, given that the United States did not appear to be an outlier withregard to utilization of services, it is unlikely that a lack of social spend-ing results in higher health care spending due to a misallocation ofresources that results in greater need (and overutilization).

Another common perception among policy makers is that theUS system is often perceived to be disproportionately driven byspecialist care. However, the number of specialist practitioners inthe US system, both as an absolute number and a percentage, wasnot considerably different from comparison countries. One expla-nation may be differences in the way primary care services aredelivered in other countries. In many other countries, nurses andallied health professionals may make up a higher proportion of thehealth care workforce,21 although we did not find substantiallyhigher numbers of nurses in the other countries. The extent towhich this explains variation in numbers of physicians across sys-tems is unclear, but it is unlikely to fully account for why the UnitedStates is not an outlier.

Although the ratio of primary care physicians to specialists wassimilar between the United States and other high-income countries,

Figure 8. Performance on Key Measures of Utilization

0.5 1.0 1.5 2.00

No. of Hospital Bed Days per Inpatient

Japan

Germany

France

Switzerland

Sweden

Australia

United Kingdom

The Netherlands

United States

Denmark

Canada

Hospital bed daysC

2.5 2 4 6 8 10 12 14 160

Length of Stay per Inpatient, d

Japan

Germany

France

Switzerland

Sweden

Australia

United Kingdom

The Netherlands

United States

Denmark

Canada

All-cause length of stayD

18

15050 100 2502000

Hospital Discharges per 1000 Population

Japan

Germany

France

Switzerland

Sweden

Australia

United Kingdom

The Netherlands

United States

Denmark

Canada

Hospital dischargesA

300 102 4 6 8 120

Physician Visits per Capita in a Given Year

Japan

Germany

France

Switzerland

Sweden

Australia

United Kingdom

The Netherlands

United States

Denmark

Canada

ConsultationsaB

14

The vertical dashed lines indicate mean values.a Consultations is the mean number of consultations or visits with a physician per person per year in all care delivery settings.

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1034 JAMA March 13, 2018 Volume 319, Number 10 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

the salaries paid to both generalist and specialist physicians weremarkedly higher in the United States, where specialists were paidtwice as much as those in the United Kingdom or Germany and pri-mary care physicians and nurses also had substantially higher sala-ries. However, it can be difficult to compare salaries of workers fromvarious countries. In general, salaries for professionals are higher inthe United States than in other countries, and in addition, workersin the United States bear higher costs in some areas, such as for healthcare insurance, higher education, or planning for retirement, thanworkers in other countries. Some of these issues are accounted forin the ratio of national average wage, but US physicians and nursesstill had the highest ratio.

Some of the differential observed in cost between physiciansand nurses in the United States and in the other countries may re-flect differences in productivity or the extent to which training costsare borne by the individual, although in either case it is unlikely toaccount for the magnitude of the difference. In 2011, Laugesen andGlied19 estimated that the investment repayment cost for private

education in the United States would amount to about $21 300 peryear for a primary care physician and about $24 400 for an ortho-pedic surgeon over a 35-year period.

Taking this investment into account, however, does not explainthe more than $200 000 difference in compensation observed forphysicians between countries. Although remuneration varies widelyacross systems, the optimal level of compensation remains unclear.Salaries in the United States may be high, but recent debates on re-muneration of medical staff in the United Kingdom and France, forexample, suggest that salaries in other countries may be too low.22

Other indicators, such as average wages for competitive nonhealthprofessions or retention of medical graduates, may help inform ap-propriate salaries of health care professionals in a given country.

Prices of services were not examined directly, but US healthcare spending was found to be higher than in other countriesdespite similar utilization patterns, suggesting that higher priceswere the primary cause of high health care spending in the UnitedStates relative to other nations. This is consistent with prior work

Figure 9. Pharmaceuticals

Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11 Mean

Retail pharmaceutical spendingper capita, US $

Denmark573

NLD292

Sweden501

UK383

Australia346

France541

CHE776

Germany480

Canada587

Japan443

US1026

541

Crestor (cholesterol)

Lantus (diabetes) DenmarkNA

CHENA

NLDNA

SwedenNA

France47

Australia54

Germany61

Japan64

UK64

Canada67

US186

78

Prices, US $ per moa

Advair (asthma) DenmarkNA

CHENA

NLDNA

SwedenNA

UKNA

Australia29

France35

Germany38

Japan51

Canada74

US155

64

Humira (rheumatoid arthritis) DenmarkNA

CHENA

NLDNA

SwedenNA

Japan980

France982

UK1158

Canada1164

Australia1243

Germany1749

US2505

1436

AustraliaNA

CanadaNA

DenmarkNA

NLDNA

SwedenNA

France11

Germany12

UK16

Japan18

CHE26

US111

NANew chemical entities, No.b

Public spending US34

Canada36

Denmark43

CHE43

Australia49

Sweden52

NLD65

UK66

Japan71

Germany75

France80

56

Private insurance

Private out-of-pocket spending Germany18

France19

Japan28

US30

NLD33

Canada34

UK36

Sweden48

Australia50

Denmark51

CHE51

36

Pharmaceutical expenditure by financing type, % of total spending

Australia0

Sweden0

UK0

Japan1

France1

NLD2

Germany7

Denmark8

CHE8

Canada30

US36

8

Volume NLD17

Australia30

Sweden44

Denmark54

CHE54

Japan56

Canada70

France70

Germany80

UK83

US84

58

Value

Share of generics, % of totalc

Denmark14

CHE14

Australia15

Sweden15

NLD16

France16

US28

Canada29

Japan33

UK33

Germany37

23

JapanNA

NLD10.7

Sweden12.9

Germany14.4

Denmark16.6

UK20.1

US24

Canada25

Australia28.3

France29.9

CHENA

20.2Antibiotic prescribing, defineddaily doses per 1000 populationd

DenmarkNA

CHENA

NLDNA

SwedenNA

Australia9

France20

UK26

Japan29

Canada32

Germany41

US86

35

NLD466

Total spending per capita, US $ Denmark675

CHE939

Sweden566

Australia560

France697

UK779

Japan837

Canada613

Germany667

US1443

749

NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.See eTable 5 in Supplement 2 for data ordered by country.a US discounted prices are listed; nondiscounted prices are $216.00 for Crestor,

$372.75 for long-acting insulin, $309.60 for Advair, and $3430.82 for Humira.b A new chemical entity is a compound without any precedent among the

regulated and approved drug products.c Volume is most often the proportion of total prescriptions that were for

generic brands. Volumes can be expressed in defined daily doses or as anumber of packages/boxes or standard units. Value is most often the

proportion of total cost (ie, government and patient expenditure) that was forgeneric brands. Values can be, for instance, the turnover of pharmaceuticalcompanies, the amount paid for pharmaceuticals by third-party payers, or theamount paid by all payers (third-party and consumers). Market value is mostoften at ex-factory prices, while amounts paid by third-party payers andconsumers are in general at retail prices.

d Defined daily dose is the assumed mean maintenance dose per day for a drugused for its main indication in adults. Data shown here are actual mean defineddaily doses for each country.

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© 2018 American Medical Association. All rights reserved.

by Anderson et al,23 which also illustrated higher health carespending in the United States despite similar inputs and levels ofcare utilization, and more recent work by Dieleman et al.13 In addi-tion to differential prices for physician services and pharmaceuti-cals, these results suggest that prices for nonphysician services andprocedures also appeared to be markedly higher in the UnitedStates. For the select procedures for which comparable data wereavailable, the United States paid considerably more than its coun-terparts. In 2013, the International Federation of Health Plans24

reported that the average cost in the United States was $75 345for a coronary artery bypass graft surgery, whereas the costsin the Netherlands and Switzerland were $15 742 and $36 509,respectively. Computed tomography was also much higher in the

United States, with an average payment of $896 per scan com-pared with $97 in Canada, $279 in the Netherlands, $432 in Swit-zerland, and $500 in Australia in 2013. Similarly, the mean paymentfor an MRI in the United States was $1145 compared with $350 inAustralia and $461 in the Netherlands.

Of particular interest to US health policy makers is the role ofthe pharmaceutical market and its influence on health care spend-ing. Not surprisingly, US spending on pharmaceuticals was almostdouble the spending in comparison countries. Previous work sug-gests that this is driven by high prices for brand-name drugs ratherthan by utilization, which is comparable with other high-incomecountries.24-27 Across comparison countries, the United States hadthe highest volume of generics, accounting for more than 80% of

Figure 10. Access and Quality

Access, %

Able to get same- or next-day appointmenta

Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11

JapanNA

DenmarkNA

CHENA

Canada43

Sweden49

US51

Germany53

France56

UK57

Australia67

NLD77

57

Mean

2-mo Wait time to see specialist JapanNA

DenmarkNA

Germany3

France4

US6

NLD7

CHE9

Australia13

Sweden19

UK19

Canada39

13

Adequate time with regular(primary) physician

JapanNA

DenmarkNA

FranceNA

Sweden78

Canada79

US81

Australia83

CHE84

NLD85

UK86

Germany88

83

System works well JapanNA

DenmarkNA

NLDNA

US19

Canada35

Australia44

Sweden44

UK44

France54

CHE58

Germany60

45

Fundamental changes needed JapanNA

DenmarkNA

NLDNA

CHE37

Germany37

France41

Australia46

Sweden46

UK46

US53

Canada55

45

Measles immunization, %of children

Canada90

Denmark91

France91

US92

Australia93

CHE93

UK93

NLD96

Germany97

Japan98

Sweden98

94

Breast cancer screening, %of women aged 50-69 yb

Japan41

CHE47

France52

Australia55

Germany71

Canada72

Sweden75

UK76

NLD79

US81

Denmark84

67

Complete rebuild of healthsystem needed

JapanNA

DenmarkNA

NLDNA

CHE3

Germany3

Australia4

France4

UK7

Canada9

Sweden10

US23

8

Clinical outcomes

30-d Stroke mortality per1000 patientsc

JapanNA

DenmarkNA

NLDNA

US4.2

Germany6.4

CHE6.9

France7.9

UK9.2

Australia9.3

Sweden9.6

Canada10

7.9

30-d Mortality per 1000 patientswith acute myocardial infarction

JapanNA

DenmarkNA

NLDNA

Australia4.1

US5.5

Canada6.7

France7.2

UK7.6

CHE7.7

Sweden8.3

Germany8.7

7

Foreign body left per100 000 discharges

JapanNA

DenmarkNA

NLDNA

US4.1

Sweden4.6

Germany5.5

UK6.1

France6.2

Australia8.6

Canada8.6

CHE12.3

7

Obstetric trauma withoutinstrument per 100 deliveries

JapanNA

France0.6

US1.5

Germany2.1

Australia2.4

NLD2.5

Denmark2.6

CHE2.6

Sweden2.8

UK2.8

Canada3.1

2.3

Diabetes hospitalizations per100 000 populationd

NLD69.8

CHE72.6

UK72.8

Canada93.7

Sweden96

Denmark113.4

Australia141.1

France150.6

Japan162.3

US191

Germany218.3

125.6

Diabetes hospitalizations as aratio of population with diabetese

CHE1.20

NLD1.20

France1.20

Canada1.30

UK1.70

Denmark1.80

Sweden1.90

US2

Germany2.40

Australia2.80

Japan2.80

2.00

Asthma hospitalizations as aratio of population with asthmag

Canada0.20

Japan0.30

Sweden0.30

CHE0.40

Australia0.60

NLD0.70

Germany0.70

Denmark0.80

UK1.00

US1.20

0.70

Asthma hospitalizations per100 000 populationf

Canada14.6

Sweden19

CHE27.5

Germany28.7

France29.6

Japan34.7

NLD36

Denmark50.6

Australia64.8

France0.80

UK71

US89.7

42.4

Avoidable hospitalizations

Prevention

Perceptions, %

NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.See eTable 6 in Supplement 2 for data ordered by country.a Able to get same- or next-day appointment when sick, excluding those who

did not need to see a physician or nurse.b Women aged 40 to 49 years in Sweden.c Thirty-day stroke mortality after hospital admission for ischemic stroke.

d Limited to a primary diagnosis of diabetes.e Diabetes hospitalizations are limited to persons aged 15 years or older, whereas

the denominator (population with diabetes) is both adult and pediatric.f Limited to a primary diagnosis of asthma.g Asthma hospitalizations are limited to persons aged 15 years or older, whereas

the denominator (population with asthma) is both adult and pediatric.

Clinical Review & Education Special Communication Health Care Spending in the United States and Other High-Income Countries

1036 JAMA March 13, 2018 Volume 319, Number 10 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

total pharmaceuticals used by US residents yet just under 30% ofthe United States’ total spending on pharmaceuticals. Australia andFrance had much smaller generic market penetration rates, presum-ably because brand-name drugs are comparatively affordable.25

Although the United States’ high prices of pharmaceuticals arecontroversial, these prices have been viewed as critical to innova-tion, including US production of new chemical entities.18,28 Whetherinnovation justifies high levels of spending is not clear.

Performance on access is also a central concern to policy mak-ers. These data indicated that the United States had the lowest rateof insurance coverage. However, the percentage of the populationwith health insurance is at a historical high and has continued to in-crease since the passage of the Affordable Care Act. Out-of-pocketspending was also surprisingly low in the United States, which maybe explained in part by the relatively high proportion of patients whodo not seek care or who skip consultations because of high costs.Prior work has shown that out-of-pocket spending is more concen-trated among the poor.29 Other factors influencing access to carein the United States aside from affordability likely include the coun-try’s considerable landmass (and correspondingly large rural popu-lation). Personal choice is an additional albeit contentious factor. Forexample, the Kaiser Family Foundation has found that approxi-mately 20% of uninsured US residents have incomes of 400% ormore of the federal poverty level and have largely chosen to forgo

insurance.30 In the other countries in this study with similar healthinsurance designs (the Netherlands and Switzerland), the propor-tion of the population choosing to forego coverage is considerablyless.31,32 Still, a substantial proportion of people would benefit fromcoverage but remain uninsured in the United States, and increas-ing coverage for these individuals remains a policy priority.

A central concern in the United States is the extent to whichgreater health care spending translates to better outcomes. Com-paring intermediate country-level health care outcomes across arange of health care services showed that the United States doesperform favorably on certain acute care outcomes but less so forprimary care measures. Notably, the United States had among thehighest breast cancer screening rates and the lowest 30-day mor-tality rates for acute myocardial infarction and stroke. Although therates of avoidable hospitalizations in the United States, such as fordiabetes and asthma, are well above those of most of the countriesin the analysis, accounting for the United States’ higher prevalenceof both diseases reduced this gap considerably. The United Stateshas relatively poor population health outcomes, which likely repre-sents a combination of factors including issues with the affordabil-ity of care. However, the United States average, in comparisonto averages of much smaller, more homogeneous countries, maylead to erroneous conclusions. For example, the life expectancy ofMinnesota, a state comparable in size and demographics to

Figure 11. Distribution and Equity

Out-of-pocket spending

Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11 Mean

As % of total health expenditure NLD5.2

France6.3

UK9.7

US11

Germany13.2

Denmark13.4

Canada13.6

Japan13.9

Sweden14.1

Australia18.8

CHE26.8

13.3

As % of household consumption

Equity

Horizontal inequity index, %a AustraliaNA

JapanNA

DenmarkNA

CHENA

NLDNA

SwedenNA

UK0.40

Germany1.00

France1.30

Canada1.90

US6

2.10

NLD1.3

France1.4

UK1.4

Germany1.8

Japan2.2

Canada2.3

Denmark2.6

US2.6

Australia3.2

Sweden3.4

CHE4.5

2.4

Consultation skippedbecause of cost

JapanNA

DenmarkNA

Germany2.6

Sweden3.9

UK4.2

Canada6.6

CHE7

France9

NLD12.5

Australia16.2

US22.3

9.4

% Unmet need, below-averageincome

% Unmet need, above-averageincome

JapanNA

DenmarkNA

Germany6

Sweden7

UK7

Australia13

Canada13

France14

NLD16

CHE22

US32

14.4

Unmet needb

JapanNA

DenmarkNA

UK8

Sweden16

Germany16

Australia24

NLD29

Canada30

France30

CHE31

US43

25.2

Rural population, % oftotal population

Japan6

NLD9

Australia10

Denmark12

Sweden14

UK17

Canada18

Germany18

US18

France20

CHE26

15

Population density per sq mile

Geographic breakdown

Australia3

Canada4

Sweden24

US35

France122

Denmark136

CHE212

Germany237

UK271

Japan348

NLD505

173

Urban physicians per1000 population

DenmarkNA

NLDNA

UKNA

Germany2

Australia2.6

CHE2.8

Japan2.9

US3.2

Canada4.1

France4.1

Sweden4.5

3.3

2.1Rural physicians per1000 population

DenmarkNA

NLDNA

UKNA

Canada0.4

Germany1.3

Japan1.4

US1.4

Australia1.7

France2.5

Sweden3.5

CHE4.4

NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.See eTable 7 in Supplement 2 for data ordered by country.a The horizontal inequity index is the percentage probability of a physician visit

in the past 12 months by wealth. If the index is greater than 0, thenhigh-income groups access physicians more than low-income groups afteradjustment for relative need.

b Regarding unmet need, the Commonwealth Fund International Health Policy

Survey poses a number of questions to a representative sample from eachcountry. For this indicator, it was analyzed whether a respondent did notconsult with or visit a physician because of cost, skipped a medical test,treatment, or follow-up that was recommended by a physician because ofcost, or did not fill or collect a prescription for medicine or skipped dosesof medicine because of cost. Low income is defined as household incomeless than 50% of the country median.

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Sweden or Denmark, has more similar population health outcomesto these countries than Minnesota has in comparison to Mississippi.

This analysis extends to a body of work that has explored UShealth care spending33 by revisiting comparisons following the pas-sage of the Affordable Care Act, which has both increased cover-age and spurred health care delivery reform toward the delivery ofhigh-value care.9,13 Similar to previous work by Garber and Skinner,10

Reinhardt et al,12 and Anderson et al23 that examined US health carespending relative to other OECD countries, we found that the UnitedStates spent significantly more on health care despite having simi-lar levels of utilization. However, from 2010 onward it appeared thatthe United States had similar levels of public social spending com-pared with other high-income countries. While public social spend-ing has increased since 2010 (from 15.6% of GDP in 2005 to 19.3%of GDP in 2010), utilization rates have remained relativelyunchanged.20,23 This finding suggests that differences in socialspending are less likely to be the main driver of differences in healthcare spending than previous works have suggested.34 This is a simi-lar conclusion to recent work by Dieleman et al,13 which identifiedprices and intensity of care to be largely related to increases in healthcare spending over the past 15 years and negatively associated withdisease prevalence or incidence.

This study has several limitations. First, there was limited avail-ability of comparable data across health systems, which restrictedthe areas of health system performance we were able to compare.In particular, data on prices across systems were lacking, as was thenumber of indicators on quality and coverage. The indicators se-lected thus provide a snapshot of performance in some domains—particularly quality—which may not be representative of quality ofthe entire system or may be limited due to data availability acrossall countries. For instance, 30-day mortality rates reflect only in-hospital rates, which may influence the apparent variations ob-served, particularly given differences in length of stay and dis-charge practices across countries. Second, because of the difficultiesin collecting and standardizing indicators across countries, some of

the data used reflect different years, may be out of date, or may havebeen measured differently based on country-specific definitions ofvariables. Even when data were collected from the same source, is-sues of comparability remain because of fundamental differencesin how systems are organized and, in turn, how care is categorized.Two areas of particular concern are outpatient spending and the pri-mary care workforce. We attempted to address limitations in theworkforce data by utilizing a functionality-based approach to iden-tifying who provides primary care services in each country and bycross-referencing resulting numbers with country experts. Third, thestudy was able to present only descriptive comparative findings, andit is not possible to make any causal inferences. Fourth, the data didnot adjust for factors such as underlying population differences orsystem delivery and organizational factors, which likely influencesome of the observed variation in this space. Fifth, the response rateto some surveys that were the basis for some measures, such as abil-ity to get same- or next-day appointment and 2-month wait time tosee a specialist physician, were not good across all countries. Sixth,we did not consider the actual prices of devices, which, given theincreasing number of hip and knee replacements and use of otherdevices, are emerging as an important consideration in the cost ofcare in the United States.

ConclusionsThe United States spent approximately twice as much as otherhigh-income countries on medical care, yet utilization rates in theUnited States were largely similar to those in other nations. Pricesof labor and goods, including pharmaceuticals, and administrativecosts appeared to be the major drivers of the difference in overallcost between the United States and other high-income countries.As patients, physicians, policy makers, and legislators activelydebate the future of the US health system, data such as these areneeded to inform policy decisions.

ARTICLE INFORMATION

Accepted for Publication: February 2, 2018.

Author Contributions: Dr Papanicolas and MsWoskie had full access to all of the data in the studyand take responsibility for the integrity of the dataand the accuracy of the data analysis.Concept and design: All authors.Acquisition, analysis, or interpretation of data: Allauthors.Drafting of the manuscript: Papanicolas, Woskie.Critical revision of the manuscript for importantintellectual content: All authors.Statistical analysis: Woskie.Administrative, technical, or material support: Allauthors.Supervision: Papanicolas, Jha.

Conflict of Interest Disclosures: All authors havecompleted and submitted the ICMJE Form forDisclosure of Potential Conflicts of Interest andnone were reported.

Additional Contributions: We thank DuncanOrlander, BA, Harvard School of Public HealthDepartment of Health Policy and Management,for research assistance (compensated as partof regular pay).

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Health Care Spending in the United States and Other High-Income Countries Special Communication Clinical Review & Education

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