The united countries of America: benchmarking the quality of US health care.

Social scientists often cite international statistics to demonstrate that the United States lags woefully behind other developed countries in the quality of health care.1,2 According to a Commonwealth Fund study of 19 countries, for example, the United States had the highest number of deaths that could have been prevented using existing health care procedures.3 A January 2008 position paper in the Annals of Internal Medicine warned that the United States ranks last among 6 developed nations (the others were Australia, Canada, Germany, New Zealand, and the United Kingdom) in quality of, access to, and equity of care, among other measures.4 How, policy experts and journalists ask, can the richest country in the world rank so low? What can be done to elevate our national health care system to the level of countries such as Sweden, Denmark, and Finland? As the authors of the Annals study opined, “The United States has much to learn from these countries.” We share the view that successful practices should be studied as potential models. One land, in particular, stands out to us as worthy of scrutiny, a land even better suited for study than those used in the Annals review. Located in the Northern Hemisphere, it has 5.3 million inhabitants notable for their overall health as well as a strong, comprehensive system of health care coverage. Best of all, to study and to learn from this “country,” US health care officials do not even need to pack their passports. The land of which we speak is Minnesota. Not only is Minnesota consistently cited by the Commonwealth Fund and others as among the best US states when it comes to the availability and implementation of health care, it compares favorably in that area with the very countries cited in surveys as having superior health care to the United States. Consider Finland, a country often and justifiably lauded for its good health care, with a population (5.3 million) and demographic characteristics similar to those of Minnesota.5 Among benchmarks of comparison, Finland's rate of mortality amenable to health care was 93.0 per 100,000 (2002-2003 data),3 somewhat higher than Minnesota's rate of 63.9 per 100,000 (2004-2005)6; Finland's infant mortality rate (deaths of infants younger than 1 year per 1000 live births) was 3.43 (2011),7 somewhat lower than Minnesota's, which was 5.22 (2005)8; and Finland's life expectancy at birth was 79.27 years (2011),9 slightly shorter than Minnesota's of 80.5 years (2005).10 Indeed, when an American state can be measured against a similar country or region elsewhere, it tends to compare favorably. A 1993 study reported in Pediatrics compared infant mortality in Michigan with the Lorraine region of France—chosen for their similar socioeconomic makeup. Although crude infant mortality rates overall in the United States were higher than for much of the developed world, the study found that the rates in Michigan were lower than those in Lorraine—thanks (the authors surmised) to better access to neonatal intensive care.11 Nonetheless, blanket comparisons between the United States and individual countries persist and extend well beyond medicine. Recently, a column in the New York Times presented statistics that showed the United States to be trailing in areas ranging from life expectancy, to student performance in math, to “food insecurity” (the percentage of respondents who said there had been times in the past 12 months when they did not have enough money to buy food).12 The author concluded “Not only are we not No. 1... we are among the worst of the worst.” In the words of the column's headline writer, the United States is an “Empire at the End of Decadence.”12 Our intention is not to minimize the serious and complex challenges facing US health care and society as a whole, nor to sound a jingoistic refrain that America has nothing to learn from the outside world. Indeed, those reflexive chants of “We're Number One!” seem as shortsighted and misguided as the lamentations that we are bringing up the rear. And it is clear that we have much to learn from our neighbors, near and far. Rather, we question what seems an overemphasis on statistical comparisons between a country of more than 300 million citizens—a country with liberal immigration policies and wide geographic, cultural, and economic diversity—and select, individual countries that are at once smaller and have more homogenous populations. (New Zealand, which has good reason to be proud of its health care system and is often used in comparisons, has a population [4.3 million] a little over half the size of New York City's [8.4 million] and one that is more demographically homogenous). Although the United States is certainly a unified republic politically, it more closely resembles 50 separate countries when it comes to health care delivery, each with its own government, its own immigration patterns, and its own socioeconomic challenges. Sparsely populated, mostly rural Wyoming, with a half million residents, has very different health care needs from California, with its diverse, immigrant-rich population of over 37 million. The same holds for small, homogenous, prosperous Vermont, with excellent health care statistics, when compared with, say, Mississippi.6 (The federal taxes paid by the citizens of Vermont do, however, help pay for the medical costs of the citizens of Mississippi, whereas the European countries typically used for comparisons are not for the most part levied for each other's medical expenses.) Clearly, health-related information from countries, provinces, states, and other regions throughout the world can serve a highly useful purpose in helping us to know where there is a pressing need for improvement and where there is excellence that can be achieved under the best of circumstances. Agencies such as the Commonwealth Fund are an extremely valuable source for this information. However, lumping Wyoming, California, Vermont, and Mississippi together with 46 other states, and then comparing the combined results against Belgium or Switzerland (or even more populous countries, such as Germany or France), seems to us to be less productive than comparisons within our own country. This is particularly true because it is so hard to find countries, and regions within countries, that have demographic characteristics similar to American states, Finland's similarity to Minnesota and Lorraine's similarity to Michigan being exceptions. Countries with populations similar in size to American states tend to be quite different in other demographic characteristics (Table).13,14 The United Kingdom (population, 62.7 million; infant mortality rate, 4.62; and life expectancy, 80.05 years) is a country with more ethnic diversity than Finland and one that is used regularly in the international comparisons.15 Yet it is hard to find a sufficiently similar American state for comparison. California (population, 37.3 million; infant mortality rate, 5.2; and life expectancy, 79.7 years),16,17 the state that most closely approximates the United Kingdom in size of population, has substantially more diversity (57.6% white, 2011 census)18 than the United Kingdom (92.1% white, 2001 census).15 TABLE. comparisons of Populations Between countries and states Although we share a sense of urgency about the need to strive continually to provide better access to health care,19,20 education, and proper nourishment, we cannot share the pessimism that such statistical comparisons reveal us to be a nation on the decline, that we suffer from some intrinsic national character defect, and that the solutions to our problems lie primarily in the sociopolitical structure of another, ostensibly more humane, republic. Indeed, an analysis of disparities in mortality among 8 regions in the United States21 and an analysis of recently released data demonstrating a wide range in life expectancy among counties throughout the United States—from 65.9 to 81.1 years for men and 73.5 to 86.0 years for women22—lend credence to the argument that it is better to focus on disparities between states, and perhaps even regions (eg, counties within states), than on our country as a whole for purposes of comparisons. Particularly in the area of health care, we think the answer lies not in becoming Luxembourg, Singapore, Denmark, or Austria—impossible, even if we were so inclined—but in asking why some American states lag so far behind other American states. Why, for example, do Mississippi, Louisiana, and Georgia have such a high rate of mortality amenable to health care when compared with Idaho, Oregon, and Washington?6 What can we do to eliminate these very real disparities, and, instead of focusing on what separates us from other countries, address the greatest challenge before us, in this vast, multifarious land—being the best at who we are and who we must become?