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Just to take this issue somewhat seriously... As Alan says, the U.S. fails miserably in overall statistics. The system's value for money can't possibly be comparable to other systems', because any overall difference in quality could not possibly equal the difference in cost. Besides, the proportion of uninsured means U.S. access on average is pretty bad, and also reduces any plausible measure of overall quality. We don't need the full set of Commonwealth measures to know that. The more interesting question is whether, for the well-insured portion of the population (which includes the median voter), the U.S. health care system provides care that is equal to or superior to that offered in other systems. I think a focus on such a question on the part of the well-insured is short-sighted, because they should not assume they will stay well-insured. But, for most voters, the question is whether reform to make the system "more like other countries" would improve their situation. For most voters, costs may be a horribly bad value but (a) they're used to paying what they pay, and (b) they do not see a large part of the costs because it is the employer share of insurance premia. So the question is: if you are well-insured, how does U.S. care compare to care in other countries? The Commonwealth data may help one think about that question. However, in a lot of cases, poor U.S. performance on measures may simply be due to the large number of uninsured (who, for example, will not have a regular doctor, normally). This is especially true when the variation across countries is small, so it's really only a matter of a few percentage points between the highest and lowest rankings. Moreover, the data greatly emphasize process measures (e.g. electronic medical records) and primary care, as opposed to (for example) access to surgery. I know the theories that support that emphasis, but do not expect the public to believe them. Nor would the public necessarily weight the scales in the same way. For example, timeliness of care (Exhibit 5) might seem more important to the average person than the process measures that dominate the Coordinated Care category (Exhibit 4c). The well-insured person also might care much more about timeliness for herself than about the equity scales. On average, then, the Commonwealth data reports on the overall system in ways that are useful from a population perspective and so from a policy-maker's view, but do not necessarily reflect reality as it will be perceived by an individual voter assessing her stakes in change, or by politicians considering the views of individual voters. To put this another way: when I have seen comparisons of care actually received for specific diseases, the U.S. does not normally get scored as the lowest. It is not systematically the most successful, but the measures tend to put it in the upper half. Please don't get me wrong: the system still is a miserable failure, given what we spend and the access problems. But if we were to focus on the *median* citizen and what she cares about for her own care, we might conclude that the Commonwealth data doesn't accurately measure that. It's still something I use, but not quite in the way suggested by the authors. When I've used past studies it has been mainly to challenge audiences' presumptions that U.S. quality justifies our other problems. So I've displayed quality measures that might seem particularly important to individuals. I don't feel a need to argue we're worst. At our level of costs and access, I'm more interested in showing we're not, on quality, best. cheers, Joe White On Thu, Jun 24, 2010 at 5:39 AM, Adam Oliver <[log in to unmask]> wrote: > I personally don't think that the US system of health care is optimal (!!), > but I don't need to see some dubious ranking exercise to tell me that. > > Still, the Dutch rather than the French will be pleased this time. Maybe > these things follow fortunes in world cups? Or commodity prices of cheese? > In fact, that's it - you can rank countries' health care systems by the > quality of the cheese they produce. Wisconsin better get its act together. >