How Does the Quality of U.S. Health Care Compare Internationally?

How Does the Quality of U.S. Health Care Compare
                          Timely Analysis of Immediate Health Policy Issues
                                             August 2009
                                       Elizabeth Docteur and Robert A. Berenson

Introduction                                 aspects of health care signify its     individuals and populations
                                             quality and which ones are most        increase the likelihood of desired
There is a perception among many             important.                             health outcomes and are consistent
Americans that despite coverage,                                                    with current professional
cost and other problems in the               This brief brings together available   knowledge.”4 A similar definition
health care system, the quality of           evidence on how quality of care in     is used by the U.S. Agency for
health care in the United States is          the United States compares to that     Healthcare Research and Quality:
better than it is anywhere else in           of other countries and comments        “Quality health care means doing
the world and might be threatened            on the implications of the evidence    the right thing at the right time in
by health reform. In fact, 55                for the health reform debate. By       the right way for the right person
percent of Americans surveyed last           exploring how the quality of our       and having the best results
year said U.S. patients receive              care compares internationally, we      possible.”5 Both definitions refer to
better quality of care than do those         can address the underlying             characteristics of health care that
in other nations, even though only           attitudes and concerns that people     are increasingly referred to as
45percent said they thought the              have about health reform. For          “technical” or “clinical" quality or
United States had the world’s best           example, if claims that the United     “effectiveness.”6
health care system.1 And while               States has the best quality of care
Americans overwhelmingly                     in the world — overall or in           In the context of efforts to assess
support government action to                 particular respects — were well        health system performance, the
increase coverage and reduce the             supported by the evidence, it          term “quality” is often used to
costs of health care, a recent poll          would caution us against adopting      encompass a range of desirable or
found that 63 percent worry that             forms of health reform that            positive attributes of health care
the quality of their own care would          threaten those attributes of our       and the overall performance of
get worse if the government                  health system responsible for this     health-care systems. A review of
ensured health care for all.2                standing. But if quality of care is    eight country-specific and
Another poll found that as many as           not remarkable — or may be even        internationally developed
81percent of Americans have such             lagging — there should be less         frameworks for evaluating health
concerns.3                                   reluctance to change. In addition, a   systems found a great deal of
                                             more explicit need for health          commonality in how performance
Participants in the current reform                                                  has been conceptualized.7 In
debate refer to the relative quality         reform to address quality
                                             improvement would appear               addition to effectiveness, the
of U.S. health care as providing                                                    researchers identified 14 other
support for their views, and                 warranted.
                                                                                    dimensions of the performance of
perceptions of health-care quality           What constitutes high-                 health care systems: acceptability,
— what it is and where it can be                                                    accessibility, appropriateness, care
                                             quality health care?
found — are often at the heart of                                                   environment and amenities,
disagreements over what form of              A number of definitions of health      competence or capability,
health reform the country should             care quality have been put forward     continuity, expenditure or cost,
adopt. But hard facts to support             over the years. The U.S. Institute     efficiency, equity, governance,
claims are often missing, and it is          of Medicine’s definition, which        patient-centeredness (-focus) or
clear that quality of care experts,          has grounded expert work in the        responsiveness, safety,
policy makers, health care                   United States and elsewhere,           sustainability, and timeliness.
providers and the general public all         describes quality as “the degree to
have different ideas as to which             which health services for
Many of these performance                 superiority, including a belief that          many holes in our knowledge of
dimensions might reasonably be            Americans with good insurance                 the relative quality in many areas,
considered to be attributes of high-      coverage uniquely benefit from                it is impossible to use a single
quality care (e.g., appropriateness,      prompt availability and                       measure as a meaningful proxy.
competence, timeliness). Those in         accessibility of cutting-edge                 Measures that reflect multiple
a second group (e.g., cost,               medical procedures, medicines,                dimensions of quality have a
governance, sustainability) are           and devices, as well as highly                certain appeal as performance
readily observed as separate              educated and well-trained health              indicators for policy-makers,
performance concerns. Reasonable          care professionals, who know and              although more specific or narrow
people might have different views         consistently do what is best for              measures have the advantage of
on whether others (e.g.,                  their patients. On the other hand,            being more actionable for
accessibility, acceptability,             those who assert that we have                 administrators and clinicians. And
responsiveness) are dimensions of         inferior quality of care point to our         even with a broad set of
quality or closely related concepts,      relatively poor population health             comparative measures, people may
and indeed these are treated in           status,8 and factors such as barriers         differ on which measures are most
different ways in the frameworks          to access for those without                   important, for example, those
reviewed. Accessibility is                adequate insurance coverage or                focusing on the level of typical or
particularly difficult to disentangle     limited health plan provider                  average care for common
from considerations of health care        networks and insufficient                     conditions versus the care
quality in that it is a prerequisite to   coordination among providers in               available for unusual, life-
receipt of quality health care.           the fragmented health care delivery           threatening conditions.
Availability of providers and             system.
services, coverage, benefits and                                                        The evidentiary basis for cross-
affordability all come into play as       All of these aspects of quality and           country comparisons of quality
potential explanations for different      broader health system performance             could be strengthened by
user experiences with the health          are important and legitimate                  additional studies and
care system and the outcomes              considerations; therefore, we cast a          improvements in methods and
attained. Finally, (technical)            relatively wide net in this brief.            data. Nonetheless, a number of
efficiency is a function of the           Specifically, we focus on                     comparative studies on the quality
quality and quantity of services          effectiveness (or “technical” or              of care have been published.
produced at a given cost.                 “clinical” quality) and consider              Below we review some of the key
Efficiency, or value for money, is a      additional dimensions of quality or           findings from recent research that
performance consideration of great        health system performance that are            provide insight on how the quality
interest to public authorities and        most closely related:                         of care in the United States
purchasers, although only modest          appropriateness, safety,                      compares to the quality of care
headway in measuring efficiency           accessibility, acceptability, and             in other nations. We explore
in health care has been made to           responsiveness.                               quality as assessed by measures
date, reflecting limitations in the                                                     based upon population health
                                          What is the evidence on                       status, measures of processes
capacity to measure the quality of
health care.                              how quality of care in                        and outcomes of care for particular
                                          the United States                             conditions, measures of patient
It is evident from the U.S. reform        compares to other                             safety, and indicators based
debates that popular conceptions of                                                     on patients’ experience with
what constitutes good quality
                                          countries?                                    health services. In each area,
health care encompass a range of          To make an informed assessment                we put forward the evidence
dimensions. Although obviously            about the quality of care in one              we could find on how the
high quality implies superior             health system versus another, it is           attribute in question stacks up
health outcomes, other attributes         important to look at a wide range             (or fails to do so).
considered indicative of quality          of indicators. Because health care
appear to underlie popular                involves a complex array of
expressions of U.S. health care           activities, and because there are

                                                                            Timely Analysis of Immediate Health Policy Issues 2
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                           mortality) show the United States              both men and women at age 65 is
                                            to be among the worst performers.              above the Organisation for
differences in life                                                                        Economic Co-operation and
expectancy and                              The United States is not among top             Development (OECD) average, but
mortality indicative of                     performers in terms of life                    below what the top countries have
                                            expectancy, an indicator                       achieved, particularly for women.9
differences in health                       influenced by factors outside the
care quality?                               health system in addition to health            Among 19 countries included in a
While U.S. life expectancy is at or         care. We rank among the lower                  recent study of amenable
below the average in comparison             third of developed countries in life           mortality,10 the United States had
with that of other developed                expectancy at birth. Life                      the highest rate of deaths from
countries, findings from research           expectancy at age 65 may be a                  conditions that could have been
that has adjusted mortality to              better indicator of U.S. health care           prevented or treated successfully.
account for deaths not related to           performance because all older                  The extent to which differences
health care (so-called amenable             Americans have reasonably good                 across countries in the prevalence
                                            insurance coverage through                     of particular conditions may
                                            Medicare. U.S. life expectancy for             explain the poor U.S. showing in

                                                                               Timely Analysis of Immediate Health Policy Issues 3
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,                health system ranked somewhat                 survival rates for individuals with
although studies in which it was            better (16 of 19) among its peers in          particular conditions. Such
possible to adjust for such                 minimizing amenable mortality. In             measures are less sensitive to
differences found that the greatest         the years between the two studies,            differences across countries in
part of regional differences in             there was an average reduction in             disease prevalence.
mortality for certain conditions            amenable mortality for men of 17
were explained by differences in            percent across all countries                  Below we review available
disease prevalence.11 A recent              included in the study, compared               evidence on U.S. quality of care in
study comparing the United States           with only a 4 percent reduction in            a variety of clinical areas, in
and 10 European countries found             the rate of amenable mortality for            comparison with other countries.
that the United States had a much           men in the United States.                     The overall evidence is mixed,
higher prevalence of nine of 10                                                           indicating that the United States
conditions, including cancer, heart         Studies of processes                          has neither the best nor the worst
disease, and stroke, in its                 and outcomes of care for                      quality of health care for particular
population over age 50.12                                                                 conditions among developed
                                            particular conditions                         countries. In certain cases where
However, it is unlikely that relative       reveal differences in
differences across countries in the                                                       U.S. quality appears low relative to
prevalence of disease changed
                                            health-care quality                           that of other countries — in the
during the five years that had                                                            areas of prevention and care for
                                            Measures specifically designed to
passed since an earlier study13 by                                                        chronic conditions, for example —
                                            assess technical/clinical quality of
the same authors using the same             care focus on health services and             access barriers experienced by the
methodology, in which the U.S.              health outcomes, such as five-year            uninsured and the underinsured
                                                                                          may contribute to the results seen.

                                                                              Timely Analysis of Immediate Health Policy Issues 4
States came in below average in a
   Measuring the technical quality or effectiveness of health care:                    field where one-third of OECD
   A brief primer                                                                      countries have rates above 95
   The science of health care quality measurement has been developed over
   the course of several decades. Quality measures include those to assess             Quality of care for chronic
   health care processes (what was done), outcomes (what was achieved) and             conditions
   structural measures that evaluate the capacity to do what needs to be done.         Findings on the quality of U.S.
   Process measures can be further categorized as measures of overuse (when            care for several chronic conditions
   patients get services that are inappropriate for their medical condition,           also provide a mixed picture.
   subjecting them to unwarranted risk and/or expense), underuse (when
   patients do not receive care that is indicated based on their medical               Among 30 OECD countries, the
   condition) and misuse (when a service is provided in a technically                  United States ranked below
   incorrect manner), although the bulk of the measures used regularly for             average in adult asthma care. Adult
   comparison relate to underuse of services considered medically necessary            hospital admission rates for
   in defined circumstances.                                                           asthma, an indicator of inadequate
                                                                                       care for the condition, were second
   Quality can be assessed objectively (against standards defined by evidence          highest among 17 countries
   or professional agreement) or subjectively (against patients’ expectations          reporting (12 per 10,000 U.S.
   or experiences, or reviewer judgment, for examples). Assessment draws               versus 5.8 OECD average) and
   upon empirical data, such as administrative and medical records or patient          U.S. asthma mortality, double the
   registries and the perceptions of those involved in health care (surveys,           OECD average rate, was fifth
   testimonials). Quality is evaluated for populations and sub-groups within           highest among 25 countries
   the population, as there is a particular interest in evaluating whether and         reporting.17
   how differences in health care contribute to observed disparities in health
   status.                                                                             A handful of studies undertaken in
                                                                                       the 1990s18 have compared
                                                                                       outcomes for U.S. and Canadian
Quality of preventive care                average mammography rates (61
                                                                                       patients with end-stage renal
                                          percent U.S. versus 55 percent
The evidence on how the United                                                         disease and found that Canadians
                                          OECD), although was far below
States compares to other developed                                                     have longer survival times while in
                                          the best performers (82-98 percent
countries in terms of the quality of                                                   hemodialysis or peritoneal dialysis
                                          in four countries). However, the
its preventive care is quite mixed.                                                    programs, and after receipt of
                                          United States had the highest
                                                                                       kidney transplant, even when
In a report that summarized survey        cervical cancer screening rate (83
                                                                                       extensive adjustment for
research comparing quality of care        percent) among 22 countries
                                                                                       comorbidity is done.
in five countries, Davis et al.14         reporting data to OECD.
concluded that the United States                                                       A survey of patients in six
                                          Among 30 OECD countries, the
had relatively high-quality                                                            countries19 found that more than
                                          United States had above-average
preventive care. 85 percent of                                                         half of U.S. diabetics had received
                                          rates of flu vaccination for senior
American women reported having                                                         four recommended services, a rate
                                          citizens (65 percent U.S. versus 55
had a Pap smear within the last                                                        comparable to the UK and
                                          percent OECD average and 80
two years and 84 percent of                                                            Germany, and higher than the rate
                                          percent in top-performing
American women age 50 to 64                                                            seen in Australia, Canada and New
                                          Australia). However, childhood
reported having received a                                                             Zealand. The same survey found
                                          vaccination rates were below the
mammogram within the last two                                                          that 85 percent of U.S.
                                          OECD average.16 The U.S.
years, the highest shares among the                                                    hypertension patients reported
                                          pertussis vaccination rate stood at
countries included in the survey.                                                      having received two recommended
                                          86 percent in 2005; only Austria
Perhaps reflecting differences in                                                      tests, a rate identical to Canada and
                                          and Canada reported lower rates.
data sources, the OECD15 found            Even with a 92 percent childhood
                                                                                       exceeded only by Germany (91
that the United States had above-                                                      percent).
                                          measles vaccination, the United

                                                                           Timely Analysis of Immediate Health Policy Issues 5
Quality of care for certain                early postoperative events. The           United States for patients age 65 or
acute conditions                           United States and Manitoba                older at diagnosis. In the case of
                                           used a more advanced surgical             stomach cancer, the U.S. survival
Studies of diverse conditions              method for cataract removal as            rate for patients under age 45 was
ranging from heart disease, hip            compared with Barcelona or                below those of many European
fracture and vision impairment             Denmark.24                                nations, but similar among the
also are mixed in terms of their                                                     older patients. Other studies (e.g.,
findings as to how U.S. quality        Quality of cancer care                        Coleman, et al. 2008)26 have also
compares to that of other countries.                                                 found that U.S. survival rates for
                                       While interpreting the available
•              20
    Yusuf et al. studied patients      evidence is challenging in the light          certain cancers, particularly
    undergoing invasive cardiac        of different screening protocols              prostate cancer, are among the
    procedures in six countries and    across countries, it does suggest             best. Among 30 OECD countries,
    found that higher rates of         that the United States as one of              the United States had one of the
    invasive and revascularization     several world leaders in providing            best five-year survival rates for
    procedures in United States        high-quality cancer care.                     patients with breast or colorectal
    and Brazil were associated                                                       cancer.27
    with lower rates of refractory     A study by Gatta and colleagues,25
                                       looked at five-year cancer survival           There is an important link between
    angina or readmission for                                                        survival rates and screening rates
    unstable angina, no apparent       rates for the United States and 17
                                       European countries. The United                for many cancers (e.g., melanoma,
    reduction in cardiovascular                                                      prostate cancer, breast cancer,
    death or myocardial infarction,    States had the highest survival
                                       rates for cancer of the colon,                colorectal cancer). Many cancers
    but higher rates of stroke. Tu                                                   are more amenable to treatment
    et al.21 found that short-term,    rectum, lung, breast, and prostate.
                                       U.S. survival rates were also                 when caught early. But it is also
    but not long-term, cardiac                                                       true that in countries with higher
    outcomes were better in the        among the highest for melanoma
                                       (fourth), uterine (second) and                screening, more cancers will be
    United States than Ontario.                                                      diagnosed early, and survival rates
                                       ovarian (fifth) cancer, cervical
•   Ho et al.22 found that inpatient   cancer (sixth), Hodgkins disease              in those countries will be higher
    hip fracture mortality was         (third) and non-Hodgkins                      simply because there are more
    higher in Canada (Manitoba         lymphoma (fourth). The United                 patients in the denominator with
    and Quebec) than in the United     States was ninth in survival of               less advanced disease. Thus, Gatta
    States (California and             stomach cancer. Although average              et al.28 found that those countries
    Massachusetts). Canadians had      survival differences between the              with the highest breast cancer
    longer waits for surgery,          United States and Europe as a                 incidence rate (share of population
    although this was found not to     whole were in some cases large,               newly diagnosed with the disease
    explain the difference in          the difference between the United             in a given year) also had the
    mortality observed.                States and the other countries with           highest survival rates.
                                       relatively high five-year survival            Differing national commitments to
•   Norregaard et al.23 found          rates were generally small                    screening becomes an issue,
    similar postoperative visual       (approximately 3 to 4 percent for             particularly, in the case of prostate
    acuity for cataract patients       many cancers) and (due to small               cancer, where U.S. incidence rates
    across four countries studied,     sample sizes) usually not                     are double those of Europe
    including the United States,       statistically significant. The study          because aggressive screening
    despite considerable               also looked at cross-country                  uncovers cancers at a very early
    differences in the organization    differences by population group,              stage. The implications for quality
    of care and patterns of clinical   finding that survival rates for               are complicated, in that cancer
    practice. The United States had    colon, breast and uterine cancer              detection has instigated more
    fewer adverse intra-operative      were similar in the United States             treatments with serious risk of
    events than the other three        and Europe for patients under 45              quality of life deterioration for a
    sites studied but, along with      years, but were much better in the            condition that is very slow to
    Manitoba, had higher rates of

                                                                         Timely Analysis of Immediate Health Policy Issues 6
develop. In 2008, the U.S.              U.S.-Canada                                    does not vary across countries with
Preventive Services Task Force          comparisons more often                         different service rates.
updated its screening advice,
recommending that known risks of
                                        find Canadian quality is                       The degree of variation in the
screening outweigh potential            better                                         share of populations receiving
benefits for older men, and that                                                       particular services is greater than
                                        A significant share of the academic            what would be expected based on
informed patient preferences            research studies comparing the
should serve as a determinant of                                                       population health status
                                        outcomes and effectiveness of                  differences, raising a question as to
appropriate care in younger men.        health care across countries
Other countries, such as Denmark,                                                      whether there is underuse of the
                                        consists of U.S./Canada                        procedure in countries with
had recommended against                 comparisons, perhaps reflecting
widespread use of the test as early                                                    relatively low rates or overuse in
                                        policy interest, data availability or          the countries with relatively high
as 1990 (cited in Coleman et al.        other factors. Although studies
2008).29                                                                               rates. For example, OECD
                                        findings go in both directions, the            countries’ rates of caesarean
Differences across countries in         bulk of the research finds higher              sections per 100 live births range
access to diagnostic and treatment      quality of care in Canada.                     from 13.6 to 37.9, with U.S. rates
services explain most of the            A review of the evidence on                    among the highest in the OECD.
observed differences in cancer          quality differences between the                Although determining the extent to
survival rates.30 Better survival       United States and Canada found                 which the procedure is overused
rates are associated with higher        that each of the two countries                 requires investigation of patient
national income levels, higher          performed better in different                  characteristics, including age and
levels of expenditure on health,        studies. Guyatt et al.32 identified 38         comorbidities, the World Health
and higher investment in health         studies comparing populations of               Organization has stated that rates
technology, as proxied by               patients in Canada and the United              above 15 percent offer no benefits
indicators such as the rate of CT       States. Studies addressed diverse              in terms of population health.33
scanners per person. The                problems, including cancer,                    The United States also has the
relationship between cancer             coronary artery disease, chronic               highest rates of coronary
survival and level of expenditure       illnesses and surgical procedures.             revascularization procedures, with
on diagnosis and treatment has yet      Of 10 studies that included                    more than double the rates of other
to be fully explored, due to data       extensive statistical adjustment and           countries with similar mortality
limitations, although some cross-       enrolled broad populations, five               rates from heart disease.34
country differences in expenditure      favored Canada, two favored the
have been documented. Using an                                                         However, relying on assessment of
                                        United States, and three showed                performance against evidence-
approach to assess relative             equivalent or mixed results.
spending across nations with                                                           based criteria, McGlynn et al.35
different income levels, OECD                                                          found comparable rates of
                                        Overuse of health                              inappropriate use of coronary
found that the United States spent      services not linked with
between 41 and 62 percent of its                                                       angiography and CABG, when
per capita GDP on the first six
                                        service volume                                 comparing New York State and
months of breast cancer treatment                                                      Canada, despite different rates of
                                        Although there have been
following diagnosis for each                                                           use of service in the areas studied.
                                        relatively few studies comparing
patient, while Canada and France                                                       Findings from studies by Bernstein
                                        the rates of overuse of health
spent about one-third of their                                                         et al.36 and Gandjour et al.37 also
                                        services, the limited available
respective per capita GDPs for                                                         suggest that rates of inappropriate
                                        evidence suggests that higher rates
treatment during the initial phase.31                                                  services are not dependent on the
                                        of certain surgeries and procedures
                                                                                       frequency of the procedure.
                                        in the United States put more
                                                                                       Despite performing relatively few
                                        Americans at risk, in comparison
                                                                                       cardiovascular procedures, in
                                        with their counterparts, even if it is
                                                                                       comparison with the United States,
                                        the case that the share of
                                                                                       the rates of inappropriate surgeries
                                        procedures that are inappropriate

                                                                           Timely Analysis of Immediate Health Policy Issues 7
in the UK and Germany were             more likely than patients in other            Australia, Canada, New Zealand
comparable.                            countries to report mistakes or               and the United Kingdom,
                                       adverse events and gaps in expert-            American doctors were less likely
Higher rates of surgery may have       recommended safe medication                   to agree that their health care
both positive and negative impact      management practices.39 A survey              system works well and more likely
of health outcomes. On the one         of chronically ill or intensively ill         to consider that the system needs
hand, when performed on                patients in eight countries40 found           complete rebuilding. A 2003
appropriate candidates, surgery        that the United States had the                survey of hospital executives
will tend to have positive benefits    highest reported rates of problems            yielded a similar finding; half of
in terms of life expectancy and        such as being given the wrong                 American hospital executives said
morbidity associated with the          medication or dosage,                         they were not satisfied with the
underlying condition. On the other,    experiencing a medical error,                 performance of their country’s
greater per capita rates of heart      receiving incorrect test results, or          health care system, compared with
surgery may contribute to the          facing delays in hearing about                between 4 and 12 percent of
higher rates of mortality due to       abnormal test results. Patient                hospital executives in four other
surgical and medical errors in the     reports of these types of problems            countries.42
United States.                         were lowest in the Netherlands (17
                                       percent), France (18 percent), and            Davis43 reviewed findings from
Patient safety problems                                                              multi-country surveys conducted
                                       Germany (19 percent) and highest
appear more prevalent in               in the United States (34 percent).            in 2004 and 2005 that examined
the United States                                                                    patients’ satisfaction and
                                       Physician and patient                         experience with their health care.
Few studies have compared patient                                                    Patients assigned the U.S. health
safety at an international level, as
                                       perceptions of health
                                                                                     system mixed marks in terms of
data and indicators for use within     care quality suggest                          whether their health care providers
countries are still in development.    strengths and                                 communicated needed
Notwithstanding such limitations,      weaknesses of U.S. care                       information. U.S. patients were
available evidence suggests that                                                     less satisfied than patients in other
patients may be at greater risk of     As with most of the indicators
                                                                                     countries with the quality of
safety problems in the United          described above, physician and
                                                                                     communication relating to doctor’s
States than they are elsewhere.        patient reports suggest some areas
                                                                                     office visits, but more satisfied
                                       of strength, but as a general matter
                                                                                     than other patients with the quality
Data are available for cross-          do not distinguish American health
                                                                                     of communication relating to
national comparisons on mortality      care as providing especially high
                                                                                     hospitalization. On the other hand,
due to surgical and medical            quality compared to the health care
                                                                                     U.S. patients were less satisfied
errors.38 These data show that the     provided in other countries.
                                                                                     than patients in other countries
United States has relatively high
                                       A survey of physicians in five                with how much their physicians
rates, in comparison with other
OECD countries, but the rates may      countries41 found that U.S.                   engaged them in making health
                                       physicians were more likely than              care decisions. In terms of
be problematic as quality
                                       physicians in other countries to              satisfaction with the level of
indicators due to differences in
                                       report that interventions in patient          choice of doctor, Americans were
reporting accuracy across countries
                                       care geared towards cost control              less satisfied than patients from
and the relative infrequency of this
                                       were threatening the quality of               New Zealand and more satisfied
                                       care they could provide to their              that Canadian patients. Finally, in
Surveys provide another source of      patients. U.S. physicians were less           terms of timeliness, American and
information on relative safety. A      likely to report that community               German patients reported
six-country survey of patients with    resources were inadequate, but                relatively short waiting times for
a high incidence of chronic illness    more likely to say that limitations           seeing a specialist or obtaining
and recent intensive use of the        on the medicines they could                   elective surgery. But Americans
health care system found that          prescribe posed a problem.                    were less likely to say they could
patients in the United States were     Compared with doctors in                      get medical attention when needed

                                                                         Timely Analysis of Immediate Health Policy Issues 8
and could readily obtain care on       with other countries studied,                uninsured receive fewer preventive
nights and weekends. Considering       resulting in the United States               and diagnostic services, tend to be
timeliness measures as a whole,        dropping from 16th to 19th place             more severely ill when diagnosed,
German patients were more              over five years. Furthermore, the            and receive less therapeutic care.
satisfied than American patients,      findings showing that the United             He concluded that insurance
and British and Canadian patients      States does better than Europe in            coverage could reduce mortality by
were least satisfied.                  cancer survival for the over-65              an estimated 4 to 25 percent,
                                       population suggests a possible role          depending on the condition.
Is the average quality of              for insurance status as an
care in the United States              explanatory factor, especially since         But all of this does not necessarily
                                       working age and retirees have the            mean that the uninsured have
negatively affected by                                                              worse quality of care, as measured
access barriers faced by               same coverage in most European
                                       countries.                                   by provision of evidence-based,
the uninsured?                                                                      recommended processes of care
                                       In addition, there is evidence to            that are likely to improve patient
When comparing the quality of
                                       suggest that access barriers are an          outcomes. In fact, a study by Asch
care in the United States to that of
                                       issue affecting U.S. performance,            et al.51 found that health insurance
other countries it is impossible to
                                       in particular. As compared with the          status was largely unrelated to the
ignore one stark difference — the      residents of other countries, many           quality of care as measured by
fact that close to one-fifth of the    more Americans — and                         adherence to professionally
U.S. population under age 65 is                                                     recommended standards of care,
                                       chronically ill Americans — say
uninsured. The United States is                                                     among those with at least one
                                       they skip medicines or medical
one of only three countries in the
                                       appointments due to cost.45 46 Such          contact with the health care system
OECD, together with Mexico and                                                      within a two-year period. This
                                       behavior, which may reflect
Turkey, which has a sizeable share                                                  somewhat surprising finding
                                       problems of underinsurance as
of its population lacking coverage.                                                 suggests that the access barriers
                                       well as uninsurance, may result in
It stands to reason that some of the   impaired health outcomes. By                 experienced by the uninsured may
gap between United States and          contrast, the types of access                not result in differential treatment
other countries in average quality     problems reported in other                   once an uninsured person succeeds
may well be related, in at least       countries — mainly longer waits              in engaging with the health care
some part, to the insurance            for elective surgeries — are likely          delivery system.
coverage problem in this country.      to affect perceptions of service
Most of today’s measures capture       quality and reduced quality of life
                                                                                    Summary and
problems of “underuse,” or the         during the waiting period without            conclusions
share of a population that receives    impact on clinical outcomes.47               Taken collectively, the findings
the screening or treatment                                                          from international studies of health
indicated, based on agreed medical     Based on a comprehensive review
                                       of the relevant research literature,         care quality do not in and of
practice standards. For many such                                                   themselves provide a definitive
measures, quality and access are       the Institute of Medicine48
                                       concluded that the uninsured have            answer to the question of how the
intrinsically linked.                                                               United States compares in terms of
                                       worse health and higher mortality
There is, in fact, some suggestive     than the insured population in the           the quality of its health care. While
evidence of a quality-coverage         United States. Population based              the evidence base is incomplete
relationship. In their updated study   studies have shown that uninsured            and suffers from other limitations,
of amenable mortality, Nolte and       Americans have shorter survival              it does not provide support for the
McKee44 suggest that an increase       times for conditions such as cancer          oft-repeated claim that the “U.S.
in the share of Americans              of the breast, colorectum and                health care is the best in the
uninsured between the two study        prostate than those with                     world.” In fact, there is no hard
periods may be responsible for the     insurance.49 A review of the                 evidence that identifies particular
failure of the United States to        research literature over the past 25         areas in which U.S. health care
improve its performance apace          years by Hadley50 found that the             quality is truly exceptional.

                                                                        Timely Analysis of Immediate Health Policy Issues 9
Instead, the picture that emerges       information technology,                        other developed countries achieve
from the information available on       differences in the coordination of             comparable quality of care while
technical quality and related           care and the fragmentation of                  devoting at most two-thirds the
aspects of health system                health care delivery, variations in            share of their national income.
performance is a mixed bag, with        reliance of incentives for providers
the United States doing relatively      and consumers to provide and                   Faced with the evidence, one
well in some areas — such as            select care based on consideration             might well ask why it is that
                                        of quality). We do know, however,              assertions of the superiority of
cancer care — and less well in
                                        from a five-country survey of                  U.S. health care are so common.
others — such as mortality from
                                        primary care physicians52 that U.S.            Technical definitions and popular
conditions amenable to prevention
                                        physicians’ practices are more                 conceptions of quality include
and treatment. Many Americans
                                        limited in information capacity,               many different dimensions and
would be surprised by the findings
                                        provide less patient access outside            there may not be agreement about
from studies showing that U.S.
                                        of traditional work hours, and are             which dimensions are most
health care is not clearly superior
                                        among the least likely to work in              important. For example, people
to that received by Canadians, and
                                        teams or to receive financial                  who make the claims that the
that in some respects Canadian
                                        rewards for quality, all factors that          United States has the “best quality
care has been shown to be of
                                        could bear on the quality of                   of care” in the world may be
higher quality.
                                        primary care furnished.                        prioritizing a degree of access to
To be sure, there are limitations to                                                   medical technology and innovation
the current evidence base. In           Taken together, these studies do               which they believe to be unique to
particular, there is no data or         provide a strong basis for                     the United States. Perhaps media
evidence by which to answer the         determining whether proposed                   attention paid to outcomes for a
question of whether the United          health reform initiatives might                select few (e.g., multiple organ
States is a place where one finds       threaten or, alternatively,                    transplant recipients, high-risk
health care that exceeds the quality    strengthen the current level of U.S.           delivery of multiple births) has
of the best care available              quality. While evidence is not                 cast into shadow the average
elsewhere in the world — in other       conclusive, it is clear that the               outcomes of the majority of
words, whether the “best U.S.           argument that reform of the U.S.               Americans with more routine, yet
health care is the best in the          health system stands to endanger               serious, conditions and other
world.” Although it is often held       “the best health care quality in the           health care needs.
that the U.S. strength lies in state-   world” lacks foundation. Like
                                        other countries, the United States             But a less-than-fully informed
of-the-art, technically oriented                                                       public comes at a cost in that
care, especially focused on             has been found to have both
                                        strengths and weaknesses in terms              assertions of excellence divert
“rescue” care, rather than care for                                                    attention from the need to inspire
more routine acute and chronic          of the quality of care available, and
                                        the quality of care the population             and foster systematic quality
conditions, studies typically do not                                                   improvement activities.
compare the “best” care offered in      receives. The main ways in which
                                        the United States differs from                 Furthermore, there seems to be a
different countries. Further, there                                                    routine genuflection to the
remain other aspects of health care     other developed countries are in
                                        the very high costs of its health              widespread belief of U.S. quality
for which we have no quality                                                           excellence, even among experts. In
measures or inadequate data for         care and the share of its population
                                        that is uninsured.                             an environment where even
comparisons.                                                                           insured Americans receive only
Existing studies also fail to tell us   In the light of the fact that the              about half of the services that
much at all about the reasons for       United States spends twice as                  experts consider necessary, there is
the apparent differences in quality     much per person on health care as              a strong argument for placing
observed across countries,              its peers, those who question the              quality firmly on the health reform
although numerous hypotheses            value for money obtained in U.S.               agenda.53 In short, health reform
have been put forward (e.g.,            health expenditures are on a firm              can be seen as an opportunity to
differences in the use of health        footing. The evidence suggests that            systematically improve quality of

                                                                         Timely Analysis of Immediate Health Policy Issues 10
care, rather than as a threat to       has the “best” quality of care in the          health system on quality. If reform
existing levels of quality.            world are sometimes put forward                accomplishes no more than
                                       to support views that reforms are              extending insurance coverage to
Health reform provides an              unwarranted on quality grounds                 the more than 45 million
opportunity to build on strengths      and even risky — particularly                  Americans without insurance, it
and correct weaknesses, work           those reforms that would modify                will be an important step forward,
towards aims for improvement,          U.S. health financing, coverage or             but more is needed to ensure health
such as those defined by IOM in        delivery arrangements in ways                  care quality improvement. To the
Crossing the Quality Chasm,54 that     similar to those used in other                 extent it is possible to improve
care be safe, effective, patient-      countries.                                     health care delivery through
centered, timely, efficient and                                                       reforms that strengthen incentives
equitable. The IOM continues to        On the basis of this review it is              to apply knowledge and meet
push for quality improvement           safe to say that U.S. health care is           quality standards, employ
based on the evident gap between       not pre-eminent on quality;                    technology to reduce errors and
what is done and what should be        furthermore, one can surely argue              ensure appropriate care, and help
done, what can be achieved and         that U.S. health care quality is not           consumers and patients demand
what is achieved, but international    at risk from the kinds of health               better quality, even more might be
comparisons have not played a          reform proposals receiving                     achieved.
major role in pushing forward that     attention. On the contrary, our
message. On the contrary,              findings strengthen arguments that
unsubstantiated claims that, despite   reform is needed to improve the
any shortfalls, the United States      relative performance of the U.S.

                                                                        Timely Analysis of Immediate Health Policy Issues 11
14                                                             26
                                                       Davis, K, C Schoen, S C Schoenbaum, AJ                         Coleman, Michael P., Manuela Quaresma,
Notes                                               Audet, MM Doty, AL Holmgren, and JL Kriss,                     Franco Berrino, Jean-Michel Lutz, Roberta De
                                                    “Mirror, Mirror on the Wall: An Update on the                  Angelis, Riccardo Capocaccia, Paolo Baili,
 Reuters (2008), “Republicans and Democrats         Quality of American Health Care through the                    Bernard Rachet, Gemma Gatta, Timo Hakulinen,
Diverge on Health Care Issues,” March 20.           Patient’s Lens,” The Commonwealth Fund, April                  Andrea Micheli, Milena Sant, Hannah K Weir, J
                                                    2006.                                                          Mark Elwood, Hideaki Tsukuma, Sergio Koifman,
2                                                                                                                  Gulnar Azevedo e Silva, Silvia Francisci, Mariano
  Sack, K and M Connelly (2009), “In Poll, Wide     15
Support for Government-Run Health,” New York             OECD, “Quality of Care.”                                  Santaquilani, Arduino Verdecchia, Hans H Storm,
Times, June 21.                                     16
                                                                                                                   John L Young, and the CONCORD Working
                                                         OECD, “Quality of Care.”                                  Group (2008), “Cancer survival in five continents:
 Connolly, C and J Cohen (2009), “Most              17                                                             a worldwide population-based study
                                                         OECD, “Quality of Care.”
Americans Want Health Reform But Fear Its Side                                                                     (CONCORD),” The Lancet, Vol. 9, August.
Effects,” Washington Post, June 24.                 18
                                                      Guyatt GH, PJ Devereaux, J Lexchin, SB Stone,                27
                                                                                                                        OECD, “Quality of Care.”
4                                                   MA Yalnizyan, D Himmelstein, et al. A systematic
 Institute of Medicine (1990), Medicare: A
                                                    review of studies comparing health outcomes in                 28
                                                                                                                      Gatta G, “Towards a Comparison of Survival in
Strategy for Quality Assurance, Volume II.
                                                    Canada and the United States. Open Med                         American and European Cancer Patients.”
Washington, DC: National Academy Press.
5                                                                                                                  29
 Agency for Healthcare Research and Quality,        19
                                                                                                                      Coleman, M “Cancer survival in Five
                                                      Schoen, C, R Osborn, PT Huynh, et al., “Taking               Continents.”
“Your guide to choosing quality healthcare.”
                                                    the Pulse of Health Care Systems: Experiences of
Rockville: Agency for Healthcare Research and
                                                    Patients with Health Problems in Six Countries,”               30
                                                                                                                      Coleman, M “Cancer survival in Five
Quality; 1998. Available at:
                                                    Health Affairs Web Exclusive, November 3, 2005,                Continents.” Accessed
May 20, 2009.                                                                                                      31
                                                                                                                      OECD (2003), “Summary of Results from Breast
6                                                      Yusuf, S, M Flather, J Pogue, D Hunt, J Varigos             Cancer Disease Study,” chapter 4 in A Disease-
 Arah, OA, NS Klazinga, DMJ Delnoij, AHA Ten
                                                    et al. (1998), “Variations between Countries in                based Comparison of Health Systems: What is Best
Asbroek and T Clusters (2003), “Conceptual
                                                    Invasive Cardiac Procedures and Outcomes in                    at What Cost,” (Organization for Economic
Frameworks for Health Systems Performance: A
                                                    Patients with Suspected Unstable Angina or                     Cooperation and Development, Paris.
Quest for Effectiveness, Quality and Improvement,
                                                    Myocardial Infarction without Initial ST
International Journal for Quality in Health Care;                                                                  32
                                                    Elevation,” The Lancet, Vol. 352, August 15.                        Guyatt GH Open Med.
Vol. 15, No. 5, pp. 377-398.
                                                    21                                                             33
7                                                      Tu, J, C Pashos, C Naylor, E Chen et al. (1997),               Althabe F, Belizán JF. Caesarean Section: The
 Arah OA, Westert GP, Hurst J, Klazinga NS.
                                                    “Use of Cardiac Procedures and Outcomes in                     Paradox. The Lancet 2006;3 68:1472-3.
(2006), “A conceptual framework for the OECD
                                                    Elderly Patients with Myocardial Infarction in the
Health Care Quality Indicators Project,”                                                                           34
                                                                                                                        OECD, “Quality of Care.”
                                                    United States and Canada,” The New England
International Journal of Quality in Health Care.
                                                    Journal of Medicine, 336:21, May 22.                           35
Sep;18 Suppl 1:5-13.                                                                                                  McGlynn, E, D Naylor, et al. (2004),
                                                      Ho, V, B Hamilton and L Roos (2000), “Multiple               “Comparison of the Appropriateness of Coronary
  Carey, D, B Herring and P Lenain (2009),                                                                         Angiography and Coronary Artery Bypass Graft
                                                    Approaches to Assessing the Effects of Delays for
"Health Care Reform in the United States," OECD                                                                    Surgery Between Canada and New York State,”
                                                    Hip Fracture Patients in the United States and
Economics Department Working Paper No. 665,                                                                        JAMA Vol. 272, No. 12, September 28.
                                                    Canada,” Health Services Research, 34:7 March.
Organization for Economic Cooperation and
Development: Paris.                                                                                                36
                                                     Norregaard, J, C Hindsberger, J Alonso, L                       Bernstein SJ, J Kosecoff, D Gray, JR Hampton,
9                                                   Bellan, P Bernth-Petersen, et al. (1998), “Visual              RH Brook, (1993), “The Appropriateness of the
    OECD, “Quality of Care.”                                                                                       Use of Cardiovascular Procedures: British versus
                                                    Outcomes of Cataract Surgery in the United States,
10                                                  Canada, Denmark and Spain,” Archives of                        U.S. Perspectives,” International Journal of
   Nolte and McKee (2008), “Measuring the Health
                                                    Ophthalmology, Vol. 116, August.                               Technology Assessment in Health Care. Winter;
of Nations: Updating an Earlier Analysis,” Health
Affairs, 27, no. 1: 58-71.                          24
                                                       Norregaard, J, P Bernth-Petersen, L Bellan, J
11                                                  Alonso, et al., (1999), “Intraoperative Clinical                  Gandjour, A, I Neumann, and K Wilhelm-
  Nolte and McKee (2004), Does Health Care
                                                    Practice and Risk of Early Complications after                 Lauterbach (2003), “Appropriateness of Invasive
Save Lives? Avoidable Mortality Revisited, The
                                                    Cataract Extraction in the United States, Canada,              Cardiovascular Interventions in German Hospitals
Nuffield Trust.
                                                    Denmark and Spain,” Ophthalmology 106:42-48.                   (2000–2001): an evaluation using the RAND
   Thorpe, KE, DH Howard, and K Galactionova                                                                       appropriateness criteria,” European Journal of
(2007), "Differences in Disease Prevalence as a       Gatta, G, R Capocaccia, MP Coleman, LA                       Cardio-Thoracic Surgery, Volume 24, Issue 4,
Source of the U.S.-European Health Care Spending    Gloeckler Ries, T Hakulinen, A Micheli, M Sant,                October.
Gap," Health Affairs Web Exclusive, 2 October.      A.Verdecchia and F Berrino (2000), “Towards a
                                                    Comparison of Survival in American and European                  OECD (2008), OECD Health Data, Organization
  Nolte and McKee (2003), “Measuring the Health     Cancer Patients,” Cancer, Vol. 89, No. 4, pp. 893-             for Economic Cooperation and Development,
of Nations: Analysis of Mortality Amenable to       900.                                                           Paris.
Health Care,” BMJ 327: 15 November.                                                                                39
                                                                                                                      Schoen, et al., “Taking the Pulse of Health Care

                                                                                                        Timely Analysis of Immediate Health Policy Issues 12
40                                                  46                                                           52
   Schoen C, R Osborn, SK How, M Doty, and J             Schoen C, “In Chronic Condition.”                          Schoen, C, R Osborn, PT Huynh, et al., “On the
Peugh. (2008), “In Chronic Condition: Experiences                                                                Front Lines of Care: Primary Care Doctors' Office
Of Patients With Complex Health Care Needs, In        Hurst, J and L Siciliani (2003), "Tackling                 Systems, Experiences, and Views in Seven
Eight Countries, 2008,”Health Affairs, 28, no. 1    Excessive Waiting Times for Elective Surgery: A              Countries,” Health Affairs Web Exclusive,
(2009): w1-w16 (Published online 13 November        Comparison of Policies in Twelve OECD                        November 2, 2006, w555–w571.
2008).                                              Countries," OECD Health Working Paper, No.6
                                                    (OECD: Paris.                                                   McGlynn, E (2008), “The Case for Keeping
  Blendon R, C Schoen, K Donelan, R Osborn, C                                                                    Quality on the Health Reform Agenda,” testimony
DesRoches, K Scoles, K Davis, K Binns, and K           Institute of Medicine (2009), America’s                   before the U.S. Senate Committee on Finance, June
Zapert, “Physicians' Views on Quality of Care: A    Uninsured Crisis: Consequences for Health and                3.
Five-Country Comparison,” Based on                  Health Care. Washington, DC: National Academy
Commonwealth Fund 2000 International Health         Press.                                                          Institute of Medicine (2001), Crossing the
Policy Survey of Physicians, The Commonwealth                                                                    Quality Chasm: A New Health System for the 21st
Fund, Health Affairs, May/June 2001.                   McDavid, K, T Tucker, A Sloggett and MP                   Century. Washington, DC: National Academy
                                                    Coleman (2003), “Cancer Survival in Kentucky                 Press.
   Blendon R, C Schoen, C DesRoches et al.,         and Health Insurance Coverage,” Archives of
“Confronting Competing Demands to Improve           Internal Medicine 163:2135-2144.                                OECD (2009), Health Care Quality Indicators
Quality: A Five-Country Hospital Survey,” Health                                                                 Project,, accessed
Affairs, May/June 2004 23(3):119- 35.                 Hadley J, (2003), “Sicker and Poorer—The                   June 14, 2009.
                                                    Consequences of Being Uninsured: A Review of
     Davis K “Mirror, Mirror on the Wall.”          the Research on the Relationship between Health                The Commonwealth Fund, Surveys:
                                                    Insurance, Medical Care Use, Health, Work, and               International Health Policy,
 Nolte and McKee, “Measuring the Health of          Income,” in Medical Care Research and Review 60    
Nations.”                                           3S.                                                          All.aspx?topic=International+Health+Policy,
                                                                                                                 accessed May 15, 2009.
45                                                  51
  Schoen, C and M Doty, “Inequities in Access to       Asch, S, E Kerr, J Keesey, JL Adams, CM
Medical Care in Five Countries: Findings from the   Setodji, S Malik and E McGlynn (2006), “Who is                    OECD, “Quality of Care.”
2001 Commonwealth Fund International Health         at Greatest Risk for Receiving Poor-Quality Health
Policy Survey,” Health Policy, March 2004           Care?” NEJM 354:11, pp. 1147-1156, March 16.

                                                                                                      Timely Analysis of Immediate Health Policy Issues 13
The views expressed are those of the authors and should not be attributed to any campaign or to the Robert Wood Johnson
Foundation, or the Urban Institute, its trustees, or its funders.

About the Authors and Acknowledgements
Elizabeth Docteur is an independent health policy analyst and researcher. She was formerly the deputy head of the health
division at the Organization for Economic Cooperation and Development from 2005 to 2009. Robert A. Berenson is an Institute
Fellow at the Urban Institute.
The authors thank Stan Dorn, Kelly Devers, Elizabeth McGlynn, Sheila Leatherman, and Michael Millenson for their comments
and suggestions. This research was funded by the Robert Wood Johnson Foundation.

About the Urban Institute
The Urban Institute is a nonprofit, nonpartisan policy research and educational organization that examines the social, economic,
and governance problems facing the nation.

About the Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s
largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a
diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change.
For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems
that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care
they need, the Foundation expects to make a difference in your lifetime. For more information, visit

                                                                                   Timely Analysis of Immediate Health Policy Issues 14
You can also read