US health system ranks last compared with peer nations, report finds
Despite Americans paying nearly double that of other nations, the US fares poorly in list of 10 countries
The United States health system ranked dead last in an international comparison of 10 peer nations, according to a new report by the Commonwealth Fund.
In spite of Americans paying nearly double that of other countries, the system performed poorly on health equity, access to care and outcomes.
“I see the human toll of these shortcomings on a daily basis,” said Dr Joseph Betancourt, the president of the Commonwealth Fund, a foundation with a focus on healthcare research and policy.
“I see patients who cannot afford their medications … I see older patients arrive sicker than they should because they spent the majority of their lives uninsured,” said Betancourt. “It’s time we finally build a health system that delivers quality affordable healthcare for all Americans.”
However, even as high healthcare prices bite into workers’ paychecks, the economy and inflation dominate voters’ concerns. Neither Kamala Harris nor Donald Trump has proposed major healthcare reforms.
The Democratic presidential nominee has largely reframed healthcare as an economic issue, promising medical debt relief while highlighting the Biden administration’s successes, such as Medicare drug price negotiations.
The Republican presidential nominee said he has “concepts of a plan” to improve healthcare, but has made no proposals. The conservative policy agenda Project 2025 has largely proposed gutting scientific and public health infrastructure.
However, when asked about healthcare issues, voters overwhelmingly ranked cost at the top. The cost of drugs, doctors and insurance are the top issue for Democrats (42%) and Republicans (45%), according to Kaiser Family Foundation health system polling. Americans spend $4.5tn per year on healthcare, or more than $13,000 per person per year on healthcare, according to federal government data.
The Commonwealth Fund’s report is the 20th in their “Mirror, Mirror” series, an international comparison of the US health system to nine wealthy democracies including Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK, Sweden and Switzerland. The foundation calls this year’s report a “portrait of a failing US health system”.
The report uses 70 indicators from across five main sectors, including access to care, health equity, care process, administrative efficiency and outcomes. The measures are derived from a survey conducted by Commonwealth as well as publicly available measures from the World Health Organization, OECD and Our World in Data.
In all but “care process” – the domain that covers issues such as reconciling medications – the US ranked as the last or penultimate nation. Presenters for Commonwealth noted the US is often “in a class of its own” far below the nearest peer nation.
“Poverty, homelessness, hunger, discrimination, substance abuse – other countries don’t make their health systems work so hard,” said Reginald D Williams II, vice-president of the fund. He said most peer nations cover more of their citizens’ basic needs. “Too many individuals in the US face a lifetime of inequity, it doesn’t have to be this way.”
But recommendations to improve the US health system’s standing among peer nations will not be easy to implement.
The fund said the US would need to expand insurance coverage and make “meaningful” improvements on the amount of healthcare expenses patients pay themselves; minimize the complexity and variation in insurance plans to improve administrative efficiency; build a viable primary care and public health system; and invest in social wellbeing, rather than thrust problems of social inequity onto the health system.
“I don’t expect we will in one fell swoop rewrite the social contract,” said Dr David Blumenthal, the fund’s past president and an author of the report. “The American electorate makes choices about which direction to move in, and that is very much an issue in this election.”
Today, at a White House reception in celebration of Hispanic Heritage Month, President Joe Biden said: "We don't demonize immigrants. We don't single them out for attacks. We don't believe they're poisoning the blood of the country. We're a nation of immigrants, and that's why we're so damn strong."
Biden’s celebration of the country’s heritage might have doubled as a celebration of the success of his approach to piloting the economy out of the ravages of the pandemic. Today the Fed cut interest rates a half a point, a dramatic cut indicating that it considers inflation to be under control. Treasury Secretary Janet Yellen has maintained that it would be possible to slow inflation without causing a recession—a so-called soft landing—and she appears to have been vindicated.
Federal Reserve chief Jerome Powell said: “The labor market is in solid condition, and our intention with our policy move today is to keep it there. You can say that about the whole economy: The US economy is in good shape. It’s growing at a solid pace, inflation is coming down. The labor market is at a strong pace. We want to keep it there. That’s what we’re doing.”
Powell, whom Trump first appointed to his position, said, “We do our work to serve all Americans. We’re not serving any politician, any political figure, any cause, any issue, nothing. It’s just maximum employment and price stability on behalf of all Americans.”
Powell was anticipating accusations from Trump that his cutting of rates was an attempt to benefit Harris before the election. Indeed, Jeff Stein of the Washington Post reported that Trump advisor Steven Moore called the move “jaw-dropping. There's no reason they couldn't do 25 now and 25 right after the election. Why not wait till then?” Moore added, "I'm not saying [the] reduction isn't justified—it may well be and they have more data than I do. But i just think, 'why now?’” Alabama senator Tommy Tuberville called the cut “shamelessly political.”
The New Yorker’s Philip Gourevitch noted that “Trump has been begging officials worldwide not to do the right thing for years to help rig the election for him—no deal in Gaza, no defense of Ukraine, no Kremlin hostages release, no border deal, no continuing resolution, no interest rate cuts etc—just sabotage & subterfuge.”
That impulse to focus on regaining power rather than serving the country was at least part of what was behind Republican vice presidential candidate J.D. Vance’s lie about Haitian immigrants in Springfield, Ohio. That story has gotten even darker as it turns out Vance and Trump received definitive assurances on September 9 that the rumor was false, but Trump ran with it in the presidential debate of September 10 anyway. Now, although it has been made very clear—including by Republican Ohio governor Mike DeWine—that the Haitian immigrants in Springfield are there legally, Vance told a reporter today that he personally considers the programs under which they came illegal, so he is still “going to call [a Haitian migrant] an illegal alien.”
The lies about those immigrants have so derailed the Springfield community with bomb threats and public safety concerns that when the Trump campaign suggested Trump was planning a visit there, the city’s Republican mayor, Rob Rue, backed by DeWine, threw cold water on the idea. “It would be an extreme strain on our resources. So it’d be fine with me if they decided not to make that visit,” Rue said. Nonetheless, tonight, Trump told a crowd in Long Island, New York, that he will go to Springfield within the next two weeks.
The false allegation against Haitian immigrants has sparked outrage, but it has accomplished one thing for the campaign, anyway: it has gotten Trump at least to speak about immigration—which was the issue they planned to campaign on—rather than Hannibal Lecter, electric boats, and sharks, although he continues to insist that “everyone is agreeing that I won the Debate with Kamala.” Trump, Vance, and Republican lawmakers are now talking more about policies.
In the presidential debate of September 10, Trump admitted that after nine years of promising he would release a new and better healthcare plan than the Affordable Care Act in just a few weeks, all he really had were “concepts of a plan.” Vance has begun to explain to audiences that he intends to separate people into different insurance pools according to their health conditions and risk levels. That business model meant that insurers could refuse to insure people with pre-existing conditions, and overturning it was a key driver of the ACA.
Senate and House Republicans told Peter Sullivan of Axios that if they regain control of the government, they will work to get rid of the provision in the Inflation Reduction Act that permits the government to negotiate with pharmaceutical companies over drug prices. Negotiations on the first ten drugs, completed in August, will lower the cost of those drugs enough to save taxpayers $6 billion a year, while those enrolled in Medicare will save $1.5 billion in out-of-pocket expenses.
Yesterday Trump promised New Yorkers that he would restore the state and local tax deduction (SALT) that he himself capped at $10,000 in his 2017 tax cuts. In part, the cap was designed to punish Democratic states that had high taxes and higher government services, but now he wants to appeal to voters in those same states. On CNBC, host Joe Kernan pointed out that this would blow up the deficit, but House speaker Mike Johnson said that the party would nonetheless consider such a measure because it would continue to stand behind less regulation and lower taxes.
In a conversation with Arkansas governor Sarah Huckabee Sanders, his former press secretary, Trump delivered another stream of consciousness commentary in which he appeared to suggest that he would lower food prices by cutting imports. Economics professor Justin Wolfers noted: “I'm exhausted even saying it, but blocking supply won't reduce prices, and it's not even close.” Sarah Longwell of The Bulwark added, “Tell me more about why you have to vote for Trump because of his ‘policies.’”
Trump has said he supports in vitro fertilization, or IVF, as have a number of Republican lawmakers, but today, 44 Republican senators once again blocked the Senate from passing a measure protecting it. The procedure is in danger from state laws establishing “fetal personhood,” which give a fertilized egg all the rights of a human being as established by the Fourteenth Amendment. That concept is in the 2024 Republican Party platform.
Trump has also demanded that Republicans in Congress shut down the government unless a continuing resolution to fund the government contains the so-called SAVE Act requiring people to show proof of citizenship when registering to vote. Speaker Johnson continues to suggest that undocumented immigrants vote in elections, but it is illegal for even documented noncitizens to do so, and Aaron Reichlin-Melnick of the nonprofit American Immigration Council notes that even the right-wing Heritage Foundation has found only 12 cases of such illegal voting in the past 40 years.
Johnson brought the continuing resolution bill with the SAVE Act up for a vote today. It failed by a vote of 202 to 220. If the House and then the Senate don’t pass a funding bill, the government will shut down on October 1.
Republican endorsements of the Harris-Walz ticket continue to pile up. On Monday, six-term representative Bob Inglis (R-SC) told the Charleston City Paper that “Donald Trump is a clear and present danger to the republic” and said he would vote for Harris. “If Donald Trump loses, that would be a good thing for the Republican Party,” Inglis said. “Because then we could have a Republican rethink and get a correction.”
George W. Bush’s attorney general Alberto Gonzales, conservative columnist George Will, more than 230 former officials for presidents George H.W. Bush and George W. Bush, and 17 former staff members for Ronald Reagan have all recently added their names to the list of those supporting Harris. Today more than 100 Republican former members of Congress and national security officials who served in Republican administrations endorsed Harris, saying they “firmly oppose the election of Donald Trump.” They cited his chaotic governance, his praising of enemies and undermining allies, his politicizing the military and disparaging veterans, his susceptibility to manipulation by Russian president Vladimir Putin, and his attempt to overthrow democracy. They praised Harris for her consistent championing of “the rule of law, democracy, and our constitutional principles.”
Yesterday, singer-songwriters Billie Eilish, who has 119 million followers on Instagram, and Finneas, who has 4.2 million, asked people to register and to vote for Harris and Walz. “Vote like your life depends on it,” Eilish said, “because it does.”
Yuval is popular and I've enjoyed his interviews lately. His scientific research has been criticized however – here's an example from Current Affairs:
The Dangerous Populist Science of Yuval Noah Harari
Definitely not me.
In his latest book, “Nexus,” the historian examines the history of information networks and the challenges posed by the AI revolution.
Review by Justin Smith-Ruiu
September 11, 2024 at 9:00 a.m. EDT
A curious blind spot limits the persuasiveness of many recent books warning of the threats and challenges of our AI revolution: They consistently fail to acknowledge the extent to which they are themselves already reflective of the automation of so much of contemporary life. Yuval Noah Harari’s latest book is no exception, as indeed at several points it betrays what at least looks to be an assembly-line process behind its creation.
I do not know how many humans, machines or collectivities of both had a hand in bringing Harari’s “Nexus: A Brief History of Information Networks From the Stone Age to AI” into the world in its final form. But it does not give the overall impression of having been produced by a singular mind, laboring away in seclusion to deliver to the world its original insights.
That said, the elevator pitch version of the book is a good one: It is a history of human information networks, broadly conceived to include communication forms from text messages to smoke signals, markings on cave walls, and indeed face-to-face speech or gesture. This history is related from a perspective sufficiently zoomed out to reveal both the real continuities and the surprising discontinuities between, say, cuneiform clay tablets and iPhones. Harari ultimately comes around to laying out his concerns about the rise of AI, but it’s never totally clear what worries him, even if he frets that whatever it is threatens to change the nature of human consciousness for the worse.
This latest book builds, of course, on Harari’s string of tremendous successes, and it surely is a reflection of this success that the latest offering has the air of a big-budget production with several hands contributing to its manufacture. Harari, a scholar of the Middle Ages by training, has largely cornered the market on popular explorations of “big history,” a trend within academic history that does not limit itself to expertise and close reading of archival sources from a narrow period, but rather considers all of human history within its vastly larger context, which includes not just the prehistory of Homo sapiens but also primate evolution, the origins of life and even the big bang. Harari’s previous work, especially “Sapiens: A Brief History of Humankind” (2011), has excelled in delivering to a mass readership some idea of how much we share with human beings vastly removed from us in time. With “Nexus,” Harari’s purpose is to look at humanity’s future prospects, which are, he believes, significantly compromised by our most recent information technologies.
In the book’s opening section, Harari sets out to refute what he calls the “naive view of information.” This is the idea that when humans gather more information, they have a greater share of truth, which will in turn bring them greater wisdom and greater power. To the contrary, Harari argues, there is no correlation at all between information, truth and the ability to hold sway over other people. What binds human information networks together is not primarily the truth but stories. This is why religions have been so successful over the millennia, even if they seem ripe for disproving. Religions “work” not because they convey the truth but because they keep a large and often widely dispersed network of people connected, both to one another and to the story they all tell.
The history of information revolutions bears this thesis out. A naive information theorist might suppose that the Gutenberg revolution led to a sharp decrease in the circulation of misinformation. Yet it did no such thing, Harari writes. While it did enable the publication of scientific treatises, it also facilitated the spread of wild conspiracy theories, futile sectarian hairsplitting and such travesties as the early modern European witch hunts.
This attempt at a grand history of narrative begins to break down, however, when Harari insists on understanding narrative in biological terms. Harari has been much criticized, especially in academic circles, for repeating the great sin of E.O. Wilson, Jared Diamond and others: In their eagerness to portray human individuals and human society as part of a natural world that includes, for example, ants, they understand human morality as little more than a secondary consequence of strictly natural forces at work at a deeper level.
There is much in “Nexus” that seems to justify this association. In one particularly weak section, Harari cites animal precedents for many classic human myths and folk tales. It is true that the strongest of a batch of tiger shark fetuses will devour its siblings in utero — adelphophagy, it’s called. But Harari takes such scientific observations as a reason to conclude that stories such as the Ramayana that feature sibling rivalry may appropriately be described as “biological dramas.” One might just as easily look at the phenomenon of “loon fallout,” where migratory birds sometimes fall from the sky to their death as a result of challenging atmospheric conditions, and conclude that the Sandra Bullock film “Gravity” (2013), about a space vessel in orbit being pulled perilously down to Earth, is likewise a “biological” and a “physical” drama.
Indeed, pretty much anything that happens to, or is done by, a human being has analogues in the animal and broader natural world. But what a story is, and the reason we tell stories, cannot be captured by appeals to biology, or indeed to the physics of planetary gravitation. The difference between a tiger shark eating its siblings and a human committing fratricide is that the latter is inevitably followed by court proceedings, memoirs, conversations with kin. This is what makes human fratricide into “fratricide,” while using that word in reference to tiger sharks is only a façon de parler. This is also, though Harari does not seem to see it, what matters in the stories he calls “biological dramas,” and it is also the thing that matters in stories that have no obvious animal counterpart.
Harari’s view grows more muddled still when he takes up the question of artificial intelligence. For him, Assyrian clay tablets, Gutenberg’s presses and all the other information technologies that have brought us to the present moment could record and propagate only the information that humans wished to see recorded and propagated. By contrast, Harari maintains, AI itself “decides” what information circulates through our networks.
The notion of “decision” is central to his argument. In a key chapter opening Part II, “The New Members: How Computers Are Different From Printing Presses,” Harari uses “decision,” in its noun or verb form, upward of 13 times, by my count, to describe what machines now do, as well as related terms such as “choose” and “act.” This vocabulary implies that computers possess what philosophers call “intentionality” — the capability to follow courses of action that emerge from within themselves rather than from external mechanical pressures or from algorithmic “if-then’s.”
Eventually, seven pages into the chapter, Harari does acknowledge that some readers will have a problem with his decision to describe the way machines act as essentially identical to the way humans do. But he bites the bullet confidently — I suppose to his credit, in a perverse way — and simply insists that any purported difference here is an illusion. After all, he notes, “human soldiers are shaped by their genetic code and follow orders issued by executives, yet they can still make independent decisions.”
That’s a pretty quick and easy way to dispatch the enormous problem of the differences between human agency and machine intelligence. No matter what your theory of where morality comes from, it is a fact that we regularly put on trial soldiers who commit massacres, and the language used to describe what they have done is laden with moral notions such as culpability. If an AI were to cause a massacre, it would, by contrast — one hopes — simply be decommissioned. At worst, the humans who developed it might face prosecution.
Reading Harari, I sometimes thought of Henry Miller’s very different book titled “Nexus.” To a friend who had harshly criticized the trilogy of which “Nexus” is a part, Miller replied: “If it was not good, it was true.” Miller has in mind here the sort of “truth” that is experienced as an inner feeling and that attaches to the hard work of honestly exploring one’s own depths. This is work that no machine has yet given any evidence of being able to perform.
This great difference between human beings and machines — that we can look within while they cannot — is also what explains why soldiers who decide to commit massacres can be held legally and morally culpable, even if bloodthirstiness is written into our DNA. This is a difference that is of little interest to Harari, who leaves us uncertain as to what exactly he thinks is being threatened by the rise of the machines. If our consciousness really is ontologically on par with AI, if AI makes “decisions” just like we do, but better, then it is not really clear what is worth preserving about our particular sort of agency in the world.
Miller’s “Nexus,” by contrast, gives us a fairly compelling account of what makes us special: an understanding that interest in truth can be a moral project. Harari has nothing of the kind to offer. Nothing, that is, besides a fuzzy batch of misguided animal fables and often-unpersuasive reflections on technology. In the end, this is a book about AI that shares in the prevailing spirit of the era of ChatGPT. This is not an accusation that the author turned to that new resource to generate his book for him. It is only an acknowledgment that a lucid reader cannot help but see just how reflective this book is of the same worrisome trends that Harari, along with the entire team sustaining the Harari industry, proposes to expose and critique.
Justin Smith-Ruiu’s most recent book is “The Internet Is Not What You Think It Is.” He is the founding editor of the online magazine the Hinternet.
I suspect there might be a bit of jealousy – academia is known for that sort of thing.
