Two years after its landmark report on U.S. health care, the Commonwealth Fund has released an update.  Vast, careful, detailed, and thoughtful, it paints a difficult picture. 

Most of the data is from 2006; the data of the 2006 study was mostly from 2004.  Over that two-year period, a few specific areas improved somewhat – treatment markers for pneumonia, heart failure, and heart attack, for instance, ticked up noticeably once the federal government started publishing them on its Hospital Compare site.  And twice the percentage of doctors (28% vs. 14%) used electronic medical records.

But even the most encouraging numbers pale in comparison with the numbers from Europe, Japan, Australia, and elsewhere.  And in most areas, especially access and efficiency, the U.S. system falls far behind other countries – even farther behind than it did two years ago, as many other countries are using new information technologies and centralized systems to reap substantial improvements over short periods of time.  Just take one measure that could stand for many.  The World Health Organization takes a measure called "preventable mortality" that counts deaths below the age of 75 from conditions that are amenable to medical treatment.  It counts deaths from heart attacks and diabetes, for instance, not deaths from war or natural disaster.  The Commonwealth Fund report looked at these numbers from 1997/1998 and 2002/2003 (the latest year available) for 19 of the most-developed countries.  Though all 19 countries improved their grade measurably in those five years, the United States ended up in last place, behind Portugal and Ireland.

It's an astonishing picture, and a sobering one.  Yet the report, and the various industry figures who commented on it in a New York Times article, missed the opportunity to ask the big, systemic question:  Why do we get such a poor return for so much money?  What is the systemic twist that means we don't get what we think we are paying for?  Both presidential candidates and both parties seem to be proposing only minor adjustments to the current system, yet the differences between ours and other systems are jaw-droppingly vast.  We pay twice as much per person as most other systems.  We will pay, among other things, around $180 billion to health plans for administrative costs (such as marketing, processing, and profit) – far more than it would take to underwrite health insurance for all uninsured Americans.  That comes to 7.5% of all national health expenditures.  Even trimming that to the 5% common in other systems with lots of private insurance (like Switzerland and Germany) would free up $60 billion without any other change.  Other statistics on cost and quality suggest that standardization of care, just imitating the low-cost, high-quality areas of the country as medicine is currently practiced, could save from 10 percent to 30 percent or more of what we now pay.

Clearly, across the system, we are not paying people and organizations to provide us with high-quality, comprehensive, sensible health care at the lowest possible cost.  If you ask yourself, Then what are we paying people to do?  The shortest route to a sensible answer is to look at what they are actually doing.  People and organizations, in aggregate, are pretty good at figuring out what they are really being paid to do – and they do it.