Nick McClary

Nick McClary

Over the past few columns we’ve covered a 2018 study published in the Journal of the American Medical Association (JAMA) that compared health care in the U.S. to ten other high-income countries. If you missed those columns, you can read them on For review, the study revealed what many studies have before it: the U.S. spends nearly twice as much for health care as the average of other high-income countries and we consistently have the worst outcomes. These outcomes include life expectancy, maternal and infant death during childbirth, and more.

To close the series, I want to examine one last objection I often hear regarding changes to our health care system. This objection typically goes, “you can’t compare us to other countries because the U.S. population is so much different.” Usually, it is argued either that we are different by size, obesity, and/or illegal immigration.

First, the U.S. population is undoubtedly larger than most other countries. In the JAMA study, for example, the U.S. had a population of 323 million at the time of the study with Japan and Germany rounding out the top three at 127 million and 83 million, respectively. The lowest populations in the study included Sweden, Switzerland, and Denmark at 10 million, 8 million, and 6 million, respectively. While the U.S. population is larger than every other country in the study, we have to acknowledge the large differences between other countries as well.

Japan and Germany, for example, have a far larger population that Switzerland and Denmark. However, Germany and Japan were in the bottom half of health spending per capita and Japan ranked best in terms of life expectancy and infant mortality. Japan and Germany both implement universal health coverage systems with relative success compared to the U.S. as do the other countries in the study. While there could be difficulties encountered while implementing universal health coverage in the U.S. due to the size of the population, population size was not a strong predictor of health care success in the study and I believe is a weak argument for preventing large-scale change in our health care system.

Next, obesity plays a big part in health outcomes and health spending and, of course, the U.S. had the highest overweight or obesity rate at 70.1%. However, the rest of the top 5 were all at 60% or greater. Japan finished at the bottom with only 23.8%, which is probably a strong reason why they had the highest life expectancy in the study. Obesity alone, though, doesn’t appear to be an absolute predictor for higher costs and poorer health outcomes. Australia, for example, had the second highest overweight/obesity rate, yet was in the top (best) three for life expectancy and most of the infant and maternal mortality outcomes. All of this while ranking fourth best for mean health spending per capita. Obesity absolutely plays a role in health care costs and outcomes but from looking at this study, I’m not sure we can blame obesity as the primary driver of our increased costs and poor outcomes.

The last common variant of this argument I hear is typically, “we can’t afford universal health care because we can’t afford to take care of illegal immigrants.” Universal health care does not mean care for illegal immigrants though. From my research into other country’s health care systems, it appears the interaction at the doctor’s office is very similar to ours: you show up with your insurance card to prove you have coverage and then receive care. In addition, this argument misses that we are already taking care of illegal immigrants. It is illegal for a hospital that receives Medicare funding to turn anyone away when they go to the emergency room. We all pay for them to receive care in the form of higher hospital costs for us. Besides, an illegal immigration problem is not a good reason to fail at fixing our health care system.

Now, I don’t want it to appear that I think that any of these things don’t hold merit. They absolutely do. Obesity is undoubtedly a driver of increased costs and poor outcomes. The size and diversity of our population definitely adds another layer to consider when comparing our country to others. However, the biggest variable that stands out to me is the setup of our health care system including much lower health insurance coverage compared to other countries.

To conclude this series, our country overall has the worst health outcomes and spends by far the most money compared to other countries. I believe the biggest reason for this is our health system structure. The best system that I can see from other countries is a national health insurance system (not single payer) where every person is mandated to have health insurance coverage, every person able to pay for insurance pays into the system, and all insurance companies are not-for-profit.

Lastly, while this series has been more about the shortfalls of our health system I would be remiss to not recognize that we have the best medical schools in the world and are the center of research and innovation for new treatments. Any changes to the system have to weigh the impacts on research and innovation thus a gradual transition to universal coverage (not single payer) is likely the best bet.

Nick McClary earned his doctor of physical therapy from the University of Tennessee Health Science Center. He also holds a masters in business administration. He is a Georgetown County native. Send him your health and fitness questions at: