The Cleveland Observer
Comparing Performance in 10 Nations, the Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System provides a sobering analysis of the U.S. health care system compared to nine other high-income countries. The eighth edition of the report, which examines access to care, health outcomes, administrative efficiency, and equity, highlights a glaring disparity: despite spending significantly more on health care than any other country, the U.S. ranks last overall.
The findings have particular implications for urban communities in the United States, where access to affordable, high-quality health care remains a critical issue. In Cleveland and other cities, residents face numerous barriers to receiving timely care, exacerbating health disparities and economic instability.
Surveys indicate that health care is among the top priorities for voters in the November presidential election. Vice President Kamala Harris has pitched building on the Affordable Care Act, commonly known as Obamacare. Former President Donald Trump has given little detail about his health care vision; his running mate, JD Vance, has suggested deregulation.
How the U.S. Compares
The Mirror, Mirror 2024 report analyzed health systems in 10 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the U.S. While every country has strengths and weaknesses, the U.S. is an outlier in both health outcomes and spending. Despite investing more than 16% of its gross domestic product (GDP) in health care—compared to around 10% in other nations—the U.S. has worse health outcomes than all its peers.
In urban areas, the challenges are acute. Access to affordable care is hampered by fragmented insurance systems, high deductibles, and extensive out-of-pocket costs. As of 2023, 41% of Americans reported spending $1,000 or more on health care out of pocket. For residents of cities like Cleveland, where poverty rates are high and access to primary care is limited, the cost of care can deter people from seeking necessary medical attention.
The Impact on Urban Communities 
The report identifies access to care and equity as critical areas where the U.S. continues to lag. Cities with large, underserved populations, including Cleveland, experience significant disparities in health care access. The U.S. ranks poorly in equity, with large differences in health care experiences between individuals with above-average and below-average incomes.
While some countries, like Germany and Australia, have systems in place to cap out-of-pocket costs, ensuring affordability for all citizens, the U.S. lacks similar safeguards. The Affordable Care Act (ACA) has made strides in reducing the number of uninsured, but 26 million Americans remain without coverage, and many more are underinsured. This leaves urban residents disproportionately burdened by the cost of care.
For Clevelanders, who often rely on safety-net health services, these financial barriers lead to skipped medical appointments, unfilled prescriptions, and worsening health conditions. The lack of affordability has ripple effects across urban communities, deepening economic inequalities and limiting social mobility.
The Administrative Burden
Another key finding in the Mirror, Mirror 2024 report is the U.S.’s inefficiency in health care administration. The country ranks last in administrative efficiency, with doctors and patients frequently reporting challenges related to billing, insurance claims, and paperwork. In cities like Cleveland, this administrative complexity further strains the health system.
The U.S. health care system, with its multitude of insurance plans and varying coverage options, places a heavy burden on both patients and providers. This inefficiency leads to delays in care and increases the likelihood that patients will avoid seeking treatment due to confusion or frustration with the system.
Health Outcomes and Public Health Concerns
One of the most alarming findings in the report is the poor performance of the U.S. in health outcomes. Life expectancy in the U.S. is more than four years lower than the average of the other countries studied, and the U.S. has the highest rates of preventable deaths. The ongoing substance abuse crisis, combined with high levels of gun violence, disproportionately affects urban areas, exacerbating the already poor health outcomes.
COVID-19 further exposed weaknesses in the U.S. health system. The report notes that countries like Australia and New Zealand, which implemented swift public health interventions, managed to mitigate the pandemic’s impact far better than the U.S. In urban communities, where social determinants of health such as housing, income, and education are already inequitable, the pandemic’s toll has been even more devastating.
The Way Forward for U.S. Cities
The report emphasizes that improving the U.S. health care system will require substantial policy reforms, particularly to address the needs of urban communities. Key areas for reform include:
Expanding Coverage and Reducing Costs: The U.S. needs to further reduce the number of uninsured and underinsured people. This could be achieved through continued expansion of Medicaid, increased subsidies for ACA marketplace plans, or even more radical reforms like a public option or single-payer system.
Investing in Primary Care: Primary care shortages, particularly in urban areas, contribute to the poor health outcomes seen across the U.S. The report recommends investing in primary care providers and improving compensation to attract more doctors to underserved communities.
Addressing Social Determinants of Health: Public health initiatives must go beyond the health care system itself and address the broader social issues that affect urban populations, such as poverty, housing insecurity, and education. By focusing on these areas, cities like Cleveland could see improvements in overall health outcomes.
Reducing Administrative Complexity: Simplifying the U.S. health care system, reducing the number of plans and insurance complexities, would make the system more navigable for patients and providers alike. This could lead to greater efficiency and fewer barriers to care.
Conclusion
The Mirror, Mirror 2024 report highlights significant shortcomings in the U.S. health care system, with particularly stark consequences for urban communities. In cities like Cleveland, where access to affordable care is already limited, the financial burden, administrative inefficiencies, and poor health outcomes exacerbate long-standing inequities. Comprehensive reforms are essential to improving the health and well-being of America’s urban populations.
