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Spending more, feeling worse: medical care expenditures and self rated health
  1. M S Kaplan1,
  2. B H McFarland2,
  3. J T Newsom3,
  4. N Huguet4
  1. 1School of Community Health, Portland State University, USA
  2. 2Department of Psychiatry, Oregon Health and Science University, USA
  3. 3Institute on Aging, Portland State University
  4. 4School of Community Health, Portland State University
  1. Correspondence to:
 Dr M S Kaplan
 School of Community Health, Portland State University, PO Box 751, Portland, Oregon 97207, USA;

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International comparisons show that the United States spends more on health care than other industrialised nations.1 According to 2000 data, the United States led the way in per capita healthcare spending at $4631, more than double the Organization for Economic Cooperation and Development (OECD) median of $1983 (in purchasing power parities based on the US dollar).2

Despite massive medical care expenditures, the US lags behind its industrialised counterparts in major indicators of population health. For example, researchers have reported that the US has lower life expectancy at birth and higher maternal and infant mortality.3,4 Equally important, cross national studies consistently show that US citizens are less satisfied with their healthcare system than Canadians or Europeans.2

Another key indicator of population health, not previously used in cross national comparisons, is self rated health (SRH). As a broad measure of health status, SRH focuses on a person’s subjective perceptions of their health. This popular single item measure on both sides of the Atlantic is related to mortality and to rates of recovery from episodes of illness across the life span.5 Drawing on comparable datasets, we asked whether the prevalence of poor self rated health is higher in the US than in Canada or the European Union.

Data (weighted) were obtained from the 1996/97 Canadian National Population Health Survey—NPHS (n = 66 435), the 1996 US National Health Interview Survey—NHIS (n = 63 402), and the 1996 European Commission Eurobarometer (n = 16 235). Age specific self rated health was assessed using the NPHS and NHIS questions “In general would you say your health is excellent, very good, good, fair, or poor?” In the Eurobarometer, self rated health was assessed with “Over the last 12 months, would you say your health has on the whole been very good, good, fair, bad or very bad?” In our analysis, “poor health” refers to responses of “fair” or “poor” in the NPHS and NHIS and to “bad” or “very bad” in the Eurobarometer. Data for national healthcare expenditures were obtained from the OECD (

Figure 1 shows that the US, Canada, and the European Union (EU-15) differ in terms of the prevalence of poor SRH. While outspending Canada on a per capita basis by 1.8 to 1 and the EU-15 by 2.2 to 1,6 the US had higher prevalences of poor self rated health across the age span.

Overall, Canadians and Europeans spend about half of what Americans spend on health care yet feel better in nearly all age categories. As an approximate significance test for differences in average SRH, we computed t values pooling the standard errors across studies. The results indicated there were no significant differences between samples at the youngest age groups, but for middle age and older groups, beginning with age 30, Americans had significantly (p<0.05) higher prevalence of poor SRH. Interestingly, disparities in SRH seem to increase with advancing age, underscoring the need for better care and more complete coverage across the entire life span.

Our study confirms and complements earlier research indicating that the expensive and technologically advanced healthcare system in the US does not yield population health outcomes (including SRH) comparable to those in countries with much lower spending whether measured per capita or as a percentage of gross domestic product (GDP).2,3,7 Unequal and uncoordinated provision of care along with other inefficiencies in the US health system7 may explain why Americans spend more but feel worse.

Figure 1

National healthcare expenditures and self rated health. Data sources: National Population Health Survey 1996–97 (Canada), National Health Interview Survey 1996 (US), and European Commission Eurobarometer 1996 (EU-15). *Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, and United Kingdom.


Eurobarometer and National Health Interview Survey data were made available through the Inter-university Consortium for Political and Social Research. All computations on the National Population Health Survey were prepared by Portland State University, and the responsibility for the use and interpretation of these data is entirely that of the authors.