America's terrible health care system

Welcome to Wonkbook, Ezra Klein and Evan Soltas's morning policy news primer. To subscribe by e-mail, click here. Send comments, criticism, or ideas to Wonkbook at Gmail dot com. To read more by Ezra and his team, go to Wonkblog.

As often happens, the prospect of reform has led to a sudden eruption of affection for the health-care status quo. The airwaves are alive with impassioned protests against the idea that anyone might change a market that relies on discriminating against the old, the sick, the female, and people who don't read the fine print of insurance policies. This is the best health care in the world, you know.

The Commonwealth Fund's latest survey of international health systems stands as a refreshing reality check. Their data compares the U.S. to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, and the United Kingdom on a host of health-system measures, both objective (like diabetes amputations) and subjective (like satisfaction). The results are a reminder of why reform is so badly needed.

Start with cost. Americans spend 17.7 percent of GDP on health care. No one else spends even 12 percent. Let's make that more concrete: If Americans only spent 12 percent of GDP on health care we would have saved $893 billion in 2012.

The reason isn't that Americans get more health care than anyone else. We have more uninsured than anyone else. We have fewer physicians per capita than anyone but the Japanese. We go to the doctor less often than anyone but the Swiss. We don't have more hospital beds than other developed countries, and when we do go to the hospital, we don't stay longer.

But we do pay more for the privilege. The average hospital stay costs more than $21,000 in the U.S. It costs only $8,363 in France. (See ' Why an MRI costs $1,080 in America and $280 in France'.) Administrative costs in the U.S. are more than three times higher than in most nations with universal health-care systems.

Nor do we receive better, swifter, or more flexible service. For all the talk of waiting lines in foreign countries, America is second only to Canada in the number of adults reporting difficulty getting a next-day appointment when they're sick. Americans also find it unusually difficult to get after-hours care, and by a wide margin, Americans are more likely than residents of any other developed country to report that cost is a barrier to getting health care. Oh, and Americans are more likely to report being the victim of a medical error.

There are some bright spots for the American medical system. Residents of the U.S. find it easy to get quick appointments with specialists, and only citizens of France, Germany, the Netherlands, and Switzerland report that they can get schedule elective surgeries as rapidly.

The data on quality, however, is more mixed. Americans lead the world in five-year survival for breast cancer. But we lag competitor nations on diabetes amputations. And we're only middle-of-the-pack on surviving myocardial infractions (a common kind of heart attack).

This is, to say the least, a pretty poor performance for a health-care system that costs so much more than any other. And it shows up in public surveys. Only 29 percent of Americans say the health-care system works well and only minor changes are necessary. That's lower than anywhere save Australia. Meanwhile, 29 percent say the system needs to be completely rebuilt. That's higher than anywhere else in the survey, period.

Change is painful. But the status quo is a disaster.

Wonkbook's Number of the Day: 1.3 million. That's how many people will lose their unemployment benefits in the last week of December, when the federal emergency extension expires.

Wonkbook's Graph of the Day: Everything you need to know about the Obamacare 'fix' in one flowchart.

Wonkbook's Top 5 Stories: (1) low expectations for Healthcare.gov; (2) what if things never get better?; (3) does the NSA like the taste of backlash?; (4) bringing back the nuclear-option DEFCON; and (5) gay marriage's finish line.

1. Top story: Healthcare.gov just wants to be a B-student

@JohnJHarwood: What Obamacare opponents rarely acknowledge: insurance 'cancellation' letter does NOT mean recipient can't buy insurance. Before ACA, it did

Explainer: Here's where your state stands on Obama's cancellation fix. Sarah Kliff and Lena H. Sun in The Washington Post.

@MichaelRStrain: It is *painful* to hear pundits claim that 'conservatives' don't have an Obamacare alternative. Conservative intellectuals do; pols don't.

Interview: Mike Kreidler, Washington's insurance regulator who turned down Obama's Obamacare fix. Sarah Kliff in The Washington Post.

Explainer: Local coverage of Obamacare has been brutal. Andrew Kaczynski in BuzzFeed.

@KipPiper: Cost sharing subsidies in Obamacare exchange plans are subject to 2014 sequester (~ 7.2% cut). Premium subsidies exempt.

CARNEY: Blame and subsidize. 'In waiving the part of Obamacare that outlaws many insurance plans, Obama tried to shift blame for any cancellations to the insurers. But on Friday, he met with representatives from these same companies, sparking speculation that he had plans to offer them subsidies to help smooth Obamacare's rocky rollout. This seeming schizophrenia is standard fare in the love-hate relationship between Obama and the insurers.' Timothy P. Carney in The Washington Examiner.

Music recommendations interlude: Top opinion M. Ward, 'Chinese Translation.' 2. What if things never get better? Today in depressing thoughts.

Aaron Carroll schools us all interlude: In this awesome video, he explains the science behind the HPV vaccine.

3. Does the NSA like the taste of backlash?

In memoriam interlude: Doris Lessing, Nobel laureate author.

4. Bringing back the nuclear-option DEFCON PSA interlude: 5. When you know gay marriage is nearing the finish line Is this an alcohol commercial or an anti-drinking ad? Or both?

Adorable animals returns interlude: So many golden retrievers.

Reading material interlude: The best sentences Wonkblog read today.

Et Cetera

Wash. insurance regulator supports Obamacare - and rejected Obama's 'fix.' Here's why. Sarah Kliff.

Here's what's wrong with Rand Paul's 'Audit the Fed' bill. Mike Konczal.

Longread: Washington State discovers that it's not so easy to create a legal marijuana economy. Patrick Radden Keefe in The New Yorker.

The GOP's 'Agenda 2014' is literally blank. Jake Sherman and John Bresnahan in Politico.

Meanwhile in foreign policy, the U.S. may soon begin training Libyan security forces. Julian E. Barnes in The Wall Street Journal.

Wonkbook is produced with help from Michelle Williams.

Immigrant rules to be relaxed for military kin. Miriam Jordan in The Wall Street Journal.

Got tips, additions, or comments? E-mail me.