In high school, 66 percent earns a “D” -- not quite bad enough to fail, but still dismally below average.

And 66 is exactly the score the U.S. health system received in the most comprehensive grading to date of areas such as access to care, quality, cost, and efficiency.

The score comes from the Commonwealth Fund, a nonpartisan health policy think tank in Washington.

The group evaluated more than three dozen different measures to come up with a composite score for American health care in relation to top-performing nations -- or, in some cases, individual states.

The categories included areas such as long, healthy, and productive lives (the U.S. scored a 69 on this), quality (71), access (67), efficiency (51), and equity (71).

“Some might ask if it is a ‘C,’ [is it] an ‘F’?” says James Mongan, MD, chairman of the commission that issued the report. “To me … the message is clear. We can do much better and we need to do much better.”

Countless reports have detailed how the United States lags other nations -- some industrialized, and some not-so-industrialized -- in bellwether statistics such as infant mortality and overall life expectancy.

But it's not for lack of money. The U.S. spends a far bigger chunk of its economy on health care than any other nation, but has less and less to show for it.

The U.S. now spends more than $6,000 per capita on medical care, compared with $2,000 to $3,000 spent by the U.K., Germany, Canada, and France.

But a major lack of efficiency and equity lead to rampant waste that squanders resources that could be spent improving health, the commission’s report suggests.

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45.8 Million in U.S. Now Lack Health Insurance

Fragmented Care

A third of the adult population under 65 lacks adequate health insurance, forcing them to seek more expensive care in hospital emergency rooms and other places.

That often precludes what the preventive care experts consider the gold standard of health care.

The report stresses that the U.S. is not without quality, efficient care.

For example, the nation’s best hospitals discharge 90 percent of heart attack patients with written educational materials containing advice on how to avoid another attack. Meanwhile, the national average is only 50 percent.

“The challenge, I think, is spread. It’s a very fragmented system,” says Maureen Bisognano, a member of the commission and executive vice president of the Institute for Healthcare Improvement, a New York-based policy group.

Among the report’s other findings:

Hospital and doctor care for heart attacks, hip fractures, and colon cancer now cost a median of $26,000, though quality is largely unrelated to how much is spent. The U.S. spends more than 3 times what France does administering health insurance, as a percentage of overall medical spending. Fewer than 20 percent of U.S. doctors use electronic medical records, among the lowest rates in industrialized countries. 1/3 of American adults have outstanding medical debt.

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Appetite for Reform?

The commission urged U.S. policy makers to take broad steps to guarantee universal access to health insurance.

But that goal has proven politically hazardous, most recently in 1994, when the White House tried and failed to execute broad health insurance reforms, led by Sen. Hillary Rodham Clinton, D-N.Y., then the first lady.

Ever since, lawmakers have shied away from comprehensive reforms in favor of smaller, incremental steps.

Medicare is beginning to use financial incentives to convince hospitals, nursing homes, and others to report quality information to the public.

And the government is slowly shepherding the development of electronic medical records like those already widely used in many European countries -- another of the commission’s recommendations.

But experts warned that, overall, reforms are moving too slowly to keep up with a rapidly aging U.S. population.

“The security of a healthy nation is at stake. Actions are urgently needed,” says Cathy Schoen, the commission’s research director.

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By Todd Zwillich, reviewed by Louise Chang, MD

SOURCES: Commonwealth Fund National Scorecard on U.S. Health System Performance, Sept. 20, 2006. James Mongan, MD, chairman, Commonwealth Fund Commission on a High Performance Health System. Maureen Bisognano, executive vice president, Institute for Healthcare Improvement; member, Commonwealth Commission. Cathy Schoen, senior vice president for research and evaluation, Commonwealth Fund.