The past week has brought a lot of heat if not light to the ongoing battle over health care reform in the United States. On Tuesday, President Obama unveiled a "Patients Bill of Rights" touting new consumer protections. Meanwhile, even as polls show the Affordable Care Act is becoming more popular, House Minority Leader John Boehner pronounced it a failure despite its provisions having not taken effect. But as a new Commonwealth Fund study revealed, the bottom line is unchanged. The United States' health care system is still the worst among industrialized nations. And, as it turns out, its performance is most pitiful where Republicans poll best.

Back in 2000, the U.S ranked a dismal 37th in an eye-opening if controversial World Health Organization assessment of global health care. Then in 2003, a Commonwealth Fund report revealed America ranked last across virtually every category of health care cost, access, efficiency, quality and lifestyles compared to Australia, Britain, Canada, Germany and New Zealand. Three years later in 2006, another Commonwealth Fund study ("U.S. Health System performance: A National Scorecard") of 19 industrialized nations ranked the U.S. 19th in infant mortality, 15th in preventable mortality and 14th in the use of electronic medical records, all despite spending far and away the greatest percentage of GDP on health care. Relative to other comparable countries surveyed, the U.S. has the greatest incidence of medical and prescription errors, highest emergency room waiting times and ranks near the bottom in duplicate medical tests. The U.S. spends 7.3% of its health dollars on administration and insurance, compared to just 1.9% in France, 2.6% in Canada, and 3.3% in the UK.

Now, in "Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update," the latest Commonwealth Fund assessment finds little has changed:

Among the seven nations studied--Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States--the U.S. ranks last overall, as it did in the 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, coordination, efficiency, and equity. The Netherlands ranks first, followed closely by the U.K. and Australia. The 2010 edition includes data from the seven countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care..

The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Health reform legislation recently signed into law by President Barack Obama should begin to improve the affordability of insurance and access to care when fully implemented in 2014. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical homes." Without reform, it is not surprising that the U.S. currently underperforms relative to other countries on measures of access to care and equity in health care between populations with above-average and below-average incomes.

The table above (and the accompanying Commonwealth Fund chart pack and interactive comparison) summarizes an the critical condition of the grotesquely expensive and shockingly underperforming American health care system.

While not highlighted in this report, the Commonwealth Fund has detailed elsewhere the tremendous disparity in health care performance within the United States. Unsurprisingly, health care is worst in those reddest of red states, especially in the South.

In October, the Commonwealth Fund released its 2009 state health care scorecard. There, too, Mississippi led the Republican south in providing dismal health care. Again, while nine of the top 10 performing states voted for Barack Obama in 2008, four of the bottom five (including Arkansas, Mississippi, Oklahoma and Louisiana) and 14 of the last 20 backed John McCain. (That at least is an improvement from the 2007 data, in which all 10 cellar dwellers had voted for George W. Bush three years earlier.)

The diagnosis isn't pretty for Republicans committed to denying the health care their constituents need most of all. A 2009 UnitedHealth study looked at "22 indicators of health, including everything from how many children receive recommended vaccinations, to obesity and smoking rates, to cancer deaths" and similarly found that nine of the top 10 healthiest states voted for Barack Obama in 2008. Conversely, 9 of the 10 cellar dwellers backed John McCain in 2008; four years earlier, the 15 unhealthiest states all voted for George W. Bush for President.

Despite the grim findings of its research, the Commonwealth Fund concludes that thanks to President Obama and Democrats in Congress, all is not lost:

Newly enacted health reform legislation in the U.S. will start to address these problems by extending coverage to those without and helping to close gaps in coverage--leading to improved disease management, care coordination, and better outcomes over time.

That realization is increasingly dawning on the American people. As Gallup found in a poll released this week, the Affordable Care Act is popular among everyone but seniors. Which comes as no surprise, given the centerpiece of the Republican opposition to any health care reform centered on scaring the bejesus out of the elderly. (That is particularly galling coming from the Party which tried to kill Medicare in the 1960's, wanted to gut it in the 1990's, and is hoping to privatize it now.)

The United States may have perhaps the worst health care system among the industrialized nations. But despite John Boehner and the GOP's worst, Americans increasingly understand it doesn't have to be that way.

(This piece also appears at Perrspectives.)