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U.S. Health System Ranks Last Among Wealthy Countries

Why the lackluster performance? A new Commonwealth Fund report explains.

By Liz Seegert

The United States spends more on health care than any other wealthy country. Yet, it ranks dead last compared with 10 others overall as well as for affordability, equity and health care outcomes (it ranked next to last for administrative efficiency). A new report from The Commonwealth Fund shows that reducing the income gap between high and low earners plays a significant role in providing high quality, equally accessible health care.

U.S. Health System
Credit: Adobe Stock

Despite making meaningful progress to insure millions of people under The Affordable Care Act, the U.S. health system costs more and performs worse than Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom, based on 72 criteria in five categories The Commonwealth Fund reviewed.

The differences in the U.S. system were especially striking when measured against top-ranked U.K., Australia and the Netherlands.

Why the Gap?

“Other countries have much better primary care than the U.S., invest more in primary care physicians than in specialists and have health systems that are more equitable,” said Dr. David Blumenthal, president of The Commonwealth Fund, during a teleconference with reporters. “In no other country does income inequality so profoundly limit access to care as it does here.”

The U.S. has ranked at the bottom of similar reports since 2004. Some of these differences come from the unique structure of the U.S. health system, Blumenthal said. We are the only country among those surveyed that does not offer some type of universal coverage.

Health care spending has grown faster in the United States than elsewhere, but that doesn’t mean better performance, said Dr. Eric Schneider, lead author of the report and The Commonwealth Fund’s senior vice president for policy and research. He hopes the U.S. can adopt other nations’ successful approaches here.

The one bright spot for the U.S in the report was in care processes, where it ranks fifth. This category evaluates preventive services, safety of care, care coordination and patient engagement in their own care. Criteria like wellness counseling, doctor-patient relationships and shared decision-making between primary providers and specialists showed strong positive results. But this wasn’t enough to lift the U.S. out of its last-place spot overall.

All countries have room to improve in various ways, Schneider said. “No one country ranks first consistently.”

Where the U.S. Health System Falls Short

The report emphasizes precise deficiencies in American performance. It found the United States:

  • Ranks last on access to care, most notably in affordability; The Netherlands performs best.
  • Ranks 10th in administrative efficiency, with more U.S. doctors reporting restriction-related coverage problems than any other country but France. Australia, New Zealand, the U. K. and Norway ranked highest. Other countries are more efficient because they standardize benefits and administration burden.
  • Has the lowest level of health care equity, which examines how even-handed each country’s system is for people with below-average versus above-average incomes. Relative to other countries, a greater proportion of Americans struggle with costs of care and there are greater differences between lower- and higher-income adults. That leads to skipping doctor or dental appointments, foregoing treatments or tests or not filling prescriptions because of cost. The U.K., the Netherlands and Sweden showed the smallest gaps.
  • Has the highest rate of “mortality amenable to outcomes,” which measures the likelihood of preventable death caused by conditions that could be treated under an effective health system. And, compared with other countries, the U.S. also had the smallest decrease in this measure over the past decade.

In addition to offering universal coverage and good primary care, other countries also invest heavily in early prevention, detection and treatment before problems become untreatable, Schneider said. While the U.S. is experimenting with some comprehensive programs, it’s nowhere near the level of other nations.

The performance of the U.S. is “lackluster” when juxtaposed with other wealthy nations, the report concluded. Each of the three top-ranked countries have different financing systems, but all achieve high performance.

How the United States Can Do Better

The report recommends:

  • Strengthening preventive services, including more investment in deterring chronic disease and in a primary care workforce that is available on nights and weekends.
  • Supporting organizations that excel at care coordination and moving away from fee-for-service payments to better coordinate care.
  • Expanding health insurance coverage, allowing people to get the care they need at little or no cost. Universal coverage makes primary care widely available and reduces gaps in care, the report says.
  • Cutting down on paperwork. We lead the world when it comes to burdensome requirements of the health system. Only 6 percent of doctors in Norway and Sweden said they wasted time or had difficulty with billing and paperwork, compared with more than 50 percent of U.S. doctors surveyed.
  • Reducing disparities in care. Lower income is associated with higher health risks, but people have greater difficulty in accessing care or treatment because of high costs.

The U.S. will likely follow its own path rather than adopting another country’s health care system to address these challenges, Schneider said. However, to become a truly high-performing health system, we need to learn from other countries to meet the issues of access, administrative burden, equity and health outcomes.

Liz Seegert
Liz Seegert New York-based journalist Liz Seegert has spent more than 30 years reporting and writing about health and general news topics for print, digital and broadcast media. Her primary beats currently include aging, boomers, social determinants of health and health policy. She is topic editor on aging for the Association of Health Care Journalists. Her work has appeared in numerous media outlets, including Consumer Reports,, Medical Economics, The Los Angeles Times and The Hartford Courant.  Read More
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