U.S. ranks worst in health care survey of 10 high-income countries—despite spending the most

Americans live the sickest lives and die the youngest, per a report by the Commonwealth Fund, an independent health care research firm. Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System was published Thursday.

The U.S. came in last in three of five categories—equity, health outcomes, and access to care—in addition to having the poorest overall ranking. The country performed slightly better in administrative efficiency, finishing ninth behind Switzerland. This, despite spending more than any other nation included in the assessment.

“The U.S. is failing one of its principal obligations as a nation: to protect the health and welfare of its people,” Dr. Joseph Betancourt, president of the Commonwealth Fund, said in a prepared statement. “The status quo—continually spending the most and getting the least for our health care dollars—is not sustainable. It isn’t about lack of resources—it’s clearly about how they are being spent.”

The U.S. excelled only in a category called care process, which considers safety, prevention, coordination, and patient engagement. Its second-place finish, the report said, “is the result of the successful provision of preventive services, such as mammograms and flu vaccinations, and an emphasis on patient safety.”

Mirror, Mirror used data collected from 2021 through 2023, with 70 metrics spanning the five categories. Commonwealth Fund International Health Policy Survey respondents included primary care physicians, the general population of adults aged 18 and older, and a subset of those 65 and older. Additional data sources included the World Health Organization and the Organization for Economic Cooperation and Development.

Below are each country’s 2024 ranking, compared to the previous 2021 report. Norway, which took the top spot three years ago, exited the International Health Policy Survey and isn’t included in this year’s rankings.

High-income countries with best health care systems

1. Australia (up from No. 3)
2. Netherlands (same)
3. U.K. (up from No. 4)
4. New Zealand (up from No. 6)
5. France (up from No. 8)

High-income countries with worst health care systems

6. Sweden (up from No. 7)
7. Canada (up from No. 10)
8. Switzerland (up from No. 9)
9. Germany (down from No. 5)
10. U.S. (technically up from No. 11 but still last place)

While differences in overall performance between most countries was relatively small, the report noted, the U.S. was the sole outlier with “dramatically lower” performance.

Other health care rankings

• Best access to care: Netherlands (same)
• Worst access to care: U.S. (same)
• Best administrative efficiency: U.K. (was Norway)
• Worst administrative efficiency: Switzerland (was U.S.)
• Best care process: New Zealand (same)
• Worst care process: Sweden (same)
• Best equity: Australia (same)
• Worst equity: U.S. (same)
• Best health outcomes: Australia (same)
• Worst health outcomes: U.S. (same)

“Mirror, Mirror underscores the importance of international comparisons, offering evidence and inspiration to improve America’s health system,” Reginald Williams, Commonwealth Fund vice president of international policy and practice innovations, said in a prepared statement. “While other nations have successfully met their populations’ health needs, the U.S. health system continues to lag significantly.

“This report shows that by adopting proven strategies and making smart investments, America can enhance its health system to better meet the needs of its people. There’s no reason we can’t elevate our standing if we choose to do so.”

How much is the U.S. spending on health care?

The nation’s relatively high health care spending isn’t new, but the gap between U.S. expenditures and those of the nine other ranked countries has widened to a chasm.

Beginning in 1980, U.S. health care spending was 8.2% of its gross domestic product (GDP); the U.K. had the lowest spending at 5.1%. By 2020, U.S. spending had climbed to a high of 18.6%. That dipped to 16.5% in 2022, when spending of the other nine countries was between 9.8% (Australia) and 12.6% (Germany). 

The report highlights the irony that the country that spent the most on health care, the U.S., performed the poorest. What’s more, the two countries that performed the best, Australia and the Netherlands, spent the least.

Hope not lost for U.S. health care reform

In this presidential election year, health care reform is top of mind for American voters on both sides of the political aisle, and Mirror, Mirror paints the nation’s problems in striking contrast.

Health insurance coverage in the U.S. is fragmented—leaving 26 million Americans uninsured—while the other nine countries boast universal coverage. Navigating medical bills is a nightmare for many Americans, yet the U.K. and Australia minimize billing burdens. The U.S. has the highest rates of preventable and treatable deaths among all ages. Americans are projected to live four fewer years than the 10-country average, in no small part due to gun violence and substance abuse.

The list goes on. Still, Commonwealth Fund researchers concluded their findings presented more a teachable moment than an insurmountable obstacle. In a news release about the report, they recommended a number of policy initiatives, including:

• Make health care more affordable and more accessible by extending health care coverage to the remaining uninsured and reforming insurance coverage to meet minimal standards of adequacy, including limits on patients’ out-of-pocket expenses.
• Improve health equity by eliminating disparities in the health and health care delivery that low-income individuals, Black, Latino, and Indigenous people, women, and people who live in rural areas receive. These populations often face discrimination and receive lower-quality care.

“Too many Americans are living shorter, sicker lives because of this failure,” Betancourt said. “We need to build a health system that is affordable and that works for everyone. It’s past time that we step up to this challenge.”

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