By Joshua P. Cohen

Among ten peer nations, Americans live the shortest lives and are the least healthy, despite the United States spending the most on healthcare, according to a recent Commonwealth Fund study.

The U.S. healthcare system ranks last among ten comparably wealthy, industrialized nations on important metrics, such as life expectancy, preventable deaths, access to healthcare and health equity. Yet, the U.S. spends the most of any nation examined in the study, twice the average per capita.

Conspicuously, Americans face the most barriers to obtaining affordable healthcare. This is partly due to the U.S. being the only nation in the study that does not provide universal health coverage. Twenty-five million Americans are uninsured, and tens of millions more are underinsured, meaning they have high deductibles, cost-sharing and limited affordable care options. More than 100 million Americans are saddled with medical debt. Yet the vast majority of these people have employment and health insurance.

Also, physicians and patients in the U.S. experience the greatest burdens when it comes to payment and billing. The complexity and fragmentation of the U.S. healthcare system, with its mix of public and private insurers and thousands of health plans, force healthcare providers and patients to navigate a labyrinth of coverage and cost-sharing requirements, paperwork and insurance disputes. In addition, U.S. patients are more likely to report they don’t have a regular doctor or care setting compared to residents of other countries.

Other countries’ healthcare systems aren’t perfect by any means. The Commonwealth Fund report points to challenges in the United Kingdom, for instance, in terms of long wait times and resource constraints due to staffing shortages and budget cuts. Also, health equity is a persistent problem in New Zealand, which ranked worse than the U.S. on that metric. And countries such as Switzerland also have a relatively high administrative burden.

The Commonwealth Fund has published similar reports in the past. And its publication series on international comparisons of healthcare system performance is not the first to show large discrepancies between the U.S. and its peers. Comparing the quality of healthcare systems with respect to key health outcomes such as quality of care and life expectancy, Peterson-KFF demonstrate in a publication posted in October 2023 how poorly the U.S. stacks up against its peers. What stands out the most is that despite allocating considerably more money per capita to healthcare than any nation with comparable gross domestic product per capita, the U.S. has a significantly lower life expectancy. The gap has widened substantially since around 2010, as the figure below shows.

The problem is not just mortality indices. Across a wide range of measures of quality of care the U.S. fares relatively poorly. The U.S. performs worse in certain treatment outcomes, such as maternal mortality; patient safety measures, such as medication or treatment errors; and patients unable to get adequate care owing to affordability issues.

Researchers published a landmark study more than a decade ago, “Shorter Lives, Poorer Health.” The results showed then, before the stagnant growth and subsequent decline in life expectancy which began around 2010, that the U.S. was stalling on population-wide health outcome advances while other countries steadily improved. As outcomes have worsened since that time, American life expectancy is now lower than that of Cuba, Lebanon and the Czech Republic.

Comparing health system performance internationally is difficult as each country operates within a distinct political and socioeconomic framework. Some of the observed disparity can be attributed to aspects cited in the studies above related to the fragmented U.S. set of sub-systems rather than an overarching health system. But socioeconomic and other factors, including baseline population health, also play a role.

Every health system presumably aims to provide accessible, high-quality care that improves health outcomes subject to budget or resource constraints. Nations do this in different ways. It is evident from the Commonwealth Fund study that more spending on healthcare, as the U.S. does, isn’t associated with better health outcomes.