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Dead Last: U.S. Health Care System Continues to Rank Behind Other Industrialized Countries

Health Letter, November 2014

By Michael Carome, M.D.

The U.S. spends more on health care per person than other major industrialized nations — a lot more. In 2011, expenditures for health care totaled $8,500 per person in the U.S. The country next closest in spending, among 10 other major industrialized nations, was Norway, which spent $5,700 per person. New Zealand spent the least on health care, at $3,200 per person.

Unfortunately, despite far outspending the rest of the world, the U.S. doesn’t even come close to having the best health care system in the world.

The Commonwealth Fund in June issued a report examining that troubling fact. The report, “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, ” ranked the U.S. last overall among 11 major industrialized countries as of 2013 (see table below). This continues a trend that the Commonwealth Fund has documented in prior reports published in 2004, 2006, 2007 and 2010. The report also revealed that the U.S. had worse health outcomes than the other countries.

The Commonwealth Fund is a private foundation created in 1918. Its mission is “to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable.” It pursues that goal in part by funding research examining health care issues.

Overall Ranking of Health Care System Performance in 11 Industrialized Nations

Country Ranking
United Kingdom 1
Switzerland 2
Sweden 3
Australia 4
Germany 5
Netherlands 5
New Zealand 7
Norway 7
France 9
Canada 10
United States 11

How the U.S. scores

The Commonwealth Fund report’s authors assessed five key elements of health care system performance: population health, access, efficiency, equity and quality. The U.S. ranked last or close to last on four of these elements and in the middle on the fifth. A closer look at the details of the report reveals many troubling deficiencies with respect to each of these aspects of the U.S. health care system relative to other countries.

Population health

The ultimate measure of whether a country’s health care system is functioning at a high level is reflected in whether people on average are able to lead long, healthy and productive lives. In this regard, the U.S. is a dismal failure for many people.

To assess this aspect of national health care system performance, the report authors examined three important measures: preventable mortality, defined as deaths that could have been prevented with timely and effective care; infant mortality, defined as deaths per 1,000 live births; and healthy life expectancy, defined as being in good health at age 60. The U.S. ranked last on the first two outcomes and second-to-last on the third, resulting in an overall last-place ranking on the measure of healthy lives. In contrast, France and Sweden ranked first and second, respectively, on the overall measure.

That the U.S. achieves the worst health outcomes among major industrialized nations aligns with the findings of other experts, including the prestigious Institute of Medicine (IOM). In its 2013 report, “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” the IOM documented that the U.S. generally has worse health outcomes and higher premature-death rates in all age groups and income levels than the average among 16 other high-income nations.


The Commonwealth Fund report’s authors defined good access to health care as the ability to obtain affordable care in a timely manner. On this element of health care system performance, the U.S. ranked ninth overall.

Not surprisingly, the U.S. ranked last on every indicator used to evaluate whether access to care was affordable. For example, patients in the U.S. are far more likely than those in the other 10 nations to forgo filling a prescription; skip a recommended medical test, treatment or follow-up; or neglect care for a medical problem because of cost. U.S. patients are also much more likely to have out-of-pocket medical expenses that exceed $1,000 annually and to have payment for health insurance claims denied.

With respect to timeliness of care, patients in the U.S. fare somewhat better, with the U.S. ranking fifth overall. U.S. patients, at least those that are well-insured, are able to see specialists and receive treatment after diagnosis sooner than patients in nearly all the other countries. However, the U.S. ranked in the bottom half on access to same- or next-day care for a medical problem, access to non-emergency care in the evening or on weekends, emergency care waiting times, and elective surgery waiting times.


To measure efficiency, the report’s authors looked at total national spending on health as a percentage of gross domestic product (GDP) and the percentage of health care dollars spent on health administration and insurance. The U.S. health care system was found to be the most inefficient, whereas the U.K. and Sweden were ranked the most efficient.

The U.S. expends more on health care as a percentage of GDP than any of the other countries in the study. It also spends more on health administration and insurance. Both patients and doctors in the U.S. spend more time than nearly every other country on paperwork and disputes related to medical bills and insurance claims. And patients in the U.S. are far more likely than those in the other countries to be sent for duplicate medical tests, which often expose them to unnecessary costs and risks of harm.


According to the Institute of Medicine, an equitable health care system provides care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status. The Commonwealth Fund focused on socioeconomic status when ranking the countries’ health care systems on the element of equity. Once again, the U.S. system ranked last in overall equity, based on patients’ income status, in the performance of its health care system.

In assessing the equity of national health care system performance, the report’s authors divided adults in each country into two income categories: those with the lower 50 percent of incomes and those with the higher 50 percent. They found that low-income adults in the U.S. are much more likely to forgo medical care because of costs than those in other industrialized countries. (Of note, adults with below-average incomes are more likely to suffer from chronic diseases.)


The only glimmer of “good” news in the Commonwealth Fund report relates to the quality of health care in the U.S. The report authors defined high-quality care as care that is effective, safe, coordinated and patient-centered. On this element of health care system performance, the U.S. overall ranked fifth, with the U.K. ranked first and Norway last.

For health care effectiveness, the U.S. ranked third overall. The U.S. does particularly well in providing preventive care, such as advice on diet and exercise, in comparison with other nations. But it fared poorly with respect to chronically ill patients not receiving recommended tests, treatments or follow-up care because of cost, ranking last on this element of health care quality.

The U.S. also had a mediocre ranking on the safety of its health care system, ranking seventh, while the U.K. ranked first. The measurement of safety took into consideration medical errors resulting from treatment. In comparison to most other countries, patients in the U.S. were more likely to be given the wrong medication or wrong dose at a pharmacy or while hospitalized (ranked ninth), to receive incorrect results for a diagnostic or lab test (ranked eighth), or to experience delays in being notified about abnormal test results (ranked ninth). Each of these circumstances poses an obvious threat to patient safety.

On health care coordination, the U.S. ranked sixth. One key to achieving such coordination is having a regular doctor or clinic that manages a patient’s care. The U.S. had the lowest percentage of patients with a regular doctor or clinic. Only 91 percent of sicker adults in the U.S. had a regular doctor to manage their care. In contrast, 100 percent of such patients in the Netherlands reported having a regular doctor, as did 99 percent of those in France, New Zealand, Norway, Switzerland and the U.K.

Far from the best

Some commentators and many members of Congress, in an effort to defend the status quo, assert that the U.S. has the best health care system in the world. As demonstrated by the Commonwealth Fund’s data, such assertions are patently false. The U.S. health care system lags behind — in many respects, far behind — all other major industrialized countries examined in the Commonwealth Fund report on multiple measures of performance, despite spending far more per capita than the other countries.

One factor that distinguishes the U.S. from all other major industrialized nations is the lack of a universal health care system, either through national single-payer health insurance or a national health care system. The authors of the report suggest that implementation of the Affordable Care Act (ACA) will improve the United States’ performance. However, because the ACA preserves the for-profit private health insurance industry, as well as profit-driven hospitals and health care institutions, the U.S. undoubtedly will fail to achieve the type of high-quality, efficient, equitable health care system that people deserve. Private health insurers and medical institutions will continue to put making money ahead of patient health. Implementation of a single-payer national health insurance system is the only way forward for the U.S. to achieve the best health system in the world.


[1] Davis K, Stremikis K, Squires D, Schoen D. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. The Commonwealth Foundation. June 2014. [Page 7 ,Exhibit EX-1, bottom row; amount rounded to the nearest one hundred]

[2] Ibid.

[3] Ibid.

[4] The Commonwealth Fund. Mission statement. http://www.commonwealthfund.org/about-us/mission-statement. Accessed October 13, 2014.

[5] Ibid.

[6] National Research Council and Institute of Medicine. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Panel on Understanding Cross-National Health Differences Among High-Income Countries. 2013. Washington, DC: The National Academies Press.