Thursday’s findings were based on tens of thousands of survey responses from primary care physicians and residents in high-income countries collected over the last three years.

The researchers looked at how the U.S. compared with nine other countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland and the United Kingdom. Each country was graded on five categories: access to care, care process, administrative efficiency, equity and health outcomes.

No country was at the top or bottom in every category. The countries that ranked in the top three overall were Australia, the Netherlands and the U.K. Australia, and the Netherlands also had the lowest health care spending, according to the report.

The researchers said the U.S. stood out for its “exceptionally weak” performance. 

It ranked last or near last in every category except one — care process — in which it ranked second behind New Zealand. Care process measures things like preventive services, including mammograms and flu vaccinations, and engagement with patients. 

The complex labyrinth of hospital bills, insurance disputes and out-of-pocket requirements that patients and doctors are forced to navigate put the U.S. second to last in administrative efficiency. 

“We have so many different insurers, each of which is selling a different product with different requirements in order for physicians or hospitals and other providers to get paid and for the patients to have their care covered,” Blumenthal said. “That leads to denial of service. It leads to bargaining that goes on between doctors and hospitals and insurers’ companies.”

The U.S. was also second to last in equity, with many lower-income people reporting that they couldn’t afford the care they needed and more people reporting unfair treatment or discrimination.

Notably, the U.S. had the lowest life expectancy and the highest rates of preventable and treatable excess deaths, which was aggravated by the pandemic. 

Last year, the average life expectancy in the U.S. was 77.5 years, up just over a year from 2021, when the pandemic drove life expectancy down to 76.4 years, according to the most recent data from the Centers for Disease Control and Prevention.

“That is a new finding,” Blumenthal said. “We have never had a pandemic-related finding in a previous report, and it shows that, unfortunately, our general low performance held true in our performance on Covid mortality.”

Advanced medical care out of reach for many

Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, said the findings align with other research consistently ranking the U.S. near the bottom of peer countries on nearly all leading health indicators, including life expectancy, child and maternal mortality, access to health care and equity.

Many of America’s most vulnerable, including racial minorities and people with low incomes, are uninsured or underinsured, Gostin noted. Given the high cost of medical services, many people delay or avoid care.

“The United States provides perhaps the most advanced medical treatments in the world, but only for those who can afford it,” Gostin said. “For far too many people, high-quality medical care is out of reach.”

Dr. Adam Gaffney, a critical care physician at the Cambridge Health Alliance in Massachusetts, pointed out that the U.S. differs from the other countries in one critical area: universal health care coverage.

“A universal health care system can make a difference,” Gaffney said, “not only because everyone is covered and can see a doctor when they need to, but because they have a long-standing health care provider who can provide counsel and advice and treatment and prevention of common conditions.”

The U.S. has ranked last in previous Commonwealth Fund reports, but the researchers tried to avoid direct comparisons from report to report because they change the questions and the countries that participate.

Thursday’s report also listed solutions to the country’s health care problems, including lowering the cost of care and expanding access to coverage.

“The shortcomings of the United States are clear from this international analysis, but so are the opportunities for change,” said Reginald Williams II, vice president of the International Health Policy and Practice Innovations program at The Commonwealth Fund.