The United States spends more on health care than other wealthy nations, but its health system is the worst among them, a new reports shows. 

The report from The Commonwealth Fund, an independent research group, analyzed the performance of health systems in 10 countries to assess ways the U.S. could improve its own health system. Americans have the shortest lives and the most avoidable deaths compared to the other nations, with Australia and Switzerland coming out on top, the report determined.

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Researchers looked at in five areas: access to care, care process, administrative efficiency, equity and health outcomes. Australia, the Netherlands and the United Kingdom had the best performing health systems. The other countries examined were Canada, France, Germany, New Zealand, Sweden and Switzerland. 

“The only clear outlier is the U.S., where health system performance is dramatically lower,” the report said. “U.S. health care can be a nightmarish maze for patients and care providers alike.” 

The U.S. spends a much higher percentage of its gross domestic product – a comprehensive measure of economic activity – on its health system than the other countries, the report found. The U.S. spent more than 16% of its GDP on health care in 2022. The other countries were spending between 8% and 12% of GDP by 2023. The researchers projected that the U.S. will spend more than 20% of its GDP in health care by 2035.

Despite this spending, the U.S. ranked at the bottom of the list for accessibility and affordability of care. The U.S. has a “fragmented” health system, with most people receiving health insurance coverage through employers, the report said. And even though the Affordable Care Act expanded Medicaid and helped subsidize private insurance, 26 million Americans still don’t have health insurance.

“U.S. patients are more likely than their peers in most other countries to report they don’t have a regular doctor or place of care and face limited options for getting treatment after regular office hours,” the report said. It also found that a shortage of primary care providers aggravated accessibility issues.

The Netherlands, the U.K. and Germany were at the top of the list for accessibility and affordability.

The U.S. along with New Zealand also ranked lowest in terms of equity. They had the “highest income-related differences in reported cost-related access issues and instances of unfair treatment or feelings that health concerns were not taken seriously by health care professionals because of their racial or ethnic background,” the report said. Australia and Germany fared the best. 

The report outlined several steps the U.S. should to take to improve its health system:

• Reduce financial barriers to health care accessibility by extending coverage to the remaining uninsured

• Minimize the variation and complexity of insurance plans

• Build a robust primary care system by improving the compensation of primary care clinicians and increasing investments in the training of primary care providers

• Address the uncontrolled consolidation of health care resources in local markets, which drive prices higher and makes insurance less affordable

• Create a viable public health system capable of mitigating the burdens of chronic disease and organize national defenses against likely future pandemics

• Improve interventions to reduce gun violence and deaths from substance use, remedy the historical and ongoing effects of racism on the health of Black, Hispanic and Indigenous people, and institute policies that protect against poverty, homelessness and hunger

This report was the eighth from The Commonwealth Fund, but it differed from previous reports because it accounted for COVID-19’s impact on health systems and included more measures for equity, such as gender, rural versus non-rural locations and patients’ experiences of discrimination.