The United States ranks last overall among high-income nations in healthcare performance. The Commonwealth Fund’s 2024 Mirror, Mirror report, which compares 10 wealthy countries across dozens of measures, placed the U.S. at the bottom of the list. Australia, the Netherlands, and the United Kingdom topped the rankings. This result is especially striking given that the U.S. spends far more on healthcare than any other country in the world.
How the U.S. Compares Overall
The Commonwealth Fund assessment evaluates countries on access to care, care process, administrative efficiency, equity, and health outcomes. The U.S. ranked last not just overall but specifically last in health outcomes, last in equity, and last (tied with Switzerland) in administrative efficiency. No other country in the analysis performed as poorly across so many categories simultaneously.
The 10 countries in the comparison are Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. Every one of these peer nations achieves better overall results while spending significantly less money.
What the U.S. Spends vs. What It Gets
In 2024, the U.S. devoted 17.2% of its GDP to healthcare. The OECD average was 9.3%. Germany, the next highest spender, allocated 12.3%, nearly five percentage points less than the U.S. In other words, the American system costs roughly twice what peer countries spend, and the gap has been consistent for years, peaking at 18.5% of GDP during 2020.
Where does that extra money go? Administrative costs are a major factor. Activities related to planning, regulating, and managing health systems account for about 8% of total U.S. healthcare spending, compared to 1% to 3% in other high-income countries. The rest of the premium is driven largely by higher prices for drugs, medical services, and labor, not by Americans using more healthcare. Utilization rates in the U.S. are largely similar to those in other wealthy nations.
Health Outcomes Lag Behind
Despite the spending, Americans die at higher rates from conditions that good medical care can treat. The U.S. has the highest rate of deaths amenable to healthcare among comparable countries. These are deaths from causes like diabetes, infections, and treatable cancers where timely, effective care should prevent a fatal outcome. Between 2004 and 2014, the U.S. improved on this measure, but its gains were the smallest of any peer country, leaving it roughly 40 more preventable deaths per 100,000 people behind the average.
Maternal mortality tells a similar story. In 2022, roughly 22 mothers died for every 100,000 live births in the U.S. That rate is more than double, sometimes triple, the rate in most other high-income countries. In half of the peer nations studied, the figure was below five deaths per 100,000.
Affordability and Access
In 2021, 27 million Americans (8.3% of the population) had no health insurance at all. Most peer countries provide universal or near-universal coverage. The consequences are measurable: 85% of uninsured adults under 65 report difficulty affording healthcare, and even among insured adults, 47% say paying for care is somewhat or very difficult.
Medical debt is a distinctly American problem. Roughly 23 million adults owe more than $250 in healthcare debt. Compared to residents of other wealthy nations, Americans face more severe challenges affording care regardless of income level, and the burden falls hardest on those without insurance.
Where the U.S. Does Well
The picture is not uniformly bleak. The U.S. performs well in certain areas of clinical quality, particularly cancer treatment. Five-year survival for breast cancer is 84% in the U.S. compared to 81% across Europe, and U.S. survival rates have historically been higher than those of any individual European country. The gap has narrowed over time, and when you compare by tumor stage, survival rates for early-stage cancers are nearly identical (96% to 98%) across Western Europe and the U.S. The American advantage appears most in later-stage diagnoses, suggesting the U.S. system is better at aggressive treatment of advanced disease.
The U.S. also benefits from world-class research hospitals, rapid adoption of new technologies, and shorter wait times for elective procedures compared to some countries with single-payer systems like Canada and the U.K. For patients with good insurance and access to top medical centers, the quality of care can be exceptional.
Why the Rankings Look This Way
The core tension in the U.S. system is that it delivers excellent care to some people while leaving millions underserved. The rankings reflect population-level performance, meaning they capture the full range of experiences, from a patient at a leading cancer center to someone skipping medications because of cost. Countries that rank higher tend to have universal coverage, stronger primary care infrastructure, and lower administrative complexity. Their outcomes are more consistent across income levels and demographics.
The equity gap is central. The U.S. ranks last on equity measures because health outcomes vary dramatically by race, income, and geography. A wealthy resident of a major metro area may experience healthcare comparable to the best in the world, while a low-income resident in a rural community faces barriers that look nothing like a high-income country. The rankings capture both experiences and average them together, which is why the U.S. consistently lands at the bottom despite pockets of excellence.