The United States spends more on healthcare than any other country in the world, yet its residents live shorter lives, die more often during childbirth, and carry billions of dollars in medical debt. In 2024, the U.S. spent over $14,880 per person on healthcare, roughly 2.5 times the average across wealthy nations. The next highest spenders, Switzerland, Norway, and Germany, each spent only about two-thirds of that amount. The gap between what Americans pay and what they get in return is the core of the problem, and it has several interlocking causes.
Spending More, Living Less
The most straightforward way to judge a healthcare system is whether it keeps people alive. By that measure, the U.S. falls strikingly short. Life expectancy across wealthy nations averaged 81.1 years in 2023. Twenty-seven countries cleared the 80-year mark. The United States landed in a second tier, with a life expectancy between 75 and 80 years, alongside the lowest-performing economies in the group.
This gap isn’t new, and it was widening even before the pandemic. Between 2010 and 2019, life expectancy gains slowed in many countries, but the U.S. and Canada were hit particularly hard, in part because opioid use drove up deaths among working-age adults. The result is a country that pays a premium for healthcare and gets worse population-level results than nations spending far less.
Where the Money Actually Goes
A massive share of U.S. healthcare spending never touches a patient. Roughly 20% to 25% of every healthcare dollar, about $1 trillion per year, goes to administration: billing, coding, insurance paperwork, prior authorizations, and negotiations between hospitals and insurers. Hospital-level data backs this up. An analysis of over 5,600 hospitals found that administrative expenses made up 17% of total hospital costs in aggregate, with some studies using different methods placing the figure closer to 26%.
This overhead exists because the U.S. has no single system. Instead, thousands of private insurers each set their own rules, coverage criteria, and reimbursement rates. Every doctor’s office and hospital must staff entire departments just to navigate this patchwork. Countries with simpler insurance structures, whether single-payer or tightly regulated multi-payer systems, spend a fraction of that on paperwork.
Drug Prices With No Ceiling
Prescription drugs cost dramatically more in the U.S. than in peer countries. A Government Accountability Office analysis of 2020 data found that U.S. retail prices for 20 selected brand-name drugs were two to four times higher than prices in Australia, Canada, and France. The same pill, made in the same factory, simply costs more when sold to an American.
Most other wealthy nations negotiate drug prices at a national level, using their buying power to set limits on what pharmaceutical companies can charge. The U.S. historically left pricing almost entirely to the market. Recent legislation has begun to allow Medicare to negotiate prices on a handful of drugs, but the vast majority of medications remain unregulated in price. For patients without generous insurance, this means choosing between filling a prescription and paying rent.
Hospital Pricing No One Can Decode
Hospital pricing in the U.S. operates through a system called the chargemaster, a list of prices each hospital sets for every procedure and service it offers. In theory, a 2019 federal rule requiring hospitals to publish these lists was supposed to bring transparency. In practice, chargemasters are nearly impossible for patients to use. Each hospital formats its list differently, the prices listed rarely reflect what a patient will actually pay, and the variation between hospitals is enormous.
One analysis found that median listed prices for the same procedure varied by 87% between states. For individual items, the spread was even wider: prices for a common heart medication ranged by 243% across the 500 hospitals generating the most revenue from uninsured patients. While listed prices serve as starting points for insurer negotiations, research shows they directly correlate with higher costs for both consumers and insurance companies. The system effectively hides the true cost of care until after you’ve received it.
27 Million People Without Coverage
In early 2024, 27.1 million people in the United States had no health insurance at all, an uninsured rate of 8.2%. Among working-age adults (18 to 64), the rate was 11.5%. Even among children, 5.2% lacked coverage, a number that had ticked upward from 4.3% the previous quarter.
These numbers actually represent improvement. The uninsured rate dropped significantly after the Affordable Care Act expanded Medicaid and created insurance marketplaces. But millions remain in a coverage gap, particularly in states that chose not to expand Medicaid. And being uninsured in the U.S. carries far greater consequences than in countries where public hospitals provide free or low-cost care regardless of insurance status. An uninsured American facing a serious diagnosis can quickly accumulate tens of thousands of dollars in bills.
Medical Debt as a National Crisis
Even people with insurance aren’t protected from financial harm. In 2024, 36% of U.S. households reported carrying some form of medical debt, whether a past-due bill, an active collection account, or an ongoing payment plan with a provider. One in five households had a past-due medical bill. Among those contacted by debt collectors about medical bills, estimates of the average total amount in active collection ranged from $2,456 to $7,931, depending on how the data was calculated.
Medical debt isn’t just a billing problem. It delays care, because people who owe money for past visits avoid seeking treatment for new problems. It damages credit scores, making it harder to rent an apartment or qualify for a loan. And it’s largely unique to the United States among wealthy nations. In most peer countries, out-of-pocket costs are capped at levels that make catastrophic medical debt essentially impossible.
Maternal Mortality That Defies Expectations
Perhaps no single statistic captures the dysfunction of U.S. healthcare as sharply as maternal mortality. In 2022, approximately 22 mothers died for every 100,000 live births in the United States. That rate is more than double, and in some comparisons triple, the rate in most other high-income countries. In the United Kingdom, the rate over a recent three-year period was about 13.4 per 100,000. In half the countries studied by the Commonwealth Fund, fewer than five mothers died per 100,000 births.
The causes are layered: fragmented prenatal care, racial disparities in how pregnancy complications are treated, hospital closures in rural areas, and gaps in postpartum follow-up. But the overarching pattern is the same one that shows up across U.S. healthcare. The infrastructure exists to deliver excellent care for some, while systemic failures leave others without access to even basic services.
Not Enough Doctors to Go Around
The U.S. is also running out of physicians. Federal projections estimate a national shortage of roughly 81,000 doctors by 2035. The Association of American Medical Colleges puts the range at 13,500 to 86,000 by 2036, depending on policy changes and retirement trends. The shortage hits primary care and rural communities hardest, where patients already drive hours to see a doctor.
The bottleneck isn’t a lack of people who want to become doctors. It’s a lack of residency training positions, which are largely funded by Medicare and have been capped by Congress since 1997. Medical schools have expanded enrollment, but graduates can’t practice independently without completing a residency. The result is a pipeline that produces fewer trained physicians than the population needs, a gap that widens every year as the population ages and existing doctors retire.
A System Designed for No One
What makes U.S. healthcare uniquely dysfunctional isn’t any single flaw. It’s that the system was never designed as a system at all. It evolved through decades of employer-based insurance, patchwork public programs, and market-driven pricing, with no central authority coordinating costs, access, or quality. Hospitals set their own prices. Insurers set their own rules. Drug companies charge what the market will bear. Patients navigate a maze that even trained researchers struggle to decode.
The countries that outperform the U.S. don’t have identical systems, but they share a common feature: deliberate decisions to cap costs, guarantee access, and treat healthcare as infrastructure rather than a marketplace. The U.S. has the medical talent, technology, and research capacity to lead the world in health outcomes. The gap between that potential and reality is what people mean when they call the system broken.