The United States ranks last among eleven high-income countries on the overall performance of its healthcare system, despite spending a far greater share of its gross domestic product on health care, a report from the Commonwealth Fund finds.

Based on an analysis of seventy-one performance measures across five domains — access to care, care process, administrative efficiency, equity, and healthcare outcomes — the report, Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries, found that the U.S. healthcare system ranked eleventh in four of the five domains, with an overall score far below that of tenth-ranked Canada. In the domain of care process, which includes measures of preventive care, safe care, coordinated care, and engagement and patient preferences, the U.S. ranked second. In the equity domain, the analysis found the largest disparities between income levels in the U.S. — except for measures related to preventive services and safety of care — especially in access to medical and dental care, medical bill burdens, difficulty obtaining after-hours care, and use of web portals to improve patient engagement.

The report also notes that in the healthcare outcomes domain, the U.S. had the highest infant mortality rate (5.7 deaths per 1,000 live births); the lowest life expectancy at age 60 (23.1 years); a preventable mortality rate (177 deaths per 100,000 population) more than double that of the best-performing country, Switzerland; a maternal mortality rate (17.4 deaths per 100,000 live births) twice that of France, the country with the next-highest rate; and a persistently high ten-year trend in avoidable mortality — which fell just 5 percent between 2007 and 2017.

The top-performing countries overall were Norway, the Netherlands, and Australia. According to the study, four features distinguish top performing countries from the U.S.: They provide for universal coverage and remove cost barriers; invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and invest in social services, especially for children and working-age adults.

"As the COVID-19 pandemic has amply shown, no nation has the perfect health system," the report's authors conclude. "Health care is a work in progress; the science continues to advance, creating new opportunities and challenges. But by learning from what's worked and what hasn't elsewhere in the world, all countries have the opportunity to try out new policies and practices that may move them closer to the ideal of a health system that achieves optimal health for all its people at a price the nation can afford."