The United States spends nearly twice as much on healthcare as any other wealthy nation – 18% of its entire economy, or $12,649 per person – yet it achieves some of the poorest health outcomes in the developed world, according to the Commonwealth Fund’s 2026 report card. American life expectancy has peaked at 79 years, more than two years below the OECD average of 82.7 years, and its rate of deaths that good medical care should have prevented is the second worst among comparable nations, ahead only of Mexico.
Domestic failures: spending without results
The report grades the US across four areas – coverage, affordability, the delivery of care, and equity – and finds it failing or nearly failing on every count. The United States and Mexico are the only countries studied that have never guaranteed universal healthcare coverage, leaving approximately 27 million Americans without any insurance. Uninsured rates are higher among Hispanic, Black, and American Indian or Alaska Native populations, as well as lower-income individuals and those living in states that have not expanded Medicaid.
Primary care is particularly weak. The US has only 0.3 primary care physicians per 1,000 people, compared with the OECD average of 1.1. That shortage means nearly a third of the population – roughly 100 million people – has no regular place to seek care until they are sick enough to require hospital admission. Americans are also far more likely than their peers in other wealthy countries to forgo needed medical care because of cost. Out-of-pocket spending on prescription drugs averages more than $400 per person each year, compared with less than $100 in France.
Health equity remains a deep problem. Black women die in childbirth in the United States at a rate higher than the national maternal mortality rate of any other wealthy country measured. The one genuinely positive finding in the report is that Americans who have a regular doctor rate that relationship among the best in the world. As one clinician put it, the bedside still works – but everything surrounding it does not.
And the domestic picture is set to worsen. Independent analysts project that recent and proposed federal policy changes will leave an additional 17 million Americans uninsured by 2034, returning the country to levels not seen since before the Affordable Care Act, and leading to tens of thousands more preventable deaths every year.
Global retreat: a hollowed-out health leadership
But the Commonwealth Fund report card measures only domestic performance. A second, less formal report card – on the United States’ global health leadership – tells an even starker story, because the country has largely stopped sitting the exam. For decades the US led the world’s defences against disease, funding roughly 40% of global humanitarian aid and helping build the surveillance and treatment networks that caught outbreaks before they spread. In just over a year, the US Agency for International Development has been cut from around 10,000 staff to fewer than 300. The country has withdrawn from the World Health Organization, a move that jeopardises global pandemic preparedness and creates a vacuum for nations such as India, Saudi Arabia, Russia and China to exert more influence on global health priorities.
The consequences are measurable. A Lancet analysis projects that the aid cuts alone will cause an additional 14 million deaths globally by 2030, including 4.5 million children under the age of five. In a more severe scenario, that number could reach 22.6 million. Already, the cuts have led to the closure of soup kitchens, shortages of medicines, and reduced food rations in affected regions.
The cost is no longer theoretical. An Ebola outbreak is spreading through the Democratic Republic of the Congo and Uganda, caused by the Bundibugyo strain – a species of the virus for which the licensed Ebola vaccine and antibody drugs, developed against a different strain, are not effective. The World Health Organization declared an international emergency on 17 May. The US Centers for Disease Control and Prevention learned of the outbreak roughly a day before the rest of the world did, a delay that would have been unthinkable in past outbreaks, when American disease detectives would have been in the room far sooner. As one African public health leader put it, the United States is now missing in action.
Closer to home, an outbreak of Andes strain hantavirus – the one form of the rodent-borne virus known to spread between people – surfaced aboard a cruise ship. The health secretary, Robert F Kennedy Jr, assured the public it was “under control”. But the federal programme designed to investigate shipborne outbreaks had already been hollowed out, its full-time staff cut a year ago. The CDC has been involved in monitoring and repatriating affected American passengers, but its capacity to respond has been significantly reduced.
The administration disputes that its cuts hampered the Ebola response, and points to emergency money it has since mobilised. But these failures do not arrive as policy debates.
Inside the ICU: the human cost
Robert B Shpiner, a clinical professor of medicine in pulmonary and critical care at the David Geffen School of Medicine at UCLA, has spent more than four decades in the medical intensive care unit. He does not read the Commonwealth Fund’s numbers as statistics. “I read them as the people I admit,” he writes.
In his unit, the failures arrive as the patient who could not afford the prescription, the rural patient an hour from the nearest doctor, the imported infection with nowhere to surge – respiratory failure, shock, isolation precautions. Abroad, they arrive as a child dead of something a bednet or a course of antiretrovirals would have prevented. A nation that runs on the thinnest healthcare margins in the wealthy world – with the fewest doctors, the fewest hospital beds, and the highest share of patients who skip care they cannot afford – is the last one that can afford to look away from what spreads next.
“It is the same country making the same choice on both sides of the same report card,” Shpiner writes. “We already know the grade. We are choosing not to read it.”