Comparing U.S. Health Care to Systems in 11 Other Socialist Democracies (Costs & Outcomes)
- Don Hilborn
- Jan 7
- 10 min read
Introduction and Health System Overview
The United States stands out among high-income nations for lacking universal health coverage, whereas countries like Sweden, Norway, Finland, Denmark, Iceland, Germany, the Netherlands, France, Spain, Portugal, Canada, and New Zealand all achieved universal or near-universal coverage decades ago. For example, New Zealand established a public health system in the late 1930s (≈85 years ago), Canada in the 1960s (≈60 years ago), and many Western European countries by the 1970s (≈50+ years ago). In contrast, the U.S. system developed piecemeal and remains a mix of private insurance and public programs (Medicare, Medicaid, etc.), leaving about 8–9% of Americans uninsured even today. Below, we compare the health care spending, health outcomes, and access to care (including wait times) between the U.S. and these countries, using the most recent data (primarily from the last ~5 years).
Health Care Spending: Total Costs and Per-Capita Expenditure
Overall Spending: The United States spends far more on health care than any of the other countries in absolute terms and as a share of its economy. In 2021, U.S. health expenditures were 17.8% of GDP, nearly double the average in other OECD countries. (Pandemic spending caused a spike to ~18.6% in 2020, but it has since declined to ~16.5–16.7% in 2022–23[1].) By comparison, most of the European and Commonwealth countries spend around 9–12% of GDP on health. For instance, Germany and France spend roughly 12–13% of GDP on health, Sweden about 11.3%, and Spain around 10.3%[2][3]. Some smaller or lower-income OECD countries spend under 10% (Finland ~9.9%, Norway ~9.8% in 2021)[2][4]. Clearly, the U.S. devotes a much larger share of its economy to health care than its peers.
Per-Capita Spending: On a per person basis, U.S. spending is even more of an outlier. In 2022, health expenditure per capita in the U.S. reached about $12,900 (PPP) – roughly twice what other high-income countries spend on average[5]. Table 1 below shows the per-capita spending and % of GDP for the U.S. and the comparison countries. The U.S. spending per person is thousands of dollars higher than in the other nations. For example, Germany and Norway spend around $8,500–$8,600 per person, and countries like Sweden, France, Canada, and Denmark are on the order of $6,500–$7,000 per person – roughly half the U.S. level[6][7]. Some countries (e.g. Spain, Portugal) spend even less, around $4,500–$5,000 per capita. This gap in spending has widened over time: in 1970 the U.S. spent ~6% of GDP on health (similar to peers), but since the 1980s U.S. costs have grown much faster.
Drivers of Cost: Despite these higher expenditures, Americans do not use vastly more health services than citizens of other countries. Research indicates the spending gap is largely driven by higher prices (for medications, procedures, administration, etc.) in the U.S., rather than greater utilization. For instance, hospital stays and doctor visit rates are actually lower in the U.S. on average, but the price per unit of care (e.g. a surgery or drug) is much higher[8]. The U.S. also spends about $1,000+ per capita on administrative costs, several times what other countries spend, due to the complexity of its private insurance billing and multi-payer system[9].
Table 1. Health Expenditure Comparison – U.S. vs. Selected Countries (latest data, approx. 2021–2022)[6][2]
Country | Health Spending per Capita (USD PPP) | Health Spending (% of GDP) |
United States | $12,900 (highest)[7] | 16.8–17.8% (highest) |
Germany | ~$8,650[6] | ~12.7%[10] |
Norway | ~$8,530[7] | ~9.8%[4] |
Netherlands | ~$7,520[7] | ~11.1%[11] |
Sweden | ~$6,980[7] | ~11.3%[12] |
France | ~$6,700[6] | ~12.2%[10] |
Canada | ~$6,880[13] | ~12.4%[14] |
Denmark | ~$6,660[15] | ~10.7%[2] |
New Zealand | ~$6,480[7] | ~10.2%[11] |
Iceland | ~$5,960[6] | ~9.7%[10] |
Finland | ~$5,765[15] | ~9.9%[2] |
Spain | ~$4,740[7] | ~10.3%[3] |
Portugal | ~$4,590[7] | ~11.2%[4] |
Sources: OECD Health Data (2019–2024)[16][2]. U.S. values are highest in each category. (PPP = purchasing power parity, adjusting for cost of living differences.)
As shown above, the U.S. spends about double the dollars per person compared to countries like France, Canada, or Sweden, and an even greater multiple compared to Southern European nations like Spain or Portugal. Yet this extra spending has not bought the U.S. better aggregate health outcomes – in fact, the opposite is often true, as discussed next.
Health Outcomes: Life Expectancy, Mortality, and Disease-Specific Results
Despite outspending everyone else, Americans have poorer health outcomes overall than people in peer countries[17]. This section compares key indicators:
Life Expectancy: Americans live shorter lives on average. Prior to the COVID-19 pandemic, life expectancy at birth in the U.S. had plateaued at around 78.8 years (2019), roughly 3–4 years less than the average in comparable countries (~82–83 years). The pandemic then drove U.S. life expectancy down to ~77.0 years in 2020–2021 – a drop of nearly 2 years, the largest decline among these nations. Other high-income countries saw much smaller COVID-related decreases (e.g. a few months on average), and by 2021 most still averaged ~82 years life expectancy. Provisional data for 2023 show the U.S. rebounding to about 78.4 years, but it still lags ~4+ years behind its peers (which recovered to ~82.5–83 years). In short, virtually all the countries in our comparison – from Canada and France to the Nordics – enjoy life expectancies in the low-to-mid 80s, whereas the U.S. is around 77–78 years[18]. This disparity has widened over time.
Infant and Maternal Mortality: The U.S. has the highest infant mortality rate and the highest maternal mortality rate of any wealthy nation. In 2020, U.S. infant mortality was about 5.4 deaths per 1,000 live births, far above the rates in Europe – for example, Norway’s rate is only 1.6 per 1,000 (and most similar countries are in the 2–3 per 1,000 range). Maternal mortality in the U.S. was about 24 deaths per 100,000 births in 2020, more than three times higher than in most of the other high-income countries (which often have single-digit maternal death rates). These poor outcomes are linked to factors like inadequate prenatal care, a higher prevalence of chronic health conditions (obesity, diabetes, heart disease) in American mothers, and social disparities. Notably, safety during childbirth is worse in the U.S. – maternal death and obstetric injury rates are higher than in Europe[19].
Disease-Specific Outcomes: On many condition-specific metrics, the U.S. also underperforms. Americans have higher death rates from avoidable or treatable causes (so-called “amenable mortality”) than residents of any other high-income country. For example, the U.S. has a significantly higher rate of deaths from heart disease and deaths from conditions like drug overdoses (poisonings) and traffic accidents, contributing to more years of life lost before age 75 compared to peer nations. The U.S. also has the highest prevalence of chronic illnesses: about 30% of U.S. adults have multiple chronic conditions (e.g. diabetes, hypertension, etc.), nearly double the rate in France (≈17%). Poor management of chronic diseases is reflected in measures like uncontrolled diabetes – the U.S. has higher rates of diabetes-related complications and deaths than many countries. In contrast, on some acute care outcomes the U.S. does as well or better: for instance, 30-day survival rates after a heart attack or stroke in the U.S. are comparable or even slightly better than the average in other countries. The U.S. also excels at preventive screening for certain cancers – rates of breast cancer and colorectal cancer screening are among the highest in the U.S.. Additionally, cancer survival rates in the U.S. are generally on par with other advanced countries, suggesting that once people do get care for serious conditions, the quality of treatment can be high. Overall, however, the burden of chronic and preventable disease is heavier in America, dragging its health indicators down.
Visualizing Spending vs. Life Expectancy: The paradox of “more spending for worse health” in the U.S. is illustrated in Figure 1. The chart plots health care spending per capita against life expectancy in each country. The United States (far right) spends roughly twice as much as others but has the lowest life expectancy (late 70s), while countries spending much less achieve around 82–83 years on average.
Figure 1: Health Care Spending per Capita vs. Life Expectancy. The U.S. is a clear outlier – it spends far more (x-axis) but achieves a lower life expectancy (y-axis) than peer nations[16][18]. Data circa 2021–2024, from OECD Health Statistics.
Access to Care and Wait Times
Beyond spending and outcomes, there are key differences in accessibility and timeliness of care:
Coverage and Affordability: Every country in this group guarantees health coverage for all residents – except the United States. In the U.S., about 9% remain uninsured and even many insured individuals face high out-of-pocket costs. Consequently, cost is a significant barrier in the U.S.: over 1 in 4 Americans report skipping needed doctor visits, tests, or treatments due to cost, a much higher fraction than in other countries. (Even insured Americans often have substantial copays and deductibles.) Other universal-coverage countries also have some cost-sharing, but the rate of cost-related care avoidance is typically lower. For example, in Canada, UK, etc., only around 5–10% of patients report financial barriers to access, versus ~25% in the U.S.
Provider Access (Supply of Doctors/Hospitals): The U.S. actually has fewer doctors and hospital beds per capita than most of these countries. The U.S. has only about 2.7 physicians per 1,000 people, compared to an average of about 3.5–4 per 1,000 in Western Europe. Americans also visit the doctor less often on average than people in, say, France or Germany. Contributing factors include the U.S. emphasis on specialty care (and a shortage of primary care physicians) and the high cost of medical education leading to fewer practitioners. Several countries (France, Sweden, etc.) have more robust primary care systems and a higher proportion of general practitioners, facilitating more regular and accessible care. The U.S. also has fewer hospital beds per capita than peers like Germany or France, which can affect access to inpatient care.
Wait Times for Care: A common criticism of universal systems is that non-urgent care may involve longer waits, and indeed in some countries patients can face delays for elective services. For example, according to one Commonwealth Fund survey, about 30% of Canadians and 28% of Norwegians reported waiting two months or more to see a specialist, whereas only 6% of Americans reported such long waits[20]. Similarly, elective surgeries (like hip or knee replacements) tend to happen faster in the U.S. on average. However, it’s important to note context: urgent or emergent needs are prioritized in all these systems (nobody waits for emergency care), and countries like Germany, France, and Sweden manage to keep specialist waits relatively short (often <4 weeks in many cases). In France and Germany, for instance, fewer than 5% of patients waited over 2 months for a specialist. The UK and Canada historically have had the longest waits among this group, due to resource constraints and centralized prioritization. The United States’ “short waits” also come with a caveat: while those who can afford or have insurance may get quicker elective appointments, millions of Americans forego care entirely due to cost, which isn’t captured in wait-time statistics. In effect, some Americans have an infinite wait (never getting care) if they are uninsured or underinsured – a problem largely solved by universal health coverage elsewhere.
Patient Experience: Surveys by the Commonwealth Fund and others find that Americans are more likely to report difficulty getting same-day or next-day primary care than citizens of some peer countries. Only about 51% of Americans said they could get a same- or next-day appointment when sick, which is slightly below the international average (57%). Countries like Germany or New Zealand often report higher same-day access, whereas Canada and the UK might be lower. Additionally, Americans face more bureaucratic hurdles (e.g. dealing with insurance claims, network restrictions), whereas patients in universal systems don’t need to navigate multiple insurers. On the other hand, the U.S. offers more choice of providers and extensive availability of new technologies and specialized treatments (albeit at high cost), which can benefit those with access.
In summary, the trade-offs in access are clear: Universal health systems guarantee coverage and eliminate financial barriers to care for everyone, but some (particularly single-payer models) may impose longer waits for certain non-urgent services. The U.S. system offers faster access for those with good insurance or money, but leaves a substantial minority without adequate access at all, and creates cost-related barriers that are virtually nonexistent in countries like Sweden or France.
Conclusion
Over the past five decades, these 11 countries – from the Nordic region to Canada and New Zealand – have built health systems that provide broadly better health outcomes at a fraction of the cost of the U.S. system. The United States today spends about twice as much per person on health care as its peers[5][21], yet Americans die younger and suffer higher rates of infant and maternal mortality, chronic disease, and preventable deaths. While the U.S. excels in certain cutting-edge treatments and preventive screenings, its overall performance is hampered by inequitable access, high costs, and a focus on illness treatment rather than social health determinants.
In comparing these nations, we see that universal health coverage and stronger primary care can achieve longer life expectancy and healthier populations without breaking the bank. No system is perfect – for instance, Canada and others must manage wait times, and all face rising costs – but every other country in this group manages to insure everyone for far less money than the U.S., and with generally better health results. These findings underscore a key lesson: how a health system is organized and financed has profound implications for a nation’s health, its economy, and the wellbeing of its people. The U.S. has enormous opportunities to learn from these international models to improve affordability, access, and outcomes in the years ahead[17].
Sources: Official health data from OECD, Commonwealth Fund, Kaiser Family Foundation, and World Bank; see references linked inline. All data are the latest available (~2019–2024). The analysis covers the United States (USA) and 11 countries: Sweden, Norway, Finland, Denmark, Iceland (Nordics), Germany, Netherlands, France, Spain, Portugal (continental Europe), Canada, and New Zealand.
[1] [5] How does health spending in the U.S. compare to other countries? - Peterson-KFF Health System Tracker
[2] [3] [4] [10] [11] [12] [14] Health spending as percent of gross domestic product (GDP) by country - Wikipedia
[16] Health expenditure per capita: Health at a Glance 2025 | OECD
[18] Life expectancy: Society at a Glance 2024 | OECD
[19] International Comparison of Health Systems | KFF
[20] Waited Two Months or More for Specialist Appointment | Commonwealth Fund
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