Health — United States · Synthesis

The highest health spending in the world. The United States devotes about 17% of its GDP to health (CMS/OECD), by far the highest share among major countries — nearly double the OECD average per capita. This spending is mostly private (employment-linked insurance), supplemented by the public programs Medicare (the elderly) and Medicaid (low income).

A life expectancy lower than other wealthy countries. Life expectancy at birth stands at around 78.4 years (2023), recovering after the pandemic trough (≈ 76.4 years in 2021), but it remains the lowest of the major developed countries. This is the central paradox: the highest spending, for lagging health outcomes.

"Avoidable" excess mortality and specific crises. Several factors weigh in: the overdose epidemic (opioids, fentanyl) that causes tens of thousands of deaths a year, firearm mortality (see Security category), obesity and chronic diseases, as well as a maternal mortality high for a wealthy country (CDC).

Incomplete coverage. Despite the expansion allowed by the Affordable Care Act, about 26 million people remain without health insurance (≈ 8% of the population). Household out-of-pocket costs and the risk of personal bankruptcy linked to medical expenses are among the highest in the developed world.

Relatively high infant mortality. Infant mortality (≈ 5.4-5.6 per 1,000 births, CDC) is higher than in most comparable countries, a reflection of inequalities in access and perinatal organization.

Containing continuously rising spending. Aging and the cost of new treatments drive Medicare and Medicaid spending, at the heart of the CBO's debt projections (see Economy category). Price control (drugs, procedures) is a recurring debate; the negotiation of drug prices by Medicare is one step toward it.

Coverage and access. Expanding or restricting coverage (ACA subsidies, Medicaid by state) remains a divisive political issue. Reducing the share of the uninsured population is a debated objective, with highly contested modalities.

Public health crises. The fight against overdoses (fentanyl), obesity (the rise of new anti-obesity treatments), mental health and maternal mortality are priorities identified by the CDC, decisive for raising life expectancy.

Health inequalities. Gaps in life expectancy by income, origin and territory are marked. Reducing them requires acting on access to care, prevention and the social determinants of health.

The open questions. Three issues will shape the period: (1) improving health outcomes without further increasing spending; (2) reducing the uninsured share; (3) curbing the crises (overdoses, obesity, maternal mortality) that weigh on life expectancy.

Placed in their environment, the United States is a singular case: the highest spending for the weakest outcomes among the major wealthy countries — an unfavorable cost/outcome ratio well documented by the OECD.

Three takeaways. (1) Spending: off the chart. At ≈ 17% of GDP, the United States spends markedly more than France (≈ 11.9%), Germany (≈ 11.8%), Canada (≈ 11%) and the EU average (≈ 10.4%).

(2) Life expectancy: the lowest in the group. At ≈ 78.4 years, it is lower than Canada (≈ 82.6), France (≈ 82.8), the United Kingdom (≈ 81.3) and Germany (≈ 81.2) — a gap of several years despite higher spending.

(3) Coverage: an exception. Unlike the other major wealthy countries, the United States has no universal health coverage; the uninsured share and out-of-pocket costs are among the highest in the developed world.