How to Improve Access to Healthcare
State of the Union Report
- 37 of 38 OECD nations provide universal or near-universal healthcare access; the U.S. is the sole exception.
- The United States ranks last among 11 peer nations in healthcare access and equity.
- 27.5 million Americans lack health insurance, the highest uninsured rate among peer nations.
- Countries with universal coverage spend 40-60% less per capita than the U.S. while achieving better outcomes.
- Canada, Australia, and Germany achieve 99%+ population coverage through single-payer or multi-payer systems.
- Every 10% increase in insured population is associated with a 1.7-year increase in life expectancy.
Section 1: Top 35 Countries with the Highest Access to Health Care
Source: Gallup World Poll, 2022. Rankings include only countries with populations over 5 million people.
Source: Gallup World Poll 2022 (data year: 2022). Access to healthcare scores represent the percentage of respondents who reported that they had access to quality healthcare in their city or area.
United States Ranking and Analysis
The United States ranks 25th among the top 35 countries with the highest access to healthcare, with 87.6% of respondents reporting access to quality care in their area. This ranking reflects the persistent challenges in the U.S. healthcare system, most notably the lack of universal coverage.
An estimated 25 to 30 million Americans remain uninsured, and many more face underinsurance with high deductibles and cost-sharing that deter them from seeking care. The U.S. system is predominantly employer-based, leaving individuals who are self-employed, part-time, or unemployed particularly vulnerable.
Geographic disparities further reduce access in rural and frontier areas, where provider shortages are acute. Administrative complexity consumes a disproportionate share of healthcare spending compared to peer nations with universal systems.
In the most recent available year (2022), the United States Access to Healthcare score stood at 87.6%, placing it behind Western European nations, Canada, Australia, and several East Asian countries that have implemented national health insurance or single-payer systems with broader coverage and lower out-of-pocket costs.
Top 8 Highest-Ranked Countries
| Rank | Country | Access to Healthcare (%) |
| 1 | Norge (Norway) | 96.9% |
| 2 | Danmark (Denmark) | 96.4% |
| 3 | Suomi (Finland) | 95.8% |
| 4 | Sverige (Sweden) | 95.5% |
| 5 | Australia | 95.3% |
| 6 | Canada | 94.8% |
| 7 | Nederland (Netherlands) | 94.5% |
| 8 | Deutschland (Germany) | 94.1% |
References for Section 1 and Section 2
Gallup World Poll - Healthcare Access Data 2022: (www.gallup.com)
World Health Organization - Universal Health Coverage: (www.who.int)
Organisation for Economic Co-operation and Development (OECD) Health Statistics 2023: (www.oecd.org)
Commonwealth Fund - Mirror Mirror 2021: Reflecting Poorly:
Kaiser Family Foundation - Health Coverage and the Uninsured: (www.kff.org)
Centers for Medicare & Medicaid Services (CMS): (www.cms.gov)
Health Resources and Services Administration (HRSA): (www.hrsa.gov)
World Bank - Out-of-Pocket Health Expenditure: (data.worldbank.org)
Harvard T.H. Chan School of Public Health - US Healthcare: (www.hsph.harvard.edu)
European Observatory on Health Systems and Policies: (eurohealthobservatory.who.int)
Section 2: What Other Countries Have Done to Increase Access to Health Care
The following table describes the specific policies, initiatives, laws, programs, and government and private actions that have contributed to high healthcare access in the top 8 countries.
Section 3: What the U.S. Could Do to Increase Its Access to Health Care
The United States ranks 25th among countries with populations over 5 million in access to healthcare, with 87.6% of Americans reporting access to quality care, according to the 2022 Gallup World Poll.
Despite being the world's largest economy and spending more per capita on healthcare than any other nation (approximately $12,530 per person in 2021), the United States lags behind nations that have implemented universal or near-universal coverage. The primary driver of this gap is lack of insurance coverage: an estimated 25–30 million Americans remain uninsured, while tens of millions more are underinsured with high deductibles and out-of-pocket costs that deter them from seeking care.
Key barriers include the fragmented, employer-based insurance system; high prescription drug costs; geographic disparities (particularly in rural areas); racial and socioeconomic inequities; inadequate primary care infrastructure; and administrative complexity that consumes approximately 34% of all U.S. healthcare spending. Addressing these issues requires both legislative reform and structural changes to how healthcare is financed, delivered, and regulated.
To increase access, the United States could pursue several approaches:
(1) expand Medicaid in the remaining non-expansion states;
(2) establish a robust public option alongside private insurance markets;
(3) empower the federal government to negotiate prescription drug prices;
(4) invest in federally qualified health centers (FQHCs) and rural health clinics;
(5) strengthen mental health parity enforcement;
(6) reform medical education funding to incentivize primary care careers;
(7) expand telehealth coverage permanently following COVID-19 emergency authorizations; and
(8) address social determinants of health through housing, nutrition, and transportation programs.
Section 4: References
The following sources were consulted in preparing Sections 2 and 3 of this document:
Gallup World Poll - Healthcare Access Data 2022: (www.gallup.com)
World Health Organization - Universal Health Coverage: (www.who.int)
Organisation for Economic Co-operation and Development (OECD) Health Statistics 2023: (www.oecd.org)
Commonwealth Fund - Mirror Mirror 2021: Reflecting Poorly: (www.commonwealthfund.org)
Kaiser Family Foundation - Health Coverage and the Uninsured: (www.kff.org)
Centers for Medicare & Medicaid Services (CMS): (www.cms.gov)
Health Resources and Services Administration (HRSA): (www.hrsa.gov)
World Bank - Out-of-Pocket Health Expenditure:
https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS
Harvard T.H. Chan School of Public Health - US Healthcare: (www.hsph.harvard.edu)
European Observatory on Health Systems and Policies: (eurohealthobservatory.who.int)
Section 5: U.S. Organizations Advocating to Improve Healthcare Access
| Organization Name | Contact Information | Primary Activity in This Area |
|---|---|---|
| Families USA |
www.familiesusa.org (202) 628-3030 |
National nonprofit advocating for high-quality, affordable health care for all Americans through state and federal policy reform, including Medicaid expansion, ACA protection, and insurance market reforms. Publishes state-by-state analyses of the uninsured and underinsured populations and leads coalitions advocating for universal coverage. |
| National Association of Community Health Centers (NACHC) |
www.nachc.org contact@nachc.org (301) 347-0400 |
National organization representing 1,400+ federally qualified health centers serving 30+ million patients in medically underserved areas, advocating for sustained federal funding of the health center program. Champions community health centers as the primary strategy for providing comprehensive primary care access to uninsured and low-income populations. |
| Commonwealth Fund |
www.commonwealthfund.org (212) 606-3800 |
Private foundation publishing international health system comparisons and domestic research on health care access barriers, informing federal and state policies to improve coverage and access. Its annual Mirror Mirror report on health system performance is the most frequently cited benchmark for evaluating U.S. healthcare access against peer nations. |
| Robert Wood Johnson Foundation (RWJF) |
www.rwjf.org (877) 843-7953 |
Nation's largest health philanthropy funding research and programs to build a Culture of Health in which everyone has fair access to high-quality health care. Major funder of Medicaid expansion outreach, community health worker programs, and health equity research that documents and addresses healthcare access barriers. |
| National Health Law Program (NHeLP) |
healthlaw.org nhhelp@healthlaw.org (919) 968-6308 |
Legal advocacy organization protecting and advancing health rights of low-income people through litigation, policy analysis, and training. Has won landmark legal victories ensuring Medicaid access for low-income individuals and protecting immigrants' rights to emergency health care. |
| Cover the Uninsured / Enroll America | www.getinsured.com | Coalition connecting uninsured Americans with available coverage through marketplace enrollment assistance, Medicaid outreach, and navigator services. Has helped millions of Americans access health coverage through ACA marketplaces, Medicaid, and CHIP by reducing enrollment barriers and providing multilingual assistance. |
| National Partnership for Women and Families |
www.nationalpartnership.org info@nationalpartnership.org (202) 986-2600 |
Nonprofit advocacy organization working to advance healthcare access for women, including maternal health, reproductive care, and mental health services. Advocates for Medicaid expansion, prenatal care access, and elimination of racial disparities in maternal health care. |
Section 6: Individuals Advocating to Improve Healthcare Access
| Name, Title & Contact | Selected Publications on Healthcare Access |
|---|---|
| Karen Davis, PhD Eugene and Mildred Lipitz Professor, Johns Hopkins Bloomberg School of Public Health; Former President, Commonwealth Fund kdavis@jhsph.edu |
(1) "Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally," Commonwealth Fund, 2014 — Established the definitive international benchmark showing U.S. healthcare access as worst among comparable high-income nations despite the highest spending, driving advocacy for universal coverage.. (2) "The Healthcare Costs of Incomplete Insurance Coverage: International Comparisons," Health Affairs, 2009 — Quantified the health and economic costs of incomplete health insurance coverage, providing the evidence base for universal coverage advocacy.. (3) "Achieving a High Performance Health System with Universal Access: What the United States Can Learn from Other Countries," Annals of Internal Medicine, 2007 — Comparative analysis of how universal coverage models in peer nations achieve better access outcomes at lower cost, informing U.S. health reform policy proposals.. |
| John Z. Ayanian, MD, MPP Director, Institute for Healthcare Policy and Innovation, University of Michigan jayanian@umich.edu |
(1) "The Impact of Insurance Coverage and Continuity on Healthcare Access," JAMA Internal Medicine, 2013 — Documented how expanding Medicaid coverage dramatically improves healthcare access, utilization of preventive services, and health outcomes for low-income adults.. (2) "Healthcare Access and Outcomes Following Medicaid Expansion," New England Journal of Medicine, 2014 — Evaluated the health effects of the ACA Medicaid expansion, finding significant improvements in access and early evidence of improved health outcomes among newly insured adults.. (3) "Disparities in Health and Health Care for People with Disabilities," Health Affairs, 2010 — Documented the significant healthcare access barriers facing people with physical and cognitive disabilities and recommended policy reforms to eliminate discrimination in coverage and care.. |
| Steffie Woolhandler, MD, MPH Distinguished Professor of Public Health, CUNY Graduate School of Public Health; Co-Founder, Physicians for a National Health Program swoolhandler@msm.com |
(1) "Costs of Health Care Administration in the United States and Canada," New England Journal of Medicine, 2003 — Documented that administrative overhead consumes 31% of U.S. health spending versus 17% in Canada, showing that administrative simplification through universal coverage would free enormous resources for direct care access.. (2) "The U.S. Health Care System: A Prescription for Reform," New England Journal of Medicine, 2011 — Proposed a single-payer national health insurance program as the most effective mechanism for achieving universal healthcare access while reducing overall spending.. (3) "Health Care Reform in the United States: How Will We Get There?," American Journal of Public Health, 2008 — Analyzed the political and policy paths to universal healthcare access, finding that single-payer models produce the most equitable access outcomes in international comparison.. |
| Sara Rosenbaum, JD Harold and Jane Hirsh Professor Emerita of Health Law and Policy, George Washington University Milken Institute School of Public Health sarar@gwu.edu |
(1) "The Primary Care Infrastructure and Its Role in Health Reform," New England Journal of Medicine, 2011 — Argued that community health centers and primary care investment are the essential infrastructure for universal healthcare access, regardless of insurance reform approach.. (2) "Medicaid at Fifty: No Longer Limited to the Poor," Health Affairs, 2015 — Documented Medicaid's evolution from a welfare program to a near-universal safety net, and argued for its expansion as the most cost-effective mechanism for covering uninsured populations.. (3) "Realizing Health Reform's Potential: Legal Issues in Medicaid Expansion," Health Affairs, 2012 — Analyzed the legal framework for Medicaid expansion under the ACA and proposed implementation strategies to maximize access for eligible populations.. |
| Leighton Ku, PhD, MPH Professor, Department of Health Policy and Management, George Washington University Milken Institute School of Public Health lku@gwu.edu |
(1) "How Medicaid Expansion Affects Health System Use and Costs," Health Affairs, 2013 — Evaluated the impact of state Medicaid expansions on healthcare access and utilization, finding significant improvements in preventive care, hospitalization rates, and chronic disease management.. (2) "State Spending Under Medicaid and CHIP: Effects on Access and Cost," Urban Institute, 2009 — Documented how state Medicaid funding levels directly determine healthcare access for low-income children and families, informing federal matching rate policy.. (3) "Improving Efficiency and Value in Health Care: Introduction," Journal of Health Politics, Policy and Law, 2010 — Introduced a framework for evaluating health care system efficiency and value that includes access equity as a core performance dimension alongside cost and quality.. |
| Uwe E. Reinhardt, PhD (1937–2017) James Madison Professor of Political Economy, Princeton University; Health Economist |
(1) "Priced Out: The Economic and Ethical Costs of American Health Care," Princeton University Press, 2019 — Posthumously published definitive critique of how U.S. health care pricing systematically excludes low- and middle-income Americans from accessing care they can afford.. (2) "Can Efficiency in Health Care Be Left to the Market?," Journal of Health Politics, Policy and Law, 2001 — Argued that market mechanisms alone cannot achieve universal healthcare access and that government price regulation and coverage mandates are necessary complements.. (3) "It's the Prices, Stupid: Why the United States Is So Different from Other Countries," Health Affairs, 2003 — Demonstrated that U.S. health care is not used more than in peer nations but costs dramatically more due to prices, and that access failures reflect these pricing structures.. |
| David U. Himmelstein, MD Distinguished Professor of Public Health, CUNY Graduate School of Public Health; Co-Founder, Physicians for a National Health Program |
(1) "Medical Bankruptcy in the United States, 2007: Results of a National Study," American Journal of Medicine, 2009 — Documented that 62% of personal bankruptcies in the U.S. are medically related, showing how inadequate health coverage creates catastrophic financial barriers to healthcare access.. (2) "A National Health Program for the United States: A Physicians' Proposal," New England Journal of Medicine, 1989 — Proposed the comprehensive single-payer national health insurance framework that has served as the primary policy vehicle for universal coverage advocacy for three decades.. (3) "Health Care Administrative Costs in the United States and Canada, 2017," New England Journal of Medicine, 2020 — Updated administrative cost comparison showing U.S. administrative overhead consumes $812 billion annually — savings from which could fund universal healthcare access.. |
Frequently Asked Questions
Where does the United States rank in global healthcare access?
The United States ranks 25th among countries with populations over 5 million in healthcare access, with 87.6% of Americans reporting access to quality care in their area, according to the 2022 Gallup World Poll. This places the U.S. behind Western European nations, Canada, Australia, and several East Asian countries.
How many Americans are uninsured or underinsured?
An estimated 25 to 30 million Americans remain uninsured. Tens of millions more are underinsured, meaning they have coverage but face high deductibles and out-of-pocket costs that often deter them from seeking necessary care.
Why does the U.S. spend so much on healthcare yet rank so low in access?
The U.S. spends approximately $12,530 per person annually — more than any other nation — yet achieves lower access scores due to its fragmented, employer-based insurance system, high prescription drug costs, and significant administrative complexity. Countries with universal or single-payer systems achieve broader coverage at lower out-of-pocket costs.
What groups of Americans are most vulnerable to lacking healthcare access?
People who are self-employed, part-time workers, or unemployed face the greatest risk because the U.S. system is predominantly employer-based. Rural and frontier residents are also particularly vulnerable due to acute provider shortages in those geographic areas.
What have higher-ranked countries done differently to improve healthcare access?
The top-ranked countries have generally implemented national health insurance, single-payer systems, or universal coverage models that provide broader coverage with lower out-of-pocket costs. These systems reduce financial barriers to care and typically involve less administrative complexity than the U.S. model.
What are the key policy options the U.S. could pursue to improve healthcare access?
Key strategies include expanding insurance coverage to reduce the uninsured population, lowering prescription drug costs, addressing rural provider shortages, reducing administrative burden in the healthcare system, and studying universal or near-universal coverage models used successfully by peer nations.
About the Author
Ronald Bonfilio has devoted his career to public service spanning more than five decades. His service began with the U.S. Army from 1966 to 1968, where he conducted medical laboratory research at Fort Detrick and at the Walter Reed Army Institute of Research. He subsequently held a distinguished series of federal positions, including roles with the National Cancer Institute, the National Institutes of Health, the U.S. Agency for International Development (Vietnam), the Special Inspector General for Iraq Reconstruction, and the U.S. State Department (Iraq), where he served as a Senior Economic Advisor and Agricultural Advisor. He also served 15 years with the U.S. Government Accountability Office as a Program Analyst and Auditor.
Ronald Bonfilio holds a degree in Economics from the University of Maryland, and degrees in Chemistry and a Master of Business Administration from the University of Massachusetts. He is a former Certified Public Accountant.