What Americans Get For Their Healthcare Dollars

SITUATION:

Healthcare costs sit near the top of American concerns every election cycle. Premiums are rising again in 2026, and the debate over whether the United States should look more like Canada or the United Kingdom has resurfaced.

The average unsubsidized health insurance premium in the United States reached $752 a month in 2026, a 21% increase from 2025. Some states saw far larger jumps. Arkansas premiums rose 67% in a single year.

Much of that increase traces back to the expiration of enhanced federal subsidies first introduced in 2021. Congress has not extended them, and insurers are passing the cost difference directly to policyholders.

At the same time, rural hospitals across the country are closing or cutting services. More than 100 have shut down over the past decade, and hundreds more are now operating at a financial loss.

Advocates for a government-run system point to Canada and the United Kingdom as proof that healthcare can cost less and cover everyone. Critics point to long specialist wait times in both countries as proof of the opposite. Both sides are citing real numbers. The full picture is more complicated than either slogan suggests.

THE TRUTH:

Start with the plainest number: total spending. The United States spends about $13,432 per person on healthcare each year, more than any other developed nation.

The United Kingdom spends $6,023. Canada spends roughly $9,626, combining public and private spending. That gap does not disappear once outcomes are factored in: the United States ranks last among 10 high-income nations for access, efficiency, and health outcomes, according to a Commonwealth Fund analysis, despite spending the most.

Premiums and taxes are not an apples-to-apples comparison, but they can be placed side by side.

A UK household pays roughly £4,500 a year, about $5,700, in taxes that fund the National Health Service. Canada’s government spends about $6,500 per person on its Medicare system, funded primarily through taxation. A single American paying the 2026 average premium of $752 a month would spend $9,024 a year before ever seeing a doctor, a figure that does not include deductibles, copays, or coinsurance.

Wait times tell a different story. This is where the US system performs better by most measures.

Just 27% of Americans report waiting a month or more for a specialist appointment. In Canada, that figure is 61%, and Norway ties Canada at the same rate. The United Kingdom’s National Health Service has its own backlog: the median wait for elective surgery reached approximately 14 weeks in 2026, and England’s waiting list has topped 7 million people at various points in recent years.

Life expectancy cuts against the US system, though the reasons are not simple.

Americans born in 2024 can expect to live 79.0 years, the highest figure in US history. Comparable wealthy nations average 82.7 years, a gap of roughly 3.7 years that has persisted for more than a decade. Part of that gap reflects factors outside any hospital’s control: research from the National Bureau of Economic Research found that higher US mortality among young adults is driven largely by accidents and homicides, not medical care.

At older ages, higher rates of heart disease, linked partly to a US obesity rate nearly double Canada’s, account for much of the remaining difference.

Out-of-pocket cost is where the American system creates its clearest disadvantage. When Americans report an unmet medical need, cost is the reason they avoid seeking care more than half the time. When Canadians report an unmet need, waiting time is the reason more than half the time.

Neither system has solved the problem. Each has simply chosen a different way to ration care.

Prescription drugs are where the price gap grows even larger, and the comparison gets more complicated.

US brand-name drug prices ran nearly 2.78 times as high as comparable OECD countries in 2022, according to a RAND Health Care analysis prepared for the federal government, and at least 3.22 times as high even after adjusting for US manufacturer rebates. Insulin shows the extreme version of the pattern: US prices ran nearly 10 times the average across 33 peer countries, more than 10 times prices in the United Kingdom, and more than six times prices in Canada.

That gap narrows considerably once generic drugs are counted alongside brand names.

A University of Chicago analysis found that once both brand-name and generic drugs are included, rather than just the branded products that dominate most price comparisons, US public-sector net prices were actually 18% lower on average than in five peer countries. Brand-name drugs represent only about 7% of US prescription volume, so a comparison built solely on brand names tells a skewed story in either direction.

Much of the most expensive medication in question is not actually a different drug.

Many of the highest-priced brand-name drugs cited in international comparisons are the identical product, made by the same manufacturer, sold at a lower price abroad. The reason traces back to how prices get set rather than how the drug gets made. Manufacturers in the United States are largely free to set a list price at launch. Canada and the United Kingdom instead use a system called external reference pricing, benchmarking a new drug’s price against its cost in a basket of other countries. Canada’s Patented Medicine Prices Review Board uses a basket of 11 peer countries to set price ceilings on patented medicines.

Manufacturers have, in documented cases, chosen to withdraw a product from a lower-price market entirely rather than let that price become a reference point elsewhere, a strategy pricing consultants describe as protecting the international pricing corridor.

The United States has begun testing a version of this same leverage. Under the Inflation Reduction Act, Medicare can now directly negotiate a maximum fair price for a limited number of high-spending drugs that face no generic competition, reversing a federal ban on Medicare price negotiation that had been in place since 2003. A separate executive order issued in May 2025 directs federal officials to pursue most-favored-nation pricing, aiming to align US prices with those paid in other developed countries.

Economists studying the idea caution that either approach carries a trade-off. If US prices are pegged to prices paid elsewhere, manufacturers may respond by raising prices in those other countries to preserve their margins, potentially making drugs less affordable in the very countries the US is trying to match.

Direct-to-consumer prescription drug advertising marks one of the clearest differences between the American system and its Canadian and British counterparts, though it is barely a comparison at all, since almost nowhere else permits it.

The United States and New Zealand are the only two countries in the world that allow drug companies to advertise prescription medications directly to the public. Everywhere else, including Canada and the United Kingdom, the practice is banned over concerns that a short commercial cannot adequately convey a drug’s risks alongside its benefits. The American pharmaceutical industry now spends more than $10 billion a year on this advertising.

The issue has become a rare point of agreement across the political spectrum.

Sitting senators from opposing parties have introduced legislation to ban prescription drug advertising outright, the American Medical Association has called for a full ban, and the current administration has separately pursued new restrictions on the ads through the FDA. Research on the other side of the debate finds these ads also prompt some patients to seek out care they would not otherwise pursue, meaning a ban is not a costless fix either.

Administrative overhead produces one of the starkest numbers in the entire comparison, and it runs counter to a common assumption.

In 2017, the US spent $2,497 per person on healthcare administration, or 34.2% of total health expenditures. Canada spent $551 per person, or 17.0%. Insurance overhead alone explains most of that gap: private insurers in the United States spent $844 per person on overhead, compared with just $146 in Canada.

Much of the US total comes from private companies administering Medicare Advantage and Medicaid managed-care plans, both of which carry higher overhead than traditional, government-run Medicare and Medicaid.

The same pattern shows up within the US system alone, without any international comparison required. Administrative costs for traditional Medicare and Medicaid run between 2% and 5% of spending, while private insurance administrative costs run around 17%, roughly three to eight times higher for the same basic function.

This does not mean a government-run system delivers better care. It means the specific job of processing claims and paperwork costs less when one payer does it than when many payers compete to do it.

The savings do not translate into shorter wait times. They show up as lower total spending on tasks that do not involve treating a patient.

Rural access is where all of this converges, and the picture is deteriorating.

More than 40% of rural hospitals are now operating at a financial loss. The Center for Healthcare Quality and Payment Reform counted 734 rural hospitals at risk of closure as of January 2026, about a third of all rural facilities in the country.

Closures rarely happen all at once. Hospitals first cut services that lose the most money.

Between 2011 and 2024, 331 rural hospitals stopped offering obstetric care, roughly 27% of all rural OB units nationwide. Florida lost 71% of its rural OB units, the highest share of any state.

The reasons for these closures are not primarily about government inefficiency. Research from the Center for Healthcare Quality and Payment Reform found that private insurers, not Medicare or Medicaid, are the largest source of financial losses at many rural hospitals, because rural facilities depend on private payers for the majority of their revenue and those payers frequently reimburse below the actual cost of care.

Fixed costs compound the problem. Rural hospitals must staff emergency rooms and maintain equipment regardless of how many patients walk through the door on a given day. A 2018 study found that states which expanded Medicaid saw fewer rural hospital closures and stronger financial performance, largely because more paying patients offset those fixed costs.

The 2025 federal budget law, known as the One Big Beautiful Bill Act, is projected to cut rural Medicaid spending by approximately $137 billion over 10 years, and rural hospitals in Medicaid expansion states are expected to see Medicaid revenue drop by nearly 10% on average as a result.

Physician supply compounds the access problem further: only 9.3% of US physicians currently practice in small-town or rural settings, and among physicians under 40, zero percent report a preference for rural practice, according to a 2026 survey by The Medicus Firm.

More than 83 million Americans now live in a federally designated primary care shortage area.

One driver of the physician shortage is specific to reproductive care and has emerged since 2022. A national study published in JAMA found a 4% drop in OB-GYN practitioners per 100,000 reproductive-age women in states with the most restrictive abortion laws, compared with no decline in states without new restrictions.

The pipeline problem is measurable in medical training data as well: OB-GYN residency applications fell 6.7% in states with abortion bans during the 2023-2024 cycle, while states where abortion remained legal saw a slight 0.4% increase over the same period.

Idaho offers the clearest single-state example. The state lost 35% of its obstetric physicians between August 2022 and December 2024, according to research cited by Stateline. Physicians who remain in ban states report treating time-sensitive conditions such as miscarriage and ectopic pregnancy under new legal uncertainty that did not exist before 2022.

Texas illustrates the scale of the problem in a large state. More than 45% of Texas counties are now classified as maternity care deserts, meaning no obstetric clinician and no hospital or birth center offering obstetric services exists locally. State projections show Texas will have 15% fewer OB-GYNs than needed by 2030.

The workforce decline has coincided with a measurable rise in mortality. A Johns Hopkins Bloomberg School of Public Health study of 14 states with complete or six-week abortion bans found a 9.2% increase in pregnancy-associated deaths after the bans took effect, equivalent to an estimated 68 excess deaths. Researchers excluded deaths involving COVID-19 to isolate the policy’s effect from the pandemic.

Infant mortality has moved in the same direction nationally. A separate analysis of CDC birth data from 2012 to 2023 found infant mortality rates in ban states are 5.6% above the expected rate, equivalent to an estimated 478 excess infant deaths.

That increase was not distributed evenly. Black infants in ban states saw mortality rates run roughly 11% above expected levels, about double the increase observed for the overall population. Infants with congenital anomalies saw a similarly large increase, and Southern states recorded the sharpest effects nationwide.

A second, independent Johns Hopkins analysis using a different methodology found a smaller but still measurable increase, 4.2% in infant mortality not attributable to congenital anomalies. Researchers on that study noted the pattern suggests restrictive abortion policies may be reversing years of prior progress on infant mortality in the affected states.

Nationally, more than a third of US counties are maternity care deserts, and more than 2.3 million women of childbearing age live in one. This trend predates the 2022 Supreme Court decision that overturned Roe v. Wade, but multiple studies indicate it has accelerated in states that enacted new restrictions afterward.

Federal workforce reductions add a separate layer to the access question. In March 2025, the Department of Health and Human Services cut approximately 20,000 positions as part of a restructuring effort tied to the Department of Government Efficiency (DOGE). The cuts included 3,500 positions at the FDA, 2,400 at the CDC, 1,200 at the NIH, and 300 at the Centers for Medicare and Medicaid Services.

Some of those cuts were later reversed. Hundreds of CDC employees within the National Institute for Occupational Safety and Health were reinstated in January 2026 after being laid off the previous year. By October 2025, independent tracking found that roughly 24% of CDC staff had been cut overall, through a combination of the March restructuring, additional layoffs during a 43-day government shutdown, and voluntary early retirements.

WHY IT MATTERS:

None of this data supports a simple conclusion, and readers should be skeptical of anyone who claims it does. The United States delivers shorter specialist wait times than Canada or the United Kingdom, a genuine advantage that reflects real trade-offs those countries have made in exchange for universal coverage and lower total spending.

At the same time, the belief that government administration is inherently less efficient than private administration does not hold up against the specific data on healthcare claims processing. Traditional Medicare’s administrative overhead runs a fraction of private insurance’s, both internationally and within the US system specifically.

Prescription drug pricing adds a similar wrinkle to the broader story. American patients often pay several times more for the exact same medication, from the exact same manufacturer, than patients in Canada or the United Kingdom, not because the drug costs more to produce, but because of who has the power to say no to the price being asked. That distinction has produced one of the few areas where lawmakers from both parties, physician groups, and the current administration largely agree on the underlying problem, even where they disagree sharply on the fix.

Rural Americans are experiencing the sharpest edge of these trends first. A hospital that closes its maternity ward doesn’t reopen it easily, and a young doctor who chooses not to practice in a rural county or a state with new legal restrictions on reproductive care is a decision that compounds over years, not months.

The reasons behind hospital closures are more specific than “big government” or “big insurance” alone. Private insurers reimbursing below the cost of care, fixed costs that do not shrink with patient volume, and now federal Medicaid reductions under the 2025 budget law are all measurable contributors working at once.

The OB-GYN shortage tied to abortion restrictions deserves particular attention because it is separate from the abortion debate itself. Regardless of one’s view on abortion policy, the data shows a measurable decline in the broader obstetric and gynecological workforce in states that enacted the strictest new laws, affecting access to prenatal care, cancer screenings, and treatment for pregnancy complications unrelated to elective abortion.

The mortality data compounds that concern. Multiple peer-reviewed studies, using different methods and different data sets, independently found higher pregnancy-associated deaths and higher infant deaths in ban states after the laws took effect. That level of agreement across separate research teams is not something a reader should dismiss as coincidence or politics, whatever their view of the underlying abortion policy.

Federal staffing cuts at HHS, the CDC, the FDA, and the NIH add a layer of uncertainty to a system already under strain. Some reductions have since been partially reversed by the courts, suggesting the initial cuts were not fully or legally planned before they were implemented, a detail that matters regardless of one’s view on the appropriate size of federal health agencies.

The honest conclusion is not that one country’s system is right and the others are wrong. It is that every healthcare system rations care somewhere, whether through wait times, through cost, through provider shortages, or through some combination of all three. The question worth asking is not which system is perfect. It is which trade-offs a given community, and a given country, is willing to accept, and which ones it is not.

SOURCES:

• ValuePenguin, “Average Health Insurance Cost in 2026”
• MoneyGeek, “How Much Does Health Insurance Cost? (2026 Rates)”
• Peterson-KFF Health System Tracker, international healthcare spending comparisons
• The Commonwealth Fund, international health system performance rankings
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• World Population Review, “Health Care Wait Times by Country 2026”
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• KFF, “How Does U.S. Life Expectancy Compare to Other Countries?”
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• The Medicus Firm, “The Rural Doctor Shortage in 2026”
• JAMA, national study on OB-GYN workforce decline in states with abortion restrictions
• Johns Hopkins Bloomberg School of Public Health, study on pregnancy-associated mortality in abortion-ban states
• Johns Hopkins Bloomberg School of Public Health, “Two New Studies Provide Broadest Evidence to Date of Unequal Impacts of Abortion Bans”
• AJMC, “Infant Mortality Increases Across US Following Dobbs Decision”
• AJMC, “Post-Dobbs Abortion Bans Raised Birth Rates and Strained Food Aid Program”
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