The United States consistently ranks at or near the bottom of wealthy nations on most major health measures, despite spending far more on healthcare than any peer country. Average life expectancy across OECD countries reached about 81 years in 2023, while the U.S. landed in a lower tier, between 75 and 80 years.1OECD Publishing. Health at a Glance 2025: OECD Indicators That gap is not a quirk of one statistic. It shows up in maternal deaths, infant survival, drug overdoses, gun violence, chronic disease, and how long people can expect to live at virtually every age. The picture is genuinely grim, and the reasons are more layered than any single policy failure.
The Life Expectancy Gap Is Not New
Americans sometimes assume their country trails Europe by a year or two because of a rough stretch during the pandemic. The reality is that the U.S. life expectancy disadvantage began in the 1950s and has steadily worsened over four decades.2PubMed Central. Falling Behind: The Growing Gap in Life Expectancy Between the United States and Other Countries, 1933-2021 From the mid-1930s through the late 1940s, the U.S. was actually gaining ground on peer nations. Then gains slowed, and by the time other wealthy countries hit an era of rapid improvement, the U.S. was falling behind. Between 2010 and 2019, American life expectancy grew by only about 0.06 years per year, while comparable nations did better in every phase.2PubMed Central. Falling Behind: The Growing Gap in Life Expectancy Between the United States and Other Countries, 1933-2021 During that same long arc, 56 countries on six continents surpassed the U.S. in life expectancy.
The divergence is especially stark for women. Up through the late 1970s, American women tracked closely with women in comparable high-income countries. Then they started to fall behind so dramatically that by 2007, U.S. female life expectancy corresponded to what peer countries had achieved a full decade earlier.3BMJ Open. Improving life expectancy: how many years behind has the USA fallen? A cross-national comparison among high-income countries from 1958 to 2007 The biggest mortality gap was among people aged 15 to 49, where by 2007 the U.S. had fallen roughly 40 years behind its peers for both men and women. That is not a typo: the death rates in that age group looked like what comparable countries experienced four decades prior.
Mothers and Babies
Maternal mortality is one of the starkest comparisons. In 2022, about 22 American women died for every 100,000 live births. Norway recorded zero. Switzerland reported about 1 per 100,000. Australia came in around 3.5, the United Kingdom around 5.5, and Canada around 8.4.4BMJ. US maternal mortality is far higher than that of other rich nations, study reports These are not countries with radically different biology; they are countries with different healthcare structures, prenatal care systems, and social safety nets. The U.S. spends more on healthcare than any of them and has far worse maternal outcomes.
Infant mortality tells a related but slightly different story. Neonatal mortality, meaning deaths in the first month of life, is actually similar between the U.S. and European countries. The gap opens up in postneonatal mortality, deaths between one and twelve months, and it is driven heavily by poor birth outcomes among lower-income families.5PubMed Central. Why Is Infant Mortality Higher in the United States Than in Europe? In other words, the U.S. is reasonably good at keeping premature and critically ill newborns alive in the hospital, but the social and economic conditions that families return to afterward create a survival gap that peer countries largely avoid.
Deaths of Despair and Drug-Related Mortality
The phrase “deaths of despair” covers suicide, drug overdose, and alcohol-related deaths. The U.S. stands to gain more life expectancy from eliminating these deaths than any other wealthy country studied: roughly 1.4 years for men and 0.6 years for women.6PubMed Central. Educational inequalities in deaths of despair in 14 OECD countries: a cross-sectional observational study For comparison, countries like Italy and Spain would gain less than 0.3 years for men and under 0.1 years for women. The U.S. was also ranked among the top ten countries globally for the highest deaths-of-despair mortality rates for both sexes, alongside countries like Lesotho, Belarus, and Russia.7PubMed. Deaths of despair-associated mortality rates globally: a 2000-2019 sex-specific disparities analysis
The engine behind this is drug-related mortality. A comparison of trends across the U.S., Canada, and the U.K. from 2001 to 2019 found that drug-related deaths were the primary driver of rising despair-related mortality, with dramatic increases across all U.S. age groups.8BMJ Open. Comparing trends in mid-life ‘deaths of despair’ in the USA, Canada and UK, 2001–2019: is the USA an anomaly? Canada and parts of the U.K. saw increases too, but at much lower absolute levels. The U.S. also had generally the highest suicide rates among the countries compared, and alcohol-specific mortality increased at older ages, particularly for American men, while it actually fell in Scotland from previously high levels.
When you combine drug and firearm deaths, the effect on American life expectancy is substantial. By 2020, these two causes alone reduced male life expectancy by about 1.7 years, up from about 0.7 years in 2000. Without drugs and guns, American men would have had a life expectancy of roughly 78 years in 2019, and women about 82.3 years.9PubMed. The effect of drugs and guns on life expectancy in the United States, 2000-2020 Those numbers would still leave the U.S. below the OECD average, but the gap would narrow considerably. Drug and firearm deaths are not an immutable feature of any society; they are driven by policy choices around drug regulation, prescribing practices, harm reduction, and gun access.
Diet and the Built Environment
Americans eat a diet that looks different from what people eat in most other wealthy countries, and the difference is measurable. A systematic review of ultra-processed food consumption worldwide found that the U.S. and the U.K. had the highest levels, with more than half of total energy intake coming from ultra-processed foods.10PubMed Central. A Systematic Review of Worldwide Consumption of Ultra-Processed Foods: Findings and Criticisms Italy, on the other end, reported roughly 10 percent. Ultra-processed foods are linked to higher rates of obesity, cardiovascular disease, and metabolic conditions, so this dietary pattern feeds directly into the chronic disease burden that pulls American health outcomes down.
The physical environment reinforces the dietary problem. American cities and suburbs are overwhelmingly designed around car travel, and rates of walking and cycling as daily transportation are far lower than in Europe. Research comparing active transport across countries concluded that government transport and land-use policies explain much of this gap, and changing those policies would be essential to raising physical activity levels in the U.S.11PubMed Central. Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data In many European cities, walking or cycling to the store, to school, or to work is a normal daily activity. In most of the U.S., it requires deliberate effort or is simply impractical because distances are too large and infrastructure is absent. The result is that Europeans accumulate physical activity as part of their day without thinking about it, while Americans have to carve out time for exercise and often don’t.
Spending More, Getting Less
The U.S. spent about 17.8 percent of GDP on healthcare in 2016, roughly double what peer countries spent, yet it had the lowest life expectancy and the highest infant mortality among 11 high-income nations compared in a major analysis. Utilization rates were largely similar, so Americans were not getting twice as many services for twice the price.12PubMed. Health Care Spending in the United States and Other High-Income Countries The spending gap has only grown since that analysis. Where the money goes is a complex question involving higher administrative costs, higher drug prices, higher physician salaries, and greater intensity of specialist care, but the bottom line is that Americans pay more per capita for health than anyone in the world and get measurably worse population-level results.
There is a wrinkle worth noting: the U.S. does perform well on certain clinical prevention measures. Screening rates for common cancers and the diagnosis and control of chronic conditions like hypertension and diabetes are comparable to or better than peer countries.13PubMed. Comparing US prevention efforts to other high-income countries In other words, for the portion of the population that has access to the healthcare system, the care delivered for chronic disease management is decent. The problem is not primarily what happens inside the doctor’s office. It is everything that surrounds it: who gets through the door, what conditions their lives produce in the first place, and what support exists outside the clinical encounter.
Cost as a Barrier to Care
About 8 percent of Americans are uninsured, and roughly a quarter of those who do have insurance face high out-of-pocket costs or deductibles that discourage them from seeking care. The result is that Americans are far more likely than people in peer countries to skip needed medical treatment because of cost.14Commonwealth Fund. U.S. Health Care from a Global Perspective, 2026: Expanded Edition A survey of the general population across 11 countries found that U.S. adults were significantly more likely to forgo care because of cost, struggle to pay for care even with insurance, and face time-consuming insurance complexity compared to every other country in the study.15PubMed. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries
This matters for population health in a way that is hard to overstate. When people delay care because they cannot afford a copay, minor conditions become serious ones. When a diabetic rations insulin because it costs too much, they end up in the emergency room. When a person with chest pain weighs whether an ER visit is worth the bill, survivable conditions become fatal ones. Countries with universal or near-universal coverage largely remove that calculation from their citizens’ lives.
Inequality Within the Numbers
National averages hide enormous variation within the U.S. Between 2000 and 2019, life expectancy differed dramatically by race and ethnicity. The Asian American and Pacific Islander population had a life expectancy of about 85.7 years by 2019, while the American Indian and Alaska Native population sat at roughly 73.1 years, a gap of more than 12 years between groups living in the same country.16PubMed Central. Life expectancy by county, race, and ethnicity in the USA, 2000–2019: a systematic analysis of health disparities The Latino population reached about 82.2 years, the White population about 78.9, and the Black population about 75.3. Over that two-decade span, the Black-White gap narrowed, but the gap for American Indian and Alaska Native populations actually widened. These internal disparities mean that some subpopulations in the U.S. rival the healthiest countries on earth, while others have outcomes closer to low-income nations.
Wealth-related health inequality is also more extreme in the U.S. than in Europe. An analysis of older adults across the U.S. and 14 high-income countries found that the U.S. had higher levels of wealth-related inequality in self-reported health than its European counterparts.17PubMed Central. Wealth-related inequalities in self-reported health status in the United States and 14 high-income countries Being wealthy in America protects your health to some degree, but even America’s wealthiest citizens do not enjoy the same survival advantages that European social systems provide more broadly. The research suggests that social policy and wealth redistribution mechanisms play a meaningful role in shaping health outcomes, and that the U.S. gap is not simply about individual choices or genetics.
Labor Protections and Chemical Regulation
Health is not only shaped by hospitals and clinics. Workplace policies play a direct role. A comparison of 22 countries found that only three, the United States, Canada, and Japan, had no national policy requiring employers to provide paid sick days for workers who need to miss five days to recover from something like the flu. The U.S. was the only country of the 22 that did not provide paid sick leave for a worker undergoing a 50-day cancer treatment.18PubMed Central. Ensuring a healthy and productive workforce: comparing the generosity of paid sick day and sick leave policies in 22 countries When people cannot afford to stay home while sick, they go to work, they delay treatment, and they spread infectious disease. This is one of those structural features that does not show up in healthcare spending data but quietly degrades population health.
Chemical regulation offers another window into how policy environments differ. Under the European Union’s REACH framework, companies are required to develop safety data on chemicals’ effects on human health and the environment before those chemicals enter the market. Under the U.S. Toxic Substances Control Act, companies are generally not required to develop such information unless the EPA goes through the process of issuing a specific rule demanding it.19U.S. Government Accountability Office. Chemical Regulation: Comparison of U.S. and Recently Enacted European Union Approaches to Protect against the Risks of Toxic Chemicals For existing chemicals already on the market, the U.S. system places an even lighter burden on manufacturers. The practical effect is that Americans are exposed to a wider range of inadequately studied chemicals in consumer products, food packaging, and industrial processes. Whether this translates into a measurable mortality difference is debated, but the regulatory philosophies are genuinely different, and the EU approach is more precautionary by design.
That said, the picture of transatlantic regulatory precaution is more complicated than the common narrative suggests. A quantitative comparison of regulation across dozens of risk areas found that averaging over all risks, there was no significant overall difference in precaution between the U.S. and Europe over the full study period, though there was some evidence of a modest shift toward greater European precaution since around 1990.20PubMed. Precautionary regulation in Europe and the United States: a quantitative comparison On some individual risks, the U.S. has actually been more cautious. The common story of “Europe bans everything while America allows everything” is an oversimplification, though the chemical safety gap in particular is real.
Why High Spending Does Not Fix the Problem
A natural reaction to all this data is to wonder why a country that spends so heavily on healthcare cannot buy its way out of poor outcomes. Part of the answer is that healthcare is only one input into health. The social determinants that shape how people live, what they eat, whether they can afford to see a doctor, whether they can take a sick day, whether their neighborhood is walkable, whether they are exposed to gun violence, collectively matter at least as much as the quality of a hospital’s cardiac unit. Countries that spend less on healthcare but more on social infrastructure often come out ahead on every health measure that matters.
Another part is that the U.S. healthcare system is not designed as a unified system at all. It is a patchwork of employer-based insurance, government programs for the elderly and poor, individual market plans with varying deductibles, and a large uninsured population that receives care episodically through emergency rooms. This fragmentation creates administrative waste, gaps in continuity of care, and perverse incentives that reward treatment of acute illness over prevention. Countries with single-payer or tightly regulated multi-payer systems avoid much of this overhead and can direct resources toward population-level prevention strategies more effectively.
When Americans Do Well
It would be misleading to paint American health as uniformly terrible. As noted earlier, clinical prevention measures like cancer screening and chronic disease management are areas where the U.S. performs competitively. Survival rates for certain cancers, particularly breast, prostate, and colorectal cancers, are among the highest in the world, in part because of aggressive screening and treatment. Americans with good insurance and stable incomes have access to some of the most advanced medical technology available anywhere. The problem is distributional: those advantages are concentrated among people with resources, and the overall population averages are dragged down by the large share of Americans who face barriers to access, live in environments that promote poor health, or fall through the gaps in a fragmented system.
Certain demographic groups within the U.S. also achieve health outcomes that rival or exceed those of the healthiest nations. Asian Americans had a life expectancy of nearly 86 years by 2019, which would place them at the very top of international rankings.16PubMed Central. Life expectancy by county, race, and ethnicity in the USA, 2000–2019: a systematic analysis of health disparities Latino Americans reached about 82 years, outpacing the White population by more than three years, a pattern sometimes called the Hispanic mortality paradox because it persists even though Latino Americans on average have lower incomes and less access to insurance. These within-country differences reinforce the point that the American health disadvantage is not genetic or inevitable. It is produced by specific conditions that affect some groups more than others, and it is, in principle, fixable.