The U.S. and its people spend more on healthcare than all other wealthy nations, yet we have worse outcomes than other nations.
Whether you measure health spending on a per capita basis or as a percentage of gross domestic product, the U.S. spends more than two times the average of comparable countries, according to the American Public Health Association. Relative to the size of its economy, the U.S. spends a much greater amount on health care than other wealthy countries -- about twice as much per person as comparable countries. These charts from the Health System Tracker, show the different spending levels.
Nevertheless, U.S. outcomes for a broad range of diseases and conditions lag those in other wealthy countries. Additionally, life expectancy in the U.S. lags considerably behind life expectancy in comparable wealthy countries. The average for those countries for a child born in 2018 is 82.4 years, while it is 78.7 years for a child born in the U.S, again according to the Health System Tracker.
Despite its high-priced healthcare, the U.S. ranks significantly below comparable countries in many health outcomes, including the mortality rates for respiratory and circulatory diseases. This is shown in a series of charts in the Health System Tracker's "How does the quality of the U.S. healthcare system compare to other countries?" Most notably a chart shows that the U.S. ranks last in a measure of health care access and quality, higher rates of amenable mortality (a measure of the rates of death considered preventable by timely and effective care), than comparable countries. The charts that follow show that the U.S. has higher rates of maternal mortality and hospital admissions for chronic conditions that are risk factors for COVID-19 are more frequent in the U.S. than in comparable countries.
It is important to bear in mind that the comparable countries ensure universal access to healthcare, either through a government-run health system or laws effectively making healthcare a right. The high-priced for-profit U.S. system, on the other hand, does not cover millions of people who can't afford coverage and whose states don't provide Medicaid for poor adults. In the U.S., a 2020 Commonwealth Fund study, found that 12.5 percent of adults were uninsured. "In addition, 9.5 percent of adults were insured but had a gap in coverage in the past year and 21.3 percent were underinsured." Underinsured adults are those with high deductibles and out-of-pocket costs in addition to their premiums. A total of 43.4% of U.S. adults ages 19 to 64 were inadquately insured, according to the study.
Income inequality in the United States is among the most extreme in the world.
It is often repeated that the wealthiest 10% of American households control nearly 75% of household net worth. This is income inequality. In the U.S. stagnating wages over the last few decades have shrunk the middle class. According to a recent Pew Research Center study: "Among the top 5% of households – those with incomes of at least $248,729 in 2018 – their share of all U.S. income rose from 16% in 1968 to 23% in 2018."
According to the report, "The share of American adults who live in middle-income households has decreased from 61% in 1971 to 51% in 2019. During this time, the share of adults in the upper-income tier increased from 14% to 20%, and the share in the lower-income tier increased from 25% to 29%."
Corporate CEO's earn 320 times more than the average worker, according to the Economic Policy Institute. That's up from 61 times more than the average worker in 1989.
There is additional inequality between the incomes of Black and White families, with median black household income only 61% of median white household income in 2018, again according to the Pew report.
In 2017 data from the Organization for Economic Cooperation and Development (OECD), only four other nations -- Bulgaria, Mexico, Chile and Costa Rica -- have greater income inequality.
The U.S. is ranked 9th worst of 15 countries in a 2019 report in USA Today, "Countries With the Widest Gaps Between Rich and Poor," that considered 15 both relatively wealthy OECD member states and non-OECD member states. In this survey the U.S. is more equal (very relatively speaking) than Turkey, Chile, Mexico, Brazil, Costa Rica, India, China and South Africa.
The report notes that, unlike those of other countries, U.S. tax and social safety net programs do little to close the income gap: "With a GDP per capita of $53,632 and an unemployment rate of 4.4%, the U.S. economy appears healthy. But the benefits of a strong economy are not evenly enjoyed by all Americans. Of the 325.1 million Americans, an estimated 17.8% live below the poverty line. U.S. taxes and transfers do a relatively poor job of leveling out the economic playing field. While most nations' Gini coefficients decline by more than 30% after taxes and transfers, the U.S. Gini coefficient declines by only about 23%." (The Gini coefficient ranks nations' income equality on a scale of 0 to 1.)
Long-term lack of investment has left over 40% of U.S. roads are in poor or mediocre condition, forcing individual motorists to pay over $1,000 per year in wasted time and fuel.
According to the American Society of Civil Engineers' 2021 Infrastructure Report Card,
America’s roads are critical for moving an ever-increasing number of people and goods. However, these vital lifelines are frequently underfunded, and over 40% of the system is now in poor or mediocre condition. As the backlog of rehabilitation needs grows, motorists are forced to pay over $1,000 every year in wasted time and fuel. Additionally, while traffic fatalities have been on the decline, over 36,000 people are still dying on the nation’s roads every year, and the number of pedestrian fatalities is on the rise. Federal, state, and local governments will need to prioritize strategic investments dedicated to improving and preserving roadway conditions that increase public safety on the system we have in place, as well as plan for the roadways of the future, which will need to account for connected and autonomous vehicles.
The World Economic Forum ranks countries' roads (and other markers) yearly on the basis of surveys of business executives in each country. Despite its high reliance on roads (versus rail and ship transport), the U.S. is 17th in the WEF's 2019 Country Rankings.
The United States is "facing an acute crisis of democracy," precipitated by efforts to overturn the 2020 presidential election, stated Freedom House in a special report. In its latest annual report, Freedom House gave US democracy a score lower than most western countries.
The United States is "facing an acute crisis of democracy," brought on by former President Donald Trump's efforts to overthrow the 2020 elections and the January 6th attack on the U.S. Capitol by a violent mob of Trump supporters, stated Freedom House in a special report issued earlier this year, "From Crisis to Reform: A Call to Strengthen America’s Battered Democracy."
Freedom House, which was founded to combat fascism in 1941, has been assessing the level of freedom in each country in the world, with a numerical score since 1973. Prior to the special report (and the sacking of the Capitol), in its latest annual "Freedom in the World" report issued at the end of 2020, Freedom House gave US democracy a score of 83. While still in the "free" category (as opposed to "partly free" or "not free"), 83 is lower than past ratings and significantly lower than western European countries and Canada.
Noted the special report: “...the crisis did not arise suddenly from an otherwise healthy political environment. U.S. democracy is in urgent need of repair.”
Freedom House identified three long-standing vulnerabilities that had been weakening U.S. democracy long before Trump attacked the press and the courts, and rejected Congressional oversight and safeguards against corruption. Those three vulnerabilities, according to the special report, are: "unequal treatment for people of color, the improper influence of money in politics, and partisan polarization and extremism."
As to the influence of big-money interests in politics, court rulings and legal loopholes permit unlimited political contributions -- overwhelming and shutting out individual voters as elected representatives cater to their donors. According to the special report, Trump exacerbated improper influence by appointing people to regulate areas in which they had a financial interest, and facilitating special interest groups. States the special report:
There is a widespread perception among Americans that our democracy is failing to address society’s most pressing problems, and that elected representatives are inaccessible to those without deep pockets or elite connections. People sense a disconnect between themselves and the politicians who make decisions affecting their lives, and the news dominating Washington often seems to hold little relevance for individuals' day-to-day concerns.
Partisan polarization splits the country along racial, ethnic and religious identities into red (Republican) and blue (Democratic). With little chance for third parties to prevail, space opens for radicalization. And according to the special report, partisan gerrymandering has a particularly corrosive and radicalizing effect on US politics.
While still in the "free" category (as opposed to "partly free" or "not free"), 83 is lower than past ratings and significantly lower than western European countries (in the mid- to high-90s) and Canada at 98.
As to improper influence in politics, in its "Freedom in the World" annual survey, Freedom House has scored the U.S. lower than all other large, established democracies except for Italy.
According to the special report:
the specific character of US political polarization is particularly damaging to democracy when compared with other countries. While many democracies feature sharp debate and ideological competition between left and right, partisan affiliation in the United States has also become more closely tied to racial, ethnic, and religious identity. This makes it far more difficult for parties to gain supporters through attraction and persuasion….
The federal standard is that no more than 30% of a household’s gross income should be spent on rent and utilities. But in all but 3 states, rental housing for workers making less than $15 per hour consumes more than 100% of a full-time salary.
A modest one-bedroom rental home is unaffordable to more than 40% of wage earners. A modest two-bedroom rental home is unaffordable for more than 60% of wage earners. In 2020, according to the National Low Income Housing Coalition (NLIHC), the "National Housing Wage," the amount required to rent a modest house or apartment at the market rate, was $23.96 per hour. It concluded: "The average renter’s hourly wage of $18.22 [was] $5.74 less than the national two-bedroom Housing Wage and $1.34 less than the one-bedroom Housing Wage. As a result, the average renter must work 53 hours per week to afford a modest two-bedroom apartment." And that is before earning funds for food, transportation, etc.
In all but 4 states a wage of at least $15 an hour for more than 40 hours a week is required to rent a modest two-bedroom apartment. In the four states where housing is relatively more affordable (Arkansas, Mississippi, Kentucky and West Virginia), rentals cost more than a $14 an hour wage worked for more than 40 hours.
Given these prices, as much as 38% of the labor force is unable to afford to rent a place to live. "Twelve of the 20 largest occupations in the United States pay a median hourly wage that is less than what a full-time worker needs to earn to afford a modest apartment at the national average fair market rent," according to NLIHC. Workers of color are more severely affected than white wage-earners.
Government funding for low-income housing is extremely limited and largely committed to existing projects and inadequate voucher programs with hopelessly long waiting lists.
The Affordable Housing comparison of OECD countries shows that only four countries have worse "housing cost overburden among low income tenants" than the United States, where 48% of low-income renters are paying more than they can afford for rent. A glance at the comparison's "Social Housing" tab shows that the U.S. spends far less on housing subsidies (as a percentage of GDP) than all but a very few countries.
The lack of affordable, licensed child care affects both families and the economy. Without reliable and affordable child care options, parents often must decide whether to spend a huge portion of their budget on child care. Even before the pandemic, lack of childcare forced many mothers out of the workforce, at great cost to their careers, their employers and the US economy.
According to a Center For American Progress report, "The current child care market fails families, children, and businesses. Parents are often unable to find a child care program with an open spot for their infant or toddler. If there are available options, they typically are not affordable. Infant child care costs families an average of $11,000 per year and is more than the price of public college in 33 states."
Additionally, according to the report, many states have only enough childcare slots for 1 out of 5 infants and toddlers. And "[j]ust 1 in 6 families who are eligible for child care subsidies receive them. And the subsidies that do exist for infant and toddler child care are usually inadequate, covering just a fraction of the cost of providing care."
Despite its cost to parents, childcare is scarcely profitable and childcare workers are poorly paid.
The lack of childcare, especially for infants and toddlers, drives women out of the workforce, often at huge cost to their careers. And the U.S. economy loses an estimated $57 billion annually because of child care problems, according to the Center for American Progress. (The pandemic multiplied this phenomenon.)
Families living across 30 wealthy nations in the Organisation for Economic Co-operation and Development spend on average about 15% of their net income on child care costs, CNN reported in 2018, citing a 2016 OECD report. In the United States, couples spend 25.6% of their income on child care costs and that number soars to 52.7% for single parents, according to the report.
CNN notes that in Western Europe, childcare is often heavily subsidized by the government so what parents pay is capped at a certain percent of their income. In Denmark, couples spend about 10.7% of their income, while single parents pay 2.9%, it says, citing the OECD report.
The US lags behind almost the entire world in providing national paid leave for caring to working people. And the U.S. is one of 7 countries that do not have a national program for paid maternity leave.
Unless covered by a good union contract, workers in the US do not have the benefit of paid leave for new parenthood, for sickness, or for caring for family ill members. Federal law does not mandate paid sick leave. The federal Family and Medical Leave Act (FMLA), passed in 1993, provides up to 12 weeks of unpaid leave to employees of companies with 50 or more employees. Absence of benefits amplifies stressful personal and family situations. A few states and some private employers do provide varying amounts of paid leave to their workers, according to the Kaiser Family Foundation.
Lack of paid maternity leave may hinder child development and also exacerbates home and workplace gender inequality, according to a research report by New America. The report states: "The wage gap noticeably widens when women have children, as policy, workplace practice, and traditional gender expectations of the male breadwinner and female caregiver lead to women being primarily responsible for housework and child care, even when working full time." The New America report adds that when nations have added paid paternity leave -- and fathers have taken it -- gender equality improves at home and at work.
The US is an outlier, to a shocking degree, on paid care for infants. According to comparisons by the WORLD Policy Center at the UCLA Fielding School of Public Health, only a few tiny countries, mostly in the South Pacific, do not offer paid leave to care for infants. Even low-income countries offer paid maternity leave. Most wealthy countries offer at least 14 weeks of paid leave and paid options to facilitate breast-feeding for 6 months. In this page entitled "Working Conditions Affecting Care" maps show how the US significantly trails peer countries in mandating paid leave to care for ill family members.
When it comes to paid personal sick leave, the US is also a signifcant outlier among nations, according to data presented by the WORLD Policy Center. A summary of a for-sale article in the magazine Health Affairs states: "Of the 94 percent of countries that provide permanent paid sick leave, none broadly restrict leave based on employer size, and 93 percent cover part-time workers without a minimum hours requirement," all limitations of the FMLA -- which does not even mandate or provide payment.
Access to safe, clean water is necessary for life itself. But water systems in the US have failed to maintain their delivery systems.
Access to safe, clean water is necessary for life itself, not to mention health. Water systems in the US, however, have failed to maintain their 2.2 million miles of underground delivery infrastucture, according to the American Society of Civil Engineers 2021 Report Card for America's Infrastructure. There is a water main break every two minutes, according to the Report Card, and an estimated 6 billion gallons of treated water lost each day in the US.
According to the Report Card, local water agencies are increasing their investment in replacing aging pipes. Nevertheless, for 2020, that increase was expected to involve replacement of less than 13,000 miles of pipe. In 2019, utilities were replacing between 1% and 4.8% of their pipelines annually.
The Report Card says that in coming years, the nation's water systems will require "staggering" levels of investment. It notes:
Funding for drinking water infrastructure has not kept pace with the growing need to address aging infrastructure systems, and current funding sources do not meet the total needs. In general, however, state and local governments have invested more than their federal counterparts. Despite the growing need for drinking water infrastructure, the federal government’s share of capital spending in the water sector fell from 63% in 1977 to 9% of total capital spending in 2017. On average, about two-thirds of public spending for capital investment in water infrastructure since the 1980s has been made by state and local governments.
President Biden's infrastructure plan and statements call for massive investment in pipe replacement -- and replacing all pipes with lead in them.
As governments have cut spending on higher education, public and private higher-ed institutions have kept hiking their tuition, forcing students to shoulder the high cost of pursuing a degree.
As US state governments have cut spending on higher education, higher-ed institutions have hiked up their tuition, forcing students to shoulder more of the cost of pursuing a degree. According to the Urban Institute, tuition "grew from 19 percent of higher education expenditures in 1977 to 31 percent in 2017. Tuition as a percentage of higher education spending grew in part because state direct appropriations per student declined. That is, state and local spending on higher education increased over the period in large part because tuition payments increased."
The Urban Institute's analysis was based on an Organization for Economic Cooperation and Development (OECD) report on education.
A column in Forbes, based on the same data, noted that "In countries where the government picks up most of the bill for higher education, spending per student is usually much lower." The OECD data show that US universities spend $30,165 yearly per full-time student. The Forbes column suggests that "Congress could rein in the blank-check federal student aid programs that facilitated tuition increases in the first place, forcing colleges to live within students’ and taxpayers’ means." Many of those "blank-check" programs are actually loans, with interest that increase the cost of education even more.
None of these costs include room and board, which students must pay -- or borrow to pay.
According to the OECD data, in 2017-18 US private institutions charged $29,478 annual tuition -- far more than those of other rich countries, which all charge under $10,000. Tuition at public institutions in the US was $8,000 -- again higher than all other rich countries.
In 2017 the United States spent $34,500 per FTE student, twice as high as the $17,100 average spending of OECD member countries, according to the National Center for Education Statistics, citing the OECD report mentioned above.
US universities' spending of $30,165 yearly per full-time students is almost twice the average of $15,556 that other rich countries spent, according to the OECD data.