The Commonwealth Fund published its 2026 report card on US healthcare this week, measuring the United States against 19 other wealthy countries. It runs the most expensive system on earth, and it buys some of the worst results in the developed world. I have spent more than four decades in the medical intensive care unit at UCLA, and I do not read those numbers as statistics. I read them as the people I admit.
We spend 18% of our economy on healthcare, nearly twice the average of comparable nations, and $12,649 a person, roughly 10 times what Mexico spends. For that fortune, American life expectancy peaked at 79 years, more than two years below our peers and third from the bottom of the group, above only Mexico and Turkey. Our rate of deaths that good care should have prevented is the second worst in the developed world. Only Mexico does worse.
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The report grades four areas: coverage, affordability, the delivery of care, and equity. We fail or nearly fail each one. We and Mexico are the only countries studied that have never guaranteed coverage to everyone, and 27 million Americans have none. We have the fewest primary care doctors per capita. Nearly a third of the country, 100 million people, has no regular place to seek care until they are sick enough for my unit. Black women die in childbirth here at a rate higher than the national rate of any other wealthy country measured.
One finding is genuinely good. Americans who have a regular doctor rate that relationship among the best in the world. The bedside still works. What surrounds it does not. And we are busy taking even that apart.
But the report card the country received this morning is only the domestic one. There is a second, and we are failing it more completely, because we have stopped sitting the exam altogether. For decades the US led the world’s defenses against disease, funding roughly 40% of global humanitarian aid and helping build the surveillance and treatment networks that caught outbreaks before they spread. In a little more than a year, the US Agency for International Development has gone from about 10,000 staff to fewer than 300, the country has withdrawn from the World Health Organization, and a Lancet analysis projects that the aid cuts alone will cause 14m additional deaths by 2030, among them 4.5 million children under the age of five. When the largest donor retreats, others recalibrate downward, and the toll compounds.
The cost is no longer theoretical. An Ebola outbreak is spreading through the Democratic Republic of the Congo and Uganda, caused by the Bundibugyo strain, for which the licensed Ebola vaccine and antibody drugs, developed against a different species of the virus, do not apply. The World Health Organization declared an international emergency on 17 May.
The US Centers for Disease Control and Prevention learned of it about a day before the rest of the world did, when in past outbreaks its disease detectives would have been in the room far sooner. As one African public health leader put it, the US is now missing in action.
Closer to home, a hantavirus outbreak surfaced onboard a cruise ship, caused by the Andes strain, the one form of this rodent-borne virus known to spread between people. The health secretary, Robert F Kennedy Jr, assured the public it was “under control”. The federal program built to investigate shipborne outbreaks had already been hollowed out, its full-time staff cut a year ago.
A nation that runs on the thinnest healthcare margins in the wealthy world, with the fewest doctors, the fewest hospital beds and the highest share of patients who skip care they cannot afford, is the last one that can afford to look away from what spreads next. The domestic failure the report measures and the global retreat now counted in deaths abroad come from a single decision: a country that buys the least protection per dollar for its own people has also thrown away the cheap, proven systems that protected everyone else.
Both failures are set to deepen by choice. At home, independent analysts project that recent and proposed federal changes will leave 17 million more Americans uninsured by 2034, returning the country toward where it stood before the Affordable Care Act, with tens of thousands of additional preventable deaths every year. Abroad, the funding and the expertise will not return on the timescale that outbreaks keep.
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The administration disputes that its cuts hampered the Ebola response, and points to emergency money it has since mobilized. But these failures do not arrive as policy debates. In my unit, they arrive as the patient who could not afford the prescription, the rural patient an hour from the nearest doctor, the imported infection with nowhere to surge: respiratory failure, shock, isolation precautions. Abroad, they arrive as a child dead of something a bednet or a course of antiretrovirals would have prevented. It is the same country making the same choice on both sides of the same report card. We already know the grade. We are choosing not to read it.
