The more America spends on healthcare, the sicker it gets

Welcome to Trump’s America, The i Paper’s World Insight series presenting the sharpest, deepest thinking on an era-defining shift in history and politics, investigating how Donald Trump and his administration have changed the US and the world – and where we go from here. • Hegseth is running a PR firm disguised as a defence department• The rich are building their own America• Why Americans fear getting old Every time my pal from Bournemouth comes to visit us here in Colorado, he starts complaining about the NHS: the ridiculous waiting times; the striking doctors; the ageing, decrepit hospitals. And every time I give him the same reply: “Look, Nigel, it could be worse. What if you had to get your healthcare in the USA?” Because there’s no question: The American healthcare system is performing worse than the healthcare system in Britain, or, for that matter, in any of the world’s industrialised democracies. The USA ranks at or near the bottom among the developed nations on standard gauges of medical system performance – measures such as life expectancy, neonatal mortality and recovery rates from disease or injury. Shorts Average life expectancy is 80.5 years in the world’s 38 richest countries, according to the OECD. The US ranks near the bottom in that group, with 76.5 years. The UK came in nearer the average, at 79.4 years, while Sweden, Switzerland and Japan have the longest expected lifespans, longer than 81 years.In a World Economic Forum study of 19 wealthy countries, the US ranked last in keeping newborn babies alive until their first birthday. That’s because pregnant Americans who don’t have health insurance often get no medical care until the day they show up at the hospital in labour. And most of those metrics have got even worse in Donald Trump’s second term as President. America does lead in one respect: OECD data show that the US is spending about $14,885 per person per year on healthcare – more than double the average cost among wealthy nations, and 60 per cent higher than the next biggest spender, Switzerland. (The UK comes in near the average, at $6,747 per capita). But Americans are not getting value for their money. The Commonwealth Fund, an international research organisation, publishes comparative studies of national health – taking into account factors such as access to care, efficiency and health outcomes. In its latest ranking of 10 wealthy countries published in 2024, the US ranked the worst, by large margins, on most of those measures. (For all my friend’s gripes about the NHS, the UK’s healthcare system ranked third overall, behind Australia and the Netherlands). The Commonwealth Fund also ranks nations on a benchmark called “mortality amenable to healthcare,” which is to say, if somebody has a potentially lethal disease, do they get the treatment that will save their life? Of 11 rich countries on this measure, the US ranks lowest (the UK comes in about the middle of the group). Donald Trump’s biggest impact on healthcare comes in his One Big Beautiful Bill, passed last summer (Photo: Kevin Dietsch/Getty) How can this be? The US is the world’s richest nation. We have world-class schools of medicine, nursing and public health. All over the planet, people are walking around who would be dead if it weren’t for some medical innovation developed in the US. But our country has squandered these resources through a crazy quilt of a healthcare system that gives us the highest doctor bills in the world and still leaves millions with no health insurance. Most developed countries have settled on a basic system of healthcare delivery and payment that covers everybody. America has settled on a hodgepodge. US military personnel and veterans get their care, at no cost, through a system like the NHS – government doctors in government-run hospitals. This works so well that members of Congress, including those who loudly decry “socialised medicine”, have given themselves the right to use military hospitals as well. Most civilians rely on private insurance and a mix of public and private hospitals. Because insurance companies have refused to cover pensioners – too expensive, they say – there’s Medicare, a government-run plan for people over 65. There’s a separate government system with different rules for low-income Americans, called Medicaid. Tens of millions of people are covered by one plan for some ailments and a different plan for others – and often have no coverage for hearing, vision or dental care. It’s all so complicated that a local medical practice generally needs to employ more staff in the billing office than in the treatment rooms. Hospitals routinely have hundreds of people just to do the paperwork. The result: 25 to 35 per cent of Americans’ healthcare spending goes on administrative tasks, not medical care. In the NHS, administrative costs make up about 1 per cent of the Department for Health and Social Care’s resource budget. Around 26 million Americans had no health insurance when Trump returned to the White House in 2025. Since then, various Trump “reforms” have raised the number to more like 30 million. Trump’s biggest impact on healthcare comes in his One Big Beautiful Bill, passed last summer. The changes in that bill will take effect in January 2027 – Republicans strategically delayed the effective date until after this November’s midterm elections. There will then be a large reduction in federal subsidies for health insurance premiums, and stricter eligibility rules for Medicaid. Millions more people will lose their health coverage. Trump says these changes will cut costs, but economists agree that forcing people off insurance only adds to the national medical bill. A petrol station attendant or a farmhand with no insurance can’t afford to go to a doctor for a minor pain or cough. But three months later, when that mild complaint has escalated into a life-threatening problem, the patient will head to the emergency room, the most expensive possible place to provide medical care. A condition that might have been managed with a single doctor’s visit, if confronted early, will now cost thousands of dollars for treatment in the ER. Hospitals are required by law to treat emergency cases even if the patient can’t pay. To cover the cost of caring for the uninsured, they raise their fees for everybody else. Around 26 million Americans had no health insurance when Trump returned to the White House (Photo: Jeffrey Basinger/Newsday via Getty) The US healthcare system is designed to maximise profit, not public health. America is the only advanced nation where insurers are allowed to make a profit on basic medical coverage. Other countries have recognised that there’s a direct conflict between insuring a nation’s health and making a profit on its insurance. Health insurance exists to help people get the preventive care and treatment they need by paying their medical bills. The way to make a profit is to avoid paying those bills. US insurance giants have devised ingenious methods for evading payment. They require “pre-authorisation” for many procedures and prescriptions; the insurance adjuster, not your doctor, determines what treatment you get. They set up “narrow networks” of approved doctors; if your favourite doctor isn’t on the list, insurance won’t pay. Insurers regularly deny claims weeks or months after treatment; then the hospital demands that the patient pay up. My Colorado neighbor Pam was injured in a highway crash while traveling in Arizona. With a shattered bone protruding from her arm, she was rushed to the nearest ER. After two surgeries, and four days in the hospital, she was billed $490,000. Her insurer refused to pay, on the grounds that this wasn’t an emergency. Months later, Pam is still appealing, with no payment in sight. So, Americans can often pay twice for healthcare: first, through the insurance premium, then the bill that the insurer declines to pay. Americans also pay twice as much for medicine as the Brits pay for the same pill made in the same factory. One of Trump’s sensible reform ideas was a rule saying we would pay only the average price of the drug in other advanced nations. Big Pharma has so much political clout that this proposal has gone nowhere in Congress. All in all, American healthcare tends to create more headaches than it cures. As I told my buddy from Bournemouth, the whole system makes me yearn for my days in the NHS.