The United States comes in dead last in a new, international ranking of health care systems from a top health-care non-profit.

This doesn't mean that we're the worst in the world; there are plenty of less-developed countries that have worse systems than America's. But when the United States is compared against peer countries like France and Canada it does not come out well. It comes out the very worst.

A new Commonwealth Fund report looks at how the United States stacks up against other countries on things like access to doctors and quality of care. It pulls from three separate surveys conducted over the past three years: a 2011 survey of sicker patients, a 2012 survey of doctors and a 2013 survey of adults over 18. It also uses health outcome data from the OECD and World Health Organization. This means it captures the experience of the medical system from the people who use it a lot, those who use it a little and the doctors treating them.

America ranks worst overall

The American health care system came in last both in the overall rankings, which pull together data on 11 specific measures of success for a health care system. This includes metrics like how easily residents can access health care, if that medical care is affordable and if its effective.

There was no measure where the United States came in first place — our best ranking was coming in third in the effectiveness of our medicine (more on what this means later).

In addition to coming in last overall, there were four specific measures where the United States came in last: cost-related problems, efficiency, equity and health outcomes.

America ranks worst for cost-related problems

Americans have the most trouble affording medical services; a higher percentage of Americans go without needed care because of cost than people surveyed in any other nation.

Thirty-seven percent of Americans in this survey, for example, said they skipped some type of recommended care because of the price.

Americans were almost most likely to report out-of-pocket expenses above $1,000 and to have serious problems paying their medical bills.

The challenges that Americans have paying their medical bills likely stem from two unique characteristics of the health care system. First, American health care is expensive: the United States spends way more per person on health care than other industrialized nations. We have higher prices for drugs and imaging scans than other countries. Our spending, as you can see in the Commonwealth Fund charts below, is an outlier.

The other part of the explanation: the United States is the only country in this study without universal coverage. During the Commonwealth Fund conducted this survey, the uninsured rate hovered around 15 percent. That works out to about 48 million Americans who didn't have a source of coverage to help pay their medical bills.

America ranks worst on an efficient health care system

Most countries use some form of rate-setting: the government sets specific prices for medical services that each hospital and doctor can charge. This tends to make billing simpler: hospitals know there's exactly one price for every knee replacement, CT scan and eye exam, regardless of which insurer foots the bill.

That doesn't happen in the United States. Here, we have thousands of health insurance companies who negotiate individually with hospitals and doctors. Every knee replacement in the United States has a different price depending on what deal the insurer has set up with the provider.

This means we end up spending more than other country on the business of getting bills paid. The United States, for example, devotes 7.1 percent of total health care spending on administrative costs. That's more than twice as much as the United Kingdom and three times as much as Australia.

This matters for the patient experience: More American patients report spending lots of time on paperwork related to medical bills than any other country in the survey. Doctors also reported a higher percentage of time spent dealing with administrative issues.

There's a bit of a pattern to the numbers above. The countries where more people report spending lots of time dealing with medical bills — like the United States, France and the Netherlands — are all multi-payer systems, where there are multiple insurers contracting with hospitals and doctors. The countries with the lowest rates of billing issues, like the United Kingdom and New Zealand, have a national health service, where the country owns all the doctors and hospitals. That seems to reduce the amount of complicated medical bills that turn up in patients' mailboxes.

America ranks worst on equity in health care

The Institute of Medicine defines equity as "providing care that does not vary in quality because of personal characteristics" like income or location. The United States does not do a very good job of this.

There are big gaps in how Americans with different incomes use the health-care system, with lower-earning Americans being more likely to skip recommended care. Like other measures, this reflects the high costs and insurance gaps of the American system.

"Americans with below-average incomes were much more likely than their counterparts to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs," the Commonwealth Fund report finds. "On each of these indicators, one-third or more of lower-income adults in the U.S. said they went without needed care because of cost in the past year."

The Affordable Care Act is likely to reduce, but not fully eliminate these gaps. There has already been a noticeable decline in the uninsured rate since the law's insurance expansion began. But there are also 24 states that have not yet committed to expanding Medicaid, the program meant to cover low-income Americans. Without that coverage, there will likely be millions of Americans who are still unable to afford their medical care.

America ranks worst on healthy lives

The whole goal of a health care system is to help people get healthier. The United States does spend a lot more money on health care than any other country in this survey. That could make sense if all that additional spending was leading to a better quality of life for Americans, if we lived longer, for example, or had healthier lives.

Unfortunately, the United States comes in dead last when ranked on healthy lives. This metric includes three basic indicators (the only ones available for cross-country comparisons). They are deaths that could have been prevented with care (we have more of those), infant mortality and life expectancy.

A healthy 60-year-old man in the United States can expect to live 17.5 more years, which is less than a healthy 60-year-old man in Australia (who has 18.7 additional years of life expectancy) or Switzerland (19 additional years).

Our infant mortality rate is higher than any of the other countries measured, too.

We're paying more for our health care but, at least on these three basic metrics, not getting better outcomes from our system.

One glimmer of good news: America ranks third on effective care

Not every part of the American health care system got a last-place ranking. The United States' best showing was in providing effective care, which is largely a measure of how well a health care system does following guidelines for appropriate care.

American patients are the most likely to receive reminders about preventive care they need than any other country except the Netherlands. And American doctors are the most likely to talk to their patients about exercise and physical activity.

The more effective care delivered in America doesn't seem to impact the outcomes measured in this particular survey, which are limited to life expectancy, infant mortality and preventable deaths. It's possible they might turn up in other metrics.

And, its also possible the United States' ranking could change in future surveys. Numerous surveys show that the Affordable Care Act is driving down the uninsured rate, which could reduce the cost-barriers and inequality that shows up here. In upcoming surveys, America might not come in very last.