The United States spends more on healthcare than other wealthy nations, yet ranks dead last on equity, access, efficiency, care delivery and healthcare costs.

Despite progress made in providing coverage to previously uninsured Americans via the Affordable Care Act, the latest report from The Commonwealth Fund finds that the United States offers its citizens the least financial protection among the 11 high-income countries surveyed. It is also the only one without universal health insurance coverage.

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Indeed, the U.S. has the highest costs and lowest overall performance compared to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom. The U.S. spent $9,364 per person on healthcare in 2016, compared to $4,094 in the U.K., which ranked first on performance overall.

New 11-country study finds the US health care system has widest gap between people with higher and lower incomes https://t.co/aqHhnficMl pic.twitter.com/GIfzbSgXFf — Commonwealth Fund (@commonwealthfnd) July 14, 2017

Forty-four percent of lower income Americans and 26% of higher income U.S. citizens reported financial barriers to care. Remarkably, the report noted, someone with a high income in the U.S. was more likely to report financial barriers to healthcare than a low-income person in the U.K.

“What this report tells us is that despite the substantial gains in coverage and access to care due to the Affordable Care Act, our healthcare system is still not working as well as it could for Americans, and it works especially poorly for those with middle or lower incomes,” Commonwealth Fund President David Blumenthal, M.D., said in an announcement. “The healthcare policies currently being contemplated in Congress would certainly exacerbate these challenges as millions would lose access to health insurance and affordable healthcare.”

This isn’t the first time the U.S. has fared poorly compared to other nations. Since 2004, it has ranked last in every one of six similar reports . This year the Commonwealth Fund added new measures and refined the scoring to give each country an overall score, as well as a score on five specific areas of performance. The new approach ranked the U.K. Australia and the Netherlands as top performers. New Zealand, Norway, Switzerland, Sweden and Germany were in the middle of the pack. Canada and France were near the bottom but performed better than the U.S.

Another recent global report found massive inequity within the United States in terms of access to care and the quality of care provided.

But it’s not impossible for the U.S. to move from last place to first among wealthy countries if it heeds the lessons offered from top performing countries, notes Eric Schneider, M.D., the lead author of the study and senior vice president for policy and research at the Commonwealth Fund, and David Squires, former senior researcher to the president at the Commonwealth Fund, in a piece for The New England Journal of Medicine.

This would mean the U.S. must expand health insurance coverage, such as universal coverage that provides citizens with healthcare they need at little or no cost; invest more in primary care so that it is accessible on nights and weekends; cut down on the administrative paperwork that physicians must complete so they can spend time on providing care; and invest more in social services to reduce healthcare disparities.

“If we are going to be the best, we have to do better for patients,” Schneider said in the announcement. "We are not the U.K., Australia or the Netherlands, and we don’t have to be. Each of those countries follows a different path to top performance. A country that spends as much as we do could be the best in the world. We can adapt what works in other countries and build on our own strengths to achieve a healthcare system that provides affordable, high-quality healthcare for everyone.”