<P> The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study). In 2008 the Commonwealth Fund, an advocacy group seeking greater government involvement in US healthcare, then led by former Carter administration official Karen Davis, ranked the United States last in the quality of health care among similar countries, and noted U.S. care costs the most . </P> <P> According to the WHO, the United States spent more on health care per capita ($7,146), and more on health care as percentage of its GDP (15.2%), than any other nation in 2008 . In 2013 the U.S. spent 17.1% of its total GDP on healthcare, 50% more than the second highest spending country, France (11.6%). In 2014, the U.S. spent $2.6 trillion (a 5.0% increase from 2013) on personal health care expenditures . Per per capita spending was $8,054 in 2014--up from $7,727 in 2013 . In 2011, the U.S. paid nearly twice as much as Canada yet lagged behind other wealthy nations in such measures as infant mortality and life expectancy . As of 2009, the U.S. had a higher infant mortality rate than most of the world's industrialized nations . </P> <P> Active debate about health care reform in the United States concerns questions of a right to health care, access, fairness, efficiency, cost, choice, value, and quality . Some have argued that the system does not deliver equivalent value for the money spent . According to a 2004 Institute of Medicine (IOM) report: "The United States is among the few industrialized nations in the world that does not guarantee access to health care for its population ." A 2004 OECD report said: "With the exception of Mexico, Turkey, and the United States, all OECD countries had achieved universal or near - universal (at least 98.4% insured) coverage of their populations by 1990 ." The 2004 IOM report observed that "lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States", while a 2009 Harvard study conducted by co-founders of Physicians for a National Health Program, a pro-single payer advocacy group, estimated that 44,800 excess deaths occurred annually due to lack of health insurance . The group's methodology has been criticized by economist John C. Goodman for not looking at cause of death or tracking insurance status changes over time, including the time of death . Further, a 2009 study by former Clinton policy adviser Richard Kronick found no increased mortality from being uninsured after certain risk factors were controlled for, and specifically criticized the methodology used by IOM . </P> <P> Between 2004 and 2013 a trend of high rates of un - and underinsurance and wage stagnation contributed to a health - care consumption decline for low - income Americans . This trend was reversed after the implementation of the major provisions of the Affordable Health Care Act (ACA) in 2014 . Lack of insurance or higher cost sharing (user fees for the patient with insurance) create barriers to accessing health care: use of care declines with increasing patient cost - sharing obligation . Before the ACA passed in 2014, 39% of below - average income Americans reported forgoing seeing a doctor for a medical issue (whereas 7% of low - income Canadians and 1% of low - income UK citizens reported the same). Forgone medical care due to extensive cost sharing may ultimately increase costs due to downstream medical issues; this dynamic may play a part in U.S.'s international ranking as having the highest health - care expenditures despite significant patient cost - sharing . </P>

What are the major problems in the us health care system