Health Care for Women: How the U.S. Compares Internationally

Recently released federal data once again show the United States with by far the highest rate of maternal deaths of any high-income nation, despite a decline since the COVID-19 pandemic.¹ Racial disparities are also extreme: Black women in the U.S. are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be an indicator of the nation’s wider failures with respect to women’s health and health care.

Compared to women in other high-income countries, American women have long had worse access to the health care they need. While the U.S. spends more on health care than other countries do, surveys regularly find that Americans avoid seeking care because of costs at the highest rates, even as the U.S. continues to lead in the prevalence of chronic disease.² At the same time, limited access to primary care and inadequate coordination of health services are likely factors in the nation’s poor performance when it comes to the prevention, diagnosis, and management of diseases.³

In this brief, we compare selected measures of health care access and outcomes for women in high-income countries. We drew upon data from four sources: the Commonwealth Fund’s 2023 International Health Policy Survey of Australia, Canada, France, Germany, the Netherlands, New Zealand, Switzerland, the United Kingdom, and the United States, which allowed us to analyze responses by race and ethnicity;⁴ the Centers for Disease Control and Prevention National Vital Statistics System; the Organisation for Economic Co-operation and Development (OECD); and the Institute for Health Metrics and Evaluation Global Burden of Disease. The latter two data sets permitted us to show results on selected measures for five additional countries — Chile, Japan, Korea, Norway, and Sweden. (See “How We Conducted This Survey” for more details.)

Findings

Health Status and Outcomes

High life expectancy can be attributed to a number of factors, including high living standards, a healthy lifestyle, quality education, access to comprehensive health services, and superior health outcomes.⁵ Life expectancy at birth in the U.S. was 80 years in 2022, at least two years lower than in all the other countries we examined. Within the U.S., American Indian, Alaska Native, and Black women have lower life expectancy compared to white, Asian, and Hispanic women (data not shown).⁶

A high rate of avoidable deaths — deaths before age 75 from conditions that can be prevented or treated — often indicate shortcomings in public health and care delivery systems.⁷ In the U.S., the leading causes of mortality, including heart disease, cancer, and stroke, are considered avoidable.⁸ Broad use of primary and preventive health care services, including cancer screenings and immunizations, can limit the number of premature and unnecessary deaths.⁹

Women in the U.S. have the highest rate of avoidable deaths: 270 of every 100,000 deaths could have been prevented if the right prevention or treatment were provided at the right time. Women in Japan and Korea are the least likely to die from a preventable or treatable cause.

Cardiovascular disease is the leading cause of death for women in the U.S., killing over 300,000 women in 2021 alone.¹⁰ U.S. women are more likely to die from heart disease than women in other high-income countries — compared to some countries, the U.S. rate is more than double.

More research on gender differences in risk factors is necessary to drive the effective diagnosis, management, and treatment of cardiovascular disease. Expanded insurance coverage and access to preventive screening are also critical to improving diagnosis and treatment.

Breast cancer deaths have been declining in the U.S., mainly owing to advancements in early detection and treatment.¹¹ Still, the U.S. mortality rate, about 17 per 100,000 women, exceeds rates in some peer nations.

In 2021, the U.K., Germany, and the Netherlands had the highest rates of breast cancer–related deaths. Korea had the lowest rate.

The rate of cervical cancer deaths has decreased by more than half over the past five decades with the advent of better prevention, including the HPV vaccine, and increased screening.¹² In 2021, between two and three women per 100,000 died from cervical cancer in all countries except Chile, where there with six deaths per 100,000 women.

Women in the U.S. are more likely to have multiple chronic conditions than women in most peer nations (data not shown).¹³ They are also the most likely to take multiple prescription drugs on a regular basis to treat underlying health conditions, with a quarter or more taking at least four prescription drugs. Nearly two of five Black women in the U.S. take four or more prescription medications regularly. In Germany, fewer than one in 10 women take multiple prescription drugs.

The high and rising use of prescription drugs in the U.S. is related to a multitude of factors, including longer survival times for people with chronic conditions.¹⁴

The Commonwealth Fund’s 2023 International Health Policy Survey asked respondents whether they had ever been told they had depression, anxiety, or other mental health conditions, or whether, in the past 12 months, they received mental health counseling or treatment. Mental health needs were greatest among women in the U.S. and Australia. White women in the U.S. were more likely than Black and Hispanic women to report having a mental health need.

The Commonwealth Fund survey also asked women if they were always or usually worried about at least one of the following in the past 12 months: having enough food, having enough money to pay rent or mortgage, having a clean and safe place to sleep, or having a stable job or source of income.

More women in Canada, the U.S., and France reported having at least one unmet social need. In the U.S., Black and Hispanic women were more likely than white women to report this. Only about one in 10 women in Germany and the Netherlands reported having one social need.

People with unmet social needs are more likely to require intensive and expensive medical interventions, make frequent trips to the emergency room, and face financial barriers to getting care.¹⁵

Access to Care

All countries in this analysis, except the U.S., guarantee government-provided health care coverage to all their residents. In addition to this public coverage, women in other countries also have the option to purchase additional, private coverage. In France, nearly all women have private coverage on top of their public plan.

In the U.S., 14 percent of women ages 19–64 in 2023 reported being uninsured, including over a quarter of Hispanic women. Although substantial progress has been made since the enactment of the Affordable Care Act in 2010, many women under age 65 remain ineligible for public overage or cannot access affordable private coverage.

Having a regular doctor or place of care, such as a primary care physician or a medical home, is important for getting screenings, vaccinations, and other preventive services needed to ensure good health outcomes. Having a usual source care is also essential to minimizing health disparities and improving population health.¹⁶ In the U.S. and Canada, women were the least likely to report having this. In New Zealand, the U.K., and the Netherlands, nearly all women said they have a regular doctor or place of care.

Among women in the U.S., the Commonwealth Fund survey found no racial or ethnic disparities in regular access to care.

Overuse and avoidable use of emergency departments has been a concern in the U.S. for many years.¹⁷ Not only are these facilities often functioning at high capacity or overcapacity, but the care they deliver is expensive relative to care offered in many other health care settings. Among women who either did not have a regular doctor or did not use their regular doctor for routine care, Black women in the U.S. reported the highest usage of emergency departments, followed by Hispanic women in the U.S.

Affordability of Care

The Commonwealth Fund survey asked women about times when cost prevented them from getting health care in the past year, including when they had a medical problem but did not visit a doctor; skipped a needed test, treatment, or follow-up visit; did not fill a prescription for medicine; or skipped medication doses. Half of women in the U.S. reported skipping or delaying needed care for cost reasons. Hispanic women were more likely to skip needed care than Black women and women in all the other countries. In the Netherlands, only 15 percent of women said they had forgone care for cost reasons.

America’s outlier status on this measure likely stems from the large number of working-age women who lack health insurance — nearly 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.¹⁸

Women in the U.S. and Australia — the two countries where women most often reported having a mental health care need — are the most likely to skip getting needed mental health services because of the cost. One of four women overall in the U.S. and Australia reported skipping mental health care. Our survey found no statistically significant differences between surveyed racial and ethnic groups in the U.S.

Women in Germany and the Netherlands were the least likely to report skipping mental health services because of the cost.

The Commonwealth Fund survey asked women whether they’d had at least one medical bill problem in the past year, including: having serious difficulty paying for care they’d received or being unable to pay a medical bill; spending a lot of time on paperwork or disputes related to medical bills; or having their insurer deny payment or pay less than expected for a claim.

Compared to their counterparts in the other eight countries, women in the U.S. were significantly more likely to report one or more of these medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem. There were no racial and ethnic disparities in the U.S.

Discussion

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits.¹⁹ While there is much variation across states on access to care, quality of care, and health outcomes, the United States remains the only wealthy country without universal health care.²⁰

Other countries have made substantial efforts to ensure women are able to get needed health care, which includes primary, mental, maternal, and social care. In addition to ensuring coverage for all, the other nations in this analysis generally cap annual out-of-pocket costs for covered benefits, provide cost-sharing exemptions for primary care and certain other services, and offer additional safety nets based on income and health status.²¹ For example, Canada, Germany, the Netherlands, and the U.K. impose no cost sharing for primary care visits, and France waives all copayments for care related to long-term chronic mental illnesses. Maternal care, including postpartum care, is free in most of the countries we studied and includes home visits by a nurse.²²

While the Affordable Care Act (ACA) did away with cost sharing for preventive services like wellness visits, immunizations, and cancer screenings, U.S. women still can face high out-of-pocket costs for other care. Moreover, although a recent circuit court ruling has preserved this ACA provision in Braidwood Management v. Becerra — a case that challenges the guarantee of free preventive services for privately insured individuals — that could change as the case winds its way through the courts.²³ With a future ruling in the plaintiffs’ favor, we could see less use of these services, especially among women with lower income, and worsening health outcomes.²⁴

U.S. policymakers could expand on the ACA’s reforms to allow all women to get comprehensive and affordable health care. For example, by enhancing marketplace plan subsidies and covering those low-income individuals who fall into Medicaid’s coverage gap, they could allow all women to receive primary care services without cost barriers. While the enhanced premium subsidies under the Inflation Reduction Act have led to historic gains in coverage in the marketplaces, the subsidies expire at the end of 2025; Congress will need to make those permanent to keep marketplace plans affordable.²⁵ U.S. policymakers also could extend the ACA’s requirement to cover essential health benefits, including mental health care, to the large-group employer plans that cover most Americans.

In terms of maternity care, the ACA’s expansion of eligibility for Medicaid coverage has been associated with better health outcomes in the states that have opted in, particularly lower rates of maternal mortality for Black and Latina mothers.²⁶ Yet 10 states have opted not to expand their Medicaid programs, leaving 800,000 low-income women, who are disproportionately Black or Latina, in the Medicaid coverage gap.²⁷ The 2022 U.S. Supreme Court case overturning Roe v. Wade has also threatened women’s access to reproductive care. Twenty-two states have so far imposed bans or restrictions on abortions. Additional bans and tighter restrictions may further limit women’s health care access.²⁸

The U.S. health care system too often fails women. American women face increasing threats to reproductive health care access, including abortion services, that could have a lifelong impact on physical and mental health. While the nation awaits the outcomes of legal challenges to state restrictions on these services, U.S. policymakers have a number of options to improve health and health care for women.