By Trudy Lieberman

One thing I haven’t heard much in this latest healthcare debate is that the U.S. has the best health system in the world. That’s different from the last two times around.

When the nation debated the Clinton health plan in 1994 and the Affordable Care Act in 2009-2010, a huge talking point for politicians and special business interests opposed to reform was, “The American system is so good, why change it?”

It’s different this year. Maybe that’s because the public realizes America doesn’t have the best, and their own interactions with what American healthcare has become tell them a different story. The old talking point doesn’t compute anymore.

Of course, we’ve all had some good experiences. And we generally continue to believe that the money we spend on super expensive technology and medicines equates to good care even though evidence shows those costly interventions may not deliver as advertised and actually may be harmful.

However, taken as a whole and measured on several dimensions, including access to care, administrative efficiency, equity, and health outcomes, the U.S. compares poorly relative to other industrialized countries.

In its latest study comparing the U.S. with 10 other countries — the United Kingdom, Australia, The Netherlands, New Zealand, Norway, Sweden, Switzerland, Germany, Canada, and France — the U.S. ranks dead last.  This is the sixth time since 2004 that The Commonwealth Fund, which supports Thinking About Health columns, has done such a survey.

“Each time we have managed to be last,” says Eric Schneider, a senior vice president of the Fund.

I’ve been writing about these surveys since they began, but this time the findings really grabbed my attention, especially this:

In the U.S. 44 percent of people with incomes below the median — about $55,700 in 2015 — reported that the cost of care prevented them from getting the medical treatment they needed. Twenty-six percent of those with incomes above the median also said financial barriers prevent them from getting care.  That means that the high deductibles and high coinsurance that most health plans now require make it hard to pay for care.

By contrast in the U.K., only 7 percent of people with low incomes and only 4 percent of those with higher incomes said they had trouble getting care. Yes, that’s England, the nation whose National Health Service has been much maligned by American politicians over the years.

In this latest survey, the U.K. ranked number one overall and was judged the best when it came to equity and the process of care — preventive care, safe care, coordinated care and patient preferences — and third when it came to access. People in Britain seem to be doing OK despite all those queues for services Americans have heard about from the media.

When it came to equity, access to care, and health outcomes, the U.S. ranked last, which also challenges the common assumption we have the best care in the world.

The U.S. has given a lot of attention to healthcare over the past decade, and the positive changes made by the Affordable Care Act have substantially decreased the number of uninsured and provided generous subsidies to help them buy coverage. I would have expected our rankings to improve.  I asked Schneider about that.

He explained that the lack of universal coverage is a barrier and the cost of care is st≠≠ill too high for too many Americans, even if they have insurance. Families with incomes in the middle ranges of eligibility for ACA subsidies — incomes of around $60,000 or $70,000 — get small subsidies and face high deductibles and other cost-sharing, a trade-off they must make if they can afford only plans with low premiums.

Our complicated system of getting medical bills paid and the endless negotiations between providers and insurers — in other words, the administrative hassle — is also a huge drawback. Fifty-four percent of U.S. primary care doctors said insurance restrictions made it hard to get needed treatment for their patients, Schneider said. “That’s a big problem.”

The U.K., Australia, and New Zealand shine on this dimension. Schneider said that if the U.S. changed the way it pays providers, used fee schedules and global budgets — an amount a country, group, or hospital decides it will spend on care — the public would benefit.

Just as important, Schneider told me, was the lack of U.S. investment in primary care compared to other countries where primary care is more widely and uniformly available. They dedicate a greater percentage of their medical workforce to that kind of care rather than specialty care. The U.S favors expensive specialists.

So does the U.S. do well on anything? Although we ranked last on overall health outcomes such as life expectancy at age 60, there were bright spots such as breast cancer survival and fewer hospital deaths for heart attacks and stroke.

Those few achievements are simply not good enough.

What’s your biggest beef with the healthcare system? Write to Trudy at trudy.lieberman@gmail.com.