The United States health system ranked dead last in an international comparison of 10 peer nations, according to a new report by the Commonwealth Fund.

In spite of Americans paying nearly double that of other countries, the system performed poorly on health equity, access to care and outcomes.

“I see the human toll of these shortcomings on a daily basis,” said Dr Joseph Betancourt, the president of the Commonwealth Fund, a foundation with a focus on healthcare research and policy.

“I see patients who cannot afford their medications … I see older patients arrive sicker than they should because they spent the majority of their lives uninsured,” said Betancourt. “It’s time we finally build a health system that delivers quality affordable healthcare for all Americans.”

However, even as high healthcare prices bite into workers’ paychecks, the economy and inflation dominate voters’ concerns. Neither Kamala Harris nor Donald Trump has proposed major healthcare reforms.

The Democratic presidential nominee has largely reframed healthcare as an economic issue, promising medical debt relief while highlighting the Biden administration’s successes, such as Medicare drug price negotiations.

The Republican presidential nominee said he has “concepts of a plan” to improve healthcare, but has made no proposals. The conservative policy agenda Project 2025 has largely proposed gutting scientific and public health infrastructure.

However, when asked about healthcare issues, voters overwhelmingly ranked cost at the top. The cost of drugs, doctors and insurance are the top issue for Democrats (42%) and Republicans (45%), according to Kaiser Family Foundation health system polling. Americans spend $4.5tn per year on healthcare, or more than $13,000 per person per year on healthcare, according to federal government data.

The Commonwealth Fund’s report is the 20th in their “Mirror, Mirror” series, an international comparison of the US health system to nine wealthy democracies including Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK, Sweden and Switzerland. The foundation calls this year’s report a “portrait of a failing US health system”.

The report uses 70 indicators from across five main sectors, including access to care, health equity, care process, administrative efficiency and outcomes. The measures are derived from a survey conducted by Commonwealth as well as publicly available measures from the World Health Organization, OECD and Our World in Data.

In all but “care process” – the domain that covers issues such as reconciling medications – the US ranked as the last or penultimate nation. Presenters for Commonwealth noted the US is often “in a class of its own” far below the nearest peer nation.

“Poverty, homelessness, hunger, discrimination, substance abuse – other countries don’t make their health systems work so hard,” said Reginald D Williams II, vice-president of the fund. He said most peer nations cover more of their citizens’ basic needs. “Too many individuals in the US face a lifetime of inequity, it doesn’t have to be this way.”

But recommendations to improve the US health system’s standing among peer nations will not be easy to implement.

The fund said the US would need to expand insurance coverage and make “meaningful” improvements on the amount of healthcare expenses patients pay themselves; minimize the complexity and variation in insurance plans to improve administrative efficiency; build a viable primary care and public health system; and invest in social wellbeing, rather than thrust problems of social inequity onto the health system.

“I don’t expect we will in one fell swoop rewrite the social contract,” said Dr David Blumenthal, the fund’s past president and an author of the report. “The American electorate makes choices about which direction to move in, and that is very much an issue in this election.”