It’s always been thought that having a high-paying job and generating wealth would exclude someone from going into debt. The United States is the only high-income country where, regardless of your income bracket, citizens are burdened with medical bills.

A new report by the Commonwealth Fund surveyed nine high-income countries to see how they vary in health insurance coverage and costs for their citizens. To no surprise, the U.S. is an outlier. People are more likely to skip or delay health care because of the cost.  

With higher costs come worse health outcomes and lower life expectancy. Munira Gunja, senior researcher and co-author of the report, says their goal is to analyze how the U.S. handles its growing healthcare disparities. 

“I think one of the more surprising findings is that high-income Americans can be worse off than lower or average-income people in other countries,” she says. 

Part of the issue, Gunja says, is because the U.S. has no federal universal health coverage program. This contributes to the type and quality of healthcare communities can access. And when you consider the intersection of low-income communities and communities of color, additional issues present themselves. 

The report states that U.S. adults with lower or average incomes surveyed experienced at least one cost-related problem while accessing health care. A few challenges include having a medical issue but not visiting a doctor and skipping a medical test, treatment, or follow-up that was recommended by a doctor.

Consequences of High Health Care Costs 

Regardless of income, U.S. adults are more likely to have medical bill problems. Like paying a medical bill, being unable to pay, or having insurance deny payment for medical care. Of the nine countries surveyed, the U.S. ranked 8-to-35% higher than all other high-income countries.  

The latest report is part of the Commonwealth Funds yearly analysis on how Americans access health services. The U.S., in comparison to other high-income countries, has the lowest life expectancy and the highest rate of avoidable death. This means people without health insurance or who can’t afford the costs are more likely to skip the doctor’s office.

“What ultimately ends up happening is that people die,” she says.  

Related: Medical Debt: The Price of Life 

An additional part of the U.S. health services issues are the social drivers of health. Which account for 50% of health outcomes. When people don’t have enough food, struggle to pay rent, lack a clean or safe place to sleep, or don’t have a stable income, they are more likely to need expensive medical interventions and make frequent trips to the emergency room.

As a solution, researchers point to universal health coverage. But even that isn’t enough. 

“We have to make sure that the coverage itself is comprehensive and affordable enough for people to actually use and not skip needed care,” Gunja says.