The United States spends nearly 16.9 percent of its GDP on health care, almost double the OECD average, yet Americans’ life expectancy lags behind by almost four years. Critics point to this mismatch to argue that high health-care spending, particularly on pharmaceuticals, fails to deliver better outcomes and justifies calls for drug price regulation.

However, this critique overlooks two key realities. U.S. drug spending as a share of GDP is stable and much closer to OECD averages than headlines suggest. More importantly, America’s poorer health outcomes are also driven by lifestyle and behavioral factors—like obesity, substance abuse, and poor diets—that set the stage for worse results long before care begins.

From 2000 to 2017, retail prescription drugs consistently accounted for less than 10 percent of total U.S. health-care spending. While U.S. drug prices are nearly 3 times higher than in other nations—partly due to America’s outsized role in funding global drug development and other countries benefiting from these investments—the United States’ overall pharmaceutical spending as a share of total health expenditures is in line with peer OECD nations. U.S. pharmaceutical spending was only slightly higher than that of Iceland, Finland, Switzerland, and Austria, but actually below countries such as France, the Czech Republic, Chile, Canada, Israel, and Germany.

And don’t forget, not only are the majority of the world’s new drugs developed in the United States, they’re also introduced in America first, allowing patients earlier access to cutting-edge therapies, improving health outcomes, and generating significant economic activity.

Lifestyle and Behavioral Risk Factors

Understanding why U.S. health outcomes often seem worse requires looking beyond the care provided to the health of the patients themselves. Some outcomes reflect the impact of medical care, while others are shaped by patients’ pre-existing health conditions. Ignoring these underlying differences can paint a misleading picture of health care effectiveness.

In the United States, patients often have more health risks—like chronic conditions—that predispose them to worse outcomes, regardless of care quality. This can make the system seem less effective when the real issue is the starting health of patients. Simply comparing spending and outcomes overlooks this key distinction.

• Higher rates of obesity: Obesity increases the risk of conditions such as heart disease, diabetes, and certain cancers, contributing to poorer health outcomes. Almost twice as many American adults are classified as obese (34 percent), compared to the OECD average (18 percent). Across EU countries, an average of 17 percent of individuals are obese. And from 2013 through 2023, the prevalence of severe obesity in the United States—defined as a body mass index of 40 or higher—increased from 7.7 to 9.7 percent.
• Higher rates of substance abuse: Opioid use and related deaths in the United States far exceed those in other OECD countries, reflecting a growing public health crisis. 4.6 percent of individuals aged 15-64 use opioids in America compared to the 0.9 percent OECD average. And the United States has an opioid-related death rate of 223 per million individuals, compared to an estimated average of 30 per million across OECD countries.
• Poorer dietary habits: Americans consume more ultra-processed foods (UPFs) and sugar than their OECD counterparts, contributing to higher rates of cardiometabolic diseases, obesity, diabetes, and certain cancers. The United States is the leading country in UPF consumption—UPFs account for 60 percent of caloric intake, compared to 14 to 44 percent across European countries. UPFs include processed meats, snacks, soft drinks, cookies, and candy. According to a recent survey, Americans’ average per capita consumption of sugar (126.4 grams) is the highest of countries surveyed.
• Lower physical activity rates: Physical activity is inversely associated with conditions such as obesity, diabetes, and hypertension. A cross-country study found that, at 4,774 steps, average daily steps are lower in the United States than in other countries, such as the United Kingdom (5,444 steps), Germany (5,205), France (5,141), Spain (5,936), the Netherlands (5,110), and Sweden (5,863).
• Higher rates of mental health issues: Mental health issues are more prevalent in the United States than in other OECD countries. In 2020, anxiety affected 32.8 percent of individuals in the United States, compared to 6.3 percent of citizens in Germany and 18.5 percent in France. Similarly, depression affected 26.3 percent of Americans, compared to 10.7 percent of Germans, and 15.6 percent of French. Further, the U.S. suicide rate was 14.1 deaths per 100,000 people, above the OECD average of 11.3 per 100,000.
• Higher rates of violence: The OECD Better Life Index reports that the homicide rate in the United States was 6 murders per 100,000 people, significantly higher than the OECD average of 2.6.Data from the Institute for Health Metrics and Evaluation further shows that the United States was an outlier in firearm violence in 2021, with a rate of 4.5 deaths per 100,000 people. This far exceeds rates in other countries, such as Canada (0.62), France (0.24), Belgium (0.23), and Germany (0.06).

These factors suggest that U.S. patients enter the health care system in poorer health relative to their OECD counterparts. This can make the U.S. health care system appear less effective, even though survival rates for complex conditions like cancer often exceed OECD averages due to early detection and America’s world-leading development of effective therapies.

What we learn from this context is that in comparing U.S. health outcomes to other OECD countries, raw metrics alone don’t tell the full story. While the United States spends more on health care, underlying lifestyle and behavioral risk factors—like obesity, substance abuse, poor diets, and lower physical activity—play a significant role in driving worse health outcomes. The challenge ahead is clear: by addressing the root causes of poor health and promoting healthier lifestyles, the United States can fully realize the potential of its innovative health care system. Effective care, after all, begins with healthier patients.