Perceptions often clash with reality and when it comes to decisions, perceptions often rule.

The October 19 issue of The Economist, the world’s most influential news magazine, featured a 16-page special report proclaiming the US economy to be “The Envy Of The World” – performing head and shoulders above all other nations. Few economists would disagree.

Still, a large portion of voters are voting for GOP nominee Donald Trump because they agree with his claim that the US economy is in its worst shape ever. This despite rising employment, wage and GDP growth data and record-setting stock market indexes — a report card that Trump himself used while in the White House as a measure of his success. Reality seems to be subjective.

But in the United States, the health care system is an outlier and evokes similar conflicting views. A large number of us are dissatisfied with healthcare in the United States. Yet the belief that American medicine is the best in the world is widespread among us. Furthermore, surveys show that few of us would trade US healthcare for that of other countries.

Moreover, in the 2024 presidential election, as in the previous two, restructuring or reforming health care financing is not even on voters’ radar screens. This is despite recent top GOP comments that they would again try to reform or repeal Obamacare if they were to win the White House and Congress.

Like the problems growing ominously out of 23 years of borrow-and-spend fiscal policy, health care reform simply isn’t as contentious a political issue as it was two decades ago, before the Part D Medicare drug benefit and President Barack Obama’s Affordable Care Act improvements access for a large part of the population.

Still, citizens and voters must understand three things:

• We in the US do not understand how much more expensive our healthcare is compared to other countries.

• We don’t understand how far we are behind other countries on common, but vital, measures of health outcomes.

• We do not understand that there are real costs to our health system that are not included in standard tables of health expenditures. These are costs that largely do not occur in other industrialized countries.

Begin by understanding the differences between health care (diagnosis, procedures, therapies, or medications) and health financing and administration. In terms of provision, healthcare in the US is often excellent compared to other industrialized countries. In terms of financing and administration, we are gloomy.

Start by comparing our costs with those of other countries.

These are usually done in terms of what proportion of gross domestic product – the total output of goods and services across all sectors – is used to provide and administer health care. The higher the percentage, the fewer goods and services of other types are produced to meet the different needs of households.

Various authorities use these percentages for international comparisons. Those from the Organization for Economic Co-operation and Development, an international group made up of 38 of the richest countries, are most often mentioned. The World Health Organization, a United Nations agency, is another with very similar figures. Here in our country, a federal agency, the Centers for Medicare & Medicaid Services, maintains extensive National Health Expenditure Accounts (NHEA) dating back to 1960.

All of these show that more than 17% of everything we produce in the United States now goes to providing and administering health care. So more than one dollar out of six dollars in value produced goes to health.

The second most expensive country is Germany with just under 13%. A further 14 countries, including the UK, France, the Netherlands, Sweden, Australia, New Zealand, Japan and Canada, fall between 10% and 12%. Other rich countries including Norway, Israel and Ireland fall even lower.

Also understand that since GDP is higher in our country than in these others, the differences in health spending in absolute money are even greater than as fractions of output. However, one must realize that these comparisons are tricky because they depend on exchange rates and whether these rates are adjusted for differences in the cost of living.

For example, data for 2022 shows that the share of US GDP going to health care, 17.3%, is more than half Canada’s 10.2%. NHEA data shows per capita spending of $13,393 here. Canada’s government number is Canadian $8,540 per person. If we used today’s exchange rate for a Canadian dollar worth 74 cents, our neighbor’s outlay would be $6,315. US health spending per person would be more than double that of our neighbors to the north. But the US dollar is near its strongest levels in a quarter century. If we took 10- or 20-year averages, the gap would not be as large.

Yet it is true that US health spending is always higher than other rich countries relative to output and even higher in absolute terms.

What kind of expenses do we get?

International comparisons always raise arguments about long waiting times for procedures or poorer access to cutting-edge treatments in other countries. That may be true. But in basic indicators of a population’s health, the United States lags far behind many other countries, including much poorer ones.

Life expectancy at birth is a much misunderstood measure. It depends on the death rate at each possible age in a given year. It is much more a measure of current collective health than a prediction of how long someone will live. For 2024, life expectancy is estimated at 80.9 years in the US, compared to 85.2 years in Japan, 84.2 in Canada and 82.2 in the UK. With our life expectancy of 80.9 years, we come 49th out of some 229 nations, throwing out small rich countries like Monaco and Liechtenstein, and we’re still 30 places below the healthiest major industrialized nations by this measure.

The infantry mortality rate is another useful measure of how well health care services are distributed across the general population. Singapore, Iceland, Norway and Japan have 1.5 to 1.9 infant deaths per 1,000 live births. Most other industrialized countries have rates from 2.1 to 3.9. Canada has 4.3 deaths per thousand births. We are on 5.1.

Again, disregarding small nations brings us to about 30th place. But however you put it, we are the worst OECD country, the worst rich country, the worst industrialized country, on this measure that mostly reflects routine medical care for pregnant women from all social and economic classes.

So we have shorter waiting times for knee replacements, and we can keep more small premature babies alive than many other countries. But the overall health of our people is worse than that of our key allies and key competitors.

Finally, there is the issue of costs not included in officially tabulated health expenditures. Political ads will die out in a few days, but we seniors will continue to be inundated with mailings, calls, emails and online ads trying to get us to choose some particular prescription drug plan or Medicare Advantage plan. This happens every year. Additionally, as happens every year, tens of thousands of working people must cope with switching providers because the plan offered by their employer cuts ties with one health system or another.

Retirees spend large amounts of time trying to match a dizzying array of options to their particular needs. Even though thousands of people make careers out of giving us advice, you can still be wrong. Choose a drug plan with good coverage for what you need now, and a stroke or kidney disease or other illness in February could leave you with crushingly expensive necessary medications until next year.

So one must add the value of the time US households spend managing their participation in the US health care system to the dollar figures that are formally produced. And yes, there are some non-monetary advantages to the range of “choices” we might have relative to Dutch, French or Australians. But on the whole these non-monetary costs are higher for us than for citizens of other nations.

So, if the current situation is bad, how do we change? It can be much more difficult than we realize.