According to a new performance analysis conducted by the Commonwealth Fund, the US health care system consistently underperforms, despite being the most expensive in the world. In comparison with 10 other nations, the US ranks last, as it has done in previous years’ studies.

The Commonwealth Fund is a private foundation with a mission statement of promoting a “high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.”

To do this, it supports independent research on health care issues and provides grants to faciliate improvements to health care practice and policy.

The Commonwealth Fund has previously conducted the “Mirror, Mirror” performance analysis in 2010, 2007, 2006 and 2004. In all editions of the study, the US has reported the worst health outcomes for patients, and is close to last on access, efficiency and equity of health care.

In 2014, the number of countries whose health care systems were analyzed in the study was expanded to 11, with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the UK also featuring.

Data for the report are drawn from three separate surveys conducted by the Commonwealth Fund across 2011-2013.

Read more: US health care system ranks last in new report