High-income Americans are almost as likely to defer healthcare because of cost as people with low or average incomes in eight other developed countries, a new survey brief by the Commonwealth Fund finds. The survey findings also show that nearly half of American adults (46%) faced a problem with a medical bill in the last year, and almost half with low or average incomes (46%) skipped or delayed needed care because of price " the highest rate in any of nine countries analyzed. "In some cases, lower-income people in other countries are better off than higher-income Americans," said Munira Gunja, lead author of the study. Decades of research shows the US health system is both wildly expensive and inefficient. Internationally, it has been seen as a kind of "bogeyman" and as a way not to structure a health system, according to the late Princeton University health economist Uwe Reinhardt. A staggering 18% of US GDP goes to healthcare spending, the highest in the world, and the logical result of the highest healthcare prices of any nation. Despite runaway spending, Americans also have among the worst outcomes. Recent work by population researchers at Virginia Commonwealth University, found US life expectancy has slipped for decades and now ranks 46th among 200 nations. The US is also the only nation surveyed without guaranteed universal health coverage for every citizen.