The U.S. health care system has been subject to heated debate over the past decade, but one thing that has remained consistent is the level of performance, which has been ranked as the worst among industrialized nations for the fifth time, according to the 2014 Commonwealth Fund survey 2014. The Commonwealth Fund report compares the U.S. with 10 other nations: France, Australia, Germany, Canada, Sweden, New Zealand, Norway, the Netherlands, Switzerland and the U.K. were all judged to be superior based on various factors. These include quality of care, access to doctors and equity throughout the country. Although the U.S. has the most expensive health care system in the world, the nation ranks lowest in terms of "efficiency, equity and outcomes," according to the report. One of the most piercing revelations is that the high rate of expenditure for insurance is not commensurate to the satisfaction of patients or quality of service. High out-of-pocket costs and gaps in coverage "undermine efforts in the U.S. to improve care coordination," the report summarized. "Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home," it said. A lack of universal health care was noted as the key difference between the U.S. and the other industrial nations.