Americans spend more on health care coverage than those who live in some of the world’s wealthiest nations. Yet, adults in the United States are thought to have worse health compared to people in countries like Australia, Canada, and Germany. What gives?

It has to do with money, according to a recent study published online in Health Affairs. The extremely high cost of health care in the U.S. is what ranks Americans so low on the health scale.

Study authors conducted telephone surveys in 11 different countries—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., and the U.S.—between March and June 2016 among adults age 18 and older. They asked respondents questions about their experiences with their health care systems, namely the type of accessibility, quality, and affordability. The respondents also answered questions having to do with personal health and well-being.

The results? Thirty-three percent of adults in the U.S. said they would go without recommended health care, not see a doctor when sick, or fail to fill a prescription because of the cost. Although this number is down from 37% in 2013, only 7% of respondents in the U.K. and 8% in the Netherlands and Sweden said they experienced any affordability issues, according to the survey.

 

What’s more, 31% of Americans surveyed reported some type of “material hardship;” 15% said they were concerned about having enough money to buy nutritious food; and another 16% said they were struggling to afford their rent or mortgage.

Overall, the U.S. performed poorly in almost all measures when compared to the 10 other countries surveyed. However, similar percentages of adults in the U.S. and Canada have multiple “chronic conditions,” such as arthritis, asthma, diabetes, or heart disease, at 28% and 22%, respectively. Still, America and Canada were the only two countries to report a number over 20%.

Although the U.S. has made progress in expanding insurance coverage under the Affordable Care Act, notes the study, it “still remains an outlier among high-income countries in ensuring access to health care,” according to the study’s authors.

One bright side, the U.S. reported more access to specialists, with only 6% of American adults reporting they had to wait longer than two months to see a specialist—a comparable rate to the other countries surveyed, according to the study.