NEW YORK — One of the most contentious issues of the U.S. presidential campaign will be how to fix what many agree is a malfunctioning health-care system. Adding fuel to the fire is a recent study detailing the shortcomings of the U.S. health-care system compared with those of Australia, Canada, Germany, New Zealand and Britain.

The study, entitled “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care,” released by the Commonwealth Fund in New York, finds that not only is the U.S. health-care system the most expensive in the world (double that of the next most costly, Canada) but that it comes in dead last in most measures of performance.

Although U.S. political leaders are fond of stating that we have the best health-care system in the world, they fail to add an important caveat: It is the best for those who can afford it. For the rest of the population, disadvantages far outweigh the merits.

This new study not only confirms the findings of previous Commonwealth Fund studies but also that of a World Health Organization analysis in 2000: that the overall performance of the U.S. health-care system ranks 37th among all countries included in the analysis.

Presidential candidates will be asked to justify the costs (15 percent of GDP and estimated to reach 19.6 percent by 2016) of such a disadvantageous system that also fails to insure a sizable portion of the population. The most notable way in which the United States differs from other developed countries is in the absence of universal coverage. But it is also last in terms of access, patient safety, efficiency and equity.

The other five countries considered spend considerably less on health care — per capita and as a percentage of GDP. The U.S. spends more than $6,000 per person annually on health care, almost double that of Australia, Canada and Germany, all of which achieve better results on health status indicators. This suggests that the U.S. health-care system can and must do much more with its substantial investment in health.

Americans’ average life expectancy of 78 ranks 45th in the world — behind Greece, Bosnia and Jordan. Also, according to the CIA’s World Fact Book, the U.S. infant mortality rate — deaths of newborns (under age 1) per 1,000 live births — is 6.50, higher than most developed nations. Even Cuba’s IMR is 6.33.

The U.S. lags behind all industrialized nations in health insurance coverage. The most recent data available from the U.S. Census Bureau indicate that 46.6 million Americans (about 15.9 percent of the population) had no health insurance coverage during 2005, an increase of 1.3 million over the previous year. It is no wonder that medical bills, overwhelmingly, are the most common reason for personal bankruptcy in the U.S.

According to the Children’s Health Fund, 9 million children are completely uninsured in the U.S., while another 23.7 million — nearly 30 percent of the nation’s children — lack regular access to health care.

Compared with the other countries studied, the U.S. lags behind in the adoption of information technology and other national policies that promote quality improvement. Real-time information systems in countries such as New Zealand, Germany and Britain enhance physicians’ ability to monitor chronic conditions and the use of medication, including that prescribed by other physicians. In other countries, experienced nurses monitor chronic conditions, thus easing the physicians’ burden.

The U.S. also shows poor performance with regard to national health expenditures and administrative costs. Americans with below-average income are more reluctant to visit a physician when sick, get a recommended test, fill a prescription, undergo necessary treatment, or receive a proper followup.

These rankings are based on national mortality data and the perceptions and experiences of physicians and patients; they do not include information from medical records or other administrative data. Yet they paint a disturbing picture of the most expensive health-care system in the world.

Only structural reform can solve the U.S. health-care system’s deep problems. All people must be adequately insured and everyone must have access to good care. At the same time, the U.S. must incorporate the advantages of modern health information technology to develop an integrated medical record and information system. Lessons from other countries should be applied in the U.S.

In a recent article in the Journal of the American Medical Association, Dr. Ezekiel J. Emanuel, of the Department of Clinical Bioethics at the National Institutes of Health, stated, “The U.S. health-care system is considered a dysfunctional mess.” Is this an understatement?