The US healthcare system ranks dead last compared to other industrialized nations when it comes to affordability and patient access, according to a new survey.

The 2013 survey of the American healthcare landscape was conducted by the Commonwealth Fund just prior to the full implementation of the Obama administration’s Affordable Care Act (ACA).

“I would say that we found two things that really seem to drive the higher barriers to healthcare in the US,” said David Squires, a senior researcher with the Commonwealth Fund in New York City. “The first is that we have a huge uninsured population, which at least at the time of the survey was about 50 million people. And, the second is that we have millions more who have some kind of insurance, but the coverage isn’t really good enough to protect them fully if they actually become ill.”