The U.S. may have won the first round of the World Cup, but it has come up short in another international contest—Best Healthcare System, according to a new report from the Commonwealth Fund.

The fourth installment of the Commonwealth Fund’s “Mirror, Mirror” series, which examines and compares healthcare systems around the world, finds the U.S. once again at the bottom of a list of seven leading industrialized countries. The report considers quality, efficiency, access to care, equity and the ability of its citizens to lead long, healthy, productive lives. The Netherlands, the United Kingdom and Australia topped the list, with the U.S. vying with Canada for last place.

The U.S. spends roughly $7,290 per capita on healthcare—twice as much as Canada and nearly three-times as much as New Zealand, according to the report. The Netherlands, which tops the lists, doles out $3,837 per capita. In the U.K., 13% of those with chronic conditions went without needed care during 2008. In the U.S., the number was 54%. Chronic conditions, such as diabetes, heart disease or chronic obstructive pulmonary disease, affect up to 90% of seniors.

Researchers acknowledged that any relative comparison of healthcare systems has inherent limitations. They noted that the study was based on national mortality data and the perceptions and experiences of patients and physicians. Once the Patient Protection and Affordable Care Act is fully implemented, the U.S.’s rank should rise, according to the report.