A 2015 Commonwealth Fund brief showed that — before the major provisions of the Affordable Care Act were introduced — the United States had worse outcomes and spent more on health care, primarily because of greater use of medical technology and higher prices, compared to other high-income countries. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes but second on care process measures.