The U.S. retirement slide is now a healthcare problem

The United States fell to 24th in Natixis Investment Managers' 2026 Global Retirement Index, three places below its 21st-place finish in 2025 and ten below the 14th it held in 2016, with three of the index's four sub-indices deteriorating. The headline is not new ground for this publication, which has argued that the slide is fiscal rather than a plan-design failure, but the detail underneath it moves the argument somewhere plan sponsors rarely look: healthcare.

The sharpest movement came in Finances in Retirement, where the U.S. dropped eight places to 18th, a fall Natixis attributes to renewed inflationary pressure and entrenched government indebtedness. Dave Goodsell, who runs the firm's Center for Investor Insight, describes a retirement model built for stable employment, steady inflation and predictable government support now absorbing an aging population, heavier public debt and prices that outrun paychecks. None of that yields to a different fund lineup.

The household side already looks decided: in Natixis's 2025 Global Survey of Individual Investors, 76 percent of American investors said mounting public debt will ultimately reduce their retirement benefits, and 77 percent expected growing deficits to become higher taxes. Forty-one percent said inflation is killing their retirement dreams, and two-thirds of investors globally said higher everyday prices are forcing them to save less — answers that describe a saver base planning around a benefit cut and a tax increase that have not happened yet.

Health is where the arithmetic turns ugly. The U.S. spends more per person on healthcare than any other country in the 44-nation index and still ranks 25th in its Health sub-index, the highest price in the sample buying a mid-table placement. One in three Americans fears going broke covering healthcare and long-term care in retirement, against a 24 percent global average, and more than 700,000 people now collect Social Security while living abroad, up more than 60 percent from roughly 431,000 two decades ago, according to Social Security Administration data — a measured response to a cost structure that no default option touches.

The advisory half of the research, 2,950 investment professionals across 23 countries, names the mismatch plainly: 52 percent of advisors called unrealistic return expectations the biggest planning mistake their clients make, while American investors expect long-term returns of 8.9 percent above inflation and advisors put a realistic figure nearer 7.4 percent. That roughly 1.5-point gap is the only number in the release a plan sponsor or an advisor can act on this quarter.

The index is a policy document whether or not it reads like one. Its finances category tracks inflation and sovereign debt — levers held by the Fed and Congress, not by a committee that meets quarterly to review a lineup — so the repair identified in earlier coverage still sits outside the plan. The health category is harder, because the spending is already the highest in the field and the outcome is still 25th. Watch the 2027 health score: it will move on provider pricing and long-term care costs, and the retirement industry has no lever on either.