New York, NY, November 18, 2010—A new 11-country survey from The Commonwealth Fund finds that adults in the United States are far more likely than those in 10 other industrialized nations to go without health care because of costs, have trouble paying medical bills, encounter high medical bills even when insured, and have disputes with their insurers or discover insurance wouldn’t pay as they expected. According to the report, the findings highlight the need for Affordable Care Act reforms that will ensure access to health care, protect people from medical debt, and simplify health insurance.
The U.S. stands out for the most negative insurance-related experiences. One third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared to as few as 5 percent to 6 percent in the Netherlands and the U.K., according to the study published today as a Health Affairs Web First article. In addition, one-fifth of U.S. adults had major problems paying medical bills, compared to 9 percent in France, the next highest country, 2 percent in the U.K., 3 percent in Germany, and 4 percent in the Netherlands. Uninsured and insured U.S. adults reported equally high rates of out-of-pocket costs, with one-third (35%) of U.S. adults paying $1,000 or more out-of-pocket in the past year for medical bills, significantly higher than all of the other countries.
The study analyzes findings from the Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries, focusing on insurance and access to health care experiences reported by 19,700 adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. The study reveals widespread disparities by income within the United States. Lower income U.S. adults were far more likely than those with above average incomes to report difficulty with medical bills and timely access to health care.
"We spend far more on health care than any of these countries, but this study highlights pervasive gaps in U.S. health insurance that put families’ health and budgets at risk," said Commonwealth Fund Senior Vice President Cathy Schoen, lead author of the article. "In fact, the U.S. is the only country in the study where having health insurance doesn’t guarantee you access to health care or financial protection when you’re sick. This is avoidable—other countries have designed their insurance systems to value access and limit out-of-pocket costs."
The U.S. also stood out for its complex insurance system, the study found. Thirty-one percent of U.S. adults either spent a lot of time dealing with insurance paperwork, had their insurer deny a claim, or had their insurer pay less than they anticipated. In contrast, only 13 percent of adults in Switzerland, 20 percent of adults in the Netherlands, and 23 percent of adults in Germany—all countries with competitive health insurance markets—reported these problems. U.S. adults under 65 were the most likely to experience problems dealing with their health insurance providers—the 65 and older Medicare population was much less likely to report these issues.
According to the study, the U.S. stood alone among the countries for its persistent and wide disparities among income groups—even for those with insurance. Although the uninsured were at highest risk for skipping needed care, working-age U.S. adults with below-average incomes who were insured all year were significantly more likely than those with above-average incomes to go without needed care because of costs and have serious problems paying medical bills—nearly half (46%) went without needed care and one third had one bill problem, double the rates reported by above-average income insured adults.
"What we are hearing directly from adults around the world, and what we hear regularly at home, is that there is substantial room for improvement in the U.S. health insurance system," said Commonwealth Fund President Karen Davis. "The good news is that there are opportunities to learn from other countries, and Affordable Care Act reforms will provide affordable insurance options for the uninsured, make sure insurance pays for essential care, and provide financial security for millions."
Looking beyond how health insurance affects access to health care, the survey found substantial differences among countries on access to care when sick, access after hours, and wait times for more specialized care.
Confidence in Affording Care and Getting Effective Care When Needed
Differences by Income
Insurance Design Matters
The study included countries with diverse insurance arrangements, including three countries— Germany, the Netherlands, and Switzerland—that have achieved near-universal coverage with competitive health insurance markets, a requirement that all residents have insurance, and provisions to assure that insurance and care are affordable. As the article describes, each of these countries has developed insurance system rules that ensure people with health insurance are protected. Countries that require people to pay for some portion of their health care costs out-of-pocket, such as France, Germany, and Switzerland have limited out-of-pocket costs to patients. Germany limits out-of-pocket costs based on income, and France lowers or eliminates cost-sharing for those with chronic conditions and for medications that have been proven to be highly effective. To address insurance affordability, Swiss and Dutch systems provide assistance in paying premiums to 30 to 40 percent of their populations.
The authors note that with insurance expansions under health reform, the U.S. performance should improve over time. However, out-of-pocket spending will remain high compared to other countries, and affordability provisions may need to be strengthened over time.
Harris Interactive, Inc. and international survey firms in various countries conducted the interviews by telephone with nationally representative cross-sections of adults ages 18 and older in the eleven countries between March and June, 2010. The final study included 3,552 adults in Australia, 3,302 in Canada, 1,302 in France, 1,005 in Germany, 1,001 in the Netherlands, 1,000 in New Zealand, 1,058 in Norway, 2,100 in Sweden, 1,306 in Switzerland, 1,511 in the United Kingdom, and 2,501 in the United States. The Commonwealth Fund provided core support for the survey with co-funding to expand the countries included in the survey provided by the German Institute for Quality and Efficiency in Health Care; Haute Authorité de Santé and Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (France); Dutch Ministry of Health, Welfare, and Sport and the Scientific Institute for Quality of Healthcare at Radboud University Nijmegen, in the Netherlands; Norwegian Knowledge Centre for the Health Services; Swedish Ministry of Health and Social Affairs; and the Swiss Federal Office of Public Health. In addition, support for expanded country samples was provided by the UK Health Foundation; Australian Commission on Safety and Quality in Health Care and the Bureau of Health Information; and the Health Council of Canada, Ontario Health Quality Council, and Québec Health Commission. The interviews were conducted in language appropriate to the country, with an option for French in Canada and Spanish in the United States. The margin of sample error for country averages are approximately ±2 percent for the Australia, Canada, Sweden and the U.S., and ±3 percent for the other countries at the 95 percent confidence level.