New 11-Country Survey of People 65 and Older Finds Those in U.S. Are Sickest and Most Likely to Have Problems Paying Medical Bills, Getting Needed Health Care

Commonwealth Fund Survey Underscores Importance of Medicare for Older Adults; Finds U.S. Does Well on Helping Patients with Chronic Illness and Access to Specialty Care


New York, NY, November 19, 2014—Eighty-seven percent of U.S. adults age 65 and older have at least one chronic illness and 68 percent have two or more, the highest rates in a new 11-country Commonwealth Fund survey whose findings were published today as a Health Affairs Web First. About half (53%)  of the U.S. respondents reported taking four or more medications—the highest rate of the 11 countries. Moreover, 25 percent of older U.S. adults saw four or more doctors in the past year, second only to Germany (39%). The survey findings indicate that older Americans are sicker than their counterparts in the other countries, despite the fact that the U.S. population is the youngest.

The United States also stands out for having the most 65-and-older adults reporting they skipped needed health care because of costs (19%). U.S. older adults were also among the most likely to report they had trouble paying their medical bills (11%). In contrast, just 3 percent of older adults in France skipped health care because of costs, and only 1 percent in Norway and Sweden said they struggled to pay medical bills.

The Health Affairs article, “International Survey of Older Adults Finds Shortcomings In Access, Coordination, and Patient-Centered Care,” analyzes responses from more than 15,000 older adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the U.S. The study focused exclusively on the health care experiences of adults age 65 and over, providing a unique window, the authors say, into how Medicare beneficiaries in the U.S. compare to older adults in other high-income nations, all of which have some form of universal health insurance coverage.

“Previous surveys have shown that older people with Medicare coverage fare better than working-age adults in the U.S.,” said Robin Osborn, the lead author and Vice President and Director for The Commonwealth Fund’s International Program in Health Policy and Practice Innovations. “This new survey shows that there are areas, such as managing patients who have chronic illnesses and hospital discharge planning, where the U.S. does well compared to other countries. However, older Americans struggle more to get and afford the health care they need, indicating the need to improve Medicare’s financial protections.”

Older U.S. Adults Spend More Than Adults in Other Countries for Poorer Access to Health Care

Despite the near-universal coverage that Medicare provides, older U.S. adults in the survey incurred substantial out-of-pocket costs. Twenty-one percent spent $2,000 or more a year out-of-pocket on health care, a higher rate than any other country except Switzerland, where 22 percent spent that much. In the U.K., only 2 percent spent $2,000 or more, and in France, virtually no one did.

Although U.S. adults spent more, the survey found that they were less likely to have timely access to the health care they need:

  • Only 57 percent of older U.S. adults reported they could get a same- or next-day doctor’s appointment when they were sick, compared to 83 percent in France and New Zealand, and 81 percent in Germany.
  • Thirty-nine percent in the U.S. had used the emergency department in the past two years, among the highest rates reported. Of those who had used the emergency department, more than a third (35%) did so for a condition their primary care doctor could have treated if he or she had been available. 

People in Nearly Every Country Reported Poorly Organized Health Care

Older adults in every country surveyed reported some experiences with poorly coordinated care or gaps in communication between providers:

  • In the U.S., 35 percent reported at least one problem with care coordination in the past two years, such as not having a recommended medical test, receiving conflicting information from different doctors, or having their specialist and primary care doctor not communicating.
  • Older adults in Germany and Norway also experienced high rates of care coordination problems—41 percent and 37 percent, respectively.
  • In France, only 7 percent reported a care coordination problem. 

Bright Spots for U.S.

There were several areas in which the U.S. did better than average, or at least kept pace with the majority of the other countries:

  • Management of chronic illness: The U.S., along with the U.K., did well in some areas related to managing chronic illness. Fifty-eight percent of chronically ill older adults in the U.S. and 59 percent in the U.K. reported they had discussed their treatment goals with their doctor and had clear instructions about when to seek further care. Fewer than half of chronically ill people in the other nine countries reported the same. The U.S. also stood out with 83 percent of respondents reporting they had a treatment plan they could carry out in their everyday lives—one of the highest rates of the nations surveyed.
  • Patient–doctor communication: The vast majority of older adults in the U.S.—86 percent—reported that their doctor spent enough time with them; 81 percent said they were encouraged to ask questions.
  • Transitions from hospital to home: Only about one in four (28%) of U.S. older adults reported gaps in their discharge-planning arrangements, such as not having written instructions or not knowing what symptoms to watch for or whom to contact with a question when they left the hospital. This was among the lowest rates reported.
  • End-of-life planning: Older adults in the U.S. were the most likely to have taken steps to express their care preferences in the event they become unable to make decisions for themselves, with 78 percent reporting they had discussed with a family member, friend, or health professional the treatment they would want; 67 percent reporting they have a written plan naming someone to make their health care decisions for them; and 55 percent saying they have a written plan describing the treatment they want at the end of life.
  • Specialty care appointments: Eighty-six percent of older adults in the U.S. and 82% in Switzerland were able to get an appointment with a specialist within four weeks, the highest rates in the survey. Older adults in Canada (46%), Norway (46%), and Sweden (50%) were the least likely to have such quick access to specialty care.

“It is encouraging to see the U.S. health system doing well for older adults in areas that have been the focus of concentrated efforts to improve, such as better management of chronic illness,” said Commonwealth Fund President David Blumenthal, M.D. “Monitoring our progress over time and comparing it to other nations will be useful during the ongoing implementation of the Affordable Care Act, as more Americans gain health insurance coverage and further reforms are rolled out to improve how health care is delivered.”

Moving Forward

The study notes that all of the countries in the survey could do better, and that it is worthwhile to monitor what is working and what isn’t as they innovate to improve health care and reduce costs for their aging populations. 

In the U.S., the survey findings highlight some of Medicare’s challenges—high copayments and deductibles in many cases, and costs resulting from limitations on catastrophic expenses and long-term care coverage. But they also underscore how essential Medicare is to ensuring that older adults get the health care they need. As the country’s sicker adults over 65 continue to age and more baby boomers turn 65, the Medicare system will be strained, the authors warn. They note it will therefore be crucial to implement reforms that reduce health care costs and make sure our health care system is providing older adults with the best possible care.

Publication Details

Publication Date:
November 19, 2014
Mary Mahon, Vice President, Public Information, The Commonwealth Fund