November 16, 2016—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 high-income nations to go without needed health care because of costs and to struggle to afford basic necessities such as housing and healthy food. The survey findings, published today as a Health Affairs Web First article, also indicate that Americans are sicker than people in other countries and experience high levels of emotional distress.
Despite a significant decline from 2013, about 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 cost. By comparison, as few as 7 percent in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these cost problems. The U.S. also stands out for its exceptionally high rate of material hardship. Fifteen percent of U.S. adults reported worrying about having enough money for nutritious food and 16 percent reported struggling to afford their rent or mortgage.
Adults in the U.S. were also the most likely to be in poor health. More than a quarter (28%) of U.S. respondents reported having multiple chronic illnesses—by far the highest rate of any country surveyed—and a similar proportion (26%) said they experienced emotional distress in the past year that was difficult to cope with on their own. Respondents in Canada (27%) and Sweden (24%) reported similar levels of emotional distress.
The Commonwealth Fund’s 2016 international survey interviewed 26,863 adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Questions focused on people’s experiences with their country’s health care system—comparing their assessments of health care access, quality, and affordability—as well as on self-reported health and well-being. The study’s authors note that by examining the variation in performance of national health systems, the U.S. can gain useful insights as it implements new reforms and seeks to meet the needs of vulnerable patients.
“Previous surveys have shown that, especially compared to other industrialized nations, the U.S. has far too many people who can’t afford the care they need, even when they have health insurance,” said Robin Osborn, Vice President and Director of The Commonwealth Fund’s International Program in Health Policy and Practice Innovations and the study’s lead author. “This survey underscores that we can do better for our sickest and poorest patients, and that should be a high priority in efforts to improve our current system.”
Lack of Support for Low-Income Patients in the U.S.
Survey respondents in all 11 countries reported shortcomings in access to care for low-income adults. However, these problems were particularly acute in the U.S., where 43 percent of low-income adults reported forgoing care because of costs—the highest rate of any country. In the other countries, these rates ranged from 8 percent in the U.K. to 31 percent in Switzerland.
Moreover, when sick, low-income U.S. adults often had trouble quickly getting in to see a health care provider. More than one-third (35%) waited six days or more, compared to only 17 percent of higher-income adults.
Additional Report Highlights:
Access to Care
Primary Care and Coordination of Services
“The U.S. spends more on health care than any other country, but what we get for these significant resources falls short in terms of access to care, affordability, and coordination,” said Commonwealth Fund President David Blumenthal, M.D. “We can learn from what is working in other nations. If we’re going to do better for our patients, we need to create a health care system that addresses the needs of everyone, especially our sickest patients, and those who struggle to make ends meet.”
The authors note that by overcoming some of the major barriers to access and affordability in its health care system, the U.S. could address many of the concerns voiced in the Commonwealth Fund survey. Such steps include expanding Medicaid eligibility in the 19 states that have yet to do so, limiting the amount of money people must spend out-of-pocket for their health care, and supporting a strong primary care system.
While the Affordable Care Act has made individual insurance coverage substantially more affordable through targeted subsidies, out-of-pocket spending caps, and cost-sharing subsidies, many other countries surveyed provide better cost protection and a more extensive social safety net, the authors note.
The article will also be published in the December issue of Health Affairs.
Data came from telephone surveys conducted by SSRS, a survey research firm, and country contractors in the period March-June 2016 among nationally representative samples of noninstitutionalized adults ages eighteen and older. Samples were generated using probability-based overlapping landline and mobile phone sampling designs in most countries; both mobile and landline telephone numbers were included to improve representativeness. Standard within-household selection procedures were used to increase the likelihood of reaching an eligible respondent for landline samples.
In collaboration with researchers in each of the eleven countries, a common questionnaire was developed, translated, adapted, and pretested. Interviewers were trained to conduct interviews using a standardized protocol. Computer-assisted telephone interviews lasted from an average of seventeen minutes (in the United Kingdom) to an average of twenty-five minutes (in France). The period when data were collected in a given country ranged from seven to thirteen weeks. The overall response rates varied from 11 percent (Norway) to 47 percent (Switzerland).
International partners joined with the Commonwealth Fund to sponsor country surveys, and some countries supported the use of expanded samples to enable within-country analyses. Final country population samples ranged from 1,000 to 7,124. Data were weighted to ensure that the final outcome was representative of the adult population in each country. Weighting procedures took into account the sample design, probability of selection, and systematic nonresponse across known population parameters including region, sex, age, education, and other demographic characteristics.