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
- Fifty-one percent of U.S. adults struggled to find care in the evenings and weekends without going to a hospital emergency department. Between 40 percent and 64 percent of adults in all other countries reported similar difficulties. (The Netherlands, at 25%, was the exception.)
- Thirty-five percent of adults in the U.S. and one-third or more in Canada, Sweden, and France (33% to 41%) reported going to the emergency department for care in the past two years. The rate was strikingly lower in Germany (11%).
- Thirty-two percent of U.S. adults reported going without dental care in the past year because of costs. Lack of access to dental care was also a concern in other countries, with more than one of five adults in Switzerland, Canada, France, Australia, and New Zealand saying they skipped dental care or checkups in the past year because of costs. Only 11 percent of adults in the U.K. and the Netherlands reported this problem.
Primary Care and Coordination of Services
- About one-third (34%) of U.S. adults with a prior diagnosis of depression or anxiety reported they had not discussed with a primary care clinician in the previous two years things in their life that worried them or caused stress. Between 33 percent and 54 percent of adults in Canada, the Netherlands, New Zealand, Norway, Sweden, Germany, and the U.K. also reported not having these discussions with primary care providers.
- Adults in the U.S. (19%) and France (24%) were the most likely to say that, during the past two years, their medical records or test results had not been available at an appointment or duplicate tests had been ordered. Overall, 35 percent of adults in the U.S. experienced a care coordination problem, including duplicate tests being ordered, receiving conflicting information from different doctors, or doctors not knowing their full medical history.
- Fourteen percent of chronically ill U.S. adults did not feel they had the support they needed from health care providers to manage their conditions. This proportion is less than half that in Switzerland, New Zealand, Australia, the Netherlands, and Germany.
- U.S. adults have timely access to specialists. Only 6 percent reported waiting longer than two months for an appointment. In Germany, France, the Netherlands, and Switzerland, rates were similar, ranging from 3 percent to 9 percent.
- The U.S. is the only country where most adults had a conversation with their physician in the past two years about leading a healthy life (59%). In all other countries, the majority of respondents (59% to 83%) reported their doctor had not discussed healthy diet and exercise.
- Twenty-two percent of U.S. adults who had been hospitalized reported gaps in their discharge planning—the lowest rate of any country surveyed. For all other countries, between 28 percent and 61 percent of adults reported problems with the discharge process, such as not receiving information on what to do upon returning home or not having arrangements for follow-up care. • The Dutch health care system fares especially well on access to primary care and care coordination. According to the survey, the Netherlands has among the lowest rates of emergency department use, of not being able to get same- or next-day appointments, of difficulty getting after-hours care, and of their records not being available at an appointment or duplicate tests being ordered.
“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.