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Press Release


Dec 09, 2020

New International Study: Americans with Lower Income Are the Sickest, Most Likely to Struggle to Afford Care and Other Basic Needs Compared to Lower-Income People in Other Wealthy Countries

Eleven-Country Survey Shows Income Inequality in the U.S. and Lack of Access to Primary Care Could Threaten COVID-19 Recovery

As the COVID-19 pandemic continues to ravage the globe, new findings from the 2020 Commonwealth Fund International Health Policy Survey show that Americans with lower income face more severe health and financial hardships compared to their counterparts in other wealthy countries.

The survey, published today in Health Affairs, compared the health experiences of adults with lower income and income-related disparities across 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

Fielded between February and May 2020, during the early months of the pandemic, the survey reveals that although income-related disparities exist in other countries, they are far worse in the U.S. — and Americans’ health is suffering as a result. These greater inequalities could be undermining efforts to respond to the pandemic in the United States, including prospects for effective vaccination of the U.S. population.

Among the main findings:

  • Adults with lower income in the U.S. are sicker and most likely to struggle to make ends meet. In nearly all countries, adults with lower income were significantly more likely than wealthier adults to have multiple chronic conditions. However, across every measure the study looked at, people with lower income in the U.S. suffered more than in other countries:
    • More than one-third (36%) of U.S. adults with lower income have two or more chronic conditions — significantly more than in other countries.
    • Approximately one-third of adults with lower income in the U.S. (36%), Australia (36%), and Canada (34%) reported having anxiety or depression, the highest rates in the survey. Their counterparts in Germany (14%) and Switzerland (15%) were the least likely to report anxiety or depression.
    • More than one-quarter (28%) of U.S. adults with lower income said that, in the past year, they worried about being able to afford basic necessities such as food or housing, a significantly greater proportion than seen in other countries, where 6 percent to 22 percent reported this.
  • Half of U.S. adults with lower income skip needed care because of costs. Fifty percent reported skipping doctor visits, recommended tests, treatments, or follow-up care, or prescription medications in the past year because of the cost. In contrast, just 12 percent to 15 percent of adults with lower income in Germany, the U.K., Norway, and France reported this. Difficulty with paying medical bills is mostly a U.S. phenomenon: 36 percent of U.S. adults with low income reported this problem. That is significantly more than in all other countries, where rates ranged from 7 percent to 16 percent.
  • Adults with lower income in the U.S. have worse access to primary care. A regular source of care is crucial to long-term health. It is also central to COVID-19 recovery as people who become ill will need reliable access to treatment. Access to primary care also facilitates access to vaccines when they are available. In most countries, virtually all adults with lower income reported having a regular doctor or place of care. However, rates in the U.S., Canada, and Sweden ranged from 85 percent to 89 percent.
    • Same-day and next-day appointments: About four in 10 adults with lower income in the U.S., Canada, New Zealand, and Norway were able to get a same- or next-day appointment to see a doctor or nurse when they were sick. In contrast, most adults with lower income in Germany and the Netherlands were able to get this care (74% and 63%, respectively).
    • After-hours care: The Netherlands stands out, with only 35 percent of adults with lower income reporting difficulties getting after-hours care without going to the emergency department. In all other countries, 43 percent to 64 percent reported such difficulty, with the U.S. (58%) ranking in the middle. 
    • Emergency care: Forty-five percent of U.S. adults with lower income reported using the emergency department in the past two years for care that could have been delivered by their regular provider had it been available. That is a significantly higher rate than in Australia, France, Sweden, and the U.K.


Reginald D. Williams II, Commonwealth Fund Vice President for International Health Policy and Practice Innovations

“The inequities that we’re seeing in the U.S. and abroad have only been exacerbated by COVID-19. But what this study shows is that Americans — especially adults with lower income — are at a severe disadvantage compared to citizens of other countries. And they are paying the price with their health and their lives. As we approach the ninth month of the pandemic, we have an opportunity to advance policies that improve health insurance coverage, strengthen primary care, and increase social supports for people who are in need.”

David Blumenthal, M.D., Commonwealth Fund President

“What’s clear from this study is that we cannot continue on the path of deepening inequality. As we progress through the darkest days of COVID-19 in the U.S., people need access to affordable health care now more than ever. The new administration and Congress have an opportunity to apply the stark lessons learned from COVID-19 and over the last decade so that our health system works for everyone — no matter who they are or where they get care.”


The Commonwealth Fund study could serve as a guide for policymakers and health system leaders who are interested in supporting greater health equity in the United States. The authors believe it is critical to advance policy solutions to extend insurance coverage, make health care more affordable, and strengthen primary care. Further, they argue that making greater investments in addressing the social determinants of health — factors beyond traditional health care, such as housing, education, and nutrition, that have a substantial effect on people’s health — would translate into better health outcomes across the country. The U.S. in particular, they say, has much to gain from examining the experience of countries where universal health care begins at birth.


Data came from surveys conducted among nationally representative samples of noninstitutionalized adults age 18 and older in 11 countries during the period February–May 2020. SSRS, a survey research firm, and country contractors collected data by telephone (mobile and landline) and also online in Sweden, Switzerland, and the United States. Overall response rates varied from 14 percent (U.S., U.K., New Zealand) to 49 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 607 to 4,530.

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.


Publication Details


Dec 09, 2020


Bethanne Fox, Vice President, Outreach and Strategy, The Commonwealth Fund

[email protected]