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Mirror, Mirror 2024 is your opportunity to explore the impact of policy choices on health and well-being across 10 countries, including the U.S. Read the report here.

Area of Focus

Improving Health Care Quality

Surveys

/

Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries

Back of nurse pushing patient in wheelchair

A nurse at the Albblick nursing home in Filderstadt, Germany, pushes a resident along a corridor. Compared to their counterparts in most other wealthy countries, older Americans have greater difficulty affording health care, despite having Medicare coverage. Photo: Marijan Murat/DPA via Getty Images

A nurse at the Albblick nursing home in Filderstadt, Germany, pushes a resident along a corridor. Compared to their counterparts in most other wealthy countries, older Americans have greater difficulty affording health care, despite having Medicare coverage. Photo: Marijan Murat/DPA via Getty Images

Toplines

  • Despite having Medicare coverage, older Americans have greater difficulty affording health care than their counterparts in most of the other countries surveyed

  • Nearly one in four older U.S. adults spent at least $2,000 out of pocket on health care last year

Toplines

  • Despite having Medicare coverage, older Americans have greater difficulty affording health care than their counterparts in most of the other countries surveyed

  • Nearly one in four older U.S. adults spent at least $2,000 out of pocket on health care last year

Authors
Munira Z. Gunja, Gretchen Jacobson, Faith Leonard, Reginald D. Williams II
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Introduction

The Medicare program in the United States is a critical pathway to health care coverage for adults age 65 and older and younger people with disabilities. Beneficiaries have the option of receiving their Medicare benefits through either traditional fee-for-service Medicare or through private insurers, known as Medicare Advantage plans. Both have significant cost-sharing requirements, including deductibles and coinsurance.

Traditional Medicare does not have a limit on beneficiaries’ out-of-pocket spending for medical tests and services, such as doctor or hospital visits, and it does not cover a number of services that older adults and people with disabilities often need, including long-term care, vision, hearing, and dental services. While Medicare Advantage plans have limits on beneficiaries’ out-of-pocket costs for medical tests and services, and the vast majority provide some coverage for vision, dental, and hearing care, the care may not be more affordable.1 Unlike traditional Medicare, Medicare Advantage plans typically restrict which doctors and hospitals enrollees can see, which may cause beneficiaries to seek care out-of-network for which they have little or no coverage. Plans also often require approval to see providers, which is not required in traditional Medicare, and this may cause enrollees to pay out of pocket for delayed or denied services.2

Like several other countries, nearly all adults age 65 and older in the U.S. have health coverage. But high out-of-pocket costs in the Medicare program may still make it more difficult for older Americans to receive affordable care compared to older adults in other countries. This brief presents the first findings from the 2024 Commonwealth Fund International Health Policy Survey of Older Adults in 10 countries to explore how financial considerations affect older adults’ health care decisions. The survey involved adults age 65 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. For this analysis, U.S. respondents were limited to those with some form of Medicare coverage. To understand how differences in Medicare coverage affect the affordability of care, we also compare the responses of beneficiaries with traditional Medicare versus those with a Medicare Advantage plan. See “How We Conducted This Survey” for more details.

Highlights

  • Nearly a quarter of older adults in the U.S. spent at least USD 2,000 over the past year on out-of-pocket expenses, compared to less than 5 percent in France and the Netherlands who spent an equivalent amount.
  • Less than 10 percent of older adults across countries reported skipping needed care or forgoing medical treatment because of the cost, although older adults in the U.S. reported these cost barriers at the highest rate.
  • One of five older adults in the U.S., Australia, and Canada reported skipping needed dental care, compared to 5 percent or less of older adults in the Netherlands and Germany.
  • Less than 5 percent of older adults in all countries reported skipping mental health care over the past 12 months because of the cost.
  • In all countries, about 10 percent or less of adults reported having at least one social service need.

Survey Findings

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_01

While all countries in this analysis offer health care coverage to older adults, the amount beneficiaries are required to spend out of pocket for health services — including prescription medications, medical, and dental care — can vary greatly based on where they live.3

Older adults in the U.S. and Switzerland were most likely to spend USD 2,000 or more annually on health care.4 Less than 10 percent of adults in France, the Netherlands, Sweden, and the U.K. reported having to do the same. Higher out-of-pocket spending in countries like Switzerland is likely linked to high deductible health plans and frequently needed services like dental and hearing care not being covered by the health insurance system.5

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_02

If out-of-pocket costs for health care services are unaffordable, older adults may postpone nonurgent care or forgo it entirely. Not receiving timely care can worsen health conditions, delay diagnoses, lead to poorer health outcomes, and increase overall health care spending.6 Our survey finds that one-third of older adults in the U.S. who reported at least one cost-related access problem reported they had fair or poor health (data not shown). Cost-related access problems include one of the following over the past 12 months because of the cost: having a medical issue but not visiting a doctor; skipping a medical test, treatment, or follow-up that was recommended by a doctor; not filling a prescription; or skipping medication doses.

Across the countries, less than 10 percent of older adults reported skipping needed treatment recommended by a doctor because of the cost. Still, older adults in the U.S. and Australia reported this at the highest rates. In six of the 10 countries, less than 5 percent of older adults skipped visits to their doctor because of the cost.

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_03

Across countries, less than 10 percent of older adults reported having a medical problem but did not visit a doctor because of the cost. In the Netherlands, almost no older adults reported doing so.

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_04

Older adults in the U.S. skipped doses of medication and avoided filling prescriptions at at least double the rate of other countries. In most countries, less than 5 percent of older adults reported forgoing prescription medication.

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_05

Many countries either carve out dental care from medical coverage or do not cover it at all — despite ample evidence that oral health plays a vital role in a person’s physical health.7 In the United States, traditional Medicare provides very limited dental coverage and only when the dental services are deemed to be medically necessary or incidental to a covered medical procedure.8 However, about half of beneficiaries in traditional Medicare have some dental coverage from supplemental policies.9 The vast majority of Medicare Advantage plans provide some coverage for dental services. Yet, even with limited coverage, beneficiaries are often liable for part of the cost of covered dental services and the full cost of services not covered.

At least one of five older adults in Australia, the U.S., and Canada reported skipping dental care because of the cost. On the other end, no more than 5 percent of older adults in the Netherlands and Germany reported skipping dental care. In the Netherlands, while dental care is not covered by national insurance, the government regulates dental provider rates.10 And in Germany, public insurance fully covers preventive care but only partly covers restorative dental care, so most people with public coverage buy supplemental dental insurance.11

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_06

Poor mental health is seen as a risk factor for chronic conditions and worse physical health outcomes. All countries in this analysis provide some form of mental health coverage for their older residents.12 Medicare covers certain visits with behavioral health providers, screenings, and programs to help with beneficiaries’ mental health needs. Mental health care is the only type of care in this analysis where less than 5 percent of residents across all countries skipped care because of affordability concerns.

Gunja_affordability_older_adults_2024_intl_survey_Exhibit_07

Research shows that social drivers of health can account for up to 50 percent of health outcomes.13 We defined having a social service need as being “always” or “usually” worried about one of the following over the past 12 months: having enough food; having enough money to pay rent or mortgage; having enough money to pay for other monthly bills, like electricity, heat, and telephone; or having a stable source of income. People with unmet social needs are more likely to need intensive and expensive medical interventions, make frequent trips to the emergency room, and face financial barriers to care.14 In all countries, about 10 percent of adults or less reported having at least one social service need.

Discussion

When older people can’t afford the health care they need, it impacts the health system overall: beneficiaries avoid getting care, their health providers end up seeing sicker patients, and federal Medicare spending increases over the long term.15 In the U.S., nearly all older adults are covered by Medicare and can access, at minimum, the most basic health services. Still, our survey data shows the U.S. Medicare program could improve and be on par with other countries — in some countries, nearly no older adults report cost-related access issues. Survey data show that older Americans pay more for health care and are more likely to postpone or skip needed care because of cost than people in other high-income countries. It is no surprise then that older Americans who have financial barriers to getting care are also more likely to report poorer health than those without these same barriers (data not shown).

Mental health care illustrates the key role coverage plays in access to care: all countries in this survey cover, at the very least, basic mental health services. As a result, few beneficiaries across countries report skipping this type of care because of costs. However, concerns have been raised about the difficulty of finding mental health providers who accept Medicare or their Medicare Advantage plan in the U.S. Policymakers and researchers should monitor how these access barriers may lead to beneficiaries paying out-of-pocket for mental health care.16

Our survey does not find significant differences in measures of affordability of care for beneficiaries in Medicare Advantage versus traditional Medicare for most measures, despite the fact that Medicare Advantage plans limit enrollees’ maximum out-of-pocket expenses for medical care, have the option of lowering cost-sharing requirements, and typically include some coverage for dental care. These results are in line with other research which found that similar shares of beneficiaries in both types of coverage reported cost-related barriers to care.17

Policy changes from the Inflation Reduction Act may help make prescription drugs more affordable for beneficiaries. These changes include limiting beneficiaries’ Part D expenses for prescription drugs, negotiating drug prices, expanding subsidies for people with low incomes, and capping copayments for insulin. Some of these changes have already taken effect or will be implemented in 2025, while others, such as negotiating drug prices, are in the process of being implemented with beneficiaries experiencing potential benefits in the future.

HOW WE CONDUCTED THIS SURVEY

The 2024 Commonwealth Fund International Health Policy Survey of Older Adults was conducted from February 29 to June 20, 2024. The survey was administered to a nationally representative sample of adults age 65 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. The Commonwealth Fund contracted with SSRS, a U.S.-based survey research firm, to field the survey in the U.S. and six additional countries, as well as collaborate with fieldwork partners and oversee survey administration in the other three countries. A total of 16,737 interviews of adults age 65 and older were completed for the 2024 survey. Final country sample sizes ranged from 300 to 3,989. Interviews were completed via landline telephone, mobile telephone, or online administration. For this analysis, U.S. respondents were limited to those with some form of Medicare coverage. Respondents who reported they were dually eligible for Medicare and Medicaid were considered having “Medicare Advantage” if they reported they had a Medicare Advantage plan or “traditional Medicare” if they reported they did not have a Medicare Advantage plan. The total sample of U.S. respondents for this analysis was 1,882 (traditional Medicare = 845 and Medicare Advantage = 1,037).

In Australia, Canada, France, Germany, the Netherlands, and New Zealand, a random-digit dial (RDD) overlapping-frame telephone design was used to obtain all interviews. A large portion of the interviews in both the U.K. and the U.S. were also obtained using an overlapping-frame telephone design. The sample design in both the U.K. and the U.S. also included interviews via Verian’s Public Voice panel and the SSRS Opinion Panel, respectively. In the U.S., the SSRS Opinion Panel sample was used to target subgroups of analytical interest to the Fund, namely low-income, Black, Hispanic, and rural respondents. Sweden and Switzerland both used population-based registries to draw their sample. Additional country-specific information on the sampling frames is below:

  • For Australia and New Zealand, SSRS procured landline and cell phone RDD samples from its sampling partner, Sample Solutions. For Australia, the landline RDD frame was based on the phone number blocks used in the telephone numbering plan provided by the Australian Communications and Media Authority, and the landline RDD sample was stratified by Australia’s eight regions to ensure geographic representativeness. The selection of cell phone RDD sample in Australia used roughly the same approach as the landline sample, though geographic information is not available for this frame. The shares of each cell phone service provider for the entire market were balanced to ensure that all providers had proper representation when selecting the cell phone RDD sample. For New Zealand, the landline RDD sample was based on the numbering plan provided by Telecom of New Zealand and was stratified by New Zealand’s 16 regions plus the Chatham Islands, while the cell phone RDD sampling was essentially the same as in Australia.
  • RDD landline and cell phone sample for Canada was provided by Dynata, a premier global provider of sampling solutions. The landline sample was drawn from Dynata’s database by geography after extensive cleaning and validation. The cell phone sample was drawn from the most recent monthly Telcordia TPM (Terminating Point Master) Data file, sorted by province, carrier name, and 1,000-block to provide a stratification that would yield a representative sample, both geographically and by large and small carriers.
  • Sample Solutions provided the landline and cell phone RDD samples for France, the Netherlands, and the United Kingdom. The landline RDD frame for France was generated using the national numbering plan provided by L’Autorité de Régulation des Communications Électroniques et des Postes, an independent French agency in charge of regulating telecommunications in France. The landline RDD frame for the Netherlands was generated using the national numbering plan provided by the Ministry of Economic Affairs. The landline RDD frame for the U.K. was generated based on the phone number blocks used in the national telephone numbering plan, provided by the Office of Communications (OFCOM), London, the British Federal Network Agency, using precodes by region. Based on the numbering plan for each country, Sample Solutions stratified the landline RDD samples by official NUTS2 regions according to the population distribution in each country. For the cell phone RDD samples, the phone numbers were randomly generated similar to the landline RDD sample for each country. Since it is not possible to identify precodes by region on cell phones in France, the Netherlands, or the U.K., Sample Solutions identified providers used for residential services and excluded those used for commercial sample. Online interviews in the U.K. were completed via Verian’s Public Voice Panel, a probabilistic panel recruited via address-based online surveying and face-to-face interviews. Both recruitment protocols use probability sampling drawn to ensure the entire population of the U.K. is represented.
  • The sample for Germany was sourced from the ADM sampling system (Arbeitsgemeinschaft ADM-Telefonstichproben). The ADM master sample is based on the range of numbers available in the German telephone network as updated, monitored, and published by the Federal Network Agency (the government agency in charge of the German telephone network). Since about 99 percent of the population can be reached via at least one telephone number, the ADM system provides near-full coverage of the German population. The sample frame for Sweden utilized the Total Population Registry (RTB). The RTB includes more than 2.1 million adults age 65 and older and covers 99 percent of the Swedish population. To create the sample frame, personal identification numbers were matched with addresses so that invitations to partake in the survey could be sent to the respondents selected from the sample. Four variables were used to stratify the sample frame into a total of 36 strata: degree of urbanization (three groups), Swedish/foreign background (two groups), level of education (three groups), and age (two groups). In general, proportional allocation was used, with the exception of one stratum which oversampled individuals over 80 years of age with postsecondary education, who were born outside of Sweden, and reside in sparsely populated areas. In Switzerland, an individual sample of people age 65 and older was drawn by the Swiss Federal Statistical Office (SFSO), using Switzerland’s nationwide population registry. This registry covers nearly 100 percent of the Swiss population and is updated on a quarterly basis. The sample was stratified by the three linguistic regions: German-, French-, and Italian-speaking. The cantons of Zürich, Schaffhausen, Valais, and Basel Stadt were oversampled and extracted separately as their own strata, for a total of seven strata.
  • Three different sample frames were used for data collection in the United States: 1) landline RDD, 2) cell phone RDD, and 3) the SSRS Opinion Panel to maximize the number of interviews among subgroups of analytical interest. The landline and cell phone RDD frames were generated by Marketing Systems Group (MSG), with the cell phone RDD sample being prepared using the Advanced Cellular Frame (ACF). Both the landline and cell phone RDD samples were disproportionately stratified, based on flagging records on both RDD frames with appended data. The landline RDD sample was matched against Neustar’s Pure Consumer Premium Database to identify phone numbers that are more likely to be assigned to households with residents who are age 65 and older. The cell phone RDD sample contained an ACF flag that identified phone numbers that are more likely to belong to individuals age 65 and older. The strata containing phone numbers that were flagged across both of the RDD samples were oversampled. To reach sufficient sample sizes among subgroups of analytical interest — including Black and Hispanic adults — as well as to target adults ages 65 to 74 and males age 65 and older, online interviews in the U.S. were completed via the SSRS Opinion Panel. SSRS Opinion Panelists are recruited randomly based on a nationally representative ABS (address-based sample) probability design (including Hawaii and Alaska), yielding a nationally representative panel of U.S. adults age 18 and older.

A common questionnaire was developed, translated, adapted, and adjusted for country-specific wording as needed. Interviewers in each country were trained to conduct interviews using a standardized protocol. Response rates varied from 3 percent in the United States to 50 percent in Switzerland.

International partners joined with the Commonwealth Fund to sponsor surveys, and some countries supported the use of expanded samples to enable within-country analyses. Data were weighted to ensure that the final outcome was representative of the population of adults age 65 and older in each country. Weighting procedures considered sample design, probability of selection, and systematic nonresponse across known geographic and demographic parameters including region, sex, age, education, and other characteristics relevant to the population of each country. In the U.S., the variables used for calibration also included race and ethnicity.

The margin of sampling error for the 2024 Commonwealth Fund International Health Policy Survey of Older Adults ranged from +/– 2.3 percentage points for Canada’s sample to +/– 7.1 percentage points for France’s sample, all at the 95 percent confidence interval.

ACKNOWLEDGMENTS

The authors thank Robyn Rapoport, Rob Manley, Molly Fisch-Friedman, and Christian Kline of SSRS; and Aishu Balaji, Jen Wilson, Paul Frame, Arnav Shah, Avni Gupta, Noel Manu, Tony Shih, Sara Collins, and Paige Huffman, all of the Commonwealth Fund.

NOTES
  1. David Blumenthal and Gretchen Jacobson, “How Affordable Is Medicare Advantage?” JAMA 332, no. 16 (Aug. 28, 2024): 1331–32. ↩
  2. Gretchen Jacobson et al., Medicare Advantage vs. Traditional Medicare: How Do Beneficiaries’ Characteristics and Experiences Differ? (Commonwealth Fund, Oct. 2021). ↩
  3. Out-of-pocket costs do not include annual premiums. Annual premiums can vary greatly by country. For information on premium amounts for each country, see Roosa Tikkanen et al. (eds.), 2020 International Profiles of Health Care Systems (Commonwealth Fund, June 2020). ↩
  4. All foreign currencies were converted to U.S. dollars (USD) using May 2024 conversion rates. The dollar amount does not account for income comparisons or standard of living. ↩
  5. Roosa Tikkanen et al. (eds.), “Switzerland,” in 2020 International Profiles of Health Care Systems (Commonwealth Fund, June 2020). ↩
  6. David Blumenthal et al., Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System — Comparing Performance in 10 Nations (Commonwealth Fund, Sept. 2024). ↩
  7. Roosa Tikkanen et al. (eds.), 2020 International Profiles of Health Care Systems (Commonwealth Fund, June 2020); and “Section 1. Effect of Oral Health on the Community, Overall Well-Being, and the Economy,” in Oral Health in America: Advances and Challenges (National Institute of Dental and Craniofacial Research, Dec. 2021). ↩
  8. Amber Willink, Cathy Schoen, and Karen Davis, “Dental Care and Medicare Beneficiaries: Access Gaps, Cost Burdens, and Policy Options,” Health Affairs 35, no. 12 (Dec. 2016): 2241–48. ↩
  9. Meredith Freed et al., Medicare and Dental Coverage: A Closer Look (KFF, July 2021). ↩
  10. Roosa Tikkanen et al. (eds.), “Netherlands,” in 2020 International Profiles of Health Care Systems (Commonwealth Fund, June 2020). ↩
  11. Roosa Tikkanen et al. (eds.), “Germany,” in 2020 International Profiles of Health Care Systems (Commonwealth Fund, June 2020). ↩
  12. Roosa Tikkanen et al. (eds.), 2020 International Profiles of Health Care Systems (Commonwealth Fund, June 2020). ↩
  13. World Health Organization, “Social Determinants of Health,” 2023. ↩
  14. Seth A. Berkowitz, Travis P. Baggett, and Samuel T. Edwards, “Addressing Health-Related Social Needs: Value-Based Care or Values-Based Care?,” Journal of General Internal Medicine 34, no. 9 (Sept. 2019): 1916–18. ↩
  15. Sunha Choi, “Experiencing Financial Hardship Associated with Medical Bills and Its Effects on Health Care Behavior: A Two-Year Panel Study,” Health Education and Behavior 45, no. 4 (Aug. 2018): 616–24; and Juliette Cubanski and Tricia Neuman, What to Know About Medicare Spending and Financing (KFF, Jan. 2023). ↩
  16. U.S. Government Accountability Office, Behavioral Health: Information on Cost-Sharing in Medicare and Medicare Advantage (GAO, Sept. 2024); and Beth McGinty, “Medicare’s Mental Health Coverage: What’s Included, What’s Changed, and What Gaps Remain” (explainer), Commonwealth Fund, Mar. 2, 2023. ↩
  17. Gretchen Jacobson and David Blumenthal, “The Predominance of Medicare Advantage,” New England Journal of Medicine 389, no. 24 (Dec. 13, 2023): 2291–98; and Faith Leonard et al., Medicare’s Affordability Problem: A Look at the Cost Burdens Faced by Older Enrollees — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2022 (Commonwealth Fund, Sept. 2023). ↩

Publication Details

Date

Contact

Munira Z. Gunja, Senior Researcher, International Program in Health Policy and Practice Innovations, The Commonwealth Fund

[email protected]

Citation

Munira Z. Gunja et al., Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries (Commonwealth Fund, Dec. 2024). https://doi.org/10.26099/tgjb-1m67

Area of Focus

Topics

International,
International Surveys,
Medicare,
Medicare Advantage,
Fee for Service Medicare,
Coverage and Access,
Quality of Care

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