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Access, Affordability, and Insurance Complexity Are Often Worse in the United States Compared to 10 Other Countries

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A 2013 survey conducted in 11 countries finds that U.S. adults are significantly more likely than their counterparts to forgo health care because of the cost, to have difficulty paying for care even when they have insurance, and to deal with time-consuming insurance issues.

The Issue

Compared with the health systems of other industrialized nations, the U.S. system is an outlier in terms of health care cost, access, and affordability. Findings from a new 11-country survey from The Commonwealth Fund, published by Health Affairs, offer a baseline and benchmarks to assess the progress of U.S. insurance reform efforts.


Key Findings


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  • In 2013, more than one-third (37%) of U.S. adults went without recommended care, did not see a doctor when they were sick, or failed to fill prescriptions because of costs, compared with as few as 4 percent to 6 percent in the United Kingdom and Sweden.
  • Roughly 40 percent of both insured and uninsured U.S. respondents spent $1,000 or more out-of-pocket during the year on medical care, not counting premiums. High deductibles and cost-sharing, along with no limits on out-of-pocket costs, may explain why even insured people in the U.S. struggled to afford needed health care, the researchers said.
  • Nearly one-quarter (23%) of U.S. adults either had serious problems paying medical bills or were unable to pay them, compared with fewer than 13 percent of adults in the next-highest country, France, and 6 percent or fewer in the U.K., Sweden, and Norway.
  • About one of three (32%) U.S. adults spent a lot of time dealing with insurance paperwork and disputes or were either denied payment for a claim or paid less than expected. Only 25 percent of adults in Switzerland, 19 percent in the Netherlands, and 17 percent in Germany—all countries with competitive health insurance markets—reported these problems. U.S. insurers spent $606 per person on administrative costs, more than twice the amount in the next-highest country. Such high costs result from a complex, fragmented insurance system, the researchers write.
  • The vast majority (75%) of U.S. adults said their health system needs to undergo fundamental changes or be rebuilt completely.
  • The U.S. spends $8,508 per person on health care. That is nearly $3,000 more per person than Norway, the second-highest spender.

Addressing the Problem

The United States is beginning to implement health insurance expansions and market reforms. While the survey highlights the vulnerability of the uninsured and the importance of expanding coverage, it also indicates that having coverage alone is not sufficient. Effective insurance design, the researchers say, balances cost-sharing responsibilities with people’s ability to pay and ensures coverage of effective care. Other countries’ efforts to enhance access to primary care, including providing after-hours care and simplifying administrative complexity, also provide insights for U.S. reforms looking forward.

About the Study

Approximately 20,000 adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., and the U.S. were surveyed between February and June 2013. The survey focused on people’s experiences with their country’s health care system, particularly those related to accessing and affording health care.

The Bottom Line

Across the industrialized world, residents of the U.S. are the most likely to endorse major reforms to their health care system, perhaps signaling difficulty in affording care and dealing with insurance paperwork and complexity.

Publication Details



Robin Osborn, Senior Advisor, International Program in Health Policy and Practice Innovations, The Commonwealth Fund

[email protected]


C. Schoen, R. Osborn, D. Squires, and M. M. Doty, "Access, Affordability, and Insurance Complexity Are Often Worse in the United States Compared to 10 Other Countries," Health Affairs Web First, published online Nov. 14, 2013.