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In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to and Affordability of Health Care

Outdoor clinic

Also read a companion To the Point post, “Fewer Americans Say Cost Is a Barrier to Getting Care, But U.S. Still Has a Long Way to Go.”


An 11-country survey finds that adults in the United States are far more likely than those in other countries to go without needed care because of costs and to struggle to afford basic necessities such as housing and healthy food. U.S. adults are also more likely to report having poor health and emotional distress. Bright spots for the U.S. include rates of timely access to specialist care, discussion with a physician about ways to lead a healthy life, and coordinated hospital discharge planning.

The Issue

Asking people directly about their experiences with the health care system can reveal valuable information about how well a country is meeting the needs of its population. A new Commonwealth Fund study in Health Affairs examines patients’ experiences based on responses to a 2016 survey of adults in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

Key Findings

  • Adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs. One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs. This percentage is down from the 2013 survey (37%). As few as 7 percent of respondents in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these affordability problems.
  • U.S. adults were also the most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.
  • Half of U.S. adults struggled to get health care on the weekends and evenings without going to an emergency department. Between 40 percent and 64 percent of adults in the other countries reported the same. The Netherlands had the lowest rate on this measure, 25 percent.
  • Adults in the U.S. (19%) and France (24%) were the most likely to say that their medical records or test results had not been available at the time of an appointment or that duplicate tests had been ordered in the past two years. These problems were reported less commonly in the other countries.
  • Fourteen percent of chronically ill U.S. adults said they did not get the support they needed from health care providers to manage their conditions. This was twice the rate in Australia, Germany, the Netherlands, New Zealand, and Switzerland.
  • U.S. health care performed comparatively well in the following areas: timely access to specialists, conversations with physicians about leading a healthy life, and coordinated hospital discharge planning.

Although the U.S. has made significant progress in expanding insurance coverage under the Affordable Care Act, it remains an outlier among high-income countries in ensuring access to health care. The authors point out that all of the other countries surveyed provide universal insurance coverage, and many provide better cost protection and a more extensive safety net. To address the barriers to access and affordability identified in the survey, policymakers might consider expanding Medicaid eligibility in the 19 states that have not yet done so; limiting the amount people need to spend out of pocket on health care; and creating a stronger primary care system.

In comparison to adults in the other 10 countries, adults in the U.S. are sicker and more economically disadvantaged. The resulting challenge to the U.S. health system is compounded by higher health care costs, greater income disparities, and relatively low levels of spending on social services.

About the Study

Telephone surveys were conducted in each of the 11 countries between March and June 2016 among adults age 18 and older. Questions focused on people’s experiences with their country’s health care system in terms of access, quality, and affordability, as well as on self-reported health and well-being.

The Bottom Line

Despite progress since passage of the Affordable Care Act, adults in the United States remain more likely to go without needed health care because of costs compared to adults in other high-income countries.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


Robin Osborn et al., "In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to and Affordability of Health Care," Health Affairs, published online Nov. 16, 2016.