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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

/

Access and Quality of Care for Older Adults in 10 Countries

Findings from the 2024 Commonwealth Fund International Health Policy Survey of Older Adults
Woman on bike in greenery

A senior woman in a bright pink jacket cycles on a well-maintained bike path on July 28, 2023, in Venlo, Netherlands, where the Dutch are committed to cycling in order to support sustainable and independent mobility for people of all ages. In our survey, older adults in the Netherlands who needed to see or contact their doctor were the most likely to report they could book timely appointments and get responses to medical questions within the same day. Photo: Michael Nguyen/NurPhoto via Getty Images

A senior woman in a bright pink jacket cycles on a well-maintained bike path on July 28, 2023, in Venlo, Netherlands, where the Dutch are committed to cycling in order to support sustainable and independent mobility for people of all ages. In our survey, older adults in the Netherlands who needed to see or contact their doctor were the most likely to report they could book timely appointments and get responses to medical questions within the same day. Photo: Michael Nguyen/NurPhoto via Getty Images

Toplines

  • While most older adults with Medicare in the U.S. are satisfied with their care, only two of five needing to see a doctor were able to make an appointment within two days, and only half needing off-hours care were able to get it

  • About one of five older adults across the 10 countries surveyed said they have been treated unfairly or dismissively in their encounters with the health care system

Toplines

  • While most older adults with Medicare in the U.S. are satisfied with their care, only two of five needing to see a doctor were able to make an appointment within two days, and only half needing off-hours care were able to get it

  • About one of five older adults across the 10 countries surveyed said they have been treated unfairly or dismissively in their encounters with the health care system

Authors
Munira Z. Gunja, Arnav Shah, Faith Leonard
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Introduction

Health care systems around the world are struggling — and at times failing — to meet the unique needs of older people age 65 and older. As people age, they are more likely to develop complex health problems and need ongoing care for chronic conditions, which is often more costly than other basic and preventive services.1 It’s critical to monitor challenges that older adults may face accessing health services, as well as the quality of these services, to keep this population healthy.

In the United States, the Medicare program is a critical source of health care coverage for adults age 65 and older and younger people with disabilities. Nearly all older adults in the U.S. have health coverage through this pathway. Likewise, in many other countries, older residents have some form of health coverage either through public or privately funded health insurance programs. However, despite having health insurance, some older beneficiaries may struggle to access care that meets their needs in a timely and convenient manner.

This brief presents findings from the 2024 Commonwealth Fund International Health Policy Survey of Older Adults in 10 countries to explore what access to care, coordination of care, and quality of care look like for older adults with health coverage. 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. (See “How We Conducted This Survey“ for more details.) While some countries may also use the term “Medicare” as the name of their health coverage for citizens, for this analysis, the term “Medicare” refers to the U.S. program only.

Highlights

  • Older adults who needed off-hours care in the Netherlands were significantly more likely to report they could easily get it compared to those in other countries.
  • No more than roughly one of five older adults across countries reported problems with coordination of care between their regular doctor and specialist.
  • U.S. Medicare beneficiaries were among the most likely to report their hospital coordinated care with their regular doctor when discharged; older adults in Sweden and Germany were least likely to do so.
  • While most older adults across all countries were satisfied with the quality of their health care, U.S. Medicare beneficiaries were most likely to report their health care professional reviewed their medications with them over the course of a year.
  • Roughly one of five U.S. Medicare beneficiaries reported they felt they were treated unfairly or their concerns were dismissed while receiving care.

Findings

Access to Care

Gunja_access_quality_older_adults_10_countries_2024_survey_Exhibit_01

Having a regular doctor or place of care is key to the early detection and treatment of disease as well as effective chronic disease management.2 Patients with a usual source of care are more likely to receive immunizations, including for flu, pneumonia, and respiratory syncytial virus; blood pressure screenings; and cancer screenings. It also can lead to more positive attitudes about the health system, which may improve engagement and coordination of care.3 Nearly all older adults across surveyed countries reported having a regular doctor or place of care.

But having a regular doctor is only the start of reliable access to care — these services also need to be available outside regular operating hours, such as evenings, weekends, and holidays. Access to off-hours care can reduce the improper use of emergency departments and improve patient satisfaction.4 Among older adults who needed off-hours care, the rate of U.S. Medicare beneficiaries reporting they had access to this type of care was on par, or in some cases higher, than their counterparts in nearly all other countries. The exception was the Netherlands, where roughly three of four (74%) older adults had access to off-hours care. Among those who reported using the emergency room in the past two years, U.S. Medicare beneficiaries said their last trip to the hospital could have been avoided if their regular doctor or place of care were available at a comparable or higher rate than most other countries. The Netherlands, again, was the one exception. It should be noted, however, that while nearly half of older adults in the Netherlands reported unnecessarily going to the emergency room for care, they were also among the least likely to report using the emergency room at all over the past two years (data not shown).

Older adults in the Netherlands who needed to see or contact their doctor were the most likely to report they could book timely appointments (61%) and always or often get responses to medical questions within the same day (85%). While most U.S. Medicare beneficiaries who tried to contact their regular doctor (70%) always or often received a response regarding a medical concern on the same day, only about two of five said they were able to book an appointment within two days of when they were sick.

Coordination of Care

Gunja_access_quality_older_adults_10_countries_2024_survey_Exhibit_02

Coordination between physicians and other care providers is essential to ensuring patients’ needs and preferences are communicated at the right time to the right people.5 Nearly three of five U.S. Medicare beneficiaries reported their regular doctor often helps coordinate the care they receive from other doctors or practices. Older adults in Australia were most likely to report this compared to those in the other countries.

Gunja_access_quality_older_adults_10_countries_2024_survey_Exhibit_03

Ensuring a smooth transition for the patient from hospital to home is critical for reducing the risk of complications and unnecessary readmissions.6 U.S. Medicare beneficiaries who went to the emergency room over the past two years were significantly more likely to report the hospital prepared them for a smooth discharge compared to older adults in either all, or nearly all, countries. Measures included reviewing prescriptions and providing written instructions, making arrangements for follow-up care, and providing services to help the respondent manage their health condition at home. Older patients in Germany and Sweden were among the least likely to report sufficient coordination of care for the patient between the hospital and home.

Quality of Care

Gunja_access_quality_older_adults_10_countries_2024_survey_Exhibit_04

While access to care is a key component of health outcomes, examining patient experience — whether they are satisfied and feel the care they receive meets their needs — is just as important. Most U.S. Medicare beneficiaries are satisfied with the measures of quality of care reported in this brief, which is consistent with prior research.7 They are also more likely to report high rates of satisfaction with their care compared to older adults in Canada, Sweden, and the U.K. And compared to all other countries, U.S. Medicare beneficiaries who take at least two prescription medications are significantly more likely to report their health care professional reviewed with them all their medications over the course of the year.

Still, our findings show there is room for improvement. Roughly one in five older adults across countries reported they were treated unfairly or felt their health concerns were not taken seriously when they received care. Among this group, over one in three Medicare beneficiaries in the U.S. cited the unfair treatment was due to their age, something that is associated with poorer self-rated health and a higher risk of serious health problems in the long term (data not shown).8 After age, disability was the next most cited reason, by almost one in four Medicare beneficiaries.9

Conclusion

While most U.S. Medicare beneficiaries are satisfied with the quality of care they receive, steps need to be taken to expand access to care and ensure equitable treatment. Many older adults in the U.S. and elsewhere experience problems getting timely health care, including booking appointments within two days of their illness and getting off-hours care outside of hospitals. This is despite nearly all older adults having a regular provider. Unnecessary emergency room use is of particular concern in the U.S. because they often function at high capacity or overcapacity, and they are more expensive relative to other health care settings.10 Nearly all countries are grappling with primary care shortages coupled with physician burnout, so without major investment in primary care, access to care challenges will likely grow worse in the coming years.11 The one exception to this trend is the Netherlands, where older adults are the most likely to be able to see their regular doctor after hours and make appointments within two days. General practitioners in the Netherlands are mandated to provide at least 50 hours of after-hours care annually.12

The U.S. does comparatively well on measures of patient care coordination, consistent with other studies and previous Commonwealth Fund surveys.13 Medicare beneficiaries in the U.S. were the least likely of those surveyed to report gaps in hospital discharge planning. The Affordable Care Act’s Hospital Readmission Reduction Program reduced readmissions and helped to improve discharge planning for older adults.14 Discharge planning is also incorporated into The Joint Commission provider accreditation process.15 The ongoing implementation of policies such as President Biden’s 2023 executive order ensuring hospitals actively include family caregivers in the discharge planning process may further improve coordination of care.16 U.S. Medicare beneficiaries were also more likely than older adults in other countries to report their health care professional reviewed with them all the medications they take over the past 12 months. Private plans in Medicare are required to have annual Comprehensive Medication Reviews between providers and patients and, as of 2016, completion of these reviews is incorporated into plans’ annual star ratings.17

Finally, while most older adults across countries are satisfied with the quality of health care they receive, roughly one of five said they have been treated unfairly or dismissively in their encounters with the health care system — a contributor to poorer health outcomes in the United States and around the world.18 Across countries, age and disability were the most likely reasons reported for this treatment. Training health care workers to prevent ageism and ableism is critical to improving outcomes for older adults.19

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. To have a better understanding of the accessibility and quality of health coverage, for this analysis, U.S. respondents were limited to those with some form of Medicare coverage. The total sample of U.S. respondents for this analysis was 1,882 (dually eligible for Medicare and Medicaid = 200, traditional Medicare = 781, and Medicare Advantage = 901).

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 Régulationdes 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 NUTS2regions 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 (ArbeitsgemeinschaftADM-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 cellphone RDD frames were generated by Marketing Systems Group (MSG), with the cellphone 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, Reggie Williams, Tony Shih, and Gretchen Jacobson, all of the Commonwealth Fund.

NOTES
  1. Munira Z. Gunja et al., Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries (Commonwealth Fund, Dec. 2024). ↩
  2. Healthy People 2030, “Access to Primary Care,” Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, n.d. ↩
  3. Evan D. Gumas et al., Finger on the Pulse: The State of Primary Care in the U.S. and Nine Other Countries (Commonwealth Fund, Mar. 2024). ↩
  4. Michael Hong et al., “The Impact of Improved Access to After-Hours Primary Care on Emergency Department and Primary Care Utilization: A Systematic Review,” Health Policy 124, no. 8 (Aug. 2020): 812–18. ↩
  5. Centers for Medicare and Medicaid Services, “Care Coordination,” CMS.gov, Aug. 14, 2023. ↩
  6. Family Caregiver Alliance, Hospital Discharge Planning: A Guide for Families and Caregivers (FCA, 2025). ↩
  7. Gretchen Jacobson et al., What Do Medicare Beneficiaries Value About Their Coverage?: Findings from the Commonwealth Fund 2024 Value of Medicare Survey (Commonwealth Fund, Feb. 2024); and Juliette Cubanski et al., Overall Satisfaction with Medicare Is High, but Beneficiaries Under Age 65 with Disabilities Experience More Insurance Problems Than Older Beneficiaries (KFF, Oct. 2023). ↩
  8. Sarah E Jackson, Ruth A. Hackett, and Andrew Steptoe, “Associations Between Age Discrimination and Health and Wellbeing: Cross-Sectional and Prospective Analysis of the English Longitudinal Study of Ageing,” The Lancet Public Health 4, no. 4 (Apr. 2019): e200–e208. ↩
  9. Other reasons for unfair treatment asked were race and ethnicity, sex/gender, sexual orientation, religion or beliefs, country of origin, or a language barrier. Respondents could respond they were treated unfairly due to multiple reasons. ↩
  10. Assistant Secretary for Planning and Evaluation, Office of Health Policy, Report to Congress: Trends in the Utilization of Emergency Department Services, 2009–2018 (U.S. Department of Health and Human Services, Mar. 2, 2021); and UnitedHealth Group, “18 Million Avoidable Hospital Emergency Department Visits Add $32 Billion in Costs to the Health Care System Each Year,” July 2019. ↩
  11. Munira Z. Gunja et al., Stressed Out and Burned Out: The Global Primary Care Crisis — Findings from the 2022 International Health Policy Survey of Primary Care Physicians (Commonwealth Fund, Nov. 2022). ↩
  12. 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). ↩
  13. 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). ↩
  14. Rachel B. Zuckerman et al., “Readmissions, Observation, and the Hospital Readmissions Reduction Program,” New England Journal of Medicine 374, no. 16 (Apr. 21, 2016): 1543–51. ↩
  15. The Joint Commission, “Standards,” n.d. ↩
  16. Barbara Lyons and Jane Andrews, Policy Options to Support Family Caregiving for Medicare Beneficiaries at Home (Commonwealth Fund, Nov. 2023). ↩
  17. U.S. Social Security Administration, “Social Security Act, Title XVIII — Health Insurance for the Aged and Disabled: Section 1860D-4: Requirements for Prescription Drug Plan Sponsors,” n.d. ↩
  18. Evan D. Gumas, Morenike Ayo-Vaughan, and Munira Z. Gunja, “Health Care Workers in Canada, the U.K., and the U.S. Report Racial and Ethnic Discrimination in the Health Care System,” To the Point (blog), Commonwealth Fund, Jan. 27, 2025. ↩
  19. Todd D. Nelson, “Reducing Ageism: Which Interventions Work?,” American Journal of Public Health 109, no. 8 (Aug. 2019): 1066–67. ↩

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, Arnav Shah, and Faith Leonard, Access and Quality of Care for Older Adults in 10 Countries: Findings from the 2024 Commonwealth Fund International Health Policy Survey of Older Adults (Commonwealth Fund, Apr. 2025). https://doi.org/10.26099/4wrj-kj97

Area of Focus

Topics

International,
International Surveys,
Primary Care,
Medicare,
Health Equity,
Access to Care,
Quality of Care

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