Americans spend more on health care services than people living in 10 other wealthy countries. Yet, they are sicker and more likely to forgo needed medical care because of its cost and because of their ongoing struggle to afford other basic necessities such as housing and healthy food, according to the results of a new international survey published online last week in the journal Health Affairs.
In addition to lagging behind other high-income countries in ensuring affordable access to health care, the United States performed at or near the bottom of the list on most of the other measures in the survey, including whether health issues prevented people from working full time or from engaging in everyday activities.
No wonder, then, that the U.S. also had the highest percentage of respondents (26 percent) who said they had experienced emotional distress in the past year that was difficult to cope with alone.
A telephone survey
For the survey, which was conducted earlier this year, researchers with the Commonwealth Fund reached a representative sample of 1,000 to 7,000 adults via telephone (landline and cell) in each of 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.
The respondents answered detailed questions about their experiences with their health care systems, particularly in terms of accessibility, affordability and quality. They also answered questions about their own personal health and well-being.
Here are some of the key U.S.-related findings from the survey:
- Americans reported poorer health than their counterparts in the other countries. For example, more than one in four (28 percent) of the U.S. respondents said they had at least two chronic conditions, such as heart disease, diabetes, asthma or arthritis. The only other country with a percentage over 20 in this category was Canada (22 percent).
- Fourteen percent of chronically ill people in the U.S. said they did not get the support they needed from their health care providers to manage their chronic conditions — twice the rate of Germany, the Netherlands, Switzerland, Australia and New Zealand.
- One third (33 percent) of the U.S. respondents cited cost as the reason they had gone without recommended health care, not seen a doctor when sick, or not filled a prescription within the past twelve months. Although this number is down from 37 percent in 2013 — most likely due to expansion of health care under the Affordable Care Act (ACA), say the researchers — only 7 percent of respondents in the U.K. and 8 percent of those in the Netherlands and Sweden said they experienced any similar affordability issues.
- U.S. adults were also the most likely to report material hardships that can affect health. Fifteen percent said they were “always” or “usually” worrying about having enough money for nutritious food, and 16 percent said they often found themselves struggling to afford their rent or mortgage. By contrast, only 7 to 8 percent of adults in Germany, the Netherlands, Sweden and the United Kingdom said that cost was a barrier to getting needed medical care.
- Respondents in most countries reported that the financial barriers to accessing dental care were greater than those for medical care. But U.S. residents reported those barriers at a much higher rate (32 percent) than did the respondents from other countries, such as the Netherlands (14 percent) and the United Kingdom (11 percent).
- In all countries, low-income adults were much more likely than other adults to report health problems and difficulties accessing affordable health care, but at 43 percent, the U.S. had the highest rate of any country. One country — the U.K. — was the only one in which low-income adults were not significantly more likely than their financially better-off peers to report cost-related problems related to accessing health care.
The U.S. performed well in a few categories, however. American respondents reported relatively high rates for timely access to specialist care, for the willingness of physicians to discuss healthy lifestyles, and for coordinated hospital discharge planning.
Yet, as the researchers point out, the reason the U.S. outperformed many of the other countries on the measure of physicians talking about healthy lifestyles “may be because it has a higher prevalence of obesity and sedentary lifestyles than the other countries do.”
The Dutch system
The Commonwealth Fund’s report gives the Netherlands extra praise for getting many things right:
The Dutch system — which includes the best access to same- or next-day appointments and after-hours health care, low use of the [hospital emergency department], relatively few problems with coordination of care, and the lowest rate of reported gaps in the doctor-patient relationship — provides an example of what works.
One of the system’s features that underpin its performance is that almost all Dutch citizens are registered with a general practitioner of their choice, so that doctors know their patients’ medical history. Dutch general practitioners also have a statutory responsibility to provide after-hours care, which is usually met through cooperatives that provide walk-in care and also have electronic access to the patient’s primary care record — thus ensuring an alternative to the [emergency department] and reducing fragmentation of care. In addition 88 percent of Dutch general practitioners make home visits. …
Multidisciplinary teams are the norm in Dutch primary care, with over 90 percent of health care practices employing nurses or case managers to help manage care for patients with chronic conditions, and an increasing number of practices are participating in care groups that receive payments to assume overall clinical responsibility for managing and coordinating care for such patients.
U.S. is an ‘outlier’
The Dutch model is a far cry, however, from what happens in the U.S., as this survey makes all too clear.
“Although the United States has made significant progress in expanding coverage under the Affordable Care Act (ACA), it remains an outlier among high–income countries in ensuring access to health care,” write the Commonwealth Fund researchers. “… In addition, there are ongoing barriers to coverage, including the fact that — as of November 2016 — nineteen states have not chosen to expand eligibility for their Medicaid programs, the exclusion of undocumented immigrants from both Marketplace and Medicaid coverage, low awareness of coverage options, and concerns about affordability among those who remain uninsured.”
“An estimated twenty-three million adults in the United States lack health insurance, while the other countries in our survey have universal coverage,” they add.
With Republicans now talking about dismantling the ACA in the coming years, the number of uninsured Americans — and the health inequities associated with a lack of insurance — is likely to climb higher, not lower.
FMI: You can read the Health Affairs report on the Commonwealth Fund’s survey in the December issue of the journal.