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U.S. adults spend more on health care but are sicker than adults in 10 other wealthy countries, study finds

One third 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.

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.

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Comments (8)

  1. Submitted by Ivy Chang on 11/22/2016 - 01:03 pm.

    U.S. health care

    Why did the telephone survey concentrate on only European countries plus Canada? What happened to Asia, Australia, and South America?

  2. Submitted by Bill Willy on 11/22/2016 - 01:12 pm.

    American Exceptionalism

    First of all, your articles, Ms Perry, are ALWAYS excellent. (I’ve been meaning to say that for a couple years now but, well, you know . . . )

    Anytime the issue of obscene pharmaceutical industry profits or the growing opioid and heroin epidemic come up in the media (which seems to be happening about once a week these days) I think of your December, 2015 article, “As opioid deaths reach record high, drug industry resists efforts to rein in prescriptions”


    That article should be required reading for all MN legislators and government officials.

    Regarding this article, once again, it does an excellent job of pointing out one of the two biggest absurdities — sad, tragic, cynically criminal absurdities — of what health care industry marketing people love to call “The Greatest Health Care System in the World!”

    The “greatest health care system in the world” — that the almighty Private Sector has created, managed and profited from (“handsomely”) — has produced a product that is so far inferior to the product produced by the countries highlighted in your article that it should not only be outlawed and put out of business immediately but, if you ask me, arrested and made to pay restitution to those it has harmed.

    Your article does a fine job of clarifying that part of the proof in the pudding. I would like to add some clear as possible light to the second part of the equation . . . The part that shows just HOW much more Americans are being forced to pay for that inferior product.

    This list (from the Peter G. Peterson Foundation — not exactly a “left-leaning” organization) compares the per capita cost of America’s private sector-created health care mess with the per capita cost of the world’s other industrialized nations:

    Italy: $3,207 (per person, per year)

    United Kingdom: $3,971

    Japan $3,713

    Australia: $4,177

    France: $4,367

    Canada: $4,506

    Sweden: $5,003

    Germany: $5,119

    Switzerland: $6,787

    United States: $9,024


    In other words, it is costing “We The People” (you, me, every person in America!) an average of $5,000 per year more for health care than the people in the rest of the industrialized world.

    5,000 extra dollars per year for, as another Commonwealth Fund report put it, “poorer health outcomes, including shorter life expectancy and greater prevalence of chronic conditions.”


    The legislative defenders of that reality are claiming this massive health and financial insult is being caused by the ACA, MNSure, “Big Government.” That, of course, is another smoke-screen absurdity that has no basis in reality: The disastrous health care outcomes your article points out, as well as the per capita costs on that list, were the reality long before the ACA or MNSure was conceived or voted into law.

    Every American is being charged $5,000 per year more than necessary for their health care needs because of the Private Sector, For-Profit, “Your money or your life,” system that has been created and codified into Law by those who think that approach to life is a good thing.

    I don’t have much hope of it happening (because of the Private Sector approach defenders in office), but I recommend Minnesota look to and emulate one or more of those European examples that work (well).

    And, more specifically (and for emergency situation starters), MN should do whatever is necessary to create a “Public Health Commission” ASAP that operates like, and has the same kind of authority as, the Public Utilities Commission. Health care is no less a shared need and “utility” than water or electricity and, if the Private Sector wants to participate and profit from it, they should be subject to the same type of scrutiny and regulation.


    Anyone who claims that kind of thing is not needed or would be “just more counterproductive government regulation” is either profiting off of people’s illness, on the political take, woefully ignorant, or blindly dog paddling around in the big pool of today’s “staunch conservative” groupthink.

    Again. Good article. Keep up the good work!

    • Submitted by Ray Schoch on 11/22/2016 - 02:11 pm.

      Thanks, Bill

      You’ve saved me a lot of typing, which would only duplicate what’s above in your comment. I’d add only that legislators, especially Republicans in Minnesota, would do well to read T. R. Reid’s “The Healing of America,” which documents – documents – how France, Germany, Japan, the U.K. and Canada are able to achieve much better health outcomes for much less cost than takes place in our “good health for the wealthy” system. They’re not all government-run systems, but they ARE all closely-supervised by their respective governments, they all provide better, more comprehensive care, and they all cost less than our existing profit-based monstrosity.

  3. Submitted by Ilya Gutman on 11/22/2016 - 09:56 pm.

    The difference

    What works in 5 million people country will not work in 350 million people country… I also wonder what was included in health care cost… Chiropractors? All psychological services?

    • Submitted by Henk Tobias on 11/23/2016 - 08:36 am.

      We have 50 states…

      So we can easily separate out our care population wise. Its common knowledge that we pay much more that any other industrialized nation, no matter how you slice it.

      We used to be a can do country, now we are not. The only thing we do best anymore it make excuses: We have too many people or you didn’t include “stuff” in your study…apparently whining is something else we do well.

    • Submitted by Bill Willy on 11/23/2016 - 11:12 am.

      5 Million

      Picking up on Henk’s point, Minnesota has a population of 5.4 million.

      Picking up on what seems to be a fundamental Republican point, all these issues ought to be worked out and decided by the states (see: Medicaid “block grant” proposals, etc.).

      I don’t know the ins and outs, but as I understand the rough idea, Minnesota could (maybe) take whatever approach it/we thought best to health care, including single payer or some similar, perhaps hybrid, truly universal form along the line’s of the French system Ray mentioned, or whatever exactly it is they’re doing in the Netherlands, highlighted by Ms Perry, or a blending of whatever is working best in the world.

      Take a look at this simple (colorful) overview of “The 10 Best Health Care Systems in the World,” for example:


      Number 1? Taiwan (of all places!):

      “The Taiwanese government pays for all its citizens’ health care needs. They were able to cover the needs of the population yet have managed to decrease health care costs. Much credit is given to the rise in the use of smart cards. These smart cards already contain the patient’s medical history from birth, making it easy for doctors to diagnose any health issue. This also significantly cuts down time on paperwork, which could be a probable cause of additional costs from medical providers. This system is employment-based, therefore, the elderly and those who can’t afford the system are given subsidies.”

      Main point being, “There MUST be a better way!” and finding and implementing that better way would HAVE to include (for bare bones starters) breaking free of this incredibly stupid stalemate related to the “conservative/liberal” worm wrestle that’s taking everyone Nowhere, faster all the time.

      “Liberals” want “single payer” while “Conservatives” want to “repeal and replace” Obamacare with some version of the old same thing that’s wrecking the financial lives of the vast majority of Americans and, while it’s at it, giving them shorter lives and more illness than much less expensive, better systems (longer lives with less illness for far less money).

      Why anyone is arguing about something as stupid as whether or not fixing that would be a good idea (for EVERYone) is way beyond me. (And it’s not like it isn’t being done elsewhere and we’d have to discover and engineer some kind of “never seen before miracle” — like putting people on the moon.)

      In terms of “economic growth” and improving the economy, what do you suppose might happen if every single American had an extra $5,000 to spend on things other than health care insurance premiums, deductibles, co-pays and straight cash-out-of-pocket expenses? That alone just MIGHT set off one of the “fastest and greatest periods of economic growth in recent American history.”

      That may be an exaggeration (and it may not), but I’m sure you get the point. “All we have to do” is get our health care costs reduced to the AVERAGE cost of most of the other industrialized countries in the world and whammo — “consumer spending” on an array of things Americans have all kinds of “pent-up demand” for: “Baby needs new shoes” and televisions and college educations and smarter phones and new roofs and solar panels and furniture and appliances and cars and vacations and all those things they haven’t been able to afford for the past 30 or 40 years because they’ve had to make sure they’ve been able to pay health insurance and pharmaceutical and medical device companies and hospitals and doctors and you name it, but those are the ONLY places, or “sectors of the economy,” that extra $5,000 per person per year have been and are still going instead of into the “broader economony” where all those manufacturers and small businesses and demand-driven new jobs have been hiding. An extra $5,000 a year in American’s (or Minnesotan’s) pockets would, I suspect, go a LOT further toward creating true and lasting “economic growth,” job creation, etc., than ANY tax reduction policy EVER has or could.

      Anyway . . . Back to the main point here. If the rest of America wants to flounder around with whatever it is Republicans and DT will be pushing, there may not be anything we, in Minnesota, can do about it. But, to pick up on Henk’s other, “Can Do!” point, the 5.4 million “We The People” here in Minnesota could MAYBE start looking for that better way (better than “single payer,” better than “Obamacare” and better than the “Old Way”) and, as the Nike Swoop says, “Just DO it!”

      Or not . . . I don’t know . . . Maybe the majority of people think arguing with each other over health care-related “political ideologies” is well worth that $5,000 a year it’s costing them and everyone else in the state (see Paul Udstrand: “The incoherent result of governing by ideology”).

      I doubt many Minnesotans actually see it that way, but I could be wrong.

  4. Submitted by John Chase on 11/23/2016 - 06:28 am.

    Comparison of Health Care Systems

    Nice article. I would also suggest “The Healing of America” by T. R. Reid. He writes about his experiences of health care in various countries.

  5. Submitted by Jon Lord on 11/27/2016 - 10:42 am.

    once again

    I’m late to the discussion. I blame social media. Bill W. is right on several points from my point of view. That $5000, especially for the lowest incomes, would make a huge difference in the buying habits of millions of Americans. Millions would then get a cell phone, more food, and spend more on simple necessities (including medical) and small luxuries which would in turn help small businesses who then would buy more capital equipment, supplies, and do more hiring…the demand is there. He’s right, or I at least assume he meant, that Republicans holding the house and senate means they can now more easily ‘do nothing’ to help solve any current concerns in the state. Other than to put most of their efforts into ending MNSure without replacing it…while ignoring the condition of the roads as usual.

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