soc paper summary

By Cathy Schoen, Robin Osborn, David Squires, and Michelle M. Doty

Access, Affordability, And Insurance Complexity Are Often Worse In The United States Compared To Ten Other Countries

ABSTRACT The United States is in the midst of the most sweeping health insurance expansions and market reforms since the enactment of Medicare and Medicaid in 1965. Our 2013 survey of the general population in eleven countries—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—found that US adults were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Signaling the lack of timely access to primary care, adults in the United States and Canada reported long waits to be seen in primary care and high use of hospital emergency departments, compared to other countries. Perhaps not surprisingly, US adults were the most likely to endorse major reforms: Three out of four called for fundamental change or rebuilding. As US health insurance expansions unfold, the survey offers benchmarks to assess US progress from an international perspective, plus insights from other countries’ coverage-related policies.

T he Affordable Care Act insurance exchanges, or Marketplaces, which opened for business in Octo- ber 2013, signaled the start of a complex array of major health in-

surance reforms that take effect in 2014. Key features of the reforms include new federal sub- sidies to buy private insurance, the expansion of public coverage for the poor, and insurance mar- ket reforms to establish minimum standards for benefits and to prohibit insurers from charging more or denying coverage altogether based on a person’s sex or health status.1

The nationwide effort is the most significant health insurance change since the enactment of Medicare and Medicaid in 1965. There are an estimated fifty million uninsured people in the United States and millions more who are insured but who pay a high share of their income for medical care (a group known as the under-

insured).2 The reforms thus seek to improve ac- cess and affordability for more than one-third of the US population under age sixty-five. One way to assess the impact of US health re-

forms is to track how the health care experiences of US citizens compare over time to those of people in industrialized countries that imple- mented universal or near-universal coverage decades ago. This article reports on a 2013 survey of adults in the United States and ten other de- veloped nations concerning access and afford- ability of care and insurance complexity. The ten other countries are Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The countries with univer- sal coverage differ in their approaches to cover- age and other policies relevant to access and affordability. The study thus offers a global per- spective to augment domestic perspectives in the

doi: 10.1377/hlthaff.2013.0879 HEALTH AFFAIRS 32, NO. 12 (2013): 2205–2215 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.

Cathy Schoen ([email protected]) is senior vice president for research, policy, and evaluation at the Commonwealth Fund, in New York City.

Robin Osborn is vice president and director of the Commonwealth Fund’s International Program in Health Policy and Practice Innovations.

David Squires is senior researcher in the Commonwealth Fund’s International Program in Health Policy and Practice Innovations.

Michelle M. Doty is vice president for survey research and evaluation at the Commonwealth Fund.

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United States as reforms are implemented and evolve. Among the eleven countries, the United States

stands out for spending by far the most on health care, either per person or as a share of the na- tional economy. The United States spends al- most $3,000 more per person compared to the second-highest spender, Norway. The United States also spends almost 6 percent more as a share of the economy than the Netherlands, the country that devotes the next-largest share of its economy to health care (for details on country spending and some aspects of insurance design, see online Appendix 1).3

In addition, the United States is unique in its complexity of health insurance designs, mix of public and private insurance, and relatively limited insurance market regulations. The Netherlands, Switzerland, and Germany each rely on competing insurers (private insurers in Switzerland and the Netherlands, and social in- surance “sickness funds” in Germany). How- ever, insurers in these three countries cover the full population, irrespective of beneficiaries’ age or income; are required to accept any appli- cant; and are barred from charging higher prices for premiums to people with poorer health sta- tus. To limit adverse selection and incentives to cherry-pick healthier applicants, the countries have mechanisms for risk adjustment among competing insurers.4

Canada, France, and Australia all have core public insurance systems, with varying roles for private supplemental coverage. New Zealand, Norway, Sweden, and the United Kingdom operate public health care systems, with a more limited role for private insurance.5

As described in an earlier article that focused on insurance design, the scope of coverage for medical care and the inclusion of cost sharing for patients in the form of deductibles or copay- ments for services also varies across the coun- tries.6 Among the eleven countries, only the Netherlands, Switzerland, and the United States employ deductibles as part of the core design. The Dutch and Swiss limit the level of deductibles; the United States does not. Unlike other countries with relatively high

cost sharing, the United States also lacks stand- ards limiting out-of-pocket spending for covered benefits (Appendix 1).3 As of 2012, 31 percent of the privately insured US population under age sixty-five had a deductible of $1,200 or more, nearly double the prevalence in 2007 (17.5 percent).7

The US market reforms scheduled to be imple- mented in 2014 will for the first time set stand- ards on private insurance that limit out-of-pock- et exposure. The reforms will also provide

income-related public subsidies for premiums and reduce cost sharing for people whose in- comes fall below certain thresholds. These ef- forts will be similar in concept to provisions in Switzerland, the Netherlands, and France that seek to limit financial exposure for people who are in poor health or have low incomes. Although the comparison countries insure all

or nearly all of their populations, those countries face the challenge of how to ensure timely, af- fordable access in the years ahead if health care costs rise faster than economic growth. The 2013 Commonwealth Fund survey examined compar- ative experiences at a time of economic con- straints. It also provides baseline data and benchmarks for the United States as it begins implementing health insurance reforms.

Study Data And Methods The Survey The 2013 survey of the general pop- ulation consisted of computer-assisted tele- phone interviews of random samples of adults ages eighteen and older in eleven countries, us- ing a common questionnaire that was translated and adjusted for country-specific wording as needed. Social Science Research Solutions and country contractors conducted the interviews during February–June 2013. For the first time in the survey series, mobile phone numbers were included in all countries.8 Field times in each country ranged from four to ten weeks; most field times were eight weeks. International partners joined with the

Commonwealth Fund to sponsor country sur- veys or expand samples beyond the minimum (1,000 respondents) for further country ana- lyses.9 Final country samples, shown in Exhibit 1, ranged from 1,000 to more than 5,000. The analysis weighted final samples to reflect the distribution of the adult population in each country.10

The margin of sample error for country aver- ages was approximately plus or minus 2 percent for Canada; plus or minus 3 percent for Australia, France, Germany, the Netherlands, Sweden, Switzerland, and the United States; and plus or minus 4 percent for Norway, New Zealand, and the United Kingdom (all at the 95 percent confidence level).11 We included some data from the 2012 international survey of pri- mary care physicians12,13 to compare with the pa- tients’ reports in the 2013 survey. Appendix ta- bles show statistical tests that compare each country to each of the other ten.3

Limitations This was a rapid-response survey with field times of four to ten weeks, as noted above. Although interviewers called at least eight times if they did not receive a response, response

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Exhibit 1

Adults’ Cost-Related Access To Health Care And Affordability Problems In Eleven Countries, 2013

Percent of adults who:

In the past year:

Country Sample size

Did not see doctor when sick or did not get recom- mended care because of cost

Did not fill Rx or skipped doses because of cost

Had either cost- related access problem

Had serious problem paying or was unable to pay medical bills

Had $1,000 or more out-of- pocket medical spending

Skipped dental care or checkups because of cost

In the past 2 years had not visited dentist

Australia

All adults 2,200 14 8 16 8 25 29 28 Has chronic conditiona 538 24** 14** 27** 13** 36** 37** 28

Canada

All adults 5,412 8 8 13 7 14 21 23 Has chronic conditiona 1,702 11** 13** 18** 11** 18** 22 29**

France

All adults 1,406 14 8 18 13 7 20 27 Has chronic conditiona 381 15 6 18 15 7 23 27

Germany

All adults 1,125 10 9 15 7 11 8 10 Has chronic conditiona 338 14 11 18 9 14 8 14**

Netherlands

All adults 1,000 20 8 22 9 7 19 19 Has chronic conditiona 275 24 11** 26 12** 8 24** 20

New Zealand

All adults 1,000 20 6 21 10 9 32 41 Has chronic conditiona 304 25 6 25 11 5** 34 48**

Norway

All adults 1,000 8 5 10 6 17 25 11 Has chronic conditiona 350 7 9** 11 4 18 23 13

Sweden

All adults 2,400 4 4 6 4 2 12 10 Has chronic conditiona 814 6** 7** 10** 8** 4 15** 10

Switzerland

All adults 1,500 10 6 13 10 24 11 22 Has chronic conditiona 278 15** 9 18** 16** 39** 12 25

United Kingdom

All adults 1,000 4 2 4 1 3 6 26 Has chronic conditiona 225 4 1** 5 4** 4 9 23

United States

All adults 2,002 32 21 37 23 41 33 27 Has chronic conditiona 786 38** 29** 43** 26** 44 37** 33**

Insured all year 1,639 21 15 27 15 42 24 22 Uninsured 361 58** 36** 63** 42** 39 54** 40**

SOURCE 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries. NOTES Excluding respondents who did not answer the question. Between- country significance tests are shown in online Appendix 5 (see Note 3 in text). For all countries, significance indicators indicate significant within-country difference with respondents without a chronic condition. For the United States, significance indicators indicate significant difference with US respondents who were insured all year. aRespondents reported having been diagnosed with at least one of the following four chronic conditions: asthma or chronic lung problems, cancer, diabetes, and heart disease. **p < 0:05

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rates were relatively low. The rates were as fol- lows: Australia, 30 percent; Canada, 24 percent; France, 32 percent; Germany, 11 percent; the Netherlands, 23 percent; New Zealand, 30 per- cent; Norway, 11 percent; Sweden, 29 percent; Switzerland, 33 percent; the United Kingdom, 20 percent; and the United States, 22 percent. Particularly in Germany and Norway, the re- sponse rates introduce potential bias, although the direction of that bias is unknown. To the extent that the survey missed adults with more complex conditions, low incomes, or lack of pro- ficiency in the survey languages, the results may underestimate concerns.

Study Results Cost-Related Access And Affordability Concerns Adults responding to the survey were asked several questions regarding the affordabil- ity of health care and whether cost posed a bar- rier to access. As in previous international sur- veys, US respondents were the most likely to report high out-of-pocket costs for medical care (having spent $1,000 or more in the past year), problems paying medical bills, and forgoing care because of costs (Exhibit 1). Not surprisingly, access and affordability

problems in the United States were far higher among the uninsured: Nearly two-thirds of these respondents reported that costs had led them to skip care (Exhibit 1). However, even among respondents who wereinsured all year, US adults were significantly more likely than adults in the other countries to go without care because of costs, face high out-of-pocket spending, or (ex- cept for adults in France) be financially bur- dened by medical bills. This likely reflects both the comparatively high deductibles and cost sharing in many US insurance plans and the high underlying cost of US health care. Notably, roughly 40 percent of both insured and un- insured US respondents had spent $1,000 or more during the past year on medical care, not counting premiums. Those percentages point to often high patient cost sharing or frequent ben- efit gaps. In contrast to experiences in the United States,

fewer than 10 percent of adults reported high out-of-pocket costs in Sweden, the United Kingdom, France, the Netherlands, and New Zealand. A larger proportion of adults reported high spending in Australia and Switzerland. However, few respondents in either country said that these costs had led to access or affordability concerns, possibly reflecting spending caps and other protections in these countries’ insurance systems.5 In contrast, 25 percent of US adults had spent $2,000 or more and 9 percent had

spent $5,000 or more in the past year—rates that were more than double those in any other coun- try, except Australia (where 14 percent had spent $2,000 or more and 5 percent had spent $5,000 or more) (data not shown). Of potential concern for access in the

Netherlands, the percentage of Dutch respon- dents who reported forgoing care because of cost increased substantially from the 2010 interna- tional survey, from 6 percent to 22 percent (Appendix 2).3 In response to austerity pres- sures, recent changes in the Dutch health insur- ance system have allowed cost sharing to in- crease. Although the new levels are still low by US standards, they may be discouraging care seeking where they have been introduced. Many adults are healthy and may not need

many health services in a given year. There- fore, we examined the financial protectiveness of different systems for the subset of adults with one or more of the following four chronic con- ditions that typically entail more frequent need of medical care: diabetes, heart disease, cancer, and asthma or chronic lung problems. We found that chronically ill patients in

France, Germany, the Netherlands, Norway, and the United Kingdom were not significantly more likely than those without these conditions to forgo care or report high out-of-pocket costs (Exhibit 1). Rates of cost exposure were also low in Sweden for such vulnerable patients. In Australia, Canada, Switzerland, and the

United States, costs play a greater role in deter- ring care and causing financial stress for the chronically ill than for those without such con- ditions. Here, too, US responses stand out, with 43 percent of the chronically ill going without care because of costs and one in four having problems paying medical bills. These country

US respondents were the most likely to report high out-of- pocket costs, problems paying medical bills, and forgoing care because of costs.

◀

41% Spent $1,000 Roughly 4 in 10 US respondents, both with and without insurance, spent $1,000 or more out of pocket on medical care during the past year.

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variations likely reflect the combined impact of insurance benefits, levels of cost sharing, and income- or disease-specific protections, such as French provisions protecting those with chronic conditions in care plans.6

The survey also asked respondents about their access to and use of dental care—a benefit cov- ered for adults in only some of the countries (Appendix 1).3 A high share of US and New Zealand adults (33 percent and 32 percent, re- spectively) had gone without dental care because of costs in the past year (Exhibit 1). Germany and the United Kingdom appear to be the most pro- tective in terms of dental cost barriers. In the United States, rates of forgoing dental

care were particularly high for uninsured adults, where one in two had not seen a dentist because of costs. However, dental access concerns appear in other countries as well. More than one-fourth of adults in Australia, France, New Zealand, and the United Kingdom had not visited a dentist or received preventive dental care in the past two years.

Access And Waiting Times A strong primary care infrastructure is recognized as the corner- stone of a high-performing health care system, offering a critical entry point and a hub for orga- nizing care that is patient centered, coordinated, and comprehensive. Enhanced, accessible pri- mary care that employs teams—including

nurses—supported by information systems to help provide, manage, and coordinate care has the potential to improve health outcomes, re- duce hospital use, improve equity, and slow the rate of cost growth.14,15

Although the vast majority of adults in all countries reported having a regular doctor or place of care (data not shown), access experienc- es varied widely (Exhibit 2). Roughly 70 percent of the respondents in Germany and New Zealand reported having been able to get a same- or next- day appointment the last time they were sick. In contrast, fewer than half of adults in Canada and the United States reported such speedy access. And at least one in four adults in Canada, Norway, and the United States waited six days or more to see a doctor or nurse when sick. Asked how often they heard back the same day

when they called their regular practice with a medical question, German adults were the most likely (90 percent) to say always or often (Exhibit 2). At the low end of the spectrum, 25 percent or more of UK and US adults and 30 percent or more of Canadian and French adults said that this happened only sometimes, rarely, or never. Access to specialists also varied notably. In

Norway and Canada more than one in four of adults needing to see a specialist waited two months or longer (Exhibit 2). In contrast, most

Exhibit 2

Adults’ Access To Health Care And Wait Times In Eleven Countries, 2013

Percent of adults who:

Saw a doctor or nurse last time they needed care

Heard from the doctor’s office the same day after calling with a question during practice hoursa

Waited to see a specialistb

Country Same or next day

Waited 6 days or more

Always/ often

Sometimes/ rarely or never

Less than 4 weeks

2 months or more

AUS 58 14 79 21 51 18 CAN 41 33 67 33 39 29

FRA 57 16 63 37 51 18 GER 76 15 90 10 72 10

NETH 63 14 84 16 75 3 NZ 72 5 80 20 59 19

NOR 52 28 78 22 46 26 SWE 58 22 84 16 54 17

SWI —c —c 82 18 80 3 UK 52 16 75 25 80 7

US (all) 48 26 73 27 76 6 Insured all year 53 21 75 25 77 5 Uninsured 36** 40** 65** 35** 70** 10

SOURCE 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries. NOTES Excluding respondents who did not answer the question. Between-country significance tests are shown in online Appendix 6 (see Note 3 in text). Significance indicators indicate significant difference with US respondents who were insured all year. aOf those who called. bOf those who needed to see a specialist in the past two years. cQuestion asked differently in Switzerland. **p < 0:05

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(72–80 percent) Swiss, UK, US, Dutch, and German adults said that they were seen within four weeks. In the United States, lack of insurance under-

mined access to both primary and specialized care. Compared to those with insurance, unin- sured adults were significantly less likely to be seen quickly when they needed care, to be called back by the practice the same day, and to be seen by a specialist within four weeks (Exhibit 2). Same- or next-day access to a provider for in- sured US adults was also relatively low (53 per- cent) compared to rates reported in Germany, New Zealand, and the Netherlands—which sug- gests that there is room to improve primary care access for both the insured and the uninsured in the United States. After-Hours And E-Mail Access And

Emergency Department Use For primary care to be accessible, it must be available after hours— during the evening and on weekends and holi- days—as well as during the workday. Yet fewer than 40 percent of US, Canadian, French, and Swedish adults reported that it was very or some- what easy to be seen for care after hours without going to the emergency department (ED) (Exhibit 3). In contrast, more than half of the

adults in five countries—the United Kingdom had the highest rate, 69 percent—said that get- ting after-hours care was easy. In most of the countries where adults reported

easy access—the United Kingdom, New Zealand, the Netherlands, and Germany—primary care practices have a statutory responsibility to make arrangements to provide after-hours care. In our 2012 international survey of physicians, 90 per- cent or more of primary care doctors in these countries confirmed that they had set up ar- rangements to allow patients to see a doctor or nurse after hours (Exhibit 3). Relatively frequent use of the ED generally

tracked reports of limited access to after-hours care or lack of timely access when sick. One-third or more of adults in the United States, Canada, France, and Sweden reported having used the ED in the past two years. Patients in these countries were also among the most likely to experience long waits in the ED, with more than one in four US adults; roughly one-third of French, Norwegian, and Swedish adults; and nearly half of Canadian adults saying they had waited two hours or more to be treated (Exhibit 3). Primary care practices have the potential to

expand patients’ access beyond visits and phone

Exhibit 3

Reports Of Adults And Primary Care Physicians On After-Hours Care, Emergency Department (ED) Use, And E-Mail Access In Eleven Countries, 2012 And 2013

Percent of adults (2013) or primary care physicians (2012)

After-hours care ED use E-mail access to doctor

Country

Adults report it is somewhat or very easy to obtaina

Physicians report they have arrangementb

Adults report using ED in the past 2 years

With wait of 2 hours or more before being treatedc

Physicians report patients can e-mail practice with questions or concerns

Adults report they can e-mail their regular practice with a medical concernd

Adults report e-mailing their regular practice with a medical question in past 2 yearsd,e

AUS 46 81 22 25 21 24 9 CAN 38 46 41 48 11 10 2

FRA 36 76 31 36 39 9 2 GER 56 90 22 23 45 19 3

NETH 56 95 24 17 47 32 20 NZ 54 90 28 14 39 16 5

NOR 58 80f 28 34 27 22 6 SWE 35 68 32 32 44 20 9

SWI 49 78 28 18 68 29 15 UK 69 95 27 16 35 25 13

US (all) 39 35 39 28 35 28 6 Insured all year 43 —g 36 24 —g 31 7 Uninsured 30** —g 48** 36** —g 19** 4

SOURCES Commonwealth Fund, 2012 Commonwealth Fund International Survey of Primary Care Physicians (see Note 12 in text); 2013 Commonwealth Fund International Health Policy Surveys. NOTES Excluding respondents who did not answer the question. Between-country significance tests are shown in online Appendix 7 (see Note 3 in text). Significance indicators indicate significant difference with US respondents who were insured all year. aOf those who needed after-hours care. bPractice has arrangement for patients to see a doctor or nurse after hours without going to the ED. cOf those who used the ED in past two years. dOf those with a regular doctor or place of care. eRespondents reporting that they did not have a computer or e-mail were coded as “no”: Australia, 4%; Canada, 3%; France, 5%; Germany, 4%; the Netherlands, 2%; New Zealand, 5%; Norway, 2%; Sweden, 4%; Switzerland, 4%; United Kingdom, 5%; United States, 3%. fIn Norway, respondents were asked whether their practice had arrangements or there were regional arrangements. gNot applicable. **p < 0:05

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calls through e-mail and other electronic ex- changes. Comparisons of patients’ 2013 survey responses with the 2012 responses of primary care physicians indicate that use of such elec- tronic access is spreading slowly, and that pa- tients may not be informed of or encouraged to use such tools (Exhibit 3). Thirty-two percent of adults in the Netherlands said that they could e- mail their regular practice with a medical con- cern; the percentages in the other countries were lower. Only 2 percent of patients in Canada and France said they had e-mailed their regular prac- tice with a question; the highest rate of use was in the Netherlands, with 20 percent. In all of the countries except Australia and

Canada, the share of primary care physicians who said that their patients had e-mail access to their practice tended to be far higher than the percentage of patients who were aware of that capacity (Exhibit 3). The gap between pa- tient and physician reports was widest in Switzerland—almost forty percentage points. US patients’ reports of having e-mail access to

their regular practice rivaled responses from the leading countries, especially among the insured (Exhibit 3). For all patients, the United States ranked third among the eleven countries, at 28 percent. However, rates of e-mail use still remain low. Reflectingtheir more limitedaccess to primary

care, uninsured US adults were more likely than those with insurance to face difficulties getting after-hours care, to seek care in the ED, and to

endure long waits when in the ED (Exhibit 3). The uninsured were also less likely than the in- sured to report having e-mail access to their reg- ular practice (19 percent versus 31 percent). Administrative Costs And Complexity

Administrative complexity can generate hidden health care costs, requiring time and resources from patients, physicians, and payers. Comply- ing with coverage restrictions, billing documen- tation, and other regulations can elevate the price and erode the quality of interactions with the health system. In terms of just the costs to insurers of health

insurance administration—that is, without in- cluding administrative costs for physicians or hospitals—the United States is an outlier. According to data from the Organization for Economic Cooperation and Development (OECD),16 in 2011, US health insurers17 spent $606 per person on administrative costs—more than two times the amount in the next-highest country participating in the survey (Exhibit 4). Even the multipayer Swiss and Dutch private insurance systems operate with less than half of the US per person administrative overhead.18

Insurance-related complexity costs patients time. When asked about administrative hassles in the 2013 survey, US and Swiss adults were the most likely to report that they had spent “a lot of time on paperwork or disputes” concerning medical bills or insurance in the past year (Exhibit 4). And adults in the United States were more likely than those in any othercountry to say

Exhibit 4

Administrative Costs And Complexity Of Health Insurance In Eleven Countries, 2012 And 2013

Percent of adults reporting, in the past year:

Country

Per capita spending on health insurance administration, 2011a

“Spent a lot of time on paperwork or disputes” for medical bills or insurance, 2013b

“Insurance denied payment” or “did not pay as much as expected,” 2013b

Had either difficulty, 2013b

Percent of primary care physicians reporting the time they or their staff spend getting patients needed care because of coverage restrictions is a major problem, 2012c

AUS $70 6 15 16 11 CAN 148 5 14 15 23

FRA 277 10 17 23 20 GER 237 8 14 17 41

NETH 199 9 13 19 28 NZ 128 4 6 7 18

NOR 35 7 3 8 12 SWE 55 2 3 4 12

SWI 266 16 16 25 24 UK —d 2 3 4 10

US 606 18 28 32 54

SOURCES See below. NOTES Excluding respondents who did not answer the question. Between-country significance tests are shown in online Appendix 8 (see Note 3 in text). aOrganization for Economic Cooperation and Development, OECD health data 2013 (see Note 16 in text). Australian data from 2010. All data adjusted for differences in cost of living. b2013 Commonwealth Fund International Health Policy Survey in Eleven Countries. c2012 Commonwealth Fund International Survey of Primary Care Physicians (see Note 12 in text). dNot available.

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that their insurance had denied them payment or had not paid them as much as they had expected. About one in three US adults reported having either concern, attesting to the lack of transpar- ency and standardization of benefits coverage, the amount of paperwork required, and the com- plexity of the US health insurance system.19

Notably, US adults younger than age sixty-five were more likely to cite administrative concerns than were adults who were older and thus eligi- ble for Medicare (Appendix 3).3 This difference may reflect the more stable and more protective coverage available to older adults. US adults ages sixty-five and older were also far less likely than younger adults to go without care because of costs or to have serious problems paying medical bills. The United States also stood out in the 2012

survey of physicians in eleven countries for time- consuming insurance-related complexity. Fifty- four percent of US primary care physicians said that the amount of time that they and their staff spent dealing with coverage restrictions was a “major problem,” a significantly higher percent- age than that in any other country (Exhibit 4). In only two other countries, Germany and the Netherlands, did more than a quarter of the physicians report time-consuming insurance problems. Countries whose health systems operate on a

“National Health Service” model—New Zealand, Norway, Sweden, and the United Kingdom—had

lower administrative costs than the other study countries, based on OECD data. They also tended to have relatively fewer patients or physicians who complained about spending time on insur- ance-related paperwork, constraints, or dis- putes. In contrast, countries where private insurers

play a larger role, including offering supplemen- tal insurance with varying benefits, and where patients have higher cost sharing tended to have higher administrative costs or more patient or provider concerns. Notably, in Australia, Canada, and New Zealand, patients’ concerns about denial of payments were concentrated among people who had private supplemental coverage (data not shown). System Views Repeating a question asked

since 1998, the 2013 survey solicited adults’ over- all views of their country’s health system— whether it needed only minor changes, funda- mental changes, or to be completely rebuilt. Perhaps reflecting issues related to access, cost, and complexity in the US system, adults in that country were by far the most negative, with three out of four saying that the health system needed to undergo fundamental change or to be rebuilt (Exhibit 5). US calls for change were strongly associated with forgone care because of costs, struggles to pay bills, waits for primary care, lack of after-hours access, and insurance complexity (Appendix 4).3

Half or more of the Dutch, Swiss, and UK

Exhibit 5

Adults’ Views Of The Health System In Eleven Countries, 2013

Works well, minor changes

Percent of respondents

Fundamental changes Completely rebuilt

SOURCES 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries; Organization for Economic Cooperation and Development, OECD health data 2013 (see Note 16 in text). NOTES Excluding respondents who did not answer the question. Between-country significance tests are shown in online Appendix 9 (see Note 3 in text). The three response options were that the health system “works well, only minor changes needed”; “needs fundamental changes”; and “needs to be completely rebuilt.” aPer capita spending adjusted for differences in cost of living. Australian data are from 2010.

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respondents said that their system worked well and needed only minor changes (Exhibit 5). Compared to US adults, adults in the other ten countries were more likely to opt for minor changes and less likely to call for rebuilding the health system.Within the countries, respon- dents’ views were related to their experiences: In countries with long waits for care or high cost burdens, people calling for major change were more likely to have faced such problems (Appendix 4).3

Implications As the United States proceeds to implement in- surance expansions and market reforms, this study underscores the vulnerability of the un- insured and the importance of successfully ex- panding coverage. At the same time, the variable experiences across countries with universal cov- erage indicate that having insurance is impor- tant but not sufficient to ensure timely or afford- able access. Study findings across countries suggest the importance of calibrating any cost sharing in insurance policies to people’s ability to pay; providing payment as well as regulatory support for increased access to primary care, including after-hours care; and being alert to the time and resources required to deal with insurance complexity. Looking forward, coun- tries can examine their own and others’ experi- ences as they consider reforms that may have an impact on access or affordability.

Insurance Design And Affordability In this study, US adults—both the insured and the uninsured—were more likely than adults in other countries to report going without care be- cause of costs, having high out-of-pocket costs, and having difficulty paying medical bills. The experiences in Switzerland and other countries where mandatory insurance includes both de- ductibles and copayments indicate that it is pos- sible to incentivize patients to be sensitive to

price yet protect them against undue financial burdens when they are sick. Reforms scheduled under the Affordable Care

Act provide for subsidies to lower cost sharing for those with incomes below specified thresh- olds as well as reductions in premiums for people with low or modest incomes. However, by inter- national standards, cost-sharing exposure will remain high for those with low incomes. Also, states will have considerable leeway in insurance design for middle- and high-income families, with annual out-of-pocket maximums and de- ductibles that will continue to be high compared to those in other countries. For people with chronic, ongoing conditions, the result could be continued high medical cost burdens. To avoid such cumulative costs and resulting

barriers to effective care, France provides for either low or no cost sharing for treatments that fall within care plans for chronically ill patients. In effect, this approach protects patients’ access while ensuring that they receive care according to clinical guidelines. Australia provides addi- tional funds to cap patients’ out-of-pocket ex- penses, and Germany limits out-of-pocket spending relative to income, with lower thresh- olds for sicker patients. As the US reforms take hold, the purchasers of care—states, private in- surers, and employers—could consider how such insurance design provisions could evolve in tan- dem with efforts to hold care systems account- able for health outcomes, patients’ experiences, and costs. The scope of covered benefits also makes a

difference. Across countries, dental care is least often covered for adults (and will not be covered under scheduled US reforms). This study’s find- ings indicate that there is room to improve den- tal access in multiple countries. This could in- clude incorporating at least preventive dental care into core benefit designs, in recognition of the fact that basic dental care can provide early warnings of potentially serious physical as well as dental risks. Insurance And Primary Care Insurance de-

sign and payment policies also matter for access and countries’ primary care infrastructure. In increasing primary care access, again the United States and other countries can learn from international as well as domestic experiences. The Dutch and UK systems, for example, exempt primary care from deductibles and cost sharing; provide direct support for after-hours care coop- eratives and other arrangements; and pay prima- ry care practices in ways that support both ready access to care and the addition of nurses and other staff to primary care teams trained to pro- vide, manage, and coordinate care.20

The high rates of ED use associated with long

By international standards, cost- sharing exposure in the United States will remain high for those with low incomes.

◀

$606 Per person In 2011, US health insurers spent $606 per person on administrative costs—more than twice the amount in the next- highest participating country.

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waits for primary care in the United States (in- cluding among insured patients) and several other countries underscore the importance of 24/7 primary care coverage in terms of overall system cost and resource allocation. Past inter- national surveys of primary care physicians and “sicker” patients—those who have recently been hospitalized, are in poor health, or both—reveal discontinuities and often poor flow of informa- tion back to primary care providers for patients who are seen in emergency departments.12,21

Insurers as payers have access to this informa- tion and could do more to facilitate its flow, such as supporting information exchange for practic- es that are not formally linked to integrated systems. Insurance Complexity The experiences of

patients and physicians in other countries re- garding the time-consuming complexity of in- surance also provide potential insights for the United States. Although the Dutch, Swiss, and German health care systems all rely on competi- tive insurance markets, each of these countries has standardized benefits and both more-stan- dardized payment methods across insurers and more-centralized quality and regulatory report- ing systems, compared to the United States. A recent Institute of Medicine study estimated

that administrative layers throughout the US health insurance and care system add as much as $360 billion per year to the cost of health care—and much of that sum was deemed to be wasted, with little or no return in value.22

Evidence from other countries suggests oppor- tunities to reduce such costs. The survey results further indicate the potential to reduce patients’ frustration and improve their views of the US health system. Conversely, the US experience provides a cau-

tionary example for other countries of the poten- tial consequences of insurance complexity. Recent studies23 suggest that countries seeking to vary their insurance designs to introduce in- centives for patients to find and use high-value care may increase administrative costs. By shar- ing their experiences, all countries will be better able to ensure that resources spent on adminis- trative costs yield net returns. Cost Control A key challenge for the United

States is its already high level of health spending, which is 50–167 percent higher percapita than in the other study countries. The higher costs are particularlynotable whencomparing costs of hip

and knee replacements and prescription medi- cines.24 These costs undermine the financial pro- tections offered by insurance and drive premi- ums up. Sustaining access and affordability will likely require systemic reforms to control costs, including payment reforms to make care systems more accountable for health and cost outcomes. Although the level of health care costs in the

United States is particularly high, all of the coun- tries face health care spending growth rates that exceed the general growth rate of the economy. Holding the line will require creative responses and vigilance regarding insurance design to achieve the joint goals of safeguarding access, improving health outcomes, and meeting public expectations of high quality. Support For Reform Polls in the United

States show mixed public support and lack of knowledge about the provisions of the Affordable Care Act.25 Yet in the survey most US adults called for major change, with a minor- ity preferring the status quo. People who had experienced problems with access to or afford- ability of care or who had time-consuming insur- ance problems had more negative views than people who had not had such problems. The areasof access, affordability, and insurance com- plexity provide key indicators to monitor over time in the United States as well as other countries. Looking forward, the study indicates likely

public support in the United States for reforms if they succeed in improving access and afford- ability, strengthening primary care, and reduc- ing insurance complexity. ▪

The US experience provides a cautionary example for other countries of the potential consequences of insurance complexity.

Web First

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This study was supported by the Commonwealth Fund. The views expressed are those of the authors and should not be attributed to the Commonwealth Fund, its directors, or its officers. [Published online November 13, 2013.]

NOTES

1 Kaiser Family Foundation. Summary of the Affordable Care Act [Internet]. Menlo Park (CA): KFF; [last modi- fied 2013 Apr 23; cited 2013 Oct 18]. (Focus on Health Reform). Available from: http://kaiserfamilyfoundation .files.wordpress.com/2011/04/8061- 021.pdf

2 Schoen C, Doty MM, Robertson RH, Collins SR. Affordable Care Act re- forms could reduce the number of underinsured US adults by 70 per- cent. Health Aff (Millwood). 2011; 30(9):1762–71.

3 To access the Appendix, click on the Appendix link in the box to the right of the article online.

4 Van Ginneken E, Swartz K. Implementing insurance exchanges—lessons from Europe. N Engl J Med. 2012;367(8):691–3.

5 For country descriptions, see Thomson S, Osborn R, Squires D, Jun M, editors. International pro- files of health care systems, 2013. New York (NY): Commonwealth Fund; forthcoming 2013.

6 Schoen C, Osborn R, Squires D, Doty MM, Pierson R, Applebaum S. How health insurance design affects ac- cess to care and costs, by income, in eleven countries. Health Aff (Millwood). 2010;29(12):2323–34.

7 Cohen RA, Martinez ME. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2012. Hyattsville (MD): National Center for Health Statistics; 2013 Jun.

8 The 2013 international survey is the sixteenth in this series. The surveys alternately interview the general public, sicker patients, and primary care doctors.

9 The Commonwealth Fund provided core support, with cofunding to in- clude countries from the German Federal Ministry of Health and the BQS Institute for Quality and Patient Safety; Haute Autorité de Santé and Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (France); Dutch Ministry of Health, Welfare, and Sport and the Scientific

Institute for Quality of Healthcare at Radboud University Nijmegen Medical Centre; Norwegian Knowledge Centre for the Health Services; Swedish Ministry of Health and Social Affairs; and the Swiss Federal Office of Public Health. Support to expand samples was provided by the New South Wales Bureau of Health Information (Australia); and the Health Council of Canada, Health Quality Ontario, Commissaire à la Santé et au Bien- être du Québec, and Health Quality Council of Alberta.

10 Weights included age, sex, region, education, and additional variables consistent with standards for each country. In the United States the weighted variables also included race and ethnicity.

11 These are weight-adjusted margins of error for each country. The mar- gins of error reported apply to esti- mates of 50 percent; for smaller or larger estimates, the margin of sampling error will be smaller.

12 Commonwealth Fund. 2012 Commonwealth Fund International Survey of Primary Care Physicians. New York (NY): Commonwealth Fund; 2012.

13 A description of methodology and results for the survey in Note 12 can be found in Schoen C, Osborn R, Squires D, Doty M, Rasmussen P, Pierson R, et al. A survey of primary care doctors in ten countries shows progress in use of health informa- tion technology, less in other areas. Health Aff (Millwood). 2012;31(12): 2805–16.

14 Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood). 2013;32(4):686–94.

15 Starfield B. The future of primary care: refocusing the system. N Engl J Med. 2008;359(20):2087, 2091.

16 Organization for Economic Cooperation and Development. OECD health data 2013: statistics

and indicators. Paris: OECD; 2013. 17 Including both private insurers and

public programs such as Medicare. 18 Leu RE, Rutten FFH, Brouwer W,

Matter P, Rütschi C. The Swiss and Dutch health insurance markets: universal coverage and regulated competitive insurance markets. New York (NY): Commonwealth Fund; 2009 Jan.

19 Cutler DM, Ly DP. The (paper) work of medicine: understanding inter- national medical costs. J Econ Perspect. 2011;25(2):3–25.

20 Willcox S, Lewis G, Burgers J. Strengthening primary care: achievements and recent reforms in Australia, England, and the Netherlands. New York (NY): Commonwealth Fund; 2011 Nov.

21 Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff (Millwood). 2011;30(12): 2437–48.

22 Yong PL, Saunders RS, Olsen L, ed- itors. The healthcare imperative: lowering costs and improving out- comes: workshop series summary [Internet]. Washington (DC): National Academies Press; 2010 [cited 2013 Oct 21]. Available for download from: http://www.nap .edu/catalog.php?record_id=12750

23 See, for example, Thomson S, Schang L, Chernew ME. Value-based cost sharing in the United States and elsewhere can increase patients’ use of high-value goods and services. Health Aff (Millwood). 2013;32(4): 704–12.

24 Rosenthal E. For medical tourists, simple math. New York Times. 2013 Aug 4.

25 Kaiser Family Foundation. Kaiser health tracking poll [Internet]. Menlo Park (CA): KFF; 2013 Mar [cited 2013 Oct 21]. Available from: http://extension.umd.edu/sites/ default/files/_docs/articles/aae %20Kaiser%20tracking%20poll %203_13.pdf

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