New 11-country healthcare survey: U.S. adults spend most; forgo care due to costs, struggle to pay medical bills

Dec. 5, 2013

NEW YORK, NY – Dec. 5, 2013 – A new 11-country survey from The Commonwealth Fund finds that adults in the United States are far more likely than those in 10 other high-income industrialized nations to go without healthcare because of costs, have difficulty paying medical bills, and encounter time-consuming health insurance paperwork or disputes, including claims that were unexpectedly not paid.

More than one-third (37%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared to as few as 4 percent to 6 percent in the U.K. and Sweden, according to the study published today as a Health Affairs Web First article. In addition, nearly a quarter (23%) of U.S. adults either had serious problems paying medical bills or were unable to pay them, compared to less than 13 percent of adults in France, the next-highest country, and 6 percent or fewer in the U.K., Sweden, and Norway. About two of five (41%) U.S. adults spent $1,000 or more out-of-pocket for care in the past year—by far the highest rate of any country surveyed.

Uninsured adults in the U.S. were the most likely to struggle to afford healthcare. However, even U.S. adults insured all year were more likely than adults in other countries to forgo care because of costs, to struggle with medical bills, and to face high out-of-pocket costs, with 42 percent paying $1,000 or more out-of-pocket for medical care. According to the study, U.S. health insurance has higher deductibles and higher cost-sharing, and does not place limits on out-of-pocket costs. This potentially explains why even people with health insurance in the U.S. struggle to afford needed healthcare.

The 2013 survey of 20,045 adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States focused on people’s experiences with their country’s healthcare system, particularly those related to accessing and affording care. The study’s authors note that the findings could provide a baseline for how the U.S. health system is performing as the nation’s health insurance system undergoes the most significant changes it has seen since Medicare and Medicaid were enacted in 1965.

“For more than 10 years now, The Commonwealth Fund has compared the U.S. health system to the systems of other industrialized nations, and the U.S. has always been an outlier when it comes to costs, access, and affordability. Far too many people go without care or can’t afford to be sick, even when they have health insurance,” said Cathy Schoen, Commonwealth Fund senior vice president and lead author of the article. “This study, which offers benchmarks to assess the progress of U.S. health reforms from an international perspective, clearly underscores the need to simplify our health insurance system and ensure that people can get and afford the care they need. 

U.S. Health System Stands Out for Insurance Complexity, Negative Health System Views 

Thirty-two percent of U.S. adults either spent a lot of time dealing with insurance paperwork and disputes or had their insurer deny a claim and/or pay less than anticipated. In contrast, only 25 percent of adults in Switzerland, 19 percent in the Netherlands, and 17 percent in Germany—all countries with competitive health insurance markets—reported these problems.

Asked about overall views of their country’s healthcare system, the vast majority (75%) of U.S. adults said the health system needs to undergo fundamental changes or be rebuilt. At the other end, half or more of Dutch (51%), Swiss (54%), and U.K. (63%) adults had strong positive views of their country’s health system, saying it works well and only needs minor changes.

Notably, the U.S. spends more on healthcare per capita than any other nation—$8,508, compared to $5,669 in Norway and $5,643 in Switzerland, the next-highest-spending countries. New Zealand, which had the lowest per capita rate, spent $3,182 per person. The U.S. also spent the most on insurance administrative costs, $606 per person, compared to $277 in France and $266 in Switzerland, the next-highest countries. The report’s authors note that high administrative spending in the U.S. is a symptom of the country’s complex, more fragmented health insurance system.

“The U.S. spends more on healthcare than any other country, but what we get for these significant resources falls short in terms of access to care, affordability, and quality,” said Commonwealth Fund President David Blumenthal, M.D. “The American people clearly want fundamental reform. This explains why the individual provisions of the Affordable Care Act poll so well with the American public.”


  • U.S. adults often wait for primary care when they are sick, with fewer than half saying they were seen the same day or the next day, and one of four waiting six days or longer.
  • Along with Canadian adults, U.S. adults were more likely to report long waits for primary care and high use of hospital emergency departments compared to other countries. German, Dutch, and New Zealand adults were the most likely to be seen by a clinician rapidly, with two-thirds or more reporting they could get same- or next-day appointments for primary care. 
  • U.S. adults also faced gaps in dental care: 27 percent reported they had no dental visit in the past two years and one-third (33%) reported going without dental care because of costs in the past year. Lack of access to dental care was also a concern in other countries, as more than one of five adults in Switzerland, Canada, the U.K., France, Australia, and New Zealand said they had not had a dental visit in the past two years. 
  • The Netherlands saw a steep increase in the proportion of people forgoing care because of costs, rising from 6 percent in 2010 to 22 percent in 2013. The authors note that this is potentially in response to austerity measures that have increased the amount Dutch patients spend out-of-pocket for healthcare, although those amounts are still lower than what U.S. patients pay.
  • U.S. adults often wait for primary care when they are sick, with fewer than half saying they were seen the same day or the next day, and one of four waiting six days or longer. 

Moving Forward

The study’s authors note that many of the access and affordability concerns identified by U.S. adults could be addressed by designing health insurance and payment systems to enhance access, limit the amount of money people have to spend out-of-pocket relative to their incomes, and support strong primary care. And by simplifying health insurance, as other countries have done, the U.S. could reduce time-consuming administrative complexity and costs for patients and physicians.

The authors observe that even as the Affordable Care Act takes effect, the U.S. will remain unique among countries in covering the poor in a separate program (Medicaid) and in the high level of out-of-pocket spending. The study underscores the importance of monitoring access, affordability, and experiences with insurance over time.


Conducted by Social Science Research Solutions and contractors in each country, the telephone survey of random samples of adults age 18 or older took place from February to June 2013. The final samples of adults included: Australia, 2,200; Canada, 5,412; France, 1,406; Germany, 1,125; Netherlands, 1,000; New Zealand, l,000; Norway, 1,000; Sweden, 2,400; Switzerland, 1,500; United Kingdom, 1,000; and United States, 2,002. The margin-of-sample error at the 95 percent confidence level was: +/–2% for Canada; +/–3% for Australia, France, Germany, the Netherlands, Sweden, Switzerland, and the U.S., and +/– 4% for Norway, New Zealand, and the U.K.

The Commonwealth Fund provided core support for the survey.

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