U.S. Lags Behind Ten Other Countries in Access, Affordability of Care

Health Affairs has released a report detailing the results of a 2013 survey of adults in the United States and ten other countries, comparing the individuals’ experiences in their respective health care systems over time. According to the report, even with the key health reforms taking effect in 2014, the U.S. falls behind Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom in areas such as affordability, access, and administrative costs and complexity.

The survey data was collected over eight to ten weeks by Social Science Research Solutions through computer-assisted telephone interviews of random samples of adults ages 18 and older. Final samples from each country ranged from 1,000 to more than 5,000, and the data was weighted prior to analysis to reflect the distribution of each country’s adult population. Health Affairs also noted that, the results of the analysis may underestimate the population’s concerns to the extent that the data collection missed adults with more complex conditions, lower incomes, or a lack of proficiency in the survey languages.

Cost of Care

Respondents from the U.S. were most likely to report problems such as high out-of-pocket costs, problems paying medical bills, and choosing to forgo medical care because of costs. Forty percent of insured and uninsured adults reported spending $1000 or more during the year for medical care, not including insurance premiums. In contrast, fewer than 10 percent of respondents in Sweden, the UK, France, the Netherlands, and New Zealand reported high out-of-pocket costs. In Australia and Switzerland, despite reports of high spending, few respondents in those countries said the high costs led to access or affordability concerns. The survey linked lower costs in other countries with statutory caps on out-of-pocket expenses and low to no cost sharing for treatments. Even with the 2014 reform, by international standards, cost sharing by U.S. adults will remain high for those with low incomes.

Wait Times

One in four adults in the U.S., Canada, and Norway experienced a wait of six or more days before seeing a doctor or nurse when sick (and longer if uninsured in the U.S.). Seventy percent in Germany and New Zealand report that they were able to obtain a same- or next-day appointment when sick. However, adults in the U.S., U.K., the Netherlands, and Switzerland were able to be seen by a specialist within four weeks, unlike those in Norway and Canada who waited two months or longer.

After-Hours Access

Fewer than 40 percent of U.S., Canadian, French, and Swedish adults reported being able to receive care after hours without having to visit the emergency department. Easier after-hours access was available to adults in the U.K., New Zealand, the Netherlands, and Germany, where primary care practices are statutorily required to make arrangements for care after-hours. In all countries, email access to primary care physicians was low, with the Netherlands receiving the best email access at 32 percent.

Administrative Costs and Complexity

U.S. and Swiss adults were found to be the most likely to spend “a lot of time on paperwork or disputes” regarding both medical bills and insurance. Health insurers in the U.S. spent an average of $606 per person on administrative costs—more than two times that of the next-highest country. Adults in the U.S. were also most likely to say that their insurance denied payment or paid less than expected for claims. However, U.S. adults younger than 65 reported more administrative concerns than older adults, indicating a more stable and protective coverage for adults 65 and older.


Even with key pieces of health reform taking effect in 2014, this report shows that, while having insurance is important, doing so does not necessarily ensure access that is timely or affordable. However, with these other countries as examples, it is also clear that it is possible to create a health care system that increases access and affordability, improves primary care, and reduces the administrative complexity of insurance.