United States: Sick, Last, and Late in the Equitable Health Care Race

The United States ranks last in measures of financial access to care when compared to other high-income industrialized countries, according to a 2013 Commonwealth Fund survey published in the New England Journal of Medicine. In part due to what is an unusual lack of universal health coverage in the United States, when compared to other high-income nations, the survey identified striking financial barriers to care that affect all Americans and were shown to have a grossly disproportionate effect on low-income Americans.


The Commonwealth Fund survey examined the significance of financial barriers to care in the United States and ten other high-income countries including: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The survey evaluated the effect that health care costs have on things like willingness to fill prescriptions or visit the doctor. The findings of the survey were presented as comparisons between each of the countries individually and as a comparison between the United States and the averages of the other ten high-income nations.

Cost Barriers

According to the study, low-income Americans were more likely than their counterparts in other high-income countries to report that they had a medical problem but did not see the doctor, skipped doses of medication, did not fill a prescription, did not receive recommended treatments, or did not follow up care due to the costs of those services. The survey revealed that at least 30 percent of lower-income adults in the United States reported encountering such barriers to care, which is significantly higher than the 10 percent of lower-income adults in the ten other countries which reported such barriers.

Delays and Satisfaction

The survey findings suggest the American impression that other high-income countries achieve savings at the cost of rationing care is an unsupported belief. In fact, at least for low-income adults, researchers found that “obtaining timely primary care is a bigger problem in the United States than in other industrialized countries.” Lower income Americans were more likely than low-income individuals in other industrialized countries to report having to wait six or more days to receive medical attention. Additionally, low-income Americans reported more difficulty in attempting to receive care on evening weekends and holidays. It was also more common for low-income Americans than for low-income individuals in other countries to report experiencing at least two hour wait times in emergency rooms. Low-income Americans were also more likely to designate the quality of physician performance as poor or fair when compared to low-income individuals in the other nations.

Income Disparity

The findings become more transparent when above average income individuals are considered. In sharp distinction to the findings relative to low-income Americans, higher-income Americans were not more likely than higher-income individuals in the ten other countries to find difficulty getting appointments. In fact, two or more hour wait times in emergency rooms were reported to be less common for higher-income Americans than for higher-income individuals in the other industrialized nations. However, costs remained a factor for even higher-income Americans. The study found that higher-income Americans were still more likely than higher-income individuals in other countries to report that costs kept them from visiting a doctor to address a medical problem.


The NEJM article summarizing the survey’s findings explains that Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) may impact financial access to care for Americans going forward. At the time of the survey, the only access-related mandate that was in effect was the requirement that insurers allow children to stay on their parents’ health insurance until they turn 26. The researchers believe that the other mandates now in effect as part of the health reform law will increase access to care as more Americans obtain insurance. However, the researchers recognize that the decision of 23 states not to expand Medicaid will significantly lower the ability of the ACA to improve equitable access.


The survey identifies that additional steps need to be taken to make care affordable for all. Funding for community health centers, payment reforms, and care coordination are some of the ways that the researchers believe equitable access can become more of a reality. The survey’s authors suggest that the findings exemplify the need to find novel ways to address the significant economic based health care access disparities in the United States. Additionally, the survey authors indicate that the access disparities represent a disappointing distinction between the U.S. and its industrialized counterparts.