THE
COMMONWEALTH
FUND
The Commonwealth Fund
2010 International Health Policy Survey
in Eleven Countries
Cathy Schoen and Robin Osborn
The Commonwealth Fund
November 2010
2
2010 Commonwealth Fund International Health Policy Survey
• Telephone survey, conducted from March to June 2010, of
adults ages 18 and older in Australia, Canada, France, Germany,
the Netherlands, New Zealand, Norway, Sweden, Switzerland,
the United Kingdom, and the United States.
• Final samples: 3,552 Australia, 3,302 Canada, 1,402 France, 1,005
Germany, 1,001 Netherlands, 1,000 New Zealand, 1,058 Norway,
2,100 Sweden, 1,306 Switzerland, 1,511 United Kingdom, and
2,501 United States.
• Conducted by Harris Interactive subcontractors, and Dutch
Scientific Institute for Quality of Healthcare, Haute Authorité de
Santé (HAS), Swedish Ministry of Health, Swiss Federal Office of
Public Health, and Norwegian Knowledge for the Health Services.
• Core topics: Affordability, access, insurance complexity, equity,
and system views.
• Examined differences between above- and below-average
(median) income respondents, controlling for age and
health status.
THE
COMMONWEALTH
FUND
International Comparison of Spending on Health, 1980–2008
Total expenditures on health
as percent of GDP
Average spending on health
per capita ($US PPP)
16
6000
5000
4000
United States
Norway
Switzerland
Canada
Netherlands
Germany
France
Denmark
Australia
Sweden
United Kingdom
New Zealand
14
12
10
8
2000
4
1000
2
0
0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
3000
6
United States
France
Switzerland
Germany
Canada
Netherlands
New Zealand
Denmark
Sweden
United Kingdom
Norway
Australia
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
8000
7000
3
THE
COMMONWEALTH
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Source: OECD Health Data 2010 (June 2010).
4
Confidence, Affordability, and Access
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COMMONWEALTH
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5
Cost-Related Access Problems
in the Past Year
Percent
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Did not fill
prescription or
skipped doses
12
10
7
6
3
7
6
7
4
2
21
Had a medical
problem but
did not visit
doctor
13
4
6
16
2
9
6
5
6
2
22
Skipped test,
treatment, or
follow-up
14
5
6
10
3
8
5
4
4
3
22
Yes to at least
one of the
above
22
15
13
25
6
14 11
10
10
5
33
THE
COMMONWEALTH
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Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
6
Out-of-Pocket Medical Costs
in the Past Year, in U.S. Dollars
$200 or less
Percent
$1,000 or more
100
76
75
61
51
50
47
35
50
41 39
33
25
21
20
25
35
31
16
12
4
9
8
7
2
1
US
UK
SW
IZ
SW
E
NO
R
NZ
NE
T
GE
R
FR
CA
N
AU
S
US
UK
SW
E
SW
IZ
NO
R
NZ
H
NE
T
GE
R
FR
CA
N
AU
S
0
THE
COMMONWEALTH
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Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
7
Serious Problems Paying or Unable to Pay
Medical Bills in the Past Year
Percent
40
30
20
20
10
8
6
9
3
4
6
5
5
6
NOR
SWE
SWIZ
2
0
AUS
CAN
FR
GER NETH
NZ
UK
US
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COMMONWEALTH
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Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
8
Confident Will Receive Most-Effective Treatment if Sick
Percent responded, if they became seriously ill, confident/very confident they
would get most-effective treatment, including drugs and diagnostic tests
100
85
76
76
82
88
89
84
75
70
67
NOR
SWE
92
70
50
25
0
AUS
CAN
FR
GER NETH
NZ
SWIZ
UK
US
THE
COMMONWEALTH
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Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
9
Confident Will Be Able to Afford Needed Care
Percent responded, if they became seriously ill, confident/very confident they
would be able to afford the care they needed
100
90
81
75
64
68
73
70
75
78
69
70
58
50
25
0
AUS
CAN
FR
GER NETH
NZ
NOR
SWE
SWIZ
UK
US
THE
COMMONWEALTH
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Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
10
Primary Care, Specialist, and After-Hours
Access
THE
COMMONWEALTH
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11
Access to Doctor or Nurse When Sick or Needed Care
Same- or next-day
appointment
Percent*
Waited six days
or more
93
100
75 65
62
66
72
78
70
57
45
50
57
45
33
25
28 25
19
17 16
14
5
5
2
8
* Base: Answered question.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US
UK
SW
IZ
SW
E
NO
R
NZ
H
NE
T
GE
R
FR
CA
N
AU
S
US
UK
SW
E
SW
IZ
NO
R
NZ
H
NE
T
GE
R
FR
CA
N
AU
S
0
THE
COMMONWEALTH
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12
Difficulty Getting After-Hours Care
Without Going to the Emergency Room
Percent reported very/somewhat difficult getting care on nights,
weekends, or holidays without going to ER*
100
75
59
65
63
68
63
57
50
33
38
45
43
38
25
0
AUS
CAN
FR
GER NETH
NZ
NOR
SWE
* Base: Needed care and answered question.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
SWIZ
UK
US
THE
COMMONWEALTH
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13
Emergency Room Use in the Past Two Years
Percent
60
44
40
37
35
33
27
22
26
29
26
22
25
20
0
AUS
CAN
FR
GER NETH
NZ
NOR
SWE
SWIZ
UK
US
THE
COMMONWEALTH
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Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
14
Wait Times for Elective Surgery and
Specialist Appointments
Percent
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Specialist appointment*
Less than
4 weeks
54
41
53
83
70
61 50
45
82
72 80
2 months
or more
28
41
28
7
16
22 34
31
5
19
9
Elective surgery**
Less than
1 month
53
35
46
78
59
54 44
34
55
59 68
4 months
or more
18
25
7
0
5
8
22
7
21
21
* Base: Needed to see specialist in past 2 years.
** Base: Needed elective surgery in past 2 years.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
7
THE
COMMONWEALTH
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15
Coordination and Insurance Complexity
THE
COMMONWEALTH
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16
Coordination Problems in the Past Two Years
Percent
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Test results/
records not
available at time
of appointment
11
11
7
8
8
9
10
9
7
9
15
Received
conflicting
information from
different health
professionals
20
20 16
17
15
18
24
18
16
10 23
Duplicate tests:
doctors ordered
test that had
already been
done
10
8
14
20
4
5
9
5
11
7
Yes to at least
one of the above
28
28 28
29
21
23
31
23
24
19 37
17
THE
COMMONWEALTH
FUND
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
17
Coordination Problems in the Past Two Years,
by Number of Chronic Conditions
Percent experienced any of three
coordination problems*
No chronic conditions
2 or more chronic conditions
50
42
42
38
26
31
29
25
28 29
23
19
29
26 27
25
23
19
32
17
32 31
19
13
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
* Test results/records not available at time of appointment, received conflicting information
from different health professionals, and/or doctors ordered test that had already been done.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
SWIZ
UK
US
THE
COMMONWEALTH
FUND
18
Problems with Health Insurance
Percent reported in
the past year:
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
6
6
11
16
8
4
8
3
6
3
17
Health
insurance
denied payment
or did not pay
as much as
expected
11
12
18
11
15
4
2
2
10
2
25
Yes to either
14
15
23
23
20
6
9
4
13
5
31
Spent a lot of
time on
paperwork or
disputes over
medical bills
THE
COMMONWEALTH
FUND
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
19
2009 Survey: Primary Care Doctors Say Insurance
Restrictions on Care Are a Major Time Concern
Percent saying amount of time physician or staff spend getting patients needed
medications or treatment because of coverage restrictions is a major problem
75
48
50
34
25
19
13
16
16
17
10
10
6
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
UK
US
THE
COMMONWEALTH
FUND
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
20
Experiences by Income
Slides 21 to 26: Percentages adjusted based on logistic regression to
control for health status, age, and—in the U.S.—insurance status.
THE
COMMONWEALTH
FUND
Confident Will Receive Most-Effective Treatment if Sick,
by Income
(Adjusted) percent
confident/very confident
100
75
80
79
73
71
8885
Above-average income
82
78
88
87
81
78
Below-average income
91
72
86
9592
82
70
63
21
65
58
50
25
0
AUS*
CAN*
FR
GER
NETH*
NZ*
NOR*
SWE*
SWIZ*
Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status.
* Indicates significant within-country differences with below-average income (p < 0.05).
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
UK
US*
THE
COMMONWEALTH
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22
Cost-Related Access Problems
in the Past Year, by Income
(Adjusted) percent
experienced at least one
of three problems**
Above-average income
Below-average income
75
50
39
27
22
25
18
12
21
17 17
6
8
CAN*
FR*
13
3
20
15
8
14
12
4
5
7
NOR*
SWE*
SWIZ*
4 4
0
AUS*
GER*
NETH*
NZ*
UK
US*
Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status.
* Indicates significant within-country differences with below-average income (p < 0.05).
** Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
THE
COMMONWEALTH
FUND
23
Out-of-Pocket Spending of $1,000 or More
in the Past Year, by Income
Above-average income
(Adjusted) percent
Below-average income
60
45
45
34
31
29
30
16 17
16 15
12
15
20
11
10
5 5
5
7
11
6
2 2
0 0
0
AUS*
CAN*
FR
GER*
NETH
NZ*
NOR
SWE
SWIZ*
Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status.
* Indicates significant within-country differences with below-average income (p < 0.05).
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
UK
US*
THE
COMMONWEALTH
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24
Serious Problems Paying or Unable to Pay
Medical Bills in the Past Year, by Income
(Adjusted) percent
Above-average income
Below-average income
40
30
24
20
13
10
10
11
9
10
7
5
2
2
1
CAN*
FR*
GER*
9
9
9
6
2
2
NZ*
1
2
2
NOR*
SWE*
SWIZ*
2 3
0
AUS*
NETH*
Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status.
* Indicates significant within-country differences with below-average income (p < 0.05).
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
UK
US*
THE
COMMONWEALTH
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25
Difficulty Getting After-Hours Care,
by Income
(Adjusted) percent reported
somewhat/very difficult
Above-average income
Below-average income
100
75
72
67
64
63
60
59
5655
6770
68
55
52
44
50
31
4342
40
3437
47
31
25
0
AUS
CAN*
FR*
GER
NETH*
NZ
NOR*
SWE
SWIZ
Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status. Base: Needed care and answered question.
* Indicates significant within-country differences with below-average income (p < 0.05).
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
UK*
US*
THE
COMMONWEALTH
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26
Waited Two Months or Longer for
Specialist Appointment, by Income
(Adjusted) percent
Above-average income
Below-average income
75
45
50
40
26
31
35 35
29 30
26
24
25
15
8 9
3231
28
18
14
7
7
3
10
0
AUS*
CAN
FR
GER
NETH*
NZ*
NOR
SWE
SWIZ*
Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status. Base: Needed to see specialist in past two years.
* Indicates significant within-country differences with below-average income (p < 0.05).
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
UK
US
THE
COMMONWEALTH
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27
U.S. Adults Under Age 65, by Insurance and Income
19
Went without care
because of cost
46
69
46
$1,000 or more
out-of-pocket costs
33
35
Insured all year,
above-average
income
7
Serious problem or
unable to pay bill
31
47
32
36
Insurance difficulty
0
25
Insured all year,
below-average
income
Uninsured
50
Percent
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
75
100
THE
COMMONWEALTH
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28
Overall Views of Health Care System, 2010
Percent
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Only minor
changes
needed
24
38
42
38
51
37
40
44
46
62 29
Fundamental
changes
needed
55
51
47
48
41
51
46
45
44
34 41
Rebuild
completely
20
10
11
14
7
11
12
8
8
3
27
THE
COMMONWEALTH
FUND
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
29
Cross-Cutting Themes and Implications
for U.S. Reform
•
United States stands out
– Access problems because of costs, difficulty paying medical bills,
insurance complexity, and disparities by income
•
Insurance benefit design matters for access, protection, and simplicity
– Income-related cost-sharing and limits on out-of-pocket spending
promote access and enable ability to pay
– Special provisions necessary to protect low- and modest-income people
who are often sicker and least able to afford care if not well-insured
•
Symptoms of weaker primary care in U.S., Canada, and Sweden
•
German, Swiss, U.S., Dutch, and U.K. rapid access to specialists
– Swiss notable for rapid access to primary and specialized care
•
U.S. health reforms will make a difference—include many elements seen
internationally
– Medicaid expansion and premium assistance, limits on out-of-pocket
spending
– Insurance exchanges, benefit standards, and rules to reduce complexity
– Health care delivery system change to improve access and
integration
THE
COMMONWEALTH
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30
Acknowledgments and Cofunders
Thanks to coauthors David Squires, Michelle M. Doty, Roz Pierson, and Sandra
Applebaum, and to Harris Interactive, Inc., and contractors for conducting the
survey. Published by Health Affairs as: “How Health Insurance Design Affects
Access to Care and Costs, by Income, in Eleven Countries,” Web First,
November 18, 2010.
•
Australia: Commission on Safety and Quality in Health Care, Bureau of
Health Information
•
Canada: Health Council of Canada, Ontario Quality Council, Quebec
Health Commission
•
France: Haute Authorité de Santé (HAS), Caisse Nationale de
l’Assurance Maladie des Travailleurs Salariés (CNAMTS)
•
Germany: Institute for Quality and Efficiency in Health Care (IQWiG)
•
Netherlands: Dutch Ministry of Health, Welfare and Sport, and IQ Health,
Radboud University Nijmegen
•
Norway: Norwegian Knowledge Centre for the Health Services
•
Sweden: Swedish Ministry of Health
•
Switzerland: Federal Office of Public Health
•
United Kingdom: Health Foundation
THE
COMMONWEALTH
FUND