Press Release

Embargoed Until Contact

November 18, 2010
12:01 AM EST

Sue Ducat
Director of Communications
(301) 841-9962


From Health Affairs


Health Insurance Design: Comparing The US And Other Countries


Bethesda, MD--As the United States begins implementing health reform, how does the US experience compare with that of other high-income countries? To answer that question, The Commonwealth Fund conducted its thirteenth annual health policy survey, this year focusing on access, cost, and care experiences. Overall, the survey identified significant differences between countries and found that US adults—even when insured—were the most likely to incur high medical expenses, spend more time on paperwork, and have more claims denied.


How Health Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries
By Cathy Schoen, Robin Osborn, David Squires, Michelle M. Doty, Roz Pierson, and Sandra Applebaum


Schoen, Osborn, Squires, and Doty are affiliated with The Commonwealth Fund in New York (Schoen as a senior vice president, Osborn as a vice president, Squires as a program associate, and Doty as an assistant vice president); Pierson and Applebaum are with Harris Interactive in New York (Pierson as a vice president and Applebaum as a research manager). This study was supported by The Commonwealth Fund.


The data, collected by Harris Interactive and contractors in each country, were obtained through computer-assisted telephone interviews of random samples of adults eighteen or older in eleven countries, conducted from March through June 2010, with field times varying by country. The countries surveyed were Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States; samples sizes per country ranged from 1,000 to more than 3,500. The key findings include the following:


  • Twenty percent of US adults surveyed said they had had serious problems paying medical bills in the previous year. Responses to the same question from the other ten countries were in the single digits. US respondents were also significantly more likely than adults in other countries to have gone without care because of cost.

  • Thirty-five percent of US adults had out-of-pocket medical spending of $1,000 during the previous year, a far higher percentage than in any other country.

  • A lower proportion of adults in the United States (70 percent) than in all other countries except Sweden (67 percent) and Norway (70 percent) were confident that they would receive the most effective treatment when needed.

  • When asked about access to prompt medical care, 57 percent of US adults said they had seen a doctor or nurse the same or next day the last time they were sick and needed care. Switzerland had the most rapid access (93 percent). Adults in three other countries (Canada, Norway, and Sweden) reported longer waits than US adults.

  • Nearly one third of US adults (31 percent) reported either denial of payments by insurers or time-consuming interactions with insurers, a higher rate than in all other countries. Twenty-five percent of US respondents reported that their insurance company denied payment or did not pay as much as expected; 17 percent said they spent a lot of time on paperwork or disputes for medical bills or insurance—the highest rates in the survey.

  • The United States had the widest and most pervasive differences in access and affordability by income of the eleven countries. The United Kingdom had the least.

“Overall, the study indicates that insurance design can affect access and cost, as well as patients’ experiences interacting with insurers,” the authors conclude. They note that “as US reforms unfold, it will be important to monitor access and affordability...Tracking US experiences will also be useful for other countries, especially those contemplating less unified and more market-oriented approaches, with more extensive patient cost sharing.”

About Health Affairs

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at The full text of each Health Affairs Web First paper is available free of charge to all Web-site visitors for a two-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund.