An 11-country survey from The Commonwealth Fund findsthat adults in the United States are far more likely than those in10 other industrialized nations to go without health care becauseof costs, have trouble paying medical bills, encounter high medicalbills even when insured, and have disputes with their insurers ordiscover insurance wouldn't pay as they expected.

The U.S. stands out for the most negative insurance-relatedexperiences, according to the report. One third (33 percent) ofU.S. adults went without recommended care, did not see a doctorwhen sick, or failed to fill prescriptions because of costs,compared to as few as 5 percent to 6 percent in the Netherlands andthe U.K.

In addition, one-fifth of U.S. adults had major problems payingmedical bills, compared to 9 percent in France, the next highestcountry, 2 percent in the U.K., 3 percent in Germany, and 4 percentin the Netherlands.

Uninsured and insured U.S. adults reported equally high rates of out-of-pocket costs, with one-third (35 percent)of U.S. adults paying $1,000 or more out-of-pocket in the past yearfor medical bills, significantly higher than all of the othercountries.

The study analyzes findings from the Commonwealth Fund 2010 International Health Policy Survey in ElevenCountries, focusing on insurance and access to health careexperiences reported by 19,700 adults from 11 countries:

• Australia
• Canada
• France
• Germany
• The Netherlands
• New Zealand
• Norway
• Sweden
• Switzerland
• United Kingdom
• United States

The study reveals widespread disparities by income within theUnited States. Lower income U.S. adults were far more likely thanthose with above average incomes to report difficulty with medicalbills and timely access to health care.

"We spend far more on health care than any of these countries,but this study highlights pervasive gaps in U.S. health insurancethat put families' health and budgets at risk," said CommonwealthFund Senior Vice President Cathy Schoen, lead author of thearticle, in a statement. "In fact, the U.S. is the only country inthe study where having health insurance doesn't guarantee youaccess to health care or financial protection when you're sick.This is avoidable--other countries have designed their insurancesystems to value access and limit out-of-pocket costs."

U.S. Health System Stands Out for Insurance Problems,Income Disparities

The U.S. also stood out for its complex insurance system, thestudy found. Thirty-one percent of U.S. adults either spent a lotof time dealing with insurance paperwork, had their insurer deny aclaim, or had their insurer pay less than they anticipated.

In contrast, only 13 percent of adults in Switzerland, 20percent of adults in the Netherlands, and 23 percent of adults inGermany--all countries with competitive health insurancemarkets--reported these problems. U.S. adults under 65 were themost likely to experience problems dealing with their healthinsurance providers--the 65 and older Medicare population was muchless likely to report these issues.

According to the study, the U.S. stood alone among the countriesfor its persistent and wide disparities among income groups--evenfor those with insurance. Although the uninsured were at highestrisk for skipping needed care, working-age U.S. adults withbelow-average incomes who were insured all year were significantlymore likely than those with above-average incomes to go withoutneeded care because of costs and have serious problems payingmedical bills--nearly half (46 percent) went without needed careand one third had one bill problem, double the rates reported byabove-average income insured adults.

"What we are hearing directly from adults around the world, andwhat we hear regularly at home, is that there is substantial roomfor improvement in the U.S. health insurance system," saidCommonwealth Fund President Karen Davis. "The good news is thatthere are opportunities to learn from other countries, andAffordableCare Act reforms will provide affordable insurance options forthe uninsured, make sure insurance pays for essential care, andprovide financial security for millions."

U.S. Lags Other Countries in Access to Care When Sick;Leads with Other Countries in Access to Specialists

Looking beyond how health insurance affects access to healthcare, the survey found substantial differences among countries onaccess to care when sick, access after hours, and wait times formore specialized care.

Swiss, New Zealand, Dutch, and U.K. adults were the most likelyto report same- or next-day access to doctors when sick, with 70percent of adults in the U.K and 93 percent of Swiss adultsreporting rapid access. In contrast, only 57 percent of adults inSweden and the U.S., and less than half in Canada and Norway wereseen this quickly.

Reflecting national policy requirements for after-hours carearrangements, about two-thirds of Dutch, New Zealand, and U.K.adults found it easy to get care after hours without going to theemergency room. In contrast, two-thirds of Swedish, Canadian,French, and U.S. adults said it was difficult.

Regarding specialists, in addition to the U.S., German, Swiss,U.K, and Dutch adults reported typically rapid access tospecialists with 70 percent to 83 percent of adults in all fivecountries reporting they were seen in less than four weeks.

Confidence in Affording Care and Getting Effective CareWhen Needed

Only 58 percent of U.S. adults were confident they would be ableto afford the care they needed--the lowest rate in the survey.U.K., Swiss, and Dutch adults were the most confident they would beable to afford needed care.

Asked if they were confident they would receive the mosteffective care, 70 percent of U.S. adults were confident, comparedwith 84 percent to 92 percent of adults in France, Germany, theNetherlands, New Zealand, Switzerland, and the U.K.

Differences by Income

In all countries except the U.K., adults with incomes below thenational average were more likely than those with higher thanaverage income to report trouble with medical bills and problemswith access to care because of costs. However, income gaps werewidest in the U.S., with a spread of as much as 19 percentagepoints between low- and high-income adults.

Regarding access to primary care and waiting times, the U.K wasnotable for having few differences by income, and Switzerland andGermany stood out for rapid access to primary and specialist carefor below-average income as well as above-average income adults.The U.S. stood out for significant income gaps in primary careaccess, after hours, and specialists, even for those who wereinsured all year.

Insurance Design Matters

The study included countries with diverse insurance arrangements,including three countries-- Germany, the Netherlands, andSwitzerland--that have achieved near-universal coverage withcompetitive health insurance markets, a requirement that allresidents have insurance, and provisions to assure that insuranceand care are affordable.

Each of these countries has developed insurance system rulesthat ensure people with health insurance are protected. Countriesthat require people to pay for some portion of their health carecosts out-of-pocket, such as France, Germany, and Switzerland havelimited out-of-pocket costs to patients. Germany limitsout-of-pocket costs based on income, and France lowers oreliminates cost-sharing for those with chronic conditions and formedications that have been proven to be highly effective. Toaddress insurance affordability, Swiss and Dutch systems provideassistance in paying premiums to 30 percent to 40 percent of theirpopulations.

The authors note that with insurance expansions under healthreform, the U.S. performance should improve over time. However,out-of-pocket spending will remain high compared to othercountries, and affordability provisions may need to be strengthenedover time.