International Comparisons Reveal Public Concerns with Health Systems and Disparity Between Spending, Health Outcomes in U.S.
Contact: Mary Mahon, 212-606-3853, or Bill Byrne, 212-606-3826, both of the Commonwealth Fund
CHICAGO, June 28 /U.S. Newswire/ -- Robert Blendon and Karen Donelan of Harvard University, and Gerard Anderson of Johns Hopkins University, today discussed the importance of international comparisons of health system performance at a session of the Association for Health Services Research's annual meeting in Chicago.
Presenting data from articles they wrote for the May/June issue of the journal Health Affairs, the three authors contrasted the health care system in the United States with that in other industrialized nations by examining public attitudes and comparing data on health spending and outcomes. Analysis of the health care experiences of Americans based on their insurance status and type of plan reveals that those in managed care are more likely than those in fee-for-service to call for health system change and to experience access and cost problems. Uninsured Americans are also far more likely than others to have negative views of the health system and to experience access and cost problems.
In "The Cost of Health System Change: Public Discontent in Five Nations," Karen Donelan, Robert Blendon, Cathy Schoen, Karen Davis, and Katherine Binns report findings from The Commonwealth Fund 1998 International Health Policy Survey, conducted by the Harvard School of Public Health and Louis Harris and Associates in collaboration with the Fund. In all five countries -- Australia, Canada, New Zealand, the United Kingdom, and the United States -- a majority said their health care system either needs fundamental changes, or complete rebuilding, with fewer than 1 of 4 respondents in every country saying their system is functioning well as it is. About one of three respondents in the U.S. (33 percent), New Zealand (32 percent), and Australia (30 percent) called for a complete overhaul of their health care system. In the U.K, which spends considerably less on health care than each of the other countries surveyed, in contrast, one of seven (14 percent) of those surveyed wanted to completely rebuild the system; Britons were also least worried about future health care needs. In the U.S. cost and access concerns are high, as well as anxiety about the future.
U.S. Comparisons Reveal Coverage and Type of Plan Matter
Survey findings revealed major disparities within the U.S. in public opinion about health systems according to insurance status and type of coverage. Nearly three of five (59 percent) uninsured Americans said the system needs complete rebuilding, compared to one of three (33 percent) insured Americans. Americans in managed care (31 percent) were also more likely than those in fee-for-service plans (23 percent) to call for rebuilding the U.S. health care system. Uninsured Americans were nearly twice as likely as the insured in all countries to say the health care system needs to be completely rebuilt.
Uninsured Americans were also much more likely than those with insurance in all countries to report access and cost problems. While over two of five (42 percent) uninsured Americans reported problems paying medical bills in the past year, one of five (18 percent) Americans with insurance reported bill problems, a higher rate than in any other country. Americans in fee-for-service were least likely to report bill problems, with only one of ten (9 percent) reporting difficulties paying medical bills.
The authors note that the survey found major differences on several health experience measures for Americans in managed care plans versus those in traditional plans -- in contrast to previous studies revealing only small differences between these two groups. Those in traditional insurance plans (35 percent) are more likely than are those in managed care plans (26 percent) to rate physician and overall medical care as excellent. And they are significantly less likely (25 percent versus 40 percent) to report problems seeing specialists and consultants. When controlling for age, sex, race, income and health status, enrollment in an HMO or other managed care plan remained a highly significant predictor of lower quality ratings of doctor and overall medical care and increased difficulties seeing specialists.
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Americans' Reports on Access and Cost Problems, By Insurance Status and Type, 1998
...................................All.......Managed..Traditional
.................................insured......care.....insurance
............................................(percent)
o Having financial problems
paying medical bills..........13..........16..........9
o Inability to get needed
medical care in past year.....10..........12..........7
o Not filling prescriptions
for financial reasons.........13..........14..........12
o Difficulties (extremely,
very, somewhat difficult)
seeing specialists and
consultants...................34..........40..........25
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Cost Problems Far More Likely for Americans
Out-of-pocket costs for health care are much higher in the U.S. than in the other four countries. One of five (19 percent) U.S. respondents said they paid more than $1,000 in the past year, and nearly one of ten (8 percent) indicated they paid more than $2,000. In contrast, only 6 percent of New Zealanders paid more than $1,000. Nearly half (44 percent) of Britons indicated that they paid nothing out of pocket for medical care in the past year, while 8 percent of U.S. adults reported paying nothing out of pocket for health care during the same period.
Discontent is Widespread Though Reasons Vary
In the four countries with universal coverage the public is more likely to be unhappy with the level of funding and administration, including waiting times to receive care, while in the U.S. the public is primarily concerned with rising costs. In the U.S., three of ten (30 percent) said the most important problem was affordability of care, while in Australia nearly one of four (23 percent) and in New Zealand three of ten (29 percent) reported waiting times for care and queues as their number one concern. In the UK, nearly half (45 percent) said inadequate public funding was the top problem. In Canada, funding, system administration and resource management issues were each the top concern of one of four (25 percent).
Public Confidence in Health Care Systems Is Falling
Trends show that public dissatisfaction with the health care system in the U.S. has returned to the level it reached a decade ago. In Australia and especially Canada the public's confidence has been shaken. In New Zealand, where out-of-pocket costs have gone up with new policy changes, the public's concerns have also increased.
U.S. Health Care Expenditures Are Highest Among OECD Nations
In "Health Spending, Access, and Outcomes: Trends in Industrialized Countries," Gerard F. Anderson and Jean-Pierre Poullier note that despite the prevalence of managed care and government efforts to cut costs, per capita health care spending in the U.S. in the 1990s grew faster than in the average industrialized country. Anderson and Poullier, whose research was supported by The Commonwealth Fund, base their conclusions on OECD (Organization for Economic Cooperation and Development) data on health care spending in 1997 that allows for comparisons between health care financing and delivery systems in the 29 OECD countries. Despite spending more on its health care system than any country in the world, the U.S. lags behind the other four countries in access and financial security.
Most OECD countries implemented universal coverage between 1960 and 1997, and the U.S., Turkey, and Mexico are the only OECD countries currently without universal health insurance. But the U.S. still spends the most on health care: in 1997 the U.S. spent $3,925 per capita, or 13.5 percent of its gross domestic product on health care, while the median OECD country spent $1,728, or 7.5 percent of its GDP. From 1990 to 1997 U.S. health care spending per capita rose 4.3 percent per year compared with the OECD median of 3.8 percent. Nevertheless, the U.S. has the lowest percentage (33 percent) of the population with government-assured health insurance and 43 million citizens are without coverage.
Spending on hospital services account for much of the disparity between U.S. and other OECD nations. Per capita spending on U.S. hospitals was $1646, more than double the OECD median of $692, with the increase due to rising costs, not more use. The cost per day for a U.S. hospital has gone up an average of 15 percent annually since 1960, a much faster rate than in other OECD countries. Hospital expenditures per day in the U.S. in 1996 were $1,128 -- far more than the OECD median of $227 -- accounting for 42 percent of the U.S. health care dollar.
Doctors' incomes make up a smaller portion of the variation in health care spending among OECD nations, because physician services only account for 19.5 percent of U.S. health spending. Nevertheless, U.S. physician income averaged $199,000 in 1996, far higher than in other OECD countries for which this data is available. Spending on pharmaceuticals, in contrast, did not vary widely. Most OECD countries spend about the same per capita on pharmaceuticals, with the median OECD country spending $234 per capita on prescription drugs in 1996; the U.S. and four other countries spent over $300 per capita.
U.S. Health Outcomes Not Commensurate with High Expenditures
The authors point out the difficulties of comparisons of health outcomes using international data and the need to develop more sophisticated indicators of health status. For available measures, however, including infant mortality, life expectancy, and years of life lost, the U.S. ranked near the bottom of the OECD countries in 1996. Particularly striking is the high infant mortality rate in the U.S.: only Hungary, Korea, Mexico, Poland, and Turkey had higher infant mortality. In addition, the rate of improvement for most of the indicators has been slower in the U.S. than in the median OECD country.
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The Commonwealth Fund is a private foundation supporting independent research on health and social issues.
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/U.S. Newswire 202-347-2770/ 06/28 17:21
Copyright 1999, U.S. Newswire
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