The U.S. spends more than double what other countries spend for medical care, $6,697 per capita in 2005, but a new Commonwealth Fund seven-nation survey finds that U.S. patients are more likely to skip care because of costs.

The study surveyed 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. One third of U.S. adults called for rebuilding the system, the highest rate in any country surveyed. The U.S. also ranked last in saying only minor changes are needed in the health system.

Canadian patients are least likely to be able to get a same-day appointment with their physicians when sick and the most likely to seek care in emergency rooms as an alternative.

U.S. adults also have the highest out-of-pocket costs and greatest problems paying medical bills.


Regarding the concern that universal insurance systems result in long waits for care or “rationing,” over 50% of patients in Germany, the Netherlands, and New Zealand report rapid access to physicians while 30% of Americans do. Canada ranked last in patients saying they could get same-day appointments with their doctor at 22%.

Elective Surgery

Regarding access to elective surgery, the US ranked highest while over 50% of patients in Germany, New Zealand, and Australia waited less than a month for elective or non-emergency surgery and waits of 6 months or more were rare in these countries and the Netherlands. In Canada and the U.K., about 15% of patients reported waits of more than six months for elective or non-emergency surgery.

Out-of-pocket costs

U.S. adults were most likely to have gone without care because of cost and to have high out-of-pocket costs. In the U.S., 37% of all adults and 42% of those with chronic conditions skipped medications or avoided recommended care in the past year because of costs, rates well above all other countries. In contrast to the U.S., patients in Canada, the Netherlands, and the U.K. rarely report having to forgo needed medical care because of costs.

In addition, one-fifth of U.S. adults report serious problems paying medical bills, more than double the rate in the next highest country. And nearly one third (30%) in the U.S. spent more than $1,000 in the past year out-of-pocket, a level rare in most of the other countries.

Treatment with no benefit

U.S and German adults most reported that doctors recommended treatment the patients thought had little or no benefit.


The Netherlands had the highest (31%) percentage of people who spent time on paperwork or disputes related to medical bills or insurance. The U.S. had 24%. In the other countries, fewer than 15% reported this concern.

Emergency room visits

Canada led the survey in emergency room visits with 39%. 36% of U.S. adults visited an emergency room. In both the U.S. and Canada, about 40 percent of those with an emergency room visit said the visit was for a condition that could have been treated by their regular doctor if available.

But primary physicians are highly valued

Adults in all seven countries placed high value on having a relationship with a regular source of primary health care that is accessible and coordinates their care, that knows their medical history, is easy to contact, and helps coordinate care received from other providers.

Across very different country health care systems, the study found that only 45 to 61 percent of adults described having a primary source of care with these key attributes.

In all countries, patients with primary care relationships reported significantly more positive experiences, including having more time with their doctors, more involvement in care decisions, and better coordination with specialists and hospitals.

Those with primary care were also much less likely to report medical errors, receiving conflicting information from different doctors or to encounter coordination problems, such as diagnostic tests or medical records not being available at the time of care and duplicate tests.

Read the entire Health Affairs article here.

Survey Methodology

Harris Interactive, Inc. and country affiliates conducted the interviews by telephone with nationally representative cross-sections of adults ages 18 and older in seven countries between March 6 and May 7, 2007.

The final study included 1,009 adults in Australia, 3,003 in Canada, 1,407 in Germany, 1,557 in the Netherlands, 1,000 in New Zealand, 1,434 in the United Kingdom, and 2,500 in the United States.

The Commonwealth Fund funded the core study, partnered with the Health Council of Canada to expand the Canadian sample, and cofunded fieldwork in the Netherlands with the Dutch Ministry of Health, Welfare, and Sport and the Center for Quality of Care Research (WOK), Radboud University, Nijmegen. The German Institute for Quality and Efficiency in Health Care funded the German sample. The interviews were conducted in German in Germany, Dutch in the Netherlands, and English in the five other countries, with an option for French in Canada and Spanish in the United States.

The margin of sample error for country averages are approximately ±2 percent for the United States and Canada and ±3 percent for the other five countries at the 95 percent confidence level.

The Commonwealth Fund is a private foundation working toward a high performance health system.