Understanding What Makes Americans Dissatisfied With Their Health Care System: An International Comparison
By Joachim O. Hero, Robert J. Blendon, Alan M. Zaslavsky and Andrea L. Campbell
Health Affairs, March 2016
For decades, public satisfaction with the health care system has been lower in the United States than in other high-income countries. To better understand the distinctive nature of US health system satisfaction, we compared the determinants of satisfaction with the health system in the United States to those in seventeen other high-income countries by applying regression decomposition methods to survey data collected in the period 2011–13. We found that concerns related to “accessing most-preferred care” (the extent to which people feel that they can access their top preferences at a time of need) were more important to satisfaction in the United States than in other high-income countries, while the reverse was true for satisfaction with recent interactions with the health system. Differences among US socioeconomic groups in survey responses regarding access to most-preferred care suggest that wide variation in insurance coverage and generosity may play a role in these differences. While reductions in the uninsured population and the movement toward minimum health plan standards could help address some concerns about access to preferred care, our results raise the possibility of public backlash as market forces push plans toward more restricted access and higher cost sharing.
From the Introduction
For at least the past twenty-five years, Americans have been consistently less satisfied than residents of other high-income countries with their own nation’s health system.
In some ways, Americans’ low levels of satisfaction with their health system seem to defy expectations. For example, system satisfaction in European countries has been found to be strongly correlated with per capita expenditures.4 However, this is not the case in the United States, where per capita expenditures are high compared to those in Europe.
In our study we applied, across countries, a measure of relative importance that combined the strength of the relationship between each factor and system satisfaction with the amount that the factor varied. We focused on domains of opinion in which we most expected the United States to differ from other countries, given its unique culture and health care system. These include access barriers, satisfaction with the last health care experience, and the newly defined construct of access to most-preferred care.
From the Study Results
We found that security in accessing most-preferred care was more important in explaining overall satisfaction in the United States than in other countries, whereas satisfaction with recent health care experiences was less important. In particular, confidence in accessing the best care available explained more variance in ratings of system satisfaction in the United States than did satisfaction with a recent hospital or doctor visit — which in most countries was the most important predictor of overall satisfaction.
From the Discussion
For years the Commonwealth Fund has fielded international surveys that use mostly objective measures of patient experience. The surveys have found that the United States underperforms its peers along many dimensions of cost, access, and quality and that Americans are more in favor of major system reform than are people in other countries. In spite of these findings, researchers using the Commonwealth Fund data did not find the desire for system change in the United States to be very sensitive to performance on these measures, even measures of affordability — which leaves the determinants of desire for system change within the United States mostly unexplained. Using a different data source and more subjective measures of personal care and satisfaction, we have taken a new look at potential drivers of satisfaction in the United States and have offered evidence on the ways in which that country differs from its peers.
Comparing results for the United States and international averages, we found that access-related concerns played an outsize role in determining system satisfaction in the United States and that confidence in accessing one’s most-preferred care mattered in particular to Americans. Conversely, satisfaction with recent health care experiences, which tended to be the most consequential to system satisfaction abroad, mattered less in the United States.
One possible explanation for the dominance of access-related beliefs over experiences with care in the United States is the structure of the health insurance system. In other high-income countries, where access to health care is more uniform and minimum standards guarantee that most people receive health care of a certain quality, access to one’s top choices may be perceived as less pressing, and recent individual experiences in the health system become more salient. The wide range of insurance coverage in the United States creates more significant gaps in the kinds of care that individuals can obtain, compared to those in other high-income countries.
This explanation is consistent with research that shows deep concerns in the United States over insurance-related economic security. Wider variation in and less certainty about coverage in the United States compared to other countries may therefore explain the greater importance of access to most-preferred care and the diminished importance of recent health care experiences.
These expectations are not a matter of simply having insurance; they are also related to the type of insurance held. The patchwork of public and private sources of insurance and the wide variation in insurance generosity in the private market create large differences in the comprehensiveness of coverage among the insured. It is perhaps because of this that access to most-preferred care remained the top predictor of system satisfaction, even among Americans with insurance.
From the Policy Implications
Our research found that the concept of access to most-preferred care is particularly salient to Americans’ satisfaction with the US health care system. This research also underscores the important role that variation in insurance coverage and type in the United States may play in system satisfaction, in part through that variation’s role in giving people security about being able to exercise health care preferences when needed. Therefore, reductions in the uninsured population resulting from the ACA may marginally improve system satisfaction.
Overall gains could be limited, however, since the reductions affect only a small segment of the population, and the types of insurance that people are acquiring tend to be less generous and more restrictive than what has been available through employers. Broader improvements in satisfaction will likely require addressing the concerns of the insured as well as those of the uninsured, and the importance of Americans’ access to their top preferences indicates that this may involve issues of network adequacy and treatment availability.
From the Conclusion
Our findings raise particularly troubling questions about the implications of health care equity as it relates to variation in the types of health insurance that Americans can obtain. Changes in insurance that threaten to widen the gaps in access to and perceived quality of care between more and less privileged Americans may serve to increase the number of people who feel that their health care preferences are out of reach.
By Don McCanne, M.D.
Even though we spend more on health care than any other high-income nation, we are less satisfied with our health care system. This study indicates that the leading reason (that happens to be unique to the United States) is the concern we have about uncertainties in being able to access our most preferred care, that is, the extent to which people feel that they can access their top health care preferences at a time of need.
Wide gaps in insurance coverage, high out-of-pocket expenses, and fragmentation in insurance and delivery systems seem to be the major factors contributing to this uncertainty.
Current trends are to further restrict access through narrower networks, and to impose ever higher cost sharing, especially through higher deductibles, while perpetuating the fragmentation of our financing system. That can only increase uncertainties about our ability to access our preferred care.
Let’s hope that the inevitable backlash will send the message that we are ready for a more equitable and effective system – an improved Medicare for all with free choice of care for everyone. Americans need to be assured that the financing system does not create barriers that impair access to their top health care preferences at a time of need.