Wednesday, March 9, 2016
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.
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.
Comment by Don McCanne
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
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.
at 4:47 PM