How does the U.S. health system for older adults stack up when compared with those of 10 other wealthy countries?
Pretty poorly, according to a new international survey. Medicare beneficiaries tend to be sicker and forego care more often due to costs than their counterparts in Europe and Canada.
The Commonwealth Fund’s 20th International Health Policy survey compared health experiences of older adults, including those with the greatest medical needs, in 11 nations. The U.S. ranked at or near the bottom in many categories, including access, affordability, timeliness of care, and care coordination. The study was published in the Nov. 15 issue of Health Affairs.
For the first time, the survey looked at the experiences of high needs older adults, who are sicker and have more complex social challenges. It’s a lens we can look through and gain better understanding of how policies and care delivery systems in different nations impact the most vulnerable populations, according to lead author Robin Osborn, vice president of the Commonwealth Fund’s International Program in Health Policy and Practice Innovations.
Since almost all U.S. adults age 65 and over qualify for Medicare, they’re the only group that has universal health insurance. The survey compared this population with adults 65+ in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. Researchers found that overall, at least one in eight respondents had three or more chronic conditions. In the U.S., more than one in three (36 percent) had multiple chronic conditions. Yet, 23 percent of U.S. seniors in the survey said they did not go to a doctor when they were sick, get a recommended medical test or procedure, or fill a prescription due to high costs in the last two years. In the U.K., France, Norway and Sweden, five percent or fewer seniors reported skipping needed care due to cost concerns.
“What stands out is that U.S. older adults are sicker and more economically vulnerable, despite having Medicare, our version of universal coverage,” said Osborne in a conference call with reporters. “U.S. seniors struggle to afford care and face more financial barriers to care than in the 10 other countries.”
The structure of Medicare requires more out-of-pocket expenditures than health insurance in most of the other nations in the survey. Nearly one in four (22 percent) of U.S. seniors spent $2,000 in out-of-pocket costs, such as copays, coinsurance or prescription drugs. With the exception of Switzerland, fewer than 10 percent of seniors in other countries spent this much. Twenty-five percent of older adults in the U.S. reported concerns about having enough money to buy nutritious food, pay rent, utility bills, or had serious problems paying medical bills, the survey found. In France, the U.K., Norway and Sweden, fewer than 5 percent of seniors said they struggled financially due to health costs.
“I don’t think there’s any question that many elderly Americans pay a substantial amount out of pocket that would not be paid by people in other countries where there is no coinsurance or deductibles,” said David Blumenthal, M.D., president of the Commonwealth Fund.
Looking specifically at “high need” older adults — those with three or more chronic conditions or who struggle with activities of daily living — yielded some sobering results. Among this sub-population, a third (31 percent) of U.S. seniors skipped care because of costs, compared with only 2 percent for Sweden. They are more likely to be economically vulnerable, experience depression, anxiety, and be at greater risk of falls than their counterparts without high-needs. They’re also more likely to live alone and feel more isolated, according to Osborne. This group also has higher rates of emergency department use, more care coordination problems and more medical errors, she said.
Many U.S. seniors economically at risk
Economic vulnerability is a concern, Osborne pointed out. Poverty, unstable housing, social isolation and mental health problems contribute to higher rates of chronic illness, poorer health, higher use of the health care system and greater costs. “High levels of cost sharing, high deductibles, and copays make U.S. seniors stand out,” she said. And not in a good way. Residents in Australia and Germany also reported struggling with paying bills or rent due to high health costs.
Among the most striking findings were missed opportunities for health promotion, such as fall prevention, healthy diet, exercise and mental health issues, Osborne said. More than half of U.S. seniors said they spoke with their doctors about falls or diet and exercise; fewer reported discussing issues such as anxiety, depression or stress.
One of the issues revealed by this survey is that Medicare is not as generous as comparable insurance in other countries, Blumenthal pointed out. Social and economic disparities are also more prevalent in the U.S. than in many of these other nations.
The study concluded that a stronger social safety net is needed in the United States, especially for high-needs elderly. This would help improve health outcomes and decrease spending. Among these 11 countries, the United States stands out for a disproportionally low level of spending on social care versus health care. Compared to France or Sweden, who spend about $2 on social services for every dollar on health, the U.S. spends less than 60 cents on social services for every dollar of health care.
With cuts to Medicare potentially looming in the new tax legislation, the U.S. health system will need rely even more on proven, evidence-based home and community programs to help improve outcomes, reduce use of emergency departments and control costs, Blumenthal said. One bill to keep an eye on is the CHRONIC Act, recently passed by the Senate Finance committee. The bipartisan legislation supports care of chronically ill elders by boosting telehealth services, expanding the popular Independence at Home model, and strengthening Medicare Advantage special needs programs.
Journalists:
- Check out this recap of Independence at Home and other programs to keep seniors healthier at home from this Health Journalism 2017 panel.
- This tip sheet looks at other innovations in Medicare programs to improve quality and reduce costs
- This article from The New York Times looks at health care systems around the world.
- This 2013 Washington Post article reports on another study which ranked the US eighth in the world in caring for our elderly. What’s changed in the past four years?
