Part of the Political Issues and Policies Special Report
The American public really likes Medicare: in a Harvard School of Public Health survey, 72 percent had a favorable opinion of the federal health program for people 65+ and 54 percent in a Kaiser Family Foundation poll said Medicare is “working well for most seniors.” But a new, bubble-bursting 11-country survey finds that, in reality, Medicare pales against many other nations that also have universal health coverage for their older populations.
More precisely, according to the Commonwealth Fund’s 20thInternational Health Policy Survey, the health and well-being of many of those in Medicare is generally worse than for people over 65 in the 10 other countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom). The headline for the survey, just published in Health Affairs: Adults 65 and older in the U.S. are sicker than those of a similar age in other countries with universal health coverage and are more likely to go without needed care because of costs.
Dissatisfaction Among High-Need People Around the World
Lest you think health care is stellar in the other nations surveyed, however, there’s this: across all 11, many “high-need” people 65+ (those with multiple chronic conditions and/or trouble with the basic activities of daily living) expressed dissatisfaction with the quality of health care they’d received.
The U.S. has a significantly higher rate of high-need older adults (43 percent) than most of those other countries, however. And, the researchers said, high-need elderly are more likely to suffer economic hardship, experience depression and anxiety, live alone and feel socially isolated and be at greater risk for falls than those who aren’t high need. America also has the highest proportion of people 65+ with multiple chronic conditions.
More Financial Barriers for Older Americans
“U.S. seniors face more financial barriers to care than those in other countries and are, in effect, hit with a triple whammy — higher health care costs, higher out-of-pocket costs and because the U.S. doesn’t invest heavily in social services, they are more likely to struggle to have their basic needs met,” said Robin Osborn, lead author of the study and vice president and director of the International Program in Health Policy and Practice Innovations at The Commonwealth Fund, a private foundation studying America’s health care system.
Said Commonwealth Funds President Dr. David Blumenthal: “Clearly there are struggles everywhere, but here in the U.S., we are hearing loud and clear that many of our seniors, especially those who are sickest, need more support if they are going to get the health care they need and live healthy lives.” The United States, the researchers noted, has disproportionately low spending on social care services, compared to health services. While some countries spend $2 on social services for every dollar on health care, the U.S. spends less than 60 cents.
One caveat about the survey: older adults living in nursing homes and other facilities weren’t sampled.
The Survey’s Key Findings on Medicare vs. Other Countries
Now to some of the key findings in the survey, the Commonwealth Fund’s first one looking at the experiences of high-need older adults. “The real test of a health care system is how well it performs for patients with the greatest need,” said Osborn. And, she added, “our focus on the high-need elderly brought into sharp relief the extent to which they were exposed to financial barriers when it came to care.”
Here’s how America’s Medicare system performs against the other 10 nations:
41 percent of Americans 65+ said it was somewhat difficult to get after-hours care. While that was better than the 64 percent of Swedes who had this complaint, it was much worse than in the Netherlands and Norway, where under 30 percent had problems getting after-hours care.
31 percent of Americans age 65+ who are high-need skipped medical care because of their costs. That’s more than 15 times the rate in Sweden. Older Americans have comparatively high out-of-pocket expenses in Medicare, with co-payments, deductibles and premiums and bills for prescription drugs. Also, Medicare doesn’t cover certain expensive health costs such as hearing aids. In Canada, the Netherlands and the United Kingdom, there are no deductibles or cost sharing for primary care. France exempts people from cost sharing for primary care and prescription drugs if they have any of 32 chronic conditions.
25 percent of Americans 65+ said they were often worried about having enough money to buy nutritious meals and pay for housing, utilities or medical needs. In France, the Netherlands, New Zealand, Norway, Switzerland, Sweden and the U.K., only 10 percent or less had similar concerns.
24 percent of Americans 65+ who needed help with activities of daily living (like eating and dressing) said they didn’t get the help they needed because of costs. That was the highest of all countries surveyed. Just 6 percent or less in Sweden, France, the Netherlands and the U.K. said they didn’t get this kind of help due to costs.
Citing costs, in the past year, 23 percent of Americans 65+ either didn’t go to the doctor when they were sick, didn’t fill a prescription or skipped a dose or didn’t get a recommended test or medical treatment. America ranked worst on this measure. By contrast, no more than 5 percent of people 65+ in France, Norway, Sweden and the U.K. skipped needed care because of costs. (This statistic is shown in the graphic in the article, where figures are percentages.)
22 percent of Americans 65+ spent $2000 or more out-of-pocket for health care in the past year. In every other country surveyed other than Switzerland (31 percent), fewer than 10 percent of residents 65+ spent $2,000 or more.
15 percent of Americans 65+ reported going to the emergency room for a condition that could have been treated by a regular doctor or place of care had one been available — the highest of all nations in the survey. Rates of avoidable ER visits were 8 percent or below in all the other countries surveyed except Canada (11 percent). “Going to the emergency room, particularly for the elderly, will increase the fragmentation of care,” said Osborn. “These patients probably won’t have their health records, so they’ll be repeating tests. And they may not remember what happened in the ER when they do go to their doctor.”
Older adults in the U.S. — as well as in Canada and the U.K. — were the most likely to say they didn’t always or often hear from their regular doctor on the same day when they contacted the physician with a medical concern. But truly long waiting times to see a doctor when sick were most prevalent in Germany, Canada, Sweden and Norway; there, 26 to 34 percent said they had to wait six or more days for an appointment in the past year (18 percent of Americans said this).
All told, Blumenthal said, as a nation, “we are a little complacent about the value and benefits of Medicare.”
The Silver Lining for Medicare Beneficiaries
Where America’s health system for its older Americans shined in the survey, however, was on prevention and staying healthy.
More than half (53 percent) of Americans 65+ with a regular doctor or place of care said their physician talked to them about exercise and healthy eating — the highest of all nations. Similarly, 63 percent of Americans 65+ who felt they are at risk for falls said their doctor discussed falls with them, a higher rate than all the other countries except France (65 percent) and Australia (tied with the U.S. at 63 percent).
But “across all countries, most survey respondents said their physicians were not engaged with them in conversations about mental health,” said Osborn. “That’s a missed opportunity. Depression when coupled with other chronic conditions can increase costs 50 percent or more.”
When asked about pending legislation that could help Medicare beneficiaries in a significant way, Blumenthal pointed to the bipartisan-sponsored CHRONIC Act (Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care). “It would support chronic care to a greater extent than current Medicare,” he noted. For example, the bill would extend the federal Independence at Home program for the chronically ill who are homebound and offer more flexibility for nontraditional, nonmedical services for Medicare Advantage plans.
A final thought: No one country performed the best on all measures in the Commonwealth Fund survey. “So every country can learn from the others,” said Osborn.