The Commonwealth Fund 2016 International Health Policy Survey

The Commonwealth Fund 2016 International Health Policy Survey of Adults in 11 Countries Population health challenges and health system capacity to meet patients’ needs Michelle Mc. Evoy Doty VP, Survey Research and Evaluation

Overview: 2016 International Health Policy Survey • Surveyed adults ages 18 and older in 11 countries about their experiences • For the first time, we measured prevalence of material hardship • We also analyzed experiences of low-income adults to shed light on how well health systems respond to the needs of their most complex and socially vulnerable • Today, we’ll consider the implications of study findings in light of recent policy debates on reforming the U. S. health system 2016 International Health Policy Survey Webinar 2

Snapshots of Population Health In comparison to adults in 10 other countries, adults in the U. S. are sicker, more economically disadvantaged. 2016 International Health Policy Survey Webinar 3

Snapshot of Population Health Challenges Multiple chronic conditions* Experiencing emotional distress in past year they couldn’t cope with alone Unable to do daily activities or work fulltime because of health AUS 15 20 12 CAN 22 27 20 FRA 18 12 24 GER 17 7 15 NETH 14 19 19 NZ 16 21 15 NOR 16 20 23 SWE 18 24 22 SWIZ 15 21 13 UK 14 17 15 US 28 26 21 Percent of adults reporting: * Chronic conditions asked about were: 1) joint pain or arthritis; 2) asthma or chronic lung disease; 3) diabetes; 4) heart disease; 5) hypertension.

Material Hardship: One in five adults in the U. S. report they are usually stressed about being able to pay rent/mortgage or buy nutritious meals Percent Source: 2016 Commonwealth Fund International Health Policy Survey

Financial Barriers and Access to Care Despite progress since passage of the Affordable Care Act, U. S. remains an outlier on providing affordable access to care 2016 International Health Policy Survey Webinar 6

U. S. adults are more likely than those in other high -income countries to skip needed care because of the cost Percent reporting financial barriers to health care *Had a medical problem but did not visit doctor; skipped medical test, treatment or follow up recommended by doctor; and/or did not fill prescription or skipped doses Source: 2016 Commonwealth Fund International Health Policy Survey

More than four in ten U. S. adults are not able to get timely access to care when they need it Percent did not see doctor or nurse on same/next day last time they needed care Base: Excludes adults who did not need to make an appointment to see a doctor or nurse Source: 2016 Commonwealth Fund International Health Policy Survey

Half of U. S. adults struggle to get after-hours care without going to an emergency department Percent who said it was somewhat or very difficult to get after-hours care without going to the emergency department * Base: Excludes adults who did not need after-hours care Source: 2016 Commonwealth Fund International Health Policy Survey

One third of adults in the U. S. used the Emergency Department in the past two years Percent reporting they used the ED in past two years Source: 2016 Commonwealth Fund International Health Policy Survey

The U. S. performs comparatively well in timely access to specialists Percent waited two months or longer for specialist appointment Base: Saw or needed to see specialist in past 2 years Source: 2016 Commonwealth Fund International Health Policy Survey

Over one third of adults in the U. S. experienced a problem with care coordination Percent reporting a coordination problem* in past two years * Test results or records not available at appointment or duplicate tests ordered, specialist lacked medical history or regular doctor not informed about specialist care, or received conflicting information from different doctors or health care professionals. Source: 2016 Commonwealth Fund International Health Policy Survey

Health Care Experiences For Adults with Low Incomes As U. S. policymakers debate cutting Medicaid budgets and repealing provisions of the ACA that expanded insurance to low-income adults, it is important to look at key indicators of access and ask, “How well do lowincome adults fare in the U. S. ? How can the U. S. improve? ” 2016 International Health Policy Survey Webinar 13

In almost all countries, low-income adults are more likely than other adults to report having multiple chronic conditions Percent of low-income adults reporting multiple chronic conditions Low-income adults All other adults Chronic conditions asked about were: 1) joint pain or arthritis; 2) asthma or chronic lung disease; 3) diabetes; 4) heart disease; 5) hypertension. *Indicates differences are significant at p<0. 05. Note: “Low income” defined as household income less than 50% the country median. Sample sizes are small (n<100) in the Netherlands and UK. Source: 2016 Commonwealth Fund International Health Policy Survey

Low-income adults in the U. S. are most likely to report financial barriers to health care Percent of low income adults reporting financial barriers to health care Low income adults All other adults *Indicates differences are significant at p<0. 05. Note: “Low income” defined as household income less than 50% the country median. Sample sizes are small (n<100) in the Netherlands and UK. Source: 2016 Commonwealth Fund International Health Policy Survey

In almost half of the countries, low-income adults report longer waits for health care than the rest of the population Percent of low income adults reporting waiting 6 or more days to see Low income adults a doctor or a nurse All other adults *Indicates differences are significant at p<0. 05. Note: “Low income” defined as household income less than 50% the country median. Sample sizes are small (n<100) in the Netherlands and UK. Source: 2016 Commonwealth Fund International Health Policy Survey

In the U. S. , nearly half of low-income adults have used the ED in the past 2 years Percent of low-income adults reporting using the ED in the past 2 years Low-income adults All other adults *Indicates differences are significant at p<0. 05. Note: “Low income” defined as household income less than 50% the country median. Sample sizes are small (n<100) in the Netherlands and UK. Source: 2016 Commonwealth Fund International Health Policy Survey

Health reform in the U. S. –What are the implications for the most vulnerable? • Low-income adults in U. S. are more likely than other adults to report health problems and material hardship • Many report financial barriers to care, long waits to see providers, and ED use • The Affordable Care Act dramatically reduced the number of uninsured (particularly low-income adults) but we are a long way from universal coverage • AHCA bill passed in House would make health care for low-income adults even less affordable and harder to obtain: • Millions more uninsured • ACA’s Medicaid expansion would be phased out • Federal payments to states for their Medicaid programs would be capped • People with health problems could find it difficult to find affordable coverage, depending on what state they live in 2016 International Health Policy Survey Webinar 18

Health Care Spending as a Percentage of GDP, 1980– 2014 Percent GDP refers to gross domestic product. Source: OECD Health Data 2016. Note: Data is for current spending only, and excludes spending on capital formation of health care providers.

Takeaway Messages • Despite the U. S. ’s heavy investment in health care, in comparison to adults in 10 other countries, U. S. adults are sicker, more economically disadvantaged. • Adults in the U. S. remain an outlier in experiencing financial barriers to care • Lack of universal coverage • Coverage is more financially protective in other countries • Prices for health care tend to be significantly higher in the U. S. than in other countries. • Closing the gap with other higher-income countries will require building on our progress, not reversing it. 2016 International Health Policy Survey Webinar 20

About the Study: • 19 th survey in the series • Survey conducted by SSRS and other country partners • Nationally representative survey of adults ages 18+ • Field period was March to June 2016 • Conducted by telephone (cell and landline) • Common questionnaire developed, translated, pretested • Interviews lasted from average 17 minutes (in UK) to 25 minutes (in France) • Response rate varied from 11 percent (Norway) to 47 percent (Switzerland) 2016 International Health Policy Survey Webinar 21

Sample Sizes: Australia 5, 248 Germany 1, 000 Norway 1, 093 U. K. 1, 000 Canada 4, 547 Netherlands 1, 227 Sweden 7, 124 U. S. 2, 001 France 1, 103 New Zealand 1, 000 Switzerland 1, 520 2016 International Health Policy Survey Webinar 22

Acknowledgements With thanks to Robin Osborn, David Squires, Dana Sarnak, Eric Schneider, and Arnav Shah – and to the team at SSRS, led by Robyn Rapoport For more information, please contact me at mmd@cmwf. org 23