Whenever international comparisons are made on quality metrics, inevitably someone complains that the results are invalid because it's impossible to standardize quality across different systems. Those people are not entirely wrong. It is hard to make sure that you are measuring the exact same thing in different countries. That's why it's important to use a variety of metrics, and to acknowledge the limitations in any study and any comparison.
That said, it's sometimes easier to standardize metrics of access. Asking patients the same questions in different countries can lead to useful and valid information about how easy it is to obtain care when you need it. This topic was the focus of a recent Perspectives piece in the New England Journal of Medicine, entitled "Equitable Access to Care — How the United States Ranks Internationally".
It should come as no surprise to anyone who hears the rhetoric surrounding health care reform that more people in Canada wait a week or more to see a doctor than do so here in the United States. More people also wait that long in Norway than here. But more than one quarter of Americans need to wait that long to see a doctor, which is more than in Australia, France, Germany, the Netherlands, New Zealand, Sweden, and the United Kingdom.
Fewer Americans report that it is easy to obtain after-hours care than all of those countries except Canada, France, and Sweden. Physicians are less likely to report that they have an arrangement for after hours care in the United States than any of those countries, period.
But one of the most stunning metrics, and one that I use in almost all talks I give on the subject is this: It's not just the poorer half of Americans who have problems obtaining care. Even the wealthier do.
In Table 1 of this perspectives piece, the authors note the percentage of people with below average income who experienced barriers to care. For instance, 39% of people with below average incomes report that they did not visit a doctor because of cost in the last year. The next two lowest countries were New Zealand, with 23%, and the Netherlands, with 16%. About 31% of below-average income Americans didn't get a recommended test, treatment, or follow-up because of cost, and 30% didn't fill a prescription or skipped doses because of cost. In all of these, the United States was clearly worse than all the other countries.
But in Table 2, the authors look at people with above average income. In the United States, 17% of people with above average incomes report that they did not visit a doctor because of cost in the last year, compared with an average 5% in the other ten countries. In the United States, 11% of above-average income Americans didn't get a recommended test, treatment, or follow-up because of cost (average 3.4% for the other countries), and 12% didn't fill a prescription or skipped doses because of cost (5.7% for the other countries).
In the following chart, I've used slightly older data to give you a better picture of this. I've graphed the percentage of people in each country who report having encountered at least one of these barriers in accessing care. The blue bars are the wealthier half of each country, and the green bars are the poorer half of each country.
What's striking is that a larger percentage of the richer half of America is more likely to avoid care because of cost than the poorer half of almost every other country. Cost is an issue not just for people with below average incomes - it's an issue in the United States for people with above average incomes.
It's still too early to tell whether the ACA will change any of this. Surely insurance coverage will make it easier for some people to acces the health care system who could not before. But many barriers, including increased cost sharing and high prices, still exist. Only time will tell whether our efforts at health care reform will change some of these metrics.