How the U.S. Single-Payer System for Seniors’ Health Compares Internationally

By John R. Graham,

The Commonwealth Fund has published another survey of health care across countries. The Commonwealth Fund’s widely reported surveys, while thorough, are frustrating because they invoke abstractions (for example “universal health insurance coverage“) to explain why the U.S. health system underperforms.

The latest survey should be able to get around this problem because it surveys only people aged 65 years and older in 11 developed countries. Because almost all American seniors are on Medicare — a single-payer, government-run program that is mostly funded by taxpayers — we might expect the Commonwealth Fund to find that the U.S performs about as well as other countries.

No such luck. Kaiser Health News featured the survey’s conclusions about the challenges American seniors have, relative to their peers in other countries, in getting access to care:

Americans older than 65 are more likely to have chronic illnesses and to say they struggle to afford health care — despite qualifying for the federal Medicare program — than are seniors in other industrialized countries, according to a study by the Commonwealth Fund published Wednesday in the journal Health Affairs.

The media often manage to pluck criticisms of U.S. health care out of the Commonwealth Fund surveys that are not quite as straightforward in the reports themselves as they appear in the stories about the reports. This case is no exception.

Let’s look, for example, at the excess of chronic conditions among U.S. seniors. According the survey, 68 percent of American seniors had two or more self-reported chronic conditions (including hypertension or high blood pressure, heart disease, diabetes, lung problems, mental health problems, cancer and joint pain/arthritis). Only 44 percent of Swiss seniors had two or more chronic conditions.

However, the presence of chronic conditions is more of an input into health-system performance, rather than an output. It helps explain why 25 percent of U.S. seniors saw two or more physicians in one year, versus only 8 percent of Swiss, and why 53 percent of U.S. seniors took four or more prescriptions, versus only 29 percent of Swiss. Despite being sicker and seeing more doctors that their Swiss peers, U.S. seniors were less likely to be hospitalized overnight in the previous two years: 29 percent versus 32 percent. That is an indicator of relatively good U.S. performance.

With respect to U.S. seniors’ “struggle” to pay for care, this observation invites more questions than it answers. About 21 percent of U.S. seniors had out-of-pocket medical expenses of at least $2,000 in the previous year. However, 22 percent of Swiss also spent at least $2,000. And yet, 11 percent of U.S. seniors reported that they had problems paying or were unable to pay medical bills, versus only 2 percent of Swiss!

The United States and Switzerland have similar incomes. So, how is it that Swiss seniors are so much more able to spend at least $2,000 on medical expenses than U.S. seniors are? One answer may be that traditional Medicare has no out-of-pocket maximum, and 17 percent of Medicare beneficiaries do not have supplemental coverage that caps their potentially unlimited liability. Swiss patients do not bear this risk.

Also, Swiss patients are not forced to channel almost all their health spending through insurers. In 2006, 30.3 percent of Swiss health spending was controlled directly by patients, versus only 12.8 percent in the United States. So, Swiss of working age are more used to spending directly on health care than their American peers are. Perhaps this prepares them to be more prudent about preparing for potentially significant out-of-pocket costs when they retire.

More From NCPA: