The Paradox of Americans' Views of Their Healthcare System

The United States spends more on healthcare than any other high-income nation, but studies have shown that for decades, Americans have been less satisfied with their healthcare system than people in other countries. A new study in Health Affairs suggests that the main reason for this dissatisfaction is concern and uncertainty about being able to access “most preferred care”—that is, insecurity about the ability to get the best treatment available and being seen by the doctors they want to see when they are seriously ill.

The study, by researchers at Harvard and the Massachusetts Institute of Technology, is an international comparison that seeks to understand the factors that contribute to Americans’ dissatisfaction with their healthcare system.

Policy makers and researchers have regarded Americans’ perceptions of their healthcare system as paradoxical because in European countries, satisfaction with the healthcare system is strongly correlated with per-capita expenditures. But this is not the situation in the United States, where per-capita expenditures are high compared with those in Europe. Second, low satisfaction with the US healthcare system overall is in contrast with the fact that Americans typically cite their own healthcare arrangements as being highly satisfying, and of high quality.

The authors stated that Americans’ distinctive cultural values, wide variations in insurance coverage, and high out-of-pocket expenses may affect how they evaluate their health system. Fragmented insurance and delivery systems in the United States may lead to wider diversity in healthcare experiences and perceptions than in other countries, where healthcare systems are more centralized and uniform.

The researchers analyzed data from the International Social Survey Programme, a cross-national collaboration that fields annual surveys on topics important to social science research. The surveys focused on barriers to access, access to most-preferred care, and satisfaction with recent healthcare experiences in 17 high-income countries from 2011 to 2013.

The investigators conclude that security in accessing most-preferred care was more important in explaining overall satisfaction in the United States than in other countries, while satisfaction with recent healthcare experiences was less important. In most other countries, most recent healthcare experience was the most important predictor of overall satisfaction.

“The patchwork of public and private sources of insurance and the wide variation in insurance generosity [not being restricted] in the private market create large differences in the comprehensiveness of coverage among the insured,” the authors wrote. “It is perhaps because of this that access to most-preferred care remained the top predictor of system satisfaction, even among Americans with insurance.”

The researchers suggest that with the passage of the Affordable Care Act and subsequent reductions in the uninsured population, and the movement toward minimum health plan standards, some concerns about access to preferred care may begin to be addressed. But the researchers raise the possibility of public backlash as market forces push plans toward more restricted access and higher cost sharing.