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BMJ. 2007 November 10; 335(7627): 956.
PMCID: PMC2071992

US has highest dissatisfaction with health care

The United States is the nation most dissatisfied with its healthcare system, while the Dutch are the most satisfied, an international survey has found.

The study, of 12 000 adults in seven industrialised countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), was conducted by the US health policy charity the Commonwealth Fund (Health Affairs 2007;26:w717-34 doi: 10.1377/hlthaff.26.6.w717). The results were released last week at a news conference in Washington, DC, that involved a panel of health ministers and other representatives from several of the countries.

Just 16% of respondents in the US said that minor changes in health care are needed, while 34% said the system needed to be rebuilt completely. Among Dutch respondents 42% said that minor changes in health care are needed and only 9% thought that the system needed to be rebuilt completely. About a quarter of respondents in the four British Commonwealth countries thought their systems needed only minor tinkering; large majorities thought they needed fundamental changes or complete rebuilding. In the UK 26% said that the healthcare system needed only minor changes, 57% said fundamental changes were needed, and 15% said the system needed complete rebuilding.

“On out of pocket costs, the US is again an outlier, with almost a third reporting paying $1000 [£480; €690] or more each year,” said Cathy Schoen, one of the authors of the study. Americans with health insurance often have a high deductible threshold before coverage begins, or they must make a co-payment for visits to doctors or for prescriptions.

Ms Schoen said that, across all the countries, participants who had a “medical home” (a family doctor they use regularly) were the “least likely to report problems of coordination of care.” The study found that in all the countries about a third of the patients reported that information arising from their visits to emergency departments or from stays in hospital was not reported back to the medical home.

Health ministers participating in the news conference agreed that primary care doctors had a key role in the coordination of patients' care. Until recently the trend in medical training had been towards greater specialised training, not general practice.

The UK health minister Dawn Primarolo said that GPs' training had been revised and enhanced, the number of NHS positions had been increased, particularly in deprived areas, and payments to GPs had risen. She said, “[The role of the GP] has become very much more valued, it has much higher recognition, and it is a very good career to follow.”

The German federal health minister Ulla Schmidt said, “I think problems arise when there is a compulsory approach [patients having to go through a GP to see a specialist].” The German government has tried to use incentives in the insurance payment system to encourage patients to use the coordinating services of primary care rather than going directly to a specialist, and there is some indication that the approach is working.

The panel's moderator, Julian Le Grand, professor of social policy at the London School of Economics and Political Science, noted the paradox that the US healthcare system is often criticised while aspects of it are held up as positive examples to emulate. He asked the ministers to comment on the strengths of the systems in the US and their own countries in delivering care.

Ms Schmidt said that there was no single US system and that it was very fragmented, with extremes of good and bad. She praised its spirit of innovation, investment in research and development, and the rapid translation of findings into practice. Ms Primarolo praised US innovation and UK universality.


Articles from The BMJ are provided here courtesy of BMJ Publishing Group