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Satisfaction W ith H ealth System s In
en N ations
by R obert J. B lendon, R obert Leitm
D
Ian M
D
ataW
onelan
orrison, and K aren atch
A m id grow ing di ssa ti sfa ction w ith its
alth car e syst em , the U nited
States is incr easingly looking abroad for insights
nto health system
reform . In the Spring 1989 i ssu e of H ealt
A ffairs, an analysis of a three -
nation survey of ho w A m ericans, C ana dia
and Britons view ed the
per form ance of their health care sy stem s s
w ed that, of citizens of the
three countries, A m ericans expr essed the grea
t degree of di ssa tis fa c-
tion w ith their health system and C anadi
the least.1 In addition, only
A m ericans w ere so dissatisfied that they w
uld consider adopting the
type of health system found in another country.
he m ajority of the
pu blic (61 percent) stated they w ould pr efer the
anadian sy stem of
national health insu rance, in w hich _the gov
m ent pays m ost of the
cost of care for everyone out of taxes, and t
governm ent sets all fees
charged by doctors and hospitals_ to the curr
U .S. sy stem .
A num ber of questions w ere raised abo
the resu lts o f this survey,
including the follow ing. (1) W ere the fin
gs of this three -nation survey
repli cable across m ultiple surv eys and tim e p
ds, or w ere they a
onetim e, random result? (2) A re citizens
f oth er indu strialized cou ntries
as sati sfied w ith their governm ents_ nation
health plans as C anadians or
Britons ar e? M ight not other nations w ith
ealth system s si m ilar to these
ha ve popula tions that are di ssa tis fi ed w ith their
vernm ent -sponsored
program s? (3) W ere C a na dia ns_ fa vora ble
186H EA LT H A FFA IR S | Sum
er 1990
D ata and m ethods. T he data reported
e are derived prim arily from
three sources. T h e fir st i s a ten -nation survey c
duct ed in t w o tim e
periods by Louis H arris and A ssociates an
their interna tional a ffiliate s,
using the sam e research in stru m ent. T hes
findings are based on inter -
view s w ith scientifically selected sam pl es o
,250 respondent s in the
U nited Stat es, 1,026 in C anada, 1,669 in
reat Britain, 1,053 in W est
G erm any, 994 in A ustralia, 1,196 in Fra
, 500 in Sw eden, 1,434 in
Japan, 928 in Italy, and 1,000 in the N ethe
nds. T he A m eri can, C ana -
dian, and Briti sh survey s w er e conducted in
88 as part of our earlier
study conducted for T he Baxter Foundation, an
surv eys in the other
seven countries w ere conducted in 1990. D
ending on th e st andard of
surv ey practice in each country, som e of these n
onal surv eys w ere
conduct ed by tel ephone and other s as in -hom
interview s.
T he second source of data consists of tw
national opinion surveys on
health care conducted by the Los A ngeles T i
es and N BC : T he form er
w as conducted in 1990, involving telephone in
view s w ith 2,046 ran-
dom ly sel ected adult s, and the latter in 198
involving 2,019 adults. T he
third sour ce of data is a set of individual nati ona
pinion surveys
conduct ed betw een 1985 and 1989 by the G
lup survey organization on
general attitudes of C anadians and A m erica
Each survey involved a
random l y selected sam ple of at least 1 ,000
dults from each country.
W hen interpreting these findings, one shou
recognize that a ll public
58 63
58 68
56 65
D A T A W A T
H
W 1t
h i 8e 7 61 68
Bla ck 61 54
H ispan ic 62 57
Sources: R.J. Blendon and H . T aylor, _V iew on H ealth C
P l
Euxb h iicb iO p i n i o n i n T h r e e N a t i o n s , _ H e a l t h A f f a i r s
t 1
(Sp ring 1 9 8 9 ): 1 4 9_ 1 57 ; a nd Lo s A
Pr r o pno rt t i o n Oi t e d f S tA t e s , _ P o e lr i ncoa n g2e1l 2 P (rSet f eirrs r i nsg P o n l. ,: a H a d a atn
a e i he U n
m n s e s T o r m, e C l _
n eil h
1a l %
61 9 8 8 A 6 6 n d . 1 9 9 0
%
e a p e r C S ye s t e rm f o r . P u b l i c O p i n i o n R e s e a r c h , M
C on
Ro l th nt e a rc h 1990).
1988 1990
ref c a d
PL o we r i nC o m n a e i a n s y s t e m
pMce f ie rd e en cionucpo mo r e t h e
I nr o m d e g r e
l f anadian system C . A s
1 g, th
H9 8 i8 h i n c oe t
su pport for
m se r o n g e s t
Race
su ch a change w as found am ong m iddle -i nco
e A m ericans. T he one
di fference betw een the tw o studi es i s refle
d in the low er level of
su pport for su ch a change reported by m ino
groups in 1990.
In addition to the Los A ngeles T im es su rv e
N BC al so explored
w hether A m ericans now fa vored a n all -gov
m ent health insuran ce
system , a progra m that w ould be sim ilar
C anada_ s. In their surv ey,
condu ct ed in 1989, they ask ed w hether _you
ould favor a com prehen-
sive national health plan that w ould cover a
A m ericans and be paid for
by federal tax revenu es._ O nce again, the r
lts w ere sim ilar; 67 per cent
of th e publi c indicated su pport for th e enact m
ent of su ch a plan. N BC
also inquired about publi c attitudes tow ard the
anadian and Briti sh
health system s. T hey ask ed w hether the pub
thought the average
A m erican r eceived better m edical care t
citizens of these tw o coun -
tries,_ w her e governm ent paid for m o st hea
care costs._ O nly 27
percent thought A m ericans received better
re from their system . T he
rem aining 73 percent either believed there w a
o difference betw een
countri es (34 percent), believed A m erican s re
ved w orse-quality care
(12 per cent), or w ere unsure (27 percent). 4
Satisfaction w ith other health system s.
188H EA LT H A FFA IR S| Sum m
r 1990
of these nations spoke different languages and
presented varying histor -
ies and cultures. H ow ever, they had in com m
on the fact that each
cou ntry had established u niv ersal health insurance
verage for it s
population throu gh the fra m ew ork of either a
ial Security-like sys-
tem found in W est G er m any or a nati
al health service su ch as G reat
Britain_s. In a ddition, each nation had low e
ealth care cost s, both p er
capita and as a share of their econom y (gro
dom estic product, or G D P)
than either the U nited States or C anada. 5
A s show n in Exhibit 2, th e resu lt s o f t
ten -nation su rvey su ggest a
num ber of im portant findings. First, am o
the nations studied, C anadi-
ans w ere the m ost sati sfied w ith their curre
health care system and
A m ericans the least. T hi s latter di stinction
as shared only w ith the
Italians. O n both m easures u sed in this su
ey, tha t is, sa tis fa ction w ith
their current system or w anting their healt
care syst em rebuilt, A cri
me r e a p i-t a h e a l t h
P
cn t h n
c a n s r a M k ei n o r n i h a n g e saFnud d atm n te h t a aC o m n g l e t e l o e xep e n dai
n d e n l m o p thys n
(U .S.
s i d
n s a n at dua dn eeed .e d a c h a n g e s n e e d e d b r e b u i l d s y s t e m
C cd ol l
ee a6%
N T e t hh r l 5 nU s d e ta
n3 i8t% d S 5 % t e s$ 1 ,a4n d I t a l y , t h e c o u n t r i e s
83
t t 4 h er h 4 st 5
W h e sh e G 7 i gm e 6 n y l e v e l o f 1 , 0 4 1
it a
41 35 13 1,093
F n l 4a
p rua b c ei c d 4i 1s e n c h 2 n t m 1 0 e n t , 1 c1o u l d n o t d i f f e r m
, 05 ore
Ah e u srt r a l e a l t h 4 c a r e 4 3 r -
t i h ia 3 a 17 939
S a n d ee m 3 2 n t s . 5 8
r we g n e T h e6 U t3d
n1i, 2 e 3 S t a t e s h a s a p r i v a t e
Japan 29 47 6 915
c e r ic
b l i n i t p dl u K ianlgidsotm 2 7 h e a l5t2h
U 17 758
I ty l yt e m 1 2,
s as w 4 6h i l e 4 I t a l y 8h4a s a n a t i o n a l h e a l t h
0 1
U i cnei , e d o r gaa e s i1z e d
v o u r c et : H S ta r tv n r d -0H a r ro s0- I T a F , r 9 9 9i0 o n 2 , l0n5 1N a t i o n S u r v e y .
S a
6n
i
2e g
1 T
ae
b i h s a ve hs
a Oa s n st . e I t u rl y y , at l e oq uh s t i o n a w l i a s
e a s fa e
m w i to e dde d p arsi v o l tl o w ms : _e d i nc at
r O
h o l c ,t i t c e hse e lc h o cra r e osr s t eh o s e
r n l e m h ei n o r a ct h a n g e s a y e t nm c e s s a r yo r tkos m r e tatkye wi t ewl l , o a k d b e t t e r . _
o
ay t f r e
w p
r
n
dT ern a
b _ e s ihr i e g r e a s o m o e g o o d e t h i n g s
n n g o v r n m i n no t a l h e aal tl ht ec ra ne a t y svt e m ,I n u t 1f
e ur r si e. b
m An t a l mh a n ge r i a ra n nse e d s d et n t m $a2 e 0 i 5 1w
, e t tee r . _ c
b
es c e ep o k, t ork
c _ e r u r e e a l o n c a r eo r y s t e e a l thh s
pO p hr s th f s hm a c oa rme ; u c I t a l i ra ngs w s p te n itt t $ a8 4 w
s h w on i h h t
t om e el es) l
n e e d Uo c . S . p ld to l yl ar r b u i . d i t . _
in
Second, this i nternational survey show s tha
DATAWATCH 189
program doe s not in itself guarantee high level
f sa tis fa ction w ith a
nation_s health care system . In five countri
w ith national health plans_
A u stralia, Sw eden, Japan, G reat Britain,
nd Italy_m ore than six out o f
ten citizen s reported they de sired a fu nda m e
al change in their sy stem .
O nly in four countries_C anada, the N ether
ds, W est G erm any, and
France_did m ore than 40 percent of the populat
report relative
sa ti sfa ction w ith their current health car e a
ngem ents.
T hird, i f one excludes the U nited States
d Sw eden from the analysis,
the resu lts su ggest that am ong the nations
veyed, publi c satis fa ction i s
associated w ith higher level s of health care
pending per capita. T his m ay
be a reflection of the increased availabilit y o
m or e sophi sticated m edi cal
technologies, m ore choice of physicians, les
w aiting and travel tim e for
el ective and specialized m edical procedures,
d the age and m odernity
of hea lth ca re fa cilitie s. A m ong t he othe
ight cou ntries, C anadians ar e
m ost sati sfied and exp end the largest resour
s for health care ($1,483 per
capita); Italian s and Britons are the least sat
ied, expending the low est
am ounts ($841 and $758, respectively). 6 A si
ilar relationship can be
seen in the N etherland s, W est G er m a
and France, w hich have higher
lev els of pu blic satis fa ction a nd expend m or e t
Japan, A ustralia,
G reat Britain, and Italy for health services.
T he obvious outli er in thi s trend is the U
nited States. It has the highest
level of spending per person and reports the
w e st level of satis fa ction.
W hy citizens of Italy and Sw eden also expre
d less sa ti sfa ction w ith
190H EA LT H A FFA IR S | Sum
er 1990
seen in Exhibit 3, in data available for the p
decade, A m ericans have
been m or e optim i stic abou t their future, a
since 1985, as satisfied as
C anadians w ith the direction of their natio
s governm ent.7 T his sugg est s
that C anadian s_ view s on health care a re
being shaped solely by their
m or e positive general attitudes; rather, they are
ore sati sfied than
A m ericans specifically w ith their h ealth s
em .
Im plications For U .S. Policy
For the second tim e, the results from our
nternational survey s raise th e
sam e critical question: W hy are A m erica
so m uch m ore disaffected
w ith their health car e system than citizens
other industrialized coun-
tries? D raw ing on m yriad survey data fo
he U nited States, w e can offer
an inform ed speculation about the answ er. T
be conclusive, how ever,
w e w ould need com para tive re sponses from
e other nine countries
studied. In addition, m ore cross -national resear
s required on how
m uch variation exists in public expectations for
alth care am ong
i n d u s t r i a l i z e d P enr a e n to nws . h B assa e d t h o y a a e rs e t i is e i wd
c
ti o y e
n r a
v f e of
rrent U s u es e
. S . 1 9t 8 5d i 1 9 8, 6 w1 9 8 7 o f f e r
1988 1989
the follow i n 5g1 %p4r7e l 4i 5m
% % i n5 a r y 5 c o n c l u s i o n s .
6%5 %
C o s t a n d 3 9 u a3l8i t y 4 2i s s_ u e s . 4 1 A
q a m ericans_ h
tve t
O lpe i m l i so ifc c b o u t
h aom parative dissatis-
com ing year Percent w ho s ay nex t year w ill he
a
fr c t i o n i s n ot r el a t e d t o t w
e o areas that ofte
Ar o m b lee i c a n s . S . 6h e a l4 t% 5 3 % 6 1l% c 9 %
t u r U 1%6 h po i4y
C n aa l y d ita s .s F o r 4 e x a m 3 p l4e6,
a o u r cnea: s T n h e G a l l 4 p P o5l l ( S t o r r s , tCh 7o n np uRb l i rc C i se n t nro t o r vPe r
S u
4e
:
36
ope e f ub
c p ni ed rh , n 1 ue n c 9 t o 8
O o n ic eorn n R e s e a t c h a t t r e 1 d s dp r i r g e1 n 8 5 _ 1 9f 9 ) ;
a nrd o s s a ln ua t iCo naa a d a ,p r o pd u lc sth e d( G a t a , N1 9 8 8 _ ) 9 8 i .s
gN oG a v a li l apb l e . n l
a t
un ub i d P1 9 too m uc
or the U nited States to spend
on health care. A d ecade of su rvey results
w that no m or e than 10
DATAWATCH 191
percent) responded positively.9
Sim ilarly, A m ericans show little dissati
ction w ith the health care
they receive fro m their doctors and hospital
O nce again, m ultiple years
of survey results show little public anxi ety ove
he quality of health
s e r vi c e s a va i l a b l e. 10 I n 1 9 9 0 , o n l y 6 p er c e n t
the public reported the
quality of m edical care they received w as
ot adequate, w hile 93 percent
responded they consider ed their car e to be of
o o d q u a l i t y . 11
Inadequate insurance protection. W e conclu
that A m erican dis -
sa ti sfa ction ari se s from the int eraction betw
en our sharply rising health
care co st s and the inadequate financial protec
n provided by our health
in surance sy stem . U nlike those of C anad
W est G erm any, or the N eth-
erlands, the U .S. system provides little gu ar
ee of continuing health
in surance coverage to alm ost any individual.
1989 survey by the U .S.
C en su s Bureau portray s th e i m plications o
hi s. In a tw enty-eight-m onth
period, m ore than one A m erican in fou
28 percent) r eported they w ere
w ithout health in surance cov erage for som
period of tim e . 12 T his phe-
nom enon is alm ost nonexistent in these ot
nations.
Sim ilarly, A m ericans have no guarantee t
their em ployer w ill not
decide to reduce the breadth of their health
urance bene fits w hen they
m ay be m ost needed. A s w ith M edi
e, the scope of bene fits covered in
other cou ntries_ national health plans are sub
t to broad scrutiny, and
m ajor changes require a w idespread nation
or regional debate. In this
country, individual em ployer s, parti cularly i n n
unionized firm s, see
192H EA LT H A FFA IR S | Sum
er 1990
cou ntry does not necessarily r efle ct A m erican
der standing o f the
nature of C anada_s national health program
R ather, thi s response indi -
cates the high level of public frustration w
our current health fina nc -
ing arrangem ents. A s a final exam pl e, a r
nt study reported that 57
percent of A m ericans w ho had som eon
n their fam ily needing m edi cal
care reported som e problem s in paying for i
for 25 percent, these
paym e n t s ca u s e d f i na n ci a l di f f i cu l t i e s . 17 W e
onjecture that A m ericans
perceive that C anadians w ould have respond
di fferently.
N O T ES
1. R .J. Blendon and H . T aylor, _V iew s on H
lth C are: Public O pinion in T hree N ations,_
H ealth A ffairs (Spring 1989): 149_157; and R .J.
endon, _T hree S ystem s: A C om para-
t i ve S u r ve y, _ H ealth M anagem ent Q uarterly 1
First Q uarter 1989): 2_10.
2. Los A n geles T im es Poll, _H ealth C are in
U nited States,_ Poll no. 212 (Storrs, C onn.:
R oper C enter for Public O pinion R esearch, M
ch 1990).
3. T he italicized segm ent of the question w ordin
not technically accurate. Because 59
p e r c e n t o f a l l h e a l t h e x p e n d i t u r e s a r e p a i d f o r p r i va t
in the U nited States, taxpayers
in C anada pay m ore directly than A m ericans,
n though their total per person
outlays are low er. See S.W . Letsch, K .R . Le
and D .R . W aldo, _N ational H ealth
Expenditures, 1987,_ H ealth C are Financing Revie
10 (W inter 1988): 109_122.
4. N BC N ew s Poll (Storrs, C onn.: R oper C
er for Public O pinion R esearch, 1_25 A pril
1989).
5. G .J. Schieber, Financing and D elivering H ealth
are: A C om parative A nalysis of O EC D
C ountries (Paris: O rganization for E cono m ic C
eration and D evelopm ent, 1987), 11_
30; and G .J. Schieber and J.P. Poullier, _O ve r vi e
