Cost barriers reduce confidence in receiving medical care when seriously ill


People need to trust that necessary care will be provided in the case of serious illness or injury, but negative experiences with the healthcare system reduce confidence. In this article, we discuss the effect of cost barriers on people’s confidence in receiving safe and quality medical care when falling seriously ill in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom and the United States.

Trust, which according to Mechanic, is ‘the expectation that individuals and institutions will meet their responsibilities to us’ (1), has been analysed from different perspectives. Authors have, for instance, studied trust in one’s own medical doctor (2), patient preferences (3) and satisfaction with the healthcare system (4,5). The question of confidence in receiving safe and quality medical care when falling seriously ill, in contrast, has been neglected in previous comparative research (6). We expect that this ‘feeling of security’ is influenced by past experiences with the healthcare system, and we therefore ask in what respect negative experiences influence confidence in the healthcare system.

The analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007 (6). Negative experiences are captured by the question: ‘During the past 12 months, was there a time when you had a medical problem but did not visit a doctor because of cost?’ The lack of confidence in receiving good medical care in the future is measured by the question: ‘How confident are you that if you become seriously ill, you will get quality and safe medical care?’ In our analysis, we focused on those respondents who reported to be ‘not very’ or ‘not at all confident’. We conducted pairwise comparisons of group percentages using the Scheffe method (7) for the dependent variable (confidence).

In the US, 25% of respondents have experienced cost barriers, 20% in New Zealand, more than 13% in Australia and 12% Germany. In the Netherlands, the UK and Canada, only a small minority of the population has had the experience of not going to the doctor because of costs (Figure 1). When discussing the impact of cost barriers on confidence in receiving medical care, the very low number of individuals facing cost barriers in the latter three countries must be taken into account.

Figure 1.

 Experience of not going to the doctor because of costs, 2007. Source: Wendt et al. (6)

Women are less confident than men in their ability to receive safe and quality healthcare when ill in Germany, the UK, Australia and Canada. Education matters in the US, Australia, New Zealand and Canada, with groups with lower education being less confident. In all countries, people with below-average incomes are less confident in receiving good medical care than are those with above-average incomes (Figure 2). Being in poor health significantly reduces confidence. In Germany, New Zealand, the UK and the US, about 40% of those who consider their own health to be fair or poor are either not very or not at all confident that they will receive safe and quality medical care when seriously ill. The gap between groups with better and poorer health is greatest in the US (22 percentage points), followed by New Zealand (20), Australia (18) and the UK (17). In most countries, the experience of cost barriers has the strongest negative effect on confidence in the healthcare system. In the US, the gap between patients with and without the experience of cost barriers is almost 30 percentage points. This gap is also high in the UK and in Canada (in both countries, however, cost barriers play a minor role). In Germany, the gap between patients with and without the experience of cost barriers amounts to 17 percentage points. Among those who experienced difficulties related to costs for taking up necessary healthcare services, confidence in receiving safe and quality medical care is lower (Figure 2).

Figure 2.

 Differences in the lack of confidence in receiving medical care, 2007. Source: Authors’ calculations using the 2007 Commonwealth Fund International Health Policy Survey (6). Data weighted. Only significant group differences shown (*p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001)

The bivariate results were generally confirmed in logistic regressions that included gender, age, income, education, health status and the experience of cost barriers (not shown; see ref. 6). Although gender (except in Canada and Germany) and education (except in the US) seem to be of lesser importance, income still matters after controlling for other factors (in Canada, Germany and the UK). In addition to poor health, the experience of not going to the doctor has a strong negative effect on confidence in the overall system’s capacity to deliver health care services when necessary (not significant in Australia and the Netherlands).

The data show major disparities among social groups in all included countries regarding the confidence in receiving medical care when in need. Given the high emphasis of equality, particularly in the British NHS, these differences in confidence require further elaboration. Even if only a few patients in the British NHS have experienced cost barriers at all, those who have had this negative experience have less trust in future healthcare provision. Furthermore, poor health and low income reduce confidence not only in countries with serious access barriers, such as the US but also in countries where access to acute care is free, such as the British NHS.

The findings do not provide direct lessons as to how the disparities among education and health groups could be reduced; however, the fact that the experience of financial barriers considerably lowers confidence has important health policy implications.

Although those who did not go to the doctor because of costs have less confidence in all countries, we could show that not only in the UK but also in the Netherlands only a few people have experienced cost barriers. This phenomenon could be partly related to the fact that visits to a doctor are free and that other private out-of-pocket payments have also been particularly low for many years in both countries while remaining at a high level in the US, Australia and New Zealand. The type of co-payment, as well as the time of the introduction of co-payments, also plays a role in establishing cost barriers. In Germany, for instance, a payment of ten Euros per quarter for a doctor’s visit was introduced in 2004. This fee seems to have a stronger impact on patients’ decision to not see a doctor, as patients can be sure that these costs will apply as soon as they visit a doctor (in contrast, for instance, to co-payments for pharmaceuticals).

The trend towards increased cost-sharing for patients in healthcare systems therefore has more unintended consequences than previously realised. Beside the risk of an increased burden on low-income groups and those with a lower health status, experienced cost barriers also affect trust in the healthcare system. As trust is not only important for the legitimacy of the healthcare system but also for treatment outcomes, we suggest that policy makers consider the negative impact on trust when dealing with cost-sharing instruments. Guaranteeing access to necessary healthcare services for those who fall seriously ill can be considered the single most important task of healthcare systems in modern societies, and patients therefore need ‘markers of certainty’ (8), which indicate that this promise will be fulfilled. Being able to go to a doctor with a minor symptom seems to represent such a ‘marker of certainty’, indicating that quality healthcare will be provided when facing a serious disease.




The research reported here has received financial support from the Harkness Program of Health Policy & Practice of the Commonwealth Fund and the Bosch Foundation.