The percentage of Americans who reported cost-related barriers to health care dropped from 37 percent in 2013 to 33 percent in 2016 — a change that directly corresponds to insurance expansions under the Affordable Care Act, a new study reports. On the flip side, Americans are still more likely than peers in other high-income nations to face financial obstacles to health care.

The study is based on findings from a survey of patients and providers in 11 countries and one that the Commonwealth Fund has been conducting annually since 1998. Those 11 countries are: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the U.S. The survey typically focuses on the experiences of patients and providers; however, this year the survey also collected data on self-reported health and well-being as well as material hardship, which is a significant contributor to a person’s physical and mental health status. Here’s what the study, which was recently published in the journal Health Affairs, found.

On average, American adults reported poorer health than their counterparts in other countries, with 28 percent of U.S. adults living with at least two chronic conditions. Twenty-six percent of U.S. adults reported emotional distress in the previous year that was difficult to deal with alone. Canadian adults reported similar levels of chronic conditions and emotional distress, while French and German adults reported the lowest rates of emotional distress. On the topic of material hardship, U.S. adults were more likely than adults in all other 10 nations to report they were “always” or “usually” concerned about having enough money to buy healthy foods or pay their housing expenses. Material hardship rates were lowest in Germany.

Americans were most likely to report financial barriers to health care in 2016 — at 33 percent — though that rate has declined in recent years, the study found. In comparison, between 7 and 8 percent of adults in Germany, the Netherlands, Sweden and the United Kingdom reported that costs prevented them from accessing needed medical care. About half of Canadian, German and Norwegian adults were not able to secure a medical appointment the same or next day; and about one in five adults in Canada, Germany, Norway, Sweden and the U.S. waited six or more days for an appointment. Adults in Canada were the most likely to say they waited two or more months to see a specialist; in contrast, fewer than 10 percent of adults reported similar waiting times in France, Germany, the Netherlands, Switzerland and the U.S.

In all of the countries surveyed, except the U.S., a majority of respondents with a regular doctor said their provider did not discuss healthy diets or exercise in the previous two years. Forty-one percent of Americans reported the absence of such discussions as well. On the issue of managing chronic conditions, 14 percent of chronically ill U.S. adults said they did not have the support they needed from their health care providers. Norway, Canada and France had a similar rate, while Australia, the Netherlands and New Zealand had the lowest.

Low-income adults — those living in households with less than half of the respective country’s median income — in every country were much more likely to report health problems and material hardship, the study found, noting that “their health care experiences shine a light on how well their country’s health system responds to the needs of some of its most complex and socially vulnerable patients.” The U.S. was home to the highest rate of low-income adults who reported cost barriers to care at 43 percent. Rates in other countries ranged from 8 percent to 31 percent. Low-income adults in Canada, France, Germany, Sweden, the United Kingdom and the U.S. reported longer waits for health care than the rest of the populations. In all the countries, between one-fourth and one-half of low-income adults said they used the emergency room in the previous two years. Study authors Robin Osborn, David Squires, Michelle Doty, Dana Sarnak and Eric Schneider write:

Although the United States has made significant progress in expanding coverage under the Affordable Care Act (ACA), it remains an outlier among high-income countries in ensuring access to health care. The major coverage expansions of the law were launched only in 2014 and are thus still in a ramping-up period. In addition, there are ongoing barriers to coverage, including the fact that — as of November 2016 — nineteen states have not chosen to expand eligibility for their Medicaid programs, the exclusion of undocumented immigrants from both Marketplace and Medicaid coverage, low awareness of coverage options, and concerns about affordability among those who remain uninsured. An estimated twenty-three million adults in the United States lack health insurance, while the other countries in our survey have universal coverage.

Schneider, senior vice president for policy and research at the Commonwealth Fund, told me that one possible explanation for why the U.S. spends so much on health care may be the higher levels of material hardship among its people, noting that “by not investing in the safety net or in housing, transportation and nutrition, people end up needing (health) services that are much more costly.” One way that other countries seem to be reducing the impact of material hardship, he said, was through integrating medical care and social services. For example, in the United Kingdom, the National Health Service embeds social services into its systems.

He also noted that while many provisions in the ACA offer financial incentives for hospital and health systems to engage community and social service partners toward reducing health care costs, it’s still early in the process. Making those linkages, he said, is a difficult, long-term endeavor.

“We probably do need to spend more on public health activities, social services and stress prevention so what are small health problems don’t become big health problems that require medical attention,” Schneider said of the U.S. system.

He also said that in many European countries, such as the United Kingdom and the Netherlands, the emphasis on providing no-cost primary care and ensuring timely access to primary care is making a significant difference for the health of their populations. In comparison, the U.S. devotes many more resources toward specialty care. In fact, Schneider told me that to improve America’s health, he would make two key investments: expanding population health and prevention measures and shifting more resources into strengthening primary care. Even though the ACA has certainly been a boost to primary care — for example, more people with insurance coverage as well as required coverage of preventive services benefits the bottom lines of primary care providers — the future is uncertain, Schneider said.

“Now with the change in administration, the concern is that many of those benefits, especially the essential health benefits, will be reversed,” he said. “Many of the (potential) repeals would take us backwards in terms of insurance coverage and benefits available. That would erode much of the progress we’ve made in primary care.”

Schneider said that even for Americans who can afford care and have insurance coverage, the U.S. health care delivery systems isn’t organized optimally — “we do really well at expensive treatments, but we just don’t have that cornerstone of primary care.”

“The No. 1 difference between the U.S. and other countries is that other countries either commit to universal insurance coverage or put a lot into making sure everyone (is covered),” he told me. “That universal coverage is fundamental because without it, it’s very difficult to create a high-functioning insurance market and a health care system that serves everyone.”

For a full copy of the 11-country study, visit Health Affairs or the Commonwealth Fund.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years.