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Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage

Author

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  • Stéphanie Baggio
  • Marc Dupuis
  • Hans Wolff
  • Patrick Bodenmann

Abstract

Objectives: In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people—vulnerable groups for the burden of illness—in countries with UHC. Design: Longitudinal observational cohort study. Setting: Population-based cohort Survey of Health, Ageing and Retirement in Europe (SHARE) in twelve countries with UHC. Participants: Non-institutionalized people aged 50 and older (n = 29,260). Two subsamples were also used: participants without global activity limitation at baseline (n = 16,879) and participants without depression at baseline (n = 21,178). Main outcome measures: Risk of death, risk of global activity limitations, and risk of depression. We used mixed-effects Cox proportional hazards regressions to estimate hazard ratios (HR) for all-cause mortality, physical limitations, and depression. Results: Having a voluntary private insurance to cover health expenses not included in the public health care system (44.1% of the total sample) was a protective factor for all outcomes (HR≤0.91), controlling for a large range of socio-economic variables. On the contrary, having out-of-pocket expenditures (62.4%) was a risk factor (HR≥1.12). Conclusions: UHC systems are not free from health inequalities: there is a potential effect of lack of voluntary private insurance and out-of-pocket expenditures on mortality and health. Health care-related factors should be at focus in future researches designed to understand and address health inequalities. Reducing out-of-pocket expenditures and developing voluntary private insurance may protect against premature illness and death.

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  • Stéphanie Baggio & Marc Dupuis & Hans Wolff & Patrick Bodenmann, 2018. "Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health cover," PLOS ONE, Public Library of Science, vol. 13(10), pages 1-13, October.
    • Handle: RePEc:plo:pone00:0204666
    DOI: 10.1371/journal.pone.0204666
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    References listed on IDEAS

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    Cited by:

    1. Maria Magdalena Bujnowska-Fedak & Łukasz Wysoczański, 2020. "Access to an Electronic Health Record: A Polish National Survey," IJERPH, MDPI, vol. 17(17), pages 1-17, August.
    2. Guangsheng Wan & Zixuan Peng & Yufeng Shi & Peter C. Coyte, 2020. "What Are the Determinants of the Decision to Purchase Private Health Insurance in China?," IJERPH, MDPI, vol. 17(15), pages 1-15, July.
    3. Eun-Mi Baek & Jae-Il Oh & Eun-Jung Kwon, 2021. "The Effect of Additional Private Health Insurance on Mortality in the Context of Universal Public Health Insurance," IJERPH, MDPI, vol. 18(16), pages 1-10, August.

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