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

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.