Somebody Get Me a Doctor: Voluntary Health Insurance, Social Background and Subjective Health in Europe

BACKGROUND: The last couple of decades have seen a steady increase in the uptake of voluntary health insurance (VHI) across Europe. This may seem like a contradiction, given that health services are free and universal in most of the countries. The debate surrounding VHI is generally plagued by limited evidence on their functions and impacts on health systems, and the discussion consequently tends to be a strongly ideological one, divided between private sector and public sector advocates who selectively draw on case reports to defend their viewpoints. With this paper we examined the relationship between the level of VHI in a country and the subjective health of its citizens, and whether this relationship is contingent upon a person’s social background. DATA AND METHODS: We combined the most recent OECD data available on VHI in Europe with individual data on subjective health and socio-economic background obtained from the European Social Survey for the period 2002-20. Using multilevel modelling, we controlled for the respondents’ demographic background, income and education, and including GDP at the country-level. RESULTS: The results indicate that VHI has a short-term positive health effect for those with low education. This may reflect a so-called substitution effect: VHI initially frees up capacity in the public health services, as many instead obtain their services from the private sector, which results in better access to services for those who remain in the public sector. In the longer run, however, the results suggest that the beneficial health effects for the uneducated diminishes and even becomes negative. CONCLUSION: The findings support the argument that over time the ‘secession of the wealthy’ might have inverse equity effects, possibly due to a deteriorating public healthcare sector.