Association for Public Policy Analysis & Management

The causes of the income disparities in access across countries with universal health care coverage are not well understood.  Possible explanations for differential access to care include availability of health care providers, social networks, and environment that may make populations with lower socioeconomic status require more treatment or be more difficult to treat.  Yet most of these countries have found that universal and comprehensive insurance coverage is not sufficient to ensure equitable access to health care services.  In this paper we use data from the Global Health Observatory and the OECD to assess the role of out-pocket-spending on equity in access to care in four high-income countries.  The countries represent variation in health financing models including National Health Insurance (Canada), National Health Service (UK), Social Health Insurance (Germany) and Multi-Payer Private System (USA).  We discuss changes in out-of-pocket spending (as a % of private health care spending and as a % of total health care spending) from 2002 to 2013.  We assess the demographic profile of each country and the impact of OOP costs on beneficiaries based on relative income using a framework of equity where equity in access to care where all citizens have the same access to needed health care services regardless of income.  We include a discussion of each country’s safety net strategy to protect low-income from excessive out-of-pocket spending and the growth of supplemental insurance in each system often used to facilitate access to care.  In all systems, while out-of-pocket spending has remained relatively stable to overall health care spending, between 2002-2013, there has been an increase in supplemental private health insurance and a divergence in equitable access to care.   Even in the UK with the most concentrated government financing model, an estimated 11 percent of the population purchased private supplemental coverage.  We then assess the impact of OOP spending using data from all OECD countries using generalized linear mixed models applied to country-level data.  Key outcomes include adjusted DALY’s, life expectancy and age-standardized mortality controlling for socio-demographics, availability of primary care, level of supplemental coverage with country and time fixed effects.  We discuss the implications in the context of the World Health Organization’s objectives for a country’s health care system – to: 1) assure equity in access to health care services, 2) prevent individuals from falling into poverty as a result of contributions to health care or a catastrophic expenses, and 3) protect and improve the health status of individuals and populations by ensuring financial access to essential public and private health services.