Commodification Across European Healthcare Systems. Linking out-of-Pocket Payments to Income-Related Inequalities in Unmet Health Needs

Health is regarded as a basic human right in advanced democracies, and European welfare states are generally seen as granting access to examination or treatment on the basis of compulsory social insurance contributions or citizenship, and to finally provide healthcare according to need. However, many countries (especially in East-Central Europe) have shifted more and more financial responsibility from insurances and National Health Service towards patients. Out-of-pocket payments make up to 50% of total healthcare expenditure, and up to 3.8% of GDP. The effect of such a high reliance on out-of-pocket payments on the distribution of healthcare is theoretically straightforward: Households and individuals with low incomes cannot afford to pay for treatment, so that the probability of unmet health needs depends on income. However, the actual effect on the income-dependence of unmet health needs reveals itself only by examining empirical data. This study estimates multilevel models with survey data from the Europen Survey on Income and Living Conditions (EU-SILC) from 29 countries for up to 9 years, thus showing patterns in unmet health needs for ca. 3 million Europeans in 160 country-year observations. Our main results show three facts about the realities of European welfare states. First, income determines whether a person reports an occasion within the last year where she needed medical treatment or examination but did not receive it across all European countries and years under study. Second, the more a country relies on out-of-pocket payments as a means of healthcare financing, the higher is the proportion of respondents that report unmet health needs. Third, the share of out-of-pocket payments amplifies the effect of income dramatically. While the poorest decile “only” has a 1.4 percentage point higher probability of suffering from unmet health needs than the richest decile in a country with 5 % out-of-pocket payments of total health expenditure, this difference soars up to a dramatic 18 % in a country with 50 % out-of-pocket payments. Thus, we can speak of a commodification of healthcare in many European welfare states.