Population coverage for health care
The share of the population covered by a public or private scheme provides some indication of the financial protection against the costs associated with health care, but this is not a complete indicator of affordability as the range of services covered and the degree of cost-sharing applied to those services also matter. These three dimensions – the ‘breadth’, ‘depth’ and ‘height’ of coverage – define how comprehensive health care coverage is in a country. The indicator presented here on population coverage looks at the first dimension only, whereas the next indicator on the extent of health care coverage takes a broader look at these three dimensions together.
Most European countries have achieved universal (or near-universal) coverage of health care costs for a core set of services, usually including consultations with doctors, tests and examinations, and hospital care (Figure 7.8). Yet, in some countries coverage of these core services may not be universal. In Ireland, for example, only Medical Card and GP Card holders (less than 50% of the population) were covered for the costs of GP visits in 2019, although recent reform proposals suggest a gradual roll out of primary care coverage to the entire population (OECD/European Observatory on Health Systems and Policies, 2019a).
Three EU countries (Bulgaria, Romania and Cyprus) still had at least 10% of their population not covered for health care costs in recent years. In Bulgaria, at least one person in ten did not have health insurance in 2017, although other estimates suggest that this proportion may be closer to one in seven. This mainly concerns people in informal employment, long-term unemployed people and the Roma population who do not pay health insurance premiums either because they cannot afford it or for other reasons (OECD/European Observatory on Health Systems and Policies, 2019b). In general, people without insurance have free access to some services, like emergency care or care during pregnancy, but they need to cover all other costs out of pocket.
In Romania, the number of people without coverage is difficult to quantify because of the significant number of Romanians working abroad who are still counted as residents (around 3 to 4 million people) and thus appear in the statistics as having no insurance. The uninsured population living in Romania include mainly people working in the agricultural sector, the self-employed, unemployed people who are not registered for unemployment or social security benefits, and Roma people who do not have identity cards (precluding them from enrolling into the social security system). As in Bulgaria, the uninsured can only access a minimum benefits package, covering emergency care, treatment of communicable diseases and care during pregnancy (OECD/European Observatory on Health Systems and Policies, 2019c).
In 2019, Cyprus started to implement a major reform to move towards universal health coverage through the implementation of a National Health Insurance System (NHIS), although not all the population had registered to be beneficiaries of the new system as of early 2020. Beyond addressing coverage gaps, the new NHIS also aims to address the current fragmentation between the public and private systems (European Commission, 2020).
Although basic primary health coverage generally covers a defined set of benefits, in many countries accessing health services entails some degree of cost sharing for the majority of users. In most countries, additional health coverage can be purchased through private insurance to cover any cost-sharing left after basic coverage (complementary insurance), add additional services (supplementary insurance) or provide faster access or larger choice of providers (duplicate insurance). In most EU countries, only a small proportion of the population has an additional private health insurance, with the exception of France, Slovenia, Belgium, the Netherlands, Luxembourg and Croatia, where half or more of the population has private coverage (Figure 7.9).
Population coverage for health care is defined as the share of the population covered for a set of health care goods and services under public programmes and through private health insurance. Public coverage refers both to government programmes, generally financed by taxation, and social health insurance, generally financed by payroll taxes. The take-up of private health insurance is often voluntary, although it may be mandatory by law or compulsory for employees as part of their working conditions.
References
OECD/European Observatory on Health Systems and Policies (2019a), Ireland: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels, https://doi.org/10.1787/2393fd0a-en.
OECD/European Observatory on Health Systems and Policies (2019b), Bulgaria: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels, https://doi.org/10.1787/34781ac1-en.
OECD/European Observatory on Health Systems and Policies (2019c), Romania: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels, https://doi.org/10.1787/f345b1db-en.
European Commission (2020), 2020 European Semester: Country Report – Cyprus, https://ec.europa.eu/info/publications/2020-european-semester-country-reports_en.
Note: This excludes primary PHI. PHI can be both complementary and supplementary in Denmark and Germany.
Source: OECD Health Statistics 2020; and Voluntary health insurance in Europe, Observatory Studies Series, 2016, for non-OECD countries.