The share of a population covered for a core set of health services offers an initial assessment of access to care and financial protection. However, it is only a partial measure of access and coverage. Universal health coverage also depends on the range of services covered and the degree of cost-sharing for these. Services also need to be of sufficient quality. Indicators in this chapter focus on access in terms of the affordability, availability and use of health care services, while Chapter 6 provides indicators on quality and outcomes of care.
Most OECD countries have achieved universal (or near-universal) coverage for a core set of health services, which usually include consultations with doctors, tests and examinations, and hospital care (Figure 5.1). National health systems or social health insurance have typically been the financing schemes for achieving universal health coverage. A few countries (the Netherlands and Switzerland) have obtained universality through compulsory private health insurance – supported by public subsidies and laws on the scope and depth of coverage.
Population coverage for core services in 2019 remained below 95% in seven OECD countries, and below 90% in Mexico and the United States. Mexico has expanded coverage since 2004, but gaps remain (OECD, 2016[1]). In the United States, uninsured people tend to be working-age adults with lower education or income levels – the share of uninsured people decreased sharply from about 13% in 2013 to 9% in 2015 (United States Census Bureau, 2018[2]), but has remained relatively unchanged since then. In Ireland, although coverage is universal, less than half of the population are covered for the cost of general practitioner visits. Recent reform proposals suggest a gradual rollout of primary care coverage to the entire population (OECD/European Observatory of Health Systems and Policies, 2019[3]).
Beyond population coverage rates, satisfaction with the availability of quality health services offers further insight into effective coverage. The Gallup World Poll collects data on citizens’ satisfaction with health and other public services worldwide. While contextual and cultural factors influence survey responses, the poll allows citizens’ opinions to be compared on the basis of the same survey question. Satisfaction with the availability of quality health services averaged 71% across 37 OECD countries in 2020. Citizens in Norway (93%), Belgium and the Netherlands (both 92%) were most likely to be satisfied, while those in Poland (26%), Greece (38%) and Chile (39%) were least likely to be satisfied (Figure 5.2).
In some countries, citizens can purchase additional health coverage through voluntary private health insurance. This can cover any cost-sharing left after basic coverage (complementary insurance), add further services (supplementary insurance) or provide faster access or a wider choice of providers (duplicate insurance). Among 22 OECD countries with recent comparable data, seven had additional private insurance coverage for over half of the population in 2019 (Figure 5.3). Complementary insurance to cover cost-sharing is widely used in Slovenia and Korea (around 70% of the population). Israel and the Netherlands had the largest supplementary health insurance market (over 80% of the population), whereby private insurance pays for dental care, physiotherapy, certain prescription drugs and other services that are not publicly reimbursed. Duplicate private health insurance was most widely used in Ireland and Australia. In the United States, just under 10% of the population had complementary private health insurance. This is in addition to the 52.5% of the American population who had primary private health insurance.
Over the last decade, the population covered by additional private health insurance has increased in 20 of 25 OECD countries with comparable data, although these increases have often been small. Increases have been most marked in Korea (an additional 20% of the total population). Several factors determine how additional private health insurance evolves – notably the extent of gaps in access to publicly financed services and government interventions directed at private health insurance markets.
