The share of the population covered by a public or private scheme provides an important measure of access to care and the financial protection against the costs associated with health care. The COVID‑19 pandemic demonstrated the importance of universal health coverage as a key element for the resilience of health systems, as gaps in insurance coverage and high levels of out-of-pocket payments may deter people from seeking care, and thus contribute to virus transmission. Higher population coverage through public and primary private health insurance have been associated with lower COVID‑19 death and lower excess mortality in EU and other OECD countries (OECD, forthcoming[1]).
However, population coverage is only a partial measure of access and coverage: the range of services covered and the degree of cost-sharing for those services also define how comprehensive health care coverage is in a country (see indicator “Extent of health care coverage”).
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 7.4). 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 all GP services in 2020. However, since the beginning of the pandemic in March 2020, some GP services such as remote COVID‑19 consultations are provided free of charge for all the population.
Two EU countries (Bulgaria and Romania) still had at least 10% of their population not covered for health care costs in recent years. In both countries, the main groups of uninsured people are those living abroad but still counted as residents; long-term unemployed people; those who chose not to pay health insurance premiums; and people without a valid identity card which is a prerequisite for health insurance registration. This last issue particularly affects the Roma population and undocumented migrants (OECD/European Observatory on Health Systems and Policies, 2021[2]; 2021[3]). In general, people without insurance nonetheless have free access to some services, like care in emergency departments or care during pregnancy, but need to cover all other costs out of pocket.
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 Belgium, France, Slovenia, the Netherlands and Luxembourg, where more than half of the population has private insurance coverage (Figure 7.5).
