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 healthcare. 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. Higher population coverage through public and primary private health insurance have been associated with lower COVID‑19 death and lower excess mortality in the EU and other OECD countries (OECD, 2023[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 healthcare coverage is in a country (see indicator “Extent of healthcare coverage”).
Most European countries have achieved universal (or near-universal) coverage of the population for a core set of health services, usually including consultations with doctors, tests and examinations, and hospital care (Figure 7.3). Yet, in some countries, coverage of these core services may not be universal. In Ireland, for example, only Medical Card and GP visit card holders, who accounted for about 48% of the population in 2021, were covered for the costs of all GP services (OECD/European Observatory on Health Systems and Policies, 2023[2]).
Romania is the only EU country where at least 10% of the population is not covered for healthcare costs. The main groups of uninsured people are Romanians 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, 2023[3]). In general, people without insurance nonetheless have free access to some services, such as 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, Luxembourg and Croatia, where more than half of the population has private health insurance coverage (Figure 7.4).
Over the last decade, the population covered by additional private health insurance has increased in 14 of 22 EU countries with available data. 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.
