{"subscriber":false,"subscribedOffers":{}} The Great Recession And Increased Cost Sharing In European Health Systems | Health Affairs

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Research Article

The Great Recession And Increased Cost Sharing In European Health Systems

Affiliations
  1. Raffaele Palladino ( [email protected] ) is a PhD student in the Department of Primary Care and Public Health, Imperial College London, in the United Kingdom.
  2. John Tayu Lee is a research associate in the Department of Primary Care and Public Health, Imperial College London, and an assistant professor at the Saw Swee Hock School of Public Health, National University of Singapore.
  3. Thomas Hone is a PhD student in the Department of Primary Care and Public Health, Imperial College London.
  4. Filippos T. Filippidis is a lecturer in public health in the Department of Primary Care and Public Health, Imperial College London.
  5. Christopher Millett is a professor of public health in the Department of Primary Care and Public Health, Imperial College London.
PUBLISHED:Free Accesshttps://doi.org/10.1377/hlthaff.2015.1170

Abstract

European health systems are increasingly adopting cost-sharing models, potentially increasing out-of-pocket expenditures for patients who use health care services or buy medications. Government policies that increase patient cost sharing are responding to incremental growth in cost pressures from aging populations and the need to invest in new health technologies, as well as to general constraints on public expenditures resulting from the Great Recession (2007–09). We used data from the Survey of Health, Ageing and Retirement in Europe to examine changes from 2006–07 to 2013 in out-of-pocket expenditures among people ages fifty and older in eleven European countries. Our results identify increases both in the proportion of older European citizens who incurred out-of-pocket expenditures and in mean out-of-pocket expenditures over this period. We also identified a significant increase over time in the percentage of people who incurred catastrophic health expenditures (greater than 30 percent of the household income) in the Czech Republic, Italy, and Spain. Poorer populations were less likely than those in the highest income quintile to incur an out-of-pocket expenditure and reported lower mean out-of-pocket expenditures, which suggests that measures are in place to provide poorer groups with some financial protection. These findings indicate the substantial weakening of financial protection for people ages fifty and older in European health systems after the Great Recession.

TOPICS

A push toward achieving universal health coverage is taking place, as reflected in the recently published Sustainable Development Goals of the United Nations. 13 The focus of these efforts has been to increase health insurance coverage, improve access to essential health services, and reduce financial barriers to health care in low- and middle-income countries. 2 However, there are emerging signs that the principles of universal coverage, especially those relating to financial protection, are being undermined in several countries where this coverage has been achieved. 4,5

Despite the principle of solidarity—which assumes that every citizen makes a fair contribution to financing health care—many European health systems are increasingly adopting cost sharing to shift health care costs to patients, which results in increased copayments or out-of-pocket expenditures ( Exhibit 1 ). (For a more extensive description of cost-shifting policies, see online Appendix Exhibit 1.) 6 This is in response not only to incremental growth in cost pressures from aging populations and the need to invest in new health technologies, but also to more general constraints on public spending resulting from the Great Recession (2007–09). 7

Exhibit 1 Summary of policies affecting out-of-pocket expenditure in populations ages 50 and older in eleven European countries, 2007–13

CountryPolicies
Austria aAnnual prescription fees cap introduced (2008). Anticorruption legislation designed to reduce illegal payments to shorten operation waiting times introduced (2008)
Belgium b,cVarious changes in user charges for medicines and outpatient and primary care, and exemptions from charges introduced (2007–11).
Czech Republic dCost sharing for medicines introduced (2009), later lowered (2011), and then abolished (2013). Out-of-hours care cost sharing introduced (2008). User fees for hospital services introduced (2008), later increased (2011), and then abolished (2013). Annual cap on charges lowered (2009).
Denmark eNo specific policies.
France b,fSmall increases to cost sharing for certain medicines with limited therapeutic value (2010), all inpatient stays (2010), and certain medical devices (2011).
Germany bCost sharing abolished for outpatient visits to general practitioners and specialists (2012).
Italy bIntroduction of and then increases in cost sharing for certain medicines and certain outpatient services (2008–11).
Netherlands b,gGeneral increase in cost sharing and reductions in basic benefit package (2008–13), although exemptions to cost sharing introduced for preferred providers, medicines, and preventive services (2009). Cost sharing for long-term care increased for wealthier patients (2013).
Spain bIncreased cost sharing for supplementary services such as nonemergency transport and prostheses and introduced coinsurance and monthly cap for medicines (2012). Additional cost sharing for medicines introduced in some regions (2012) but later deemed unconstitutional and abolished (2013).
Sweden bAnnual cap on out-of-pocket expenditure for medicines increased (2012).
Switzerland bNo specific policies.

SOURCE Authors’ analysis of information listed below.

aHofmarcher MM, et al. Austria: health system review. Health Syst Transit. 2013;15(7):1–292.

b Maresso A, et al. Economic crisis, health systems, and health in Europe (Note  8 in text).

c Gerkens S, et al. Belgium: health system review. Health Syst Transit. 2010;12(5):1–266. Farfan-Portet M-I, et al. Simplification of patient cost sharing: the example of physician consultations and visits [Internet]. Brussels: Belgium Health Care Knowledge Centre; 2012 [cited 2016 Jun 1]. (KCE Report No. 180C). Available from: https://kce.fgov.be/sites/default/files/page_documents/KCE_180C_simplification_patient_cost_sharing_second%20print.pdf .

d Alexa J, et al. Czech Republic: health system review. Health Syst Transit. 2015;17(1):1–165. Bryndová L et al. Czech Republic (Note  18 in text).

eOlejaz M, et al. Denmark: Health System Review. Health Syst Transit. 2012;14(2):i–xxii, 1–192.

fChevreul K, et al. France: health system review. Health Syst Transit. 2010;12(6):1–291, xxi–xxii.

gSchäfer W, et al. The Netherlands: health system review. Health Syst Transit. 2010;12(1):v–xxvii, 1–228.

For example, France increased cost sharing for certain services in 2010 and 2011 ( Exhibit 1 ). 8 Italy introduced cost sharing and then increased it in 2008–11, and copayments for medicines were common across regions of that country. 8 In 2012 Sweden raised the annual cap on out-of-pocket spending on medicines, which resulted in greater cost burden for patients. 8

The need for increased cost sharing and the principles of universal health coverage have been a source of tension among policy makers in many countries. In Spain, additional cost sharing—mostly for medications—was introduced at the regional level in 2012, although the Spanish Constitutional Court declared it unconstitutional in 2013 ( Exhibit 1 ). 9 Similarly, user fees for hospital services were introduced in 2008 in the Czech Republic, but the Czech Constitutional Court deemed these unconstitutional as well. 8 In Denmark, user fees introduced in 2011 were abolished in 2012, but cost sharing for medicines remained in place. 8

Evaluating the impact of cost-sharing policies is important because cost sharing could cause patients to delay seeking treatment, which in turn could lead to higher health care costs in the long term and adverse effects on health. 7,1012 The policies may have a pronounced impact on older people, who are more likely than younger ones to have chronic diseases and greater health care utilization 13 but who have limited resources to pay for health care. Out-of-pocket expenditures may reduce health system efficiency (for example, through the need for administrative systems to collect money). More importantly, cost sharing is generally regressive, disproportionately affecting low-income groups and resulting in inequities in health care access and health outcomes. 10

The aim of this study was to examine changes in out-of-pocket spending among people ages fifty and older in eleven European health systems from 2006–07 to 2013. This article provides nationally representative estimates of out-of-pocket spending before and after the Great Recession.

Study Data And Methods

Data Source

We used data from the Survey of Health, Ageing and Retirement in Europe, which is a European panel survey. 14 Respondents are nationally representative samples of people ages fifty and older in twenty European countries. The survey draws its representative samples from national or regional population registries or from multistage sampling strategies. 14 Our data contained information on respondents’ sociodemographic characteristics, health status, and health care use and spending. Full details of the survey’s methods have been reported elsewhere. 15,16

For this study, we used two cross-sectional data sets, from wave 2 (2006–07) and wave 5 (2013) of the survey, which included a dedicated module on health care expenditures before and after the Great Recession. We analyzed data from the following eleven European countries present in both survey waves: Austria, Belgium, the Czech Republic, Denmark, France, Germany, Italy, the Netherlands, Spain, Sweden, and Switzerland. Information from respondents who participated in both waves was linked to construct a longitudinal analysis in this subsample. We excluded respondents living in residential care homes from our analysis because of the likely difference between their out-of-pocket expenditure profile and that of noninstitutionalized respondents.

Variables

Respondents were asked whether they had incurred out-of-pocket expenditures for medications, outpatient hospital visits, inpatient services, and home care services in the past twelve months and the amount of expenditure incurred in each area. For example, to investigate the amount of out-of-pocket expenditures for outpatient visits, respondents were asked: “Did you pay anything out of pocket for your doctor visits [in the past twelve months]?” If they said yes, they were asked: “How much did you pay overall for your doctor visits [in the past twelve months]?”

We generated the following three outcome measures for our analyses: any out-of-pocket expenditure in the past twelve months, the amount of out-of-pocket expenditure (in euros) in the past twelve months among those who had incurred any such expenditure, and whether respondents had incurred a catastrophic health expenditure. The latter was defined as total out-of-pocket expenditure incurred by individual survey respondents that exceeded 30 percent of their household income in the past year. 17 To allow us to compare out-of-pocket expenditure between survey waves, we adjusted for country-level inflation.

The following covariates were included in our analyses: age group (50–64 years, 65–79 years, or 80 years and older), sex, marital status (married or in a registered partnership, single, or divorced or widowed), educational attainment (no formal education, primary education, or secondary education or above), employment status (employed or self-employed, retired, unemployed, permanently sick or disabled, or homemaker or other), household income (in quintiles), and number of chronic diseases (none, one, or two or more).

Statistical Analysis

We calculated the proportion of respondents who had incurred any out-of-pocket expenditure and the mean, median, and interquartile range of that expenditure for those who had incurred any during the past year.

Multivariate logistic regression was used for binary outcomes (whether or not any out-of-pocket expenditure was incurred), and we report adjusted odds ratios. Log-linear regression models were employed to assess changes in the amount of out-of-pocket expenditure, as the outcome was highly skewed. Both sets of models included a dummy variable coded as 0 for wave 2 (2006–07) or 1 for wave 5 (2013) to quantify changes in outcomes between survey waves. Models were also employed to assess out-of-pocket expenditure for each specific health service.

For all regressions, we calculated pooled estimates (using data from all countries) as well as country-specific estimates. We used multivariate logistic and linear regression models with pooled data from both survey waves (since findings were similar in the two waves) to examine sociodemographic correlates of out-of-pocket expenditure.

Because only a low percentage of people incurred catastrophic health expenditure, we opted not to produce regression models for this expenditure. For each country and the pooled data, we used chi-square tests to explore differences in the percentages of respondents who incurred a catastrophic expenditure in 2006–07 and those who did so in 2013.

As a sensitivity analysis, we also conducted a longitudinal analysis on a subsample of 14,409 respondents who participated in both waves. Using multilevel models with multiple observations of individuals nested in countries, we examined changes in the likelihood of incurring an out-of-pocket expenditure and changes in mean out-of-pocket expenditure.

We performed the statistical analyses using Stata, version 12. A more detailed explanation of our methods is available in Appendix Exhibit 2. 6

Limitations

Several limitations merit discussion. First, data on out-of-pocket expenditure were self-reported. However, we did not expect any difference in reporting of that expenditure to vary by year.

Second, our findings on out-of-pocket expenditure burden in Europe cannot be directly attributed to the Great Recession. With only two waves of data available, it was not possible to adjust for underlying trends and temporal factors that could have affected out-of-pocket spending. However, the results from our longitudinal sensitivity analyses of the same data confirmed the robustness of our findings from the cross-sectional analysis and showed that the results were not due to changes in samples between survey waves.

Third, while we used an established measure of catastrophic health expenditure, 17 we could not apply more comprehensive definitions because of the absence of key variables in the data.

Finally, the Survey of Health, Ageing and Retirement in Europe provided information on out-of-pocket expenditure only in broad expenditure groupings (on medications, outpatient hospital visits, inpatient services, and home care services), which made it difficult to evaluate individual cost-sharing policies.

Study Results

The study sample consisted of 26,775 respondents to wave 2 (2006–07) of the Survey of Health, Ageing and Retirement in Europe and 51,211 respondents to wave 5 (2013). The characteristics of the study population were similar in both waves (Appendix Exhibit 3). 6 Overall, 54.6 percent of the study population was female; and 49.7 percent were ages 50–64, 36.7 percent were ages 65–79, and 13.6 percent were ages 80 years and older. Half (50.1 percent) were retired, and 72.6 percent had at least a secondary-level education. Seventy percent were married or in a registered partnership, and 46.1 percent reported having two or more chronic diseases.

Any Out-Of-Pocket Expenditure

The percentage of respondents incurring any out-of-pocket expenditure in the past twelve months increased from 63.6 percent in 2006–07 to 80.0 percent in 2013 in our pooled analysis ( Exhibit 2 ). Increases were evident in all countries except Austria, where there was a decrease from 81.1 percent to 67.5 percent of respondents. The most striking increases were in Spain (from 32.8 percent to 75.7 percent) and the Netherlands (from 31.1 percent to 70.3 percent).

Exhibit 2 Percentages of respondents to the Survey of Health, Ageing and Retirement in Europe incurring any out-of-pocket expenditure, 2006–07 and 2013

Exhibit 2
SOURCE Authors’ analysis of data from wave 2 and wave 5 of the Survey of Health, Ageing and Retirement in Europe (see Note  13 in text). NOTES Differences in the prevalence of reporting any out-of-pocket expenditure between 2006–07 and 2013 were assessed using a chi-square test. All of the results are significant ( p<0.001 ), except for Italy ( p<0.01 ).

The percentages of respondents reporting any out-of-pocket spending by source increased most for outpatient services (from 36.4 percent to 62.9 percent) (data not shown). Increases in such spending on medications rose from 58.2 percent to 65.8 percent; the increases for inpatient services and home care were from 6.1 percent to 7.4 percent and from 2.4 percent to 7.0 percent, respectively.

Results from regression analyses revealed that for the countries overall, the likelihood of incurring an out-of-pocket expenditure in 2013 was 2.62 times higher than that in 2006–07 ( Exhibit 3 ). The countries with the most pronounced increases were Denmark and Spain. Austria was the only country in which respondents were less likely to incur an out-of-pocket expenditure in 2013 than in 2006–07. Women, people with chronic diseases, and people in the richest quintile were more likely to incur an out-of-pocket expenditure in both survey years, compared to men, people without chronic diseases, and those in the poorest quintile, respectively (Appendix Exhibit 7). 6

Exhibit 3 Likelihood of having any out-of-pocket expenditure and mean out-of-pocket expenditure in 2013, compared to 2006–07

Any out-of-pocket expenditureMean out-of-pocket expenditure
CountryAOR95% CISample sizeDifference (%)95% CISample size
Austria0.450.37, 0.555,312101.078.6, 126.33,805
Belgium2.321.67, 3.228,50437.526.3, 49.78,003
Czech Republic3.853.11, 4.788,27075.962.4, 90.47,344
Denmark8.476.77, 10.616,53336.727.7, 46.45,799
France3.873.28, 4.577,18335.815.8, 59.34,156
Germany1.130.96, 1.338,03242.532.5, 53.36,862
Italy1.321.10, 1.597,52972.254.2, 92.25,788
Netherlands5.194.48, 6.026,638−10.5−22.6, 3.53,599
Spain8.226.78, 9.978,474−7.5−23.4, 11.75,052
Sweden3.702.64, 5.177,15640.632.3, 49.46,772
Switzerland1.801.50, 2.174,35576.760.0, 95.23,560
Pooled data2.622.43, 2.8277,98643.637.2, 50.360,740

SOURCE Authors’ analysis of data from wave 2 and wave 5 of the Survey of Health, Ageing and Retirement in Europe (see Note  13 in text). NOTES The exhibit shows results from multivariate logistic regressions on the likelihood of incurring any out-of-pocket expenditure in 2013 relative to in 2006–07 (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]). It also shows results from multivariate log-linear regression models that assessed changes in the mean out-of-pocket-expenditure in 2013 relative to in 2006–07 (percentage difference between the two time periods and 95% CIs). Results from 2006–07 were adjusted for country-level inflation in 2013. Adjusted odds ratios and differences were significant at alpha = 0.001 in all cases except the following: Germany, p>0.01 for AOR; Italy, 0.01>p>0.001 for AOR; Netherlands, p>0.01 for difference; Spain, p>0.01 for difference.

By source of out-of-pocket expenditure, respondents in all countries except Switzerland had an increased likelihood of incurring such an expenditure for outpatient and home care services in 2013 than in 2006–07 (Appendix Exhibit 9). 6 The Czech Republic was the only country whose respondents had greater likelihood over time of incurring an out-of-pocket expenditure for inpatient services. Changes in the likelihood of incurring an out-of-pocket expenditure for medications between 2006–07 and 2013 varied across countries, with the likelihood lower over time in Austria, Germany, and Switzerland and higher in the Czech Republic, Denmark, France, the Netherlands, Spain, and Sweden. There was no change in likelihood between the two periods in Belgium or Italy.

Amount Of Out-Of-Pocket Spending

Mean out-of-pocket expenditure incurred in the past twelve months increased in the eleven countries overall from 358.5 in 2006–07 to 479.7 in 2013, after adjustment for inflation ( Exhibit 4 ). Increases were found in all countries except the Netherlands and Spain. The largest increases were in France and Austria, where mean out-of-pocket expenditure increased from 247.3 to 451.0 and from 405.7 to 716.1, respectively.

Exhibit 4 Mean and median out-of-pocket expenditures (euros) by respondents to the Survey of Health, Ageing and Retirement in Europe who had such an expenditure, 2006–07 and 2013

Exhibit 4
SOURCE Authors’ analysis of data from wave 2 and wave 5 of the Survey of Health, Ageing and Retirement in Europe (see Note  13 in text). NOTE Results from 2006–07 were adjusted for country-level inflation in 2013.

In multivariate regression, the mean out-of-pocket expenditure in the countries overall was 43.6 percent higher in 2013 than in 2006–07, after demographic and socioeconomic factors and inflation were controlled for ( Exhibit 3 ). The greatest increase in mean out-of-pocket expenditure was found in Austria; there was no increase in the Netherlands or Spain.

Increasing mean out-of-pocket spending in the pooled analysis was driven by outpatient spending, which increased 41.3 percent (95% confidence interval: 33.7, 49.4), while mean spending on inpatient services fell 14.1 percent (95% CI: −22.1, −5.29) (Appendix Exhibit 9). 6 Changes in mean spending for medication and home care were not significant in the pooled analysis.

Change over time in mean out-of-pocket spending by source showed considerable variation (Appendix Exhibit 9). 6 Spending for outpatient services increased for all countries except the Czech Republic and the Netherlands, where it decreased, and France and Denmark, where there was no change. There was a significant increase in mean out-of-pocket spending for home care only in Belgium, Denmark, France, and Switzerland. The change over time in mean out-of-pocket spending for medications varied, with increases in Austria, the Czech Republic, Italy, and Switzerland; no change in Germany, the Netherlands, and Sweden; and deceases in Belgium, Denmark, France, and Spain.

In both 2006–07 and 2013, increasing age was associated with higher out-of-pocket spending for all countries except Denmark, Spain, and Switzerland (Appendix Exhibit 8). 6 Respondents ages 65–79 and those ages 80 and older incurred 9.4 percent (95% CI: 2.0, 16.2) and 52.2 percent (95% CI: 39.1, 64.9) higher out-of-pocket expenditure, respectively, than people ages 50–64. Spending incurred by women was 18.5 percent (95% CI: 12.7, 23.4) higher than that incurred by men in the countries overall, but no difference between women and men was found in Denmark, Sweden, and Switzerland.

Mean out-of-pocket expenditure for the eleven countries was 32.3 percent (95% CI: 24.6, 40.5) and 80.4 percent (95% CI: 69.9, 89.6) higher for people with one or with two or more chronic diseases, respectively, compared to those with no such condition (Appendix Exhibit 5). 6 The same trend was evident in all countries except France. Additionally, for all countries except France and Italy, there was decreasing mean out-of-pocket expenditure across income quintiles, with the poorest quintile paying 27.4 percent less than the richest quintile. Compared to people who were retired, those who were permanently sick or disabled incurred 27.1 percent higher out-of-pocket expenditure across all countries (95% CI: 12.7, 41.9).

Catastrophic Health Spending

The proportion of respondents who incurred catastrophic health spending (more than 30 percent of annual income spent on health care) increased from 2.3 percent (95% CI: 2.0, 2.7) in 2006–07 to 3.9 percent (95% CI: 3.5,4.3) in 2013 in our pooled analysis ( Exhibit 5 ). The Czech Republic, Italy, and Spain also experienced significant increases.

Exhibit 5 Percentages of respondents to the Survey of Health, Ageing and Retirement in Europe incurring catastrophic health care expenditures, 2006–07 and 2013

Exhibit 5
SOURCE Authors’ analysis of data from wave 2 and wave 5 of the Survey of Health, Ageing and Retirement in Europe (see Note  13 in text). NOTES Differences in the prevalence of catastrophic health care expenditures between 2006–07 and 2013 were assessed using a chi-square test. The error bars indicate 95% confidence intervals. *** p<0.01

Sensitivity Analysis

A longitudinal analysis of respondents who participated in both survey waves showed results that were concordant with our main findings (Appendix Exhibit 10). 6 In the sensitivity analysis, respondents were 3.4 times more likely to incur an out-of-pocket expenditure in 2013 than they were in 2006–07 (95% CI: 3.16, 3.73). An increase in the number of chronic diseases was associated with an increased likelihood of incurring any out-of-pocket expenditure, with people who had two or more chronic diseases being 3.96 times more likely to incur any out-of-pocket expenditure, compared to those with no chronic disease (95% CI: 3.61, 4.34). Compared to respondents in the richest income quintile, those in the poorest and next-poorest quintiles were 0.69 times (95% CI: 0.62, 0.78) and 0.81 times (95% CI: 0.72, 0.90) less likely to incur any out-of-pocket expenditure, respectively.

In the same sensitivity analysis, respondents’ mean out-of-pocket spending in 2013 was 56.8 percent (95% CI: 50.7, 61.6) higher that in 2006–07 (Appendix Exhibit 10). 6 Respondents ages 80 and older spent 44.8 percent (95% CI: 35.0, 55.3) more than those ages 50–64. And people with two or more chronic diseases spent 89.6 percent (95% CI: 82.2, 99.4) more than those with no chronic disease.

Discussion

Our results show that people ages fifty and older across Europe had greater burden of out-of-pocket expenditure in 2013—in terms of both the likelihood of incurring such an expenditure and the average amount spent when incurring one—compared to 2006–07: The likelihood of having any out-of-pocket expenditure was 2.62 times greater and the mean out-of-pocket expenditure was 43.6 percent higher in 2013, after socioeconomic and demographic factors and inflation were controlled for. And there were significant increases over time in the percentages of older populations reporting catastrophic health spending in the Czech Republic, Italy, and Spain.

Our findings demonstrate that recent cost-sharing policies ( Exhibit 1 and Appendix Exhibit 1) 6 increased financial burden for the elderly in Europe. 7,18 In 2012 the concurrent increase of copayments (mainly for medicines) and increase in the cap on out-of-pocket expenditures for medicines 8 in Spain were reflected in our findings. Substantially higher percentages of people incurred an out-of-pocket expenditure in 2013 than in 2006–07, even though the mean out-of-pocket expenditure did not change significantly.

Across Italy, regions have been allowed to increase user charges, with specific copayments for outpatient and specialist services and cost sharing for medicines introduced in 2008. 8 Our findings for Italy indicate that over time, a higher percentage of people incurred higher out-of-pocket expenditures, particularly for medicines and outpatient services.

The Czech Republic introduced user fees for doctor visits, inpatient services, and out-of-hours care in 2008 and a copayment for prescriptions in 2009. 19 This burden on individuals was also reflected in our results, which were obtained before some of these user fees were removed in 2013. 8

The increases in catastrophic health care spending in the Czech Republic, Italy, and Spain show the impact of these policies. In Spain, the introduction of copayments led to a rapid reduction in the number of prescriptions. 20 In the Czech Republic, user fees reduced utilization, lowered consumption of prescriptions, and increased catastrophic expenditures especially in elderly populations. 21,22 In Italy, the introduction of medication copayments reduced adherence to pharmacologic treatments in patients living in regions where the copayments were introduced, compared to those living in other regions. 23

In other countries, catastrophic expenditure did not increase significantly, but there was an almost universal increase in mean out-of-pocket spending among people ages fifty and older over time. The introduction and expansion of user fees and increases in caps on out-of-pocket expenditure in countries such as Denmark, France, the Netherlands, and Sweden were reflected in our results. 8,18

We found that people in poorer income quintiles were less likely to incur any out-of-pocket expenditure and reported lower mean out-of-pocket expenditure, compared to people in the highest income quintile. This suggests that better financial protection from increasing health care costs exists among vulnerable populations than among the highest-income populations. In contrast, previous studies conducted in low- and middle-income countries have shown that people in groups with lower socioeconomic status were more likely than people with higher socioeconomic status to be disproportionally affected by cost sharing. 2426 Even in high-income settings, cost sharing may undermine equity in the use of health services, as it undermines the generally progressive basis of pooling resources for the provision of health care. 27

Our findings may indicate that European governments are protecting people with lower socioeconomic status from regressive cost-sharing policies through, for example, exemptions and reduced fees. 7 However, these results could also reflect differing utilization patterns across groups of different socioeconomic status and may indicate that people with lower socioeconomic status are forgoing treatment and thus avoiding out-of-pocket expenditures. 28 Women and people with multiple chronic diseases reported a higher likelihood of incurring an out-of-pocket expenditure and increased mean out-of-pocket spending, compared to men and people without chronic diseases, respectively—findings that are in line with those of previous studies. 25,26,2931

Policy Implications

Achieving comprehensive universal health coverage has been identified as an important global priority, as reflected in the Sustainable Development Goals that were established in 2015. Our findings highlight the importance of financial protection as part of the principles of universal health coverage in health systems where such coverage has been achieved. The external constraints on public expenditures in some European countries during the Great Recession—in particular, Italy 32 and Spain 33 —may have dictated the adoption of new cost-sharing models in these settings. It is noteworthy that the prevalence of catastrophic health spending increased sharply in these two countries, which indicates a substantial erosion of universal health coverage.

In contrast, most European countries had a choice between protecting national financial resources allocated to health care, through increasing their debt or by reprioritizing spending on various social policy programs, and increased cost sharing. Most changes to cost-sharing arrangements implemented after the Great Recession focused on medications and outpatient services, which are the areas where the greatest increases in out-of-pocket spending were seen. This raises the possibility of adverse consequences for population health, given other evidence that failure to seek health services and nonadherence to medications because of cost may have increased in European countries. 23,34,35

The increased cost sharing found in this study took place in the context of a concerted drive to identify and realize cost savings in European health systems during the study period. This includes efforts to reduce health system overheads and staff numbers, introducing pay-for-performance reimbursement, and increasing efficiency (for example, through the use of generic medicines, reductions in the oversupply of medications, and adjustments to staff mix). Shifting care from hospitals to primary care, where costs are lower, has also been a common approach. 7 More research is needed to evaluate the long-term impact of these policies on health care utilization, health outcomes, and patient satisfaction. Our findings highlight the importance of regular monitoring of out-of-pocket expenditures, catastrophic health expenditures, and nonuse of health care because of cost in European health systems. 28

Conclusion

European citizens ages fifty and older were more likely to incur an out-of-pocket expenditure and to have higher mean out-of-pocket expenditures in 2013 than in 2006–07. The prevalence of catastrophic health spending increased over this period in the Czech Republic, Italy, and Spain. These findings indicate that the financial protection for older people in many European health systems became weaker after the Great Recession and that continued monitoring of out-of-pocket expenditures is warranted.

ACKNOWLEDGMENTS

Raffaele Palladino is funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care program for North West London. Christopher Millett is supported by an NIHR research professorship award. The views expressed in this article are those of the authors and not necessarily those of the National Health Service, the NIHR, or the UK Department of Health. This article uses data from the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 5 release 1.0.0, as of March 31, 2015 (DOI: 10.6103/SHARE.w5.100), and the SHARE wave 2 release 2.6.0, as of November 29, 2013 (DOI: 10.6103/SHARE.w2.260). The SHARE data collection has primarily been funded by the European Commission through the 5th Framework Programme (Project No. QLK6-CT-2001-00360 in the thematic program Quality of Life), through the 6th Framework Programme (projects SHARE-I3, RII-CT-2006-062193, COMPARE, CIT5- CT-2005-028857, and SHARELIFE, CIT4-CT-2006-028812), and through the 7th Framework Programme (SHARE-PREP, No. 211909; SHARE-LEAP, No. 227822; and SHARE M4, No. 261982). Additional funding from the US National Institute on Aging (Grant Nos. U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, R21 AG025169, Y1-AG-4553-01, IAG BSR06-11, and OGHA 04-064) and the German Ministry of Education and Research, as well as from various other national sources, is gratefully acknowledged. For a full list of funding institutions, see the SHARE website, http://www.share-project.org/contact-organisation/funding.html .

NOTES

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  • 3 Open Working Group of the General Assembly on Sustainable Development Goals . Open Working Group proposal for Sustainable Development Goals [Internet]. New York (NY) : United Nations ; [cited 2016 Jun 1 ]. Available from: https://sustainabledevelopment.un.org/content/documents/1579SDGs%20Proposal.pdf Google Scholar
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