How social policies can improve financial accessibility of healthcare: a multi-level analysis of unmet medical need in European countries

In this paper, households in the lowest income quintile (Q1) are referred to as “income poor”. This concept is broader than the official EU definition of “at risk of poverty”, which takes 60 % of the national median, and according to which just the lowest 16.8 % of the European population were poor in 2012 (national values varying between 7.9 in Iceland and 23.1 in Greece). Households in the second lowest income quintile (Q2) are referred to as the “lower middle class”, they are above the national poverty line. National social protection policies can yet again define their target group in a different way (e.g. taking income above the minimum wage).

Health spending measures the costs of health services (out/in-patient care, long-term care, prevention and public health services) and goods (pharmaceuticals and other medical goods) [51].

User fees can take the form of ‘co-payments’ (users pay a fixed amount per doctor visit), ‘co-insurance’ (users pay a proportion of total medical costs) or ‘deductible pricing’ (users bear costs until a fixed amount). Co-payments are the most common way of patient-cost-sharing in Europe [31].

For countries subject to bailout agreements the healthcare sector reforms were in part mandated by the troika comprising the European Commission, the European Central Bank and the International Monetary Fund [52]. For other European countries, increased healthcare efficiency was recommended in the European Semester process [53].

During the Great Recession, 17 out of the 28 European Member States lowered their public health spending as a percentage of GDP [14]. Cuts were applied to healthcare expenditures (e.g. by lowering wages for staff and re-setting prices paid for generic drugs) and by changing the structural determinants for access to healthcare: Infrastructure was reduced by lowering the number of hospital beds, by closing hospitals in rural areas (e.g. in Sweden, Bulgaria and Romania) [7, 33], and by laying off staff [32]. Population coverage was made more restrictive by shifting from universal service provision to provision based on citizenship (Spain). In other countries, long-term unemployed (Greece) and individuals with private debts towards public institutions (Slovenia) faced difficulties in insurance coverage [7]. Service coverage was reduced by lowering publicly provided support for purchasing pharmaceutical products and by cutting treatment programmes for mental health, physiotherapy and non-urgent ambulance services [32]. In Greece, Ireland, Italy, Latvia, Portugal, Romania, the Slovak Republic and Slovenia co-payments were introduced or raised, increasing private healthcare costs by up to 15 % [7, 14].

This minimum social standard is often based on a basket of goods, whose size and composition is highly dependent on the welfare state regime and a country’s living standard [54].