Inequalities in unmet needs in select European and Commonwealth countries

One of the most vexing challenges to universal health insurance systems sustainability among developed countries is the rate of public health spending, which has grown faster than GDP over the past 15 years. The struggle to fund escalating public health costs has put pressure on governments to find alternatives to the current, predominantly public, financing structures. One such alternative has been to turn to private funding of health care through out-of-pocket spending by individuals and the development of private health insurance markets. Here, as in many countries, these policy changes provoke intense debate, as some of the policy instruments used to reach those goals, such as restricting the eligibility criteria for public insurance, may in fact have the unexpected effect of erecting supplementary barriers to health insurance coverage. Moreover, if these barriers and their impacts are unequally distributed in the population, they have the potential to increase social inequalities in health. As our systematic review of the literature shows, this turn towards private insurance and out-of-pocket spending may contribute to greater social inequalities in health compared to public insurance. One important pathway that may contribute to social inequalities in health may be through access to care, as those of lower socioeconomic status may be more likely to forgo needed care due to income related barriers (i.e., copayments or insurance premiums). In contrast, mandatory coverage through public means has the potential to mitigate socioeconomic differentials in health, as it will ensure that income does not have an impact on access to health services.