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Objectives  In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people—vulnerable groups for the burden of illness—in countries with UHC.    Design  Longitudinal observational cohort study.    Setting  Population-based cohort Survey of Health, Ageing and Retirement in Europe (SHARE) in twelve countries with UHC.    Participants  Non-institutionalized people aged 50 and older (n = 29,260). Two subsamples were also used: participants without global activity limitation at baseline (n = 16,879) and participants without depression at baseline (n = 21,178).    Main outcome measures  Risk of death, risk of global activity limitations, and risk of depression. We used mixed-effects Cox proportional hazards regressions to estimate hazard ratios (HR) for all-cause mortality, physical limitations, and depression.    Results  Having a voluntary private insurance to cover health expenses not included in the public health care system (44.1% of the total sample) was a protective factor for all outcomes (HR≤0.91), controlling for a large range of socio-economic variables. On the contrary, having out-of-pocket expenditures (62.4%) was a risk factor (HR≥1.12).    Conclusions  UHC systems are not free from health inequalities: there is a potential effect of lack of voluntary private insurance and out-of-pocket expenditures on mortality and health. Health care-related factors should be at focus in future researches designed to understand and address health inequalities. Reducing out-of-pocket expenditures and developing voluntary private insurance may protect against premature illness and death.

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Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage