Support for private involvement in a National Health Service: the role of private health insurance, self-rated health and socioeconomic status

Allowing people to purchase certain services outside of the public sector has generally not been regarded as a desirable policy for healthcare, since it may create a two-tier system, thereby intensifying the existing inequalities in health between people with high and low income. Still, one of the greatest pressures for change in modern health systems has been in the relative role of the private sector in the operation and, in some countries, the funding of health care services. The demand for private health insurance (PHI) as a mean to partially supplement the NHS coverage is often regarded as a potential signal for a declining support for the NHS. Our paper follows up on this discussion by investigating the preferences for private involvement in a NHS. We pursue two questions. First, are the purchasers of PHI those who are less supportive of a public health system? The argument that private services will lead to a downward spiral towards a ‘poor service for the poor’ depends upon the premise that support for public sector services is negatively associated with private demand, and using the Norwegian healthcare system as our case we set out to test to what extent that proposition is true in practice. Secondly, are the supporters of more private health services those that stand to benefit the most from it; i.e. the better off, better educated and of best health? The study builds on a national survey among 7,500 Norwegians in 2014. The analysis first used factor analysis to uncover two components: provision, which relate to the question of whether the delivery of health services should be public or private, and payment, which captures the willingness to introduce deductibles on public health services. A multivariate analysis then employed additive indexes representing each of these two components as dependent variables to uncover whether the attitudes were related to PHI uptake, satisfaction with health services, socioeconomic status and self-rated health, while also controlling for other important factors such as age, gender, political sympathies, and health sector employment. The results showed that the willingness to increase private provision of services was positively associated with PHI uptake, as well as with income, while the association with education and health service satisfaction was the opposite. PHI uptake and income was furthermore positively related to the willingness of increasing the use of deductibles, while self-rated health worked in the opposite direction. The results thus seem to suggest that concerns about the equity implications related to PHI may be warranted: assuming that the expressed preferences in our study reflect the potential demand for private services, an increasing role for private actors may lead to the development of a group of well-off and healthy users who demand almost all their health care from the private sector and who have little commitment to public funding of health care.