Abstract:
This thesis examines the usefulness of voluntary health insurance (VHI) as a lever
for improving health system performance. It posits that VHI may further health
policy goals if it addresses gaps in statutory coverage, if it does not make those who
rely on statutory coverage worse off, and if those who need VHI have access to it.
The thesis presents four studies that analyse markets for VHI in the European Union;
developments in public policy towards VHI, including the implications of the EUlevel regulatory framework for VHI; the impact of VHI on health system
performance; the effects of allowing people to choose between statutory and
voluntary health insurance; and VHI’s influence on consumer mobility where
insurers compete to offer statutory benefits. The thesis finds that while VHI is critical
to financial protection in some countries, it does not always address key gaps in
statutory coverage or reach those who need it, and the depth of its coverage has
declined over time, even in heavily regulated markets. VHI has a regressive effect on
equity in health financing, lowers equity in the use of health services and does not
seem to have a positive effect on efficiency, partly because insurers in many
countries lack appropriate incentives. What is more, a failure to align incentives
across VHI and statutory health insurance can undermine the efficiency of public
spending on health. Many of VHI’s negative effects can be attributed to poor policy
design. Policy makers can try and ensure VHI contributes to rather than undermines
health system performance through the following mechanisms: better understanding
of VHI’s interaction with the health system; stronger policy design, focusing on
aligning incentives in pursuit of health policy goals and ensuring efficiency in the use
of public resources; willingness and capacity to regulate the market to secure
financial and consumer protection; and regular monitoring and evaluation.
