Applied Health Economics and Health Policy

, Volume 15, Issue 5, pp 545–555 | Cite as

Out-of-Pocket Payments and Subjective Unmet Need of Healthcare

  • Erik SchokkaertEmail author
  • Jonas Steel
  • Carine Van de Voorde
Current Opinion


We present a critical review of the literature that discusses the link between the level of out-of-pocket payments in developed countries and the share of people in these countries reporting that they postpone or forgo healthcare for financial reasons. We discuss the pros and cons of measuring access problems with this subjective variable. Whereas the quantitative findings in terms of numbers of people postponing care must be interpreted with utmost caution, the picture for the vulnerable groups in society is reasonably robust and unsurprising: people with low incomes and high morbidity and incomplete (or non-existent) insurance coverage are most likely to postpone or forgo healthcare for financial reasons. It is more surprising that people with high incomes and generous insurance coverage also report that they postpone care. We focus on some policy-relevant issues that call for further research: the subtle interactions between financial and non-financial factors, the possibility of differentiation of out-of-pocket payments between patients and between healthcare services, and the normative debate around accessibility and affordability.


Dental Care Price Elasticity Utilization Data Financial Reason European Social Survey 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Author Contributions

The authors contributed equally to the content of the paper. The final version was written by ES.

Compliance with Ethical Standards

Conflict of interest

Erik Schokkaert, Jonas Steel and Carine Van de Voorde have no conflicts of interest.


No external funding was received for the work reported in this study.


  1. 1.
    Schokkaert E, Van de Voorde C. User charges. In: Glied S, Smith P, editors. Oxford handbook on health economics. Oxford: Oxford University Press; 2011. p. 329–53.Google Scholar
  2. 2.
    Allin S, Grignon M, Le Grand J. Subjective unmet need and utilization of health care services in Canada: what are the equity implications? Soc Sci Med. 2010;70:465–72.CrossRefPubMedGoogle Scholar
  3. 3.
    Legal R, Vicard A. Renoncement aux soins pour raisons financières. Doss Solidar Santé. 2015; 28.Google Scholar
  4. 4.
    Desprès C. Significations du renoncement aux soins: une analyse anthropologique. Sci Soc Santé. 2013;31:71–96.CrossRefGoogle Scholar
  5. 5.
    Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284:2061–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Cunningham PJ, Kemper P. Ability to obtain medical care for the uninsured: how much does it vary across communities? JAMA. 1998;280:921–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Diamant AL, Hays RD, Morales LS, Ford W, et al. Delays and unmet need for health care among adult primary care patients in a restructured urban public health system. Am J Public Health. 2004;94:783–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Hong YR, Holcomb D, Bhandari M, Larkin L. Affordable care act: comparison of healthcare indicators among different insurance beneficiaries with new coverage eligibility. BMC Health Serv Res. 2016;16:114.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Malecki K, Wisk LE, Walsh M, McWilliams C, Eggers S, Olson M. Oral health equity and unmet dental care needs in a population-based sample: findings from the survey of the health of Wisconsin. Am J Public Health. 2015;105:S466–74.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Shi DL, Stevens GD. Vulnerability and unmet health care needs. J Gen Intern Med. 2005;20:148–54.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Strunk BC, Cunningham PJ. Treading Water: Americans’ Access to Needed Medical Care, 1997–2001. Tracking Report No. 1. Washington, DC: Center for Studying Health System Change; March 2002.Google Scholar
  12. 12.
    Reschovsky JD, Kemper P, Tu H. Does type of health insurance affect health care use and assessments of care among the privately insured? Health Serv Res. 2000;35:219–37.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Chaupain-Guillot S, Guillot O. Health system characteristics and unmet care needs in Europe: an analysis based on EU-SILC data. Eur J Health Econ. 2015;16:781–96.CrossRefPubMedGoogle Scholar
  14. 14.
    Israel S. How social policies can improve financial accessibility of healthcare: a multi-level analysis of unmet medical need in European countries. Int J Equity Health. 2016;15:41.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Mielck A, Kiess R, von dem Knesebeck O, Stirbu I, Kunst AE. Association between forgone care and household income among the elderly in five Western European countries—analyses based on survey data from the SHARE-study. BMC Health Serv Res. 2009;9:52.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Elofsson S, Unden A-L, Krakau I. Patient charges: a hindrance to financially and psychosocially disadvantage groups seeking care. Soc Sci Med. 1998;46(10):1375–80.CrossRefPubMedGoogle Scholar
  17. 17.
    Guend H, Tesseron A-L 2009. Unmet needs for primary care in the context of a universal healthcare system. The case of Québec. Centre—Urbanisation Culture Société (INRS) working paper no. 2009–04. Québec: INRS; 2009.Google Scholar
  18. 18.
    Himmelstein DU, Woolhandler S. Care denied: US residents who are unable to obtain needed medical services. Am J Public Health. 1995;85:341–4.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Kyriopoulos I-I, Zavras D, Skroumpelos A, Mylona K, Athanasakis K, Kyriopoulos J. Barriers in access to healthcare services for chronic patients in times of austerity: an empirical approach in Greece. Int J Equity Health. 2014;13:54.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Skroumpelos A, Pavi E, Mylona K, Kyriopoulos J. The impact of economic crisis on chronic patients’ self-rated health, health expenditures and health services utilization. Diseases. 2014;2(2):93–105. doi: 10.3390/diseases2020093.CrossRefGoogle Scholar
  21. 21.
    Adams M, Augustyns N, Janssens H, Vriesacker B, Van Hal G. What socio-demographic factors influence poverty and financial health care access among disabled people in Flanders: a cross-sectional study. Arch Public Health. 2014;72(1):5.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Skinner AC, Mayer ML. Effects of insurance status on children’s access to specialty care: a systematic review of the literature. BMC Health Serv Res. 2007;7:194.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Gnanasekaran SK, Boudreau AA, Soobader M-J, Yucel R, Hill K, Kuhlthau K. State policy environment and delayed or forgone care among children with special health care needs. Matern Child Health J. 2007;12:739–46.CrossRefGoogle Scholar
  24. 24.
    Hill KS, Freeman LC, Yucel RM, Kuhlthau KA. Unmet need among children with special health care needs in Massachusetts. Matern Child Health J. 2007;12:650–61.CrossRefPubMedGoogle Scholar
  25. 25.
    Kane DJ, Zotti ME, Rosenberg D. Factors associated with health care access for Mississippi children with special health care needs. Matern Child Health J. 2005;9:S23–31.CrossRefPubMedGoogle Scholar
  26. 26.
    Lehrer JA, Pantell R, Tebb K, Shafer M-A. Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern. J Adolesc Health. 2007;40:218–26.CrossRefPubMedGoogle Scholar
  27. 27.
    Lewis C, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics. 2005;116:e426–31.CrossRefPubMedGoogle Scholar
  28. 28.
    Tang MH, Hill KS, Boudreau AA, Yucel RM, Perrin JM, Kuhlthau KA. Medicaid managed care and the unmet need for mental health care among children with special health care needs. Health Serv Res. 2008;43:882–900.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Wisk LE, Witt WP. Predictors of delayed or forgone needed health care for families with children. Pediatrics. 2012;130:1027–37.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Baggett TP, O’Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a National study. Am J Public Health. 2010;100:1326–33.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Hwang SW, Ueng JJM, Chiu S, Kiss A, Tolomiczenko G, Cowan L, Levinson W, Redelmeier DA. Universal health insurance and health care access for homeless persons. Am J Public Health. 2010;100:1454–61.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285:200–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Lewis JH, Andersen RM, Gelberg L. Health care for homeless women. J Gen Intern Med. 2003;18:921–8.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically iii adults: the treatments people forgo, how often, and who is at risk. Am J Public Health. 2004;94:1782–7.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Ronksley PE, Sanmartin C, Quan H, Ravani P, Tonelli M, Manns B, Hemmelgarn BR. Association between chronic conditions and perceived unmet health care needs. Open Med. 2012;6:e48–58.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Ronksley PE, Sanmartin C, Quan H, Ravani P, Tonelli M, Manns B, Hemmelgarn BR. Association between perceived unmet health care needs and risk of adverse health outcomes among patients with chronic medical conditions. Open Med. 2013;7(1):e21–30.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Horner-Johnson W, Dobbertin K, Lee JC, Andresen EM, the Expert Panel on Disability and Health Disparities. Disparities in health care access and receipt of preventive services by disability type: analysis of the medical expenditure panel survey. Health Serv Res. 2014;49:1980–99.Google Scholar
  38. 38.
    Michalopoulos C, Wittenburg D, Israel DAR, Warren A. The effects of health care benefits on health care use and health: a randomized trial for disability insurance beneficiaries. Med Care. 2012;50:764–71.CrossRefPubMedGoogle Scholar
  39. 39.
    Bremer P. Forgone care and financial burden due to out-of-pocket payments within the German health care system. Health Econ Rev. 2014;4(1):1–9.CrossRefGoogle Scholar
  40. 40.
    Klein D, Turvey C, Wallace R. Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates. Gerontologist. 2004;44:779–87.CrossRefPubMedGoogle Scholar
  41. 41.
    Litwin H, Sapir EV. Forgone health care due to cost among older adults in European countries and in Israel. Eur J Ageing. 2009;6:167–76.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Rogowski J, Lillard LA, Kington R. The financial burden of prescription drug use among elderly persons. Gerontologist. 1997;37:475–82.CrossRefPubMedGoogle Scholar
  43. 43.
    Lebrun LA, Dubay LC. Access to primary and preventive care among foreign-born adults in Canada and the United States. Health Serv Res. 2010;45:1693–719.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Cylus J, Papanicolas I. An analysis of perceived access to health care in Europe: how universal is universal coverage? Health Policy. 2015;119:1133–44.CrossRefPubMedGoogle Scholar
  45. 45.
    Smith P. User charges and priority setting in health care: balancing equity and efficiency. J Health Econ. 2005;24(5):1018–29.CrossRefPubMedGoogle Scholar
  46. 46.
    Bazin F, Parizot I, Chauvin P. Original approach to the individual characteristics associated with forgone healthcare. Eur J Public Health. 2005;15:361–7.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Åhs AMH, Westerling R. Health care utilization among persons who are unemployed or outside the labour force. Health Policy. 2006;78:178–93.CrossRefPubMedGoogle Scholar
  48. 48.
    Hendryx MS, Ahern MM, Lovrich NP, McCurdy AH. Access to health care and community social capital. Health Serv Res. 2002;37:85–101.CrossRefPubMedCentralGoogle Scholar
  49. 49.
    Law M, Wilson K, Eyles J, Elliott S, Jerrett M, Moffat T, Luginaah I. Meeting health need, accessing health care: the role of neighbourhood. Health Place. 2005;11(4):367–77.CrossRefPubMedGoogle Scholar
  50. 50.
    Mollborn S, Stepanikova I, Cook KS. Delayed care and unmet needs among health care system users: when does fiduciary trust in a physician matter? Health Serv Res. 2005;40:1898–917.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Wiltshire JC, Person SD, Kiefe CI, Allison JJ. Disentangling the influence of socioeconomic status on differences between African American and white women in unmet medical needs. Am J Public Health. 2009;99:1659–65.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Schokkaert E, Van de Voorde C, Dormont B, Fleurbaey M, Luchini S, Samson A-L, Thébaut C. Equity in health and equivalent incomes. In: Rosa Dias P, O’Donnell O, editors. Health and Inequality (Research on Economic Inequality, vol. 21). Bingley: Emerald; 2013, p. 131–56.Google Scholar
  53. 53.
    Bundorf K, Pauly M. Is health insurance affordable for the uninsured? J Health Econ. 2006;25(4):650–73.CrossRefPubMedGoogle Scholar
  54. 54.
    Glied S. Mandates and the affordability of health care. Inquiry. 2009;46:203–14.PubMedGoogle Scholar
  55. 55.
    Fleurbaey M, Schokkaert E. Inequity in health and health care. In: Barros P, McGuire T, Pauly M, editors. Handbook of health economics, vol. 2. New York: Elsevier; 2012. p. 1003–92.Google Scholar
  56. 56.
    Chernew M, Rosen A, Fendrick M. Value-based insurance design. Health Aff. 2007;30:w195–203.CrossRefGoogle Scholar
  57. 57.
    van Doorslaer E, Van Ourti T. Measuring inequality and inequity in health and health care. In: Glied S, Smith P, editors. Oxford handbook on health economics. Oxford: Oxford University Press; 2011. p. 837–69.Google Scholar
  58. 58.
    Balabanova D, McKee M. Understanding informal payments for health care: the example of Bulgaria. Health Policy. 2002;62:243–73.CrossRefPubMedGoogle Scholar
  59. 59.
    Balabanova D, McKee M, Pomerleau JRR, Haerpfer C. Health service utilization in the former Soviet Union: evidence from eight countries. Health Serv Res. 2004;39:1927–50.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Ensor T. Informal payments for health care in transition economies. Soc Sci Med. 2004;58:237–46.CrossRefPubMedGoogle Scholar
  61. 61.
    Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T. Informal payments in public hospitals in Greece. Health Policy. 2008;87:72–81.CrossRefPubMedGoogle Scholar
  62. 62.
    Szende A, Culyer A. The inequity of informal payments for health care: the case of Hungary. Health Policy. 2006;75:262–71.CrossRefPubMedGoogle Scholar
  63. 63.
    Cutler D, Zeckhauser R. The anatomy of health insurance. In: Culyer A, Newhouse J, editors. Handbook of health economics. New York: Elsevier; 2000. p. 563–643.Google Scholar
  64. 64.
    McGuire T. Demand for health insurance. In: Barros P, McGuire T, Pauly M, editors. Handbook of health economics, vol. 2. New York: Elsevier; 2012. p. 317–96.Google Scholar
  65. 65.
    De Graeve D, Van Ourti T. The distributional impact of health financing in Europe: a review. World Econ. 2003;26:1459–79.CrossRefGoogle Scholar
  66. 66.
    Wagstaff A, van Doorslaer E. Equity in health care finance and delivery. In: Culyer A, Newhouse J, editors. Handbook of health economics. New York: Elsevier; 2000. p. 1803–62.Google Scholar
  67. 67.
    Wagstaff A, van Doorslaer E, et al. Equity in the finance of health care: some further international comparisons. J Health Econ. 1999;18:263–90.CrossRefPubMedGoogle Scholar
  68. 68.
    Vrijens F, Renard F, Camberlin C, et al. Performance of the Belgian Health System—Report 2015. KCE Reports 259C. Brussels: Belgian Health Care Knowledge Centre (KCE); 2016.Google Scholar
  69. 69.
    Ashton C, Haidet P, Paterniti DA, et al. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? J Gen Intern Med. 2003;18(2):146–52.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    van Doorslaer E, O’Donnell O, Rannan-Eliya RP, et al. Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data. Lancet. 2006;368:1357–64.CrossRefPubMedGoogle Scholar
  71. 71.
    van Doorslaer E, O’Donnell O, Rannan-Eliya RP, et al. Catastrophic payments for health care in Asia. Health Econ. 2007;16:1159–84.CrossRefPubMedGoogle Scholar
  72. 72.
    Wagstaff A. Measuring financial protection in health. Policy Research Working Paper 4554. World Bank; 2008.Google Scholar
  73. 73.
    Xu K, Evans D, Kawabata K, Zeramdini R, Klavus J, Murray C. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362:111–7.CrossRefPubMedGoogle Scholar
  74. 74.
    Farfan-Portet M-I, Van de Voorde C, Vrijens F, Vander Stichele R. Patient socioeconomic determinants of the choice of generic versus brand name drugs in the context of a reference price system: evidence from Belgian prescription data. Eur J Health Econ. 2012;13(3):301–13.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Vrijens F, Van de Voorde C, Farfan-Portet M-I, Vander Stichele R. Patient socioeconomic determinants for the choice of the cheapest molecule within a cluster: evidence from Belgian prescription data. Eur J Health Econ. 2012;13(3):315–25.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of EconomicsKU Leuven and CORE, Université catholique de LouvainLouvain-la-NeuveBelgium
  2. 2.Department of EconomicsKU LeuvenLouvainBelgium

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