Is Universal Healthcare a Realistic Ask for Europeans?

Out-of-pocket costs are silent barriers to healthcare, said João Vasco Santos, MD, PhD, president of the Public Health Economics Section at the European Public Health Association. “They result in financial hardship and unmet health needs in every European country, disproportionately affecting various groups, particularly those experiencing social vulnerability. These costs delay treatment, exacerbating health inequality even further. They are also the most regressive form of health financing,” he told Medscape Medical News.

In 2023, nearly 4% of adults in the European Union (EU) reported having unmet medical needs, and close to 5% experienced unmet dental needs. Although the EU generally offers extensive healthcare coverage, significant barriers persist for certain vulnerable groups, including the need to pay out of pocket for services such as optical treatments, dental care, physiotherapy, reproductive health, psychotherapy, and prescribed medicines for common chronic conditions.

According to the World Health Organization (WHO), up to 1 in 5 European households face catastrophic health costs, leaving them unable to afford essentials like food, housing, and heating. Another 1%-12% of households end up in poverty or even worse financial struggles due to out-of-pocket healthcare payments.

Experts told Medscape Medical News that, to improve healthcare access, especially to vulnerable groups, EU countries need to learn from each other’s experiences, set benchmarks, and collect high-quality data.

The Cost of European Healthcare

“We see out-of-pocket payments in every health system in Europe,” said Sarah Thomson, PhD, senior health financing specialist at the WHO Barcelona Office for Health Systems Financing. These payments result when people are not entitled to publicly financed healthcare but also when co-payments are required for covered healthcare, particularly for outpatient prescribed medicines, she explained.

“Even among high-income individuals, there are times when they may face financial hardship due to out-of-pocket spending, particularly regarding certain medical products or dental care,” said Santos.

Thomson explained that healthcare accessibility and costs vary significantly across the EU. For example, in the Netherlands, prepaid public funding covers approximately 80%-90% of healthcare costs, leaving only about 10% to be paid out of pocket. In contrast, Italy has significantly higher out-of-pocket expenses, accounting for around 23% of its current health spending.

“The more countries invest publicly in their health systems, the less people usually have to pay out of pocket,” said Thomson. “As a result, the share of total health spending from out-of-pocket payments is much smaller in the Netherlands than in Italy.”

This isn’t the only factor that affects access to healthcare, however.

Another factor is whether the healthcare system is designed to include co-payments and whether low-income households are exempted or if there is an income-based cap on them, Thomson explained.

Understanding Two Different Approaches

European healthcare financing varies widely from being primarily through the government budget, like in Italy, to heavily relying on employer and employee social insurance contributions, like in the Netherlands, or something in between, such as in France. Thomson said that users can face some level of co-payment in any of these models.

In 2023, out-of-pocket payments represented 23% of Italy’s €176 billion healthcare bill, up by 10% from the previous year, explained Domenica Matranga, PhD, professor of medical statistics at the University of Palermo, Palermo, Italy, to Medscape Medical News. “There was a dramatic increase because this is the effect of the enormous public debt we have and of unacceptably long waiting lists.”

Italy’s National Health Service is funded through general taxation and provides universal coverage for all citizens and residents, with hospitals and most primary care services largely free at the point of use. While each region is responsible for organizing and delivering health services, the essential benefits package is established nationally and must be offered uniformly throughout the country.

Still, there are problems. There is a significant disparity in access to high-quality healthcare between the north and south.

Additionally, Italians are required to make co-payments for certain services, including medicines, outpatient specialist visits, diagnostic tests, and dental care. And even though financial support is provided for very young children, pensioners, and the unemployed, for example, there is no overall cap on co-payments.

The Netherlands, on the other end, operates under a social health insurance system. Dutch residents must register for mandatory healthcare insurance, and they all receive at least a government-defined basic benefits package. They pay monthly insurance premiums and have an annual deductible of approximately €385. They do not need to make additional payments for general practitioner visits or standard hospital care. However, they must pay the initial portion of their healthcare costs related to non–primary care services out of pocket each year before their insurance coverage takes effect.

“We have universal health coverage that is quite comprehensive in the Netherlands,” said Pieter Bakx, PhD, an associate professor affiliated with the Health Economics group at the Erasmus School of Health Policy and Management, Rotterdam, the Netherlands. “The defined set of benefits is relatively broad, and co-payments tend to be low. This applies particularly to long-term care; when compared to neighboring countries, people pay relatively low user fees.”

The Dutch population typically reports low levels of unmet medical treatment needs. They do have some out-of-pocket expenses for services such as adult dental work, physiotherapy beyond a certain limit, and eyeglasses. However, their out-of-pocket spending is far below the EU average. To cover expenses that fall outside the basic benefits package of their insurance, they usually purchase supplementary voluntary health insurance policies.

Toward Fairer European Healthcare

“Introducing an EU-wide benchmark or target for all countries would be a good approach to improving healthcare affordability in our continent,” said Santos. A good equity-based benchmark could be for no more than 2% of EU households to experience catastrophic health spending, he said. “Then, consider coverage, coverage, coverage. I think it’s all about coverage policies and trying to showcase how these coverage policies in some countries are achieving results in terms of access to healthcare.”

Thomson added that learning from one another is often overlooked. Despite the potential benefits of observing how other countries address common problems, she said there is typically a surprising lack of understanding about these approaches. This gap exists partly because policymakers often lack the time to explore international solutions when faced with immediate crises, and because politics is a cyclical process and people constantly change. There is significant need to actively promote and support the sharing of experiences and knowledge among different countries, she said, but quality data are necessary before information can be shared.

“I think the EU can play a significant role in data collection, ensuring that countries gather information on who experiences unmet healthcare needs, who face financial hardship, and the reasons behind this,” Thomson added. “The EU could do more to encourage member states to collect this data more regularly because data is very powerful.”

Bakx emphasized that Europeans are all in the same boat. The population is aging, which means that the demand for healthcare will increase while the supply of healthcare workers will decrease.

“The big challenge now, and even more in the future, is the demographic transition,” agreed Franca Maino, PhD, associate professor of social and political sciences at the University of Milan, Milan, Italy, and scientific director of the Percorsi di Secondo Welfare Observatory. “So it’s really crucial to have a guiding framework at the EU level to develop long-term care systems in all member states. As of now, some countries don’t have a [proper] long-term care system.”

Santos, Thomson, Matranga, Bakx, and Maino reported having no relevant financial relationships.