Insured but unequal: who really utilizes voluntary health insurance in Israel? Evidence from two consecutive...

Financial pressures on health systems have increased in recent years. Voluntary health insurance (VHI) could, in principle, fill in the gaps in public coverage and funding. However, there is little evidence on realized access to VHI-funded care - who uses it and for what services, especially in countries with high VHI ownership, such as Israel. Our study assesses gaps in VHI uptake and utilization across the Israeli population.

Two consecutive cross-sectional data were collected through two national surveys among the adult population (aged 22+) conducted in 2012 and again in 2022, with respective response rates of 61% (N= 2,330) and 52% (N = 2,536). Bivariate analyses (ꭓ²) estimated the differences between population groups in the rates of VHI ownership and utilization of services at least once during the two years preceding the survey, while multivariable logistic regressions estimated the corresponding odds ratios.

VHI ownership rates remained high (around 83%) in both surveys but varied across subgroups. Arabs, residents of peripheral areas, and those in the lowest income quintile had lower ownership rates and lower likelihood of owning it. Overall, VHI self-reported utilization stood at 66% in 2022, lower than 76% in 2012. Visits to specialists were the only service category with increased utilization (from 20% to 28%). In 2022, VHI owners with lower incomes, lower education, and those residing in peripheral areas were also less likely to report utilizing VHI. Yet, Arabs and ultra-Orthodox Jews were more likely to report utilizing VHI. Those reporting poor health were also more likely to report utilizing VHI.

Our study examines VHI ownership trends and gaps in utilization of VHI-funded services in Israeli populations. The regressive nature of VHI premiums and disproportionately higher utilization by owners with higher socioeconomic status highlights the limitations of VHI as a sustainable and equitable financing policy tool for healthcare to policymakers. This unequal coverage demonstrates that VHI is not a full substitute for public funds, potentially indicating access barriers, while showing that fewer insured are benefiting from coverage. Its role should be clearly defined to ensure it complements public healthcare coverage.