Patient cost sharing and social inequalities in access to health care in three western European countries.

This study evaluates the association between social class and health services use in France, Germany and Spain, three countries with universal health coverage but with different cost-sharing systems. In France, patients share the cost of both physician visits and hospitalization, in Germany they share the cost of hospitalization, and in Spain there is no system of patient cost sharing. The data were obtained from national health surveys carried out in each of these countries during the last decade of the 20th century. We found that persons belonging to a low social class had fewer physician visits than those belonging to a high social class in France, whereas the opposite occurred in Germany and Spain. After adjusting for a measure of the need for health care, the results in France changed little, whereas no significant differences by social class were seen in Germany and Spain. Persons of low social class had more hospital admissions than those of high social class in France and Spain, while no statistically different differences were seen in Germany. After adjusting for need, no significant differences were seen in any of the three countries. Although other factors related with the structure of the health system can not be ruled out, our findings suggest that patient cost sharing reduces the frequency of physician visits and that this decrease is greater in the low social classes, whereas the effect of co-payment for hospitalization on the frequency of hospital admission is not clear.